Archer 2

A Choice A is correct. Amenorrhea (absence of menstrual period) is a presumptive sign of pregnancy. Presumptive signs of pregnancy are symptoms and signs that the patient experiences. Presumptive signs may resemble pregnancy signs and symptoms but may also be caused by other etiologies. While amenorrhea is a presumptive sign of pregnancy, missing a period can also result from other conditions such as stress, hypothyroidism, and anorexia. Choices B and D are incorrect. A positive cardiac activity on ultrasound (Choice B) and auscultation of fetal heart tones (Choice D) would be a positive sign of pregnancy. Positive signs of pregnancy are signs that cannot, under any circumstances, be mistaken for other conditions. Positive signs confirm that the pregnancy has occurred. Choice C is incorrect. An enlarged uterus would be detected by the examiner and would be a probable sign of pregnancy. Probable pregnancy signs indicate pregnancy in most cases; however, there is still the chance they can be caused by conditions other than pregnancy. While an enlarged uterus is a probable pregnancy sign, other conditions such as uterine tumors, fibroids, and adenomyomas may also cause such a finding. Another example of a probable sign of pregnancy is a positive urine pregnancy test.

A 28-year-old female presents to the obstetrics office, suspecting she may be pregnant. Which of the following would the nurse recognize as a presumptive sign of pregnancy? A. Amenorrhea B. Positive fetal cardiac activity on ultrasound C. Enlarged uterus D. Auscultation of fetal heart tones

D Choice D is correct. The nurse should cover the incision site with an occlusive dressing whenever a chest tube is pulled out. This action places a seal over the site. The nurse should then notify the physician regarding the incident. Choice A is incorrect. A chest x-ray might be ordered by the physician to check for lung expansion. However, this is not the initial action for the nurse. Choice B is incorrect. The nurse is not allowed to insert a chest tube into the client. Choice C is incorrect. The nurse must place an occlusive dressing first before notifying the physician.

A client admitted for a pneumothorax three days ago accidentally pulled out his chest tube. Which action should be the nurse's initial intervention? A. Arrange for a chest x-ray. B. Reinsert the tube herself. C. Notify the physician. D. Place a vaseline gauze over the incision site.

C Choice C is correct. The client is displaying acute confusion. The best response for the nurse would be to provide the client with additional food as he requests it. Choice A is incorrect. The client with acute confusion can forget that he has already eaten. There is no use in arguing with the client. Choice B is incorrect. The client with acute confusion can forget that he has already eaten. There is no use in arguing with the client. Choice D is incorrect. The statement dismisses the client's concern. This is an inappropriate response.

A client with Alzheimer's disease is eating in the dining hall along with the other clients. Thirty minutes later, he says to the nurse, "When can I have my breakfast? They haven't given me anything to eat yet." The most appropriate response for the nurse would be: A. "I saw you eating breakfast 30 minutes ago." B. "Are you still not full? I'll ask the kitchen what they served you." C. "I can get you some bread if you like. What else would you like?" D. "You have to wait until it's lunchtime."

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

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

A Choice A is correct. The nurse should anticipate receiving arterial blood gas results indicative of respiratory acidosis, such as those presented in Choice A. Typically, respiratory acidosis is caused by a decrease in the client's respiratory rate or volume (hypoventilation) due to central nervous system, pulmonary, or iatrogenic conditions. Choice B is incorrect. This result is indicative of a normal arterial blood gas result. Choice C is incorrect. This arterial blood gas result indicates respiratory alkalosis. Clients at risk for respiratory alkalosis include those experiencing hyperventilation (i.e., a client experiencing a panic attack), as this rapid, shallow breathing pattern causes the loss of carbon dioxide (CO2) and subsequent alkalotic pH change. Choice D is incorrect. This arterial blood gas result indicates metabolic alkalosis. The nurse would not anticipate receiving this type of ABG result, as metabolic alkalosis is typically found in clients following prolonged vomiting, hypovolemia, diuretic use, and/or hypokalemia.

A nurse is caring for a client with acute respiratory failure in the intensive care unit (ICU). The nurse would anticipate which of the following arterial blood gas (ABG) results? A. pH 7.29, PCO2 56, PaO2 83, HCO3 22 B. pH 7.38, PCO2 40, PaO2 92, HCO3 25 C. pH 7.49, PCO2 30, PaO2 96, HCO3 28 D. pH 7.50, PCO2 44, PaO2 93, HCO3 34

C Choice C is correct. The GOLD report identifies cigarette smoking as the leading risk factor for the development of COPD. Any or all of the others may also be contributing factors. "Never smokers" may develop COPD, but they typically do not have an increased risk of lung cancer or cardiovascular problems compared to smokers with COPD. Choice A is incorrect. Genetics does seem to play a part in the development of COPD. Choice B is incorrect. Gender may play a role in the development of COPD since it may influence occupation choice which may increase exposure to environmental toxins. Choice D is incorrect. Low birth weight influenced by socioeconomic status may hurt lung development.

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report. the leading risk factor for the development of chronic obstructive pulmonary disease (COPD) is: A. Genetics B. Gender C. Cigarette smoking D. Socioeconomic factors

A Choice A is correct. Oligohydramnios results from a severe reduction in the amount of amniotic fluid. It results in less than expected fetal growth. Also, because of the low amount of amniotic fluid, the fetus will be more easily outlined and palpated. Choice B is incorrect. Macrosomia is defined as a newborn that is significantly larger than average. These babies have a birth weight of more than 8 lbs, 13 oz. Choice C is incorrect. Hydramnios is a condition in which excessive amounts of amniotic fluid accumulates during pregnancy. Choice D is incorrect. Amniotic fluid embolism is characterized by an acute collapse of mother and baby due to an allergic-type response to amniotic fluid entering the mother's circulatory system.

At 25 weeks gestation, a pregnant client presents with a uterine growth size that is less than expected, decreased fetal movement, and an easily palpable fetus. Which of the following is this likely related to? A. Oligohydramnios B. Macrosomia C. Hydramnios D. Amniotic fluid embolism

A Choice A is correct. The nurse should watch for signs of metabolic acidosis, as diarrhea is one of the conditions most commonly associated with this acid-base imbalance due to bicarbonate loss occurring with diarrhea. Symptoms and signs of metabolic acidosis are primarily those of the underlying cause (i.e., here, the client's diarrhea). More severe acidemia (i.e., pH < 7.10) may cause nausea, vomiting, and malaise. Choice B is incorrect. Clients with vomiting, diuretic use, or excessive over-the-counter antacid use are at risk for metabolic alkalosis. Metabolic alkalosis occurs due to an elevation of sodium bicarbonate which leads to an increase in a client's HCO3- level. Choice C is incorrect. Malnutrition is a possible long-term complication of ulcerative colitis. This complication typically requires more than 24 hours of active symptoms before occurring. Choice D is incorrect. Malabsorption is a possible long-term complication of ulcerative colitis. This complication typically requires more than 24 hours of active symptoms before occurring. Recognize that when caring for a client experiencing 24 hours of diarrhea, the nurse should assess the client for signs and symptoms of metabolic acidosis. Treatment of metabolic acidosis is based on the cause of the metabolic acidosis. Ulcerative colitis is a chronic inflammatory and ulcerative disease arising in the colonic mucosa, characterized most often by bloody diarrhea. Extraintestinal symptoms, particularly arthritis, may occur. Long-term risk of colon cancer is elevated compared to unaffected people. Diagnosis is by colonoscopy. Treatment occurs with various medications (i.e., 5-aminosalicylic acid, corticosteroids, immunomodulators, biologics, and/or antibiotics) and surgery in some clients.

During shift change, a nurse receives report regarding a client with ulcerative colitis, learning the client has experienced severe diarrhea over the past 24 hours. When assessing the client, the nurse should watch for signs of: A. Metabolic acidosis B. Metabolic alkalosis C. Malnutrition D. Malabsorption

b Choice B is correct. Obsessive-compulsive personality disorder is characterized by a pervasive preoccupation with orderliness, perfectionism, and control (with no room for flexibility) that ultimately slows or interferes with completing a task. Because clients with obsessive-compulsive personality disorder need to be in control, they tend to be solitary in their endeavors and mistrust help from others. Choice A is incorrect. A borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations, and impulsivity. Choice C is incorrect. Bipolar disorder is characterized by episodes of mania and depression, which may alternate, although many clients have a predominance of one or the other. Bipolar disorder markedly impairs the client's ability to function at work and to interact socially, and the risk of suicide is significant. Only a minimal percentage of clients alternate back and forth between mania and depression during each cycle; in most cycles, one or the other predominates. Choice D is incorrect. Codependency is characterized by the client's dysfunctional relationship with another individual, enabling dependency or addiction to substances or behaviors (i.e., alcohol, drugs, gambling, etc.). To maintain a sense of control, obsessive-compulsive disorder clients focus on rules, minute details, procedures, schedules, and lists. As a result, the main point of a project or activity is lost. These clients repeatedly check for mistakes and pay extraordinary attention to detail. OCD clients do not make good use of their time, often leaving the most important tasks until the end. Their preoccupation with the details and ensuring everything is perfect can endlessly delay completion. When focused on one task, these clients may neglect all other aspects of their life.

Select the psychiatric mental health disorder that is accurately paired with its signs and symptoms. A. Borderline personality disorder: Intense irrational fears and the need for orderliness and perfection B. Obsessive-compulsive disorder: The need for control, orderliness, and perfection C. Bipolar disorder: Fears of abandonment, feelings of emptiness, and unstable relationships with others D. Codependency: Fears of abandonment, a need for control, and a need for perfection

A, B, C Choices A, B, and C are correct. This patient is at risk for fluid volume imbalance, infection, and hyperglycemia. These risks occur because of the high volume of glucose in most TPN solutions and because the nurse administers the solution through a central venous catheter. Any time the nurse delivers nutrition through an IV catheter, the patient is at risk for fluid volume imbalance. Choice D is incorrect. TPN does NOT predispose a patient to gastrointestinal tract dysfunction. However, in a case with a patient who has GI dysfunction, enteral nutrition through an NG or other tube might be contraindicated.

The nurse in the ICU is caring for a patient receiving total parenteral nutrition (TPN). Essential nursing diagnoses on the care plan for this patient include: Select all that apply. A. Risk for fluid volume imbalance B. Risk for infection C. Risk for hyperglycemia D. Risk for gastrointestinal tract dysfunction

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

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

C Choice C is correct. The living will is a document whose precise purpose is to allow individuals to record specific instructions about the type of health care they would like to receive in particular end-of-life or incapacitated states. Choice A is incorrect. The combination advance medical directive appoints a proxy (agent) whom the client trusts to make decisions. The client has stated that he has no one he believes can make decisions for him. Choice B is incorrect. A durable power of attorney for health care appoints an agent that the person trusts to make decisions in the event of incapacity. The patient has told the nurse he has no one that he can trust. Choice D is incorrect. A proxy is an agent. The client has stated he has no one that he trusts to designate.

The patient tells his nurse that he has no one he trusts to make healthcare decisions if he becomes incapacitated. What should the nurse suggest he prepare? A. Combination advance medical directive B. Durable power of attorney for health care C. Living will D. Proxy for health care

D Choice D is correct. Shoulder pain may occur following a cesarean section due to gas or referred pain from the surgery. The nurse should assess the patient's pain to determine the cause before administering medications or other interventions. Choice A is incorrect. The nurse should first assess the patient's pain to determine the cause before administering pain medication. Choice B is incorrect. The nurse should first assess the patient's pain. If assessment data indicates the patient's pain is cardiac, an EKG may be indicated. Choice C is incorrect. Ambulation may help if the patient's pain is related to gas/indigestion, but the nurse should first assess the patient's pain before implementing this intervention.

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

13 mL

The primary healthcare provider (PHCP) prescribes 400,000 units of penicillin G benzathine. The label on the medication reads penicillin G benzathine 300,000 units / 10 mL. The nurse prepares how many milliliters to administer the appropriate dose? Fill in the blank. Round your answer to the nearest whole number.

11.4 mL/hr

The primary healthcare provider (PHCP) prescribes a regular insulin infusion. The prescription is for 4.5 units/hr. The label on the medication reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many mL/hr should the client receive? Fill in the blank. Round your answer to the nearest tenth.

A Choice A is correct. Dietary roughage (or fiber) with sufficient fluids and exercise may help relieve constipation. Constipation in pregnant women is thought to occur due to hormones that relax the intestinal muscle and by the pressure of the expanding uterus on the intestines. Relaxation of the intestinal muscle causes food and waste to move slower through your system. Sometimes iron tablets may contribute to constipation. Choice B is incorrect. Over-the-counter medications should be avoided during pregnancy. Choice C is incorrect. The supine position can place additional pressure on the aorta and vena cava, leading to vena cava syndrome. Choice D is incorrect. A reduction of iron supplements during pregnancy may reduce hemoglobin production and result in a less than effective immune system.

What intervention is appropriate for the nurse to teach her pregnant patient about relieving constipation? A. Increasing the consumption of fruits and vegetables B. Taking a mild over-the-counter laxative C. Lying flat on the back when sleeping D. Reduce the consumption of iron by at least ½

C Choice C is correct. Assessment-related tasks are not within the scope of the unlicensed assistive personnel's (UAP) role. The RN should perform the assessment and evaluation of a patient's response to any intervention. Choice A is incorrect. Obtaining and reporting vital signs, such as oxygen saturation via pulse oximeter, is within the scope of the UAP role. Choice B is incorrect. Adjusting the nasal cannula for proper positioning and patient comfort is within the scope of the UAP role. Choice D is incorrect. Only answers A and B are appropriate delegation.

Which action is not appropriate for the RN to delegate to the UAP? A. Obtain oxygen saturation via pulse oximeter. B. Assist the patient with adjustment of nasal cannula tubing. C. Assess a client's reaction to oxygen therapy and for any worsening shortness of breath D. All of the above.

C Choice C is correct. A central concept of patient advocacy is ensuring that the patient's decisions are based on sufficient information and understanding while supporting the patient's right to exercise autonomy. Choice A is incorrect. This answer does not serve to support the patient's right to autonomy. Choice B is incorrect. A referral to the lactation consultant is not necessarily indicated. Choice D is incorrect. While the nurse should support the patient's choice, it is essential to confirm that the patient's decision-making process is based on adequate information.

A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate. A. Remind the patient of why breast feeding is the best method of infant feeding. B. Request a referral to the lactation consultant. C. Determine the patient's knowledge base related to infant feeding options. D. Accept the patient's decision without further discussion

B Choice B is correct. Clients are placed on nothing by mouth (NPO) before procedures such as an EGD. Clients with chronic kidney disease (CKD) are especially prone to hypernatremia upon water depletion. CKD impairs the kidney's ability to concentrate the urine, and therefore, more free water is lost in the early stages of CKD. Often, these clients need to ingest more fluids. In clients with CKD, prolonged insufficient water intake while on NPO status may result in negative water balance and the development of hypernatremia. Choice A is incorrect. Hypercalcemia is most commonly caused by excessive oral intake of calcium or impaired excretion of calcium. Calcium balance is not acutely altered by insufficient water intake during NPO status. Choice C is incorrect. Hyperkalemia is most commonly caused by excessive oral intake of high potassium foods or potassium retaining medications (ACE inhibitors and potassium-sparing diuretics such as spironolactone). Although chronic kidney disease may cause hyperkalemia due to impaired potassium excretion, this electrolyte is not acutely altered by insufficient water intake during the temporary NPO status. The nurse should recognize that water depletion can quickly lead to hypernatremia in CKD clients. Choice D is incorrect. Hypomagnesemia is caused by insufficient magnesium intake, absorption problems, or conditions that shift magnesium into cells, such as ascites and hyperglycemia. Magnesium would not be significantly reduced by a temporary NPO status or chronic renal disease. Learning objective: The nurse should recognize and monitor water depletion associated with acute electrolyte imbalances such as hypernatremia during NPO status in CKD clients.

A patient with chronic renal disease is scheduled for an esophagogastroduodenoscopy (EGD). Which of the following imbalances should the nurse monitor for? A. Hypercalcemia B. Hypernatremia C. Hyperkalemia D. Hypomagnesemia

B Choice B is correct. Upon assessment of the child's medical history, the nurse should anticipate a finding of a viral infection -- specifically influenza (A or B) or varicella -- within the preceding two-week period. Choice A is incorrect. Cellulitis is a bacterial infection not typically associated with Reye syndrome. Choice C is incorrect. Meningitis, including viral meningitis, is not commonly associated with Reye syndrome. Choice D is incorrect. Mumps, although viral, is not generally associated with Reye syndrome.

A toddler has just been diagnosed with Reye syndrome. Upon assessment of the child's medical history, which condition should the nurse expect? A. Cellulitis B. Influenza C. Meningitis D. Mumps

B Choice B is correct. Due to the shortness of breath, leg swelling, and patient's age, the nurse can suspect that this patient is suffering from congestive heart failure (CHF). The drug of choice in managing fluid overload in CHF is a loop-acting diuretic, i.e. furosemide, also known as Lasix. Furosemide acts on the ascending limb of Henle's loop and blocks the sodium-potassium-chloride cotransporter; thus, inhibiting sodium and chloride reabsorption. Decreased NaCl reabsorption will result in hypotonicity in the nephron's interstitial space, leading to significant free water excretion. Furosemide is also used in managing non-cardiac peripheral edema, fluid retention, and ascites. Choice A is incorrect. Mannitol is a diuretic used for the reduction in increased intracranial pressure. This is because mannitol is an osmotic diuretic that does not cross the blood-brain barrier. A gradient is developed between plasma and brain cells, causing a shift from the extracellular space into the blood vessels. Choice C is incorrect. Hydrochlorothiazide is a thiazide diuretic. These diuretics also inhibit the sodium/chloride cotransporter, but their site of action is in the "distal convoluted tubule" of the nephron. Thiazide diuretics are used in treating hypertension. The amount of NaCl reabsorption in the distal tubule is small. Therefore, blocking this site alone does not cause large enough diuresis. Hence, thiazides are not the drug of choice in heart failure. In CHF, loop diuretics are most effective because their site of action is on Henle's loop, where 25% of NaCl reabsorption occurs. Hence, these agents promote the most effective diuresis in CHF. Choice D is incorrect. Spironolactone is a potassium-sparing diuretic. Spironolactone helps treat high blood pressure, edema, ascites, and conditions with high hormone aldosterone levels (Conn's syndrome, primary hyperaldosteronism).

An 81-year-old adult arrives in the emergency department complaining of shortness of breath and bilateral leg swelling. Following an EKG order, what is the first drug the nurse should expect the doctor to order? A. Mannitol B. Furosemide C. Hydrochlorothiazide D. Spironolactone

Oral stage Anal stage Phallic stage Latency stage Genital stage The oral stage is first. According to Freud's psychosexual stages, children from 0 to 1 years old are in the oral stage. In this stage, children are interested in putting things in their mouths, sucking, and tasting. They will put unfamiliar objects in their mouth and derive pleasure from oral activities. The second is the anal stage. Children from 2-3 years old are in the anal stage. This is the stage when toilet training occurs. If children can complete this activity, they pass out of the anal stage, but if they struggle, they may become 'stuck' in their psychosexual development. The third is the phallic stage. Freud believes that 3-6-year-old children are in the phallic stage of psychosexual development. In this stage, boys become very attached to their mothers, whereas girls become very attached to their fathers. Fourth is the latency stage. According to Freud's psychosexual stages, children from 6 years old until puberty starts are in the latency stage. In the latency stage, children spend most of their time with peers of the same sex. This is when they begin school and tend to interact mainly with those of the same sex. Lastly is the genital stage. This stage occurs from puberty and beyond. In the genital stage, individuals are attracted to opposite-sex peers.

Place the following stages of Freud's psychosexual development in the correct order. Oral stage Phallic stage Genital stage Anal stage Latency stage

B Choice B is correct. The skin disorder that is appropriately paired with an independent nursing intervention that can correct it or prevent it from getting worse is the use of limited mild soap to help with excessive dryness. Choice A is incorrect. Although the application of an antiseptic spray to correct or prevent erythema from getting worse may be indicated, the use of any antiseptic spray is a dependent and not independent nursing intervention. Dependent nursing interventions need a doctor's order and because an antiseptic topical skin spray contains a medication, you must have a doctor's prescription to use it for erythema. Choice C is incorrect. Although the application of an antimicrobial cream to correct or prevent abrasions may be indicated, the use of any antimicrobial cream is a dependent and not independent nursing intervention. Dependent nursing interventions need a doctor's order and because antimicrobial topical skin creams contain a medication, you must have a doctor's prescription to use it for erythema. Choice D is incorrect. Hirsutism is a skin disorder that is characterized by the abnormal growth of unwanted hair on areas such as a female client's face; washing the area carefully and gently will not correct or prevent it. Shaving and tweezing the unwanted hair, however, are two independent nursing interventions that can be implemented to correct hirsutism.

Select the skin disorder that is appropriately paired with an independent nursing intervention that can correct it or prevent it from getting worse. A. Erythema: The application of an antiseptic spray B. Excessive dryness: Using limited mild soap for bathing C. Abrasions: The application of an antimicrobial cream D. Hirsutism: Washing the area carefully and gently

D Choice D is correct. The patient with Clostridium difficile (C. diff) should be placed in a private room. This infection is a significant health threat that can lead to death in sick or immunocompromised patients. Clostridium difficile symptoms include persistent watery diarrhea, abdominal pain, nausea, fever, and appetite loss. It is spread quickly from one person to another, so exceptional hand hygiene must be practiced by anyone coming into contact with the patient. Also, personnel must use gloves and gowns when caring for these patients. Full contact-enteric precautions must be practiced. Contact enteric precautions include all contact precautions plus washing hands with soap and water when leaving the patient room. Choices A, B, and C are incorrect. Patients with seizures, diabetes, and hyperthyroidism do not require placement in a private room since they do not pose a threat to others.

The charge nurse is making room assignments for four new patients being admitted to the unit. There is one private room available. The patient who should be assigned to the private room is the patient with: A. Seizures B. Diabetes C. Hyperthyroidism D. Clostridium difficile

B Choice B is correct. Collecting a sputum sample is within the scope of practice for an LPN/LVN. Further, cystic fibrosis is a chronic condition that has an acuity level appropriate for an LPN. Choices A, C, and D are incorrect. An RN is assigned unstable clients who has an unpredictable outcome. A client with acute compartment syndrome awaiting emergency surgery will require an RN because this individuals condition may deteriorate and the client will require education regarding the procedure. A client with acute respiratory failure receiving high-flow oxygen is an unstable diagnosis requiring an care by an RN. Finally, the same with the client with sepsis requiring vasopressors. This client does not have a predictable outcome and should be cared for by the RN.

The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN? A. admitted with acute compartment syndrome awaiting emergency surgery. B. with cystic fibrosis who needs an early morning sputum sample collection. C. with acute respiratory failure receiving high-flow oxygen therapy. D. sepsis requiring multiple intravenous (IV) antibiotics and initiation of vasopressors.

A, B, C Choices A, B, and C are correct. During an external disaster such as a mass shooting, it is reasonable for the nurse to anticipate a surge in clients. To accommodate the surge of individuals, the nurse should advocate for the timely disposition of clients (either admission or discharge) to clear up necessary space. If a client is discharged but cannot leave until the transportation is arranged, they should be placed in a designated discharge area. The charge nurse will need to modify the nurse/client ratio as the influx in clients will require more staffing resources. Choices D and E are incorrect. Switching documentation methods from electronic to paper would jeopardize client safety. This also would decrease efficiency. This would be an inappropriate action. The charge nurse should not be responsible for frequently updating the media. This would be the responsibility of the facilities administration. Key recommendations when preparing for a surge in clients Check and test communications systems Open the incident command center and review action plans Arrange for as many safe discharges as possible Modify the nurse/client ratio to one that is safe and practical Clear the emergency department (ED) by having the physician determine the client's disposition (discharge or admit) Consult the medical director regarding elective surgeries and surgical support staff Notify ancillary departments (laboratory and blood bank)

The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The charge nurse should take which action to prepare for the surge in clients? Select all that apply. A. Work to arrange timely discharge and admission for appropriate clients. B. Establish a holding area for discharged clients not able to go home. C. Modify the nurse/client ratio to accommodate the surge levels. D. Instruct staff to switch from electronic to paper documentation. E. Prepare to provide frequent updates to local media

A Choice A is correct. It is usual for toddlers to play by themselves and not interact with each other. This is called "parallel play." Choice B is incorrect. This statement is blaming the mother and makes her feel guilty for her child's behavior. The nurse should not mention this statement. Choice C is incorrect. This is normal behavior for the toddler. There is no need for the nurse to mention this situation to the physician. Choice D is incorrect. There is no need to refer the child to a child psychologist regarding the child's behavior. Although a session with the child psychologist would be helpful for the mother to understand her child's behavior better; however, it is not necessary.

The mother of a 2-year-old boy states to the nurse during their check-up: "I just don't get it. He just sits there and plays on his own while all his other cousins play with each other. Is there anything wrong with him?" Which response by the nurse is most appropriate? A. "Your child is a toddler. It's normal for his age to just play all by himself while other children play too." B. "Did you encourage him to play with the other children? Maybe you don't encourage him that's why he doesn't play with them." C. "Let's mention that to the doctor when he comes in to see him." D. "I really recommend your child be checked by a child psychologist."

A, C Choices A and C are correct. The nurse has noted fetal tachycardia. Any increase in fetal heart rate above 160 is considered tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention. Any non-reassuring fetal heart rate will require intervention. One could remember these interventions with the mnemonic: LION: lie the mother on her left side, increase IV fluids, oxygen, and notify the healthcare provider. In this case, the non-reassuring sign of fetal tachycardia necessitates intervention, therefore lying the mother on her left side is an appropriate intervention. Administering oxygen is an appropriate nursing intervention for the noted fetal tachycardia. The idea is to improve fetal oxygenation. This will go along with repositioning the mother onto her left side, increasing the rate of IV fluid administration, and notifying the healthcare provider. Choice B is incorrect. Decreasing the rate of the mother's IV fluids is not appropriate. Instead, the nurse should increase the IV fluid rate to help better facilitate blood perfusion to the placenta and fetus. Choice D is incorrect. It is inappropriate to continue to observe the mother. The nurse has noted fetal tachycardia, a non-reassuring sign that requires intervention. The nurse should lay the mother on her left side, increase her IV fluids, administer oxygen, and notify the healthcare provider.

The nurse assists a mother in labor to the bathroom and notes that the fetal heart rate increases from 130 to 190. She sits the mother back down in bed, and the fetal heart rate remains 190. Which of the following nursing actions would be appropriate? Select all that apply. A. Lie the mother down on her left side B. Decrease the rate of her IV fluids C. Administer oxygen D. Continue to just observe the mother

A, B, E Choices A, B, and E are correct. The nurse should acutely assess and maintain airway patency for a client admitted with a significant burn. Further, the nurse should keep the client on NPO status because of the risk of oral mucosa irritation and gastrointestinal dysfunction. A twelve-lead electrocardiogram is necessary because the potassium shifts extracellular, leading to hyperkalemia acutely. This may lead to cardiac dysrhythmias. Finally, the nurse should obtain an arterial blood gas to determine the client's arterial oxygen status. Choices C and D are incorrect. Rapid intravenous access needs to be obtained. If this is not available, the provider should insert a central line for fluid resuscitation. The client will initially be prescribed isotonic intravenous fluids such as Lactated Ringers. Hypertonic saline is indicated for increased intracranial pressure. Full-thickness burns should be irrigated with sterile saline, not disinfectants such as chlorhexidine. The burn should then be covered with a sterile, non-adherent dressing. A client with a significant thermal burn requires immediate intervention. The nurse should assess the client's airway, breathing, and circulation. Following a thermal burn, the immediate threat to a client is the risk of carbon monoxide poisoning and smoke inhalation. For major thermal burns, the nurse should anticipate using the rule of nines to estimate the area affected and the Parkland formula to guide prescribed isotonic fluid resuscitation. The Parkland formula is 4 mL x the client's weight in kilograms x total body surface area burned. This will provide the total amount of isotonic fluid needed in the first twenty-four hours.

The nurse cares for a newly admitted client with a full-thickness burn of over 25% of the total body surface area. The nurse should take which of the following actions? Select all that apply. A. Keep the patient on NPO status B. Obtain a 12-lead electrocardiogram C. Prepare to infuse hypertonic saline D. Irrigate the burns with chlorhexidine E. Obtain an arterial blood gas (ABG)

C Choice C is correct. Due to the inability of the left ventricle to pump blood, there is an accumulation of blood behind it, leading to congestion in the pulmonary veins down to the lungs. Choice A is incorrect. Venous congestion in the liver occurs because of a decrease in the functioning of the right ventricle. Choice B is incorrect. Hypoperfusion of tissues is a consequence of most forms of heart failure. However, the manifestations of left heart failure occur because of pulmonary congestion. Choice D is incorrect. The heart being unable to meet the accelerated needs of the body despite its standard cardiac output is a description of high output heart failure. This occurs in sepsis, Paget's disease, beriberi, anemia, and other conditions

The nurse in the emergency department is taking care of a patient diagnosed with left ventricular failure. The patient presents with fatigue, muscular weakness, and dyspnea. The patient is seen coughing and sitting in a "three-point position". The nurse understands that manifestations of left-sided heart failure present themselves as respiratory problems because: A. There is venous congestion in the liver. B. There is hypoperfusion of tissue cells. C. There is pulmonary congestion. D. Despite the normal cardiac output, the heart is still not able to meet the accelerated demands of the body.

D Choice D is correct. Rheumatoid arthritis (RA) is an autoimmune disorder characterized by symptoms such as bilateral joint pain, joint swelling, fatigue, low-grade fever, and weight loss. Low-grade fever is a manifestation of inflammation. Rheumatoid arthritis causes inflammation of the joints. Usually, the joint involvement is symmetric and bilateral. Choices A, B, and C are incorrect. Janeway lesions are a clinical feature associated with bacterial endocarditis. Tophi is a clinical feature associated with gout. Unilateral joint pain is consistent with osteoarthritis, not with RA. Joint involvement in RA is bilateral. RA is an autoimmune disease that may produce systemic symptoms such as fever, fatigue, weight loss, dysphoria, symmetric joint pain, joint swelling, and joint stiffness persistent in the morning. Risk factors for RA include family history, female gender, and cigarette smoking. Medications primarily utilized in managing RA include disease-modifying antirheumatic drugs (DMARDs) and corticosteroids.

The nurse is assessing a client who is newly diagnosed with rheumatoid arthritis (RA). Which of the following findings is consistent with this diagnosis? A. Janeway lesions B. Tophi C. Unilateral joint pain D. Low-grade fever

A, C Choices A and C are correct. Bleeding precautions are an essential educational point for a patient with ALL. Due to the excess of blast cells, their platelet count will drop. With decreased platelets, it will take the patient longer than usual to clot, leading to an increased bleeding risk (Choice A). Neutropenic precautions are essential to discuss with the family of a child with ALL. Since the child has a low absolute neutrophil count and a high blast percentage, their ability to fight infections will be severely impaired. This means that special precautions need to be in place to protect the child from disease. These neutropenic precautions include no fresh flowers or plants in the room; all visitors should wash their hands before entering the room and wear a mask, no sick visitors, and keep the door closed (Choice C) Choice B is incorrect. Contact precautions are not necessary for a patient with ALL. Contact precautions would be used for a disease that is spread from person to person via contact with the infectious agent, such as MRSA. ALL is not a contagious disease that can be transmitted from person to person, so contact precautions are unnecessary. Choice D is incorrect. Sternal precautions are unnecessary for the patient with ALL. Sternal precautions are put in place after an incision is made on the sternum during cardiothoracic surgery. It is to prevent excessive pulling and tension on these sutures while the sternum heals. The patient with ALL does not need sternal precautions

The nurse is caring for a 3-year-old newly diagnosed with acute lymphoblastic leukemia (ALL). While talking to the family, which of the following educational points does the nurse know to reinforce based on the child's diagnosis? Select all that apply. A. Bleeding precautions B. Contact precautions C. Neutropenic precautions D. Sternal precautions

C Choice C is correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder. If a client is taking the benzodiazepine alprazolam, this will increase the seizure threshold and may attenuate the efficacy of ECT. Benzodiazepines and anticonvulsants should therefore be avoided in clients receiving ECT. Choices A, B, and D are incorrect. Antidepressant medications (such as sertraline) and antipsychotics (such as ziprasidone) may be given concurrently with ECT. These medications may enhance the efficacy of the treatment. Proton pump inhibitors (such as omeprazole) are typically given on the day of treatment to prevent gastric reflux and aspiration. Electroconvulsive therapy (ECT) is an effective treatment for various conditions, including major depressive disorder, psychosis, and post-partum disorders. A stigma is attached to ECT that it is somehow inhumane. This stigma is false, as ECT is a highly effective treatment when medications are ineffective. Nursing care for ECT includes witnessing informed consent, ensuring that the client is NPO prior to the procedure, and preprocedural laboratory work, including a 12-lead electrocardiogram (ECG) has been completed. Certain medications should be withheld prior to ECT, including anticonvulsants and benzodiazepines.

The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). Which medication should the nurse question? A. Sertraline B. Omeprazole C. Alprazolam D. Ziprasidone

A Choice A is correct. A lack of cortisol and aldosterone characterizes Addison's disease. The priority for the nurse is to administer the prescribed hydrocortisone to prevent the client from developing a life-threatening Addisonian crisis. Choices B, C, and D are incorrect. The nurse should incorporate a plan of care that involves offering salty snacks and water since sodium levels may be low in a client with Addison's disease. Changes to the integument are common with Addison's and include increased pigmentation. Fatigue is a common manifestation that should enable the nurse to encourage frequent rest periods. Addison's disease is when the client has insufficient cortisol and aldosterone. The mainstay treatment is lifelong corticosteroid replacement with hydrocortisone. If the client experiences stressful events or illnesses, the dosage may need to increase. During an adrenal crisis, the priority treatment is administering hydrocortisone intravenously. The client is volume depleted, hypoglycemic, and hyponatremic and will need rapid fluid resuscitation. Dangerously high potassium levels are also evident in an adrenal crisis and require cardiac monitoring and medications such as sodium polystyrene.

The nurse is caring for a client who has Addison's disease. Which of the following interventions would be a priority? A. Administer prescribed hydrocortisone B. Offer salty snacks and water C. Assess skin integrity D. Encourage frequent rest periods

A Choice A is correct. Manual cervical exams should be questioned if a client has placenta previa. The reasoning is that palpation of the placenta previa through a partially dilated cervix may cause severe hemorrhage. Choices B, C, and D are incorrect. These orders are appropriate for a client with placenta previa. Transvaginal and transabdominal ultrasounds are safe. Transvaginal ultrasound is the most accurate way to assess placenta previa. A nonstress test is often completed to determine fetal well-being. This is a non-invasive test usually conducted during the third trimester.

The nurse is caring for a client with placenta previa. Which of the following orders by the primary healthcare provider (PHCP) should the nurse question? A. Manual cervical exam B. Transabdominal ultrasound C. Nonstress test D. Transvaginal ultrasound

C Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, which is one of the earliest manifestations of shock, and the nurse needs to assess the client further. Choice B is incorrect. A low-grade temperature is an expected finding following surgery because of the inflammation. Choices A and D are incorrect. Incisional pain and hypoactive bowel sounds are all expected findings in the immediate post-operative period.

The nurse is caring for a patient who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings would be essential for the nurse to follow-up? A. Incisional pain level of "6" on a 1-10 scale. B. An oral temperature of 99.5 degrees Fahrenheit. C. A heart rate of 112 beats-per-minute (BPM). D. Hypoactive bowel sounds in all four quadrants.

A Choice A is correct. Glomerular filtration rate (GFR) measures kidney function. Health care practitioners use GFR to evaluate the stage of kidney disease, and in some cases, to determine drug dosing. A GFR of 120 mL/minute falls within the normal expected GFR range of 90 to 125 mL per minute. Choice B is incorrect. A GFR of 60 mL/minute is too low and, if chronic, indicates chronic kidney disease stage II. Choice C is incorrect. A GFR of 150 mL/minute is too high and may indicate a testing error that requires a re-test. Choice D is incorrect. A GFR of less than or equal to 15 mL/minute represents end-stage kidney disease (CKD, stage V) and is not a normal finding. Usually, these patients end up needing dialysis. Learning objective: A normal GFR falls between 90 mL/minute to 125 ml/minute. Chronic kidney disease (CKD) is staged based on the GFR and classified into stages I, II, III, IV, and V.

The nurse is caring for a patient with suspected kidney disease. Which of the following glomerular filtration rates is considered within normal limits? A. 120 mL per minute B. 60 mL per minute C. 150 mL per minute D. 15 mL per minute

A, B, C, D Choices A, B, C, and D are correct. Age-related skin changes include decreased dermal blood flow, which causes dry skin. The development of actinic lentigo (known as liver spots but have nothing to do with the liver) are darkened parts of the skin commonly found on the wrists, back of the hands, and forearms. Other age-related changes include the degeneration of elastic fibers, which causes decreased tone and elasticity. Finally, loss of subcutaneous fat is an expected finding which may cause hypothermia and pressure ulcers. Choice E is incorrect. Increased epidermal thickness is not an age-related change; instead, the decreased epidermal thickness occurs, causing the skin to be fragile and transparent. Some of the age-related skin changes include - Decreased epidermal thickness Increased epidermal permeability Decreased dermal blood flow Thinning subcutaneous layer Degeneration of elastic fibers

The nurse is conducting a community health class on skin changes for older adults. It would be appropriate for the nurse to state which of the following are normal age-related changes? Select all that apply. A. Decreased dermal blood flow B. Development of actinic lentigo C. Degeneration of elastic fibers D. Loss of subcutaneous fat E. Increased epidermal thickness

B, C, E Choices B, C, and E are correct. Addison's disease is a problem dealing with a deficient amount of aldosterone and cortisol. Aldosterone is responsible for sodium retention and potassium elimination. A clinical feature of this disorder includes elevated potassium; thus, continuous cardiac monitoring is warranted. The priority treatment for a client with Addison's is to replace the missing steroid, thus, hydrocortisone is essential. The nurse should implement fall precautions because, with a low amount of cortisol and aldosterone, the client is at risk for dehydration, leading to orthostatic hypotension. Choices A, D, and F are incorrect. A high potassium diet is contraindicated for a client with Addison's as their potassium will already be elevated. The client should consume low potassium foods and be encouraged to increase their fluids as dehydration is a common manifestation of this disease. Finally, the nurse must monitor the patient's fluid volume status, but an indwelling catheter is invasive and raises the risk of infection. Addison's disease (adrenal insufficiency) is characterized by an insufficient amount of glucocorticoid and mineralocorticoid. Lifelong steroid replacement is often necessary to manage this condition. Teaching points for a client with adrenal insufficiency include - Medication adherence to the prescribed corticosteroid Dietary management involves adequate sodium and reducing potassium Self-monitoring of weight and blood pressure Notifying the primary healthcare provider of any stressful events or illnesses which may trigger a crisis Wear a medical alert ID bracelet or tag Keep a dose of emergency hydrocortisone at all times, and know when and how to administer the injection Understand and be alert for the signs of an Addisonian crisis (profound fatigue, dizziness, abdominal cramping, confusion)

The nurse is developing a plan of care for a client diagnosed with Addison's disease. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Diet high in potassium B. Continuous telemetry monitoring C. Intravenous hydrocortisone D. Fluid restriction E. Fall precautions F. Indwelling urinary catheter

D Choice D is correct. Aspart insulin is a rapid actin insulin that should be administered to the client no greater than 10-15 minutes prior to the meal or while the client is actively eating. Prior to the administration of this insulin, the client's blood glucose should be obtained. Choices A, B, and C are incorrect. These are inappropriate times to administer aspart insulin. Rapid onset insulins (lispro, aspart, glulisine) are given 10-15 minutes before a meal or while the client is actively eating.

The nurse is educating a client about newly prescribed aspart insulin. The nurse should instruct the client to self-administer this insulin A. 30-45 minutes before a meal. B. one hour after a meal. C. 20-30 minutes before a meal. D. 10-15 minutes before a meal.

A

The nurse is performing a physical assessment. The nurse should assess the client's visual acuity by obtaining which of the following? A. Snellen chart B. Tonometer device C. Penlight D. Slit lamp

C Choice C is correct. Placing the client supine or Trendelenburg for this procedure would be appropriate. One of these two positions is acceptable to decrease the risk of air embolism. The client should not have their head elevated for this procedure. Choice A, B, and D are incorrect. The positioning of a client is essential to avoiding an air embolism. Thus, having a client high-Fowler's, lateral, or reverse Trendenlenberg would be contraindicated. If a client experiences an air embolism, turning the client to the left-lateral position would be appropriate, but not for the procedure of removing a central line itself. While removing a central venous catheter, the client should be positioned supine or in Trendelenburg. The catheter should not be removed while the client is sitting up because this would increase the risk of air embolism because the atmospheric pressure is relatively higher than the intrathoracic pressure. To ensure that the intrathoracic pressure is higher than atmospheric pressure, position the client in either supine or Trendelenburg and have the client hold their breath or perform a Valsalva maneuver during removal.

The nurse is preparing to remove a central venous catheter. It would be appropriate to place the client in which position for this procedure? A. Reverse Trendelenburg B. Left lateral C. Trendelenburg D. High-Fowler's

B Choice B is correct. The nurse providing education to this mother would be most accurate in reminding the mother to refrain from administering systemic steroids to the child in the five days prior to the exam. Systemic corticosteroids, as well as anti-histamine medications, may interfere with the test results by reducing reactions and giving false-negative results. Choice A is incorrect. Anti-histamines should not be given in five days before the exam. Choice C is incorrect. This child can bathe as normal and should not have their skin cleaned vigorously before the exam. Choice D is incorrect. NPO status, or nothing by mouth, is not necessary for this exam. Children should eat like usual and encourage them to eat small meals if they are nervous.

The nurse is providing education to the mother of an 8-year-old boy scheduled to receive a scratch skin test to assess for the presence of allergies. The nurse would be correct in encouraging the mother to do which of the following actions to prepare for the test? A. Administer a single dose of anti-histamine medication one day before the test to prepare for any discomfort B. Refrain from administering systemic steroids to the child in the 5 days preceding the exam. C. Scrub the child's skin vigorously before the exam. D. Maintain NPO status for twelve hours before the test

D Choice D is correct. Fluids should be avoided for at least 30 minutes to one hour after consuming meals to decrease the likelihood of dumping syndrome. Fluids fill up the stomach quickly and will move food more quickly into the small intestine. Therefore, the client should be educated to wait 30-60 minutes after a meal before consuming fluids. Choice A is incorrect. Consuming fluids before meals increase the speed of gastric emptying, subsequently increasing the likelihood of dumping syndrome. Clients should be advised to avoid drinking fluids within a half hour before eating. Choice B is incorrect. Consuming fluids with meals increases the speed of gastric emptying, subsequently increasing the likelihood of dumping syndrome. Clients should be advised to avoid drinking fluids with their meals. Choice C is incorrect. Consuming fluids before and during meals increases the speed of gastric emptying, subsequently increasing the likelihood of dumping syndrome. Clients should be advised to avoid drinking fluids 30 minutes before meals, during meals, and 30-60 minutes after meals to decrease the likelihood of experiencing dumping syndrome symptoms. When providing nursing education regarding fluid consumption to a client with dumping syndrome, identify "the client should drink fluids at least half an hour after meals" as the accurate statement. Dumping syndrome is a collection of symptoms that occur when the contents of the stomach empty too rapidly into the small intestine. A large percentage of dumping syndrome cases are associated with gastric surgery, with an estimated 20-50% of clients who undergo surgery to remove or bypass the stomach (e.g., gastrectomy, gastric bypass surgery, gastric sleeve surgery, etc.) ultimately developing symptoms of dumping syndrome. Rapid gastric emptying causes large amounts of undigested food to empty rapidly into the small intestine, causing the client to experience nausea, abdominal cramping, diarrhea, and/or rapid blood glucose responses.

The nurse is providing health education to a client with dumping syndrome. Which teaching point about drinking fluids is accurate? A. The client should drink fluids immediately before meals. B. The client must only drink fluids with meals. C. The client must drink fluids before and during meals. D. The client should avoid drinking fluids for at least half an hour after meals.

B Choice B is correct. Patients should be discouraged from using over-the-counter topical glucocorticoids on their face because these creams may cause permanent hypopigmentation and thinning of the skin. Instead, patients with facial atopic dermatitis should seek treatment from their primary health care provider. Choices A, C, and D are incorrect. Most over-the-counter topical glucocorticoids may be safely used short-term on the hips, shins, and abdomen. If atopic dermatitis is not resolved after following the over-the-counter instructions, patients should speak with their health care team to avoid adverse effects of these medications, including hypopigmentation and thinning skin as stated above, as well as enlarged blood vessels and increased localized hair growth.

The nurse is providing teaching to a patient in the clinic with atopic dermatitis. The patient is using over the counter glucocorticoids to treat the condition with some relief. The nurse should advise this patient to avoid applying the cream to which part of the patient's body? A. Hips B. Face C. Shins D. Abdomen

B Choice B is correct. Clinical features of acute glomerulonephritis (AGN) include proteinuria, hematuria, periorbital edema, weight gain, high blood pressure, and decreased glomerular filtration rate (GFR). Choices A, C, and D are incorrect. Individuals with glomerulonephritis would have oliguria and not polyuria. This is explained because of the massive inflammation occurring in the glomerulus. Glycosuria and ketonuria are not features of this disease; instead, these may be expected in a client with uncontrolled blood glucose. AGN is a serious condition secondary to many infectious processes such as streptococcal infections, mononucleosis, and hepatitis. Nursing care aims to prevent the most common complication, which is fluid volume overload. The client may have dietary restrictions such as fluid, sodium, and potassium. The nurse should monitor the client's intake and output, weight, and blood pressure.

The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding? A. Ketonuria B. Hematuria C. Polyuria D. Glycosuria

D Choice D is correct. A client with hypoparathyroidism should receive a diet that is high in calcium and low in phosphorus. A high calcium diet may increase the client's serum calcium levels. A low phosphorus diet ensures that his phosphorus levels are reduced enough so that it will not interfere with his calcium levels. Calcium and phosphorus have an inversely proportional relationship. Choice A is incorrect. It does not matter whether the client is eating a high-calorie diet, as long as the client adheres to a diet high in calcium and low in phosphorus. Choice B is incorrect. A client with hypoparathyroidism should receive a diet that is high in calcium and low in phosphorus. Choice C is incorrect. A client with hypoparathyroidism should receive a diet that is high in calcium and low in phosphorus.

The nurse is reviewing the diet of the patient with hypoparathyroidism. The nurse understands that the client should be on what type of diet? A. High calorie, low calcium diet B. Low calcium, low phosphorus diet C. High phosphorus, low calcium diet D. High calcium, low phosphorus diet

B Choice B is correct. After oral surgery or a tonsillectomy, the physician will order a series of labs, including hematocrit, hemoglobin, and prothrombin time. The results of these labs are evaluated to determine whether or not the patient is experiencing bleeding as a result of the surgery and if they can adequately bleed. Choice A is incorrect. BUN levels, or blood urea nitrogen levels, help health care providers evaluate kidney function by calculating how nitrogen is in the blood. Nitrogen is a byproduct of urea, which is made by the kidneys when proteins are broken down. This test is not ordered routinely after oral surgery. Choice C is incorrect. Creatinine laboratory values evaluate kidney function. Creatinine is produced when muscles metabolize. This test is not ordered routinely after oral surgery. Choice D is incorrect. A test to evaluate viral load is used in cases of HIV and Hepatitis. This test is generally run when a viral disease is suspected or being managed. A patient's viral load is not ordered routinely after oral surgery.

The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to? A. BUN level B. Prothrombin time C. Creatinine level D. Viral load

B Choice B is correct. Logrolling the client is a priority to maintain proper body alignment and prevent injury to the spinal cord. Choice A is incorrect. The PCA delivers a fixed amount of analgesic to the client every time he presses the button. The priority of the nurse should be to prevent spinal cord injury to the client. Choice C is incorrect. The client is in the first 24 hours post-surgery and should be on bed rest. Ambulation is not a priority at this time. Choice D is incorrect. The client can put pillows under the client's legs to increase comfort; however, the priority nursing diagnosis is to prevent post-operative complications.

The nurse is taking care of an 8-hour post-operative spinal surgery client. What should be the priority nursing intervention for the client? A. Assess how much opioid analgesics the client is using via the patient-controlled analgesia (PCA) pump. B. Logroll the client with three staff when turning the client from side to side. C. Assist the client in ambulating to the bathroom. D. Place pillows under the thighs of each leg when the client is in the supine position.

D Choice D is correct. A woman using oral contraceptives is not at risk for toxic shock syndrome (TSS) since there is no area where the Staphylococcus aureus bacteria can infect/build a colony. Choices A, B, C are incorrect. Toxic shock syndrome is an accumulation of toxins that are produced by the microorganism, Staphylococcus aureus. Women who are using tampons, cervical caps, and diaphragms are at risk for TSS due to the build-up of S. aureus colonies in the areas where they are located.

The nurse is talking to a group of women about the dangers and ways of acquiring toxic shock syndrome (TSS). The nurse would mention that all of the following women have a high risk of acquiring TSS, except: A. A teenage girl using an absorbent tampon. B. A 29-year-old woman using a cervical cap. C. A 31-year-old woman using a diaphragm. D. A 35-year-old woman using oral contraceptives.

C Choice C is correct. The school-aged kids' cognitive levels are now developed to enable understanding of and adherence to rules. They are now susceptible to instruction. Choice A is incorrect. School-aged kids have greater freedom. They become more adventurous and daring. Choice B is incorrect. School-aged kids are still prone to dangers in the home because of their increased motor abilities and independence. They should be made aware of hazards such as firearms, alcohol, and medications. Choice D is incorrect. School-aged kids are now able to exercise control. They are a lot easier to control compare to pre-schoolers.

The nurse is the guest speaker in a seminar at a local elementary school. She is talking about accident prevention for school-aged children. Which statement by the attendees indicates an understanding of the topic? A. "School-aged children become settled and less adventurous compared to pre-schoolers." B. "School-aged children are less susceptible to home hazards than pre-schoolers." C. "School-aged children understand the dangers when you explain it to them." D. "School-aged kids are less controlled by their parents compared to toddlers."

C Choice C is correct. Promoting independence in decision-making by including the client in their care is the top priority for a 17-year-old with CF. They will soon be making the transition to adult doctors and teams and have a legal say in their treatment as an adult. Facilitating their independence is very important. Choice A is incorrect. By the time the child has reached adolescence they have been living with CF for many years and have already had many opportunities for the teen to learn about their condition. This is not the most important priority for a teenager with CF. Choice B is incorrect. Facilitating interaction amongst peers is important, but as a teenager, this patient will already have had a lot of experience interacting with their peers. This is not the most important priority for a teenager with CF, rather it would be a higher priority in school-age clients. Choice D is incorrect. Emphasizing the importance of education and remaining in school is not the most important priority for a teenager with CF. This client is 17 and has already been in school for over 10 years. The time to emphasize the importance of education as a top priority is in the school-age client and early teen years. The 17-year-old has another goal that is of higher priority.

The nurse is working with a 17-year-old client diagnosed with cystic fibrosis. Which of the following is the most important for clients of this age with cystic fibrosis? A. Providing opportunities for the teen to learn about their condition. B. Facilitating interaction amongst peers. C. Promoting independence in decision making by including the patient in their care. D. Emphasizing the importance of education and remaining in school.

A Choice A is correct. After informing the client's wife that she " . . . should not warm up the car in the garage because it is hazardous," you would explain how a buildup of carbon monoxide would occur and why it be deadly. Based on her statement, the client's spouse demonstrated a knowledge deficit by telling you that she warms up the car in the garage. In response, you must address her knowledge deficit with patient (or caregiver) education. Choice B is incorrect. This is an incorrect statement that reinforces a dangerous behavior that places the client at risk for carbon monoxide poisoning. Choice C is incorrect. Suggesting to the client's spouse that the client should be dressed in warmer clothing does not resolve the issue regarding the risk of carbon monoxide poisoning. Choice D is incorrect. A statement made in this manner is not therapeutic communication, as it does not address the spouse's learning deficit regarding the potential for carbon monoxide poisoning. If a statement is made to a client or a caregiver similar to this, the nurse will likely alienate the receiver of the message from that point forward. Carbon monoxide poisoning causes acute symptoms such as headache, nausea, weakness, angina, dyspnea, loss of consciousness, seizures, and coma. Weeks later, neuropsychiatric symptoms may develop. Diagnosis is made by carboxyhemoglobin levels and arterial blood gases (ABGs), including measured oxygen saturation. Treatment is with supplemental oxygen. Household carbon monoxide detectors may aid in prevention.

The spouse of your elderly male client tells you that her husband becomes so cold when he is outdoors that she warms up his car in the garage before helping him get into his car. How should you respond to her statement? A. "You should not warm up the car in the garage because it is hazardous." B. "That is a good idea, as your husband frequently complains about being cold." C. "You can also dress him in warmer clothing than needed so he is not cold." D. "That is the most foolish thing I have heard in a long time. You have to stop that."

B Choice B is correct. The patient should be sitting when deep breathing and coughing. This position allows the patient to support his incision with a pillow, providing abdominal support when coughing. It also allows the lungs to expand more fully because it enables the diaphragm to move downwards under gravity. Coughing and deep breathing exercises are essential to enhance lung expansion and mobilize secretions, thereby preventing atelectasis (collapse of the alveoli) and pneumonia. Instructions on deep breathing exercises should include: Place the palms down on the rib cage's border and inhale slowly and evenly through the nose until the enormous chest expansion is achieved. Hold the breath for 2 to 3 seconds. Then exhale slowly through the mouth. Continue exhalation until maximum chest contraction has been achieved Choice A is incorrect. The supine position is more comfortable. However, it does not permit the lungs to fully expand. Choice C and D are incorrect. There is no association between loosening respiratory secretions or relaxation when in the sitting position. The sitting position allows lung expansion and can help mobilize the respiratory secretions, not necessarily loosen the secretions.

When instructing a post-surgical patient with an abdominal incision on deep breathing and coughing, the nurse explains that the patient should be sitting up for these activities because: A. It is physically more comfortable for the patient B. Helps the patient to support their incision with a pillow C. Loosens respiratory secretions D. Allows the patient to observe their area and relax

D Choice D is correct. Evidence shows that adequate intake of folate before conception and in the first trimester of pregnancy reduces the incidence of neural tube defects. The U.S. Public Health Service recommends that all women of childbearing age and capable of pregnancy consume 400 ugs of synthetic folic acid daily from either foods or supplements. Folic acid (vitamin B9) works with vitamin B12 and vitamin C to help the body break down, use, and make new proteins. The vitamin helps form red and white blood cells. It also helps produce DNA, the building block of the human body, which carries genetic information. Folic acid is water-soluble vitamin B9; this means it is not stored in the fat tissues of the body. The remaining amounts of the vitamin leave the body through the urine. Since folate is not stored in the body in large amounts, your blood levels will get low after only a few weeks of eating a diet low in folate. Folate is found in green leafy vegetables and liver. Groups of people considered at-risk for folate deficiency include women who are pregnant, women who wish to become pregnant, alcoholics, liver disease and dialysis patients, as well as breast-feeding mothers. Contributors to folate deficiency include: Diseases in which folic acid is not well absorbed in the digestive system (such as Celiac disease or Crohn disease) Drinking too much alcohol Eating overcooked fruits and vegetables, since folate can be easily destroyed by heat. Hemolytic anemia Certain medicines (such as phenytoin, sulfasalazine, or trimethoprim-sulfamethoxazole) Eating an unhealthy diet that does not include enough fruits and vegetables Kidney dialysis Choices A, B, and C are incorrect. All individuals can have deficiencies in folate, however, the client at the highest risk of complications among those listed is the 25-year-old woman who is attempting to conceive.

Which of the following clients is at the highest risk for complications related to folate deficiency? A. An 80-year-old man living in a nursing home B. A 4-year-old boy who is developmentally delayed C. A 16-year-old girl who just started her menstrual cycle D. A 25-year-old woman who is attempting to get pregnant

D Choice D is correct. A client with a dangerous negative nitrogen balance is most likely to receive total parenteral nutrition (TPN). For example, a client who has endured a severe burn injury may have a negative nitrogen balance, which requires the administration of total parenteral nutrition. Amino acids are building blocks of proteins and nitrogen is an essential component of amino acids. Therefore, protein metabolism can be determined by measuring nitrogen balance. Nitrogen balance is given by subtracting nitrogen output from nitrogen input. A negative balance means the amount lost is greater than the amount ingested. A negative nitrogen balance is used to assess malnutrition. Clients with severe negative nitrogen balance will benefit from total parenteral nutrition. Other conditions where total parenteral nutrition is indicated include advanced cancer, advanced acquired immunodeficiency disorder, and severe gastrointestinal disease, which requires complete bowel rest. Choice A is incorrect. A client who is adversely affected with dysphagia would not likely receive total parenteral nutrition. A client who is adversely affected by dysphagia would most likely receive enteral nutrition rather than parenteral nutrition to meet their nutritional needs. Enteral nutrition can be given via tube feedings in the setting of dysphagia. Choice B is incorrect. A client who is adversely affected with aphasia would not likely receive parenteral nutrition. A client who is negatively affected by aphasia has a communication disorder, rather than a nutritional disease or nutritional need. Choice C is incorrect. A client with a dangerous positive nitrogen balance would not be likely to receive parenteral nutrition to meet their nutritional needs. Additional protein is not necessary.

Which of the following clients is the most likely to receive total parenteral nutrition? A. A client who is adversely affected with dysphagia. B. A client who is adversely affected with aphasia. C. A client with a dangerous positive nitrogen balance. D. A client with a dangerous negative nitrogen balance.

B, C Choices B and C are correct. Dystocia, which is prolonged and painful labor, is a risk factor for postpartum hemorrhage. Prolonged labor, specifically, can dramatically increase the risk of postpartum hemorrhage (Choice B). Placenta previa is a risk factor for postpartum hemorrhage. In placenta previa, the placenta is covering the cervix of the mother rather than sitting in the fundus of the uterus as it should be. This puts the mother at risk for postpartum hemorrhage (Choice C). Choice A is incorrect. Microcephaly is a newborn complication where the newborn is born with a head smaller than average. This is not a risk factor for a woman to experience postpartum hemorrhage. If you selected this answer, you might have gotten it confused with macrosomia, a condition where the infant is larger than average, specifically higher than 4,000 g. This is a risk factor for postpartum hemorrhage. Choice D is incorrect. A singleton pregnancy or a pregnancy with only one fetus does not pose a risk for postpartum hemorrhage. The risk factor for postpartum hemorrhage occurs with multiples, such as twins or triplets.

Which of the following conditions are considered risk factors for postpartum hemorrhage? Select all that apply. A. Microcephaly B. Dystocia C. Placenta previa D. Singleton pregnancy

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

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

B Choice B is correct. Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult. Choice A is incorrect. Bowel sounds of 14 per minute are considered normal. Choice C is incorrect. Although bowel sounds more significant than 30 per minute are considered hyperactive, it is not as immediate a concern as choice B. Choice D is incorrect. Bowel sounds usually are high-pitched. However, the rate of bowel sounds here is more normal than choice B.

Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit? A. Bowel sounds of 14 per minute B. High-pitched bowel sounds at a rate of 4 per minute C. Bowel sounds greater than 60 per minute D. Low-pitched bowel sounds at a rate of 30 per minute

A, B A is correct. Menarche is defined as the first occurrence of menstruation, or the first time a female gets her period. This is one of the most important milestones of female adolescents. It typically occurs about two years after thelarche, or the beginning of breast development. B is correct. Thelarche is defined as the beginning of breast development at the onset of puberty. This is a significant milestone for female adolescents. It can occur anywhere between 8 years of age and 13-years-old, as there is significant individual variation. Choice C is incorrect. A deepening voice is a characteristic of male development during adolescence. This is not typical for females to experience. Choice D is incorrect. Growing facial hair is a characteristic of male development during adolescence. This is not typical for females to experience.

Which of the following growth milestones are expected for female adolescents? Select all that apply. A. Menarche B. Thelarche C. Deepening voice D. Development of facial hair

D Which of the following members of the intradisciplinary team should be consulted for an infant suspected of having Celiac disease? Correct A. Pharmacist [0%] B. Pulmonologist [5%] C. Occupational therapist [1%] D. Dietician [93%] Easy Difficulty Level 94% of peers got it right 8 s Time Taken Subject Child Health Lesson Gastrointestinal/Nutrition Client Need Area Management of Care Client Need Topic Collaboration with Interdisciplinary Team Question Type Application EXPLANATION Choice D is correct. Consulting with a dietician is of the utmost importance for the patient who is suspected of having Celiac disease. The dietician is the expert in this area and will provide support, education, and a dietary plan for this patient. Learning to avoid gluten can be difficult for the family, so the dietician is the best resource to help them navigate this. Choice A is incorrect. A pharmacist may be involved in the intradisciplinary team, but there is another specialist of particular importance in the answer choices (a dietician) for the patient with Celiac disease. Choice B is incorrect. It is not necessary to consult with a pulmonologist for a patient with Celiac disease. They should not be experiencing respiratory issues, as Celiac disease is a gastrointestinal disorder. Choice C is incorrect. It is not necessary to consult with an occupational therapist for a patient with Celiac disease. Celiac disease is a gastrointestinal disorder that should not affect the normal functioning and ADLs of this patient.

Which of the following members of the intradisciplinary team should be consulted for an infant suspected of having Celiac disease? A. Pharmacist B. Pulmonologist C. Occupational therapist D. Dietician

A Choice A is correct. To manage time; the nurse should establish goals and priorities for each day and include the patient in prioritizing tasks. Choice B is incorrect. "Need to do" should be differentiated from "nice to do" tasks. Choices C and D are incorrect. The nurse should establish a timeline and allocate priorities to hours in the workday. This will allow the nurse to recognize any falling behind and correct the problem before the day is lost. Additionally, using teamwork appropriately will enhance the work schedule.

Which of the following nursing actions reflects effective time management? A. The nurse asks the patient what is their priority to accomplish each day B. The nurse includes a "nice to do" for every "need to do" task on the list C. The nurse "front loads" the schedule with "must-do" priorities D. The nurse avoids helping other nurses if scheduling does not permit it

A, B Choices A and B are correct. Infants should triple their birth weight by 12 months of age (Choice A). Infants should double their birth weight by six months of age (Choice B). Choice C is incorrect. Infants should triple their birth weight by 12 months of age, not six months of age. If an infant has already tripled their birth weight at six months of age, this represents too much weight gain and could pose a potential problem. A nutritionist and special infant care team should be consulted. Choice D is incorrect. Infants should double their birth weight by six months of age, not 12 months of age. If it takes an infant 12 months to increase their birth weight, this indicates that they are not growing fast enough, and there may be issues related to their growth and development. A nutritionist and special infant care team should be consulted.

Which of the following statements regarding growth in the infant are true? Select all that apply. A. Infants should triple their birth weight by 12 months of age. B. Infants should double their birth weight by 6 months of age. C. Infants should triple their birth weight by 6 months of age. D. Infants should double their birth weight by 12 months of age.

b Choice B is correct. Atrial natriuretic peptide (ANP) works to cause sodium excretion and, therefore, the excretion of water. This is to lower the fluid volume through diuresis. Choice A is incorrect. The atrial natriuretic peptide is found in the atria of the heart. There are stretch receptors present there, which will sense an increase in fluid in the center, releasing ANP when the fluid volume is high. Choice C is incorrect. ANP works to decrease the fluid volume, not increase it, through sodium and water excretion. Choice D is incorrect. ANP works the opposite of aldosterone, not synergistically with it. Aldosterone causes sodium and water retention, increasing fluid volume, whereas ANP causes sodium and water excretion, thus decreasing fluid amount.

Which of the following statements regarding the hormone atrial natriuretic peptide (ANP) are true? Select all that apply. A. ANP is found in the brain. B. ANP causes the excretion of sodium. C. ANP works to increase fluid volume. D. ANP works synergistically with aldosterone.

D Choice D is correct. The perception of pain and its impact on our clients greatly varies among people. For example, gender, cultural beliefs, and individuals' unique pain thresholds all impact our clients' perceptions of pain. Choice A is incorrect. Allodynia is the pathophysiological perception of pain when no painful stimulus is applied. Allodynia, like other abnormal pain processing and pain perception processes, indicates the presence of a neuropathic process. Choice B is incorrect. Scientific evidence supports the presence of pain during neonatal circumcision, something that was not recognized in the past. Choice C is incorrect. Hyperalgesia is a synonym for hyperpathia. Hyperalgesia is an abnormal pain response that is characterized by an intense and severe perception of pain when the stimulus is not at all severe.

Which statement below relating to pain and pain perception is accurate? A. Allodynia is the pathophysiological absence of pain when a painful stimulus is applied. B. Scientific evidence does not support the presence of pain during neonatal circumcision. C. Hyperanalgesia is the opposite of hyperpathia, both of which are abnormal pain responses. D. The perception of pain and its impact on our clients greatly varies among people.

B Choice B is correct. This patient is displaying signs and symptoms of congenital heart disease; specifically coarctation of the aorta. Even if you did not know which congenital heart disease they may have, you would be expected to know that the healthcare provider needs to be notified of these symptoms. Your patient is in normal sinus rhythm and has a normal heart rate for the newborn age group. The systolic murmur, the gradient in peripheral pulses, and 5 second capillary refill are all abnormal. The murmur indicates that there is an opening somewhere in the heart where there should not be. This could be an ASD, VSD, or one of the bypasses in fetal circulation (the ductus arteriosus or foramen ovale) may not have closed on their own. The gradient in pulses indicates that there is more blood flow in the top half of the body than in the lower half - this is what points to coarctation of the aorta. A capillary refill time of 5 seconds is the last abnormal sign for this patient. Capillary refill should be less than 3 seconds in a newborn - delayed capillary refill indicates poor perfusion and must be addressed quickly. It is important to recognize that these are abnormal signs and symptoms and need to be reported to the health care provider for prompt intervention.

While performing a cardiovascular assessment on an infant at 2 hours of life, you note the following: Normal sinus rhythm HR = 178 Systolic murmur +1 pedal pulses +3 radial pulses 5 second capillary refill No edema What is the priority nursing action after this assessment? A. Continue to monitor B. Notify the health care provider C. Administer PRN acetaminophen D. Re-evaluate the patient in one hour

D Choice D is correct. An "adjuvant" analgesic is the term that is synonymous with an analgesic. Adjuvants, also called co-analgesics, are analgesic medications that can be used alone or in combination with other analgesics to relieve pain. An "adjuvant" analgesic is a medication primarily indicated for conditions other than pain treatment; however, they have analgesic effects and can be used in pain management. Examples include anticonvulsants like gabapentin and pregabalin, tricyclic antidepressants (TCAs) such as amitriptyline, and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine, corticosteroids, topical anesthetics (e.g., lidocaine patch), and other topical agents (e.g., capsaicin). Choice A is incorrect. Equianalgesic is not synonymous with analgesic. Equianalgesic is the term used to describe the comparative potency and dose of an opioid analgesic that is equivalent to that of another analgesic in pain relief. In most studies, the equivalent dose of an analgesic has been standardized to 10 mg of parenteral morphine. Choice B is incorrect. Placebo is not synonymous with an analgesic. A placebo is an oral sugar pill or normal saline that may have an effect unrelated to the properties and composition of the placebo. Choice C is incorrect. NSAIDs are non-steroidal anti-inflammatory drugs. Their anti-inflammatory properties make NSAIDs useful as analgesics but are not synonymous with analgesics.

While reviewing the principles of pain management, the nurse understands which of the following terms is synonymous with an "analgesic"? A. Equianalgesic B. Placebo C. NSAID D. Adjuvant

D Choice D is correct. Ailurophobia is best described as an unreasonable fear of cats. The psychiatric mental health treatment interventions for phobias are based on the specific type of phobia. For example, ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear. Choice A is incorrect. A fear of social interactions is referred to as a social phobia. Social interaction phobias are typically treated with exposure therapy, antidepressants, or beta-blockers. Choice B is incorrect. The fear of clowns, which is referred to as coulrophobia, is typically treated with exposure therapy. Choice C is incorrect. The fear of crowds, which is referred to as enochlophobia, is also typically treated with exposure therapy.

While rounding in the mental health unit, you are learning about specific phobias. You should be aware that ailurophobia is an unreasonable fear of: A. Social interactions B. Clowns C. Crowds D. Cats

D Choice D is correct. Naloxone is the antidote for opioid overdose. Naloxone would be used in the overdose of morphine, fentanyl, oxycodone, or other opioid medications. Choice A is incorrect. Sodium bicarbonate is a base produced by the kidneys to buffer the pH of the blood. When the pH is acidic, sodium bicarbonate is produced to help bring the pH back to the appropriate range. This medication is administered when there is an acid-base imbalance in the body, specifically for an acidotic pH with a base deficit. It would not be indicated in the care of a morphine overdose. Choice B is incorrect. Flumazenil is the antidote for benzodiazepine overdose. Morphine is an opioid, not a benzodiazepine, so the nurse would not expect to administer flumazenil to this patient. Choice C is incorrect. Diphenhydramine is an antihistamine commonly prescribed for allergies. There would be no indication for diphenhydramine in a morphine overdose, so the nurse would not expect to administer this to the patient.

While working in the emergency department, the nurse is taking care of a client who has overdosed on morphine. Which of the following medications does she expect the healthcare provider will order? A. Sodium bicarbonate B. Flumazenil C. Diphenhydramine D. Naloxone

A, D Choices A and D are correct. Lanugo (Choice A) is defined as "fine and soft hair that covers the body and limbs of a human fetus/newborn." It is abnormal for a 16-year-old to have lanugo. In a patient who is severely underweight and has lost a large amount of subcutaneous fat, such as in a patient with anorexia nervosa, the body will develop lanugo as a way to insulate itself. Hypothermia (Choice D) is a severe complication of anorexia nervosa. Subcutaneous fat is necessary to insulate the body and regulate the temperature. Clients with anorexia nervosa lose a significant amount of subcutaneous fat due to malnourishment and weight loss. Consequently, they are prone to hypothermia. Choice B is incorrect. Amenorrhea (lack of menstrual period) rather than increased menses is a complication seen in anorexia nervosa—self-inflicted starvation in anorexia nervosa results in malnourishment, hormonal imbalance, and amenorrhea. Choice C is incorrect. Hypotension is seen in anorexia nervosa, not hypertension. Clients with anorexia are prone to malnourishment and dehydration. Dehydration results in fluid-volume deficit and hypotension. Electrolyte imbalance such as hypernatremia is also seen due to free water deficit and concentrated body fluids.

You are assessing a 16-year-old female with anorexia nervosa. Which of the following symptoms and signs would you expect to find? Select all that apply. A. Lanugo B. Heavy menstrual periods C. Hypertension D. Hypothermia

B Choice B is correct. As the supervising nurse on your client care unit, you should investigate and explore the near misses similar to how you deal with sentinel events. Near misses, such as these inaccuracies, should be reported per hospital policy to be studied and examined to circumvent future errors. Choice A is incorrect. Although you should praise the staff for catching these inaccuracies before a medication error occurred, this is not the priority action. Choice C is incorrect. Although unit-dose dispensing was inaccurate, it did not result in a medication error. These near misses are not actual medical errors. Near misses are also referred to as close calls and should be investigated and explored. A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. Such an adverse event could include side effects to medications/vaccines, medical procedures, or errors during the execution of care. They may or may not be from negligence. Choice D is incorrect. Since a near miss is not a medical error, it does not have to be reported to the State Department of Health. The World Health Organization previously defined a near-miss as "an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted." In simple terms, a near-miss is a close call that could easily have resulted in patient harm but ultimately did not. Tracking near misses provides insight into loopholes in the healthcare system and aids in designing multiple checkpoints to prevent specific catastrophes.

You are assigned to supervise a client care unit. Over the last several months, the nurses in the unit have told you that the unit dose dispensing of medications by the pharmacy has not been accurate at all times. Fortunately, there have been no medication errors as a result of these inaccuracies. Which of the following actions should be prioritized? A. Praise the staff for catching these inaccuracies B. Investigate and explore these near misses C. Investigate and explore these medical errors D. Report these inaccuracies to the State Department of Health

A, B A is correct. Polycythemia is an abnormally increased hemoglobin concentration in the blood; it is a severe long-term effect of congestive heart failure. It is due to the impact of chronic hypoxia on the body. The body senses the decrease in oxygen and increases its production of red blood cells to carry more oxygen to the body. The problem is that there is no more oxygen available, so the body continues to be hypoxic and continues to produce red blood cells in an attempt to correct this. After overproducing red blood cells, the blood becomes very thick. B is correct. Clubbing is defined as a bulbous enlargement of the ends of the fingers or toes. It is a sign of chronic hypoxia. Patients who experience congestive heart failure over long periods often experience clubbing in their fingertips due to the lack of oxygen reaching their distal extremities over time. Choice C is incorrect. Pulsus alternans is a physical finding with an arterial pulse waveform showing strong and weak beats alternating. It is suggestive of left ventricular systolic impairment. It is not a finding specific to chronic periods of hypoxia, rather, it represents soft heart function. Choice D is incorrect. Macewen's sign is not a sign of chronic hypoxia; instead, it is a sign used to detect hydrocephalus. The examiner percusses on the skull near the junction of the frontal, temporal, and parietal bones and can auscultate a "cracked pot" or hyper-resonant sound if hydrocephalus is present. Macewen's sign is not related to congestive heart failure or chronic hypoxia.

You are teaching a group of new graduate nurses about the long term effects of congestive heart failure. You know that they understand your teaching when they state the following expected findings. Select all that apply. A. Polycythemia B. Clubbing C. Pulsus alternans D. Macewen's sign

B Choice B is correct. Stagnant water and food particles can be a breeding ground for pathogenic microorganisms. A patient with an AIDS diagnosis is susceptible to contracting illness/infections more quickly due to the deficiency in his/her immune system. The focus of education should include measures to protect the patient from contracting illnesses from others. Choices A and C are incorrect. Washing dishes with someone else's or sharing bathroom facilities does not protect the patient or the roommate from illness or spread of disease. Choice D is incorrect. Using hand sanitizer is recommended for all people to help prevent the spread of germs.

You are the nurse performing education for a patient with AIDS at the community clinic. Which of the following statements is an example of appropriate teaching? A. "Do not wash your dishes with your roommate's dishes." B. "Clean all utensils and dishes before reusing them." C. "Do not use the same shower or toilet as your roommate." D. "Hand sanitizer is not necessary unless you plan on touching someone else."

D Choice D is correct. You should state that medication peaks and troughs are essential to ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect. Peak and trough levels are most often performed for the clients receiving antimicrobial medication(s). Choice A is incorrect. Peaks and troughs of medications are not indicated to monitor a sensitive reaction to the medication. Choice B is incorrect. Peaks and troughs of medications are not indicated to monitor if an adverse reaction to the medication is occurring. Choice C is incorrect. The main reason for measuring peaks and troughs of medications is to ensure therapeutic drug levels. Although this may affect the dosing schedule, the primary reason for measuring these labs is not to determine the dosing schedule.

You have been asked by a new graduate nurse why peaks and trough levels of medications are measured. How should you respond to this new graduate nurse's question? A. "Monitoring medication peaks and troughs are important to ensure that the medication is not causing a sensitivity reaction." B. "Measuring medication peaks and troughs are necessary to ensure that the medication is not causing an adverse effect" C. "We can ensure that the medication is administered at the most effective intervals by measuring peaks and troughs." D. "Medication peaks and troughs are essential to monitor and ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect."

D Choice D is correct. You should state that medication peaks and troughs are essential to ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect. Peak and trough levels are most often performed for the clients receiving antimicrobial medication(s). Choice A is incorrect. Peaks and troughs of medications are not indicated to monitor a sensitive reaction to the medication. Choice B is incorrect. Peaks and troughs of medications are not indicated to monitor if an adverse reaction to the medication is occurring. Choice C is incorrect. The main reason for measuring peaks and troughs of medications is to ensure therapeutic drug levels. Although this may affect the dosing schedule, the primary reason for measuring these labs is not to determine the dosing schedule. Peak and trough are used to describe drug concentrations. Both peak and trough levels are typically measured from blood samples. The peak level is when the drug has reached the highest level in the blood. This must be monitored, as drug toxicity may occur if the peak blood level elevates above a therapeutic level. The trough level is the lowest blood level of a drug. The time the peak level is taken depends on the medication's route of administration, while the trough level is taken just prior to administration of the next dose. If the trough level is too low, the drug may not be at a therapeutic level capable of generating a response. Therapeutic drug monitoring is utilized to verify therapeutic effects and minimize drug toxicity. A clinical pharmacist often carries out this monitoring.

You have been asked by a new graduate nurse why peaks and trough levels of medications are measured. How should you respond to this new graduate nurse's question? A. "Monitoring medication peaks and troughs are important to ensure that the medication is not causing a sensitivity reaction." B. "Measuring medication peaks and troughs are necessary to ensure that the medication is not causing an adverse effect." C. "We can ensure that the medication is administered at the most effective intervals by measuring peaks and troughs." D. "Medication peaks and troughs are essential to monitor and ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect."