mynclex set 1

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply. 1. Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask IncorrectCorrect answer 3,4 30%Answered correctly

-Airborne precautions- -Indications Tuberculosis Varicella zoster* (chickenpox) Herpes zoster** (shingles) Rubeola (measles) -Components N95 respirator or powered air-purifying respirator Negative-pressure isolation room with high-efficiency particulate air filter As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield *Only when uncrusted lesions are present; contact precautions also required.**Only in disseminated disease or immunocompromised clients; contact precautions also required. Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. (Options 1 and 2) Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). (Option 5) For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation. Educational objective:Tuberculosis requires airborne precautions. Clients suspected of having tuberculosis should be given a surgical mask to wear on entering any health care setting. Clients are placed in negative-pressure isolation rooms. Nurses must use a class N95 or higher particulate respirator. Additional Information Safety and Infection Control NCSBN Client Need

The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath. What is the nurse's priority action? 1. Direct the UAP to apply a protective foam dressing (1%) 2. Document results of the Braden Scale in the electronic record (1%) 3. Notify the health care provider (HCP) (1%) 4. Perform an assessment on the client's skin (96%) Correct 4 96%Answered correctly

A reddened area on the sacrum puts the client at risk for skin breakdown. The nurse should first perform an assessment on the client's skin to see if there are any other reddened areas or skin breakdown present. This should be compared to previous assessments or serve as a baseline assessment of skin integrity. The Braden Scale, a tool for predicting pressure sore risk, would be appropriate to use as part of the assessment. (Option 1) After the nurse has performed a skin assessment, it may be appropriate to direct the UAP to apply a protective foam dressing to the area. (Option 2) Documentation should occur after the client has been assessed thoroughly and received care. (Option 3) After assessing the client, the nurse can decide whether to notify the HCP. Educational objective:When the nurse receives report of a change in client condition from the UAP, the nurse should reassess the client before completing other interventions. Additional Information Basic Care and Comfort NCSBN Client Need

The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UAP) asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful? 1. "No, absence seizures can look like daydreaming or staring off into space." (93%) 2. "No, you are wrong. Don't worry about that." (0%) 3. "Yes, so please let me know if you see the client do that." (5%) 4. "You don't have to monitor the client for seizures." (0%) Correct 1 93%Answered correctly

Absence seizures typically occur in children. The presentation is classic and includes the following: Daydreaming episodes or brief (<10 seconds) staring spells Absence of warning and postictal phases Absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity) Unresponsiveness during the seizure No memory of the seizure The most helpful response by the nurse is one that corrects while educating the UAP (Option 1). The UAP may be present when a client has a seizure, and understanding of what to expect will aid client care. (Options 2 and 4) Although it is not the responsibility of the UAP to monitor the client, the UAP may witness a seizure and call for help if needed. (Option 3) Seizures may include tonic (body stiffening), clonic (muscle jerking), atonic (loss of muscle tone or "drop attack"), myoclonic (brief muscle jerk), or tonic-clonic (alternating stiffening and jerking) body motions. Absence seizures do not typically involve these body motions. Educational objective:Absence seizures are brief periods of staring; there is no evidence of tonic-clonic activity or postictal confusion. The UAP should be educated about absence seizures when involved in the care of such clients. Additional Information Physiological Adaptation NCSBN Client Need

When performing developmental screenings in the well-child clinic, the registered nurse understands that which child is at highest risk of developing autism spectrum disorder? 1. 2-year-old who has a vocabulary of 10 words (31%) 2. 3-year-old who received measles, mumps, and rubella immunization at age 1 year (2%) 3. 4-year-old whose 10-year-old sibling has the disorder (32%) 4. 5-year-old whose parents were age 42 at the time of birth (33%) Correct 3 32%Answered correctly

Although the cause of autism spectrum disorder (ASD) is unknown, numerous studies indicate that it has a strong genetic component. The underlying genetic source is unknown in the majority of cases; however, researchers hypothesize that genetic factors predispose to an autism phenotype and that genetic expression is influenced by environmental factors. (Option 1) A 2-year-old with a vocabulary of a few words only is a concern; however, there are a number of factors and/or conditions that could cause language or overall developmental delay. (Option 2) There is no scientific evidence that the measles, mumps, and rubella vaccine or thimerosal-containing vaccines (eg, influenza) are linked to ASD. (Option 4) Retrospective studies have linked parents of older age to autism; however, this association is inconclusive. Educational objective:There is strong scientific evidence of a genetic component to autism spectrum disorder (ASD). As a result, parents who have a child with ASD are at higher risk of having another child with this disorder. There is no evidence that supports a link between vaccines and ASD, and studies on associations between advanced parental age and the disorder are inconclusive.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs." (46%) 2. "His heart has stopped and we are attempting to revive him." (13%) 3. "I don't know how he is doing but you need to come." (1%) 4. "I will have the health care provider talk to you once you arrive." (38%) IncorrectCorrect answer 1

Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely. (Option 2) This is a true statement but it is being given abruptly to the family without support or gradual adjustment. It might be so distressing that they cannot travel to the hospital safely. (Option 3) This is not a true statement and violates the principle of veracity. It will do nothing to help the family and might even cause them alarm that a nurse there is not informed about what is going on with their child. (Option 4) Although this is an option, it does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider, and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client's prognosis. Educational objective:The ethical principle of beneficence means doing good. It can involve not saying all known information immediately but delaying notification until appropriate support is in place. Additional Information Management of Care NCSBN Client Need

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? 1. "Can you lock your dresser drawer?" (55%) 2. "Make sure all of your medicines have childproof caps." (38%) 3. "That sounds like a safe plan." (2%) 4. "You need to keep an eye on your child at all times." (3%) Correct 1 55%Answered correctly

Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like many over-the-counter cold products. They usually find medicines when exploring their environment and "getting into everything" when no one is watching. Children may find medicine in a parent's coat pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that seems out of reach, children can climb on a chair or stool to reach it. Medications are the leading cause of child poisoning. The best preventive measures include placing all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting them away after each use (Option 1). (Option 2) Advising a parent/caregiver to ensure that medicine containers have childproof caps is an appropriate instruction; however, it is not the priority response in this situation. (Option 3) Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked. (Option 4) Although it is impossible for a parent or caregiver to watch a child every minute of the day, toddlers need adult supervision when active and exploring their environment. Educational objective:The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use.

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? Select all that apply. 1. Administer an analgesic as needed 2. Determine if there is bladder distention 3. Measure the client's blood pressure 4. Place the client in the Sims' position 5. Remove constrictive clothing IncorrectCorrect answer 2,3,5 44%Answered correctly

Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia (autonomic hyperreflexia). It is an uncompensated sympathetic nervous system stimulation. Classic signs include hypertension (up to 300 mm Hg systolic), throbbing headache, diaphoresis above the level of injury, bradycardia (30-40/min), piloerection ("goose bumps"), flushing, and nausea. This is a life-threatening condition that requires immediate intervention to prevent complications (eg, hypertensive stroke, seizures). Clients with a spinal cord injury should have their blood pressure checked when they report a headache (Option 3). The most common cause of autonomic dysreflexia is bladder irritation due to distention. The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed (Option 2). Bowel impaction can also be a cause; a digital rectal examination should be performed. Constrictive clothing should be removed to decrease skin stimulation (Option 5). The primary health care provider should be notified. An alpha-adrenergic blocker or an arteriolar vasodilator (eg, nifedipine) may be prescribed. (Option 1) Headaches associated with autonomic dysreflexia are typically due to severe hypertension and often resolve after blood pressure has been treated. (Option 4) The client should have the head of the bed elevated 45 degrees or high Fowler's to lower blood pressure. The Sims' position is flat and side-lying. Educational objective:Autonomic dysreflexia is a life-threatening condition in a client with high spinal cord injury. Classic signs/symptoms include severe hypertension, throbbing headache, diaphoresis, bradycardia, flushing, and piloerection. Emergency treatment includes correcting the cause (check bowel or bladder distention), removing tight clothing, and raising the head of the bed. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is assigned to care for a client who had a total hip replacement an hour ago. Which of the following should the nurse assess first? 1. Amount of drainage in suction drainage device (28%) 2. Client's level of pain and last dose of pain medication (20%) 3. Proper placement of the abduction pillow (45%) 4. Urine in the catheter bag for presence of cloudiness or pus (5%) Correct 1 28%Answered correctly

Common complications following total hip replacement are bleeding, prosthesis dislocation, deep vein thrombosis, and infection. Total joint replacements carry a risk of serious blood loss; therefore, the nurse should check the drainage device and dressing frequently to monitor blood loss, especially during the first several postoperative hours. (Option 2) Pain is typically controlled via a patient-controlled analgesia device with a programmed dosage and lockout. The client's level of pain should be assessed, but assessing for hemorrhage is the priority. (Option 3) Following total hip replacement, the client will have an abduction pillow between the legs to prevent adduction of the affected leg. Adduction of the leg could potentiate dislocation of the prosthesis. It is important that the client not flex the affected hip more than 90 degrees, as this could dislocate the prosthesis. Therefore, the client should be provided elevated toilet seats and chairs that do not recline. The nurse should assess for signs of hip dislocation, including shortening and internal rotation of the leg. Although providing an abduction pillow is important, assessing for hemorrhage is the priority. (Option 4) Assessment of the urine in a postoperative client's catheter bag is important but is not priority in this situation. Educational objective:Orthopedic surgeries, particularly total hip replacement, can cause significant blood loss. Assessing the dressing and drainage device is a priority over positioning an abduction pillow and evaluating the client's pain and quality of urine.

The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue teaching the client and verify understanding by return demonstration (90%) 2. Discuss how important it is for the client to pay attention during the teaching (2%) 3. Maintain eye contact during the teaching by following the client's movements (2%) 4. Provide written instructions and a private place for the client to learn independently (5%) Correct 1 90%Answered correctly

Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration. (Option 2) Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful. (Option 3) In the American Indian culture, it is disrespectful to maintain eye contact during a conversation. (Option 4) A client learning the process of self-administration of insulin requires guidance and evaluation from the registered nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently. Educational objective:Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? 1. "I will ask the health care provider to explain the consequences of your procedure." (10%) 2. "This is a common complication that will require you to have a hearing test every year." (5%) 3. "This is a common complication; your health care provider will order a consult for the speech pathologist." (25%) 4. "This is the reason you are using a special swallowing technique when you eat and drink." (58%) Correct 4 58%Answered correctly

Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: Inhale deeply Hold breath tightly to close the vocal cords Place food in mouth and swallow while continuing to hold breath Cough to dispel remaining food from vocal cords Swallow a second time before breathing (Option 1) This would be considered "passing the buck." The nurse should try to address the client's concerns before calling the health care provider. (Option 2) Cranial nerve VIII (vestibulocochlear) affects hearing and equilibrium, not swallowing. (Option 3) The speech pathologist conducts a swallowing assessment early on to evaluate a client's ability to swallow safely. This consult is not done at discharge. Educational objective: Clients who undergo a partial laryngectomy are at increased risk for aspiration. As a result, they are taught a swallowing technique (supraglottic swallow) to decrease this risk.

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter? 1. Have the client wear a mask (88%) 2. Have the client wear gloves (1%) 3. Wear a mask (8%) 4. Wear an isolation gown (1%) Correct 88%Answered correctly

Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room. (Option 2) Gloves are not required as part of droplet precautions. Standard precautions should guide the use of gloves in clients on droplet precautions. (Option 3) The transporter does not need to wear a mask outside of the client's room as long as the client keeps a mask on to prevent transmission of infection. (Option 4) An isolation gown is not required for droplet precautions. Educational objective:Droplet precautions require the use of regular masks to prevent the transmission of infection. A mask should be worn by the client when outside the hospital room and by staff when in the client's room. Additional Information Safety and Infection Control NCSBN Client Need

/A home health nurse is assessing for complications in a client who has been using crutches for 2 weeks. Assessing for which finding is most important? 1. Biceps muscle spasm (14%) 2. Forearm swelling (22%) 3. Hand and wrist weakness (35%) 4. Shoulder range of motion (26%) IncorrectCorrect answer 3 35%Answered correctly

Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axilla. This leads to a reversible condition known as crutch paralysis, or palsy, which manifests as muscle weakness and/or sensory symptoms (tingling, numbness) of the arm, wrist, and hand. It is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Therefore, clients are taught to support body weight on the hands and arms, not the axillae, when ambulating to ensure that there is a 1-2 in (2.5-5 cm) space between the axilla and the axilla crutch pad. Crutches should be checked for proper length. (Option 1) Triceps muscle spasm can occur due to increased muscle use, especially in clients with decreased upper body strength. Triceps and biceps muscle spasms are not complications associated with crutch walking. (Option 2) Forearm swelling is not a common complication associated with crutch walking. In rare cases, arterial obstruction can cause ischemic symptoms. (Option 4) Restricted shoulder range of motion is not a major complication of crutch use. Educational objective:Clients are taught to support their body weight on the hands and arms, not the axillae, when ambulating with crutches. Prolonged and continual excessive pressure on the axillae can damage the radial nerve, resulting in crutch paralysis - muscle weakness and/or sensory symptoms over the forearm, wrist, and hand. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply. 1. "I can apply Vaseline to my nose when my nostrils feel dry from the oxygen." 2. "I can cook on my gas stove as long as I have a fire extinguisher in the kitchen." 3. "I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath." 4. "I should not polish my nails when using my oxygen." 5. "I should not use a wool blanket on my bed." IncorrectCorrect answer 1,2,3 21%Answered correctly

Oxygen is a colorless, odorless gas that supports combustion and makes up about 21% of the atmosphere. Oxygen is not combustible itself, but it can feed a fire if one occurs. When using home oxygen, safety precautions are imperative. Vaseline is an oil-based, flammable product and should be avoided. A water-soluble lubricant may be used instead. Oxygen canisters should be kept at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable. The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO2 to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and can even be dangerous in clients with COPD as they can decrease the drive to breathe. The client should notify the care provider about excessive shortness of breath as additional treatment may be indicated. (Option 4) The client understands that nail polish remover and nail polish contain acetone, which is highly combustible. (Option 5) Clients should avoid synthetic and wool fabrics because they can cause static electricity, which may ignite a fire in the presence of oxygen. Clients should use cotton blankets and wear cotton fabrics. Educational objective:Safety precautions for home oxygen use include the following: no smoking; electrical devices in good condition and plugs grounded; avoiding volatile, flammable products and materials that generate static electricity; staying at least 5-10 feet away from open sources of flame; keeping fire extinguishers readily available; and regularly testing smoke detectors. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose? 1. 1 mL (1%) 2. 3 mL (10%) 3. 10 mL (80%) 4. 30 mL (8%) IncorrectCorrect answer 3 80%Answered correctly

Flushing the lumen of a central venous access device (central venous catheter [CVC]) with normal saline is recommended to assess patency before medication infusion, prevent medication incompatibilities after infusion, and prevent occlusion after blood sampling. A 10-mL syringe is generally preferred for flushing the lumen of a CVC (Option 3). The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC. (Options 1 and 2) A smaller syringe (eg, 1 mL, 3 mL) creates more pressure, which increases the risk for damage to the CVC. (Option 4) A 30-mL syringe is unnecessarily large to flush a CVC. Educational objective:When flushing the lumen of a central venous catheter, the nurse should use the safest syringe possible and the "push-pause" method to avoid exerting too much pressure, which may damage the catheter. The smaller the syringe, the greater the amount of pressure exerted during the flush. A 10-mL syringe is generally recommended; however, it is also important to consult the manufacturer's guidelines. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need Copyright © UWorld. All rights reserved.

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? 1. Contact the national database to see if the client has a healthcare proxy (1%) 2. Contact the police to help identify the client and locate family members (2%) 3. Obtain a court order for the client's surgical procedure (3%) 4. Transport the client to the operating room under implied consent (93%) Correct 93%Answered correctly

Implied consent in emergency situations includes the following criteria: There is an emergency Treatment is required to protect the client's health It is impractical to obtain consent It is believed that the client would want treatment if able to consent In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed. (Option 1) This client's name is not known and there is no national database of healthcare proxy names/power of attorney. (Option 2) This should also be done but results may not be obtained in a timely manner. The client needs immediate surgery and this should proceed with the client as a "John Doe" (placeholder name) in the meantime. (Option 3) This would cause considerable delay. Court orders are used for protective custody to take control of the care of a minor when the adult parent is refusing necessary life-saving care. Educational objective:Emergency life-saving care can proceed for a client who cannot give consent if it is essential and believed that the client would want treatment if able to consent. Care is rendered under the principle of implied consent.

The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first? 1. 3-month-old whose posterior occiput appears flattened (8%) 2. 4-month-old who has sclera visible above the iris (sunset eyes) (58%) 3. 6-month-old who has vomited twice and has had 8 wet diapers in the last 24 hours (22%) 4. 9-month-old whose toes fan out and big toe dorsiflexes when plantar surface is stroked (10%) IncorrectCorrect answer 2 58%Answered correctly

Hydrocephalus is an increase in intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid flow. Increased ICP can progress to brain damage and death. Signs of increased ICP in children include bulging fontanelles, increasing head circumference, and sunset eyes (or setting-sun sign) (sclera visible above the iris). Sunset eyes occur when periaqueductal structures are compressed from increased ICP, paralyzing the upward gaze. This is a late sign of increased ICP that requires timely treatment (eg, shunt placement) and is the priority (Option 2). (Option 1) Positional plagiocephaly (flat head syndrome) occurs when an infant is placed in the same position (eg, supine) for an extended period of time and the pliable skull molds to the surface (flattens). Parents can intervene to avoid or correct plagiocephaly (eg, periodically repositioning the head during sleep, tummy time). Minor skull deformation is not a priority. (Option 3) Eight wet diapers in 24 hours is within the normal range (6-10 diapers/day or approximately 1 diaper every 4 hours), indicating that the infant is likely producing >1 mL/kg/hr urine output and is not dehydrated, despite vomiting. (Option 4) The Babinski reflex (ie, toes fan outward and the big toe dorsiflexes with stimuli) is expected in infants and is a normal finding up to age 1 year. However, its presence beyond this age can indicate neurologic disease. Educational objective:The presence of sunset eyes (sclera visible above the iris) is a late sign of increased intracranial pressure and a priority to report to the health care provider.

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." (16%) 2. "It prevents seizure development." (59%) 3. "It prevents blood clots in legs." (3%) 4. "It reduces swelling around the tumor." (20%) Correct 2 59%Answered correctly

Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective:Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse? 1. "I understand your desire to leave, but it would be very risky." (2%) 2. "I will ask the palliative care nurse to talk with you to help clarify your care goals." (3%) 3. "I will let the HCP know that you want to be discharged and do everything I can to make it happen." (5%) 4. "Tell me more about your need to leave the hospital." (87%) Correct

Knowing that this client has just received bad news with a limited prognosis, the nurse should anticipate that the client's urgent request for discharge may be due to concerns about needing to complete unfinished business while still functioning. Examples of end-of-life "business" include concerns about family, finances, business responsibilities, and dealing with property and possessions. To get more information, the nurse should assess the client's concern and the motivation behind the request by asking an open-ended question, such as "Tell me more about ______." It is important to gain the client's trust, to actively listen, and to avoid immediately jumping to problem-solving during this assessment (Option 4). With the information gained from the assessment, the nurse will be able to problem-solve with the client while intervening and advocating as appropriate. (Option 1) Although leaving may be risky for the client, the nurse's warning is not an appropriate initial action. (Option 2) The nurse is not taking the time to listen but is passing this responsibility to another member of the team. A palliative care nurse referral may be appropriate in this situation, but the nurse needs more information and must take the time to listen to the client now. (Option 3) This option does not acknowledge the HCP's concern about the client still needing to be hospitalized. The nurse must first understand the client's situation and then take this information to the HCP to negotiate for a solution that acknowledges the concerns of both. Educational objective:A client facing the end of life often has unfinished business that needs to be completed, which may motivate the client to become anxious or insist on discharge. The nurse should assess the client's concern and use this information to design a care plan that will allow the client to make necessary preparations while ensuring medical care to control symptoms.

A client with Parkinson disease is prescribed carbidopa-levodopa. Which of the following instructions should the nurse include with the client's discharge teaching? Select all that apply. 1. "Change positions slowly, and sit on the side of the bed before standing." 2. "This medication takes several weeks to reach maximum benefit." 3. "You may experience some facial and eye twitching, but this is not harmful." 4. "Your tremors should disappear completely while on this medication." 5. "Your urine and saliva may turn reddish-brown, but this is not harmful." IncorrectCorrect answer 1,2,5 30%Answered correctly

Parkinson disease (PD) is characterized by decreased dopamine levels, uncontrolled acetylcholine, and formation of abnormal protein clusters (Lewy bodies) in the brain. PD causes both physical and neurological (eg, mood alterations, dementia) symptoms. Carbidopa-levodopa is a combination antiparkinsonian medication used to reduce physical symptoms of PD by increasing dopamine levels in the brain. Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the brain. Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain, which makes levodopa more effective. Client teaching for carbidopa-levodopa includes: Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side effect (Option 1) Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2) Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur while taking carbidopa-levodopa (Option 5) Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa (Option 3) Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of carbidopa-levodopa and should be reported immediately to the health care provider. (Option 4) Carbidopa-levodopa often decreases, but does not eliminate, tremor and rigidity. Educational objective:Carbidopa-levodopa is a medication used to reduce symptoms of tremor and rigidity in clients with Parkinson disease. Teach clients that the medication takes several weeks to become effective; urine, perspiration, or saliva discoloration is a common side effect; and fall precautions should be implemented for client safety. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply. 1. Advance past the external sphincter only 2. Guide suppository along the rectal wall 3. Hold buttocks together firmly after insertion 4. Position client supine with knees and feet raised 5. Use gloved fifth finger for insertion IncorrectCorrect answer 2,3,4,5 9%Answered correctly

Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce distress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure. Basic steps for suppository administration include the following: Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) (Option 4). Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years (Option 5). Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption (Option 2). Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion (Option 3). If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository. (Option 1) The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect. Educational objective:In children younger than age 3 years, suppositories are inserted with the fifth finger of the nurse's gloved hand. Age-appropriate explanations and/or distractions are implemented to reduce distress. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)? 1. Blood pressure of 180/100 mm Hg (27%) 2. Creatinine of 2 mg/dL (176.8 µmol/L) (14%) 3. Hemoglobin of 9.8 g/dL (98 g/L) (13%) 4. Platelet count of 120,000/mm3 (120 x 109/L) (43%) Correct 1 27%Answered correctly

Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy (Option 1). (Option 2) An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L) can be expected in a client with probable renal disease. This is not the most important finding to report to the HCP. (Option 3) A decreased hemoglobin level (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production. The nurse should continue to monitor the client's hemoglobin post-procedure as it can decrease further (within 6 hours) if bleeding occurs. (Option 4) Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-400,000/mm3 [150-400 x109/L]), it is not the most important finding to report to the HCP. Educational objective:The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management. Which statement by the client indicates comprehension of teaching? 1. "Even with appropriate treatment joint damage and disability are inevitable." (16%) 2. "My arthritis can be resolved if I can improve my diet and lose weight." (7%) 3. "My methotrexate should be taken even when my joints aren't hurting." (61%) 4. "When my joints hurt, I should rest frequently and try not to move them." (14%) IncorrectCorrect answer 3 61%Answered correctly

Rheumatoid arthritis (RA) is a chronic, relapsing autoimmune disorder causing painful inflammation of synovial joints and fibrosis and stiffening of synovial membranes. Contracture of ligaments and joint remodeling may occur, resulting in weakness and deformity. Clients with RA require education on prevention of disease progression, including: Joint protection - Fibrosis from RA can shorten tendons and ligaments when joints are flexed for prolonged periods. Body aligners or immobilizers should be used when resting to keep extremities straight (especially with advanced disease). Medications - RA is often treated using a regimen of disease-modifying antirheumatic drugs (eg, methotrexate), and clients should take their medication as prescribed regardless of symptoms (Option 3). (Option 1) Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic drugs and joint protection. (Option 2) Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However, obesity is unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause weight loss. The nurse should ensure that clients with RA have access to adequate nutrition. (Option 4) During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of motion exercises to prevent loss of function. Educational objective:Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes pain and joint deformity. Clients with RA should be taught to remain active to prevent contracture, take immunosuppressant medications consistently, use body aligners to prevent joint contracture, and eat a balanced diet. Additional Information Physiological Adaptation NCSBN Client Need

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? 1. Inject into the upper arm where the sleeve can be pulled up (14%) 2. Inject into the most accessible vein (1%) 3. Inject through the clothing into thigh and hold in place for 10 seconds (69%) 4. Take the child inside, remove excess clothing, and inject into the thigh (13%) Correct 69%Answered correctly

The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4). (Option 1) The EpiPen should be injected into the mid-outer thigh, not the upper arm. (Option 2) IV epinephrine is not administered outside the hospital setting. It requires cardiac monitoring and is indicated in clients with profound hypotension (shock) or those who do not respond to intramuscular epinephrine and fluid resuscitation. Educational objective:The EpiPen is designed to be delivered through clothing in the mid-outer thigh area. The nurse should not delay anaphylaxis treatment by attempting to remove the client's clothing.

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? 1. A sitting position is assumed as the head is bowed slightly forward (37%) 2. The client points the spray tip toward the nasal septum during instillation (39%) 3. The nasal spray tip is inserted into the nostril as the other nostril is occluded (13%) 4. While administering the medication, the client inhales deeply through the nose (9%) Correct 2 39%Answered correctly

The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse teaches the client to: Assume a high Fowler's position with head slightly tilted forward (Option 1) Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger (Option 3) Point the nasal spray tip toward the side and away from the center of the nose (Option 2) Spray the medication into the nose while inhaling deeply (Option 4) Remove the nozzle from the nose and breathe through the mouth Repeat the above steps for the other nostril Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation Educational objective:The correct administration of nasal medication includes pointing the nasal spray tip toward the side and away from the center of the nose. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is preparing to infuse 2 units of packed red blood cells (PRBCs) to a client with a gastrointestinal bleed. Which actions should the nurse take? Select all that apply. 1. Assess client's vital signs 2. Infuse both units simultaneously 3. Obtain a Y tubing set and prime with normal saline (NS) 4. Plan to remain with client during the 1st 15 minutes of transfusion 5. Set infusion pump to deliver unit over 30 to 45 minutes 6. Spike filtered intravenous (IV) tubing with dextrose 5% water (D5W) Correct 63%Answered correctly 134

The procedure for safe blood administration includes the following: Obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 2 client identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time (Option 2). Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help. Use a Y tubing, prime with NS, and then clamp the NS side (Option 6). Spike the blood product, leaving the blood side of the Y tube open while keeping the saline side clamped for infusion. The saline is only used to prime the tubing and flush after the infusion. It does not infuse simultaneously. Set the infusion pump to deliver blood over 2-4 hours as prescribed (Option 5). Rapid infusion of the blood puts the client at greater risk for transfusion reaction and fluid volume overload. Remain with the client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion immediately if a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions. Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always take a final set of vital signs after the infusion is complete. On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through with NS. Return the blood bag with the attached set-up to the laboratory after completion or dispose of in accordance with hospital policy. Use new IV Y tubing set-up for the second unit of blood. Educational objective:Always verify blood products, type and crossmatch results, and client identifiers with another nurse prior to transfusion. Obtain vital signs before, during, and after blood administration. Use Y tubing primed with NS and an IV pump for administration. Watch for transfusion reaction and stop the transfusion immediately if a reaction occurs. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action? 1. Holds the package 6" (15 cm) above the sterile field and drops the sterile gauze onto the field (3%) 2. Opens the sterile gauze package with ungloved hands (13%) 3. Places the sterile gauze dressings within 2" (5 cm) from the edge of the sterile drape (7%) 4. Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago (75%) IncorrectCorrect answer 4 75%Answered correctly

The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions' policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened >24 hours ago. The general steps for preparing the sterile field for a wet-to-damp dressing change include: Perform hand hygiene. Open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze (Option 2). Hold the inverted opened gauze package 6" (15 cm) above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field (Option 1). Place the sterile dressings on the sterile field 2" (5 cm) from the edge; the 1" (2.5 cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces (Option 3). Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits). Educational objective:The general steps for preparing the sterile field for a wet-to-damp dressing change include: Perform hand hygiene. Open a sterile gauze package with ungloved hands. Hold the inverted opened gauze package 6" (15 cm) above the sterile field. Place the sterile gauze dressing more than 1" (2.5 cm) from the edge of the sterile field. Use sterile NSS from a recapped bottle that was opened <24 hours ago (if policy permits). Additional Information Safety and Infection Control NCSBN Client Need

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "Help me!" What action should the nurse take first? 1. Administer midazolam per protocol (20%) 2. Check the client's pulse oximeter (51%) 3. Give more morphine per protocol (7%) 4. Open the airway with head tilt-chin lift (19%) Correct 51%Answered correctly

When there is new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation (or blood glucose). The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy but responds to a voice command. (Option 1) Adequate oxygenation should be established first before administering additional benzodiazepine for sedation. (Option 3) Oxygenation should be assessed before administering additional narcotics for pain. Change in the level of consciousness (restlessness/agitation or lethargy/sedation) can be an indication of excess medication and should be assessed before administering additional drugs. (Option 4) If the client is speaking, the airway is open. Opening the airway would be an initial response if there is new onset of snoring respirations (the tongue falling back due to relaxation and blocking the airway). Normal respirations should be effortless and quiet. Educational objective:When new-onset restlessness occurs during procedural sedation, oxygenation should be considered first before administering additional medications. If the client is snoring, opening the airway should be considered.

he nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply. 1. Client coughs and gasps when swallowing food and liquids 2. Client is easily frustrated while attempting to speak 3. Client is unable to understand speech and is completely nonverbal 4. Client misunderstands and inappropriately responds to verbal instruction 5. Client's speech is limited to short phrases that require effort IncorrectCorrect answer 2,5 35%Answered correctly

Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the") (Option 5). Clients with Broca aphasia are aware of their deficits and can become frustrated easily (Option 2). In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment. (Option 1) Trouble swallowing, often identified by coughing and gasping when eating and drinking, is dysphagia, which is not related to Broca aphasia. (Option 3) Clients with damage to multiple language areas of the brain may develop global aphasia, resulting in the inability to read, write, or understand speech. This is the most severe form of aphasia. (Option 4) Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern. Educational objective:Damage to the frontal lobe of the brain may cause Broca (expressive) aphasia. Clients with this condition demonstrate effortful and sensible speech characterized by short, limited sentences, with retained ability to comprehend speech. This impairment often causes clients with Broca aphasia to be frustrated when speaking.

/The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the head of the bed 45 degrees (29%) 2. Holds the weight while the client is repositioned up in bed (41%) 3. Loosens the Velcro straps when the client reports that the boot is too tight (27%) 4. Provides the client with a fracture pan for elimination needs (1%) IncorrectCorrect answer 1 29%Answered correctly

Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Appropriate actions for a client in Buck's skin traction include: The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding (Option 1). Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes (Option 3). Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort (Option 4). Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity (Option 2). Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation. Educational objective:To maintain effective pull and avoid interrupting traction, weights should be free-hanging at all times. Proper body alignment should be maintained with the client supine or in semi-Fowler's position (maximum 30 degrees). The nurse should monitor the neurovascular status and skin integrity of the limb in traction. Additional Information Basic Care and Comfort NCSBN Client Need Copyright © UWorld. All rights reserved.

/A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? 1. Belief that the current surroundings are a racetrack (10%) 2. GCS score was "11" one hour ago (67%) 3. Recent vital signs show blood pressure of 120/80 mm Hg and pulse of 82/min (7%) 4. Reported allergy to penicillin and vancomycin (14%) Correct 2 67%Answered correctly

The GCS quantifies the level of consciousness in a client with acute brain injury by measuring eye opening (alertness), verbal response (orientation), and motor response (eg, obeying a command, frontal lobe function). The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise. (Option 1) Orientation to place is part of the GCS score (under best verbal). The total score and the negative trend are more indicative of the client's condition than any individual GCS component. (Option 3) This client's vital signs are within normal limits and are not significant. It would be more important to communicate if there is absence of Cushing's triad (bradycardia, bradypnea/Cheyne-Stokes, and widening pulse pressure) or to give a brief summary of overall vital signs (eg, "normal"); exact readings are accessible and can be recited if the oncoming nurse needs to know them. However, reporting the negative neurological trend in the GCS score is the priority. (Option 4) Although it is important to be aware of allergies, the oncoming nurse can find that information on the chart if these medications are ordered. The main concern is blunt head trauma and not infection; therefore, it is unlikely that the oncoming nurse will be required to know this information and need to administer antibiotics. Educational objective:It is a priority to report a negative neurological trend as evidenced by GCS score in a client with blunt head trauma. Additional Information Reduction of Risk Potential NCSBN Client Need

-Exhibit Intake and output record Emesis120 mL Wet diaper 150 g Wet diaper 252 g Wet diaper 346 g *Weight of a dry diaper = 30 g The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number. Click on the exhibit button for additional information. Answer: (mL) IncorrectCorrect answer 178 53%Answered correctly

To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr. Calculation: Urine output in diapers: Diaper 1: 50 − 30 = 20 gDiaper 2: 52 − 30 = 22 gDiaper 3: 46 − 30 = 16 g Total mg of urine: 58 g = 58 mL Total output: (Emesis) + (Urine) = 120 mL + 58 mL = 178 mL Educational objective:Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid.

A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (tPA). Which client statement would be most important to clarify before administering tPA? 1. "I can't believe this is happening right after my stomach surgery." (42%) 2. "I had a concussion after a car accident a year ago." (14%) 3. "I started noticing my right arm becoming weak approximately an hour ago." (18%) 4. "I stopped taking my warfarin 4 weeks ago." (24%) Correct 1 42%Answered correctly

Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke. It must be administered within a 3- to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA (Option 1). (Option 2) A client's history of stroke or head trauma in the last 3 months could exclude tPA use. (Option 3) The nurse should determine when the client first developed stroke symptoms. tPA can be administered if symptoms started within the last 3 to 4½ hours or based on facility guidelines. (Option 4) Current anticoagulant use may exclude a client from receiving tPA. The duration of action for warfarin is 2-5 days; this client can safely receive tPA as warfarin was discontinued 4 weeks ago. However, if pending coagulation studies drawn prior to tPA administration are elevated, the infusion may be discontinued. Educational objective:Tissue plasminogen activator (tPA) dissolves clots in an ischemic stroke and must be administered within a 3- to 4½-hour window from onset of symptoms. The nurse assesses for contraindications to tPA due to the risk of hemorrhage.

A client postoperative from a transurethral prostatectomy has a triple-lumen, indwelling urinary catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters (mL) should the nurse document as the net urine output for the shift? Record your answer using a whole number. Answer: (mL) Correct 74%Answered correctly

A transurethral prostatectomy (TURP) is a surgical prostate-removal procedure commonly performed for male clients with prostate cancer. Following a TURP, clients typically receive continuous bladder irrigation (CBI) with a sterile, isotonic solution (eg, normal saline) via indwelling urinary catheter. CBI prevents bladder obstruction by large blood clots in the bladder or urethra. Monitoring urine output in clients receiving CBI can be challenging because there is continuous output from the irrigation. To calculate net urine output, the nurse should subtract the irrigation input from the total catheter output. Use the following steps to calculate the net urinary output: Calculate the total volume of irrigation solution infused into the bladder Irrigation infusion rate×hours infused=total irrigation volumeIrrigation infusion rate×hours infused=total irrigation volume OR (175mLhr)(8 hr )=1400 mL irrigation volume175mLhr8 hr =1400 mL irrigation volume Calculate the net urine output Catheter output−irrigation volume=net urine outputCatheter output-irrigation volume=net urine output OR 2300 mL catheter output−1400 mL irrigation volume=900 mL net urine output2300 mL catheter output-1400 mL irrigation volume=900 mL net urine output Educational objective:Continuous bladder irrigation is a therapy commonly used to prevent bladder obstruction by blood clots after a prostatectomy. To calculate the net urine output in a client with continuous bladder irrigation, the nurse should subtract the total amount of irrigating solution infused from the total amount of catheter output. Additional Information Basic Care and Comfort NCSBN Client Need

A client with ascites had 5400 mL of fluid removed during paracentesis. The health care provider prescribes 8 g of albumin IV per 1000 mL of fluid removed. If the albumin is supplied as 25 g in 100-mL bottles, how many mL will the nurse administer? Record your answer using one decimal place. Answer: (mL) IncorrectCorrect answer 172.8 49%Answered correctly

Albumin may be given after paracentesis to prevent volume depletion in a client with cirrhotic ascites. Using dimensional analysis, use the following steps to calculate the volume of albumin per dose in milliliters: Identify the prescribed, available, and required medication information Prescribed:8 g albuminL removed peritoneal fluid|dose Available:25 g albumin100 mL Required:mLdosePrescribed:8 g albuminL removed peritoneal fluiddose Available:25 g albumin100 mL Required:mLdose Convert prescription to the volume needed for administration Prescription×available data=mL/dosePrescription×available data=mL/dose OR (g albuminL peritoneal fluid|dose)(L peritoneal fluidmL peritoneal fluid)(mL peritoneal fluid )(mLg albumin)=mL albumindoseg albuminL peritoneal fluiddoseL peritoneal fluidmL peritoneal fluidmL peritoneal fluid mLg albumin=mL albumindose OR ⎛⎝8 g albuminL peritoneal fluid|dose⎞⎠⎛⎝L peritoneal fluid1000 mL peritoneal fluid⎞⎠⎛⎝5400 mL peritoneal fluid ⎞⎠⎛⎝100 mL25 g albumin⎞⎠8 g albuminL peritoneal fluiddoseL peritoneal fluid1000 mL peritoneal fluid5400 mL peritoneal fluid 100 mL25 g albumin =172.8 mL albumindose=172.8 mL albumindose Educational objective:Albumin may be given after paracentesis to prevent volume depletion. To calculate the volume per dose of albumin, the nurse should first identify the prescribed dose (eg, 8 g/L peritoneal fluid) and available medication (eg, 25 g/100 mL) and then convert to volume in milliliters per dose (eg, 172.8 mL). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. 1. Client admitted with white blood cell count of 28,000 mm3 (28.0 × 109/L) and dies from sepsis 2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 3. Client refuses pneumonia vaccination and contracts pneumonia 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 5. Provider was not notified of client's positive blood culture results Correct 59%Answered correctly 245

An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 2 is a treatment error. Option 4 is a communication error as well as inadequate follow-up. Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals. (Option 1) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option 3) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship. Educational objective:Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems. Additional Information Safety and Infection Control NCSBN Client Need

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese and their English proficiency is very limited. What is the best approach for the nurse to use when instructing the parents on how to care for the child at home? 1. Demonstrate the procedure using simple English phrases (13%) 2. Give the parents written instructions with picture illustrations (6%) 3. Tell the parents to have a friend or relative come in to translate (2%) 4. Use an interpreter via the telephone interpretation service (77%) IncorrectCorrect answer 4 77%Answered correctly

Effective teaching can be accomplished only with effective communication, which can be compromised by language barriers, cultural differences, and low health literacy. When an interpreter is necessary, using a translator who is skilled in medical terminology is the best approach to provide accurate information (Option 4). Hearing instructions and information in one's primary language decreases the risk of adverse clinical consequences. When a professional medical translator is unavailable, language lines, telephone systems, and remote video interpreting services can be used. Translation by family members and friends should only be used as a last resort and only with the permission of the client, especially in situations where sensitive information needs to be communicated (Option 3). Children should not be used as translators except in an emergency situation when there are no other options. (Option 1) This client's parents have very limited English language proficiency; this approach will not be effective in providing instructions about the child's care at home. (Option 2) Providing written materials without verbal teaching does not give the client (or the client's legal guardian) the chance to ask questions, nor does it give the nurse the opportunity to assess the client's understanding of the given information. Educational objective:When language is a barrier to effective communication and teaching, the nurse should use a trained medical interpreter for translation purposes. Additional Information Management of Care NCSBN Client Need

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply. 1. "I can mix the medication in a bowl of my child's favorite cereal." 2. "I should give another dose if my child vomits after taking the medication." 3. "I should measure liquid medications using an oral syringe." 4. "I will encourage my child to help me as I prepare the medication." 5. "I will place my child in time-out if the medication is refused." Correct 63%Answered correctly

For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses (Option 3). Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control (Option 4). (Option 1) The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. (Option 2) Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. (Option 5) Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior. Educational objective:For pediatric clients, liquid medication should be measured with an oral syringe for accuracy. To prevent inaccurate dosing, parents should not mix medications with meals or give additional medication if vomiting occurs. To promote initiative and cooperation from preschool children (age 3-6), parents should provide positive reinforcement (eg, stickers) and allow children to participate in self-administration. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need Copyright © UWorld. All rights reserved.

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? 1. Assist the client in ambulating to the bathroom (23%) 2. Dim the room lights (11%) 3. Place the bed in low position with all side rails up (62%) 4. Turn off the television (2%) Correct 3 62%Answered correctly

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating (Option 1), placing the bed in low position, and raising side rails. However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient (Option 3). (Options 2 and 4) Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television and not looking at flickering lights. Educational objective:Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights. Additional Information Safety and Infection Control NCSBN Client Need

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. 1. Age of 50 2. Diagnosis of ovarian cancer 3. Lying pulse 80/min, standing pulse 110/min 4. Osteoarthritis of knees 5. Takes carbidopa/levodopa 6. Uses a cane to ambulate Correct 3456

Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls (Option 3). Osteoarthritis of the knees limits joint mobility, increasing the risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat or bed height are factors that increase this risk (Option 4). Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls (Option 5). The use of an ambulatory aid such as a cane, walker, or crutches indicates a balance/gait problem and places the client at higher risk of falling (Option 6). (Option 1) Fall risk does not increase until age >65-75. (Option 2) Ovarian cancer does not inherently affect cognition and neurologic or muscular function and is therefore not a risk for falling. Advanced disease with weakness, perhaps from the treatment, could constitute a risk for a fall. Educational objective:Fall risks include using assistive ambulatory devices, orthostasis, taking sedatives or antiparkinson medications, or being age >65-70. Additional Information Safety and Infection Control NCSBN Client Need

The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention? 1. Monitor gag and swallowing reflexes closely (19%) 2. Provide for client assistance with ambulation (56%) 3. Provide sensory stimulation (7%) 4. Speak at a normal volume while facing the client directly (16%) Correct 56%Answered correctly 2

The Romberg test, part of a focused neurologic examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation. (Option 1) Damage to the glossopharyngeal and vagus nerves (cranial nerves IX and X) would cause problems with swallowing and the gag reflex. (Option 3) Providing for sensory stimulation is important in many disorders of the neurologic system. However, this would not be needed for a client with a positive Romberg test. (Option 4) Speaking at a normal voice while facing a client directly is a measure used for those with hearing loss. Educational objective:A client with a positive Romberg test has a loss of sense of self in space and needs assistance with ambulation to prevent injury and provide safety.

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. 1. Ask a family member about the client's preferences for room arrangement 2. Offer the client an elbow to hold, and walk a half-step ahead for guidance 3. Say "goodbye" when leaving the room to help orient the client 4. Speak slowly and slightly louder so the client can understand 5. Use a clock-face pattern to explain food arrangement on the client's meal tray IncorrectCorrect answer 2,3,5 53%Answered correctly

The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following: Offer the client an elbow for guidance while walking slightly ahead and describing the environment (Option 2). Announce room entry and exit to orient and avoid startling the client (Option 3). Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily (Option 5). Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. Orient the client to the room and maintain this orientation for safety. (Option 1) Asking the caregiver or family member about the client's personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement. (Option 4) The nurse should speak to the client in a normal tone of voice to facilitate communication. Speaking slowly and slightly louder would be useful for a client with a hearing deficit. Educational objective:When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences. Additional Information Physiological Adaptation NCSBN Client Need

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following? 1. Allows the client to sip the medication from a cup (0%) 2. Expels the medication from a dropper onto the back of the tongue (7%) 3. Mixes the medication in the infant's bottle of formula (0%) 4. Using a syringe, administers the medication in small amounts into the back of the cheek (91%) Correct

Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed. (Option 1) Although cup feeding may be a method used to feed infants in specific cases, medication administration requires a more accurate measurement. A syringe can provide an accurate measurement and decrease the risk of waste due to the infant's spitting or drooling. (Option 2) Infants have a decreased gag reflex. Dispensing medication onto the back of the tongue would increase the risk for aspiration of the medication. (Option 3) It is very important for the infant to receive the entire dose of the medication. Medication should never be mixed in a bottle of formula as the infant may not consume the entire amount. Educational objective:The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration. Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount of medication is consumed. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need Copyright © UWorld. All rights reserved.

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? 1. Facilitate immediate removal of people from the area (78%) 2. Inform the client that the client cannot act that way (9%) 3. Pull the fire alarm to get additional immediate help (6%) 4. State that the nurse can see the client is upset (4%) Correct 1

When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. (Option 2) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. (Option 3) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. (Option 4) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective:Safety is the priority when violence occurs. People should leave the area and call security immediately. Additional Information Safety and Infection Control NCSBN Client Need

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication. What is the most appropriate action for the RN to take? 1. Administer the hydromorphone (17%) 2. Ask the licensed practical nurse to administer the medication (2%) 3. Ask the unlicensed assistive personnel to take repeat vital signs (22%) 4. Contact the health care provider (57%) IncorrectCorrect answer 4 57%Answered correctly

A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication. (Option 1) A STAT medication dose was administered and cannot be repeated without a new prescription. (Option 2) In most states, the registered nurse (RN) cannot delegate the administration of IV opioids to the licensed practical nurse, and it cannot be administered without a new prescription. (Option 3) The RN can delegate repeat vital sign checks to the unlicensed assistive personnel, but it is not the most appropriate action. Educational objective:A STAT order indicates that a medication is to be given immediately and only once. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit? 1. The elbow is flexed at 90 degrees (15%) 2. The hand is held slightly below elbow level (63%) 3. The sling ends in the middle of the palm with fingers visible (12%) 4. The sling supports the wrist (7%) IncorrectCorrect answer 2 63%Answered correctly

A sling is used to support the shoulder after a fracture, dislocation, injury, or surgery. Commercially made slings are used almost exclusively. They have a sleeve that fits around the injured extremity and extends above the elbow and adjustable straps to provide a snug and comfortable fit around the waist and neck. To prevent injury and provide proper support of the affected extremity, the nurse should evaluate the proper fit of the sling by assessing for the following factors: Elbow is flexed at 90 degrees to support the forearm, prevent swelling, and relieve shoulder pressure (Option 1) Hand is held slightly above the level of the elbow, through adjustment of the neck strap, to prevent venous pooling and edema (Option 2) Bottom of the sling ends in the middle of the palm with the fingers visible, to be able to assess circulation, sensation, and movement (Option 3) Sling supports the wrist joint with the thumb facing upward or inward toward the body, to maintain proper alignment (Option 4) Skin irritation, which can occur under the sling and around the neck if the strap is too tight Educational objective:To ensure proper shoulder sling fit, the nurse should assess for the following: Elbow is flexed at 90 degrees Hand is held slightly above the level of the elbow Bottom of the sling ends in the middle of the palm with the fingers visible Sling supports the wrist joint Additional Information Basic Care and Comfort NCSBN Client Need

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls? 1. Have a respite caregiver come once a week to stay with the client so the spouse can go shopping (0%) 2. Purchase a walker for the client to use when ambulating around the home (4%) 3. Remove all area rugs and install grab bars in the bathroom (91%) 4. Take the client for an annual eye exam and new glasses (2%) Correct 91%Answered correctly

All of the choices are appropriate options to reduce falls in the home, but the one with the greatest impact is the removal of all area rugs and installation of grab bars in the bathroom. Area rugs can still cause falls for the client with a walker, with new glasses, and with someone present. In addition, many falls occur in the bathroom while toileting and bathing, making grab bars highly beneficial. (Option 1) Not leaving the client alone is preferable and could decrease the incidence of falls while the spouse is away. However, it is less effective than the removal of area rugs and installation of grab bars in the bathroom. (Option 2) A walker would be beneficial for this client but could get caught on an area rug. (Option 4) Poor eyesight can contribute to falls, but the removal of rugs and installation of grab bars will have a greater impact. Educational objective:The nurse should educate the client and family about removing area rugs and installing grab bars in the bathroom to reduce the risk of falls in the home. Additional Information Safety and Infection Control NCSBN Client Need

The nurse is educating a client recently diagnosed with anaphylactic allergy to latex. Which statement made by the client indicates that the client understood the condition correctly? 1. "I do not need to worry about my allergy when I am outside of a health care environment." (0%) 2. "I just need to check labels to ensure products do not contain latex and I will be fine." (18%) 3. "I should always carry my Epi-pen in case I have difficulty breathing." (78%) 4. "I should take better care of myself and eat healthy foods like bananas and chestnuts." (2%) Correct 3 78%Answered correctly

Anaphylactic shock is a medical emergency and the most severe form of an allergic reaction. Hives, itching, or a skin rash may or may not appear before rapid swelling of the mouth and throat (angioedema) makes breathing difficult or impossible within a span of minutes. Quick application of an epinephrine auto-injector (Epi-pen) into the thigh is the only acceptable option for treating anaphylactic shock. The intramuscular adrenaline injection immediately counteracts the life-threatening swelling, hypotension, and vasodilation that characterize anaphylaxis. Diphenhydramine (Benadryl) is also given to treat any associated rash or itching (hives, wheals, urticaria) but is not sufficient as a monotherapy. (Option 1) Latex products are everywhere. Clients and staff members should be educated and reminded about exposure to plastic products, condoms, and all other medical products containing latex. (Option 2) Numerous products may contain trace amounts of latex; this crucial information may be omitted on the labels. (Option 4) Bananas, avocados, chestnuts, and kiwifruit have been classified as having high-risk potential for cross-reaction allergy development. Clients should be advised to watch for potential allergic reactions due to a cross-allergen. Educational objective:Anaphylaxis is a medical emergency, and any client with a history of severe allergic reaction (sudden blotchy skin rash or swelling of the lips and mouth) should always carry an EpiPen. Epinephrine injection is the only option for treating anaphylaxis. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply. 1. Fold tube in half and mark at the halfway point 2. Extend tape measure from naris to stomach 3. Measure from tip of nose to earlobe to xiphoid process 4. Place a small piece of tape at the point of measurement 5. Use rubber clamp after measuring to mark the point of measurement Correct 64%Answered correctly

Because distance from the nares to the stomach varies with each client, it is important to measure and mark the NG tube prior to insertion to ensure its correct placement in the stomach. The Traditional Method is most commonly used for large-bore NG tube placement. Traditional Method: Using the end of the tube that will eventually rest in the stomach, measure from the tip of the nose, extend the tube to the earlobe and then down to the xiphoid process (Options 1, 2, and 3). Mark the distance with a small piece of tape that can be easily removed (Options 4 and 5). Educational objective:Ensure proper measurement prior to inserting a large-bore NG tube by measuring from the tip of the nose, extending the tube to the earlobe, and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed. Additional Information Reduction of Risk Potential NCSBN Client Need

/A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? 1. "I should leave the harness on during diaper changes." (14%) 2. "I will adjust the harness straps every 3-5 days." (67%) 3. "I will inspect the skin under the straps 2-3 times daily." (5%) 4. "The harness should keep my baby's legs bent and spread apart." (12%) IncorrectCorrect answer 2 67%Answered correctly

DDH is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods such as the Pavlik harness are most successful when initiated during the first 6 months of life. After this time, surgery is generally required. The Pavlik harness is the most common tool used to treat early DDH. It maintains the infant's hips in a slightly flexed and abducted position (ie, legs bent and spread apart), allowing for proper hip development (Option 4). Pavlik harnesses are typically worn for 3-5 months or until the hip joint is stable. The straps are assessed every 1-2 weeks by the health care provider (HCP) and adjusted as necessary to account for infant growth. However, parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip (Option 2). Care of the infant wearing a Pavlik harness includes the following: Assess skin 2-3 times daily for redness or breakdown under the straps (Option 3) Dress the child in a shirt and knee socks under the harness to protect the skin Apply diapers underneath the straps to keep the harness clean and dry Leave the harness on at all times, unless otherwise indicated by the HCP (Option 1) Educational objective:The Pavlik harness is used in the treatment of DDH; it maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Strap adjustments should be performed by the HCP to allow for proper positioning and avoid nerve or vascular damage. Additional Information Reduction of Risk Potential NCSBN Client Need

The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn? 1. Choose an infant carrier with a narrow seat (9%) 2. Place 2 diapers on the infant at all times (4%) 3. Swaddle the infant with hips flexed and abducted (65%) 4. Use an infant swing that keeps both legs straight (20%) Correct 3 65%Answered correctly

Developmental dysplasia of the hip (DDH) is a range of various hip abnormalities that may be present at birth or develop during the first few years of life. There are many risk factors, including breech birth, large infant size, and family history. Although all cases cannot be prevented, several interventions have been shown to help reduce the risk of DDH development. Key measures include: Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement (Option 3) Choosing infant carriers or car seats with wide bases - infant seats should allow for proper hip positioning in an abducted manner Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together (Option 1) Narrow infant carriers prevent proper hip abduction, putting a strain on the hip ligaments and possibly leading to DDH. (Option 2) Double/triple diapering is no longer recommended as a preventive measure for DDH. This practice can cause extension of the hip, leading to abnormal development. (Option 4) Infant swings, bouncers, wraps, and other similar items can cause the legs to be positioned straight and together, which can increase the risk for DDH. Educational objective:DDH is a range of hip abnormalities that may be present at birth or develop in early childhood. Preventive measures include proper swaddling with hips bent up and out, and avoiding seats or carriers that hold the legs straight and together. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse is teaching a client to self-administer enoxaparin subcutaneously for the outpatient treatment of deep-vein thrombosis (DVT). The client points to the site of planned injection. Which site indicates that the client understands the instructions? Correct 47%Answered correctly 22 secs Time Spent 04/16/2020Last Updated Explanation

Enoxaparin is a low-molecular-weight heparin used in the prevention and treatment of DVT. It is administered as a deep subcutaneous injection and is usually given in the abdomen. Clients or family members may be taught how to administer the injections. The injection should be made on the right or left side of the abdomen, at least 2 in from the umbilicus. An inch of skin should be pinched up and the injection made into the fold of skin with the needle inserted at a 90-degree angle. Educational objective:The nurse can teach a client or caregiver to inject subcutaneous enoxaparin. The appropriate site of injection is on the right or left side of the abdomen at least 2 in from the umbilicus.

The nurse inserts a small-bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? 1. Crush and administer medications (0%) 2. Dilute enteral formula as prescribed (0%) 3. Flush the tube with 30 mL of water (6%) 4. Verify tube placement with an x-ray (92%) Correct 92%Answered correctly 4

Enteral feedings are given to provide nutrition to clients who are unable to take in nutrients by mouth. Placement verification is imperative prior to initiating enteral feedings to prevent complications such as aspiration. Lung aspiration can lead to pneumonia, acute respiratory distress syndrome, and abscess formation. Methods to verify the tube placement include the following: Imaging - visualization of tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings Gastric content pH testing - although testing the pH of aspirated contents is an evidence-based method, it is typically used to assess for displacement after initial x-ray verification. It can also be used to test the position of the tube prior to each feed as the frequent x-rays expose the client to radiation. Gastric pH is usually acidic (<5) because of acid secretion. pH ≥6 indicates bronchial secretions and incorrect placement. Air auscultation - verification by auscultating air is not an evidence-based method for placement verification After placement is verified, the nurse may flush the tube with water (Option 3), administer prescribed medications (Option 1), flush the tube again, and then prepare and deliver the enteral feeding (Option 2). Educational objective:Visualization of NG tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings. Verification by auscultating air is not an evidence-based method of placement verification. Additional Information Reduction of Risk Potential NCSBN Client Need

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate order. All options must be used. Unordered Options 1. Assess for presence of adequate pulse 2. Complete an incident report 3. Get help and move the client to the bed 4. Inspect the client for injuries 5. Notify the client's health care provider (HCP) Your Response/ Correct Response 1. Assess for presence of adequate pulse 4. Inspect the client for injuries 3. Get help and move the client to the bed 5. Notify the client's health care provider (HCP) 2. Complete an incident report Correct 57%Answered correctly

Establishing the presence of the client's ABCs/physiological stability is first step as the client could have lost consciousness or had a cardiovascular event that caused the fall. The need for immediate resuscitation should be assessed first (Option 1). The presence of gross injuries should be established prior to moving the client so that appropriate immobilization can be taken. If awake, clients should be asked what body parts were struck, how they fell, if they hit their head, and what currently hurts. The spine should be immobilized and a cervical collar used for any neck pain (Option 4). Additional help should be obtained to move the client to proper position at the site and avoid injury to the staff. After emergent stabilization, the client should be returned to bed for vital signs and further assessment (Option 3). The HCP should be notified of the incident and assessment findings (Option 5). Documentation should be made in the client's chart and an incident report filed for risk management (Option 2). Educational objective:The appropriate order of actions when a client is found on the floor is assessment of stability, assessment of injuries, moving the client, notifications, and documentation. Additional Information Safety and Infection Control

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply. 1. Combine all medications and administer together 2. Crush each medication separately before administration 3. Determine if the medications are available in liquid form 4. Flush the tube before and after medication administration 5. Mix medications with enteral feeding formula before administration Correct 234

Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form because liquid medications are less likely to clog the tube (Option 3). Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical reactions) between medications or interference with absorption (Option 2). In addition, a feeding tube should be flushed before and after each medication is given to avoid potential drug interactions and ensure tube patency (Option 4). (Option 1) When using a feeding tube, each medication should be administered individually to prevent interactions between medications. (Option 5) Medications mixed with enteral feedings may form a thick consistency and clog the tube. Educational objective:When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions. Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first? 1. Client who sustained a closed, incomplete ulnar fracture while playing sports (2%) 2. Client with bilateral metacarpal fractures after falling out of bed (1%) 3. Client with multiple myeloma who has a vertebral fracture and aching back pain (30%) 4. Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation (65%) Correct 4 65%Answered correctly

Joint dislocations may become orthopedic emergencies because articular bone may compress surrounding vasculature, causing limb-threatening distal ischemia (Option 4). When a joint is dislocated, the articular tissues, blood vessels, and nerves are often traumatized by stretching. Signs of joint dislocation include pain, deformity, decreased range of motion, and extremity paresthesia. The nurse should frequently assess neurovascular status and provide analgesics until the dislocation can be reduced and immobilized. (Option 1) In incomplete greenstick fractures, the bone bends and cracks but remains in one piece. These fractures are most common in children, as their bones are soft and flexible. The nurse should provide analgesics and offer reassurance; however, the client with neurovascular impairment should be assessed first. (Option 2) Fractures of the bones of the hand (ie, metacarpals) are common in fall injuries, when the brunt of the fall is borne against the hands and fingers, resulting in hyperflexion or hyperextension. The nurse should provide analgesics; however, the client with neurovascular impairment should be assessed first. (Option 3) Pathologic vertebral compression fractures and pain are expected in clients with multiple myeloma. These clients commonly experience fractures of the vertebral column and spinal processes as the cancer weakens and decalcifies the vertebrae. This client should be evaluated next to rule out spinal cord involvement. Educational objective:Joint dislocations may constitute an orthopedic emergency. Because articular tissues, blood vessels, and nerves are stretched and compressed, neurovascular compromise may occur. Prolonged disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity. Additional Information Management of Care NCSBN Client Need Copyright

A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision. The client's spouse arrives and demands to be with the client. Which action should the nurse take? 1. Allow the spouse in the room, out of the way of care providers, and explain the events occurring with the client (59%) 2. Assist the spouse in observing outside the room through a window and have a chaplain explain the care being provided (1%) 3. Explain the client's condition, but inform the spouse that entering the room is not allowed until the client is stabilized (26%) 4. Inform the spouse that being in the room during procedures is unsafe for the client, and escort the spouse to the waiting area (12%) IncorrectCorrect answer 1 59%Answered correctly

Family member presence at bedside during invasive procedures or resuscitation efforts is an important component of psychosocial care for the client and family. When a client's support person is allowed to be present at bedside to witness care during acute events, the support person is often able to better understand the client's condition and may have decreased anxiety and better coping with unexpected or poor outcomes (eg, cardiac arrest, death). Therefore, the nurse should, when possible, support and facilitate family presence in the room and provide information about the events that are occurring (Option 1). (Option 2) Requiring family members to watch through the window, rather than at the bedside, may increase their stress and impair coping. Although chaplains may assist with an individual's emotional or spiritual needs, chaplains are not trained to provide information related to medical or surgical interventions. (Option 3) Denying the support person's presence in the room may be appropriate in certain situations (eg, uncontrollable emotional outbursts, interference with care, risks to support person health/safety). However, the nurse should provide the option of being present in the room when possible. (Option 4) Although some health care professionals express concern that support person presence may negatively impact client outcomes, there is no evidence for this claim. Educational objective:The presence of family members during invasive procedures supports the psychosocial needs of the client and family. The nurse should reinforce family presence at bedside and provide information to the client's support person about the care being provided. Additional Information Management of Care NCSBN Client Need

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply. 1. Achieve and maintain a healthy weight 2. Avoid foods containing protein 3. Drink plenty of fluids 4. Increase meat intake 5. Limit alcohol consumption IncorrectCorrect answer 1,3,5 63%Answered correctly

Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications (Option 1). Suggested modifications include: Increasing fluid intake (2 L/day) to help eliminate excess uric acid (Option 3) Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) Limiting alcohol intake, especially beer (Option 5) Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates (Option 2) It is unpalatable and impractical to avoid all foods containing protein. The risk of developing gout increases with high dietary purine intake but not necessarily with protein intake. Low-fat dairy products are good sources of protein that are associated with a reduced risk of gout. (Option 4) Increasing intake of meat, especially organ meats, will not prevent future gout attacks but may precipitate them. Educational objective:Weight loss and dietary modifications may reduce the frequency of acute episodes of gout. These strategies include increasing fluids, limiting daily alcohol consumption, and avoiding organ meats and seafood to reduce purine load. Additional Information Physiological Adaptation NCSBN Client Need

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? 1. Auscultate breath sounds to assess for crackles (49%) 2. Monitor for >50 mL/hr urine output (28%) 3. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 (13%) 4. Press over the tibia to assess for pitting edema (8%) IncorrectCorrect answer 1 49%Answered correctly

Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function. (Option 2) Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication. (Option 3) Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of treatment. (Option 4) The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area. Educational objective:Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.

The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met? 1. Chart audits found clients' self-reported pain scores improved by 10% (63%) 2. Number of narcotics used on the unit increased by 20% (2%) 3. Positive comments on returned client satisfaction surveys increased by 30% (28%) 4. Survey found that 90% of the nurses believed clients had better pain control (6%) Correct 63%Answered correctly 1

Measurements should be objective, rather than subjective. Evidence-based criteria should be used, if applicable. These survey results are objective, retrospective measurements of a positive change. (Option 2) This increase in use could be attributed to many other factors, including difference in the number or type of clients on the unit and theft of the narcotics. In addition, clients may obtain pain relief by alternate means. (Option 3) These are subjective criteria. It is possible to consider satisfaction as an outcome, but there is no indication in the option that the percentage of returned surveys is a satisfactory amount. There is no indication whether the positive comments are about pain relief or other aspects of care. There is no indication if these clients had pain relief as part of their nursing needs. (Option 4) This is a subjective perception on the part of the nurses that may or may not be accurate. Educational objective:The outcomes of a quality improvement program should be objective and measureable. Additional Information Management of Care NCSBN Client Need

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time? 1. Evening primrose (14%) 2. Ginseng (9%) 3. Melatonin (70%) 4. St. John's wort (6%) Correct 3 70%Answered correctly

Melatonin supplements are thought to help the body adjust quickly to new surroundings and time zones (jet lag). Most practitioners agree that the lowest possible dose should be used and should be taken only for a short time. There are no long-term studies on the safety of melatonin. Higher doses may cause side effects such as vivid dreams and nightmares. Research suggests that taking melatonin once a person has reached the travel destination is sufficient and that starting it prior to or during air travel may actually slow the recovery of jet lag, energy, and alertness. (Option 1) Evening primrose may be used for eczema or skin irritations. (Option 2) Ginseng is used to promote mental alertness and enhance the immune system. (Option 4) St. John's wort is used for treatment of depression. It has many interactions with other prescription medications. Educational objective:Short-term use of low-dose melatonin may be considered to treat jet lag and fatigue from traveling across time zones.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? 1. Ask the health care provider to prescribe a different calcium channel blocker (13%) 2. Consult with the pharmacist to see if an alternate form of the drug is available (76%) 3. Open the capsule and sprinkle the medication in a cup of applesauce (6%) 4. Warn the client about the dangers of uncontrolled hypertension (3%) Correct 2 76%Answered correctly

Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill. (Option 1) It is not necessary to ask the health care provider to prescribe a different medication unless the religious dietary laws cannot be relaxed or the client desires a kosher alternate form of diltiazem (Cardizem) that is unavailable. (Option 3) Extended-release capsules should be swallowed whole. Crushing or breaking the capsule may cause uncontrolled delivery of the medication and increase the risk of overdose or other serious adverse effects. (Option 4) Although it is important to perform client teaching, the nurse should first assess the reason for this client's nonadherence to the prescribed regimen. Additionally, the nurse should avoid using scare tactics in client teaching. Educational objective:Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill. Additional Information Psychosocial Integrity NCSBN Client Need Copyright © UWorld. All rights reserved.

During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? 1. Client reports burning during injection into the IV line (4%) 2. Client reports dizziness when getting up to use the bathroom (2%) 3. Client's blood pressure is 106/68 mm Hg (2%) 4. Client's respiratory rate is 11/min (90%) Correct 4 90%Answered correctly

Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. (Option 1) Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. (Option 2) The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. (Option 3) Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored. This blood pressure reading is not severely low and is not a priority over the respiratory depression. Educational objective:Morphine administration can cause respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is <12/min. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action? 1. Check the urethral catheter and drainage tubing (82%) 2. Irrigate the catheter with 30 mL of sterile normal saline (3%) 3. Notify the health care provider (1%) 4. Remove and reinsert the next-larger-size catheter (12%) Correct 82%Answered correctly 1

Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size can cause leakage of urine from the insertion site of an indwelling urinary catheter. The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing (Option 1). These interventions may alleviate obstruction: Remove kinking or compression of the catheter or tubing. Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag. If these interventions fail, the nurse should then notify the health care provider (HCP) (Option 3). (Option 2) Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder. (Option 4) The client has the recommended size of catheter and balloon for an adult male. The HCP may prescribe removal and reinsertion of a different-size catheter if other measures fail to relieve obstruction. Educational objective:If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse should assess for obstruction, kinking, or compression of the catheter or drainage tubing; bladder spasms; and improper catheter size. Additional Information Reduction of Risk Potential NCSBN Client Need

The graduate nurse (GN) is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the GN causes the nurse preceptor to intervene? 1. Measures the oropharyngeal airway against the cheek and jaw angle before insertion (30%) 2. Rotates the device tip downward once it reaches the soft palate (21%) 3. Suctions secretions from the mouth and pharynx prior to device insertion (13%) 4. Tapes the external portion of the inserted oropharyngeal airway to the client's cheek (35%) IncorrectCorrect answer 4 35%Answered correctly

Oropharyngeal airways (OPAs) are temporary artificial airway devices used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client often coughs or gags, indicating a need to remove the OPA; clients may also independently remove or expel it. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth because an obstructed (eg, taped) OPA may cause choking and aspiration (Option 4). (Option 1) Appropriate OPA size should be measured prior to insertion because an inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the flange next to the client's cheek. With correct sizing, the OPA curve reaches the jaw angle. (Options 2 and 3) When inserting an OPA, the nurse should initially suction the upper airway to remove secretions. The OPA is then inserted with the distal end pointing upward toward the roof of the mouth to prevent tongue displacement and tracheal obstruction. Once the OPA reaches the soft palate, the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency. Educational objective:An oropharyngeal airway (OPA) is a temporary artificial airway used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. An OPA should never be taped in place because of the risk of choking and aspiration when the client awakens.

The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D intake. Which lunch food is the best choice? 1. Broiled chicken breast (14%) 2. Canned sardines (42%) 3. Egg white omelet (29%) 4. Peanut butter (14%) Correct 2 42%Answered correctly

Osteopenia is more than normal bone loss for the client's age and sex. Adequate dietary intake of calcium and vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to osteoporosis. Milk and milk products are the best sources of calcium. However, other food sources are available for individuals who are lactose intolerant. They include some fish (eg, sardines, salmon, trout), tofu, some green vegetables (eg, spinach, kale, broccoli), and almonds. Good food sources of vitamin D include egg yolks and oily fish (eg, salmon, sardines, tuna). Canned sardines are the best choice as sardines are an excellent source of calcium and vitamin D (Option 2). (Options 1, 3, and 4) These foods have only small amounts of calcium per serving and no vitamin D. Educational objective:Sardines are a good alternate dietary source of both calcium and vitamin D for individuals who are lactose intolerant.

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? 1. "I am feeling unsteady when I walk." (30%) 2. "I am getting up to urinate about 4 times during the night." (4%) 3. "I have a metallic taste in my mouth when I eat." (25%) 4. "My gums are getting so puffy and red." (40%) IncorrectCorrect answer 1 30%Answered correctly

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. (Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. (Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. (Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms. Educational objective:Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider? 1. The client ate a full breakfast that morning (0%) 2. The client has an implantable cardioverter defibrillator (ICD) (92%) 3. The client is allergic to povidone-iodine (6%) 4. The client took all prescribed cardiac medications before arriving (0%) Correct 2

Radio waves and a magnetic field are used to view soft tissue during MRI. This test is especially useful in diagnosing tumors, disc disease, avascular necrosis, ligament tears, cartilage tears, and osteomyelitis. MRIs can have open or closed chambers. The client should be advised that the procedure is painless but the machine will make loud tapping noises and may cause claustrophobia in some clients inside a closed chamber. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function. (Options 1 and 4) MRI is a noninvasive test that does not require anesthesia. The client is not required to have nothing by mouth and can take medications as normally indicated. (Option 3) No povidone-iodine (Betadine) is used during an MRI; gadolinium contrast is used. Educational objective:MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of an MRI can damage implantable devices or interfere with their function.

The nurse provides discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching? 1. "I have to give myself shots in the belly because my spouse is afraid of needles!" (31%) 2. "I have to use a walker because I can't bear any weight on this knee yet." (52%) 3. "I will call my health care provider if I get short of breath or sore or swollen below my knee." (5%) 4. "The raised toilet seat makes it easier for me to get on and off the toilet by myself." (10%) IncorrectCorrect answer 2 52%Answered correctly

The average hospital length of stay following total knee arthroplasty is 3-5 days. After the surgery, immediate initiation of physical therapy is a priority. An isometric quadriceps setting is initiated on the 1st postoperative day. The client should be fully weight bearing by discharge. Clients use an assistive device (eg, walker, crutches, cane, grab bar, hand rails) to help them sit, rise safely from a sitting to a standing position, and to negotiate steps (Option 2). A knee immobilizer is used to maintain extension during ambulation and at rest for about 4 weeks. (Options 1 and 3) Venous thromboembolism (eg, deep vein thrombosis [DVT], pulmonary embolism [PE]) following knee arthroplasty is a major preventable complication. Anticoagulation with oral anticoagulants (rivaroxaban) or enoxaparin (Lovenox) injections is therefore prescribed for at least 2 weeks after surgery. Ankle exercises, anti-embolic stockings, and frequent mobilization are prescribed as well. Clients are taught to recognize the warning signs and symptoms of DVT (eg, new swelling, tenderness, pain below the knee) or PE (eg, shortness of breath, pleuritic chest pain). (Option 4) A raised toilet seat facilitates sitting on and rising from the toilet without over-bending the knee. Assistive devices, such as a long-handled shoehorn, shower chair, or grab bar, are also helpful for client safety at home. Educational objective:A client with total knee arthroplasty needs assistive devices (eg, walker, crutches) and a knee immobilizer to help ambulation; the client should be fully weight bearing by discharge. Prophylactic anticoagulation and recognition of postoperative complications (eg, DVT, PE) are also important.

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? 1. 2-point gait (28%) 2. 3-point gait (34%) 3. 4-point gait (36%) 4. 5-point gait (1%) IncorrectCorrect answer 3 36%Answered correctly

The client who is rehabilitating from an injury of the lower extremity usually progresses from no touch down, non-weight bearing status, using the 3-point gait (Option 2) to touch down with partial weight bearing status, using the 2 point-gait (Option 1), to full weight bearing status, using the 4-point gait. The nurse teaches the client how to use the most advanced gait, the 4-point crutch gait. It requires weight bearing on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1 foot; 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left foot, and advance left crutch, then right foot. (Option 3) (Option 4) There are 5 crutch gaits: 2-point, 3-point, 4-point, swing-to, and swing-through. There is no 5-point crutch gait. Educational objective:The 4-point crutch gait is appropriate for a client with leg weakness, who can bear partial or full weight with both legs. It is the easiest gait to use as it resembles normal walking and provides the most stability with 3 points of support on the ground at all times. Additional Information Basic Care and Comfort NCSBN Client Need

When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain? 1. Client's ethnic background (1%) 2. Client's report of symptoms (77%) 3. Client's vital signs (18%) 4. Extent of client's injury (1%) Correct 2 77%Answered correctly

The client's self-report of symptoms is always the most reliable indicator of the client's pain. The nurse does not have the ability to determine the extent of pain the client is experiencing—only the client can report this. In the nonverbal client, the nurse may use nonverbal pain scales such as the Wong-Baker pain rating scale. (Option 1) Although clients from various ethnic backgrounds may express pain differently, it is not appropriate for the nurse to assume that ethnic background is a reliable source of information when determining pain. (Option 3) Although changes in vital signs may occur in acute pain (generally increased respiratory rate and heart rate), these changes are not the most reliable source of information when determining pain. (Option 4) The extent of a client's injury is not a reliable source of information when determining pain because all clients experience pain differently. What one client may feel as excruciating pain another client may not. Educational objective:The most reliable indicator for the client's pain is the client's self-report of symptoms. Nurses should not assume what the client's pain level is based on injury or ethnicity. Although a change in vital signs may occur in the client in pain, this is not the most reliable indicator. Additional Information Basic Care and Comfort NCSBN Client Need Copyright © UWorld. All rights reserved.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? 1. "I can perform the stick on either the medial or lateral side of the outer aspect of the heel." (35%) 2. "Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture." (15%) 3. "The heel area should be warmed for 3-5 minutes prior to puncture." (17%) 4. "Venipuncture should be reserved only for failed heel sticks because it is more painful." (32%) Correct 4 32%Answered correctly

The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: Select a location on the medial or lateral side of the outer aspect of the heel (Option 1). Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation (Option 3). Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain (Option 2). Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed (Option 4). Educational objective:To perform a neonatal heel stick, select a location on the medial or lateral side of the outer aspect of the heel to avoid insult to the calcaneus bone. Provide comfort measures (eg, nonnutritive sucking), warm the selected puncture site to promote vasodilation, cleanse with alcohol, and puncture using an automatic lancet. Additional Information Reduction of Risk Potential NCSBN Client Need

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? 1. Administer the medication and monitor client frequently (1%) 2. Ask a nursing colleague if this drug amount is used (0%) 3. Check hydromorphone dose that the client had previously (14%) 4. Question the prescription with the prescriber (82%) Correct 82%Answered correctly 4

The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a hydromorphone dose that is too high given that the typical maximum dose is 2 mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically. (Option 1) A prescription that greatly exceeds the safety range should not be given without questioning/clarification. However, anytime the outer limit of drug dosing of a potent narcotic is administered, the client should be monitored frequently for adverse effects. This includes the sedation scale and arousability as sedation precedes respiratory depression for narcotics. (Option 2) When there is a medication dosing question, authoritative resources (eg, the pharmacist, current drug literature) should be consulted rather than relying on a nursing colleague who could be mistaken. (Option 3) Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned or clarified. Educational objective:When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? 1. Document a description of the injury (15%) 2. Question the mother about where the infant sleeps (26%) 3. Report the injury per facility protocol (52%) 4. Separate the mother from the infant (4%) IncorrectCorrect answer 3 52%Answered correctly

The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada (Option 3). However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, Mongolian spots) mimicking maltreatment. After reporting suspected maltreatment, the nurse should: Facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination) Document facts and observations objectively, using medical terms when possible (Option 1). Include the history provided by the parent or caregiver and the time period from injury occurrence to evaluation. Perform a review of child-care practices with the caregiver (Option 2). (Option 4) A child and caregiver should only be separated when the child is in immediate physical danger or if authorities must interview a verbal child without the parent present. Educational objective:Injuries in a nonambulatory child, especially fractures, warrant suspicion. The nurse has a duty to report suspected child maltreatment to the appropriate authorities as required by law. Additional Information Psychosocial Integrity NCSBN Client Need

The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary? 1. "I will concentrate on leaning forward as I carefully sit down in a chair." (55%) 2. "I will do my leg raises and quadriceps and buttock isometric exercises 2-3 times a day." (23%) 3. "I will use the sock puller that the therapist gave me when I get dressed." (2%) 4. "My child got me a riser for the toilet seat at home. I hope my feet reach the floor!" (18%) Correct 1 55%Answered correctly

To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided. (Option 2) The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and continues them for several months after discharge. These include isometric quadriceps and gluteal setting, leg raises, and abduction exercises from the supine and standing positions. (Option 3) The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees when dressing or putting on slippers, shoes, and socks. The client is instructed to use assistive equipment when getting dressed, such as a reacher/grabber, sock puller, or a long-handled shoehorn. (Option 4) The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion when getting on and off the toilet seat. Educational objective:To avoid prosthesis dislocation following hip arthroplasty, key discharge teaching points include performing leg exercises to strengthen the muscles around the hip and avoiding excessive hip flexion (>90 degrees) when sitting, dressing, and toileting.

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client? 1. "Ask the client's wife if she would like to give the bed bath." (49%) 2. "Do not make eye contact with the client during the bath." (15%) 3. "The client may prefer for you not to talk to him during the bath." (5%) 4. "Touching the head is a sign of disrespect; let the client wash his own face." (29%) IncorrectCorrect answer 1 49%Answered correctly

To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female health care worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present. (Option 2) Eye contact varies greatly among cultural groups. Some cultures (eg, Arab, Asian, Native American) view eye contact as a sign of disrespect or aggressiveness. This could be a concern with this client, but it is not as high a priority as respecting the client's cultural beliefs of not being alone in the same room with a member of the opposite sex. (Option 3) Some cultures (eg, Native American, Asian) are comfortable with silence and see it as a sign of respect, privacy, or respect for elders. (Option 4) In some Asian and Hispanic cultures, the head is thought to be the basis of one's strength or soul, and touching a person's head is considered disrespectful. Educational objective:The nurse should be aware that in many Arab cultures a man is not allowed to be alone with a woman other than his wife. In addition, cultural customs may not allow physical care by a member of the opposite sex. The nurse needs to plan accordingly to provide culturally sensitive care. Additional Information Psychosocial Integrity