mynclex set 2 - 44

The nurse is caring for a client who will have a copper intrauterine device (IUD) inserted. When reinforcing teaching related to the copper IUD, which of the following nurse statements are appropriate? Select all that apply. 1. "Backup contraception is needed for 2 days until the IUD is effective." 2. "Heavier menses and more menstrual cramping are common in clients using a copper IUD." 3. "Missing a period while using a copper IUD is normal and no reason for concern." 4. "You may have cramping and vaginal spotting for a short time after IUD insertion." 5. "You should check for the IUD strings at least once a month after menses." OmittedCorrect answer 2,4,5 21%Answered correctly

A copper intrauterine device (IUD) is a form of long-acting, reversible contraception that causes an intrauterine inflammatory effect that impairs sperm mobility and prevents implantation of a fertilized egg. It is a highly effective contraceptive and is also used for emergency contraception. IUD insertion commonly causes mild discomfort, cramping, and/or light vaginal bleeding (Option 4). Ibuprofen is recommended before and after insertion for relief of cramping/pain. Menstrual changes are also common among IUD users. For clients with copper IUDs, heavier bleeding and increased cramping during menses are the most common and expected side effects (Option 2). The client should check for the strings at least monthly to ensure that the IUD has not been expelled (Option 5). (Option 1) Unlike levonorgestrel IUDs, copper IUDs have an immediate contraceptive effect; backup contraception is not required. Condoms are recommended for clients who are at risk for sexually transmitted infections. (Option 3) Although pregnancy risk is low (<1%) when using the copper IUD, pregnancy is possible (eg, device expelled). Ovulation and menses still occur when using the copper IUD because the device does not contain hormones. A pregnancy test is necessary if a period is missed. Educational objective:A copper intrauterine device (IUD) is a form of long-acting, reversible contraception that has an immediate contraceptive effect upon placement. Mild discomfort (eg, cramping, spotting) is associated with IUD insertion, and clients should anticipate heavier bleeding and increased cramping during menses. IUD strings should be checked at least every month to ensure that the IUD has not been expelled. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply. 1. Client may be required to lie flat for several hours following the procedure 2. Client may feel warm or flushed when contrast dye is injected during the procedure 3. Client should expect to stay in the hospital for 1-3 days following the procedure 4. Client should not eat or drink anything for 6-12 hours before the procedure 5. Client will receive general anesthesia and will not be awake during the procedure OmittedCorrect answer 1,2,4 40%Answered correctly

A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) (Option 4) The client may feel warm or flushed while the contrast dye is being injected (Option 2) Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis (Option 1) (Option 3) If the procedure is just a diagnostic study, the client often goes home the same day. Hospitalization for 1-3 days may be required if angioplasty or stent placement is performed. (Option 5) General anesthesia is not used during coronary angiography. Sedating medications are given during the procedure. Educational objective:Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply. 1. Do you have black tarry stool? 2. Do you use intravenous (IV) illicit drugs? 3. How much alcohol do you typically drink? 4. Were you recently immunized for pneumonia? 5. What over-the-counter drugs do you take? OmittedCorrect answer 2,3,5 48%Answered correctly

ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake (Option 3), some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements (Option 5). IV illicit drug use increases the risk for hepatitis B and C infection (Option 2). (Option 1) Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. (Option 4) Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high. Educational objective:ALT/AST are enzymes indicating liver injury. Besides the obvious viral hepatitis, it can result from excess chronic alcohol intake or some over-the-counter drugs, including acetaminophen.

The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones? 1. "If I am in the green zone (PEF 80%-100% of personal best) but am coughing, wheezing, and having more trouble breathing, I will not make any changes in my medications." (5%) 2. "If I am in the yellow zone (50%-80%) and I return to the green zone after taking my rescue medication, I will not make any changes in my daily medications." (53%) 3. "If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for 1-2 days and call my health care provider (HCP) for follow-up care." (33%) 4. "If I remain in the red zone, my lips are blue, and my PEF is still <50% of my personal best reading after taking my rescue medication, I will wait 15 minutes before calling an ambulance." (6%) OmittedCorrect answer 3 33%Answered correctl

An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option 1). Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option 2). Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option 4). Educational objective:A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms. Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications. Additional Information Physiological Adaptation NCSBN Client Need

///Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis? 1. Bounding peripheral pulses (12%) 2. Diastolic murmur (27%) 3. Loud second heart sound (13%) 4. Syncope on exertion (46%) OmittedCorrect answer 4 46%Answered correctly

Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot overcome the worsening obstruction, and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures) and weak, thready peripheral pulses. With exertion, the volume of blood that is pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope. (Option 1) In aortic stenosis, pulses are weak due to obstruction of outflow from the left ventricle. Pulses would be bounding in aortic regurgitation due to more blood being pumped each time (blood accumulation from regurgitation of the previous systole). (Option 2) On auscultation, aortic stenosis produces a loud, ejection systolic murmur over the aortic area as blood is ejected from the left ventricle through the stenosed aortic valve during systole. (Option 3) The second heart sound (S2) is produced by the closure of aortic and pulmonic valves. When these valves are stiff and difficult to close (as with aortic stenosis), S2 is soft or absent. Educational objective:Aortic stenosis obstructs blood flow during systole from the left ventricle to the aorta. Clients will develop exertional dyspnea, chest pain, and syncope as the heart is unable to overcome the obstruction to pump enough blood to meet metabolic demands. A systolic ejection murmur over the aortic area, soft or absent second heart sounds, and weak peripheral pulses are characteristic.

A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention? 1. Apply a snug-fitting diaper following the procedure (17%) 2. Anticipate the use of clean technique during the circumcision (16%) 3. Offer oral fluids during the procedure (7%) 4. Wrap the newborn's upper body in a blanket restraint for the circumcision (58%) OmittedCorrect answer 4 58%Answered correctly

Application of a blanket restraint or the use of a special board prevents injury during circumcision. Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage pain during circumcision. (Option 1) A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. (Option 2) Sterile technique is used during the surgical procedure of circumcision. (Option 3) The infant should not be fed during circumcision to prevent the risk of aspiration. A pacifier dipped in a concentrated sucrose solution is offered as a nonpharmacologic pain management technique. Educational objective:During circumcision, the newborn is restrained in a wrapped blanket or placed on a special board to prevent injury. Non-nutritive sucking of a concentrated sucrose solution is offered for pain management.

The emergency nurse admits a client who was rescued from a burning building. The client's arms and chest are covered with dry, leathery, charred skin that does not blanch. Which new prescription should the nurse implement first? 1. Administer 50-100 mcg fentanyl IV push q30min, PRN for pain (7%) 2. Apply topical bacitracin ointment to burn wounds, twice daily (1%) 3. Infuse 150 mL/hr lactated Ringer solution IV continuously (80%) 4. Obtain equipment and prepare client for escharotomy (10%) OmittedCorrect answer 3 80%Answered correctly

Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. These injuries may be life-threatening, depending on the extent of tissue injury and organ damage. To prioritize the initial management of burn injuries, nurses should use the ABCs (ie, airway, breathing, circulation). Circulatory compromise is common after sustaining a burn, as extensive tissue injury combined with the systemic inflammatory response causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses begin rapidly after a burn and may lead to hypovolemic shock and death. Therefore, the nurse should prioritize initiation of fluid resuscitation (Option 3). (Option 1) Although full-thickness burns destroy nerves and may be painless, clients with burns often have severe pain. However, pain is not life-threatening and may be treated after restoration of ABCs. (Option 2) Burn injuries impair immune system function and skin integrity, increasing the risk for infection. Prevention of infection with topical antimicrobials (eg, bacitracin, silver sulfadiazine) is important. However, restoration of ABCs is the priority. (Option 4) An escharotomy is a surgery involving incisions made through eschar (burned tissue) and is performed to prevent tissue ischemia and necrosis from impaired circulation. However, stabilizing circulatory status is the priority. Educational objective:Nurses should prioritize the initial management of burn injuries using the ABCs (ie, airway, breathing, circulation). Fluid administration, a life-saving measure for clients with burn injuries, stabilizes circulation and should be performed as soon as possible.

A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse? 1. "I may feel a sharp pain that shoots to my leg, but it should pass soon." (13%) 2. "I will go to the bathroom and try to urinate before the procedure." (2%) 3. "I will need to lie on my stomach during the procedure." (81%) 4. "The physician will insert a needle between the bones in my lower spine." (1%) OmittedCorrect answer 3 81%Answered correctly

Cerebrospinal fluid (CSF) is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms. Normal CSF pressure is 60-150 mm H2O. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or ventriculostomy. Prior to a lumbar puncture, clients are instructed as follows: Empty the bladder before the procedure (Option 2) The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle (Option 3). A sterile needle will be inserted between the L3/4 or L4/5 interspace (Option 4) Pain may be felt radiating down the leg, but it should be temporary (Option 1) After the procedure, instruct the client as follows: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache Increase fluid intake for at least 24 hours to prevent dehydration Educational objective:Lumbar puncture can be performed with clients in the sitting position or positioned on the left side with the knees drawn up (fetal position). Additional Information Reduction of Risk Potential NCSBN Client Need

A nurse is discharging a client who has been hospitalized with streptococcal infective endocarditis (IE). Which statement by the client would indicate a need for further teaching? 1. "I may need prophylactic antibiotics before dental work from now on." (5%) 2. "I should call my health care provider (HCP) or 911 right away if I notice my speech is slurred." (3%) 3. "I shouldn't be concerned if I continue to have a fever at home." (81%) 4. "I will expect a home health nurse to give me IV antibiotics for several more weeks." (9%) OmittedCorrect answer 3 81%Answered correctly

Clients with IE usually have fever for several days during the initial stages of antibiotic therapy. By the time they are discharged, fever subsides or becomes occasional and low-grade. The nurse should teach the client to monitor temperature regularly at home. Persistent temperature elevations may mean that the antibiotic therapy is ineffective or complications have developed. The client should notify the HCP if a fever persists at home. (Option 1) A client who has had IE is at risk for reoccurrence. This client should receive prophylactic antibiotics for certain high-risk procedures (eg, manipulation of gingival tissue). (Option 2) IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur. Slurred speech could indicate that embolization has caused a possible stroke. (Option 4) IE can require IV antibiotics for up to 4-6 weeks. The client may be discharged home once hemodynamically stable, and a home health nurse will come to administer the antibiotics through the client's PICC line. Educational objective:The nurse should teach the client with IE to expect to receive IV antibiotics for several weeks after returning home and to report a persistent fever; any signs of embolization such as slurred speech, one-sided weakness, or paralysis; or a painful, cold extremity. Prophylactic antibiotics will be required for certain high-risk procedures.

/The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first? 1. Client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour (63%) 2. Client 6 hours postoperative rotator cuff repair with a sling immobilizer who has moderate swelling and tingling of the hand and fingers (27%) 3. Client 8 hours postoperative total knee arthroplasty who has 2 closed-wound suction drains and a total output of 200 mL sanguineous drainage (6%) 4. Male client 1 day postoperative total hip replacement prescribed enoxaparin who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) (3%) OmittedCorrect answer 1 63%Answered correctly

Compartment syndrome results from swelling and increased pressure within a confined space (a compartment). It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset (eg, surgical fasciotomy, cast removal), irreversible nerve and muscle injury can occur. (Option 2) Immobilization of the extremity in a sling can lead to venous pooling and edema of the hands and fingers if the sling is not applied properly. The nurse should evaluate the elbow and hand positions and perform a neurovascular assessment, but this is not the priority. (Option 3) Sanguineous (red) wound drainage at 25 mL/hr is expected 1 day postoperative knee replacement. Drains are usually removed in 24 hours unless drainage is excessive (eg, >1500 mL/24 hr). (Option 4) Anticoagulant therapy (eg, unfractionated heparin, enoxaparin, fondaparinux) is standard following total hip replacement. Slightly decreased hematocrit and hemoglobin levels (normal male: 39%-50% [0.39-.50], 13.2-17.3 g/dL [132-173 g/L], respectively) are expected due to intra- and postoperative blood loss. Educational objective:Compartment syndrome is a medical emergency that requires decompression within 4-6 hours of onset (eg, fasciotomy, cast removal) to prevent irreversible nerve and muscle injury. Additional Information Management of Care NCSBN Client Need

The nurse is caring for a client in soft wrist restraints. Which tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply. 1. Assist the client with using a bedpan 2. Check pulses and sensation of extremities 3. Observe skin for signs of impairment 4. Perform range-of-motion exercises 5. Turn and reposition the client in bed OmittedCorrect answer 1,4,5 69%Answered correctly

Delegating care to unlicensed assistive personnel (UAP) requires understanding of both body policies and staff member training. UAP may assist with care of stable clients related to tasks of basic hygiene (eg, bathing, toileting) and daily living (eg, feeding, positioning, range-of-motion exercises); measurement and documentation of vital signs and intake and output; and technical skills (eg, capillary blood glucose monitoring, IV catheter removal) with appropriate training (Options 1, 4, and 5). Assurance of appropriateness and completion of delegated tasks remain the duty of the nurse. (Options 2 and 3) When physical restraints are applied to a client, the nurse is responsible for the primary and ongoing assessments (eg, skin integrity, peripheral pulses, neurovascular status), determining appropriateness of restraint type, need for continued use, and psychological response. These tasks may not be delegated to the UAP. The UAP may report changes in these areas if noted but must not be expected to monitor for changes. Educational objective:Nurses may delegate to unlicensed assistive personnel tasks that relate to basic hygiene; tasks of daily living; measurement and documentation of vital signs and intake and output; and validated technical skills. Activities requiring assessment may be performed only by the nurse.

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy. Which intervention should the nurse implement? 1. Administer desmopressin (65%) 2. Assess fasting blood glucose (16%) 3. Institute fluid restriction (14%) 4. Place the client in the Trendelenburg position (3%) OmittedCorrect answer 1 65%Answered correctly

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option 3). ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). (Option 2) DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria). (Option 4) The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions. Educational objective:DI occurs when there is insufficient production/suppression of ADH. It is characterized by polydipsia and polyuria with diluted urine. Oral and/or intravenous fluid replacement is imperative to prevent dehydration. DI is treated with ADH replacement drugs (eg, desmopressin acetate [DDAVP]). Clients should be monitored for urine output, urine specific gravity, and serum sodium.

//A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply. 1. Drink plenty of fluids 2. Exercise regularly 3. Follow a low-residue diet 4. Include whole grains, fruits, and vegetables in the diet 5. Increase intake of red meat OmittedCorrect answer 1,2,4 24%Answered correctly

Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula). Diverticulosis is characterized by the presence of these protrusions; the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce the risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past, clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that avoidance of these foods will prevent an episode of diverticulitis. (Option 3) A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. (Option 5) Increased consumption of red meat and other high-fat foods can increase the risk of diverticulitis. Educational objective:Clients with diverticulosis should take measures to prevent constipation (eg, high-fiber diet, increased fluid intake, regular exercise), which may help prevent recurring episodes of acute diverticulitis.

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures. Which findings does the nurse expect to assess to support this diagnosis? Select all that apply. 1. Confusion and restlessness 2. Increasing pain despite the opioid analgesia 3. Paresthesia of the affected extremity 4. Petechiae over neck and chest 5. Pulse oximeter showing hypoxia OmittedCorrect answer 1,4,5 25%Answered correctly

FES is a rare, but life-threatening complication that occurs in clients with long bone and pelvis fractures. It can also occur in nontrauma-related conditions, such as pancreatitis and liposuction. It usually develops 24-72 hours following the injury or surgical repair. There are no specific diagnostic tests to identify FES. However, the initial characteristic signs and symptoms include: Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus (Option 5). Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia (Option 1). Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE (Option 4). Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction. (Options 2 and 3) Increasing, severe pain unrelieved by opioid analgesia or pain that is disproportionate to the injury and paresthesia (eg, numbness, tingling, burning) of the affected extremity are assessment findings indicative of compartment syndrome. Educational objective:FES presents with a triad of respiratory distress, mental status changes, and petechial skin rash. Fever and thrombocytopenia can also be present. Additional Information Physiological Adaptation NCSBN Client Need

*The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply. 1. Cold intolerance 2. Constipation 3. Fever 4. Menstrual irregularity 5. Night sweats 6. Tachycardia OmittedCorrect answer 1,2,4 44%Answered correctly

Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating. (Options 3, 5, and 6) Fever, tachycardia, and sweating are signs of hyperthyroidism, which is a hypermetabolic state, with signs and symptoms that are usually the opposite of those seen in hypothyroidism. The presenting symptoms of a hyperthyroid client would likely include weight loss despite an increased appetite and difficulty sleeping. Educational objective:Hypothyroidism is associated with symptoms of a low metabolic rate; hyperthyroidism causes symptoms of a high metabolic rate. Additional Information Physiological Adaptation NCSBN Client Need

/While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." (11%) 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." (80%) 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." (3%) 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?" (5%) OmittedCorrect answer 2 80%Answered correctly

Five rights of delegation Right task Within delegatee's scope of practice Routine, frequently recurring task; minimal potential risk Established sequence of steps; requires little to no modification for individual clients Predictable outcome Right circumstances Relatively stable client; noncomplex task Adequate staffing, resources & supervision available Right person Delegator should assess competency prior to delegating Delegatee must have the appropriate knowledge, skills & abilities Right direction/communication Delegator needs to provide clear instructions; must include specific client concerns & observations to be reported back or recorded Delegatee should verbalize understanding & have the opportunity to ask questions Right supervision/evaluation Monitor, evaluate & intervene as needed Delegator retains ultimate accountability for task In the Joint Statement on Delegation (2007), the American Nurses Association and the National Council of State Boards of Nursing outline the 5 Rights of Delegation as seen in the table above. The RN needs to direct the UAP's actions and communicate clearly about the assigned tasks including any specific information necessary for completion (eg, methods for collection, time frame, when to report back to the RN). Option 2 gives the UAP directions with prioritization and specific instructions for reporting back findings. (Option 1) The time frame in this option should be more specific. In addition, there is no communication about what the RN expects as follow-up. (Option 3) The instruction to "keep a close eye" on the client leaves the UAP too much room for interpretation. The expectation from the RN is not clear and the UAP needs more direction. (Option 4) The instructions are too broad and don't give a specific time frame. This delegation also needs to communicate the method needed to accomplish the task. Educational objective:The RN should communicate directions to the delegate that include any unique client requirements and characteristics as well as clear expectations on what to do, what to report, and when to ask for assistance.

The nurse is performing an assessment on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool (meconium) 4. Nonbilious vomiting 5. Refusal to feed OmittedCorrect answer 2,3,5 38%Answered correctly

Hirschsprung disease occurs when a child is born with some sections of the distal large intestine missing nerve cells; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They will also have difficulty feeding and often vomit green bile. (Option 1) An infant with Hirschsprung disease will not have passed meconium. Bright red bleeding from the rectum would not occur. However, rectal bleeding could be a symptom of Meckel's diverticulum, a remnant of the umbilical cord that should have disintegrated at 8 weeks in utero but became an out pouch in the small intestine. (Option 4) Nonbilious vomiting is seen in conditions where the pathology is proximal to the pylorus (eg, hypertrophic pyloric stenosis). Bilious (green) vomiting is seen in conditions where the pathology is distal to the duodenum as the common bile duct drains at the duodenum. In Hirschsprung disease, the pathology is at the distal colon; green bilious vomiting is expected. Educational objective:Hirschsprung disease is caused by a lack of specialized nerve cells in portions of the distal large intestine; this renders the internal sphincter unable to relax. Infants with Hirschsprung disease will not pass meconium but will have distended abdomens and bilious emesis. Additional Information Physiological Adaptation NCSBN Client Need

The nurse assesses a client with a history of cystic fibrosis who is being admitted with a pulmonary exacerbation. Which assessment finding would require immediate action? 1. Current pulse oximetry reading is 90% on room air (30%) 2. Expectorating blood-tinged sputum (49%) 3. Loss of appetite and recent 5-lb (2.3-kg) weight loss (8%) 4. No bowel movement in the past 48 hours (11%) OmittedCorrect answer 1 30%Answered correctly

In cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes the secretions from the exocrine glands to be thicker and stickier than normal. The sticky respiratory secretions lead to the inability to clear the airway and a chronic cough. The client eventually develops chronic lung disease (bronchiectasis) and is at risk for recurrent lung infections. These clients are also at risk for rupture of the damaged alveoli, which results in sudden-onset pneumothorax. Findings of pneumothorax include sudden worsening of dyspnea, tachypnea, tachycardia, and a drop in oxygen saturation. Because many of these findings can be seen with lung infection, a sudden drop in oxygen saturation could be the only early clue. The client with CF will often have a decreased pulse oximetry (reflects oxygen saturation in the blood) reading due to the chronicity of the disease process and damage to the lungs; however, a reading of 90% requires urgent intervention. (Option 2) Clients with CF often cough up blood-streaked sputum (hemoptysis) as a result of damage to blood vessels in the airway walls secondary to infections. However, this usually resolves with treatment of the infection. Frank hemoptysis needs urgent assessment. (Option 3) Maintaining weight is a challenge in those with CF due to the malabsorption of carbohydrates, fats, and proteins caused by the impaired enzyme secretions in the gastrointestinal tract. In addition, weight and appetite loss may indicate an undiagnosed underlying lung infection. This will need to be addressed, but oxygenation is the priority. (Option 4) Fecal retention and impaction are common in CF due to decreased water and salt secretion into the intestines. This will need to be addressed, but oxygenation is the priority. Educational objective:When addressing the multiple needs of a client with cystic fibrosis, airway and oxygen saturation are the priorities. Pneumothorax can be a complication of cystic fibrosis. Additional Information Physiological Adaptation NCSBN Client Need

An overweight toddler is diagnosed with iron deficiency anemia. Which is the most likely explanation for the anemia? 1. Excessive intake of meat products (3%) 2. Excessive intake of milk (64%) 3. Gastrointestinal blood loss (18%) 4. Impaired iron transfer from the mother (13%) OmittedCorrect answer 2 64%Answered correctly

Iron deficiency anemia is the most common chronic nutritional disorder in children. There are many risk factors for iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1 year. One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight, toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of milk, a poor source of available iron. Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake (16-24 oz/day) in toddlers to ensure a balanced diet. (Option 1) Red meat and other meat products are considered good sources of dietary iron. However, clients may be at risk for obesity if meat consumption exceeds protein and caloric needs. (Option 3) Gastrointestinal blood loss, which can occur if infants under age 1 year are fed cow's milk, is a potential cause of iron deficiency anemia. However, excessive milk intake is a more common cause, particularly in clients over age 1 year. (Option 4) Impaired or decreased iron transfer is a potential cause of iron deficiency anemia, particularly in preterm infants or infants born in multiples. However, iron stores received from the mother are typically depleted by age 5-6 months (2-3 months for preterm infants); after this point, iron must be acquired through dietary sources. Because this client is a toddler (age 1-3 years), impaired iron transfer is not a likely cause of the current anemia. Educational objective:Iron deficiency anemia is the most common nutritional disorder in children. Risk factors include premature birth, cow's milk before age 1 year, and excessive milk intake in toddlers. Prevention and treatment are achieved through proper nutrition (eg, meat, leafy green vegetables, fortified cereal) and supplementation.

/The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client. Which action by the GN indicates the need for further education from the nurse preceptor? 1. Discourages the client from rubbing the injection site after the injection (7%) 2. Ejects the air bubble from the prefilled syringe before administration (55%) 3. Inserts the needle and injects the medication at a 90-degree angle (14%) 4. Selects an injection site on the left lateral side of the abdomen (22%) OmittedCorrect answer 2 55%Answered correctly

Low-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error (Option 2). (Option 1) After subcutaneous anticoagulant injection, the client should not rub the injection site as this increases bruising and the risk for hematoma. (Option 3) A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In general, subcutaneous injections are administered at a 90-degree angle if 2 in (5 cm) of tissue can be grasped or a 45-degree angle if only 1 in (2.5 cm) of tissue can be grasped. (Option 4) Subcutaneous anticoagulants are best absorbed when administered in the lower part of the right or left lateral abdominal wall (ie, "love handles"), at least 2 in (5 cm) away from the umbilicus. Educational objective:Low-molecular-weight heparin is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose during injection. The nurse should not expel the air bubble prior to administration as this could result in some medication being left in the syringe and an incomplete dose delivery.

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply. 1. Palliative care focuses on quality of life and can be provided at any time 2. Palliative care is only possible with a terminal diagnosis of ≤6 months 3. Palliative care is provided by a multidisciplinary team 4. Palliative care is another term for hospice care 5. Palliative care provides relief from symptoms associated with chronic illnesses OmittedCorrect answer 1,3,5 38%Answered correctly

Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder. (Option 2) Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease (eg, advanced heart failure or cancer). (Option 4) The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment. Educational objective:Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families. Additional Information Basic Care and Comfort NCSBN Client Need

/A client is admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? 1. Decreased albumin (2%) 2. Elevated troponin (1%) 3. Hyperkalemia (10%) 4. Hypocalcemia (85%) OmittedCorrect answer 4 85%Answered correctly

Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia (capillary leak → third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to hypocalcemia. (Option 1) Decreased albumin levels are seen with malnutrition; clients who are alcoholics can have low serum albumin but that alone is not responsible for the client's symptom. (Option 2) Troponin elevation is specific to myocardial infarction and is unrelated to pancreatitis. (Option 3) Potassium abnormalities are not usually present in acute pancreatitis. They are more likely to occur with hemolysis, when the intracellular potassium enters the serum. The ecchymoses in pancreatitis (Grey Turner's sign, Cullen's sign) are due to the blood-stained exudates from autodigestion and are usually only seen in severe cases. Educational objective:Complications of acute severe pancreatitis include hyperglycemia, hypocalcemia, hypovolemia, and ARDS. Trousseau's (carpal spasm) and Chvostek's (facial twitching) signs are an indication of hypocalcemia from the decrease in threshold for contraction.

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse teach the client to expect while taking this medication? 1. Constipation (5%) 2. Difficulty sleeping (2%) 3. Discoloration of urine (75%) 4. Dry mouth (16%) OmittedCorrect answer 3 75%Answered correctly

Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics. (Options 1, 2, and 4) Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride. Educational objective:Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection. An expected side effect of the drug is orange-red discoloration of urine.

/The parents of a 5-year-old ask the school nurse for advice on how to tell their child about being adopted. Which developmentally appropriate thought about adoption by the child does the nurse counsel the parents to anticipate? 1. Feels responsible for being placed for adoption (28%) 2. Imagines what life would be like with a different family (10%) 3. Is unable to conceptualize differences between adoptive and biological parents (56%) 4. Worries about what peers will say or think (4%) OmittedCorrect answer 1

Piaget's theory of cognitive development Age (approximate) Cognitivedevelopmental stage Characteristics Birth to 2 years Sensorimotor Learning by sense & movement, exploration, early verbal skills 2 to 7 years Preoperational Improved language, poor causality (eg, magical thinking), egocentrism 7 to 11 years Concrete operational Able to reason if concrete objects are used to teach 11+ years Formal operational Abstract thinking & reasoning Children age 3-6 (preschool) are in Piaget's preoperational stage of cognitive development. At age 5, children are not able to fully understand cause and effect and will therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior). Five-year-olds are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. The child might notice that friends are not adopted. Preschool-age children may also believe they are responsible for being adopted and may develop separation issues and fear abandonment. (Option 2) School-age children may imagine how life would be different if they were with their biological parents. Self-esteem issues begin to develop around this time with the possible sense of loss of the biological family. School-age children may be sensitive to physical differences between themselves and their adoptive family. (Option 3) Children age 3 and under are unable to understand differences between adoptive and biological parents. The age at which to begin discussions about being adopted is debatable, but use of positive language is always encouraged. The terms "given up" or "put up" for adoption or someone's "real" parents are inappropriate and should be avoided. (Option 4) Adolescents have abstract thinking abilities that enable introspection about their adoption. They typically do not like differing from their peers. Open and honest communication is important at this age. Educational objective:Preschool-age children (3-6 years) are in Piaget's preoperational stage of cognitive development. They become increasingly verbal but are unable to understand cause and effect, often ascribing inappropriate causes to phenomena; therefore, the adopted child may feel responsible for being adopted.

A school nurse is educating the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching? 1. "I will launder recently worn clothing, sheets, and towels in hot water." (78%) 2. "I will make sure all eating utensils are placed in the dishwasher." (1%) 3. "I will spray the house with insecticide to control this problem." (2%) 4. "I will throw away stuffed animals and toys that cannot be washed." (17%) OmittedCorrect answer 1 78%Answered correctly

Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of the use of pediculicides and the removal of nits (eggs). (Option 2) Head lice are not spread by oral contact with eating utensils. Instead, they are spread by direct person-to-person contact or by nits that hatch in the environment and remain on clothing, combs, and pillows. (Option 3) Spraying insecticides around children and pets in the home is not recommended due to the risk of inhalation or skin contact. (Option 4) Items that cannot be washed or dry cleaned may be placed in sealed plastic bags for 14 days to kill active lice or lice that hatch from the nits in 7-10 days. Vacuuming of furniture, carpets, stuffed toys, rugs, and mattresses is also recommended to prevent the spread of lice and nits. Educational objective:Pediculosis capitis (head lice) is a common parasitic infestation of the scalp that is typically seen in school-aged children. It is spread by contact with personal items such as clothing, combs, and bedding.

/A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? 1. 1-person stand and pivot with gait belt and walker (55%) 2. 1-person standby assist with walker (16%) 3. 2-person motorized stand-assist lift (7%) 4. 2-person stand and pivot with gait belt and walker (20%) OmittedCorrect answer 1 55%Answered correctly

Recommended bed-to-chair transfer method Weight bearing Transfer method Full Independent; no assistance required 1-person standby assistance or observation for clients who are uncooperative or at high risk for falls Partial 1-person assist stand & pivot transfer with gait belt or motorized assist device if cooperative 2-person assist with full-body sling if client is uncooperative None Motorized assist device if client is cooperative & has upper body strength 2-person assist with full-body sling if client is uncooperative &/or has no upper body strength Client should use as much of his or her own strength as possible. Use assistive devices when lifting >35 lb (15.9 kg) of client's body weight. To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: Whether the client can bear weight Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift (Option 1). If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance (Option 2). (Option 3) This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. (Option 4) If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible. Educational objective:If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift.

The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? 1. Abrupt-onset hypertension and headache (38%) 2. Blue and cold fingertips (23%) 3. Dry cough and exertional dyspnea (15%) 4. Heartburn and difficulty swallowing (22%) OmittedCorrect answer 1 38%Answered correctly

Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal. (Option 2) Raynaud phenomenon can develop secondary to scleroderma. It is characterized by vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening. (Option 3) Pulmonary fibrosis is a progressive complication of scleroderma that is defined as scarring of lung tissue, which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen. This is not immediately life-threatening. (Option 4) Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with scleroderma. This is due to the disease process of internal scarring, and it is not life-threatening. Educational objective:Scleroderma is caused by collagen overproduction; it is a lifelong disease without a cure. Treatment is aimed at controlling symptoms and preventing further complications. Renal crisis is life-threatening and should be recognized and treated immediately.

/A 28-year-old client is seeking advice from the nurse about why she has not been able to conceive. The client is discouraged and states that she has been "trying to get pregnant for 4 months." Which statement by the nurse is best? 1. "Adoption or surrogacy are options for those who are unable to conceive." (0%) 2. "Consider talking to your health care provider about fertility-enhancing medications that can help you conceive more quickly." (28%) 3. "There is no cause for concern unless you haven't been able to conceive for 1 year." (37%) 4. "Using an over-the-counter urine ovulation detector kit to time sexual intercourse may improve your chances of conceiving." (34%) OmittedCorrect answer 4 34%Answered correctly

Teaching about menstrual cycle physiology increases fertility awareness and helps couples optimize their chances of becoming pregnant sooner. Timing of sexual intercourse near ovulation (ie, "fertile window") is essential to conception because the ovum and sperm have limited viability in the reproductive tract. Instructing the client about how to track menstrual cycles (eg, length and regularity of menses) and recognize signs of ovulation (eg, cyclic changes in cervical mucus) may improve fertility awareness. Urine ovulation predictor kits may also be used to detect the surge of luteinizing hormone (LH) that precedes ovulation by 12-24 hours. These predictor kits are easily accessed, over-the-counter tests that can help the client time intercourse during the "fertile window" to improve chances of conceiving (Option 4). (Option 1) It is best to provide teaching and encouragement rather than alternatives to pregnancy (eg, adoption, surrogacy). (Option 2) Teaching about fertility-enhancing medications (eg, clomiphene) may be indicated for clients unable to conceive naturally but is not the best reply to this client at this time. (Option 3) Infertility is the inability to conceive after 12 months of frequent, unprotected intercourse for clients without medical complications (eg, advanced maternal age). However, this is not the best response because this teaching does not assist the client. Educational objective:Teaching clients about menstrual cycle physiology may increase fertility awareness and improve their chances of achieving pregnancy sooner. Over-the-counter ovulation predictor kits detect the surge of luteinizing hormone (LH) that precedes ovulation so that clients can time sexual intercourse during their "fertile window." Additional Information Health Promotion and Maintenance NCSBN Client Need Copyright © U

The nurse is preparing to administer digoxin to a client. Prior to giving the medication, the nurse should assess the apical pulse rate. Select the best location to auscultate the apical pulse. IncorrectCorrect answer Refer to Hotspot 45%Answered correctly

The apical pulse is best assessed by placing the stethoscope diaphragm at the apex of the heart/mitral area. This is located at the fifth intercostal space on the midclavicular line. For a client receiving digoxin, the apical heart rate should be assessed for 1 full minute. If the heart rate is <60/min, the nurse should consider holding the dose based on the health care provider's instructions. In addition to the apical heart rate, digoxin and potassium levels should be assessed if available. Digoxin has a very narrow therapeutic range (0.5-2.0 ng/mL), and hypokalemia can potentiate digoxin toxicity (>2.0 ng/mL). Educational objective:To assess the apical heart rate, the nurse needs to place the stethoscope diaphragm on the chest at the apex/mitral area (fifth intercostal space on the midclavicular line).

The nurse is caring for an adult client at the clinic who asks the nurse to look at a "black skin lesion." What assessment findings would be a classic indication of a potential malignant skin neoplasm? Select all that apply. 1. Blanches with manual pressure 2. Half of the lesion is raised and half is flat 3. History of purulent drainage 4. Lesion is the size of a nickel 5. Various color shades are present OmittedCorrect answer 2,4,5 37%Answered correctly

The examination for skin cancer follows the ABCDE rule: Asymmetry (eg, one half unlike the other) (Option 2) Border irregularity (eg, edges are notched or irregular) Color changes and variation (eg, different brown or black pigmentation) (Option 5) Diameter of 6 mm or larger (about the size of a pencil eraser) (Option 4) Evolving (eg, appearance is changing in shape, size, color) (Option 1) Normal variations in skin will blanch with manual pressure. Failure to blanch is typically an indication that there is blood beneath the skin, as in petechiae and/or purpura. (Option 3) Pus or purulent drainage is usually indicative of an infectious process, not cancer. Educational objective:Examination of a skin lesion for malignancy should include ABCDE: Asymmetry, Border irregularity, Color change and variation, Diameter of 6 mm or more, and Evolving in appearance.

////The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins OmittedCorrect answer 2,4,5 22%Answered correctly

The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. (Option 1) The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks. (Option 3) Jaundice is best assessed in natural lighting, with gentle pressure to the skin over a firm surface such as the nose, forehead, or sternum. It first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. It is usually related to problems of the liver. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system. Educational objective:Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls.

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? 1. Activate the code system (8%) 2. Call the health care provider (HCP) stat (7%) 3. Check the apical pulse (82%) 4. Check the blood pressure (1%) OmittedCorrect answer 3 82%Answered correctly

The nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support. (Option 1) Activating the code system is not appropriate as this client has an order to withhold resuscitation. (Option 2) The nurse should assess the client and then call the HCP. A stat page is not needed when the client is DNR. (Option 4) Measuring the blood pressure is not appropriate if this client has stopped breathing. Checking an apical or central pulse would be appropriate after noticing that the client is not breathing. Educational objective:A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the HCP to confirm the death.

EXHIBIT -Medication administration record- Allergies: None Medications Time Haloperidol: 5 mg orally, twice a day 0900, 2100 Hydrochlorothiazide: 25 mg orally, daily 0900 Omeprazole: 20 mg orally, daily 0900 Acetaminophen: 650 mg orally, PRN Every 4 hours The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. 1. Give all medications, including acetaminophen, and reassess in 30 minutes (10%) 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes (14%) 3. Hold the haloperidol and notify the health care provider (HCP) immediately (61%) 4. Hold the hydrochlorothiazide and notify the HCP immediately (13%) OmittedCorrect answer 3 61%Answered correctly

This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). (Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective:NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication.

/A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority? 1. Ask the client how long the leg has been tender and warm (16%) 2. Assess the electrocardiogram (ECG) for any ectopic beats (2%) 3. Check vital signs including pulse oximetry (10%) 4. Complete neurovascular assessment on lower extremities (70%) OmittedCorrect answer 4 70%Answered correctly

This client with a tender calf that feels warm to the touch is exhibiting signs and symptoms of a possible deep vein thrombosis (DVT). Additionally, the client has several risk factors for DVT (age >60, being hospitalized and in bed for 3 days). The nurse will need to notify the health care provider (HCP) immediately. However, prior to this, the nurse must perform a thorough assessment of the client to report to the HCP. The priority action by the nurse should include a thorough neurovascular assessment of the extremities, including presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. (Options 1, 2, and 3) These are all assessments that the nurse should collect to report to the HCP but are not as high of a priority or as relevant to the specific situation that the client is currently experiencing. Educational objective:The nurse that suspects DVT should perform a thorough neurovascular assessment of the client's extremities, including presence and quality of DP and PT pulses, temperature of extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. The findings should be reported immediately to the HCP.

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. 1. Capillary refill is less than 3 seconds 2. Pulse pressure is narrowed 3. Systolic blood pressure drops only when standing 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020 OmittedCorrect answer 1,4,5 45%Answered correctly

This client's initial vital signs show tachycardia and hypotension, which are classic signs of hypovolemia. Normal capillary refill is less than 3 seconds and is an indication of normal hydration and perfusion (Option 1). Obligatory urine output is 30 mL/hr, and this client has 90 mL/hr. Urine output is one of the best indicators of adequate rehydration (Option 4). The urine specific gravity is within a normal range (1.003 to 1.030), which can indicate normal hydration (Option 5). (Option 2) Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock and would not indicate adequate rehydration. The client arrived with a narrow pulse pressure already. (Option 3) This is indicative of orthostatic vital signs. When a client stands, the body normally vasoconstricts to maintain the blood pressure from the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted, and there is no compensatory mechanism left to adjust to the position change. Educational objective:Signs of adequate hydration are normal urine specific gravity (1.003 to 1.030), adequate volume of urine output (>30 mL/hr), and capillary refill of less than 3 seconds. Pulse pressure narrows in shock, and positive orthostatic vital signs (decreasing systolic blood pressure and rising heart rate) with position change indicate dehydration.

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse? Select all that apply. 1. "Abusers often have a history of growing up in an environment of domestic violence." 2. "Abusers often have a history of substance abuse." 3. "Child abusers always present as being agitated or out of control." 4. "Most child abusers have a sense of low self-esteem." 5. "Teenage parents are particularly vulnerable to abusing their children." OmittedCorrect answer 1,2,4,5 27%Answered correctly

Typical characteristics of child abuse perpetrators include: Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child Confusion between punishment and discipline; having a stern, authoritative approach to discipline Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation (Option 1) Low self-esteem—a sense of incompetence or unworthiness as a parent (Option 4) A history of substance abuse; use of alcohol or drugs at the time the abuse occurs (Option 2) Punitive treatment and/or abuse as a child Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age (Option 5) Resentment or rejection of the child Low tolerance for frustration and poor impulse control Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury (Option 3) Child abusers are not easily identified by appearance; they often appear calm and well in control but may have violent outbursts, typically in private. Educational objective:Child abusers often have a history of growing up in an environment of domestic violence and have a sense of low self-esteem. History of substance abuse is also a risk factor. Teenage parents are particularly vulnerable to abusing their children. Additional Information Psychosocial Integrity NCSBN Client Need

A client in the intensive care unit is receiving IV vancomycin and gentamicin. The nurse should monitor for which potential complication with the administration of these medications? 1. Blood in nasogastric tube drainage (1%) 2. Decrease in red blood cell (RBC) count (5%) 3. Increase in serum creatinine level (71%) 4. Onset of muscle aches and cramping (21%) OmittedCorrect answer 3 71%Answered correctly

Vancomycin and aminoglycosides (eg, gentamicin, amikacin, tobramycin) are strong antibiotics that can cause nephrotoxicity and ototoxicity. The client receiving these medications simultaneously would be at an even higher risk for these adverse reactions. The nurse should monitor the client's renal function by assessing blood urea nitrogen (BUN) and creatinine levels and measuring urinary output. Increased levels of BUN and creatinine may indicate kidney damage. The health care provider should be notified before continuing these medications. (Option 1) Blood in the nasogastric tube could be a complication of peptic ulcer disease and the use of nonsteroidal anti-inflammatory drugs and corticosteroids. (Option 2) A decrease in the RBC count may be evidence of bone marrow suppression that can occur with use of certain cancer drugs (eg, methotrexate). (Option 4) Muscle cramping can occur occasionally with use of gentamicin but is not an indication to stop the infusion. Muscle aching and cramping that may signify a complication occur with the use of statins (eg, atorvastatin, rosuvastatin) and fibrates (eg, gemfibrozil, fenofibrate). Educational objective:The nurse should recognize that the risk of nephrotoxicity and ototoxicity is potentiated when vancomycin and aminoglycosides (eg, gentamicin) are administered together. Kidney and hearing functions should be closely monitored in these clients. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistant Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply. 1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L) 2. Creatinine is 2.1 mg/dL (185.6 µmol/L) 3. Glucose is 140 mg/dL (7.7 mmol/L) 4. Hemoglobin is 15 g/dL (150 g/L) 5. Magnesium is 1.5 mEq/L (0.75 mmol/L) 6. White blood cell count is 14,000/mm3 (14.0 × 109/L) OmittedCorrect answer 1,2 37%Answered correctly

Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea associated with Clostridium difficile. Serum vancomycin trough level is monitored before the 4th dose (15-20 mg/L [10.4-13.8 µmol/L] is optimal). Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients receiving the drug due to increased risk of nephrotoxicity, especially in those with impaired renal function, receiving aminoglycosides, and who are >60 years old. The health care provider (HCP) can lower the dose, decrease the drug administration frequency, or discontinue vancomycin. It is important to know the baseline values of BUN and creatinine to monitor trending and identify if there is an increase. Before administering this drug, the nurse should notify the HCP that the client's BUN (60 mg/dL [21.4 mmol/L]) and creatinine (2.1 mg/dL [185.6 µmol/L]) are both increased. The normal range for BUN is 6-20 mg/dL (2.1-7.1 mmol/L) and creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). (Option 3) An elevated glucose level (>110 mg/dL [6.1 mmol/L]) is expected in a client with an infection due to physiological stress and gluconeogenesis; this does not need to be reported to the HCP. (Option 4) A hemoglobin level of 15 g/dL (150 g/L) is normal (13.2-17.3 g/dL [132-173 g/L] in adult men; 11.7-15.5 g/dL [117-155 g/L] in adult women) and does not need to be reported to the HCP. (Option 5) A magnesium level of 1.5 mEq/L (0.75 mmol/L) is normal (1.5-2.5 mEq/L [0.75-1.25 mmol/L]) and does not need to be reported to the HCP. (Option 6) A white blood cell count of 14,000/mm3 (14.0 × 109/L) is elevated and expected in a client with a serious infection; this does not need to be reported to the HCP. Educational objective:As nephrotoxicity can occur, monitoring of vancomycin trough level to maintain optimal drug level and renal function is indicated in clients receiving vancomycin, especially in those with impaired renal function and who are >60 years old.

The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply. 1. Avoid raw, unpeeled fruits or vegetables 2. Limit contact with infected pets 3. Use insect (mosquito) repellent 4. Wash all bedding in hot water 5. Wear long-sleeved, light-colored clothes OmittedCorrect answer 3,5 39%Answered correctly

West Nile virus is a mosquito-borne disease (encephalitis) that occurs mainly during the summer months, especially during humid weather. Prevention focuses on avoiding mosquitoes and using an insect repellent. Prevention also includes wearing long sleeves, long pants, and light colors and avoiding outdoor activities at dawn and dusk when mosquitoes are most active (Options 3 and 5). (Option 1) Food and water precautions are emphasized for infectious diseases contracted through contaminated water or food, such as hepatitis A or typhoid (enteric) fever. (Option 2) Limiting contact with infected pets is classic advice for avoiding ringworm, a superficial fungal skin infection. (Option 4) Washing bedding in hot water is a classic instruction to help reduce allergies/asthma (eg, commonly from mites) or scabies (a contagious skin infection caused by mites). Educational objective:West Nile virus is transmitted by an infected mosquito bite. Prevention focuses on avoiding mosquitoes and using a mosquito repellent. Prevention also includes keeping arms and legs covered with light-colored clothing and avoiding outdoor activities at dawn and dusk.