mynclex set 3 - 43

/The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body. During the first 24 hours, the nurse would anticipate which of the following assessments? 1. Hemoglobin 10.2 g/dL (102 g/L) (13%) 2. Hyperactive bowel sounds (1%) 3. Serum sodium 152 mEq/L (152 mmol/L) (43%) 4. Tall, peaked T waves on ECG (41%) OmittedCorrect answer 4 41%Answered correctly

Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third spacing). In the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the surrounding interstitium, causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia. Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia (potassium >5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG changes (tall, peaked T waves, shortened QT interval), and cardiac arrhythmias (Option 4). (Option 1) Hematocrit and hemoglobin values will be elevated due to hypovolemia (hemoconcentration). (Option 2) The sympathetic nervous system is activated in response to a burn, causing decreased peristalsis. Nausea, vomiting, gastric distension, and paralytic ileus may occur. (Option 3) Sodium is the most abundant extracellular cation. Hyponatremia (sodium <135 mEq/L [135 mmol/L]) occurs as sodium is lost via fluid shifts and insensible losses. Educational objective:Burn injuries cause cellular destruction, capillary leaking, and fluid shifts. Fluids are lost during the emergent phase (first 24-72 hours), resulting in hypovolemia and hyponatremia. The blood becomes more viscous and increased hematocrit and hemoglobin values result. Cellular damage releases potassium, which causes hyperkalemia. Additional Information Physiological Adaptation NCSBN Client Need

/A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? 1. Expressive speech, vision (72%) 2. Light touch, hearing (3%) 3. Sense of position, graphesthesia (16%) 4. Weber tuning fork test, cranial nerve I (7%) OmittedCorrect answer 1 72%Answered correctly

Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech (Broca area), and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lobe, where vision is processed. (Option 2) The temporal lobe (lateral aspect of the brain) controls hearing and integrates sensory data (eg, auditory, visual, somatic). The Wernicke speech area in the temporal lobe is responsible for language comprehension. Light touch is processed by the sensory cortex in the parietal lobe. (Option 3) An interruption of sensory function indicates injury to either the spinal column or the parietal lobe. These injuries affect proprioception (awareness of body positioning) and graphesthesia (ability to identify writing on the skin, by touch). (Option 4) The Weber test screens for conductive hearing loss by checking whether a tuning fork held along the midline of the head is heard evenly in both ears. Cranial nerve I is the olfactory nerve. Hearing and smell are both processed by the temporal lobe. Educational objective:Coup-contrecoup injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision.

/An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's first action? 1. Administer analgesia (12%) 2. Apply an ice pack to the wrist (10%) 3. Assess capillary refill and sensation (64%) 4. Elevate the wrist above heart level (12%) OmittedCorrect answer 3 64%Answered correctly

A Colles' fracture is a type of wrist fracture (distal radius fracture) that causes a characteristic dinner fork deformity of the wrist. It usually occurs when the client tries to break a fall with an outstretched arm or hand, and lands on the heel of the hand. It is one of the most common fractures in women age >50 and is related to osteopenia or osteoporosis. While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing interventions should include: Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent reduction of the fracture is indicated. Administering analgesia to promote comfort (Option 1). Applying an ice pack to the wrist to help reduce edema and inflammation (Option 2). Elevating the extremity on a pillow above heart level to reduce edema (Option 4). Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion. Educational objective:While a client with a traumatic wrist fracture is undergoing evaluation by the HCP in the ED to determine appropriate treatment, the nurse assesses circulation, sensation, and movement of the affected hand, and then performs nursing interventions to reduce pain and edema.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help (3%) 2. Delegate the task to unlicensed assistive personnel (1%) 3. Premedicate the client for pain (7%) 4. Verify the client's activity prescription (88%) OmittedCorrect answer 4 88%Answered correctly

A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option 3) The nurse should assess the client's pain level before providing pain medication. Educational objective:The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? Select all that apply. 1. Apple juice 2. Cherry popsicle 3. Chicken broth 4. Frozen yogurt 5. Unsweetened tea 6. Vanilla ice cream OmittedCorrect answer 1,3,5 37%Answered correctly

A client recovering from abdominal surgery first consumes ice chips after demonstrating adequate bowel function (return of bowel sounds and passing flatus). After ice chips, postoperative diet progression continues to clear liquids, full liquids, soft diet, and then regular diet. Unsweetened tea, chicken broth, and apple juice are appropriate food choices for a client on a clear liquid diet (Options 1, 3, and 5). (Option 2) Popsicles are part of a clear liquid diet. However, red dyes in clear liquids (eg, cherry popsicles, red gelatin) should not be given to clients with recent gastrointestinal bleeding. If a client vomits, the vomitus may appear red and falsely lead the nurse to believe that the client is bleeding. It is important to implement prudent nursing judgment and fully consider the client's condition when making care decisions; for this client, a green or yellow popsicle would be more appropriate. (Options 4 and 6) Frozen yogurt and vanilla ice cream are appropriate food choices for a client on a full liquid diet. Educational objective:A postoperative diet begins with ice chips and progresses to clear liquids, full liquids, soft diet, and then regular diet. Clear liquids with red dyes should not be given to clients with recent gastrointestinal bleeding. Additional Information Basic Care and Comfort NCSBN Client Need

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the best response by the nurse? 1. "But you look so thin." (0%) 2. "I don't see you that way; you are making progress toward a healthy weight." (86%) 3. "If you continue to gain weight at this rate, you will be able to go home soon." (10%) 4. "You are not fat; it's all in your imagination." (2%) OmittedCorrect answer 2 86%Answered correctly

A nursing diagnosis associated with anorexia nervosa is disturbed body image/low self esteem. There is often a large disparity between actual weight and the client's perceived weight. Clients with anorexia nervosa think of themselves as overweight and fat. The nursing care plan should include helping the client develop a realistic perception of weight and body image. The nurse can confront the client about the misinterpretation of body weight by presenting reality without challenging the client's illogical thinking. The client's weight should be discussed in the context of overall health. The nurse also needs to be aware of his/her own reaction to the client's behaviors and statement. It is not uncommon for caregivers and care providers to feel frustrated or even angry when caring for a client with an eating disorder. The nurse must maintain a neutral attitude and approach, avoiding arguing or disagreeing with the client's statements. (Option 1) This response is judgmental, reinforces the idea of "thinness," and does not help the client develop a more realistic body image. (Option 3) Establishing a goal weight is part of the nursing care plan for the client with anorexia nervosa; clients are usually not discharged from inpatient treatment until goal weight is achieved. However, this response does not address the client's misperception of body weight. (Option 4) This response dismisses the client's concern and does not present the reality of the situation. Educational objective:Clients with anorexia nervosa have disturbed body image and see themselves as being fat or overweight even when they are severely underweight or even at a normal body weight. The nurse can help the client develop a more realistic self image by presenting the situation realistically and discussing weight in terms of the client's health.

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam (9%) 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L) (16%) 3. Administered warfarin to a client with International Normalized Ratio of 6 (64%) 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg (8%) OmittedCorrect answer 3 64%Answered correctly

A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4. (Option 1) Flumazenil is the appropriate antidote for a benzodiazepine overdose. (Option 2) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent hypoglycemia. This is an appropriate action. (Option 4) Nitroprusside is a potent vasodilator often used for hypertensive urgencies. Educational objective:The target International Normalized Ratio (INR) for most conditions in which warfarin is used is normally 2-3 and is occasionally 3.5. The risk of bleeding increases as the INR rises. Additional Information Management of Care NCSBN Client Need

A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first? 1. Check the vital signs (41%) 2. Draw blood for hemoglobin and hematocrit (1%) 3. Lower the head of the bed (31%) 4. Maintain an IV line with normal saline (24%) OmittedCorrect answer 3 31%Answered correctly

Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions. (Option 1) Assessing and recording vital signs is appropriate and should be reported to the health care provider, but this is not the priority. (Option 2) Monitoring hemoglobin and hematocrit levels is appropriate to assess the severity of blood loss and need for possible blood transfusion. Blood loss typically takes a few hours to reflect on the client's laboratory report; therefore, this is not the priority. (Option 4) Ensuring IV access and continuing fluid administration is appropriate. This maintains fluid volume due to blood loss and corrects or reduces potential for hypovolemic shock. This can be done after lowering the head of the bed. Educational objective:A client with significant blood loss has a medical emergency, and interventions that will hemodynamically stabilize the client should take priority.

/The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up? 1. A bruit cannot be auscultated over the fistula site (88%) 2. Capillary refill of 2 seconds is assessed on the left hand (2%) 3. Client reports squeezing a rubber ball with the left hand several times daily (8%) 4. Incision is dry with no redness and has sterile skin closures in place (0%) OmittedCorrect answer 1 88%Answered correctly

An arteriovenous fistula is a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in clients with kidney disease. Arterial blood flowing through this vein causes it to engorge and thicken (mature) over a period of several weeks, after which it can sustain frequent access by 2 large-bore needles required for dialysis. Maturing of the fistula is aided by having the client perform hand exercises, such as squeezing a rubber ball, that increase blood flow through the vein. Following fistula placement, it is important to monitor for patency. A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula. Absence of the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can also signal potential clotting. (Option 2) Capillary refill of <3 seconds is considered normal and indicates acceptable blood flow to the area. (Option 3) Daily hand exercises such as squeezing handgrips or a rubber ball are performed to help properly mature the fistula. (Option 4) A dry surgical incision without redness, warmth, and induration is an optimal finding. Sterile skin closures (eg, Steri-Strips) are used to help hold the incision together as it heals. Educational objective:Following placement of an arteriovenous fistula, it is imperative to monitor for signs of potential clotting of the fistula such as absence of a bruit, absence of a thrill, decreased capillary refill, and coolness of the extremity below the fistula.

/The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured femur. Which of the following interventions are appropriate to include in the client's plan of care? Select all that apply. 1. Assess for increasing drainage from pin sites 2. Check for loose pins and tighten them if loose 3. Maintain bed rest until the device is removed 4. Monitor pulses distal to the external fixation device 5. Perform pin care with a sterile cleaning solution OmittedCorrect answer 1,4,5 37%Answered correctly

An external fixator is a device used to stabilize broken bones; metal pins are placed through the tissue into the bone and connect to a frame outside the skin. The nurse should monitor clients with external fixation closely for signs of neurovascular compromise and pin site infection, which can lead to osteomyelitis. When caring for clients with external fixation, the nurse can help prevent infection and maintain extremity and device integrity by: Assessing the pin sites regularly for new, increased, and/or purulent drainage and checking the skin surrounding the pins for erythema, warmth, pain, or breakdown (Option 1) Assessing for signs of compartment syndrome (eg, decreased pulses, coolness, pain, numbness) (Option 4) Performing pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze (Option 5) Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose (Option 2) The nurse should never manipulate loose pins but should instead notify the HCP immediately if loose pins are noted on assessment. (Option 3) The nurse should promote early mobilization for clients with external fixation devices. Some clients may begin walking with physical therapy the day after surgery. Educational objective:When caring for clients with external fixation, the nurse should assess for signs of infection (eg, pin site drainage), perform pin care with a sterile cleaning solution, assess for loose pins, monitor for signs of neurovascular impairment (eg, decreased pulses, coolness), and promote early mobilization. Additional Information Reduction of Risk Potential NCSBN Client Need

A client comes to the emergency department following a bee sting. The client has a diffuse rash, hypotension, and throat tightness. One injection of IM epinephrine does not improve the client's condition. What action should the nurse take next? 1. Administer IV fluid bolus (7%) 2. Administer methylprednisolone (20%) 3. Prepare for emergency cricothyrotomy (14%) 4. Repeat IM epinephrine injection (57%) OmittedCorrect answer 4 57%Answered correctly

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine), can lead to cardiac/respiratory arrest. The management of anaphylactic shock includes: Ensure patent airway, administer oxygen Remove insect stinger if present IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes. Place in recumbent position and elevate legs Maintain blood pressure with IV fluids, volume expanders or vasopressors Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema (Option 1, 2, and 3) These are appropriate responses that should come after a repeat dose of epinephrine has been given. Educational objective:IM epinephrine is the single most important medication to be given in anaphylactic shock. The dose should be repeated every 5-15 minutes if symptoms are still present. Antihistamines, corticosteroids, and IV fluids are other supportive treatments.

The nurse receives laboratory reports on 4 clients. Which report is most concerning and should be reported to the health care provider? 1. The client admitted with asthma exacerbation who has a PaCO2 of 32 mm Hg (4.26 kPa) (20%) 2. The client diagnosed with chronic obstructive pulmonary disease whose latest arterial blood gas shows a PaO2 of 85 mm Hg (11.33 kPa) (11%) 3. The client receiving warfarin for atrial fibrillation whose morning laboratory report includes an INR of 2.5 (7%) 4. The client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL (70 g/L) (59%) OmittedCorrect answer 4 59%Answered correctly

Blood loss is a common complication of a total knee replacement, and a hemoglobin level of 7 g/dL (70 g/L) is very low (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]). This client needs to be assessed for any active bleeding as well as for respiratory and cardiac complications (eg, rapid pulse, shortness of breath) resulting from the low hemoglobin level. The health care provider must be notified. (Option 1) Normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). Clients with asthma exacerbations, as well as those with panic attacks, pulmonary embolism, and pneumonia, will have rapid breathing. In all of these conditions, this rapid breathing pushes more CO2 out of lungs, with a mild decrease in PaCO2 as the body's expected compensatory response. In these clients, retention of CO2 (or even normal PaCO2) is more dangerous as it indicates respiratory muscle fatigue (failure) resulting in retention of PaCO2. (Option 2) PaO2 >80 mm Hg (10.66 kPa) is considered a normal finding. In clients with chronic obstructive pulmonary disease (COPD), airflow out of the lungs is impeded, trapping CO2 in the lungs. The body adjusts to the higher CO2 level (which would cause an increase in respirations in a non-COPD client) and then uses the PaO2 as the drive for breathing. (Option 3) Warfarin is prescribed to prevent blood clotting in clients with atrial fibrillation. To be therapeutic and prevent clotting, the dosage of warfarin is adjusted to maintain an INR of 2-3. This client's INR is therapeutic for the diagnosis of atrial fibrillation. Educational objective:Blood loss is a common complication of a total knee replacement. Monitoring the client postoperatively for signs of blood loss and active bleeding is a priority. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation? 1. B-type natriuretic peptide (BNP) 1382 pg/mL [1382 pmol/L] (75%) 2. Flat jugular veins when seated at a 45-degree angle (6%) 3. Sodium 150 mEq/L [150 mmol/L] (13%) 4. Urine output greater than 100 mL/hr (5%) OmittedCorrect answer 1 75%Answered correctly

Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of left ventricular filling pressure elevation and mortality. A normal BNP level is <100 pg/mL [<100 pmol/L]. The nurse would expect a high BNP in a client exhibiting symptoms of acute decompensated heart failure. (Option 2) Jugular veins should normally flatten and disappear as the client is raised to an upright position. Jugular venous distension present above a 45-degree seated position indicates fluid volume excess and elevated cardiac filling pressures that occur with heart failure. (Option 3) Normal sodium level is 135-145 mEq/L [135-145 mmol/L]. Serum sodium can be normal or low in heart failure clients. Low levels are due to dilution from excess free water. (Option 4) Urine output of 100 mL/hr should be adequate to maintain fluid volume status. Inadequate urine output may cause fluid retention and volume overload, precipitating an exacerbation of heart failure. A state of low cardiac output may also decrease renal perfusion, resulting in renal dysfunction and decreased urine output. Diuretic therapy is the mainstay treatment for fluid volume overload. The nurse should expect to see an increase in urine output in response to diuretic administration. Educational objective:The nurse should assess the BNP level in clients admitted with heart failure exacerbations. Elevated BNP levels indicate increased ventricular stretch and correlate with severity of heart failure and fluid volume overload. Heart failure clients may also present with jugular venous distension, low serum sodium, and decreased urine output. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse in an ambulatory care center is teaching a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching? 1. "If I have a sudden change in my mood, I should call my physician immediately." (9%) 2. "If I have trouble swallowing the tablet, I can cut it in half." (81%) 3. "If I miss a dose, I should not double the next dose to catch up." (5%) 4. "It may take several weeks before I get better." (3%) OmittedCorrect answer 2 81%Answered correctly

Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major depressive disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of bupropion hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets. Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too rapid absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed whole, with or without food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion hydrochloride. Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual behavior or mood changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of depression and/or their family members need education and information on the increased risk of suicide (Option 1). Additional instructions to a client about the use of bupropion hydrochloride include the following: Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol Do not double up on the medication if a scheduled dose is missed (Option 3) Take the medication at the same time each day It may take several weeks to feel the effects of bupropion hydrochloride (Option 4) Weight loss may occur when taking this medication Educational objective:No form of bupropion hydrochloride should be crushed, chewed, or cut due to the risk of seizures and other adverse effects caused by the more rapid absorption and resulting higher serum levels of the drug. No medications labeled SR or XL should be altered before they are administered. This type of medication preparation should be swallowed whole.

/The nurse educator is completing a staff education conference about prenatal carrier screening. Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis? 1. "Both parents must be carriers of the abnormal gene for offspring to have the disorder." (57%) 2. "Female offspring are most often affected by the inheritance pattern of cystic fibrosis." (19%) 3. "If the female partner is a carrier, only male offspring will have the disorder." (14%) 4. "The inheritance pattern for cystic fibrosis does not skip generations." (8%) OmittedCorrect answer 1 57%Answered correctly

Carrier screening offers clients who are unaffected by a genetic disorder the option to discover whether they possess an abnormal gene (ie, are carriers) that may affect health outcomes of future offspring. This type of genetic testing is frequently offered preconceptionally/prenatally to guide pregnancy decision-making. Cystic fibrosis follows an autosomal recessive inheritance pattern, meaning that offspring must receive two abnormal genes (one from each parent) to be affected with the disorder (Option 1). Other disorders following this inheritance pattern include phenylketonuria, Tay-Sachs disease, and sickle cell disease. (Option 2) Male and female offspring have the same likelihood of inheriting autosomal recessive disorders because the abnormal gene is not linked to a sex chromosome. (Option 3) X-linked recessive disorders (eg, hemophilia, Duchenne muscular dystrophy) most often affect male offspring. This inheritance pattern occurs because male offspring who receive an abnormal sex chromosome from a female carrier (ie, X chromosome) will have the disorder because, unlike female offspring, they only have one X chromosome. (Option 4) Because carriers with no evidence of the disorder can pass an abnormal gene to offspring, autosomal recessive conditions may not present in every generation. However, autosomal dominant inheritance patterns (eg, Huntington disease, achondroplasia) are noted in each previous generation because affected offspring must have an affected parent. Educational objective:Cystic fibrosis is a disorder with an autosomal recessive inheritance pattern. Affected offspring must inherit two abnormal genes (one from each parent). Male and female offspring are equally affected because the disorder is not sex-linked.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? 1. The client has acute urinary retention (66%) 2. The client is confused and incontinent (18%) 3. The client is elderly and at risk for falls (4%) 4. The client is receiving intravenous diuretics (10%) OmittedCorrect answer 1 66%Answered correctly

Catheter-associated urinary tract infections are prevalent in hospital settings. Only indwelling urinary catheters should be used when appropriate. Appropriate uses include the following: Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery During prolonged immobilization when bedrest is essential To improve end-of-life comfort To facilitate healing of an open perineal or sacral wound in incontinent clients Inappropriate uses include the following: Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently (Options 2, 3, and 4) For obtaining a urine culture when the client can follow instructions and void voluntarily Postoperatively for prolonged periods when other appropriate indications are not present Educational objective:The use of indwelling urinary catheters should be minimized during hospitalization. Appropriate use includes urinary obstruction or retention, some perioperative circumstances, required prolonged immobilization, end-of-life comfort, and facilitating healing of an open perineal or sacral wound. Indwelling urinary catheters should not be used for convenience or as a substitute for nursing care. Additional Information Safety and Infection Control NCSBN Client Need

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? Select all that apply. 1. Client is on a calorie-restricted diet for obesity 2. Creatinine is 1.3 mg/dL (115 µmol/L) 3. History of congenital heart disease 4. International Normalized Ratio of 2.5 5. Presence of prosthetic valve OmittedCorrect answer 3,4,5 36%Answered correctly

Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures (eg, dental work). These clients should receive prophylactic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated International Normalized Ratio (2.0-3.0) to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures (Options 3, 4, and 5). (Option 1) A history of obesity and a calorie-restricted diet are not significant for oral surgery. (Option 2) This creatinine level is within normal limits (0.6-1.3 mg/dL [53-115 µmol/L]) and would not require reporting. Educational objective:Prior to oral surgery, it is necessary to report findings that will place a client at risk for the development of endocarditis (eg, presence of prosthetic valves, history of congenital heart disease) and bleeding (eg, elevated International Normalized Ratio). Additional Information Reduction of Risk Potential NCSBN Client Need

EX- Vital signs Temperature-98.4 F (36.9 C) Blood pressure-124/78 mm Hg Heart rate-46/min and irregularly irregular Respirations-22/min The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information. 1. Diltiazem extended-release PO 2. Heparin subcutaneous injection 3. Lisinopril PO 4. Metoprolol PO 5. Timolol ophthalmic OmittedCorrect answer 2,3 10%Answered correctly

Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate [HR] <60/min). Therefore, medications that can decrease HR should be held and the health care provider (HCP) notified. The reason for holding the medication (HR 46/min) and an HCP contact note should be documented. Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and is safe to administer (Option 2). Lisinopril, an ACE inhibitor, does not lower HR and is not contraindicated in clients with bradycardia (Option 3). The client is not hypotensive; therefore, lisinopril is safe to administer. (Option 1) Non-dihydropyridine calcium channel blockers (eg, diltiazem, verapamil) can decrease HR and should be held in clients with bradycardia. (Options 4 and 5) All beta blockers (eg, metoprolol, timolol, atenolol), including eye drops that can be absorbed systemically, can decrease the HR and should be held until the prescriptions can be clarified by the HCP. Educational objective:Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol and timolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil).

The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse? 1. "I will raise the head of the bed so it is easier to see the television." (15%) 2. "I will turn down the lights when I leave." (1%) 3. "Let me move your belongings closer so you can reach them." (1%) 4. "You should do deep breathing and coughing exercises." (81%) OmittedCorrect answer 4 81%Answered correctly

Clients with elevated ICP should avoid anything that increases intrathoracic or intraabdominal pressure as these also indirectly increase ICP. These activities include straining, coughing, and blowing the nose. Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The head of the bed should be maintained at 30 degrees, high enough to allow for cerebrospinal fluid drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli, including no bright lights or multiple visitors, as stimulation can increase ICP. (Option 1) The head of the bed should be raised to 30 degrees and maintained. This may require follow-up, but not immediate intervention, by the nurse. (Option 2) Turning down the lights is appropriate as clients with ICP benefit from a quiet, nonstimulating environment. (Option 3) Bringing items closer to the client prevents straining from reaching and is appropriate. Educational objective:Clients with increased ICP should be encouraged not to cough, strain, or increase abdominal or thoracic pressure. The head of the bed should be maintained at 30 degrees, and stimulation in the room should be minimized.

/A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take? 1. Give scheduled dose of metoprolol 50 mg orally (1%) 2. Instruct client to cough forcefully (7%) 3. Place client in reverse Trendelenburg position (23%) 4. Prepare to administer atropine 0.5 mg intravenous (IV) push (67%) OmittedCorrect answer 4 67%Answered correctly

Clients with symptomatic bradycardia should be treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine should be considered. (Option 1) Metoprolol is a beta blocker and would further reduce the heart rate. The nurse should not administer this medication and instead notify the health care provider. (Option 2) A forceful cough may cause a vasovagal reaction and further reduce the heart rate. (Option 3) The Trendelenburg position, not the reverse Trendelenburg position, is used with clients with hypotension. Educational objective:The client with symptomatic bradycardia should be treated initially with IV atropine. Transcutaneous pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective.

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? 1. "I am not sleeping well at night and would like a sleeping aid." (7%) 2. "I do not know how well I will do on this restricted diet." (9%) 3. "I have been having quite a bit of nausea and constipation." (15%) 4. "This medicine is not working; I am so tired of being depressed." (67%) OmittedCorrect answer 4 67%Answered correctly

Commonly used monoamine oxidase inhibitors (MAOIs) include isocarboxazid, phenelzine, and tranylcypromine. These first-generation antidepressants are used only for resistant depression due to serious adverse affects. These medications inhibit the enzyme that breaks up norepinephrine, serotonin, and dopamine, thereby increasing their availability in the body. Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present (Option 4). (Option 1) MAOIs should be administered in the morning, as sleep dysfunction is common. This client statement should prompt a discussion of current medication habits, but is not the priority. (Option 2) Clients taking MAOIs need to avoid tyramine-containing foods (eg, cheese, overripe fruit, liquor, beef/chicken liver, fermented products) due to risk of hypertensive crisis. A medication change might be considered if a client is unable to adhere to the restrictions, but would not be priority. (Option 3) Nausea and constipation are adverse effects of MAOIs. Although strategies for management of adverse effects should be discussed, this is not priority. Educational objective:MAOIs and other antidepressants are associated with increased risk of suicidal ideation during the first few weeks of treatment. Clients taking MAOIs need to avoid tyramine-containing foods due to risk of hypertensive crisis. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? Select all that apply. 1. Elevate the head of the hospital bed 2. Instruct the client to avoid tobacco and caffeine 3. Offer small, frequent, low-fat meals 4. Provide a girdle to reduce the hernia 5. Teach the client to avoid lifting or straining OmittedCorrect answer 1,2,3,5 33%Answered correctly

Conditions that increase intraabdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting) and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia (rolling hernia) occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased intraabdominal pressure or supine positioning. Interventions to reduce herniation include the following: Diet modification—avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric distension. Avoid consumption of meals close to bedtime and nocturnal eating (Option 3). Lifestyle changes—smoking cessation, weight loss (Option 2). Avoid lifting or straining (Option 5). Elevate the head of the bed to approximately 30 degrees—this can be done at home using pillows or 4 - 6 inch blocks under the bed (Option 1). (Option 4) Wearing a girdle or tight clothes increases intraabdominal pressure and should be avoided. Educational objective:Hiatal hernias occur due to a weakening diaphragm and increased intraabdominal pressure. Nursing interventions to prevent hiatal hernias are similar to those used for gastroesophageal reflux disease (GERD), and they focus on decreasing intraabdominal pressure.

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required? 1. "I may experience flushing but will continue to take the medication as prescribed." (17%) 2. "I should lie down before taking the medication." (22%) 3. "I should not swallow the tablet." (2%) 4. "I will wait to call 911 if I don't experience relief after the third tablet." (57%) OmittedCorrect answer 4 57%Answered correctly

Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4). NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead. (Option 1) Headache and flushing are common side effects of NTG due to systemic vasodilation. (Option 2) The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension. Educational objective:The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed.

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection? 1. Assist the client to the shower and provide directions to use antibacterial soap (8%) 2. Delay the bath until the client has received antibiotic therapy for 24 hours (13%) 3. Use a bath basin with warm water and a new wash cloth for each body area (35%) 4. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client (42%) OmittedCorrect answer 4 42%Answered correctly

Current evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection. (Option 1) This action may be appropriate for a client in the home setting. However, most clients in the ICU are unable to go to the shower or have monitoring equipment and/or invasive lines that would make bathing difficult. Chlorhexidine is recommended in the hospital setting. (Option 2) It is not appropriate to delay bathing as the client's skin and incision need to be cleaned. Delay should only occur if the client is unstable. (Option 3) This option would be appropriate if the bath water contained a solution of chlorhexidine. Educational objective:Pre-moistened cloths or warm water with a chlorhexidine solution should be used when bathing clients infected with MRSA or other drug-resistant organisms.

/Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply. 1. "Avoid foods that may cause epigastric distress such as spicy or acidic foods." 2. "It is best if you refrain from consuming alcohol products." 3. "Report black tarry stools to your health care provider immediately." 4. "Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days." 5. "You may take over-the-counter drugs such as aspirin if you have mild epigastric pain." OmittedCorrect answer 1,2,3,4 49%Answered correctly

Discharge instructions for peptic ulcer disease Lifestylemodifications Avoid spicy foods, acidic foods, black pepper. Avoid substances that may stimulate acid secretion & delay healing (eg, nonsteroidal anti-inflammatory drugs, alcohol, caffeine, chocolate, tobacco). Reduce stress & obtain sufficient rest. Complications Call health care provider if signs of these complications are present:Gastrointestinal bleeding: Orthostatic hypotension (lightheadedness, dizziness), tachycardia & melena/black stoolsPerforation: Increased epigastric pain, nausea, vomiting & fever Medications Take prescribed triple-drug therapy to avoid relapse. Client teaching related to peptic ulcer disease (PUD) includes lifestyle changes (eg, dietary modifications, stress reduction), PUD complications, and medication administration. Helicobacter pylori infection and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors for complicated PUD. H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin). (Option 5) Clients with PUD should avoid NSAIDs [eg, aspirin, ibuprofen (Motrin)] as they inhibit prostaglandin synthesis, increase gastric secretion, and reduce the integrity of the mucosal barrier. Educational objective:Clients with peptic ulcer disease should avoid NSAIDs, smoking, and excess use of alcohol or caffeine.

The public health nurse has received a referral to make a follow-up home visit to a 1-year-old recently diagnosed with failure to thrive (FTT). Which intervention is the priority nursing action for this child? 1. Assess overall parenting skills (10%) 2. Complete a 24-hour dietary intake (8%) 3. Measure the child's height, weight, and head circumference (52%) 4. Observe the child feeding (28%) OmittedCorrect answer 4 28%Answered correctly

FTT is generally defined as weight less than 80% of ideal for age and/or depressed weight for length, correcting for gestational age, sex, and special medical conditions. The underlying cause of FTT is inadequate dietary intake; contributing factors include a disturbance in feeding behavior and psychosocial factors. Observing the child feeding or when hungry will provide the nurse the opportunity to identify potential factors contributing to insufficient intake. The nurse can observe the type of food being offered, the quantity of food consumed, how the child is held or positioned while being fed, the amount of time for feeding, the parent's response to the child's cues, the tone of the feeding, and the interaction between the child and the parent. (Option 1) As part of the home visit, the nurse will assess overall parenting skills. It is most important for the focus of the visit to be on the nutritional intake of the child and the feeding experience. (Option 2) A 24-hour dietary intake is an assessment tool to obtain information regarding nutritional intake. However, because the child's intake would be reported by the parent, it may not be accurate and does not provide information about what takes place during the feeding itself. (Option 3) This is an appropriate nursing action, but it provides no information about the factors contributing to the child's insufficient intake. Educational objective:FTT is generally defined as weight less than 80% of ideal for age and/or depressed weight for length, correcting for gestational age, sex, and special medical conditions. Observation of the child while being fed may provide information related to the cause of inadequate dietary intake, including disturbances in feeding behavior and psychosocial factors.

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which instructions related to this medication should the nurse provide? Select all that apply. 1. Apply a heating pad over the patch to aid drug absorption 2. Cut the patch in half before application if less medication is needed 3. Fold the used patch in half so that the edges adhere and immediately discard 4. Place the patch 1 in (2.5 cm) from the source of pain for maximal effectiveness 5. Remove the old patch when applying a new patch every 72 hours OmittedCorrect answer 3,5 44%Answered correctly

Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one (Option 5). Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregivers (Option 3). (Option 1) Heat (eg, heating pad) should not be placed over a patch as this accelerates absorption. (Option 2) Cutting a transdermal patch damages the drug-delivery system, results in administration of an imprecise dose, and risks exposure to the person cutting the patch. (Option 4) Transdermal patches should be applied to an area of flat, intact skin (eg, upper back, chest) to prevent accidental removal. The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain. Educational objective:Fentanyl patches are changed every 72 hours, and used patches must be folded and discarded securely before a new one is applied. Patches should be applied to flat, intact skin to prevent accidental removal. Patches should not be cut, and heat should not be placed over them.

/A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? Select all that apply. 1. Add the medication to the bottle of formula before feeding 2. Direct liquid medication toward the inside of the infant's cheek 3. Hold the infant in a semi-reclining position during administration 4. Measure and administer the medication using an oral syringe 5. Open the infant's mouth by gently pinching the nose shut OmittedCorrect answer 2,3,4 65%Answered correctly

Giving oral medications to infants requires specialized techniques for safe administration. A plastic, disposable oral syringe can be used for accurate dosing and ease of delivery (Option 4). Oral medication should be administered with the infant in a semi-reclining position, which is similar to the feeding position (Option 3). This position promotes comfort, prevents aspiration, and may be better controlled by the nurse if the infant resists the medication. Liquid medications administered by oral syringe should be directed toward the back and inside of the infant's cheek (Option 2). The medication should be dispensed slowly in small amounts, allowing the infant to swallow between squirts to prevent aspiration. (Option 1) Medications are never mixed in a bottle of infant formula as this can affect the taste and the infant may then refuse the formula in the future. In addition, if the infant does not complete the full feed, underdosing will occur. (Option 5) Pinching the nose shut during medication administration may cause aspiration. The infant's mouth should be opened by applying gentle pressure to the chin or cheeks. Educational objective:Disposable oral syringes are the preferred tool to administer oral medications to infants. Infants should be held in a semi-reclining position, and medications should be given slowly in small amounts directed toward the back and inside of the cheek.

A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply. 1. Influenza injection 2. Influenza nasal spray 3. Measles, mumps, and rubella 4. Tetanus, diphtheria, and pertussis 5. Varicella OmittedCorrect answer 1,4 33%Answered correctly

Health promotion during pregnancy includes the administration or avoidance of certain vaccines to decrease risks to mother and fetus. Pregnant women have suppressed immune systems and are at increased risk for illness and subsequent complications. Some viruses (eg, rubella, varicella) can cause severe birth defects if contracted during pregnancy. Inactivated vaccines contain a "killed" version of the virus and pose no risk of causing illness from the vaccine. Some vaccines contain weakened (ie, attenuated) live virus and pose a slight theoretical risk of contracting the illness from the vaccine. For this reason, women should not receive live virus vaccines during pregnancy or become pregnant within 4 weeks of receiving such a vaccine. The tetanus, diphtheria, and pertussis (Tdap) vaccine is recommended for all pregnant women between the beginning of the 27th and the end of the 36th week of gestation as it provides the newborn with passive immunity against pertussis (whooping cough) (Option 4). During influenza season (October-March), it is safe and recommended for pregnant women to receive the injectable inactivated influenza vaccine regardless of trimester (Option 1). (Options 2, 3, and 5) The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses and are contraindicated in pregnancy. Educational objective:Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given during pregnancy to protect pregnant clients from illness and provide the fetus with passive immunity. Live virus vaccines are contraindicated in pregnancy. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Administers coagulation factor replacement IV push 2. Administers ibuprofen PO PRN for pain 3. Applies ice packs to the affected joint hourly for 15 minutes 4. Elevates the affected leg in the extended position 5. Performs neurologic assessment every 30 minutes for 6 hours OmittedCorrect answer 1,3,4,5 28%Answered correctly

Hemophilia is a group of disorders characterized by deficiencies in production or use of coagulation proteins (eg, factor VIII, factor IX), resulting in impaired clot formation and increased risk for uncontrolled bleeding. Hemophilia is typically identified by prolonged or excessive bleeding, severe bruising, or joint bleeding (ie, hemarthrosis) after injuries or procedures. Administration of supplemental IV clotting factors (eg, factor VIII, factor IX) is the primary treatment for acute bleeding in clients with hemophilia (Option 1). Clients with hemophilia have increased risk of hemarthrosis (ie, bleeding in joint). In addition to administration of IV clotting factors, hemarthrosis is managed with rest, ice, compression, and elevation (RICE). Application of ice or cold packs promotes local vasoconstriction and clot formation (Option 3). The affected joint should be maintained in the extended position to prevent flexion contracture (Option 4). Frequent neurologic assessments are required for clients with hemophilia who have suspected (facial laceration in this client) or confirmed head trauma, as neurologic alteration may indicate intracranial bleeding (Option 5). (Option 2) When caring for clients with hemophilia, the nurse should eliminate factors that increase bleeding risk or promote complications from bleeding. NSAIDs (eg, aspirin, ibuprofen) are avoided as they inhibit platelet aggregation, which increases bleeding risk Educational objective:For acute bleeding, clients with hemophilia are treated with supplemental IV clotting factors. Hemarthrosis is managed with rest, ice, compression, and elevation, and the affected joint should remain extended to prevent contractures. NSAIDs (eg, ibuprofen) increase bleeding risk and should be avoided for clients with hemophilia.

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? 1. Decrease mean arterial pressure (MAP) by no more than 25% (52%) 2. Keep blood pressure at or below 120/80 mm Hg (19%) 3. Maintain heart rate (HR) of 60-100/min (10%) 4. Maintain urine output of at least 30 mL/hr (17%) OmittedCorrect answer 1 52%Answered correctly

Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3 (Option 2) A blood pressure of 120/80 mm Hg (MAP 93 mm Hg) is too low for an initial goal. This rapid drop from the client's initial pressure of 250/145 mm Hg (MAP 180 mm Hg) is a decrease of greater than 25% and could cause organ damage. However, it may be necessary to lower the SBP below 120 mm Hg if the client is experiencing an aortic dissection, as a higher BP can cause rupture. (Option 3) The nurse should monitor HR and rhythm for signs of MI or heart failure. However, the priority goal for this client is to achieve a therapeutic blood pressure, not HR. (Option 4) The nurse should carefully monitor urine output as an indicator of renal function. Output should be greater than 30 mL/hr, but this is not the priority goal in management of hypertensive crisis. Educational objective:Hypertensive crisis may require continuous infusion of an IV vasodilator. BP should be lowered slowly to prevent organ damage. The initial goal is to lower MAP by 25% or less or to maintain MAP of 110-115 mm Hg. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse teaches disease management to a group of clients with type I diabetes mellitus. Which of the following should the nurse teach as signs or symptoms associated with hypoglycemia? Select all that apply. 1. Diaphoresis 2. Flushing 3. Pallor 4. Polyuria 5. Trembling OmittedCorrect answer 1,3,5 46%Answered correctly

Hypoglycemia (low blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication that occurs when levels of insulin exceed the proportion of glucose. Epinephrine is one of the major hormones released during a hypoglycemic reaction and may cause early symptoms such as trembling, palpitations, anxiety/arousal, and restlessness. Diaphoresis and pallor are present on examination. When the brain is deprived of glucose due to prolonged and severe hypoglycemia, neuroglycopenic symptoms (confusion, seizures, coma) develop. (Option 2) Flushing (red skin) is commonly seen with fever, carcinoid syndrome, polycythemia vera, and sexual intercourse. Flushing is not seen with hypoglycemia. (Option 4) Polyuria and weight loss are usually associated with hyperglycemia, not hypoglycemia. Educational objective:Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication. Signs and symptoms include shakiness, palpitations, anxiety/arousal, restlessness, diaphoresis, and pallor.

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? 1. Bradycardia (16%) 2. Hypokalemia (49%) 3. Nephrotoxicity (15%) 4. Ototoxicity (18%) OmittedCorrect answer 4 18%Answered correctly

IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min (Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide. (Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. (Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration. Educational objective:High doses of IV furosemide should be administered slowly to prevent ototoxicity.

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I don't know why this is being reported. I told the health care provider (HCP) that it was an accident." What is the best response by the nurse? 1. "A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then." (2%) 2. "Did you ask the HCP why it is being reported?" (1%) 3. "Reporting your child's injuries is required by law. It is for your child's safety and protection." (95%) 4. "Your explanation of your child's injuries does not seem plausible." (1%) OmittedCorrect answer 3 95%Answered correctly

In discussing the reporting aspect of suspected child abuse with a caregiver, the nurse needs to convey an attitude that is not judgmental, punitive, or threatening. Whether or not the parent has actually harmed or abused the child, the parent needs to know that a report will be made, why it is being filed, and an investigation will be conducted by a CPS worker and/or by the police. The nurse should emphasize that the primary concerns are for the safety and well-being of the child and that reporting is mandatory for the types of injuries sustained by the child. It is not unusual for a parent to react to this information with denial and/or anger. The nurse needs to anticipate that such a reaction may occur and maintain a supportive, empathetic, and nonaccusatory approach. (Option 1) This response also diverts the need for the nurse to provide a response or explanation to the parent. The child's caregiver should be told why the report is being filed. (Option 2) This response is nontherapeutic. It diverts the need for the nurse to respond to the parent's question, and it does not provide information or education. (Option 4) This response is confrontational and could give the parent the impression that the nurse and health care team do not believe the story of how the child sustained the injuries. The parent could react with a heightened sense of anger. Educational objective:When discussing suspected child abuse with a caregiver, the nurse needs to be supportive and empathetic and maintain a neutral, nonpunitive and nonaccusatory manner. The parent needs to be told that the safety and well-being of the child are the primary concerns and that certain types of injuries and/or situations must be reported to the appropriate CPS agencies.

The health care provider gives the preoperative nurse a signed consent form and walks away rapidly. The client turns to the nurse and states, "I don't know what is going on. Why do I need surgery?" What is the most appropriate action? 1. Call the nursing supervisor (8%) 2. Call the operating room scheduler and cancel the surgery (2%) 3. Page the health care provider and request clarification on behalf of the client (88%) 4. Report the incident to hospital administration (0%) OmittedCorrect answer 3 88%Answered correctly

Informed consent requires that the health care provider performing the procedure explain everything to the client's satisfaction (within reason). Signed consent may be witnessed by the nurse. If the client does not fully understand informed consent, the nurse must notify the health care provider or refer up the chain of nursing command. The nurse is not responsible for verifying that the client understands the procedure and its respective risks. (Option 1) This would be appropriate if the health care provider refuses to talk to the client. (Option 2) This is not the nurse's responsibility; this request would have to be relayed up the chain of nursing command. (Option 4) This is premature; the incident is isolated and not all facts are known. Educational objective:Clients may not consent to an invasive procedure without being informed of the clinical reasoning, consequences, and possible complications.

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? 1. "I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." (58%) 2. "I will immediately change the tracheostomy tube if my child has difficulty breathing." (8%) 3. "I will provide deep suctioning frequently to prevent any airway obstruction." (21%) 4. "I will remove the humidifier if my child starts developing more secretions." (11%) OmittedCorrect answer 1 58%Answered correctly

In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. (Option 2) Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. (Option 3) A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning. (Option 4) Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect. Educational objective:Clients with a tracheostomy should always carry two spare tubes, one the same size and one a size smaller, to ensure that the tube can be replaced quickly and effectively. Additional Information Reduction of Risk Potential NCSBN Client Need

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction? 1. Ensure that the client is never left alone (34%) 2. Notify neighbors of the client's tendency to wander (1%) 3. Place a chain lock on the door above or below the client's eye level (33%) 4. Place a safe return bracelet on the client's non-dominant hand (30%) OmittedCorrect answer 3 33%Answered correctly

Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads (Option 3). Adding a motion sensor or alarm that goes off when someone tries to exit Placing a large stop sign on door exits Disguising a door with a curtain or wall hanging Using childproof doorknob covers Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. (Option 1) Clients with AD should not be left alone; however, it is impossible for any caregiver to watch another person every minute of the day. Clients with AD can walk out of their homes while family members are sleeping. (Option 2) Notifying neighbors can be helpful if the client leaves the residence but will not prevent wandering. (Option 4) Safe return or identification bracelets are important, but they will not prevent wandering. A bracelet should be placed on the dominant hand to minimize the chance of removal. Educational objective:The most effective strategy to prevent clients with dementia from wandering is to make modifications to secure their environment. These include installing locks above or below eye level on doors, hiding exits with wall hangings or curtains, placing a black mat in front of exits, and using doorknob covers, motion detectors, and alarms.

The nurse is assessing a group of clients in the community health clinic for metabolic syndrome. Which clients exhibit features of the syndrome? Select all that apply. 1. Female with a low-density lipoprotein (LDL) level of 96 mg/dL (2.5 mmol/L) 2. Female with a waist circumference of 38 inches (96.5 cm) 3. Female with blood pressure of 148/90 mm Hg 4. Male with a fasting blood glucose of 99 mg/dL (5.5 mmol/L) 5. Male with a triglyceride level of 201 mg/dL (2.3 mmol/L) OmittedCorrect answer 2,3,5 45%Answered correctly

Individuals with metabolic syndrome (insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome. Metabolic syndrome is characterized by the presence of 3 or more of the following criteria: Increased waist circumference: ≥40 in (102 cm) in men, ≥35 in (89 cm) in women (Option 2) Blood pressure: ≥130 mm Hg systolic or ≥85 mm Hg diastolic or drug treatment for hypertension (Option 3) Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides (Option 5) High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C Fasting glucose levels: ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose (Option 4) The mnemonic for metabolic syndrome is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose). (Option 1) The normal LDL level is <100 mg/dL (2.6 mmol/L); therefore, this client's LDL level is within normal limits. LDL level is not a criterion for diagnosing metabolic syndrome, although a normal level is important for cardiovascular health. Educational objective:Features of metabolic syndrome include increased waist circumference, elevated blood pressure, increased triglycerides, decreased HDL, and increased fasting blood glucose. The mnemonic is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose). Additional Information Reduction of Risk Potential NCSBN Client Need

Exhibit Assessment Data Temperature- 100.4 F (38 C) Heart rate- 168/min Respirations- 68/min Capillary refill time- 4 seconds A 6-month-old infant is brought to the emergency department after experiencing vomiting and diarrhea for 4 days. Which prescription from the health care provider is the priority? Click on the exhibit button for additional information. 1. IV acetaminophen 60 mg every 6 hours (5%) 2. IV ampicillin 240 mg every 12 hours (3%) 3. IV normal saline bolus 20 mL/kg over 1 hour (86%) 4. IV ondansetron 2 mg every 8 hours (3%) OmittedCorrect answer 3 86%Answered correctly

Infants and young children have a higher percentage of body water than older children and adults. As a result, they become dehydrated quickly due to fluid losses caused by vomiting and diarrhea. Signs of severe dehydration include lethargy, sunken fontanel, increased capillary refill time, increased heart rate, and increased respiratory rate. When dehydration is severe enough to affect the client's hemodynamic status or to potentiate shock, the priority is intravenous rehydration (Option 3). (Option 1) A temperature of 100.4 F (38 C) is a mild fever in an infant and may indicate the need for acetaminophen. However, hydration of the infant takes priority over this action. (Option 2) Antibiotics may be indicated due to the infant's increased temperature. The fluid bolus is of higher priority, as restoration of circulating volume is key in severe dehydration. (Option 4) Ondansetron may be given to reduce nausea and vomiting after the infant is rehydrated intravenously, allowing for continued oral fluid replacement. Educational objective:Severe dehydration occurs more rapidly in infants and young children due to a higher percentage of body water. Signs of severe dehydration include increased capillary refill time, increased heart rate, and increased respiratory rate. When severe dehydration occurs in an infant, the priority is intravenous rehydration.

A client with chronic heart failure is being discharged home on furosemide and sustained-release potassium chloride tablets. Which instructions related to the potassium supplement should the nurse give to the client? 1. "A diet rich in protein and vitamin D will help with absorption." (13%) 2. "If the tablet is too large to swallow, crush and mix it with applesauce or pudding." (8%) 3. "Potassium tablets should be taken on an empty stomach." (16%) 4. "Take it with a full glass of water and stay sitting upright afterward." (61%) OmittedCorrect answer 4 61%Answered correctly

Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are "potassium-wasting" diuretics, meaning that clients may experience potassium loss and hypokalemia. Hypokalemia in a client with heart failure creates a risk for life-threatening cardiac dysrhythmias. Therefore, clients taking loop diuretics usually require potassium supplementation. Potassium is an erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the client should take potassium tablets with plenty of water (at least 4 oz [120 mL]) and remain sitting upright for ≥30 minutes after ingestion. This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach (Option 4). Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar instructions. (Option 1) A diet rich in protein and vitamin D helps with calcium-supplement, not potassium, absorption. (Option 2) Sustained-release medications should never be crushed as this would cause the client to absorb the medication too rapidly. (Option 3) Potassium should be taken during or immediately following meals to prevent gastric upset. Educational objective:The nurse should teach the client to take potassium tablets with plenty of water (≥4 oz [120 mL]) and to sit upright after ingestion to prevent pill-induced esophagitis. Potassium should be taken during or immediately following meals to prevent gastric upset. Sustained-release tablets should not be crushed.

/The nurse is preparing to change a negative-pressure wound therapy dressing on a client's pressure ulcer. Which actions are appropriate at this time? Select all that apply. 1. Administer prescribed pain medication 30 minutes before the procedure 2. Apply skin barrier cream to intact skin surrounding the wound 3. Apply the foam dressing to the wound bed using clean technique 4. Cut the foam dressing to the appropriate size while holding it directly over the wound 5. Ensure that the foam dressing shrinks after the device is turned on OmittedCorrect answer 1,2,5 24%Answered correctly

Negative-pressure wound therapy is the application of negative pressure to a wound to enhance bacteria and exudate removal. Negative pressure promotes healing by stimulating cell growth and vessel perfusion in the wound bed. Medications are administered preprocedure to prevent discomfort (Option 1). After wound cleansing, a skin protectant is applied around the wound to prevent breakdown and promote an air-tight seal (Option 2). A sterile foam dressing is cut to fit the wound shape and size and is placed in the wound bed. An occlusive dressing large enough to extend 1.2-2 inches (3-5 cm) beyond the wound edges is applied to create a seal. Then a vacuum-assisted closure unit is connected to create negative pressure. The foam dressing should compress when the device is turned on, indicating a proper seal and functioning equipment (Option 5). (Option 3) The foam dressing is placed using sterile, not clean, technique to prevent wound contamination. (Option 4) The foam dressing is cut to the size of the wound bed but is never cut directly over it because material can fall into the wound or injure the client. Educational objective:Negative-pressure wound therapy promotes wound healing, cell growth, and vessel perfusion. This sterile procedure creates negative pressure through a sealed dressing and vacuum-assisted closure unit. The foam dressing should not be cut directly over the wound site.

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used. Your Response/ Incorrect Response 2. Inspection 1. Auscultation 4. Percussion 3. Palpation 5. Placement of client in supine position Correct Response 5. Placement of client in supine position 2. Inspection 1. Auscultation 4. Percussion 3. Palpation OmittedCorrect answer 5,2,1,4,3 54%Answered correctly

Nursing assessments are generally performed in order of least to most invasive. To perform an abdominal assessment, the nurse places the client in the supine position to promote relaxation of the abdominal muscles. Standing on the right side of the client, the nurse makes a visual inspection of the abdomen before touching the client. After inspection, the nurse auscultates the abdomen. Auscultation is performed next because percussion and palpation may increase peristalsis, potentially leading the nurse to make an erroneous interpretation of bowel sounds. The nurse should lightly place the diaphragm of the stethoscope in the right lower quadrant because high-pitched bowel sounds are normally present in this region. After auscultation, the nurse proceeds to percussion. Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in respirations. This rigidity may affect the tone heard on percussion. Percussion is also intended to identify borders of organs that move with respiration (eg, liver, spleen). A client in pain from abdominal tenderness will likely take quick, shallow breaths, which will change how far organs are displaced and make it more difficult for the examiner to identify true borders of organs. Educational objective:Abdominal examination is performed with the client in the supine position using the following sequence: inspection, auscultation, percussion, and palpation.

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse? 1. Blood urea nitrogen 15 mg/dL (5.4 mmol/L) (5%) 2. Serum albumin 3.7 g/dL (37 g/L) (29%) 3. Serum potassium 4.5 mEq/L (4.5 mmol/L) (1%) 4. Serum sodium 153 mEq/L (153 mmol/L) (63%) OmittedCorrect answer 4 63%Answered correctly

Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration can impair wound healing. Dehydration (loss of free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145 mmol/L). The value listed, 153 mEq/L (153 mmol/L), is high. Increased serum sodium level (hypernatremia) has an osmotic action that causes water to be pulled from the interstitial spaces into the vascular system. Remember that "water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need for repair. (Option 1) Normal blood urea nitrogen (BUN) values are 6-20 mg/dL (2.1-7.1 mmol/L). Elevated BUN may indicate dehydration and could impair wound healing. (Option 2) Malnutrition can impair wound healing. Serum albumin and prealbumin levels are obtained to assess nutritional status. The normal value for albumin is 3.5-5.0 g/dL (35-50 g/L). (Option 3) The normal value for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Educational objective:Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration (hypernatremia, elevated BUN) can impair wound healing.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes? 1. "Breast changes that are not related to your cycle should be reported to your provider." (50%) 2. "If your breasts become sore during the month, you may take ibuprofen as needed." (1%) 3. "Schedule yearly clinical breast examinations with your health care provider." (31%) 4. "These cysts are benign, and research shows that they do not increase the risk of cancer." (16%) OmittedCorrect answer 1 50%Answered correctly

One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause. The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes (ie, not related to the menstrual cycle) may indicate malignancy (ie, cancer) and should be immediately reported to the health care provider (HCP) (Option 1). (Option 2) Clients should be instructed that cyclic pain and swelling may be reduced by decreasing caffeine and sodium intake; taking vitamins E, A, and B complex; wearing a support bra; utilizing cold compresses; and taking nonsteroidal anti-inflammatory drugs (eg, ibuprofen). (Option 3) Clients age >40 should receive yearly clinical breast examinations by an HCP and practice breast self-awareness. Emphasis is placed on the importance of reporting any suspicious breast changes. (Option 4) The client should be taught that fibrocystic breast changes are benign and do not increase the risk of breast cancer; however, reporting noncyclic changes is a higher priority. Educational objective:Fibrocystic breast changes are cyclic changes that occur as a result of heightened responses to estrogen and progesterone. Clients should be taught the need to report noncyclic changes to the health care provider, as well as symptom management, breast self-awareness, and the importance of regular clinical breast examinations.

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply. 1. A client diagnosed with varicella and a client with pertussis 2. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure 3. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum 4. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5. Two clients diagnosed with tuberculosis OmittedCorrect answer 4,5 59%Answered correctly

PID is an acute infection of the upper genital tract. The most common organisms are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same room. There is no infection risk for a client with gastrointestinal bleeding (Option 4). Clients with the same organism can room together (Option 5). (Option 1) Varicella (chicken pox, herpes zoster) requires airborne precautions (and contact precautions also if open lesions are present). Pertussis requires droplet precautions. Both the precautions and the organisms are different, and the clients could cross-infect each other. (Option 2) An AIIR (formerly negative-airflow room) is indicated when the client has an organism transmitted by the airborne route (eg, tuberculosis). No other client should be in the room with a client with this type of infection, especially one with a significant co-morbidity. (Option 3) Chemotherapy causes bone marrow suppression with immunosuppression. Although the client may not need reverse or protective isolation (eg, when absolute neutrophil count is ≤500/mm3), an infectious client should not be placed with this client. Yellow sputum typically indicates bacterial infection. COPD clients can have chronic colored sputum, but infection (bacterial or viral) is the primary cause of exacerbations (the most likely reason the client is in the hospital). This is not a safe option. Educational objective:For infection control, clients with same organisms can be placed together. Infectious clients cannot be placed with immunosuppressed or at-risk clients.

A client is admitted to the intensive care unit with suspected pheochromocytoma. The client's vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min. The client is sweating profusely and reports a severe headache. Which prescription should the nurse implement first? 1. Draw labs to assess electrolyte panel (13%) 2. Give acetaminophen 650 mg by mouth as needed for headache (5%) 3. Place a fan in the client's room (3%) 4. Start nitroprusside infusion at 0.5 mcg/kg/min (77%) OmittedCorrect answer 4 77%Answered correctly

Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Important points to note when caring for these clients include the following: Hypertension is difficult to treat and is often resistant to multiple drugs. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver). Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter. (Options 1, 2, and 3) Administration of acetaminophen and use of a fan may help relieve symptoms. Drawing an electrolyte panel is appropriate. However, these are not life-saving interventions and so are not the highest priority. Educational objective:Pheochromocytoma is a condition caused by a tumor in the adrenal medulla that causes release of catecholamines such as epinephrine and norepinephrine, resulting in paroxysmal hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and should be treated promptly with intravenous nitroprusside or another vasodilator (eg, phentolamine, nicardipine). Abdominal palpation should be avoided in these clients. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse is caring for a client at 30 weeks gestation who is hospitalized for preeclampsia. After reviewing the client's chart and performing an initial assessment, the nurse notes several abnormal findings. Which finding should the nurse discuss with the health care provider immediately? 1. Dark red vaginal bleeding (56%) 2. Edema of the hands and face (21%) 3. Elevated liver enzymes (19%) 4. Urine output of 150 mL in 4 hours (2%) OmittedCorrect answer 1 56%Answered correctly

Placental abruption is a potential complication of preeclampsia related to hypertension that can be life-threatening to the client or fetus. It causes premature detachment of the placenta from the uterine wall, resulting in bleeding from uterine blood vessels. Common manifestations include abdominal pain, dark red vaginal bleeding, a rigid uterus, abnormal fetal heart rate patterns, and uterine tachysystole. Once placental abruption occurs, fetal distress and maternal hypovolemia can develop quickly. Therefore, the nurse should report vaginal bleeding to the health care provider (HCP) immediately because emergency cesarean birth is very common if the client's or fetus' condition deteriorates (Option 1). (Option 2) Swelling is a common feature of preeclampsia that does not require emergency action, but the nurse should report facial or hand swelling to the HCP. (Option 3) Elevated liver enzymes are a severe feature of preeclampsia caused by impaired liver perfusion (end-organ damage) and are part of the diagnostic criteria for HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). HELLP syndrome requires prompt action because the definitive treatment is giving birth, but the client may be able to have labor induced. (Option 4) A urine output of approximately <30 mL/hr may be an early sign of kidney damage (end-organ damage) secondary to preeclampsia; the nurse should report decreasing urine output and strictly monitor intake and output. Educational objective:Placental abruption is a severe complication of preeclampsia that can be life-threatening and requires emergency action. Manifestations include dark red vaginal bleeding, abdominal pain, a rigid uterus, abnormal fetal heart rate patterns, and uterine tachysystole.

The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply. 1. Coarse crackles 2. Hyperresonance 3. Pleuritic chest pain 4. Shortness of breath 5. Trachea deviating from midline OmittedCorrect answer 1,3,4 46%Answered correctly

Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include: Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus (Option 1) Fever, chills, productive cough, dyspnea, and pleuritic chest pain (Options 3 and 4) Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. Unequal chest expansion - Decreased expansion of affected lung on palpation Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia) (Option 2) Hyperresonance is percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the pleural space (eg, pneumothorax). (Option 5) A trachea deviating from midline is not a symptom of pneumonia but instead indicates a tension pneumothorax where the trachea deviates away from the tension. Educational objective:Physical examination of a client with pneumonia can reveal crackles, increased vocal/tactile fremitus, unequal chest expansion, and bronchial breath sounds in peripheral areas. Clients often report fever, chills, productive cough, dyspnea, and pleuritic chest pain.

/The nurse has received report for a term newborn after a vaginal birth. Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy. When assessing the newborn, which finding should the nurse most likely expect? 1. Delayed meconium passage (12%) 2. Elevated hematocrit level (17%) 3. Shrill cry and frequent yawning (64%) 4. Smooth philtrum and thin upper lip (6%) OmittedCorrect answer 2 17%Answered correctly

Poorly controlled maternal diabetes negatively affects fetal growth and oxygenation throughout pregnancy. As a result, infants of diabetic mothers are at an increased risk for postnatal complications. In clients with poorly controlled diabetes, the fetus experiences hyperglycemia and produces excess insulin. To compensate, the fetus increases metabolic activity and oxygen consumption. Fetal erythropoietin production subsequently increases to produce additional red blood cells (erythropoiesis), which are needed to transport oxygen to tissues. This increased production of red blood cells leads to polycythemia (ie, hematocrit >65%) and increased circulatory viscosity (Option 2). (Option 1) Delayed meconium passage may be a sign of cystic fibrosis (a genetic condition with characteristically thick secretions that lead to intestinal blockages) or Hirschsprung disease (a condition in which a portion of the colon inhibits peristalsis). (Option 3) Yawning, sneezing, and a high-pitched cry are features of neonatal abstinence (withdrawal) syndrome due to a history of maternal substance abuse. (Option 4) A smooth philtrum, thin upper lip, and short palpebral fissures are classic facial features of infants with fetal alcohol syndrome. Educational objective:Poorly controlled diabetes negatively affects fetal oxygenation throughout pregnancy. In utero, erythropoiesis accelerates to meet additional fetal oxygen needs. Due to overproduction of red blood cells, infants of diabetic mothers commonly experience polycythemia (ie, hematocrit >65%).

/After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority? 1. Apply anti-embolism stockings (37%) 2. Assist with early ambulation (39%) 3. Offer stool softeners (11%) 4. Provide low-fat foods (11%) OmittedCorrect answer 2 39%Answered correctly

Postoperative nursing care after a laparoscopic cholecystectomy focuses on prevention of complications. Carbon dioxide (CO2) is used to inflate and expand the abdominal cavity during laparoscopic procedures to allow insertion of surgical instruments and better visualization of the abdominal organs. CO2 can irritate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the right shoulder. The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 used during surgery (Option 2). Early ambulation not only improves breathing but also decreases the risk of thromboembolism and stimulates peristalsis. (Option 1) Anti-embolism stockings help prevent the development of deep vein thrombosis, but early ambulation is more effective at thromboembolism prevention and is therefore the priority intervention. (Option 3) Stool softeners may prevent postoperative constipation caused by surgical anesthetics and opioids, which contribute to decreased peristalsis. However, early ambulation promotes bowel motility and reduces constipation. (Option 4) After laparoscopic cholecystectomy, the client should maintain a clear liquid diet until bowel sounds return. After obtaining an order from the health care provider, the nurse should advance to a low-fat diet and educate the client on weight reduction and maintaining a low-fat diet. Educational objective:The priority of care after a laparoscopic cholecystectomy is the prevention of complications. Early ambulation helps prevent complications by: improving breathing and reducing discomfort from the carbon dioxide used to expand the abdomen during surgery; decreasing the risk of thromboembolism; and stimulating peristalsis/bowel motility.

A child's arm is burned from accidentally spilling boiling water on it, and the parent calls the clinic. The nearest emergency department is an hour away. Which instructions would be appropriate to give the parent? Select all that apply. 1. "Apply antibiotic ointment to any open skin." 2. "Briefly soak the arm with cool water." 3. "Cover the area with a clean, dry cloth." 4. "Place ice on the arm to relieve pain." 5. "Remove clothing, if not stuck to skin, around the burn." OmittedCorrect answer 2,3,5 32%Answered correctly

Proper emergency care immediately following a burn can prevent infection, hypothermia, and further tissue damage. Once the source of the burn is contained, the nurse teaches the client home care that can be given prior to arrival to the emergency department. Client teaching includes: Soak area briefly in cool water to stop the burning process (Option 2). Remove any clothing or jewelry around the burn to avoid constriction as edema develops. This also allows for quick assessment of the burn by clinicians. Only a health care provider may remove clothing that is stuck to the burned area (Option 5). Cover with a clean, dry cloth to prevent contamination, further trauma, and hypothermia (Option 3). (Option 1) Medications should not be applied to a burn until prescribed by a health care provider as they may interfere with assessment of the burned area. (Option 4) Placing ice on a burn or wrapping the area in ice can increase tissue damage and may cause hypothermia with large burns. No ice, ointments, creams, or butter should be placed on the open skin. Educational objective:Caring for a burn in the home setting includes gently soaking the area with cool water; removing clothing or jewelry if not stuck to the skin; covering the affected area with clean, dry cloth/bandages; and avoiding application of medication or substances to the wound.

An 8-month-old infant is scheduled for a femorally inserted balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider that could possibly delay the procedure? 1. Auscultation of a loud heart murmur (13%) 2. Infant has been NPO for 4 hours (13%) 3. Infant has severe diaper rash (52%) 4. Slight cyanosis of the nail beds (20%) OmittedCorrect answer 3 52%Answered correctly

Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood through the narrowed pulmonary area to the lungs. In severe pulmonic stenosis, higher pressure in the right side of the heart causes unoxygenated blood to travel to the left side through the foramen ovale (or other congenital defect) and into the systemic circulation, leading to chronic hypoxia and cyanosis and requiring repair (interventional catheterization or surgery). The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the procedure if the rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick (Option 3). (Option 1) A loud heart murmur can be an expected finding in a child with pulmonic stenosis. (Option 2) Children are NPO for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter period of NPO status and should be fed right up to the time recommended by the HCP. (Option 4) Cyanosis indicates severe pulmonic stenosis with right-to-left shunt and the need for interventional catheterization or surgery without delay. Educational objective:The nurse should report the presence of severe diaper rash in an infant who has an interventional catheterization procedure planned. The rash may delay the procedure due to possible contamination at the insertion site. Additional Information Reduction of Risk Potential NCSBN Client Need

/The graduate nurse (GN) is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precepting nurse, which statement by the GN indicates an appropriate understanding? 1. "Doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy." (47%) 2. "The client will require penicillin desensitization to receive appropriate treatment." (22%) 3. "The newborn can be treated after birth if antepartum treatment is contraindicated." (22%) 4. "Treatment is only effective if provided during the primary stage of syphilis." (8%) OmittedCorrect answer 2 22%Answered correctly

Syphilis in pregnancy Screening- Universal at first prenatal visit Third trimester & delivery (if high risk) Serologic tests- Nontreponemal (RPR, VDRL) Treponemal (FTA-ABS) Treatment- Intramuscular penicillin G benzathine Pregnancy effects- Intrauterine fetal demise Preterm labor Fetal effects- Hepatic (hepatomegaly, jaundice) Hematologic (hemolytic anemia, ↓ platelets) Musculoskeletal (long bone abnormalities) Failure to thrive FTA-ABS = fluorescent treponemal antibody absorption; RPR = rapid plasma reagin;VDRL = Venereal Disease Research Laboratory test. . Syphilis is a sexually transmitted infection that crosses the placenta and may have teratogenic effects on fetal development. All pregnant clients are screened for syphilis at the initial prenatal visit, and high-risk clients are screened again during the third trimester and labor. Maternal manifestations of syphilis may vary depending on the time of diagnosis. The only adequate prenatal treatment is IM penicillin injection (ie, benzathine penicillin G). Expected outcomes include resolution of maternal infection and prevention or treatment of fetal infection. If a pregnant client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that adequate treatment can be provided (Option 2). (Option 1) Doxycycline, a tetracycline antibiotic, is a potential treatment alternative for nonpregnant clients with syphilis but is contraindicated in pregnancy because it can impair fetal bone mineralization and discolor permanent teeth. (Option 3) Syphilis that goes untreated can result in fetal or newborn death. Although some newborns require treatment after birth, complications (eg, skeletal abnormalities, anemia, preterm birth) related to congenital syphilis can be prevented with prenatal treatment. (Option 4) Many clients with primary syphilis have nonreactive serologic tests due to a delay in antibody development. However, IM penicillin therapy is appropriate for the treatment of primary, secondary, or latent syphilis. Educational objective:Syphilis is a sexually transmitted infection that crosses the placenta and may have teratogenic effects on fetal development. If a pregnant client has a penicillin allergy, penicillin desensitization is recommended to receive appropriate treatment (ie, IM benzathine penicillin G) and prevent or treat congenital syphilis.

/The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. 1. Ecchymosis of the scrotum 2. Increased abdominal girth 3. Increased urinary output 4. Report of groin pain 5. Report of increased thirst and appetite loss OmittedCorrect answer 1,2,4 32%Answered correctly

Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output (Options 1, 2, and 4). (Option 3) Urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension. (Option 5) Increased thirst and appetite loss are not signs of graft leakage. Educational objective:Signs of graft leakage that are important to monitor after repair of an abdominal aortic aneurysm include pain in the back, pelvis, or groin; ecchymosis of the groin, scrotum, or penis; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased abdominal girth; and decreased urinary output. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time? 1. Administer prescribed IV morphine (34%) 2. Facilitate hourly client use of incentive spirometry (6%) 3. Instruct client on gently splinting injury during coughing (19%) 4. Notify the health care provider immediately (39%) OmittedCorrect answer 1 34%Answered correctly

Rib fractures are often the result of blunt thoracic trauma (eg, motor vehicle collision). In the absence of significant internal injuries (eg, pneumothorax, pulmonary contusion, spleen laceration), interventions focus on pain management and pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry). Breaths may become shallow as the client experiences pain with inspiration, which can result in a buildup of secretions, atelectasis, and pneumonia. The nurse should ensure adequate pain control prior to encouraging pulmonary hygiene techniques (Option 1). (Options 2 and 3) Interventions focused on removing secretions to improve gas exchange (eg, ambulation, coughing, incentive spirometry) are appropriate after the client's pain is controlled. (Option 4) Rib fractures are very painful. Shallow breathing and reports of pain on inspiration are expected findings that do not require immediate notification of the health care provider. Educational objective:Client management for rib fractures focuses on pain control followed by pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry). Without adequate pain control, breathing can become shallow, which may lead to buildup of secretions, atelectasis, and pneumonia.

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? 1. Allow the child to stay home when the child seems particularly anxious (7%) 2. Encourage the parent/caregiver to sit in the classroom with the child (31%) 3. Insist on school attendance immediately, starting with a few hours a day (32%) 4. Return the child to school when the cause of the school phobia has been identified (27%) OmittedCorrect answer 3 32%Answered correctly

School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child experiences an irrational and persistent fear of going to school. Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships. (Option 1) Allowing the child to stay home will only reinforce the acting-out behaviors associated with refusal to attend school. The parent/caregiver needs to support the child and talk about the cause of the anxiety, but the child needs to go to school. (Option 2) Having the parent/caregiver stay in the classroom with the child is not a permanent solution to relieving the child's anxiety and is not recommended. (Option 4) Determining the cause of the school phobia is important in helping to alleviate the child's symptoms and in coping with the return to school. However, returning the child to the classroom immediately is the most important action. Educational objective:A child with school phobia needs to return to the classroom immediately. Insisting on school attendance, along with other supportive interventions, will help the child make a faster adjustment. Additional Information Psychosocial Integrity NCSBN Client Need

The health care provider (HCP) remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially? 1. Report the statement to the nurse manager (24%) 2. Tell the HCP to stop the comments (72%) 3. Walk away and say nothing (0%) 4. Write up an incident report (2%) OmittedCorrect answer 2 72%Answered correctly

Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is prohibited. Other behaviors that could be defined as sexual harassment include asking someone for a date after the other person expressed disinterest or making remarks about a person's gender or body. The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP should stop. The offending HCP may have erroneously perceived a mutual attraction. If that is not effective, additional action should be taken. The American Nurses Association cites 4 tactics to fight workplace sexual harassment: confront, report, document, and support. (Option 1) The incident should be reported, especially if the offending HCP does not stop. If the harasser is the immediate supervisor, the receiving nurse should go up the chain of command. However, the nurse should first simply tell the offending HCP to stop and see if that resolves the issue. (Option 3) The nurse should respond with assertiveness, not avoidance. Ignoring the situation may imply that the nurse does not mind the HCP's attention. (Option 4) The receiving nurse should document what occurred and how the nurse responded. The presence of witnesses should be documented. Documentation should be stored somewhere other than the workplace. However, the nurse should initially communicate assertively that the actions are to stop before documenting them. Educational objective:A nurse who receives unwanted sexual advances in the workplace should first immediately and clearly indicate that the advances are unwanted and that the offending person should stop.

/The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse? 1. Asking the client to take small sips of water during insertion (16%) 2. Marking the tube at the exit point from the naris (9%) 3. Removing the stylet before the x-ray is performed (61%) 4. Stopping insertion of the tube while the client is coughing (12%) OmittedCorrect answer 3 61%Answered correctly

Small-bore nasoenteric (eg, nasoduodenal, nasojejunal) tubes are often placed using a stylet (guide wire), a metal wire running through the tube that facilitates advancement through the gastrointestinal tract. Once the tube is inserted, the nurse should obtain an x-ray to verify that the tube terminates in the intestine as prescribed, not in the airway or stomach. After placement verification, the nurse should remove the stylet to allow tube feeding (Option 3). To avoid perforating the gut, the nurse should never reinsert the stylet when a feeding tube is in place. If the tube is not properly positioned and the stylet has been removed, the nurse must remove the tube and start over. (Options 1 and 4) The client should sip water during insertion to close the airway and open the esophagus. With each swallow the nurse should advance the tube a little. The nurse should stop advancing when the client is inhaling or coughing to avoid inserting the tube into the airway and then continue advancing when the client is able to swallow again. (Option 2) Marking the exit point from the naris on the tube allows visualization of changes in external tube length that may indicate tube dislodgement. Educational objective:After placing a new, small-bore nasoenteric (eg, nasoduodenal, nasojejunal) feeding tube, the nurse should obtain an x-ray to verify tube placement and should leave the stylet (guide wire) in place until tube placement is verified. The nurse should never reinsert a stylet into a nasoenteric tube. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings? 1. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+. (76%) 2. Bilateral DP pulses palpable. Right DP 3+, left DP 2+. (14%) 3. Bilateral popliteal pulses palpable. Right foot > left foot. (4%) 4. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+. (4%) OmittedCorrect answer 1 76%Answered correctly

The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale. 0 Absent1+ Weak2+ Normal3+ Increased, full, bounding (Option 2) DP is the correct artery being assessed, but 3+ would indicate a full, bounding pulse and 2+ would indicate a normal pulse. (Option 3) The popliteal pulse is assessed just behind the knee area, not on the foot. The description of the right foot being greater than the left foot does not indicate the force of the individual pulse. (Option 4) Posterior tibial pulses are palpated just behind the medial malleolus bone on the foot. The description of 2+ and 1+ is accurate. Educational objective:The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client's record.

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply. 1. Acute head injury with Glasgow Coma Scale of 12 2. Admitted with cirrhosis of liver with oozing esophageal varices 3. Asthma exacerbation with peak flow at 85% of personal best 4. Deep venous thrombosis on IV heparin with platelets 40,000/mm3 (40 × 109/L) 5. Myasthenia gravis with ptosis in the evening OmittedCorrect answer 3,5 34%Answered correctly

The best indication of moving air in a client with asthma is peak flow. The results are categorized as green (≥80% of personal best and good control), yellow (50%-79% of personal best and caution), and red (<50% of personal best - a medical alert). This client is currently in good control. Other findings to note include effortless breathing, no cough or wheeze, and sleeping well all night (Option 3). Myasthenia gravis is an autoimmune disease in which antibodies attack acetylcholine receptors. This results in weakness in skeletal muscles, especially in the bulbar region that involves eye movement, swallowing/speaking, and breathing. Such clients become more exhausted as the day progresses. The client can be discharged home as ptosis is an expected finding (Option 5). (Option 1) Normal Glasgow Coma Scale is 15; a score of 12 indicates impairment requiring further care. (Option 2) The varices oozing blood are at risk for rupture and/or increasing ammonia (from the digestion of protein in the blood). This client needs treatment. (Option 4) Normal platelet count is 150,000-400,000/mm3 (150-400 × 109/L). A potential complication of heparin therapy is thrombocytopenia. The client is at risk for paradoxical thrombosis (eg, stroke, arterial clots) and, rarely, bleeding. Educational objective:Clients with an acute head injury and a Glasgow Coma Scale of 12, thrombocytopenia while on heparin, or oozing varices in cirrhosis are not stable for discharge.

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit? 1. Client experiencing fever and pain with mastitis (36%) 2. Client preparing for discharge after cesarean birth (9%) 3. Client showing disinterest in caring for the newborn (5%) 4. Client with hysterectomy after postpartum hemorrhage (48%) OmittedCorrect answer 4 48%Answered correctly

The client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from the intensive care unit would have the assessment skills needed to recognize any changes. (Option 1) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option 2) A client preparing for discharge after cesarean birth would require an experienced postpartum nurse as discharge instructions would involve teaching related to both the newborn and the client. (Option 3) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues. Educational objective:Float nurses should be assigned to clients who most reflect the client population with which they are familiar. Safety is a priority when making client assignments.

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? 1. Check for Kernig's and Brudzinski's signs (19%) 2. Establish IV access (12%) 3. Place the client on droplet precautions (62%) 4. Prepare the client for lumbar puncture (5%) OmittedCorrect answer 3 62%Answered correctly

The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out. Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. Viral meningitis and other types of bacterial meningitis (ie, other than meningococcal meningitis) usually do not require droplet precautions. (Option 1) Although assessment is a priority and meningeal signs should be checked, the nurse can only safely perform these assessments once droplet precautions are in place. (Options 2 and 4) A peripheral IV catheter should be inserted to provide fluids. Subsequently, preparation for lumbar puncture is needed. However, placing the client on isolation is a priority to protect the nurse and other clients and care providers. Educational objective:The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Additional Information Physiological Adaptation NCSBN Client Need

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse? 1. Nurse has client lie supine for 5-10 minutes prior to starting procedure (7%) 2. Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding (13%) 3. Nurse starts by measuring BP and heart rate (HR) with the client standing (69%) 4. Nurse takes BP and HR after standing at 1- and 3-minute intervals (9%) OmittedCorrect answer 3 69%Answered correctly

The experienced nurse should intervene if the new RN starts BP measurement with the client in the standing position. Orthostatic BP measurement may be done to detect volume depletion or postural hypotension caused by medications or autonomic dysfunction. Procedure for measurement of orthostatic BP Have the client lie down for at least 5 minutes (Option 1) Measure BP and HR Have the client stand Repeat BP and HR measurements after standing at 1- and 3-minute intervals (Option 4) A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal (Option 2). Educational objective:To measure orthostatic BP, the nurse should have the client lie supine for 5-10 minutes and then measure BP and HR. The nurse should then have the client stand for 1 minute, measure BP and HR, and repeat the measurements at 3 minutes. Findings are significant if the systolic BP drops ≥20 mm Hg or the diastolic BP drops ≥10 mm Hg.

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction? 1. "I should avoid alcohol intake with this new medication." (2%) 2. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)." (10%) 3. "I should read the labels on all foods I eat, including those that say 'sugarless'." (3%) 4. "This medication will help me lose weight." (83%) OmittedCorrect answer 4 83%Answered correctly

The major adverse effects of sulfonylurea medications (eg, glyburide, glipizide, glimepiride) are hypoglycemia and weight gain. Weight gain should be addressed. Clients taking glyburide should be taught to use sunscreen and protective clothing as serious sunburns can occur. (Option 1) Clients taking sulfonylureas should avoid alcohol as it lowers blood glucose and can lead to severe hypoglycemia. (Option 2) Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) is a major side effect of sulfonylurea medications. A fasting blood glucose <60 mg/dL (3.3 mmol/L) indicates moderate to severe hypoglycemia and the medication needs to be reassessed. (Option 3) Even foods labeled "diabetic", "sugar free," or "sugarless" may contain carbohydrates such as honey, brown sugar, and corn syrup, all of which can elevate blood sugar. Educational objective:The major adverse effects of sulfonylurea medications are hypoglycemia and weight gain. Alcohol must be avoided while taking these medications due to the risk of severe hypoglycemia. Glyburide can also make clients sunburn easily. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first? 1. Client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain (63%) 2. Client who is 3-days postoperative right knee surgery, now reports fever, cough, and shortness of breath (15%) 3. Client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago (19%) 4. Client with a kidney stone who is requesting pain medication for severe flank pain (1%) OmittedCorrect answer 1 63%Answered correctly

The nurse should assess the postoperative client who had the bowel resection and is currently reporting shortness of breath and chest pain first. Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and increased risk for a pulmonary embolism (PE). Therefore, this client's problem poses the greatest threat to survival and requires immediate attention. (Option 2) This client likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon possible, it is not as life-threatening as acute PE. Pneumonia is fatal to clients within a period of days (rarely hours), but PE can lead to death in minutes to hours, depending on its severity. (Option 3) This client requires a thorough respiratory assessment. However, this client arrived 15 minutes ago, vital signs, including pulse oximetry, were already measured; and the day shift nurse who received the report from the PACU nurse assessed the client. (Option 4) Flank pain is expected in a client who is hospitalized for a kidney stone. Providing pain relief and comfort are priorities, but this client does not have the most urgent problem. Educational objective:The hand-off nurse-to-nurse report provides the oncoming nurse with necessary information about the clients' immediate needs, problems, and potential complications. The nurse can then use different frameworks, such as airway, breathing, circulation, Maslow's Hierarchy of Needs, degree of threat to survival, and the potential for complications to help decide which clients need immediate attention and which ones can wait.

A parent calls the nurse telehealth triage line with concerns about an allergic reaction to something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? Select all that apply. 1. Dyspnea 2. Fever 3. Lightheadedness 4. Skin rash (hives) 5. Wheezing OmittedCorrect answer 1,3,4,5 17%Answered correctly

The nurse should instruct the parent to first assess for signs of swelling of the mouth, tongue, lips, and upper airway. The child will have wheezing and difficulty breathing next, followed soon by cardiovascular symptoms. These include lightheadedness due to hypotension, loss of consciousness, and cardiovascular collapse. An anaphylactic reaction is life-threatening and requires rapid assessment and intervention. (Option 2) Fever is not a symptom of an anaphylactic reaction that would be included in the rapid assessment. Educational objective:Anaphylaxis is a medical emergency requiring rapid assessment and intervention. Symptoms of an anaphylactic reaction include signs of respiratory compromise (eg, oral and airway swelling, stridor, wheezing, chest tightness) and shock (eg, dizziness, loss of consciousness).

/The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate? 1. "The Allen's test is done to determine if capillary refill is adequate." (18%) 2. "The Allen's test is done to determine if the radial pulse is palpable." (11%) 3. "The Allen's test is done to determine the patency of the ulnar artery." (61%) 4. "The Allen's test is done to determine the presence of a neurologic deficit." (8%) OmittedCorrect answer 3 61%Answered correctly

The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps: Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used. (Option 1) Capillary refill is tested by applying pressure to the fingernail bed to cause blanching. If refill is adequate, the nail bed should become pink in less than 3 seconds after pressure is released. (Option 2) The radial artery is palpated with the fingertips to determine the presence of the radial pulse. (Option 4) A neurologic deficit is assessed by monitoring color, sensation, and movement of the hand. Educational objective:The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.

The nurse teaches a group of homeless community clients preventive measures related to transmission of hepatitis A. Which of these measures would the nurse teach as the priority precaution to prevent transmission? 1. Do not share needles when injecting drugs (5%) 2. Practice safe sex by using condoms (1%) 3. Receive the hepatitis A vaccine (5%) 4. Wash hands after bowel movements and before eating (88%) OmittedCorrect answer 4 88%Answered correctly

The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important intervention to reduce the occurrence of hepatitis A infection (Option 4). Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those with clotting disorders, and those with liver disease). (Options 1 and 2) Hepatitis A is secreted in bile and is more often transmitted via the fecal-oral route. However, the virus can also be spread through needle sharing between intravenous drug users and unsafe sexual practices. These practices should be discouraged and hand hygiene encouraged as the most important intervention for prevention. (Option 3) Vaccination is an important means of preventing infection. However, hygienic measures (eg, hand washing, sanitation, cleanliness, avoiding sharing personal items) are readily implemented by all clients regardless of means. Educational objective:Hepatitis A is spread via the fecal-oral route. Therefore, hygienic practices (eg, hand hygiene, sanitation) are the fastest and most readily available interventions available to prevent the spread of the hepatitis A virus. Needle sharing and unprotected sex should be discouraged, and all children age at least 1 year should receive the hepatitis A vaccine.

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm3 (2 x 109/L). Which client sign or symptom is the most concerning and requires immediate further nursing action? 1. Current oozing epistaxis (17%) 2. Ecchymosis on leg since yesterday (4%) 3. New-onset confusion (76%) 4. Reported history of hematuria (2%) OmittedCorrect answer 3 76%Answered correctly

Thrombotic thrombocytopenic purpura (TTP) consists of hemolytic anemia with fragmentation of erythrocytes, signs of intravascular hemolysis, thrombocytopenia, decreased renal function, and fever. Regardless of the cause of the low platelets, the concern in this case is the critically low (below 10,000/mm3 (10 x 109/L) platelet count, which puts this client at risk for internal bleeding, especially within the brain. Change in level of consciousness is the most clinically significant finding requiring an emergency response. (Option 1) The head is very vascular, and a nosebleed can occur with low platelets. A nosebleed is treated with direct pressure and application of cold. In this client, potential intracranial bleeding is the priority. (Option 2) Easy bruising can occur as a result of low platelets. However, the bruise is "old," and potential intracranial bleeding is the priority. (Option 4) Blood in the urine can be a symptom of low platelets due to lack of clotting ability. Although this is concerning, alterations in level of consciousness is the priority. Educational objective:A priority assessment in a client with low platelets is any change in level of consciousness (eg, disorientation, lethargy, restlessness). This can indicate intracranial bleeding and increased intracranial pressure. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is reinforcing instructions to a client at 34 weeks gestation who is preparing to travel by airplane. Which of the following instructions are appropriate? Select all that apply. 1. Avoid getting up during the flight unless you need the restroom 2. Carry a copy of your most up-to-date prenatal record 3. Increase fluid intake before and during the flight 4. Secure the lap belt below the abdomen and across your hips when seated 5. Wear compression hose and loose-fitting clothing OmittedCorrect answer 2,3,4,5 45%Answered correctly

Travel during pregnancy requires special modifications and precautions to ensure client safety and reduce the potential for injury and pregnancy complications. Clients should get their health care provider's approval prior to traveling long distances. Domestic air travel is usually allowed for healthy clients at <36 weeks gestation. When reinforcing education about travel safety, the nurse should instruct the client to: carry an updated copy of the prenatal record in case emergency medical care is necessary during travel (Option 2). increase fluid intake to prevent dehydration and reduce the risk of thrombus formation or preterm contractions (Option 3). secure the lap belt under the gravid abdomen and across the hips and, if available, place shoulder belts lateral to the uterus and between the breasts to prevent complications from abdominal trauma (eg, placental abruption) (Option 4). wear compression stockings and unrestrictive clothing to improve venous return and decrease the risk of thrombus formation (Option 5). avoid traveling to Zika- or malaria-prevalent areas and remote areas with poor medical care or lack of sanitation. (Option 1) Pregnancy is a hypercoagulable state that augments the risk of thrombus formation. The nurse should encourage pregnant clients who embark on long travel to walk every 1-2 hours to decrease the risk of thrombus formation. Educational objective:When education about travel safety to pregnant clients is reinforced, recommendations should include carrying the prenatal record; increasing fluid intake; wearing compression stockings and loose clothing; avoiding long periods of sitting; and wearing the lap belt underneath the gravid abdomen and across the hips. Additional Information Health Promotion and Maintenance NCSBN Client Need

/The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD). The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated. Which prescription is of concern and prompts the nurse to notify the health care provider (HCP)? 1. Lansoprazole (3%) 2. Metronidazole (10%) 3. Prednisone (48%) 4. Sulfasalazine (37%) OmittedCorrect answer 3 48%Answered correctly

Tuberculosis is an infection caused by the Mycobacterium tuberculosis microorganism. A client with active, primary TB disease has a positive tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications. A client with a latent TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, cannot transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease. Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), can convert LTBI to active disease. A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should notify the HCP. (Option 1) Lansoprazole (Prevacid) is a proton pump inhibitor used to treat ulcer disease, erosive esophagitis, and gastroesophageal reflux disease. It does not convert LTBI to active disease. (Option 2) Metronidazole (Flagyl) is an antimicrobial medication used to treat IBD and does not convert LTBI to active disease. (Option 4) Sulfasalazine (Azulfidine) is a gastrointestinal anti-inflammatory medication used to treat IBD and does not convert LTBI to active disease. Educational objective:A client with LTBI has a positive TST, is asymptomatic, and cannot transmit the disease to others. Malignancy, immunosuppressant medications, chemotherapy, and prolonged debilitating disease (eg, HIV) can convert LTBI to active disease. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need Copyright © UWorld. All rights reserved.

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply. 1. The 60-year-old client was just diagnosed with benign prostatic hyperplasia (BPH) 2. The client reports a mobile, golf ball-sized lesion under the skin over the right thigh that feels doughy 3. The client reports a nagging cough with hoarseness for the past 3 months 4. The female client who weighed 150 lb (68.0 kg) has lost 15 lb (6.8 kg) in 3 months without dieting 5. The male client reports a skin change on the breast that looks like an orange peel OmittedCorrect answer 3,4,5 31%Answered correctly

Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss (Option 4). The warning signs of cancer can be remembered with the acronym CAUTION: Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness (Option 3) Although 99% of breast cancers are found in women, men can also develop breast cancer, especially if risk factors, such as past chest radiation, are present. Later signs of breast cancer include a newly retracted nipple or an orange-peel appearance of the breast tissue (peau d'orange) caused by the plugging of dermal lymph drainage (Option 5). (Option 1) BPH is caused by hormonal changes related to aging. Growth is not related to cancer. (Option 2) Lipomas are benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy. Educational objective:Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin (orange peel) on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also indicate malignancy and require further workup.

A hospitalized client has been treated for the past 48 hours with a continuous heparin infusion for a deep vein thrombosis (DVT). When the nurse prepares to administer the evening dose of warfarin, the client's spouse says "Wait! My spouse can't have that! My spouse is already getting heparin for DVT." How should the nurse respond? 1. "Both medications will be given for several days until the warfarin has time to take effect." (69%) 2. "I will be discontinuing the heparin infusion as soon as I give this dose of warfarin." (3%) 3. "The two medications work synergistically to help break down the clot in your spouse's leg." (19%) 4. "We will hold the medication until I can call the health care provider (HCP) for clarification." (7%) OmittedCorrect answer 1 69%Answered correctly

Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse. (Option 2) The nurse should not discontinue the heparin infusion until the INR is at the therapeutic level. (Option 3) Anticoagulants like heparin and warfarin will not break down or dissolve clots. However, they inhibit any further clot formation and keep the current clot from getting larger. Thrombolytics, such as tissue plasminogen activator, do break down clots. (Option 4) Clarification from the HCP is not needed. The warfarin should be administered to the client after explaining the reasons for its use to the client and the spouse. Educational objective:Warfarin requires an overlap of therapy with unfractionated heparin infusion or low-molecular-weight heparin (eg, enoxaparin, dalteparin) for several days until the INR is in the therapeutic range for the client's condition.

A 3-month-old infant has irritability, facial edema, a 1-day history of diarrhea with adequate oral intake, and seizure activity. During assessment, the parents state that they have recently been diluting formula to save money. Which is the most likely cause for the infant's symptoms? 1. Hypernatremia due to diarrhea (9%) 2. Hypoglycemia due to dilute formula intake (16%) 3. Hypokalemia due to excess gastrointestinal output (11%) 4. Hyponatremia due to water intoxication (63%) OmittedCorrect answer 4 63%Answered correctly

Water intoxication (water overload) resulting in hyponatremia may occur in infants when formula is diluted to "stretch" the feeding to save money. Hyponatremia may also result from ingestion of plain water (eg, caregiver attempting to rehydrate an infant who has been ill). Infants have immature renal systems with a low glomerular filtration rate, which decreases their ability to excrete excess water and makes them susceptible to water intoxication. Symptoms of hyponatremia include irritability, lethargy, and, in severe cases, hypothermia and seizure activity. Breast milk and/or formula are the only sources of hydration an infant needs for the first 6 months of life. Formula should be prepared per the manufacturer's instructions. (Option 1) Hypernatremia may be caused by dehydration (eg, decreased oral intake, vomiting, diarrhea) and presents with similar neurological symptoms (eg, restlessness, seizures). The infant's history indicates adequate oral intake and signs of fluid overload (eg, facial edema), not dehydration. (Option 2) Hypoglycemia may present with irritability and seizures, but facial edema and recent history of over-diluting the formula should alert the nurse that water intoxication with hyponatremia is the most likely cause. (Option 3) Hypokalemia secondary to diarrhea may present with irritability, muscle weakness, and cardiac arrhythmias. Educational objective:Infants are susceptible to hyponatremia secondary to water intoxication, which can present with neurological symptoms (eg, lethargy, irritability, seizures). Breast milk and/or formula provide sufficient hydration for the first 6 months of life. Formula should not be diluted to save money.

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply. 1. Acting as a witness that the client signed the consent form voluntarily 2. Documenting in the medical record the date and time the signature was obtained 3. Educating the client if there is a misunderstanding about the procedure 4. Explaining to the client the right to refuse surgery 5. Verifying that the client is competent to provide informed consent OmittedCorrect answer 1,2,5 41%Answered correctly

Written consent is required for invasive procedures and surgery. Clients must be informed of and competent to understand information about the procedure, alternate treatments, and risks. They must also be informed that they have the right to refuse the procedure or surgery. The nurse's role in informed consent is to witness that the client signed the consent voluntarily and was competent at the time of signing (Options 1 and 5). The nurse should ensure that the client received necessary information and has no remaining questions about the procedure. After obtaining the signature, the nurse should document in the client's medical record that the informed consent was given and the date/time of the signature (Option 2). (Options 3 and 4) The health care provider is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternate treatments, and reinforcing that the client has the right to refuse the procedure. The health care provider should be contacted if the client does not have a correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect/incomplete information. Educational objective:The nurse's role in informed consent is to witness a client's signature and ascertain that the client signed voluntarily, was competent to provide consent at the time of signature, received the necessary information, and has no further questions.