Archer Review 4b

The nurse receives the following critical laboratory result for a client with end-stage renal disease. The nurse anticipates the physician to prescribe which blood product? See the image below. A. Packed Red Blood Cells (PRBCs) [90%] B. Fresh Frozen Plasma (FFP) [4%] C. Albumin [2%] D. Platelets [3%]

Explanation Choice A is correct. This hemoglobin and hematocrit are critically low. A transfusion of PRBCs is typically indicated once the hemoglobin is 7 g/dL or less. Choices B, C, and D are incorrect. Fresh frozen plasma (FFP) is a blood product that contains an abundance of clotting factors and thus, would not help severe anemia. Albumin is indicated for the treatment of thermal burns or third-spacing. Platelets are indicated for severe thrombocytopenia. Additional Info The normal hemoglobin and hematocrit are below:

A 90-year-old male with COPD, CHF, and hypertension is brought to the emergency department by ambulance. A nebulizer is in place upon arrival. After blood tests are drawn, the patient's arterial blood gas shows the values below. What is this patient exhibiting? pH: 7.18, CO2: 67, Bicarbonate: 23 A. Respiratory acidosis [89%] B. Metabolic acidosis [6%] C. Respiratory alkalosis [4%] D. Metabolic alkalosis [1%]

Explanation Choice A is correct. This patient is experiencing respiratory acidosis. This is most likely due to carbon dioxide retention over time because of COPD. Since this patient is experiencing a COPD exacerbation, respiratory acidosis will be worsened. Choice B is incorrect. This patient is experiencing respiratory issues and metabolic acidosis isn't likely. Choice C is incorrect. This patient has increased carbon dioxide and is not experiencing respiratory alkalosis. Choice D is incorrect. Metabolic alkalosis is unlikely in this patient since he is experiencing respiratory symptoms. NCSBN Client Needs Topic: Physiological Adaptation, Sub-Topic: Fluid and Electrolyte Imbalances

The nurse is caring for a client who was recently admitted to the cardiac floor for angina. This client states that their chest pain occurs at the same time every day at rest. The patient does not believe there are any precipitating factors. Which of the following types of angina is this patient most likely experiencing? A. Variant angina [23%] B. Stable angina [51%] C. Unstable angina [22%] D. Nonanginal pain [3%]

Explanation Choice A is correct. Variant angina, also known as Prinzmetal's angina, occurs at about the same time every day, usually at rest. Variant angina is treated with calcium channel blockers. Choice B is incorrect. Stable angina occurs after activity and is relieved by nitroglycerin tablets. Choice C is incorrect. Unstable angina is less predictable and may precipitate myocardial infarction. Choice D is incorrect. This type of discomfort does not describe nonanginal pain. NCSBN client need Topic: Physiological Integrity, physiological adaptation

Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement? A. Call for help to get the client back in bed [2%] B. Assist the client back to bed [1%] C. Establish if the client is responsive [95%] D. Ask the client what happened

Explanation Choice C is correct. Assessing if the patient is responsive is the primary concern of the nurse in this example. Choices A and B are incorrect. The client's responsiveness is a priority before moving the client. Choice D is incorrect. This answer choice would be the least important among the choices given. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Falls

You are the registered nurse in a multi-ethnic community health department clinic. In this role, you are asked to identify clients with genetic risk factors related to ethnicity to screen them for some commonly occurring diseases. You would identify a client who is of: A. Mediterranean ethnicity for cystic fibrosis [28%] B. African American ethnicity for Tay Sachs disease [29%] C. British Isles ethnicity for psychiatric mental health disorders [12%] D. Saudi Arabian ethnicity for sickle cell anemia [31%]

Explanation Choice D is correct. You would identify a client who is of Saudi Arabian ethnicity for sickle cell anemia. Other ethnicities at greatest risk for sickle cell anemia include Africans, Latin Americans, Southern Europeans, and some clients from some Mediterranean nations. Choice A is incorrect. Mediterranean clients are at risk for developing Thalassemia. Choice B is incorrect. African Americans are not at higher risk for Tay Sachs. Clients of Ashkenazi Jewish descent are at risk for Tay Sachs. Choice C is incorrect. African Americans and Native Americans are at risk for psychiatric mental health disorders. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological Adaptation

A patient with cholecystitis is reporting acute pain. Where should the nurse expect to find the location of this pain? A. Right upper quadrant, radiating to the right shoulder [62%] B. Right upper quadrant, radiating to the left shoulder [16%] C. Right lower quadrant, radiating to the pelvic bones [7%] D. Right lower quadrant, radiating to the umbilicus

Explanation Choice A is correct. Cholecystitis is known to be painful in the right upper quadrant and refers to the right shoulder and scapula. A referred pain is a pain that is felt away from the originating site. Visceral pain can be referred to a corresponding somatic structure and is mediated by similar segmental innervation of the originating visceral organ and the referred somatic site. Choice B is incorrect. Right upper quadrant pain never radiates to the left shoulder. A left upper quadrant pain may radiate to the left shoulder and such a referred pain may be noticed with splenic injury. Choice C is incorrect. A right lower quadrant pain radiates to the pelvic bones. A right lower quadrant pain radiating to pelvic bones may be noticed with ovarian torsion. Choice D is incorrect. A right lower quadrant pain radiating to the umbilicus may be seen with acute appendicitis, not cholecystitis. NCSBN client need Topic: Physiological Integrity, Physiological Adaptation

The nurse is administering medications to a 5-year-old client diagnosed with pneumonia. The health care provider has ordered a cough suppressant. Which medication does the nurse administer? A. Dextromethorphan [40%] B. Guaifenesin [46%] C. Dexmedetomidine [11%] D. Protonix [2%]

Explanation Choice A is correct. Dextromethorphan is a cough suppressant. It is the ingredient in many over the counter cough medicines such as Delsym, Robitussin, and NyQuil. Dextromethorphan works by signaling the brain to stop triggering the cough reflex. Choice B is incorrect. Guaifenesin is an expectorant, not a cough suppressant. Unlike a cough suppressant, guaifenesin loosens the congestion in a client's chest and throat making it easier for them to cough out mucus and phlegm. Choice C is incorrect. Dexmedetomidine is a sedative medication. It activates receptors in the brain that inhibit neuronal firing, which causes sedation. It is not a cough suppressant. Choice D is incorrect. Protonix is a proton pump inhibitor used to decrease the amount of acid produced by the stomach. It is not a cough suppressant. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Pediatric - Respiratory

The nurse is caring for a patient prescribed enoxaparin. Which laboratory values should the nurse monitor? A. Platelet count [31%] B. Activated Partial Thromboplastin Time (aPTT) [55%] C. International Normalized Ratio (INR) [12%] D. Troponin [1%]

Explanation Choice A is correct. Enoxaparin is a low molecular weight-based heparin, and the platelet count will need to be monitored if the client should develop heparin-induced thrombocytopenia (HIT). This condition is serious and results in a 50% decrease in the platelet count. Choices B, C, and D are incorrect. aPTT is appropriate to monitor for a patient receiving heparin as it should be prolonged 1.5 to 2 times the control (baseline) value. The INR is a monitoring parameter for warfarin. Finally, troponin is a lab test for individuals with suspected myocardial infarction. The nurse should be concerned if the troponin was elevated, indicative of injury to the myocardium. Additional Info Enoxaparin is advantageous because this medication does not require PTT monitoring. This medication may be used in the treatment or prevention of venous thromboembolism. The nurse should inject enoxaparin into the client's abdomen and refrain from massaging the area following the administration.

You are working in the pediatric emergency department. A six-year-old child is brought in lethargic with a weak pulse, blood pressure of 60/40 mm Hg, and a heart rate of 40 beats per minute. You estimate that the child weighs 20 kg. A peripheral IV is in place. The physician has ordered IV epinephrine to treat the symptomatic bradycardia. You know that a reasonable dose for this patient would be: A. 2 mL of the 1:10000 concentration IV every 3 to 5 minutes [42%] B. 2 mL of the 1:10000 concentration IV every 1 to 2 minutes [10%] C. 2 mL of the 1:10000 concentration IV one time only [25%] D. None of the above [23%]

Explanation Choice A is correct. Epinephrine is the drug of choice for bradycardia (heart rate less than 60 beats per minute) with hypotension/ shock in a child. In a six-year-old child, systolic blood pressure less than 80 mm Hg is abnormally low. In this child, bradycardia is resulting in shock. This question requires that the nurse knows: the correct dosage of epinephrine, the calculation for the total amount of drug to give for the child's weight, and the frequency of administration. Epinephrine should be given every 3 to 5 minutes until the bradycardia is resolved. Since the child has an IV, the nurse should use the 1:10000 concentration of the medication. If the child has an ET tube in place and no IV or IO access, the nurse should use the 1:1000 concentration and administer down the ET tube. The correct dosage, in this case, is 0.1 mL/kg of epinephrine. Since the child weighs 20 kg, you would give 2 mL of the epinephrine (20 kg X 0.1 mL/kg = 2 mL of epinephrine). Choice B is incorrect. This is the correct dosage of the epinephrine to be administered, but the timing of the dosage is inappropriate. This medication should only be administered every 3 to 5 minutes, not every 1 to 2 minutes. Choice C is incorrect. This is the correct dosage of the epinephrine to be administered to this client but this will likely not be a one-time only drug. This medication typically needs to be administered multiple times in critical care scenarios or scenarios involving cardiac compromise. This medication is administered every 3 to 5 minutes in a client who has hypotension and signs of poor perfusion. Choice D is incorrect. The correct response was Choice A. Learning Objective Understand that epinephrine is the drug of choice in a child with symptomatic bradycardia with hypotension, and know the dosage and dose calculation. Additional Info Source : ArcherReview In a child with bradycardia, first, identify and treat the cause. Several causes of bradycardia include hypoxia, hyperkalemia, hypothermia, heart block, acidosis, toxins/ drug overdoses, and trauma. If hypoxia, administer oxygen If hyperkalemia, administer IV calcium gluconate, reduce extracellular potassium ( insulin + dextrose, beta-2 agonists), and reduce total body potassium levels ( kayexalate, hemodialysis) If hypothermia, rewarm slowly. If there is a heart block, consult a pediatric cardiologist, administer atropine, and consider an external pacemaker ( transcutaneous and transvenous pacing). If acidosis, ventilate to washout Co2. In select cases, use sodium bicarbonate. If there is a drug overdose, supportive care and administer an antidote if available If trauma, oxygenation/ ventilation if necessary If the child is in shock or hypotensive, must proceed with immediate drug choice, which is epinephrine ( note that epinephrine is the drug of choice in a child with bradycardia and shock, whereas atropine is used first in an adult with symptomatic bradycardia) Administer epinephrine. The dose is 2 mL of the 1:10000 concentration IV and repeated every 3 to 5 minutes as needed If epinephrine fails, consider atropine 0.02 mg/kg ( max 0.5mg) consider external pacemaker

The nurse is assessing a client with a myxedema coma. Which of the following would be an expected finding? A. Glucose 59 mg/dL [48%] B. Sodium 155 mEq/L [24%] C. Serum pH 7.49 [5%] D. Temperature 102.4° F (39.1° C) [22%]

Explanation Choice A is correct. Hypoglycemia is one of many clinical features of myxedema coma. Myxedema coma is a severe form of hypothyroidism and warrants immediate medical attention. Choices B, C, and D are incorrect. Clinical features of myxedema coma include hyponatremia, hypoventilation which causes respiratory acidosis, and hypothermia. A sodium level of 155 mEq/L is hypernatremia, a serum pH of 7.49 is alkalosis, and a temperature of 102.4° F is pyrexia. All of which are not consistent findings associated with myxedema coma. Additional Info Myxedema coma is a severe form of hypothyroidism that causes an array of clinical manifestations, including: Decreased mental status Bradycardia Hyponatremia Hypoglycemia Hypotension Hypothermia Treatment is aimed at giving the client intravenous levothyroxine, corticosteroids, intravenous dextrose, rewarming, and mechanical ventilation, if necessary.

Intravenous therapies often consist of electrolyte replacement therapies. Select the electrolyte that is accurately paired with one of its functions. A. Sodium: The control and management of circulating blood volume. [63%] B. Bicarbonate: The regulation of extracellular fluid. [16%] C. Chloride: The regulation of plasma protein. [11%] D. Calcium: The metabolism of fats, carbohydrates, and proteins.

Explanation Choice A is correct. In addition to other functions, sodium controls and manages circulating blood volume, it maintains circulating blood volume, and it also is necessary for the transmission of nerve impulses. Choice B is incorrect. Bicarbonate regulates the body's acid-base balance and not the regulation of extracellular fluid. Choice C is incorrect. Chloride does not regulate plasma protein. Instead, it regulates acid-base balance and extracellular fluid balance. Choice D is incorrect. Calcium does not play a role in the metabolism of fats, carbohydrates, and proteins; however, calcium does play a role in blood clotting, the formation of teeth and bones, nerve impulse transmission, and controlling muscular contractions.

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." [92%] 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." [2%] C. "Let's mention that to the doctor when he comes in to see him." [5%] D. "I really recommend your child be checked by a child psychologist." [1%]

Explanation 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.

When assessing a client's nose, the normal expected findings should be documented as: A. Nose symmetrical and midline [84%] B. Nose symmetrical with yellow drainage [1%] C. Nose asymmetrical with clear drainage [3%] D. Nose asymmetrical and proportional to facial features [12%]

Explanation Choice A is correct. Normal documentation of the assessment of the nose would include findings such as symmetrical, midline, without drainage, and proportional to facial features. Choice B is incorrect. Yellow nasal drainage is never a normal finding. Choices C and D are incorrect. The nose should be symmetrical.

A client diagnosed with acute gastroenteritis is prescribed 30 mEq of oral potassium chloride twice daily for hypokalemia. The nurse should implement which nursing intervention when administering the medication: A. Sprinkle contents of the capsule in apple sauce to increase palatability. [28%] B. Crush the extended-release tablet to improve palatability. [2%] C. Give potassium supplements separate from other medications. [48%] D. Give potassium 2 hours before meals. [23%]

Explanation Choice A is correct. Potassium supplements can be distasteful. To improve palatability, the nurse may sprinkle the contents of the potassium capsule on apple sauce, and the client can then swallow it. The client must not chew on a capsule or tablet. Choice B is incorrect. Breaking or crushing the potassium tablet may cause too much of the drug to be released at one time. An extended-release tablet should never be crushed. Choice C is incorrect. Potassium can be given with other medications. It is not necessary to give potassium alone. Choice D is incorrect. Giving potassium two hours before meals is typically the same as providing it on an empty stomach, which predisposes the client to esophageal and gastric irritation. Potassium is irritating to the esophagus and the stomach. Potassium should not be given on an empty stomach. It is best tolerated when given with food.

A G1P0 client with a blood type A negative is at her 28th-week gestation and was advised a RhoGAM injection today. Which statement by the client indicates the need for further teaching about this therapy? A. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" [37%] B. "I understand that if we find out my baby is Rh positive, then I'll need to get another one of these injections." [19%] C. "This shot should help to protect me in future pregnancies if this baby comes out Rh positive, like her dad." [25%] D. "This shot will prevent me from becoming sensitized to Rh-positive blood." [18%]

Explanation Choice A is correct. RhoGAM is administered to Rh-negative mothers to prevent them from producing antibodies against their Rh-positive fetus. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" indicates that the client needs further teaching. Choices B, C, and D are incorrect. If the infant is Rh-positive, the mother needs to receive another dose after delivery to prevent maternal sensitization. This will also protect future pregnancies as the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization of Rh-positive blood.

Which process is most often used by performance improvement teams to find the most basic causes of process failures? A. Root cause analysis [89%] B. Nominal group process [5%] C. Determining who failed [3%] D. Negotiation [3%]

Explanation Choice A is correct. The root cause analysis process is most often used by performance improvement teams to find the most basic causes of process failures. Root cause analysis is done in a blame-free environment to dig down to the most fundamental reasons why a failed process is not fail-proof. Choice B is incorrect. The nominal group process is rarely if ever, used by performance improvement teams. Choice C is incorrect. Determining who failed is not an acceptable process for performance improvement teams. Performance improvement activities are conducted in a blame-free environment. Choice D is incorrect. Although negotiation is an effective and appropriate group process, it is not used to find the most basic causes of process failures.

The nurse is caring for a 3-year-old client diagnosed with bronchitis. The mother asks the nurse what this diagnosis means. Which response most correctly explains the diagnosis of bronchitis? A. "Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract." [28%] B. "Bronchitis occurs when an infection causes inflammation in the small airways. These include the trachea and bronchi, which are in the upper part of the respiratory tract." [19%] C. "Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the upper part of the respiratory tract." [30%] D. "Bronchitis occurs when an infection causes inflammation in the small airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract." [23%]

Explanation Choice A is correct. This statement correctly describes bronchitis to the mother. Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract. Choice B is incorrect. This statement does not correctly describe bronchitis. It incorrectly states that the inflammation is in the small airways - these are the bronchioles and inflammation here would be termed bronchiolitis. Additionally, it states that the trachea and bronchi are in the upper part of the respiratory tract, which is also not true. They are in the lower part of the respiratory tract. Choice C is incorrect. This statement does not correctly describe bronchitis. It incorrectly states that the large airways are in the upper part of the respiratory tract and this is not true. The large airways, i.e. trachea and bronchi, are in the lower respiratory tract. Choice D is incorrect. This statement does not correctly describe bronchitis. It incorrectly states that the inflammation is in the small airways - these are the bronchioles and inflammation here would be termed bronchiolitis. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic care, comfort, Pediatric - Respiratory

The nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below. A. Graves' disease [56%] B. Increased intracranial pressure [22%] C. Severe hypothermia [10%] D. Myxedema coma [12%]

Explanation Choice A is correct. This tracing reflects sinus tachycardia (ST). ST can be caused by an array of conditions such as dehydration, hypo- and hyperglycemia, stress, anxiety, and thyroid conditions such as hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism, and this increased metabolic and sympathetic activity would cause tachycardia. Choices B, C, and D are incorrect. Increased intracranial pressure would manifest with bradycardia. Hypothermia causes a slowing of metabolic and sympathetic activity; thus, bradycardia is a feature of this condition. Myxedema coma is an endocrine emergency marked by severe hypothyroidism. The hallmark of severe hypothyroidism is life-threatening bradycardia. Additional Info Sinus tachycardia is regular, with a p-Wave present. The rate of sinus tachycardia is over 100 beats per minute. Treatment of ST is the underlying cause; if the client is hypovolemic, fluids need to be replaced. ST may be worrisome as it is one of the earliest manifestations of shock.

When assessing hydration in an adult patient, the nurse will: A. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal. [43%] B. Pinch a fold of skin on the abdomen and observe for recoil to normal. [8%] C. Pinch a fold of skin on the medial aspect of the forearm and observe for recoil normal. [47%] D. Pinch a fold of skin on the forehead and allow for the skin to recoil in children. [2%]

Explanation Choice A is correct. To assess turgor in an adult, the most reliable method is to pinch a fold of skin on the anterior chest, release, and observe for the skin to promptly recoil to its original state. Choice B is incorrect. Turgor is assessed in infants and toddlers on the abdomen. Choice C is incorrect. Turgor can be checked on the inner aspect of the forearm. Choice D is incorrect. A fold of skin on the forehead can be used to check skin turgor in the elderly, not children. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Skin Assessment

As you are bathing your client and providing nail care, you notice that the client's nails look abnormal. You would document this nail abnormality as: See exhibit. A. Onychomycosis [58%] B. Onychomadesis [14%] C. Onychorrhexis [11%] D. Onychia [17%]

Explanation Choice A is correct. You would document this nail abnormality as onychomycosis. Onychomycosis is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque/yellow, and crumbling. Since Onychomycosis is the most common cause of nail dystrophy presenting to the outpatient department, a nurse plays a crucial role in the diagnosis, management, and education of the clients. Dermatophytes (Trichophyton) cause 90% of these toenail infections. The remaining 10% are caused by non-dermatophytes (Saprophytes) and yeast (Candida). The prevalence of onychomycosis in patients between 20 to 60 years of age is 20%, whereas prevalence in older adults > 70 years of age is about 50%. The nurse should be aware of the risk factors and educate at-risk clients regarding foot care. Some common risk factors for onychomycosis include immunosuppression, diabetes mellitus, age greater than 70, persistently wet feet, repetitive nail trauma, tight-fitting footwear, HIV infection, prolonged steroid use, peripheral vascular disease, and genetics. Often, patients are asymptomatic. But the quality of life can be substantially decreased because of onychomycosis. Clients may have low self-esteem and feel embarrassed about having thick, discolored nails. Also, they may report mild pain and discomfort. Diagnosis is based on history and clinical exam. Diagnosis can be confirmed by demonstrating dermatophytes in KOH preparation of nail scrapings. The condition is often challenging to treat. Recurrence and failures may be in the range of 20 to 50% (i.e., the cure rate is approximately 50%). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails. Most antifungal treatments may have liver toxicity; therefore, liver function tests may have to be monitored. Terbinafine is contraindicated in clients with baseline liver disease. Choice B is incorrect. Onychomadesis is the falling off and the separation of the nails from the nail bed. It is not the appearance of the affected nail in the exhibit. The cause of onychomadesis is often idiopathic (unknown). However, in children, it may occur as a rare complication 4 to 6 weeks following Hand, Foot, and Mouth disease. Choice C is incorrect. Onychorrhexis is the formation of vertical ridges on the nails or brittle nails that tend to break easily. The pins are not thick and discolored, as shown in the exhibit. Onychorrhexis occurs due to disordered keratinization in the nail matrix. Causes include the normal aging process, recurrent nail trauma, anemia, hypothyroidism, and eating disorders. Choice D is incorrect. Onychia is an inflammation of the nail folds. It does not appear in the exhibit provided. Onychia is not the infection of the nail itself, but rather a disease of the surrounding tissue of the nail plate.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. What is the next step to do with the urine specimen? A. Place it in a separate container and later add to the collection. [2%] B. Discard it, then the collection process begins [81%] C. Test it, then discard [3%] D. Save as part of the 24-hour collection [14%]

Explanation Choice B is correct. A 24-hour urine collection may be ordered to evaluate the type and severity of certain renal disorders. The nurse is responsible for providing the collection container and educating the patient on the correct process of collecting the specimen. At the beginning of the 24-hour urine procedure, the patient should not collect or save the first urine specimen. This first void is considered "old urine" or urine in the bladder before the test began. This specimen should be flushed and the time at which its discarded is noted. After the first discarded specimen, urine is collected for the next 24 hours. Choices A, C, and D are incorrect. The first urine is not saved or tested but discarded. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential

The nurse is caring for a client with infective endocarditis. The nurse anticipates a prescription for which medication? A. Nitroglycerin [6%] B. Vancoymycin [81%] C. Atorvastatin [4%] D. Aspirin [8%]

Explanation Choice B is correct. An essential component of treating an individual with infective endocarditis is the prompt administration of antibiotics. Blood cultures will need to be collected before administering antibiotics. Until the culture and sensitivity results are provided, broad-spectrum antibiotics such as vancomycin and piperacillin-tazobactam will be administered. Choices A, C, and D are incorrect. Aspirin, nitroglycerin, and statin are not indicated in the treatment of infective endocarditis. The primary treatment is prompt administration of antibiotics and monitoring for complications such as septic emboli. Additional Info Immediate treatment for infective endocarditis (IE) is collecting blood cultures and administering empirical antibiotics. Once the culture and sensitivity results return, the choice of antibiotic will change to one suitable for the organism. Treatment for IE can continue for up to six weeks and requires vigilant monitoring for complications such as septic emboli.

The nurse is teaching a patient who is scheduled for a transfusion of one unit of packed red blood cells (PRBCs). Which of the following information should the nurse include? A. "A baseline weight will be taken before the start of the transfusion." [4%] B. "I will be with you during the first fifteen minutes of the transfusion." [84%] C. "You will need to provide a urine sample at the end of the transfusion." [2%] D. "Please complete the required surgical consent before the transfusion." [10%]

Explanation Choice B is correct. Before the start of a transfusion for a unit of PRBCs, the nurse will need to collect the client's signature for blood consent. Baseline vital signs will be taken. The nurse is to remain with the client for the first fifteen minutes to monitor for transfusion reactions. Choices A, C, and D are incorrect. Baseline vital signs will be taken. A urine specimen is only collected if a transfusion reaction should occur. Surgical consent is not required.

A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider? A. Decreased blood urea nitrogen (BUN) level [12%] B. Decreased glomerular filtration rate (GFR) [48%] C. Decreased fasting plasma glucose [17%] D. Decreased hemoglobin A1C

Explanation Choice B is correct. Metformin is an oral anti-diabetic indicated for type 2 diabetes mellitus. Metformin may cause renal impairment and a decrease in glomerular filtration rate (GFR) would be such evidence. During Metformin therapy, the client's renal function will be periodically monitored. Choices A, C, and D are incorrect. A reduction in the blood urea nitrogen (BUN) level does not indicate nephrotoxicity (a high creatinine would indicate nephrotoxicity). A decrease in both the hemoglobin A1C and fasting plasma glucose would be the therapeutic effect of the medication. Additional Info Metformin is the first-line therapy for type II diabetes mellitus. Metformin is efficacious in having clients lose weight and decrease their hemoglobin A1C. The most common side-effect associated with Metformin initiation is gastrointestinal side effects such as bloating, diarrhea, nausea, or vomiting. The nurse should counsel the client that these side effects are transient and may be lessened by taking the medication with food. Metformin should not be taken within 48 hours of a contrast procedure because should contrast-related nephrotoxicity occur, Metformin metabolites accumulate and cause lactic acidosis.

A client is scheduled to undergo a computed tomography scan with iodine-based contrast dye. Which of the following medications may cause interaction and should be withheld for 24 hours before the procedure? A. Labetolol [7%] B. Metformin [75%] C. Levodopa [12%] D. Ondansetron [6%]

Explanation Choice B is correct. Metformin, a medication used to treat type 2 diabetes, should be held 24 hours before a procedure that uses iodine dye to reduce the risk of lactic acidosis. The drug may be resumed about 48 hours after the procedure. Choice A is incorrect. Labetalol is used to treat hypertension and is safe to take before and after an iodine-based computed tomography scan. Choice C is incorrect. Levodopa, a medication used to treat Parkinson's disease, is safe to take before and after an iodine-based computed tomography scan. Choice D is incorrect. Ondansetron, a medication used to treat nausea and vomiting, is safe to take before and after an iodine-based computed tomography scan. Additional Info The most common side-effect associated with Metformin initiation is gastrointestinal side effects such as bloating, diarrhea, nausea, or vomiting. The nurse should counsel the client that these side effects are transient and may be lessened by taking the medication with food. Metformin should not be taken within 48 hours of a contrast procedure because should contrast-related nephrotoxicity occur, Metformin metabolites accumulate and cause lactic acidosis.

The nurse is caring for a client in the emergency department. The client is short of breath upon arrival to the ED and is coughing up purulent sputum. Oxygen is being administered at 2 liters per minute via nasal cannula. The client's blood pressure is 100/58 mmHg, pulse is 88, and respiratory rate is 24. The client is afebrile with an oxygen saturation of 92%. The results of arterial blood gas testing are: pH = 7.25, PaO2 = 93, PaCO2 = 69, and HCO3 = 25. The nurse understands that this ABG shows: A. Respiratory alkalosis [4%] B. Respiratory acidosis [90%] C. Metabolic alkalosis [1%] D. Metabolic acidosis [4%]

Explanation Choice B is correct. Respiratory acidosis. The trick to interpreting ABGs is to know the normal values and to use a systematic process for interpretation. Normal values for ABGs are pH: 7.35-7.45, PaO2 = 75-100 mmHg, PaCO2 = 35-45 mmHg, HCO3 = 22-26 mEq/L, and O2 sat = 94-100%. First, look at the pH. In this case, the pH is < 7.35, which indicates an acidotic condition. Second, examine the PaCO2. In this case, the value is > 45 mmHg, which indicates this is respiratory acidosis. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Diagnostic Tests, Respiratory

The nurse is caring for a patient with a disorder of the inner ear. Which of the following is the most common complaint about patients with these disorders? A. Itchiness [4%] B. Ringing in the ears [77%] C. Hearing loss [16%] D. A burning sensation in the ear [3%]

Explanation Choice B is correct. Ringing in the ears or tinnitus is the most common complaint from people with inner ear disorders. Choice A is incorrect. Itchiness is not the most common complaint in patients with disorders of the inner ear. Instead, tinnitus (ringing of the ears) is a more common complaint. Choice C is incorrect. Hearing loss is not the most common complaint in patients with disorders of the inner ear. Instead, tinnitus (ringing of the ears) is a more common complaint. Choice D is incorrect. A burning sensation in the ear is not the most common complaint in patients with disorders of the inner ear. Instead, tinnitus (ringing of the ears) is a more common complaint. NCSBN client need Topic: Physiological integrity, physiological adaptation

The nurse is changing a diaper for her 7-month-old patient suspected of having Celiac disease. She notes a large, pale, oily stool that is malodorous. This assessment finding is known as what? A. Diarrhea [2%] B. Steatorrhea [92%] C. Hematochezia [2%] D. Melena [4%]

Explanation Choice B is correct. Steatorrhea refers to the excretion of abnormal quantities of fecal fat due to reduced fat absorption by the intestines. This produces pale, oily, malodorous stools and is a symptom of Celiac disease. Choice A is incorrect. Diarrhea refers to a condition in which feces are frequently discharged from the bowels and in a liquid form. It is not pale, oily, or malodorous stools. Choice C is incorrect. Hematochezia is defined as the passage of fresh blood from the anus. It is a sign of lower GI tract bleeding. It is not pale, oily, or malodorous stools. Choice D is incorrect. Melena is a condition with dark sticky feces containing partly digested blood. Melena is a sign of gastrointestinal (GI) bleeding, often upper GI. Pale, oily, malodorous stools do not characterize melena; rather, it is typical with steatorrhea. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatrics - Gastrointestinal

A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL today. She tells the nurse that she is taking her iron supplements twice daily. Which response by the nurse would be most appropriate? A. "You're off to a great start! Tea has much less caffeine than coffee." [8%] B. "A great addition to your cup of tea would be a little lemon. It's going to help you absorb your iron pill better." [54%] C. "Right now your iron levels are low. Please eliminate all caffeine." [36%] D. "That's alright. Drinking coffee or tea won't affect the fetus." [2%]

Explanation Choice B is correct. Tannins are polyphenolic compounds found in plants, wood, leaves, fruits, and tea. The tannin that is present in tea decreases the absorption of iron. But adding lemon juice, which is high in vitamin C, seems to cancel the inhibitory effect of tannins on iron absorption. Choices A, C, and D are incorrect. There is also no evidence that caffeine affects the absorption of iron, but when consumed in large amounts during pregnancy, it may increase the risk of spontaneous abortion, preterm birth, and small-for-gestational-age newborns. It also affects calcium and zinc in terms of absorption and excretion.

A 16-year-old has been given a referral to the optometrist for evaluation of his vision. The client is told that he will need eyeglasses. The adolescent's mother states that they do not have any money for eyeglasses and the adolescent states that he'd "rather go blind than burden his family." As a client advocate, the nurse's appropriate action would be: A. Tell the adolescent that he won't get anywhere in life without good eyesight. [1%] B. Refer the adolescent to a local service organization. [87%] C. Ask the adolescent if they have Medicare. [11%] D. Give the adolescent some money. [0%]

Explanation Choice B is correct. This is an example of client advocacy. There are many local service organizations willing to help subsidize the cost of vision tests. Examples of these organizations are the Rotary Club and Lion's Club. Choice A is incorrect. This action threatens the adolescent and makes him guilty of his actions. This is not a form of client advocacy. Choice C is incorrect. Medicare is not for teenagers and does not cover visual examinations including glasses Choice D is incorrect. The nurse should not give out any money to her clients. This is an example of unprofessionalism.

A 30-year-old female walks into urgent care two weeks after giving birth. She complains of a headache, fatigue, feeling sad, and swelling in her hands and face. While taking her vital signs, the patient states, "I'm just overwhelmed right now, and it's making me sad. I just wish you could give me something for this headache." Her vital signs are shown in the exhibit. What is the nurse's priority upon caring for this patient? See the exhibit. A. Refer her to OB/GYN [12%] B. Send the patient to the ED for her blood pressure and temperature [41%] C. Administer Tylenol for her temperature [5%] D. Send her to the ED because she is a possible to harm to herself and could be developing postpartum depression [42%]

Explanation Choice B is correct. This patient has signs and symptoms of preeclampsia. Her blood pressure is 152/90, she has a headache and swelling in her hands/face. These are symptoms of preeclampsia that may get overlooked. Preeclampsia can develop up to 6 weeks after delivery and is a life-threatening condition. It includes three main symptoms: blood pressure above 140/90 mmHg, proteinuria, and swelling (usually in the hands, face, and feet). Choice A is incorrect. Preeclampsia is a life-threatening condition that needs attention immediately. This patient should be sent to the emergency department for further treatment. Choice C is incorrect. The patient's temperature is WNL. The patient may be developing a fever, but the patient's blood pressure and swelling take priority. Choice D is incorrect. Even though postpartum depression is a serious issue and can develop from a few weeks to a year after birth, it is not the main priority at this time. The nurse should put this in the patient's chart, but preeclampsia is the main priority. Preeclampsia can lead to seizures, pulmonary edema, stroke, thromboembolism, and death. NCSBN Client Need Topic: Safe and Effective Care Environment, Sub-Topic: Care Management, Female Reproductive and Genital Problems Learning Objective Understand that preeclampsia can develop anytime up to 6 weeks postpartum. Recognize the signs that need immediate attention.

The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports A. increased ability to focus. [15%] B. decreased muscle spasms. [60%] C. improved short-term memory. [6%] D. sleeping without awakening at night. [18%]

Explanation Choice B is correct. Tizanidine is a muscle relaxant and is utilized in the treatment of multiple sclerosis. Other indications for a muscle relaxant include an injury such as a motor vehicle crash that may cause muscle spasms. Choice A, C, and D are incorrect. Tizanidine is a muscle relaxer and a central nervous system depressant (CNS). It is highly unlikely this medication would increase the ability to focus as it causes drowsiness. The drowsiness is likely to cause memory impairments, especially if it is administered to an older adult. This medication is not indicated for insomnia. Additional Info Additional Information. Muscle relaxers are central nervous system depressants. Key teaching points for this medication (and others in this class) include avoiding driving while taking the medication, and not combining the medication with alcohol. Other medicines included in this class include baclofen, carisoprodol, cyclobenzaprine, and methocarbamol.

The nurse is taking care of a client with encopresis. Which of the following statements correctly describes encopresis? A. Infrequent and hard to pass stools lasting greater than two weeks. [9%] B. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained. [31%] C. Involuntary fecal incontinence in children over the age of 4 who were previously toilet trained. [37%] D. Inability to pass stool due to fecal impaction. [24%]

Explanation Choice B is correct. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained is the definition of encopresis. Choice A is incorrect. Infrequent and hard-to-pass stools lasting greater than two weeks is the definition of constipation, not encopresis. Choice C is incorrect. Involuntary fecal incontinence in children over the age of 4 who were previously toilet trained is close to the correct definition of encopresis but leaves out the fact that it can be voluntary. There are both voluntary and involuntary causes of encopresis. Choice D is incorrect. The inability to pass stool due to fecal impaction is not the correct definition of encopresis. On the contrary, leakage of stool around fecal impaction can be a cause of encopresis. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation; Pediatrics - Gastrointestinal

The nurse is caring for a patient with the following clinical data. Based on the clinical data, the nurse should clarify with the primary healthcare provider (PHCP) on which of the following? See the exhibit. A. Urine analysis (U/A) [5%] B. Head CT Scan [11%] C. Regular diet [73%] D. Ammonia level [10%]

Explanation Choice C is correct. A regular diet prescription should be questioned for this patient because of the medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order. Choices A, B, and D are incorrect. A U/A is a logical and plausible prescription for this patient. Older adults may manifest infection as altered mental status. A CT scan should be obtained to rule out any structural abnormalities such as infarcts. An ammonia level is useful to determine if the patient has any type of metabolic encephalopathy. The level would be high if this was concerning. Additional information: AMS may be caused by a plethora of reasons, including infections such as neurosyphilis, cystitis, brain injury, dementia, delirium, or a psychiatry pathology. The nurse must implement measures to keep the patient safe such as fall precautions. The patient with altered mentation is at increased risk of falling.

The nurse is caring for a 1 year old client diagnosed with acute otitis media. The client is experiencing otalgia, has been febrile for 24 hours, and is pulling at his left ear. Which intervention is the priority nursing action? A. Position the child on his left side [12%] B. Administer antibiotic ear drops [29%] C. Administer acetaminophen as prescribed [56%] D. Apply a heat pack to the left ear [2%]

Explanation Choice C is correct. Administering acetaminophen is the priority nursing action in this scenario. The question states that the patient has been febrile for 24 hours. It is the priority of the nurse to address this concern; the nurse can do so through the administration of the antipyretic acetaminophen. Choice A is incorrect. Positioning the child on his left side is not the priority. This position is appropriate however because the child is pulling at his left ear indicating that is the affected side, so positioning on the left side will promote drainage of fluids from that ear. With that being said, there is another option with a higher priority. Choice B is incorrect. Antibiotic ear drops are not used to treat acute otitis media. Systemic antibiotics are used to treat acute otitis media infections with a bacterial cause. Amoxicillin, erythromycin, and cefixime are all systemic antibiotics that may be utilized, but antibiotic ear drops are not effective. Choice D is incorrect. Applying a heat pack to the left ear is not the priority nursing action. Heat or cold packs can be used for pain relief when the child with acute otitis media is experiencing otalgia, but the stem of the question states that this child has been febrile for 24 hours. It is not appropriate to place a heat pack on a patient who is febrile. The priority is addressing the fever.

The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response? A. Nervousness [13%] B. Warm sensation [5%] C. Angina [50%] D. Tingling sensation

Explanation Choice C is correct. Angina is a concerning finding and requires follow-up by the nurse. Vasoconstriction may occur with this medication, and thus, the client with a medical history of coronary artery disease, uncontrolled hypertension, and a previous stroke should not take this medication. Choices A, B, and D are incorrect. These are common (and expected) reactions to this medication. Thus, the nurse should educate the client to expect these sensations; the more they take the drug, the less they will experience these manifestations. Additional Info Sumatriptan is a medication indicated to abort migraine headaches. It is not a prophylactic treatment. Sumatriptan is commonly administered intranasally or subcutaneously. The nurse should educate the client that if they receive this medication as an injection, a warm and tingling sensation is normal and temporary. Contraindicated for clients with uncontrolled hypertension, coronary artery disease, and those who have sustained a stroke or myocardial infarction. The nurse should monitor the client's blood pressure, autonomic instability, altered mental status, and manifestations similar to serotonin syndrome. Common side effects include flushing, tingling, warmth, dizziness, gastric upset, nausea, and vomiting.

The mother of a 14-year-old boy with cystic fibrosis approached the nurse and voiced out her concern, "I caught him masturbating, and it disturbs me. How do I make it stop?" The most appropriate response for the nurse is: A. "Let him be. Not masturbating results in nocturnal emissions." [4%] B. "Tell him off. That behavior is not normal for 14-year-olds." [2%] C. "Let him be. It is completely normal and provides a sexual experience for him without invoking risk or harm." [91%] D. "That is not appropriate at all. It suggests a lack of interest in normal sexual expression." [3%]

Explanation Choice C is correct. Masturbation is normal behavior during adolescence, that provides for sexual relief without requiring a sexual relationship, for which an adolescent may not be ready. Choices A, B, and D are incorrect. Masturbation is not associated with nocturnal emissions and is considered normal behavior for 14-year-olds.

The nurse is caring for a 13-year-old male child in the pediatric unit with a left-side below the knee cast. The boy reports pain and numbness of the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first? A. Remove the cast. [10%] B. Have the child ambulate. [1%] C. Notify the physician. [74%] D. Elevate the leg on two pillows. [14%]

Explanation Choice C is correct. The client is already showing the signs of compartment syndrome. The client has pain, numbness, and cold feet (low perfusion). Pain, pulselessness, pallor, paresthesias, and paralysis are the "5 Ps" associated with compartment syndrome. Compartment syndrome is an emergency. The nurse should be able to recognize signs and symptoms of compartment syndrome and notify the physician STAT. Compartment syndrome often results after trauma and is more common in the anterior compartment of the leg. Following a trauma, there may be decreased intra-compartmental space or increased intra-compartmental fluid volume (due to fracture, hematoma, etc). Because the surrounding fascia is noncompliant, the compartment pressure increases. In normal circumstances, there is a balance between venous outflow and arterial inflow. But increasing compartmental pressure results in a reduction of venous outflow. Consequently, venous pressure increases, further fueling an increase in compartmental pressure. Once compartmental pressure increases more than arterial pressure, arterial blood flow gets affected, and ischemia ensues. If ischemia lasts longer, irreversible necrosis/death of the tissue occurs. Choice A is incorrect. The child is displaying signs of neurovascular compromise due to compartment syndrome. The cast should be removed to relieve pressure; however, it is not the first action to be taken by the nurse. Cast removal should be arranged after informing the physician. Fasciotomy may be needed, and the physician needs to know immediately. Choice B is incorrect. The child should not ambulate as this will increase the child's risk of further injury. Choice D is incorrect. After notifying the physician, the affected limb should be placed at the level of the heart, not above the heart level. While elevation above the heart level may help venous drainage, it also reduces arterial inflow further and worsens the ischemia. Please note that elevating the limb above the heart level is indicated to reduce edema and prevent compartment syndrome soon after the cast is applied. Once compartment syndrome has already happened, the limb must not be elevated.

The licensed practical nurse (LPN) informs the registered nurse (RN) that the 1-day post-partum client she is taking care of has changed 9 perineal pads in the last 4 hours. What is the initial action of the nurse? A. Document the finding. [13%] B. Instruct the LPN to massage the client's uterus. [6%] C. Assess the patient immediately. [81%] D. Ask the LPN why the nurse was not informed earlier. [0%]

Explanation Choice C is correct. The initial action of the RN would be to assess the client first to confirm if she has excessive bleeding. This follows the nursing process and is the correct order of prioritization. Choice A is incorrect. The RN should always verify the information before documenting it. It would be inappropriate to simply document this information, as it demonstrates potentially excessive bleeding in the client who is one day postpartum. The normal amount of bleeding is up to one perineal pad every hour. 9 saturated pads in the past 4 hours would be considered excessive. The RN must assess this patient. Choice B is incorrect. Massaging the uterus must be done by the RN, not the LPN. However, the nurse must first assess the patient for a boggy uterus and confirm excessive bleeding. Choice D is incorrect. Assessment of the client should be done first before the RN discusses the timely notification of the RN when the patient is demonstrating excessive bleeding. Always follow the nursing process when deciding which action to take first.

Select the nonverbal cue to physical and/or psychological stressors that is accurately paired with its basic human need. A. Safety and security: Signs of an internal locus of control [29%] B. Self-actualization: The lack of insight into one's limitations [22%] C. Self-esteem: The need to draw attention to self [39%] D. Safety and security: An inability to have a clear picture of reality [10%]

Explanation Choice C is correct. The need for the client to draw attention to themselves with the exclusion of others is a nonverbal cue of physical and psychological stressors that can occur primarily among those with the basic human need of love and belonging. Other love and belonging deficits can also include social withdrawal and isolation, as well as unnecessary dependency on others. Choice A is incorrect. Signs of an internal locus of control, rather than an external locus of control, are a nonverbal cue of physical and psychological stressors that can occur primarily among those with the basic human need of love and belonging and not safety and security. The person with an external locus of control blames others and other things for their problems, and a person with an internal locus of control can look at themselves and how they can control and eliminate their problems. Choice B is incorrect. The lack of insight into one's limitations, including physical limitations, is a nonverbal cue of physical and psychological stressors that can occur primarily among those with the basic human need of safety and security and not self-actualization. This lack of insight into one's limitations places clients at risk for incidents and accidents like falls, for example. Choice D is incorrect. An inability to have a clear picture of reality and to accept the fact that nonverbal cues of physical and psychological stressors can occur primarily among those with the basic human need of self-actualization rather than safety and security. Self-actualization needs are fulfilled when the individual can accept reality and have insight into their accomplishments and limitations.

Your preoperative client will be getting transwound catheter anesthesia. During your afternoon rounds on the day before surgery, the client asks you to describe transwound catheter anesthesia. How would you respond to this client's inquiry about transwound catheter anesthesia? A. Transwound catheter anesthesia is a type of anesthesia that anesthetizes a nerve plexus. [8%] B. Tell the client to ask their doctor about transwound catheter anesthesia because you, as a nurse, cannot legally discuss this. [13%] C. Transwound catheter anesthesia is a type of anesthesia that anesthetizes the incision and wound area using a multi-lumen catheter. [75%] D. Transwound catheter anesthesia is a type of local intravenous that is administered for only limb surgery.

Explanation Choice C is correct. You should state that transwound catheter anesthesia is a type of anesthesia that anesthetizes the incision and wound area using a multi-lumen catheter. Choice A is incorrect. You would not state that transwound catheter anesthesia is a type of anesthesia that anesthetizes a nerve plexus; the type of anesthesia that anesthetizes a nerve plexus is called plexus anesthesia and not the type of anesthesia that anesthetizes the incision and wound area using a multi-lumen catheter. Choice B is incorrect. You would not state that you are not legally able to discuss it because the nurse is responsible for responding to client questions and concerns. Choice D is incorrect. You would not state that transwound catheter anesthesia is a type of local intravenous that is administered for only limb surgery; the type of anesthesia that anesthetizes only a limb is a Bier's block and not the type of anesthesia that anesthetizes the incision and wound area using a multi-lumen catheter.

Parts of a pain assessment entail the subjective comments of the client in terms of their sensory and affective/emotional comments that can indicate the quality and intensity of their pain. Select the type of pain that can be shown with the client's emotions of "nagging and tender". A. Hurting pain [16%] B. Pain [12%] C. Somatic pain [28%] D. Aching pain [44%]

Explanation Choice D is correct. Aching pain in terms of affective/emotional descriptors can include the client's subjective comments that include "nagging and tender." Other personal affective descriptors can consist of "troublesome," "annoying," and "tiring". Ache is the least intense, hurt is the next level of intensity, and pain is the most intense. Choice A is incorrect. Hurting pain in the client can describe pain with affective/emotional descriptors such as "robbing", not "nagging and tender." Choice B is incorrect. Pain, in contrast to other intensity pain, is considered the highest level possible; its affective/emotional descriptors include comments such as "agonizing," suffocating" and "unbearable". Choice C is incorrect. "Nagging and tender" are not sufficient, emotional descriptors of bodily pain.

Which of the following must NOT be included in an incident or accident form or report? A. The name of the person completing the report. [9%] B. The name of the client and if anyone was injured. [17%] C. The location of the incident or accident. [4%] D. An explanation of what may have led to the incident.

Explanation Choice D is correct. An explanation of what may have led to the incident is NOT included in an incident or accident form or report. Comments about what may have led to the event are speculative and not factual. Only facts, such as the condition of the floor after a client fall, are documented on an incident or accident form or report. Choice A is incorrect. The name of the person completing the report must be included in an incident or accident form or report. Choice B is incorrect. The name of the client and anyone that was injured must be included in an incident or accident form or report. Choice C is incorrect. The location of the incident or accident must be included in an incident or accident form or report.

Which of the following lab values would be most significant in determining renal function in a client with a history of polycystic kidney disease? A. BUN 90 mg/dL [16%] B. Serum potassium 7.0 MEq/L [15%] C. Uric acid 7.5 [3%] D. Creatinine 8.7 mg/dL [65%]

Explanation Choice D is correct. Creatinine is a specific indicator of renal function/failure. Polycystic kidney disease is a genetic disorder that causes fluid-filled cysts to grow inside the kidneys. Unlike simple kidney cysts that may develop later in life, PKD cysts can change the shape of organs and alter the functioning of organs. Several tests can evaluate renal functioning. Choice A is incorrect. Although BUN is a measure of kidney function, patients without kidney disease who are dehydrated can show an elevation in BUN. Choice B is incorrect. This elevated potassium does not correspond with polycystic kidney disease. Choice C is incorrect. This uric acid level does not correspond with polycystic kidney disease. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

The physician places an order to administer gentamicin via IV for a client with acute diverticulitis. It is important for the nurse to know that IV gentamicin is administered: A. Over 1 minute as I.V. push [7%] B. Over 2 minutes as I.V. push [13%] C. As an I.V. side drip over 15-20 minutes [17%] D. As an I.V. side drip over 30-60 minutes [63%]

Explanation Choice D is correct. Gentamicin is an aminoglycoside that is nephrotoxic. Because of this, it should be administered slowly by intermittent infusion. The recommended duration of infusion for administration is 30-60 minutes. Choices A, B, and C are incorrect. It is not encouraged to be operated by bolus or I.V. push.

The nurse is caring for a client who has just been admitted with heparin-induced thrombocytopenia (HIT). Which of the following medications may have caused this condition? A. Epoetin alfa [10%] B. Clopidogrel [13%] C. Iron dextran [2%] D. Enoxaparin [75%]

Explanation Choice D is correct. HIT is a severe complication to a client taking heparinoids. Enoxaparin is low-molecular weight-based heparin (LMWH). Although it is not likely to cause HIT when compared to unfractionated heparin, the client still runs the risk of developing HIT. Choices A, B, and C are incorrect. Epoetin alfa is a colony-stimulating factor indicated for anemia secondary to renal disease. This medication would not cause HIT. Clopidogrel is an antiplatelet medication that is not implicated in HIT. Iron dextran is utilized in the treatment of anemia and would not be involved in HIT. Additional information: HIT is an adverse response to heparinoids. This autoantibody reaction causes venous and arterial thrombosis. The priority of HIT is to recognize it and stop the heparin product. The classic presentation of HIT is a reduction in the platelets by up to 50%, which is likely to occur between days four and five of heparin therapy. The nurse must report this type of platelet reduction and report it immediately to the primary healthcare physician (PHCP). Treatment of HIT includes using an agent such as argatroban, which inhibits thrombin. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Adverse Effects/Contraindications/Side Effects/Interactions

A 14-year-old is admitted to the medical ward for status asthmaticus. He was put on IV theophylline. Which manifestation would the nurse consider as a side effect of the drug? A. Grand mal seizures [9%] B. Palpitations [52%] C. Sleeplessness [10%] D. Headache

Explanation Choice D is correct. Headache is one of the most common side effects of theophylline. It is important to understand the difference between a side effect and drug toxicity, A side effect is something that can occur at a usual recommended dosage. On the contrary, drug toxicity (adverse drug event) occurs when there is overdosage or significant drug accumulation in the body above the therapeutic range. Choice A is incorrect. Seizures are a sign of toxicity from theophylline, not just a common side effect. Choice B is incorrect. Palpitations and arrhythmias are a sign of theophylline drug toxicity as well. Choice C is incorrect. Insomnia is not associated with theophylline.

The nurse is performing health education to a 21-year-old male who just had a fiberglass cast fitted on his right forearm for an ulnar fracture. They are talking about the early signs of compartment syndrome. The nurse notes that the patient has a full understanding of the topic when he states which of the following signs and symptoms: A. Pallor and pulselessness [45%] B. Inability to move his fingers and swelling at the site [22%] C. Fever and erythema [2%] D. Pain with passive motion and loss of sensation [30%]

Explanation Choice D is correct. Pain with passive motion and loss of sensation are early signs of compartment syndrome due to decreased blood flow from increased pressure of the cast. Choice A is incorrect. Pallor and pulselessness are already late signs of compartment syndrome. Choice B is incorrect. Swelling and loss of motion are also late signs of compartment syndrome. Choice C is incorrect. Fever and erythema are late signs of compartment syndrome.

A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take? A. Document the refusal [7%] B. Notify the primary healthcare provider (PHCP) [33%] C. Review the client's most recent platelet count [27%] D. Inquire with the client about the refusal [32%]

Explanation Choice D is correct. The appropriate and initial nursing action is to inquire with the client about their rationale for refusing the medication. Assessment is the initial part of the nursing process, and discussing the refusal with the client is a step the nurse should execute. Choices A, B, and C are incorrect. Documenting the refusal should not prioritize over inquiring with the client about their reasoning for refusing the prescription. If the client still refuses and after the nurse has thoroughly educated the client on the medication and its purpose. The nurse should contact the PHCP and document the refusal accordingly. Reviewing the client's platelet count is not appropriate as it is irrelevant to the refusal. This action should have been completed before obtaining the medication. Additional Information - As a competent adult, it is the client's right to refuse treatment for any reason, even when refusal might compromise the patient's health condition or death. The nurse should inquire about a refusal and clear up any questions the client may have regarding the medication or treatment. The nurse should also educate the client on the purpose of the prescription and treatment. If that is not effective, the nurse should contact the PHCP and relay the refusal. All of the actions, including the client's statements regarding the refusal, should be documented.

The nurse at the family clinic is talking to the mother of an asthmatic 13-year-old girl about how to avoid acute asthma attacks on her child. Which statement by the mother indicates a good understanding of the nurse's instructions? A. "My daughter can have any pets she likes as long as it's not a dog." [7%] B. "I can take her up to the mountains to go skiing." [12%] C. "She needs to avoid any form of exercise." [9%] D. "She needs to stop going with me to the sauna." [72%]

Explanation Choice D is correct. The mother should not expose the asthmatic child to extremes in temperature. Saunas expose the client to extreme heat, which can cause an acute asthma attack. Choice A is incorrect. Animal dander from animals can trigger an asthma attack. The client needs to avoid pets like dogs, cats, and birds. Turtles and other pets without dander can be acceptable pets for children with asthma. Choice B is incorrect. Extreme temperatures can trigger an acute asthma attack. Snow skiing exposes the child to extreme cold, which may cause a severe asthma attack. Choice C is incorrect. Extreme exercise triggers acute asthma attacks. The client should be encouraged to undergo mild exercises for activity.

What position will the nurse assist the female patient into for a comfortable genital examination? A. Semi-fowler's [1%] B. Supine with the knees bent [31%] C. Prone with the knees bent [1%] D. Semi-lithotomy

Explanation Choice D is correct. The semi-lithotomy position allows the patient to maintain eye contact with the practitioner and communicate while the procedure is being performed. It also allows adequate visualization of the female genitalia. Choice A is incorrect. Semi-Fowler's position is a semi-upright position and does not allow visualization of the female genitalia. Choice B is incorrect. A supine position with bent knees can be used; however, it is not the most comfortable position for the patient during a genital examination. Choice C is incorrect. The prone position with bent knees is not a comfortable position for genital examination. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Female Genitalia and Rectal Assessment

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? A. A client with chronic anemia requiring epoetin injections. [5%] B. A client with a resolving pneumothorax with a chest tube. [5%] C. A client with a tracheostomy requiring intermittent suctioning. [6%] D. A client with septic shock requiring intravenous (IV) vasopressors. [85%]

Explanation Choice D is correct. When making client assignments, the RN should be assigned the client with the least predictable outcome who is unstable. The client with septic shock receiving intravenous vasopressors should be assigned to the RN because of the need to titrate the vasopressors. Further, this client being in shock, is not stable and requires frequent assessment. Choices A, B, and C are incorrect. An LPN should be assigned clients who are stable and with a predictable outcome. A client with a chronic illness such as anemia requiring epoetin injections can be delegated to the LPN. Further, the client with a resolving pneumothorax may be assigned to the LPN because the condition is resolving. Finally, LPNs may do suction in an established tracheostomy. Additional Info When making client assignments, the nurse should always assign the most unstable client to the RN. This also involves clients requiring initial assessments or discharge teaching. The LPN may reinforce teaching, data collection, and care for clients with low acuity illnesses.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that droplet precautions are used for which condition? Select all that apply. A. Influenza [35%] B. Viral meningitis [25%] C. Pertussis [35%] D. Hepatitis C [3%] E. Lyme disease [2%]

Explanation Choices A and C are correct. Conditions requiring droplet precautions include influenza and pertussis. Choices B, D, and E are incorrect. Viral meningitis in adults, Hepatitis C, and Lyme disease are not spread by droplets and require only standard precautions. Meningitis may be secondary to bacteria [Neisseria meningitidis (meningococci) or E.coli, or Streptococcus pneumoniae (pneumococci)] or viruses (enteroviruses are the most common cause. Rare viral causes include mosquito-borne viruses, herpes simplex viruses, mumps). Bacterial meningitis with meningococci requires droplet precautions because meningococci spread through large droplets. Clients with meningococcal meningitis should be placed on droplet precautions (private room, mask) until they have completed 24 hours of appropriate antibiotic treatment. Viral meningitis and pneumococcal meningitis do not require droplet isolation. In adults with viral meningitis, standard precautions are sufficient. In infants and young children, viral meningitis requires contact precautions as well. Since most viral meningitis cases are due to enteroviruses that may be passed in the stool, clients with viral meningitis should be instructed to wash their hands thoroughly with soap and water after using the toilet. Additional Info Personal Protective Equipment (PPE) required for a client with droplet precautions is a surgical mask. The risk of transmitting a droplet pathogen is likely when the nurse is within three feet of the individual infected. Conditions requiring droplet precautions include: Rubella Influenza Pertussis Bacterial meningitis Pneumonic plague Diphtheria (Pharyngeal) Mumps Rhinovirus

You are providing asthma education to a teen that has just been diagnosed with asthma. Which of the following statements indicate a need for further teaching? Select all that apply. A. "When I am having an asthma attack, I should call 911 first." [41%] B. "When I am having an asthma attack, my airway is constricting and it can become dangerous." [5%] C. "I should try to identify what causes me to have an asthma attack and avoid those activities." [6%] D. "I've really been wanting to get a dog and my asthma will not stop me." [48%]

Explanation Choices A and D are correct. These statements indicate a need for further education. During an asthma attack, the first action should not be to call 911. The patient will have an asthma action plan that lists the steps she should take in the order she should take them. For most patients, the first step is to take short-acting inhaler medications. It is not necessary to first call 911 for every asthma attack (Choice A). Although asthma will not stop every child from getting a dog, pets with hair that sheds can be a trigger. It would be inadvisable for a teen newly diagnosed with asthma to get a new dog. It could end up causing more asthma attacks and present a severe problem. If the patient wants a new pet, a fish would be a better recommendation given their new asthma diagnosis (Choice D). Choice B is incorrect. This is an appropriate statement and does not indicate a need for further education. When a patient is having an asthma attack, the physiology includes inflammation and constriction of the airways. This can result in obstruction, making it impossible for the patient to breathe. That is why asthma attacks are so dangerous. Choice C is incorrect. This is an appropriate statement and does not indicate a need for further education. One of the most critical educational points for patients newly diagnosed with asthma is identifying their triggers. Triggers are what precipitate an asthma attack for that patient. For example, maybe playing soccer, or dusting the house. Whatever it is that precipitates their asthma should be avoided. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Respiratory

The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply. A. Unilateral frontotemporal pain [24%] B. Nausea [24%] C. Photophobia [23%] D. Fever [2%] E. Nuchal rigidity [5%] F. Vomiting [21%]

Explanation Choices A, B, C, and F are correct. An array of symptoms may be reported for a client experiencing a migraine headache (MH). The most common manifestations associated with an acute migraine headache include Unilateral frontotemporal pain that may be described as throbbing or dull Sensitivity to light (photophobia) and sound (phonophobia) Nausea and/or vomiting Altered mentation (drowsiness) Dizziness, numbness, and tingling sensations Choices D and E are incorrect. An acute migraine headache is not an infectious process. Thus, a fever and nuchal rigidity are not associated with this syndrome. If a client has a fever, nuchal rigidity, and photophobia, those findings are highly concerning for bacterial meningitis. Additional Info Migraine headaches have complex pathophysiology that is not entirely understood. The current thought process regarding this syndrome is that it is caused by a combination of neuronal hyperexcitability and vascular, genetic, hormonal, and environmental factors. During an acute migraine headache, often the client may feel as though they are experiencing a stroke because of transient facial paralysis and/or numbness that may be experienced.

Which of the following are the steps of blood glucose level monitoring? Select all that apply. A. Hold the finger downward so the blood will drop by gravity. [23%] B. Use sterile gauze to wipe off the first drop of blood before testing. [25%] C. Collect the second blood drop on the test strip. [30%] D. Use a lancet to prick the pad of the finger. [22%]

Explanation Choices A, B, and C are correct. The procedure for checking the client's blood glucose levels in the correct sequential order are as follows: Verify and confirm that the code strip corresponds to the meter code. Disinfect the client's finger with an alcohol swab. Prick the side of the finger using the lancet. Turn the finger down so the blood will drop with gravity. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client's finger after the specimen has been obtained. Read the client's blood glucose level on the monitor. Choice D is incorrect. The side of the finger should be pricked with the lancet, not the pad. Finger pads are not recommended for pricking because they are the thickest part of the finger, so one will have to prick deeper to get the required amount of blood NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential

The nurse is caring for a 30-year-old patient who has developed iron-deficiency anemia during pregnancy. Which complication would this patient be at an increased risk for due to iron deficiency anemia? Select all that apply. A. Low birth weight [38%] B. Preterm delivery [36%] C. Gestational diabetes [2%] D. Perinatal mortality [24%]

Explanation Choices A, B, and D are correct. During pregnancy, there is an increased demand for oxygen to supply both the mother and the developing fetus. Iron deficiency anemia occurs as a result of insufficient amounts of iron (needed to make hemoglobin) to meet oxygen demand. Iron deficiency anemia is associated with an increased risk for low birth weight, preterm delivery, and perinatal mortality. Choice C is incorrect. Iron deficiency anemia in pregnancy is not associated with an increased risk of developing gestational diabetes. NCSBN Client Need Topic: Maternal and newborn health, Subtopic: ante/Intra/postpartum care, illness management, pathophysiology

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for developing colorectal cancer? Select all that apply. A. Ulcerative colitis [24%] B. Body Mass Index (BMI) = 21 [1%] C. Human Immunodeficiency Virus (HIV) infection [11%] D. Low-fiber diet [20%] E. Excessive alcohol consumption [23%] F. African-American ethnicity [20%]

Explanation Choices A, D, E, and F are correct. Risk factors for colorectal cancer are divided into modifiable and non-modifiable types. Modifiable risk factors are usually behavioral factors that can increase a person's risk of cancer. In theory, these risk factors can be modified with interventions. Non-modifiable risk factors are those that can not be changed. Awareness of the client's risk factors will help the health care provider prescribe personalized lifestyle and cancer screening recommendations. The gold standard of colorectal cancer prevention is a colonoscopy that should begin as early as age 45 (USPTF new guidelines, 2021). (Choice A) Inflammatory bowel disease (especially ulcerative colitis) is a non-modifiable risk factor that may cause cellular damage and hasten the risk of colorectal cancer. (Choice D) A diet low in fiber is a modifiable risk factor for colon cancer. Encourage the client to increase fiber intake and decrease red meat. (Choice E) Excessive alcohol intake is a modifiable risk factor for colorectal cancer. (Choice F) African American ethnicity is a non-modifiable risk factor for colorectal cancer. Choice B is incorrect. A BMI of 21 is optimal and is not a risk factor. Obesity is a modifiable risk factor for colorectal cancer. Obesity is defined as a Body Mass Index (BMI) ≥ 30 kg/m2. Choice C is incorrect. HIV is a risk factor for many malignancies such as testicular cancer, but not colorectal cancers. Since rates of colorectal cancer are similar between people with and without HIV, existing screening guidelines are sufficient for people with HIV. Another virus called human papillomavirus (HPV) has been implicated in colorectal cancers. Learning Objective: Recognize that the risk factors for colorectal cancer include age, African American ethnicity, family history of colon cancer, certain genetic conditions, a diet low in fiber, a diet rich in red meat, obesity, smoking, and inflammatory bowel conditions (ulcerative colitis). NCSBN Client Need Topic: Health Promotion and Maintenance; Subtopic: Perform targeted assessments; GI

A 70-year-old client is seen in the outpatient clinic for perineal irritation due to urinary incontinence. Which of the following measures, if suggested to the client by the nurse, is most appropriate? Select all that apply. A. Use extra-large incontinence briefs to provide for air movement. [8%] B. Apply a generous amount of barrier cream. [23%] C. Gently cleanse the perineum 2 to 3 times per day with warm water and pat dry. [31%] D. Apply Bacitracin cream to the perineum. [13%] E. Ambulate the patient to the bathroom every two hours. [26%]

Explanation Choices B and C are correct. Protecting skin integrity by keeping the skin clean and protected from irritants, such as urine, is the most appropriate teaching. Choice A is incorrect. Extra-large briefs may not fit well and could cause further irritation by rubbing the skin. Choice D is incorrect. Bacitracin is an antibiotic cream. The patient in this scenario does not have infected skin, but rather skin irritation. Choice E is incorrect. Scheduled toileting can help patients who are unable to get out of bed or reach the bathroom alone. The nurse can help ambulate the client to the bathroom every two to four hours. While going to the bathroom every few hours may help overflow incontinence, this answer in choice E suggests that the patient has a specific type of incontinence. The question does not specify "overflow" incontinence. There are other types of incontinence (urge incontinence, stress incontinence) that may not be helped by scheduled toileting.

The nurse has provided education to a client with atrial fibrillation. Which of the following statements by the client would require a follow-up? Select all that apply. A. "I have an increased risk for a stroke." [14%] B. "I should weigh myself daily at the same time." [22%] C. "I may be prescribed medications such as amiodarone." [19%] D. "I should wear a mask when I am in public." [34%] E. "I should follow-up with my primary healthcare provider (PHCP) if I develop shortness of breath." [11%]

Explanation Choices B and D are correct. These two statements indicate that the patient needs further follow-up education to correct the misconceptions. The client does not need to weigh themselves daily (Choice B) as that would be applicable for CHF and not for atrial fibrillation. Considering daily weight checks in CHF is useful to detect excess fluid retention, which may precede symptoms such as shortness of breath. Wearing a mask in public is unnecessary as an infection is not the concern here (Choice D). Choices A, C, and E are incorrect. These options are wrong because these statements indicate correct understanding by the patient and do not require follow-up teaching. Atrial fibrillation is a common dysrhythmia that results in a decrease in an atrial kick. A client with atrial fibrillation is at risk for an ischemic stroke (Choice A) because of the formation of clots in the atrial appendage. Treatment for atrial fibrillation range from medications (diltiazem, amiodarone) to cardiac ablation (Choice C). Finally, the client needs to notify the PHCP if they develop dyspnea because this could be an indication of atrial fibrillation with a rapid ventricular response (RVR), which requires immediate medical attention (Choice E).

You have been chosen to give a presentation about maternal risk factors to your community health class. Which of the following are considered adverse risk factors in women wanting to get pregnant? Select all that apply. A. Women older than 30 years of age or less than 18 years of age [18%] B. Substance abuse [31%] C. Abuse and violence [24%] D. Concurrent medical conditions [27%]

Explanation Choices B, C, and D are correct. Substance use during pregnancy puts the fetus at risk for abnormal growth, abruptio placentae, and fetal bradycardia. This is a severe risk factor and should be discussed with women trying to conceive (Choice B). Abuse and violence put both the mother and fetus at risk. There are higher instances of abruptio placentae, preterm birth, and infections from unwanted and forced sex (Choice C). Concurrent medical conditions such as diabetes mellitus and hypertension cause the pregnancy to be considered high risk. Different risks are dependent on the situation, such as macrosomia and hypoglycemia in infants of a diabetic mother. These should be discussed thoroughly for women wishing to become pregnant who live with a severe medical condition (Choice D). Choice A is incorrect. The correct maternal risk factor is women older than 35 years of age or less than 20 years of age. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Reproductive, antepartum

While taking care of a client with heart failure in the telemetry unit, the nurse notices the transition of his heart rhythm to the one shown in the exhibit. The client is on digoxin and furosemide. He is asymptomatic, his heart rate is 40 beats per minute, and his blood pressure is 110/60 mmHg. Which of the following interventions are appropriate? See the exhibit. Select all that apply. A. Administer atropine [13%] B. Notify the physician [24%] C. Check potassium level [22%] D. Obtain digoxin level [23%] E. Administer 1-liter normal saline intravenously [10%] F. Use a transcutaneous pacer [7%]

Explanation Choices B, C, and D are correct. The telemetry strip shows a third-degree heart block, otherwise known as a complete heart block. In 3rd degree or entire heart block, there is no atrioventricular conduction, so no impulses from the supraventricular nodes (sinus impulses) are conducted to the ventricles whatsoever. This results in erratic heart rates where the sinus node and the atrioventricular nodes are beating independently. This leads to a junctional rhythm where there is no correlation between P-waves and QRS complexes. The atrial rhythm will be regular (P to P interval regular). The ventricular rhythm is steady (R-to-R range is consistent). However, the R-R interval will be variable. These are the typical characteristics of a 3rd degree AV block. If you notice a complete heart block, you must notify the physician (Choice B) immediately so appropriate interventions can be implemented. It is crucial to look for and quickly correct the reversible causes of complete heart block. A complete heart block may be secondary to different causes. In this instance, the client is on digoxin and furosemide. Based on the available information, the entire heart block may be secondary to digitalis toxicity. The most common trigger of digitalis toxicity is hypokalemia, which may occur because of the client's diuretic therapy (furosemide). The digoxin (Choice D) and potassium levels (Choice C) must be checked as soon as possible. If present, hypokalemia must be corrected quickly. Causes of a complete heart block may be grouped into reversible and irreversible causes. Treatment is directed towards addressing the symptoms and etiology. Reversible causes, such as medications (digoxin toxicity, an overdose of beta-blockers or calcium channel blockers), hypothyroidism, Lyme disease, hyperkalemia, and inferior wall MI, that transiently damage the AV node. Irreversible causes, such as anterior wall myocardial infarction, permanently damage the distal conduction system of the heart. Congenital causes, such as maternal lupus (due to maternal antibodies crossing the placenta and attacking the heart tissue of the fetus during gestation). Choices A and F are incorrect. In this instance, the client is asymptomatic and hemodynamically stable. Since the client is asymptomatic, these interventions need not be undertaken immediately. The client should be observed and monitored. One should search for and correct the reversible causes. If not readily reversible, preparation should be made for transvenous pacing. If symptoms are present, atropine should be administered (Choice A). If symptomatic, a transcutaneous pacer (Choice F) must be used until a transvenous pacemaker can be placed. A complete heart block may lead to fatal symptomatic bradycardia with a heart rate of less than 40/min. Symptoms of severe bradycardia include hypotension, congestive heart failure exacerbation, pulmonary congestion, chest pain, decreased level of consciousness, seizures, cerebral ischemia, cardiac arrest, and sudden cardiac death. As per the advanced cardiac life support (ACLS) recommendations, the first step in treating symptomatic bradycardic patients involves administering intravenous atropine. Since atropine acts at the AV node, it is rarely effective in increasing the heart rate in clients with complete heart block and 2nd-degree Mobitz type II heart block. For hemodynamically unstable patients (shock) or those with symptomatic bradycardia, immediate treatment is needed, and most often, the physician orders temporary pacing to increase heart rate and cardiac output to stabilize blood pressure. Once patients are hemodynamically stable, an attempt is made to identify any reversible cause and reverse it. In the case of digoxin toxicity, the physician may order digoxin immune Fabs, check potassium, and correct hypokalemia as low potassium may aggravate digitalis toxicity. In the case of beta-blocker overdose, glucagon is administered. In the case of calcium channel blocker overdose, calcium chloride is administered. In the case of hypothyroidism, thyroid hormone replacement is given. In the case of hyperkalemia, medicines to reduce potassium levels (insulin/dextrose; sodium bicarbonate; kayexalate) and to antagonize potassium's cardiac effects (calcium chloride). If no reversible cause can be identified, the physician inserts a permanent pacemaker. Choice E is incorrect. There is no reason to administer IV fluids since the client is hemodynamically stable. In the case of congestive heart failure, excessive and unnecessary IV hydration may worsen the client's heart failure symptoms.

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 [11%] B. Continuous telemetry monitoring [24%] C. Intravenous hydrocortisone [27%] D. Fluid restriction [5%] E. Fall precautions [27%] F. Indwelling urinary catheter [6%]

Explanation 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. Additional Info 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 supervising a new graduate place an intravenous catheter. Select all the nursing interventions that have been proven effective in terms of beginning and maintaining intravenous access. Select all the apply. A. Not attempting an intravenous start more than one time [10%] B. Using the shortest length catheter as possible [13%] C. Using the smallest size catheter as possible [16%] D. Reviewing the medical history to determine any previous untoward effects of IV access [25%] E. Using the most distal hand veins when possible [22%] F. Applying warm compresses to the site for 10 minutes [12%]

Explanation Choices B, C, and F are correct. Using the shortest length catheter as possible, using the smallest size catheter as possible, and applying warm compresses to the site for 10 minutes for vasodilation are three effective nursing interventions for beginning and maintaining intravenous therapy. Other effective nursing interventions include: Not attempting to start an intravenous line more than two times. Reviewing the client's medical history to determine if there are any contraindications to a specific IV site, like a history of mastectomy or prior lymph node dissection. To use the most distal veins of the arm, not the hand. Hand veins should be avoided whenever possible to prevent inadvertent nerve damage. Choice A is incorrect. Intravenous attempts can be attempted more than one time. It is preferred to keep the attempts to two or less. Choice D is incorrect. Although the nurse should review the medical history, the purpose of this review is to determine if there are any contraindications to a specific IV site, like a mastectomy. The purpose of this review is not to identify any previous untoward effects of IVs. For example, if the client had an IV site infection or superficial thrombophlebitis with a prior IV site, it is irrelevant to the current IV access. Choice E is incorrect. It is not appropriate to use the most distal hand veins. Distal hand veins should be avoided whenever possible to prevent inadvertent nerve damage.

While working in the triage of the pediatric emergency department, you are notified that a patient is on their way and suspected of having impetigo. What actions should the nurse take to prevent the spread of this disease? Select all that apply. A. Initiate droplet precautions [6%] B. Set up a decontamination room [19%] C. Use standard precautions [32%] D. Initiate contact precautions [43%]

Explanation Choices C and D are correct. As with every patient, standard precautions should always be followed. This will be especially important for your patient with impetigo because handwashing will prevent the spread of the infection (Choice C). Contact precautions are appropriate to prevent the spread of impetigo. Staff should be made aware of the precautions with the proper signs, gowns, and gloves readily available outside of the room (Choice D). Choice A is incorrect. Droplet precautions are not appropriate for impetigo. It is spread through contact with the skin, not respiratory droplets. Choice B is incorrect. Although very contagious, a decontamination room is not indicated for impetigo. NCSBN Client Need: Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control

Select all that apply. See the exhibits. A. Albuterol [19%] B. Hydrocortisone [14%] C. Diltiazem [20%] D. Nitroglycerin [13%] E. Furosemide [34%]

Explanation Choices D and E are correct. Pulmonary edema secondary to acute decompensated heart failure (ADHF) is a medical emergency and requires rapid treatment. Vasodilators such as nitroglycerin are employed to help decrease preload and afterload, which decreases the heart's workload. This medication is often combined with a loop diuretic such as furosemide or bumetanide to decrease volume. If vasodilators or loop diuretics are prescribed, close monitoring of the blood pressure is essential. Choices A, B, and C are incorrect. Albuterol would be unnecessary and harmful for a client with pulmonary edema and ADHF. This would be useful for a client experiencing bronchoconstriction, such as an asthma exacerbation. The assessment for this client revealed crackles in the lung fields - not wheezes. Hydrocortisone is a steroid and would be unhelpful in the management of ADHF. This medication may be detrimental as this medication leads to fluid retention. Diltiazem is a calcium channel blocker and is grossly contraindicated in ADHF because of its negative inotropic effects. NCLEX Category: Physiological adaptation Activity Statement: Medical Emergencies Question type: Analysis Additional Info Priority nursing care for a client with pulmonary edema and ADHF includes: Airway assessment and pulse oximetry monitoring High flow oxygen therapy via nonrebreather or intubation if clinically indicated Cardiac and vital sign monitoring with critical care placement High-fowler's positioning Emergent intravenous diuresis and vasodilators, as prescribed Once the client has been stabilized, the urinary output should be monitored along with daily weights to evaluate response to the therapy. VTE prophylaxis should be maintained coupled with prescriptions such as ACE inhibitors (lisinopril).

The nurse is caring for a client prescribed IV heparin. The client is prescribed 18 units/kg/hr. The client weighs 246 pounds. The heparin is labeled with 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round your answer to the nearest whole number. Fill in the blank. 20 mL/hr

Explanation The first step to solving this problem is to convert the client's weight from pounds to kilograms (kg) 246 pounds / 2.2 = 111.81 kg Next, establish the dosage that the client is to receive. 18 units x 111.81 kg = 2012.58 units Next, take the ordered amount and divide it by the dose on hand and then multiply it by the volume. 2012.58 units / 25000 units x 250 mL = 20.12 mL/hr Finally, round the mL/hr to the nearest whole number 20.12 mL = 20 mL/hr Additional Info Intravenous heparin is typically administered as a bolus dose first, then as a continuous infusion to achieve therapeutic aPTT. A baseline aPTT should be collected 6 hours after the first dose and 6 hours following any dose adjustments. The goal is to prolong the aPTT from 1.5 to 2.5 times the control value. The normal aPTT value is 30-40.

The nurse is caring for a client receiving a continuous infusion of heparin. The label reads 25,000 units of heparin in 500 mL of Dextrose 5% in water (D5W). The client is receiving 1,250 units per hour. How many milliliters (mL) did the client receive in an eight-hour shift? Fill in the blank. 200 mL

Explanation To solve this, use the formula of dose ordered / dose on hand x volume to determine the mL/hr. 1250 units / 25000 units x 500 mL = 25 mL/hr Next, take the mL/hr and multiply it by eight to determine the total volume delivered. 25 mL/hr x 8 hours = 200 mL Additional Info Intravenous heparin is typically administered as a bolus dose first, then as a continuous infusion to achieve therapeutic aPTT. A baseline aPTT should be collected 6 hours after the first dose and 6 hours following any dose adjustments. The goal is to prolong the aPTT from 1.5 to 2.5 times the control value. The normal aPTT value is 30-40.

The primary healthcare provider (PHCP) prescribes 125 mcg of digoxin by mouth, daily. The medication label reads digoxin 0.25 mg per tablet. The nurse prepares to administer how many tablet(s)? Fill in the blank Provide your answer in decimal format. 0.5 tablet(s)

First, the nurse must convert the prescription to the same units as the medication label (micrograms → milligrams) 125 micrograms → 0.125 mg (divide 125 micrograms by 1000) Next, take the dose ordered and divide it by the dose on hand and multiply by its volume 0.125 mg / 0.25 mg x 1 tablet = 0.5 tablet Additional Info Digoxin is a cardiac glycoside for treating atrial fibrillation and congestive heart failure (CHF). This medication has lost popularity in recent decades because newer agents do not require therapeutic monitoring. For a client taking digoxin, the apical pulse must be obtained before administration. The apical pulse needs to be at least 60/minute for adults; 70/minute for children; 90/minute for infants.

Explanation Choice C is correct. Hepatitis A is typically an infection that is self-limiting if the child receives the appropriate supportive care. The disease is usually transmitted by drinking water and food that is contaminated with fecal matter. Removing the source of the infection and providing a healthy diet will often help resolve the infection. A hepatitis A vaccine is available that should be given to all children and high-risk adults. This vaccine should be given in two doses. Choice A is incorrect. Acyclovir is an antiviral that is given to slow the growth of the herpes virus. Choice B is incorrect. Interferon is a protein-based medication used in many immune system diseases such as multiple sclerosis (MS). Choice D is incorrect. Ribavirin is an antiviral medication used to treat hepatitis C, not hepatitis A.

The 6-year-old immigrant child has been diagnosed with Hepatitis A. He was brought from Mexico by his grandparents a few days ago. You would expect that treatment for this child will include: A. Acyclovir [27%] B. Interferon [15%] C. Supportive care [42%] D. Ribavirin [17%]

The nurse is performing medication reconciliation for a patient in the respiratory clinic recently prescribed with terbutaline. Which medication should the nurse be concerned about? A. Atenolol [65%] B. Furosemide [17%] C. Cefuroxime [11%] D. Omeprazole [7%]

Explanation Choice A is correct. Atenolol is a beta-blocker that can interfere with the action of terbutaline due to its antagonistic effect on the beta receptor cells in the bronchi. The nurse should talk to the prescribing physician regarding shifting the atenolol to another drug class. Choice B is incorrect. Furosemide is a loop diuretic. It blocks the reabsorption of water and sodium in the loop of Henle, leading to diuresis. It does not cause any drug-drug reaction with terbutaline. Choice C is incorrect. Cefuroxime is a second-generation cephalosporin that does not produce any reaction with terbutaline. Choice D is incorrect. Omeprazole is a proton pump inhibitor. It does not produce any undesirable drug interactions with terbutaline.

Gynecomastia may occur in an older male client secondary to: A. Testosterone deficiency [78%] B. Trauma [2%] C. Lymphatic engorgement [16%] D. Decreased activity level [4%]

Explanation Choice A is correct. Changes in testosterone levels promote breast growth. Choice A is incorrect. Trauma may cause inflammation but not gynecomastia. Choice C is incorrect. Lymphatic engorgement does not naturally accompany aging. Choice D is incorrect. Decreased activity level may occur with aging, but it does not affect breast tissue. NCSBN Client Need Topic: Health Promotion and Maintenance; Subtopic: Variations in Breast Tissue

hich of the following are appropriate primary prevention strategies to teach your patient for cancer prevention? Select all that apply. A. Maintain a normal body weight [24%] B. Breast self exams for women [27%] C. HPV vaccine [27%] D. Mammograms for women over 40 years of age [21%]

Explanation Choices A and C are correct. Primary prevention strategies focus on ways to prevent the occurrence of the disease ever happening. Maintaining a healthy body weight is an excellent primary prevention strategy for preventing the development of cancer (Choice A). HPV vaccines are an excellent primary prevention strategy for preventing the development of genital cancer (Choice C). Choice B is incorrect. Breast self-exams are a secondary prevention strategy. Choice D is incorrect. Mammograms are a secondary prevention strategy. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Adult Health, Oncology

The primary healthcare provider (PHCP) prescribes cefdinir 25 mg/kg in divided doses every six hours. The infant weighs 17.6 lbs. How many milligrams should the nurse administer per dose? Fill in the blank. 200 mg

Explanation The first step is to convert the client's weight from pounds (lbs) to kilograms (kg) 17.6 lbs → 8 kg Next, multiply the prescribed dosage by the client's weight 25 mg x 8 kg = 200 mg Next, since the order is in divided doses, the nurse should divide the daily dose by 4 (four 6 hour periods in 24 hours) 200 mg / 4 = 50 mg

A nurse is in-training for the correct way to monitor blood glucose levels. Arrange the following steps of the blood glucose monitoring technique in the correct sequence. Verify and confirm that the code strip corresponds to the meter code. Turn the finger down so the blood will drop with gravity. Disinfect the client's finger with an alcohol swab. Prick the side of the finger using the lancet. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client's finger after the specimen has been obtained. Read the client's blood glucose level on the monitor.

Verify and confirm that the code strip corresponds to the meter code. Disinfect the client's finger with an alcohol swab. Prick the side of the finger using the lancet. Turn the finger down so the blood will drop with gravity. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client's finger after the specimen has been obtained. Read the client's blood glucose level on the monitor. Explanation The procedure for checking the client's blood glucose levels in the correct sequential order is as follows: Verify and confirm that the code strip corresponds to the meter code. Disinfect the client's finger with an alcohol swab. Prick the side of the finger using the lancet. Turn the finger down so the blood will drop with gravity. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client's finger after the specimen has been obtained. Read the client's blood glucose level on the monitor. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential