Archer Review 6

The RN and the LPN are caring for a client who is in four-point restraints due to combative behavior. Which of the following tasks may the nurse assign to the LPN/LVN? A. Re-assess the patient's skin integrity around the restraints hourly. [45%] B. Ensure that the physician has renewed the order for restraints, which should be done every 12 hours. [21%] C. Release the leg restraints to give the patient a break and see if his combative behavior has improved. [31%] D. Have the attending physician discontinue the restraints and give the patient a chance to behave better. [3%]

Explanation Choice A is correct. While in restraints, combative patients should be assessed hourly and non-combative patients every two hours to ensure that skin breakdown around the restraints has not occurred. LPN/LVN is not allowed to do an initial or comprehensive assessment, but a re-assessment on a stable patient is within their scope of practice. Choice B is incorrect. The RN is responsible for ensuring the order for non-violent restraints is obtained every 24 hours. This is the responsibility of the RN and not the LVN. The RN retains accountability for the orders implemented. Choice C is incorrect. The LPN/LVN should not remove restraints on a combative patient. Restraints should be eliminated at the soonest possibility but that decision should be made after consulting the RN who can perform a comprehensive assessment to judge if the restraints may be removed. The LPN/LVN should never remove restraints on a combative patient when they are alone either as this poses a safety risk to the LPN/LVN Choice D is incorrect. Discontinuation of the restraints should occur if the patient has shown improvement in their clinical situation. A RN may decide to discontinue restraints if the patient is appropriate for restraint removal. The RN would perform an overall assessment to see if it is appropriate for restraint removal. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Using Restraints in the Healthcare Facility Learning Objective Identify interventions that are appropriate for a RN to delegate to a LPN/LVN. Additional Info Source : ArcherReview Hospitals have reduced the use of physical restraints. The Joint Commission has specific standards that limit the use of physical restraints in hospitals and nursing homes. If all interventions (reminding the patient to call for assistance, distraction techniques, skin selects, etc) have not been effective, a physical restraint may be required for a limited period of time. For non-violent restraints an order must be obtained every 24 hours. For violent restraints an order from a HCP must be obtained every 4 hours. If a patient is placed in violent restraints the HCP must come and do an assessment of the patient within one hour of restraint application. The RN is responsible for obtaining the orders related to restraint application and is responsible for initial assessment and documentation of restraint application.

The nurse is teaching a client who has hypertension about the newly prescribed medication, furosemide. Which of the following should the nurse include in the teaching? A. Limit intake of bananas, cantaloupe, and potatoes. [6%] B. Avoid taking the medication with grapefruit juice. [23%] C. Take this medication in the early part of the day. [69%] D. A nagging cough can occur as a side effect of the medication. [2%]

Explanation Choice C is correct. Furosemide is a loop diuretic and may be indicated for conditions such as heart failure or hypertension. The client should be instructed to take this medication in the earlier part of the day to avoid nocturia. Choices A, B, and D are incorrect. The client should be encouraged to have a high potassium diet as this medication is potassium wasting. Thus, bananas, cantaloupe, and potatoes are encouraged. Grapefruit does not interact with furosemide as it does with medications such as verapamil. A nagging cough is a common effect associated with ACE inhibitors. Additional Info Furosemide is a loop diuretic for managing hypertension and congestive heart failure. This medication causes wasting of sodium, potassium, calcium, and magnesium. Before administering furosemide, the nurse should assess these electrolytes and the client's blood pressure.

A 70-year old man in the ICU experiences sudden cardiac arrest. The code team arrives and performs CPR. After about five minutes, the patient obtains a return of spontaneous circulation (ROSC). A carotid pulse is found, but femoral and radial pulses are not. What is this patient's approximate minimum systolic blood pressure? A. 60 mmHg [48%] B. 70 mmHg [22%] C. 80 mmHg [14%] D. 90 mmHg [16%]

Explanation Choice A is correct. Cardiac arrest is the spontaneous cessation of perfusion by the heart. Following a successful cardiopulmonary resuscitation (CPR), there is a resumption of sustained heart rhythm that perfuses the body leading to the return of pulse rate and blood pressure. This is referred to as the return of spontaneous circulation (ROSC). The signs of ROSC include significant spontaneous breathing effort, coughing, movement, palpable pulse, measurable blood pressure, or abrupt sustained increase in end-tidal CO2 (PETC02). ROSC is detected by arterial pulse palpation and end-tidal CO2 monitoring. When pulses are palpable, it can be clinically inferred that a patient with a carotid pulse has a systolic blood pressure (SBP) of at least 60 mmHg, the one with a femoral pulse has an SBP of at least 70 mmHg, and the one with a radial pulse has an SBP of at least 80 mmHg. Advanced Trauma Life Support (ATLS) algorithms have also used this 80/70/60 rule to estimate hypovolemia and triage patients in trauma settings. However, based on a couple of clinical studies, it is felt that the 80/70/60 rule tends to overestimate the SBP in hypovolemic patients. To prevent underestimating the degree of hypovolemia, ATLS has removed this recommendation from newer editions. However, the rule still serves as a rough guestimate of systolic blood pressure in other settings. Choice B is incorrect. A systolic blood pressure of at least 70 mmHg is expected when femoral pulses are palpable. Choices C and D are incorrect. A systolic blood pressure of at least 80 mmHg or above is expected when radial pulses are palpable. Learning objective: Return of spontaneous circulation (ROSC) following a successful CPR is detected by palpation of arterial pulses and monitoring of end-tidal CO2. The site of arterial pulse that is palpated provides a rough estimate of systolic blood pressure. NCSBN Client Need: Topic: Reduction of Risk Potential; Sub-topic: Changes/Abnormalities in Vital Signs

The nurse educator is talking to a group of students regarding anorexia nervosa. Which statement by the students indicates an understanding of the condition? A. "Clients with anorexia nervosa are usually perfectionists and overachievers." [55%] B. "Clients with anorexia nervosa display a binge-purge syndrome." [16%] C. "Clients with anorexia nervosa have poor dental conditions." [15%] D. "Clients with anorexia nervosa have stomach ulcers and rectal bleeding." [13%]

Explanation Choice A is correct. Clients with anorexia nervosa have the desire to please others. They need to be accurate or perfect to cope with their stress. Choice B is incorrect. This applies to clients with bulimia nervosa. Choice C is incorrect. This applies to clients with bulimia nervosa. Choice D is incorrect. This applies to clients with bulimia nervosa.

The nurse is caring for a patient with suspected kidney disease. Which of the following glomerular filtration rates is considered within normal limits? A. 120 mL per minute [43%] B. 60 mL per minute [39%] C. 150 mL per minute [7%] D. 15 mL per minute [10%]

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

The nurse is taking care of a client with hypoparathyroidism. The nurse understands that patients with hypoparathyroidism have a low serum calcium level. The nurse should be alert for the following signs and symptoms of hypocalcemia, except: A. Kernig's sign [68%] B. Trousseau's sign [6%] C. Hyperactive deep tendon reflexes [18%] D. Chvostek's sign [8%]

Explanation Choice A is correct. Kernig's sign is not a sign of hypocalcemia. However, it is a sign that indicates meningeal irritation/infection. Choice B is incorrect. Trousseau's sign is a sign related to hypocalcemia. Spasms of the wrist and hands appear after the upper arm is compressed by a blood pressure cuff. Choice C is incorrect. Hyperactive deep tendon reflexes are a result of severe neuromuscular irritability due to low serum calcium levels. Choice D is incorrect. Chvostek's sign is a sign of hypocalcemia. It can be elicited by tapping over the facial nerve and observing for the spasm of the facial muscles.

The nurse receives hand-off about a client with ulcerative colitis and was informed that the client has experienced severe diarrhea in the past 24 hours. When assessing the client, the nurse should watch out for signs of: A. Metabolic acidosis [66%] B. Metabolic alkalosis [27%] C. Malnutrition [2%] D. Malabsorption [4%]

Explanation Choice A is correct. The client experiences increased bicarbonate loss from severe diarrhea. Therefore, the nurse should assess the client for metabolic acidosis, not alkalosis (Choice B is incorrect). Choices C and D are incorrect. Malnutrition and malabsorption are possible long-term complications of ulcerative colitis and are not expected to be present after a 24-hour long bout of diarrhea.

Upon your arrival in the Labor and Delivery (L&D) department, the nurse informs you that your patient is a G1P0, 18-year-old, and the fetus is in the ROA position. As an L&D nurse, you know that when you palpate your patient's abdomen, you will find the fetus in which of the following areas? Choose the correct image.

Explanation Choice A is correct. The image shows the fetus in the ROA (Right Occiput Anterior) position. The presenting part (occiput, back of the head) is directed to the right side of the mother's pelvis and the anterior portion of the mother's pelvis. The fetal position represents the orientation of the fetus in the mother's womb, defined by the location of the presenting part of the fetus relative to the pelvis of the mother. When looking at the image, it is easy to think that this fetus is on the left side since it is on your left when you look at the image. However, if you visualize yourself as the mother, you can see that the fetus is on her right side. Choice B is incorrect. This is a fetus in the LOT (Left Occiput Transverse) position. The occiput faces left and is transversely positioned about the mother's pelvis. Choice C is incorrect. This is a fetus in the ROP (Right Occiput Posterior) position. Choice D is incorrect. This is a fetus in the LOA (Left Occiput Anterior) position. LOA is the most common fetal position. The Occiput-Anterior position is the most ideal for birth. In this image, the fetus is sitting on the left side of the mothers pelvis. When describing fetal position, always remember to articulate the position relative to the mother's pelvis! If it is on HER left side, it is LEFT! Additional Info When describing the fetal position, the 1st letter is R or L for the right or left side of the mother's pelvis. The 2nd letter represents the presenting part of the fetus - O for occiput, M for mentus (chin), and S for the sacrum. The 3rd letter will be an A or P or T for anterior or posterior or transverse location of the fetus in the mother's pelvis.

A client who is a native of the Middle East is now on her 24th-week gestation. As part of her culture, she usually wears a long robe that covers her arms and body, with a shawl that covers her head and neck. Which supplement will the nurse most likely expect to give her? A. Vitamin D [91%] B. Vitamin C [4%] C. Calcium [4%] D. Zinc [2%]

Explanation Choice A is correct. Women from the Middle East are usually covered from head to foot. This causes them to receive little sun exposure. Unless the client's diet is rich in good sources of vitamin D, she needs to supplement it. Choices B, C, and D are incorrect. The situation has no data indicating the need for vitamin C, Calcium, or Zinc supplementation.

You are caring for a toddler who is experiencing pain as the result of a tonsillectomy. Which independent nursing intervention would you implement in terms of this pain? A. Give the toddler a "magic" blanket to take the pain away. [46%] B. Administer the toddler's ordered analgesic medication. [40%] C. Provide the toddler with privacy so they are not embarassed with crying. [1%] D. Help the toddler to develop better coping skills in terms of their pain. [12%]

Explanation Choice A is correct. The independent nursing intervention you would implement for a toddler who is experiencing pain as the result of a tonsillectomy is to give the toddler a "magic" blanket to take the pain away. Toddlers are magical and mystical thinkers so this "magic" blanket may be an effective pain management technique for children of this age. Choice B is incorrect. Although you would administer the toddler's ordered analgesic medication, this is not an independent nursing intervention. It is a dependent nursing intervention because a doctor's order is necessary for the administration of medications. Choice C is incorrect. You would not provide the toddler with privacy so they are not embarrassed by crying. Instead, the presence of the parent(s) and the nurse may help to relieve the pain. Choice D is incorrect. You would not help the toddler to develop better-coping skills in terms of their pain because toddlers are not mature enough to be able to develop coping skills.

The registered nurse works with others both inside and outside of their immediate work environment in order to achieve goals and to make decisions that are best for the individual client or group of clients. What role is this nurse fulfilling with these activities? A. The nurse as a collaborator [67%] B. The nurse as a team leader [16%] C. The nurse as the delegator [3%] D. The nurse as manager [14%]

Explanation Choice A is correct. The nurse is serving in their role of the nurse as a collaborator when the registered nurse works with others both inside and outside of their immediate work environment to achieve goals and to make decisions that are best for the individual client or group of clients. Choice B is incorrect. Although the nurse also serves as a team leader in some situations such as the team leader of a workgroup or the team leader for a group of clients, team leadership is not the role that is being fulfilled when the registered nurse works with others both inside and outside of their immediate work environment to achieve goals and to make decisions that are best for the individual client or group of clients. Choice C is incorrect. Nurses serve as delegators when they delegate and assign roles/jobs to others. This role is not being fulfilled when the registered nurse works with others both inside and outside of their immediate work environment to achieve goals and to make decisions that are best for the individual client or group of clients. Choice D is incorrect. The nurse as a manager takes on administrative and clinical roles such as coordinating care but not the part that is being fulfilled when the registered nurse works with others both inside and outside of their immediate work environment to achieve goals and to make decisions that are best for the individual client or group of clients.

A patient reports feeling numbness of the throat and tongue after taking Benzonatate. Which of the following should the nurse instruct the patient? A. Swallow the medication without chewing it [25%] B. Decrease the dosage of the medication [1%] C. Stop taking the medication immediately [52%] D. This is a common side effect that will subside with repeated use of the medication [22%]

Explanation Choice A is correct. The patient should be instructed to swallow the capsules without chewing, as the medication in the capsules will cause numbness of the throat and tongue. Benzonatate is a popular antitussive. It does not act on the cough center. Instead, benzonatate has an anesthetic-like effect on stretch receptors in the lung, which interrupts the cough "message." Choices B and C are incorrect. The decision to change the dose of a medication or to discontinue its use is up to the physician, not the nurse. Choice D is incorrect. Numbness of the tongue and throat is not a common side effect of the use of Benzonatate. Rather, it occurs when the capsule is chewed and the tongue and throat are subjected to the medication within the capsule. This is why the tablet should be swallowed, not chewed. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse is caring for assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, it would be essential to follow up with which of the following clients? A. P: 109; R: 26; BP: 110/70 mmHg [38%] B. P: 90; R: 12; BP: 99/54 mmHg [26%] C. P: 100; R: 18; BP: 178/98 mmHg [30%] D. P: 88; R: 14; BP: 166/52 mmHg [6%]

Explanation Choice A is correct. The pulse and respiration rate of this client is quite concerning. Tachycardia and tachypnea may be suggested for various emergent situations such as shock. The nurse should follow up with this client first because of the tachycardia and tachypnea. Choices B, C, and D are incorrect. Each client has an altered vital sign. However, none of the vital signs are life-threatening compared to the correct response. The nurse should always attend to the unstable client, and part of that determination is assessing vital signs. Learning Objective Recognize the normal vital signs in an adult, deviations from the normal, and those that need urgent attention. Additional Info Vital signs are essential in determining a client's clinical stability. Tachycardia (heart rate greater than 100 beats per minute) may be a warning sign for shock. This also could be found in a client experiencing pain, hyperglycemia, hypoglycemia, or anxiety. Tachycardia is the earliest sign of a client developing shock. Tachypnea (respiratory rate greater than 20) may be an expected finding in some pathologies (asthma exacerbation, COPD), but when combined with tachycardia, this is quite concerning.

The patient recovering from hip surgery needs to regain strength in order to climb the flight of stairs leading to their bedroom at home. The nurse would expect which facility staff member to treat this patient's physical disability? A. Physical therapist [80%] B. Nutritionist [0%] C. Case Manager [1%] D. Occupational therapist [19%]

Explanation Choice A is correct. This patient, who has recently had major surgery that will affect their strength and ability to move, will most benefit from the services of a physical therapist. Physical therapists work to test, examine, and treat disabilities. Choice B is incorrect. A nutritionist cannot help this patient with their strength and ability to climb stairs. A nutritionist helps to plan meals for the patient and provides education on well-rounded diets. Choice C is incorrect. A case manager is responsible for coordinating a patient's care at admission and after discharge. This health care professional is not the best option to help a patient regain mobility. Choice D is incorrect. Occupational therapists help patients develop skills and use assistive devices to manage activities of daily living. NCSBN client need Topic: Management of Care: Delegation

A 32-year-old man comes into the emergency department after being hit by a baseball bat in his chest. The nurse would suspect a pneumothorax because of which sign? A. Decreased respiratory rate [3%] B. Diminished breath sounds [59%] C. Presence of a barrel chest [11%] D. A sucking sound at the injury site [27%]

Explanation Choice B is correct. A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema. Choice A is incorrect. The client who has a pneumothorax would display tachypnea (an increase in respiratory rate), not a decrease in respiratory rate. Choice C is incorrect. A barrel chest would indicate emphysema, a form of COPD. Patients with pneumothorax do not exhibit a barrel chest. Choice D is incorrect. The client's injuries are from a blunt object; therefore, the resulting pneumothorax would be a closed one. A sucking sound at the site of injury would denote an open chest injury.

The nurse is taking care of a pregnant client in her first trimester and notes that her serum potassium level is at 2.9 mEq/L. Which factor in the assessment findings could have caused this? A. Alcohol consumption during pregnancy [4%] B. Hyperemesis gravidarum [89%] C. Zero weight gain since the beginning of pregnancy [1%] D. Food aversions [5%]

Explanation Choice B is correct. A serum potassium level of 2.9 mEq/L indicates hypokalemia. Some common causes of hypokalemia include inappropriate use of diuretics, diarrhea, renal impairment, and severe vomiting brought about by hyperemesis gravidarum (as in this case). Alcohol consumption during pregnancy can cause miscarriage, stillbirth, and lifelong impairment or disabilities (Choice A is incorrect). A woman's inability to gain weight in the first trimester may be caused by food aversions but is unlikely to lead to severe potassium loss (Choice C is incorrect). Food aversions may cause a woman to feel weak and sick in the first trimester but is also unlikely to lead to hypokalemia (Choice D is incorrect).

The nurse is caring for a client who is two years old. The nurse should plan care knowing that this client is in which stage of Erikson's stages of psychosocial development? A. Initiative vs. Guilt [11%] B. Autonomy vs. Shame and Doubt [68%] C. Industry vs. Inferiority [3%] D. Trust vs. Mistrust [18%]

Explanation Choice B is correct. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is what the nurse would expect for her 2-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, leading to a sense of autonomy. When they are not successful, they think they are a failure, resulting in shame and self-doubt. Choice A is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, not your 2-year-old patient. In Initiative vs. Guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty. Choice C is incorrect. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds, not your 2-year-old patient. Children need to cope with new social and academic demands in this stage. When they are successful with this, they feel competent and achieve in the industry. When they are not successful, they handle failure, resulting in inferiority. Choice D is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months, not your 2-year-old patient. Children develop a sense of trust in this stage when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust.

The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis? A. Basic metabolic panel (BMP) [5%] B. B-type natriuretic peptide (BNP) [67%] C. Lipid profile [2%] D. Troponin [26%]

Explanation Choice B is correct. B-type natriuretic peptide (BNP) is a commonly ordered test for clients who may have heart failure. Elevations indicate worsening of heart failure as it is indicative of fluid retention. Choices A and C are incorrect. BMP and lipid profile tests are incorrect to confirm the diagnosis. Choice D is incorrect. A troponin laboratory test would be prescribed for acute coronary syndrome (ACS).

The nurse is taking care of a client who is being weaned from parenteral nutrition (PN) and is expected to begin receiving solid food today. The ongoing solution is currently running at 100 mL/hr. When the physician writes the order for oral diet, which order regarding the PN should the nurse anticipate being included? A. Discontinue the PN once the patient is taking solid food. [16%] B. Decrease the rate of PN by 30 mL/hr every 2 hours until zero. [67%] C. Start 0.9% normal saline at 30 mL/hr. [8%] D. Continue current infusion rate orders for PN. [8%]

Explanation Choice B is correct. Discontinuing PN abruptly may cause hypoglycemia, and for this reason, the PN infusion rate should be decreased gradually until the solution is finally turned off. Clients who have been on PN usually develop anorexia after being without food for some time, and the digestive tract may not be able to produce the enzymes needed for digestion all at once. Choice A is incorrect. Tapering off the infusion of PN allows the client to be adequately nourished during the transition to a healthy diet and prevents the occurrence of hypoglycemia. Choice C is incorrect. Normal saline is not the appropriate IV fluid of choice because it does not contain glucose and may also cause hypoglycemia. Choice D is incorrect. This is inappropriate and does not follow nutrition orders.

The nurse works on a medical/surgical unit and cares for a patient receiving digoxin and furosemide. Which of the following, if reported by the patient, must be assessed immediately? A. Night sweats and headache. [3%] B. Vomiting and halos around lights. [79%] C. Stomach upset and headache. [2%] D. Low blood pressure and dark urine. [15%]

Explanation Choice B is correct. Furosemide causes the patient to lose potassium. Digoxin, if taken when the patient has a low potassium level, can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. Furosemide and digoxin are often used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Patients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats. Choices A and C are incorrect. While night sweats, headaches, and upset stomach are essential symptoms and should not be ignored; these symptoms are not the most urgent symptoms that need to be assessed. Choice D is incorrect. Low blood pressure and dark urine are symptoms of dehydration. These symptoms should be assessed, but are not the most urgent.

The nurse is taking care of an 8-hour post-operative spinal surgery client. What should be the priority nursing intervention for the client? A. Assess how much opioid analgesics the client is using via the patient-controlled analgesia (PCA) pump. [24%] B. Logroll the client with three staff when turning the client from side to side. [61%] C. Assist the client in ambulating to the bathroom. [5%] D. Place pillows under the thighs of each leg when the client is in the supine position. [10%]

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

Which of the following conditions would be a possible cause of hyperactive bowel sounds? A. Paralytic ileus [15%] B. Gastroenteritis [68%] C. Late bowel obstruction [8%] D. Peritonitis [8%]

Explanation Choice B is correct. Of the options listed, gastroenteritis would be the only possible cause of hyperactive bowel sounds. Choice A is incorrect. Paralytic ileus would result in hypoactive (diminished) bowel sounds, not hyperactive. Choice C is incorrect. Late bowel obstruction would be associated with hypoactive or absent bowel sounds. Choice D is incorrect. Peritonitis would result in diminished bowel sounds due to inflammation. NCSBN Client Need Topic: Adult health - Gastrointestinal, Subtopic: potential for alterations in body systems, system-specific assessments

The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)? A. Valacyclovir [26%] B. Oseltamivir [40%] C. Azithromycin [28%] D. Ranitidine [6%]

Explanation Choice B is correct. Oseltamivir is an antiviral agent approved for the treatment of influenza. This medication should be initiated within 48 hours of symptom onset. Choices A, C, and D are incorrect. Valacyclovir is an antiviral indicated in the treatment of the herpes virus. This medication does not have efficacy in influenza. Azithromycin is an antibiotic quite effective for respiratory infections; this medication is not used in influenza infections. Ranitidine is a histamine-2 receptor blocker indicated for the treatment of allergic reactions and gastric reflux. Additional information: Influenza is a highly contagious respiratory infection. Appropriate infection control, which includes isolating the client using contact and droplet precautions. Meticulous hand hygiene should be reinforced, including alcohol-based hand sanitizers before and after client care. Medical management is aimed at providing symptomatic care by using prescribed antipyretics. Antivirals may be used to shorten the duration of the illness; the guideline is to initiate oseltamivir 48 hours within influenza symptom onset. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Expected actions/outcomes

The nurse is talking to a group of female teenagers regarding the dangers associated with human papilloma virus. Which cancer mentioned by the group would indicate an understanding of the topic? A. Neuroblastoma [1%] B. Cervical cancer [97%] C. Osteoblastoma [1%] D. Osteosarcoma [1%]

Explanation Choice B is correct. The client with HPV has a higher risk for cervical and vaginal cancer. Choice A is incorrect. This type of cancer is not related to exposure to HPV. Choice C is incorrect. This type of cancer is not related to exposure to HPV. Choice D is incorrect. This type of cancer is not related to exposure to HPV.

The nurse is caring for a bedbound patient. Which preventative intervention would decrease the risk of this patient developing contractures? A. Apply bilateral SCDs [6%] B. Perform passive range of motion exercises [86%] C. Obtain a low air loss mattress [3%] D. Apply traction to the affected extremity [5%]

Explanation Choice B is correct. The contracture describes tightness/resistance of a muscle or joint due to soft tissue fibrosis and shortening of muscles and ligaments. Contractures commonly occur due to immobility and incorrect positioning of the immobilized extremity. Performing passive range of motion exercises decreases the risk of contractures by allowing the muscles to stretch and retain flexibility. Choice A is incorrect. Sequential compression devices (SCDs) are a preventative measure to decrease the risk of the patient developing blood clots, not contractures. Choice C is incorrect. A low air loss mattress may be appropriate for this patient but will reduce the risk of pressure injury, not contracture. Choice D is incorrect. Traction is used to immobilize an injured extremity, decrease pain/muscle spasms, and align wounded bones. Contractures occur due to immobility of an extremity, so traction would be inappropriate. NCSBN Client Need Topic: Musculoskeletal, Subtopic: immobility, non-pharmacological comfort interventions, the potential for complications from health alterations, illness management

A nursing student is currently learning about domestic violence and wonders why the abused individual cannot "just quickly get out of the relationship." Which theoretical model helps in explaining the cyclical and progressive nature of domestic and spousal abuse? A. The Cycle of Abuse and Neglect [37%] B. The Cycle of Violence [43%] C. The Cycle of Impaired Couples [7%] D. The Duluth Model [13%]

Explanation Choice B is correct. The cycle of violence is a model developed in 1979 by Lenore Walker to explain the co-existence of disorder with love. It may be tough for those who have never experienced domestic abuse to understand why it is difficult for an abused individual to "just quickly leave" the relationship. Understanding the cycle of violence may help plan appropriate interventions to break the cycle and stop domestic violence. Violence often occurs in a repetitive cycle and usually consists of three phases: (1) the Tension phase, (2) the Acute explosion phase (Crisis phase), and (3) the Honeymoon Phase (calm phase). In the first phase (tension-building), the abuser gets angry, argumentative, and starts threatening. Minor fights may occur. In this phase, victims often report a feeling of walking on eggshells. As the period progresses, tension continues to build. In the second phase (explosion/crisis), significant verbal or physical abuse will occur. Major violent acts such as physical or sexual attacks will follow and may result in injury. In the third phase (Calm phase or Honeymoon period), the abuser expresses sorrow and feelings of guilt. The abuser shows love and promises to change and get himself/herself help. The victim feels like things are getting much better, but the phase does not last. The cycle starts all over again and the three steps repeat over time. It is, therefore, hard to end an abusive relationship since the three phases of love, hope, and fear, keep the cycle moving. The cycle is progressive as well. With every period, the abuse may get worse during the explosion phase. Choices A and C are incorrect. These cycles are non-existent and do not predict the progressive nature of domestic abuse. Choice D is incorrect. The Duluth Domestic Abuse Intervention Project, also called "the Duluth Model," is a model that was developed in the 1980s for guiding intervention in domestic violence. Contrary to the cycle of violence, the Duluth model maintains that the force is not cyclical but constant. The acts of violence are intentional and the motivation for violence is to exert power and control over the victim. The image below shows the "Power and Control" wheel put forward by the Duluth Model. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Abuse/Neglect

The nurse cares for an infant undergoing a surgical repair of a total anomalous pulmonary venous return tomorrow. The doctor has talked to the parents and obtained consent. The mother tells the nurse, "I'm not so sure about this. What if my baby dies?" The nurse's most appropriate response is: A. Explain the procedure to the mother. [10%] B. Notify the surgical team and have them come back to speak with the mother again. [87%] C. Reassure the mother that everything will go as planned. [3%] D. Tell the mother that because she has already signed the consent, she cannot change her mind now. [0%]

Explanation Choice B is correct. The nurse has identified that the mother has concerns about the surgery, so it is her responsibility to notify the surgical team and have them come back to speak with the mother. Choice A is incorrect. It is not the responsibility of the nurse to explain the surgical procedure to the mother. This would be acting outside of her scope of practice and would not be appropriate. The surgeon/surgical team doing the procedure should be the one explaining it again to the mother. Choice C is incorrect. It is not appropriate to reassure the mother that everything will go as planned. There are always risks involved with the surgery, so it would be inappropriate to make such statements. Choice D is incorrect. It is not appropriate to tell the mother that she cannot change her mind because she has already signed the consent paperwork. The child's legal guardian does have the ability to change their mind and should not be discouraged from asking questions. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Ethics

A 78-year-old woman is brought to the emergency department for the treatment of a fractured arm. On physical assessment, the nurse notices old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client reluctantly tells the nurse that her son frequently hits her if supper is not ready when he gets home from work. Which of the following is the most appropriate nursing response? A. "Oh, really. Let me talk to your son." [0%] B. "I appreciate your honesty, but this is a legal issue, and I must tell you that I will need to report it." [86%] C. "Let's talk about the ways you can manage your time to prevent your son from getting upset." [4%] D. "Do you have any friends that can help you out or keep you safe until you resolve these important issues with your son?"

Explanation Choice B is correct. The nurse must report situations related to child or elder abuse (as in this case), gunshot wounds, criminal acts, and certain infectious diseases. Nurses must refrain from discussing confidential issues with nonmedical personnel or the client's family or friends without the client's permission. Clients are assured that information is kept confidential unless it places the nurse under a legal obligation. Choices A, C, and D are incorrect. These responses do not address the legal implications of the situation and do not ensure a safe environment for the client.

A client is at the clinic for hypersensitivity testing with the intradermal technique. The proper technique of administering the allergen would be to position the needle: A. At 0 degrees against the skin [8%] B. At 15 degrees insertion [76%] C. At 45 degrees [9%] D. At 90 degrees with a dart-like motion [7%]

Explanation Choice B is correct. The proper angle for intradermal injections is 15 degrees. Choices A, C, and D are incorrect. A 45-degree perspective is used for subcutaneous injections, while a 90-degree angle is used for intramuscular injections. There are no injections administered at a 0-degree angle.

While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor? A. A spinal cord injury at age 12 [18%] B. An upper respiratory infection about a month ago [72%] C. Hydrocephaly as an infant [7%] D. A joint injury as a teenager [3%]

Explanation Choice B is correct. Upper respiratory infections or stomach infections correlate with the development of Guillain-Barre syndrome. Guillain-Barre syndrome is a disorder that involves the peripheral and cranial nerves causing ascending paralysis. Choice A is incorrect. Spinal cord injuries are not generally associated with Guillain-Barre syndrome. Choice C is incorrect. Hydrocephaly, as an infant, is not associated with Guillain-Barre syndrome. Hydrocephaly refers to the enlargement of the ventricles. Choice D is incorrect. Joint injuries are not associated with Guillain-Barre syndrome. NCSBN client need Topic: Physiologic Integrity, Physiological adaptation

The patient has just arrived for her initial physical examination of her new pregnancy. She received a positive pregnancy test two days ago and is three days late for her period. She asks about the following tests and procedures. She is wondering when they will be performed. The nurse would be correct in explaining which assessment will likely not be completed at this time? A. Calculation of body mass index (BMI) [5%] B. Evaluation of areas prone to edema such as the hands, face, and ankles [17%] C. Fetal doppler assessment [63%] D. Pelvic examination [15%]

Explanation Choice C is correct. A fetal doppler assessment will not be performed this early in the pregnancy. If this woman is only three days late for her period, she is between 4 and 5 weeks pregnant. Fetal heart tones cannot be heard with the doppler until about 10 - 12 weeks. Choices A, B, and D are incorrect. Calculation of body mass index, the evaluation of areas prone to swelling, and a pelvic examination are performed at the first prenatal appointment to determine the mother's baseline health status and to develop the best plan of care. NCSBN client need Topic: Health Promotion and Maintenance, Ante / Intra / Post Partum Care

The nurse is assessing a client who is newly diagnosed with irritable bowel syndrome (IBS). Which of the following findings is consistent with this diagnosis? A. Unexplained weight loss [8%] B. Epigastric pain and nausea [15%] C. Alternating constipation and diarrhea [73%] D. Low-grade fever and fatigue [4%]

Explanation Choice C is correct. Alternating constipation and diarrhea are the hallmark manifestations associated with irritable bowel syndrome (IBS). Choices A, B, and D are incorrect. Unexplained weight loss is a finding associated with multiple diseases, including colon cancer. This is not a finding relevant to IBS. Epigastric pain and nausea may be a symptom associated with pancreatitis. Finally, IBS is not an infectious process, and a fever is not an accurate clinical finding. Additional Info IBS is a disorder that manifests with alternating periods of constipation and diarrhea. While some clients may have one symptom over another, the disorder is associated with pain with defection (or after defecation), excessive flatulence, and abdominal bloating. The symptoms may relapse and remit and can be triggered by stress or food. Treatment is symptomatic with an emphasis on preventing the occurrence of triggers.

The nurse is attending to a client who is 20 weeks pregnant and has completed patient education. Which of the following statements by the client indicates that she has a good understanding of her baby's development? A. "My baby is able to breathe now." [20%] B. "My baby can open his eyes." [13%] C. "My baby is about 7 ½ inches long." [46%] D. "My baby has fully grown fingernails." [21%]

Explanation Choice C is correct. By 20 weeks gestation, the fetus is approximately 20 cm long or 7 ½ inches. This statement reflects a proper understanding of the mother regarding fetal development and does not require further teaching. Choices A, B, and D are incorrect. There are several stages of fetal development. Pregnancy comprises the first, second, and third trimesters. In the first trimester, critical events include changes to the fertilized cell and the development of major organs and structures. During the second trimester, the organs and structures continue to develop and the woman becomes more aware of the growing fetus. During the third trimester, the fetus gains weight, matures, and prepares for life outside of the uterus. Fetal lungs do not begin the movements of respiration until 24 weeks. The placenta provides oxygen to the fetus, and the developmental function of the lungs for breathing does not occur until birth; therefore, the statement in choice A needs further teaching. The fetus can open its eyes at 28 weeks gestation, not at 20 weeks; therefore, the statement in choice B needs further teaching. Fingernails begin to grow at ten weeks gestation but are not complete until 38 weeks; therefore, the statement in choice D needs further teaching. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Human Reproduction and Fetal Development

A nurse in the emergency department of a children's hospital is triaging patients. Which patient should the nurse arrange for the doctor to see first? A. A febrile 8-year-old girl complaining of pain during urination. [3%] B. A child diagnosed with leukemia displaying petechiae. [6%] C. A child diagnosed with acute epiglottitis two days ago and is drooling. [89%] D. A child with otitis media having fever. [2%]

Explanation Choice C is correct. Drooling in epiglottitis means that the child is having difficulty swallowing. This increases the risk of airway compromise. This patient should be seen by a physician immediately, and an emergency bedside tracheostomy prepared. Choice A is incorrect. A child with a urinary tract infection is expected to display dysuria and fever. This client should not be a priority over a patient in an emergency. Choice B is incorrect. The child diagnosed with leukemia is expected to have petechiae. This client should not be a priority over a patient in an emergency. Choice D is incorrect. A child with otitis media is expected to have a fever. This client should not be a priority over a patient in an emergency.

The nurse is planning a staff development conference about medication reconciliation. Which of the following information should the nurse include? A. Medication reconciliation should occur just at discharge to prevent omissions. [3%] B. Prescribed medications should be obtained and omit herbs and supplements. [2%] C. This process should occur at admission, client transfer, and discharge. [90%] D. Obtain a list of the medications instead of reviewing the list with the client [5%]

Explanation Choice C is correct. Medication reconciliation was designed to prevent omission and duplicate errors related to medication administration. Choice A, B, and D are incorrect. This process should occur at admission, transfer, and discharge - not just at discharge. The medications that should be obtained should be the prescribed and over-the-counter medications. This process should involve the client as they should confirm their adherence to the medication. Additional Info Medication reconciliation is an essential process designed to promote client safety. The client's complete list of medications (including over-the-counter medications) should be collected during this process. This process should occur at admission, client transfer, and discharge. The nurse must obtain the most recent medications from the client and their adherence (for example, a client is prescribed omeprazole, but the client indicates that they do not take the medication). This process should be thorough and involve the client.

The nurse is administering phosphate excreting medications to her patient with hypocalcemia because she understands what core information about calcium and phosphorous? A. As phosphorous exits the body so does calcium. [5%] B. Calcium is managed by the excretion of phosphorous. [9%] C. When serum phosphorous decreases, serum calcium increases. [83%] D. Phosphorous must be above 4.5 mg/dL before calcium can increase. [2%]

Explanation Choice C is correct. Phosphorous and calcium have an inverse relationship, meaning that as one level rises, the other decreases. Since this patient has hypocalcemia or low calcium, decreasing serum phosphorus through phosphate secreting medications will inversely increase serum calcium. Choices A, B, and D are not correct. These would not occur. NCSBN client need Topic: Physiologic Adaptation: Fluid and Electrolyte Imbalances

The nurse is helping a client with a chest tube ambulate to the bathroom. The client turns suddenly and the chest tube becomes dislodged. What is the priority action for the nurse to take? A. Immediately re-insert the tube and call for help. [2%] B. Place your hand over the chest tube site and yell for help. [14%] C. Place a sterile dressing taped on three sides over the chest tube site and call for help. [83%] D. Monitor the patient's vital signs while he finishes ambulating to the bathroom and then call for help. [1%]

Explanation Choice C is correct. Placing a sterile dressing that is taped on three sides over the chest tube site and calling for help would be the appropriate actions. By placing a sterile dressing over the site the nurse follows infection prevention. By taping the dressing on three sides the dressing will cover the site; this will prevent a tension pneumothorax by allowing exhaled air to escape the dressing. The nurse should then immediately call for help. Choice A is incorrect. Under no condition should the nurse ever reinsert the chest tube. This is not in the scope of practice of the nurse and it is not safe to insert a dirty item into the chest cavity of the client. Choice B is incorrect. It is not appropriate for the nurse to place their hand over the chest tube site. The chest tube site leads directly into the thoracic cavity of the client, so placing a hand over it is an infection risk. Choice D is incorrect. It is not appropriate to allow the client to finish ambulating to the bathroom and simply monitor the vital signs. Chest tube dislodgement is an emergency that requires immediate action. NCSBN Client Need: Topic: Reduction of Risk Potential; Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures, Respiratory

Which of the following over-the-counter (OTC) medications is Reye's syndrome associated with? A. Acetaminophen [10%] B. Ibuprofen [5%] C. Aspirin [80%] D. Brompheniramine/pseudoephedrine [5%]

Explanation Choice C is correct. Reye's syndrome is a potentially fatal illness that can lead to liver failure and encephalopathy. Virus-infected children who are given aspirin to manage pain, fever, and inflammation are at an increased risk of developing Reye's syndrome. Choice A is incorrect. The use of acetaminophen has not been associated with Reye's syndrome and can be safely given to patients with fever due to viral illnesses. Choice B is incorrect. Ibuprofen's adverse effects include GI irritation and bleeding; in toxic doses, both renal and hepatic failure are reported. However, ibuprofen has not been associated with the onset of Reye's disease. Choice D is incorrect. Brompheniramine/pseudoephedrine contains a first-generation OTC antihistamine and a decongestant. Neither agent has been associated with the development of Reye's syndrome. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse is caring for a client who arrives to the emergency department (ED) complaining of chest pain radiating to the arm. The nurse should do which of the following? Select all that apply. A. Obtain an electrocardiogram (ECG) [32%] B. Prepare the client for prescribed cardioversion [5%] C. Establish intravenous (IV) access [30%] D. Insert an indwelling urinary catheter [2%] E. Administer prescribed nitroglycerin [31%]

Explanation Choices A, C, and E are correct. A client presenting with chest pain radiating to the arm warrants immediate intervention as it could be an acute myocardial infarction. The nurse is correct to obtain an electrocardiogram, establish intravenous access, and administer the prescribed nitroglycerin. Choices B and D are incorrect. Preparing a client for cardioversion is not necessary unless an applicable arrhythmia is present. Finally, inserting a urinary catheter is not required for an individual presenting with angina.

The ER nurse assesses a patient for tactile fremitus. Which would be the correct way to assess for this abnormal finding? A. Percuss the apices in the supraclavicular areas. [8%] B. Instruct the patient to breathe deeply while auscultating both sides of the lungs. [13%] C. Ask the patient to say "ninety-nine" while palpating the chest. [59%] D. Place the hands along the anterolateral wall with thumbs pointing toward the xiphoid process. [19%]

Explanation Choice C is correct. Tactile (vocal) fremitus describes the vibrations that can be palpated through the chest wall during speech. To assess for tactile fremitus, the nurse would place hands over the lung apices in the supraclavicular areas and palpate from one side to the other while the patient repeats "ninety-nine" to compare vibrations. If vibrations are uneven, it may indicate pneumothorax, inflamed lung tissue, or fluid build-up. Choice A is incorrect. This would be the correct hand placement, however, assessing tactile fremitus involves no percussing. Choice B is incorrect. Assessing for tactile fremitus involves palpating for vibrations during speech, not auscultating. Choice D is incorrect. This would be the correct process for assessing the costal angle and symmetric chest expansion, not to assess for tactile fremitus.

The UAP reports to the nurse that the patient who is on oxygen is presenting with a profusely bloody nose. The patient has been on warfarin for atrial fibrillation. Which action would be the highest priority? A. Instruct the UAP to offer oral and nasal care to help with dryness. [1%] B. Notify the physician so the scheduled warfarin can be held. [24%] C. Assess the client and look for bruising, bloody stools, and bleeding gums. [68%] D. Obtain a bubbler to humidify the oxygen. [7%]

Explanation Choice C is correct. The nurse's priority action should be to assess the patient and determine if there are any other sources of bleeding. For a patient on anticoagulation, assuming that a dry nose is the only reason for profuse nasal bleeding before assessing the patient is unacceptable. Choice A is incorrect. The nurse should assess this patient, not re-send the UAP. The nurse cannot assume that the bleeding is due to nasal passage dryness alone, so the patient needs to have an assessment completed to determine the reason. If the evaluation reveals no other sites of bleeding, and if the INR returns within the therapeutic range, it can be presumed that the nasal dryness alone is the cause of such localized bleeding. Choice B is incorrect. The nurse should not call the physician until completing at least a focused assessment of the patient and current problems. If the INR is supratherapeutic and warfarin is suspected to be causing the bleeding, holding warfarin may be appropriate but would not be the highest priority at this time. Assessing for other bleeding sites and clarifying the etiology is the most crucial next intervention. Choice D is incorrect. A bubbler helps to humidify the dry air and oxygen delivered via a nasal cannula or face mask. The nurse cannot assume that the bleeding is due to nasal passage dryness, so the patient needs to have an assessment completed to determine the reason.

Your client is a 50-year-old man who sustained an air embolism after the placement of a central venous catheter. You realize the patient was not properly positioned during the procedure. Which of the following could have prevented this incident from happening?

Explanation Choice C is correct. This image shows the Trendelenburg position. In this position, the body is supine, or flat on the back, on a 15-30 degree incline with the feet elevated above the head. This position is used to prevent air embolism during central venous cannulation. When placing and removing central venous catheters, the CVP should be raised (to decrease the pressure gradient) by placing the patient in the Trendelenburg position. It should also be ensured that patients are adequately hydrated to prevent hypovolemia and to increase CVP. The Trendelenburg position is also used to increase the venous blood return to the heart when a client is affected with hypotension, hypovolemia, or shock. Choice A is incorrect. This image represents a supine position. Choice B is incorrect. This image represents a prone position. Choice D is incorrect. This image represents a Fowler's position in which the head of the bed is elevated to a 45 - 60 degrees angle.

An emergency department nurse is taking care of a 68-year-old female after she fell. The paramedics said that she was on the bathroom floor for approximately 10 hours. The nurse is straight catheterizing the patient for a urine sample when she notices the amount of urine reaches 800 mL. The urine is still flowing heavily. What action should the nurse take and why? A. Drain the patient's bladder entirely and place a small amount in a urine specimen cup. This patient needs a urine sample to check for rhabdomyolysis. [27%] B. Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output. [18%] C. Stop draining the patient's bladder because the patient is at risk for developing bladder spasms. [31%] D. Stop draining the patient's bladder and consult the physician for further instructions. [24%]

Explanation Choice C is correct. This patient is at risk of developing bladder spasms if the bladder is completely drained. Anything over 800 mL that is drained out at one time puts the patient at risk for developing bladder spasms since there is not enough time to adjust from being abundant to shrinking. Choice A is incorrect. If the patient's entire bladder is drained at once, it can develop spasms. Choice B is incorrect. The patient's bladder should not be fully drained. Choice D is incorrect. The nurse does not need to consult the physician in this situation. The bladder can be drained after waiting approximately 30-60 minutes. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Complications from Surgical Procedures and Health Alterations, Renal and Urologic Problems

The nurse is visiting an older adult client with impaired vision. It would be necessary for the nurse to follow up if the client states which of the following? Select all that apply. A. "I secured my throw rugs to the floor with tape." [32%] B. "I switched to using an electric shaver instead of a razor." [5%] C. "I usually sit in a recliner while I listen to the television." [11%] D. "I use different shaped containers with lids to organize my medications." [11%] E. "I use the upstairs bathroom instead of the one downstairs." [41%]

Explanation Choices A and E are correct. An older patient with impaired vision that lives alone has significant risk factors for falls. The nurse should follow up if the client states that they secured the scattered rugs with tape. The client should not have any scattered rugs. Finally, a client climbing the stairs to use the bathroom increases the risk of falls. The nurse should advise the patient to use the closest bathroom. Choices B, C, and D are incorrect. It is appropriate for a client to use an electric shaver versus manual shaving because of the lessened risk of injury. Reclining while watching television poses no threat to the client, and the client should be encouraged to use different shaped containers to organize their medications. Additional Info The nurse must recognize fall risk factors, including older age, sensory impairments, ambulation device(s), incontinence, and certain medications (antihypertensives, benzodiazepines, opioids). The nurse must work to reduce the client's risk of injury if these risk factors are present.

The nurse is caring for a client with urge incontinence. Which of the following actions would be appropriate for the nurse to take? A. Administer prophylactic antibiotics. [3%] B. Teach the client intermittent self-catheterization. [8%] C. Have the client void on a timed schedule. [88%] D. Provide caffeinated beverages with meals. [1%]

Explanation Choice C is correct. Urge incontinence is also known as overactive bladder (OAB). The essential manifestation of this incontinence is the involuntary loss of urine associated with a strong desire to urinate. Thus, it would be appropriate for a client to void on a timed schedule. Timed voiding enables an individual to gradually increase the amount of urine they may hold without an abrupt urge to go to the bathroom. The goal is also to prolong the time interval between urinating - up to a minimum of three or more hours. Choices A, B, and D are incorrect. Prophylactic antibiotics are not indicated for OAB ( Choice A). Instead, it is an intervention indicated for an individual at substantial risk for cystitis secondary to an invasive procedure. Teaching intermittent self-catheterization is an intervention for a client with a flaccid or spastic bladder ( Choice B). Intermittent self-catheterization is also indicated in clients with chronic urinary retention, not OAB. Bladder irritants such as caffeine and alcohol should be avoided because this triggers more urgency to void ( Choice D). Learning Objective Understand that timed voiding is an effective strategy used in treating urge incontinence. Additional Info Overactive bladder (OAB) / Urge incontinence is the involuntary loss of urine associated with a strong desire to urinate and the inability to suppress the signal from the bladder muscle to the brain that it is time to urinate. This may be idiopathic or caused by neurologic disorders, such as stroke, benign prostatic hypertrophy, or bladder inflammation or infection. The treatment for this incontinence involves Bladder training Pelvis muscle therapy Weight reduction Avoiding bladder irritants, such as caffeine and alcohol Smoking cessation Medications: anticholinergics, tricyclic antidepressants with anticholinergic and alpha-adrenergic agonist activity, beta-adrenergic agonists, and onabotulinumtoxinA Electrical stimulation device

Upon entering a patient's room, the nurse finds the patient lying on the floor of the bathroom. When documenting the incident on the patient's medical record, the nurse should include all of the following information, except? A. Provide an objective description of what happened. [27%] B. Report what the nurse observed. [13%] C. Note that an occurrence report was completed. [48%] D. Describe follow-up actions taken. [11%]

Explanation Choice C is correct. When documenting an incident, you do not mention the occurrence report in the patient's medical record. In the chart, you would provide an objective description of what happened citing your observations, and then describe the follow-up actions taken. Choices A, B, and D are incorrect. These are components of the incident report that should be included. Therefore, these are incorrect answers to the question being asked.

A breastfeeding mother is struggling to care for her infant with lactose intolerance. Which of the following foods should the mother avoid? A. Leafy greens [1%] B. Red meats [3%] C. Yogurt [91%] D. Wheat rolls [5%]

Explanation Choice C is correct. Yogurt is a dairy product and therefore contains lactose. Breastfeeding mothers with infants who are lactose intolerant should avoid dairy products such as cheese, milk, and yogurt. Choice A is incorrect. Leafy greens do not contain lactose and do not need to be avoided by the mother nursing a lactose intolerant infant. Choice B is incorrect. Red meat does not contain lactose and does not need to be avoided by the mother nursing a lactose intolerant infant. Choice D is incorrect. Wheat rolls generally do not contain lactose and do not need to be avoided by the mother nursing a lactose intolerant infant. NCSBN client need Topic: Physiological Integrity, Basic Care and Comfort

While reviewing the principles of pain management, the nurse understands which of the following terms is synonymous with an "analgesic"? A. Equianalgesic [28%] B. Placebo [3%] C. NSAID [44%] D. Adjuvant [24%]

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

When the nurse notes an irregular radial pulse in a client, further evaluation should include assessing for which of the following? A. The carotid pulse [22%] B. Diminished peripheral circulation [26%] C. The brachial pulse [17%] D. A pulse deficit [34%]

Explanation Choice D is correct. Assessing for a pulse deficit provides an indirect evaluation of the heart's ability to eject enough blood to produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse. Choices A and C are incorrect. If the pulse is irregular, the correct protocol is to assess for a pulse deficit, which means measuring the apical and radial pulses simultaneously. Choice B is incorrect. Diminished peripheral circulation is not the correct assessment. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Pulse

When observing a patient on antivirals. The nurse notices the patient has developed bruising. This could indicate which of the following? A. The patient is being abused by a family member. [5%] B. The patient is experiencing minor adverse reactions [29%] C. The patient is not taking the medications as ordered. [2%] D. The patient may be experiencing bone marrow suppression. [64%]

Explanation Choice D is correct. Bruising or bleeding when taking antivirals could indicate possible bone marrow suppression and may require dosage adjustments or a medication change. Choice A is incorrect. While abuse of any patient is a possibility, the question is regarding the use of antivirals and the symptom of bruising, which is an indication of bone marrow suppression. Choice B is incorrect. Bruising is not an adverse reaction, but may be an indication of something more serious. Choice C is incorrect. While the patient may not be taking the medication correctly, the most appropriate answer is choice D. The nurse should ask the patient to clarify how much medicine he/she is taking and how often. However, the most likely source of bruising (among these answers) is the suppression of bone marrow. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse performs a focused assessment on a casted patient experiencing increased pain in the affected limb. The nurse notes pallor and swelling distal to the cast area. The patient reports increased pain upon passively moving the extremity. Which of the following fracture-related complications should the nurse be concerned about? A. Fat embolism [7%] B. Infection [2%] C. Pulmonary embolism [2%] D. Compartment syndrome [89%]

Explanation Choice D is correct. Compartment syndrome occurs when pressure increases in one area of the fascia groups around the muscle, causing a decrease in blood flow to the other parts of the affected limb. Compartment syndrome is identified by increasing pain in the affected limb, passive pain when moved, and pale swollen tissue distal to the site. Quick diagnosis is essential in compartment syndrome because permanent damage can occur to the tissue within 4 to 6 hours. Choice A is incorrect. A fat embolism is a complication of a fracture that occurs when a fat globule from the bone marrow is released into the blood system. This complication generally occurs within 48 to 72 hours after the injury. Choice B is incorrect. A disease related to a breach can occur at any time during the healing process. While infection, usually osteomyelitis, is a complication of a fracture, it results in red and swollen skin, an elevated temperature, and some pain. Choice C is incorrect. A pulmonary embolism can occur because of a fracture but presents with chest pain and shortness of breath rather than problems at the fracture site. NCSBN client need Topic: Physiological integrity, reduction of risk potential

Select the hazard of immobility and complete bed rest that is accurately paired with one of its preventive measures. A. Renal calculi: Treatment to increase urinary alkalinity [8%] B. Hypocalcemia: Calcium supplementation [65%] C. Venous dilation: The application of heat [11%] D. Hypercalcemia: A tilt table [16%]

Explanation Choice D is correct. Hypercalcemia is a major hazard of immobility and complete bed rest. Demineralization of the bones occurs during periods of immobility and complete bed rest. Calcium and phosphate move out of the bones into the blood causing hypercalcemia. In clients who are too weak to stand up on their own, the use of a tilt table to provides early weight-bearing in the lower limbs prevents demineralization and reduces the risk of hypercalcemia. Other physiotherapy uses of tilt table include prevention of osteoporosis and pathological fractures, postural improvement, and enhancement of bowel/ bladder function. Choice A is incorrect. Renal calculi formation is one of the hazards of immobility and complete bed rest. Prolonged immobility leads to bone demineralization. Calcium and phosphate move out of the bone, accumulate in the blood, and are then excreted in the urine. Following an average of 5 weeks of bed rest, calcium excretion by the kidneys increase by 50mg/day. Immobile patients also have pooling of the urine in renal calyces. Calcium precipitates in this pooled urine thereby, leading to calcium oxalate stones. However, renal calculi cannot be prevented with measures to increase urinary alkalinity because it is alkaline pH that promotes crystallization of calcium-containing calculi. In patients who can, initiation of light bed exercises and supplementation with potassium-magnesium citrate may help reduce the risk of renal calculi. Choice B is incorrect. Hypocalcemia can certainly be prevented by calcium supplements. However, the question is about the hazard of immobility. Hypercalcemia, not hypocalcemia, is a hazard of immobility. Choice C is incorrect. Venous dilation, a hazard of immobility and complete bed rest, cannot be prevented with the application of heat. Heat is a vasodilator and, as such, would only aggravate the venous dilation.

Which of the following clients is at greatest risk for experiencing impaired vascular perfusion? A. A 76-year-old female client with a history of alcohol abuse. [3%] B. A 76-year-old female client with a history of radon gas exposure. [7%] C. A 64-year-old male client with a history of cigarette smoking. [54%] D. A 64-year-old male client with hypotension. [36%]

Explanation Choice D is correct. Perfusion refers to the continuous supply of blood through the blood vessels to vital organs. The client with hypotension is at the highest risk for impaired vascular perfusion. Hypotension can result from various causes such as adrenal insufficiency, dehydration, hemorrhage, septic shock, obstructive shock, and cardiogenic shock. A Mean Arterial Pressure (MAP) greater than 65 mmHg is essential to maintain perfusion to vital organs. Prolonged hypoperfusion may lead to end-organ damage, such as renal failure and ischemic hepatitis. Therefore, the cause of hypotension must be identified and treated right away. Choices A, B, and C are incorrect. Alcohol abuse, cigarette smoking, and exposure to radon place people at risk for cancer. Prolonged cigarette smoking hastens atherosclerosis, leads to peripheral vascular disease and thereby, impairs perfusion. However, among the listed options, the patient at the greatest risk for impaired perfusion is the one with hypotension. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential

The prenatal client is 7 months pregnant and wants to start an exercise program. The nurse should suggest which of the following exercises to the patient? A. Bike riding [1%] B. Circuit training [3%] C. Aerial yoga [31%] D. Swimming [64%]

Explanation Choice D is correct. Swimming is the best exercise at this point in the mother's pregnancy. Swimming is low impact and requires no balance, which can be troublesome with the weight a woman carries in her third trimester. Choices A, B, and C are incorrect. These activities are too high of an intensity for a woman who is just starting an exercise regimen and require careful steadiness. NCSBN client need Topic: Health Promotion and Maintenance

The nurse has received an assignment of four patients on the Medical-Surgical floor. Which patient should she/he check on first? A. A 61-year-old male patient who is one day post-op from hernia repair with complaints of pain at the incision site. [2%] B. A 68-year-old female patient with type II diabetes who is complaining of stomach discomfort. [1%] C. A 72-year-old male patient with emphysema and a history of uncontrolled hypertension who is complaining of a headache. [15%] D. A 70-year-old female patient who is two days post-op from ankle surgery who complains of feeling some shortness of breath.

Explanation Choice D is correct. The ABCs identify the airway, breathing, and cardiovascular status of the patient as the highest of all priorities in that sequential order. Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the requirements for self-esteem and esteem by others, and the self-actualization needs in that order of priority. Examples of each of these needs, according to Abraham Maslow's Hierarchy of Needs include: Physical and Biological Needs: Some physical needs include the need for the ABCs of the airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene, and elimination. Safety and Psychological Needs: The psychological or emotional, safety, and security needs include needs like low-level stress and anxiety, emotional support, comfort, environmental and medical protection, and emotional and physical security. Love and Belonging: The love and belonging needs reflect the person's innate need for love, belonging, and the acceptance of others. Self Esteem and Esteem by Others: All people have a need to be recognized and respected as a valued person by themselves and by others. People need self-worth, self-esteem, and the esteem of others. Self Actualization: Self-actualization needs to motivate the person to reach their highest level of ability and potential. In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to manage their time effectively; they should avoid unnecessary interruptions, time-wasters, and helping others when this could potentially jeopardize their priorities of care. Choice A is incorrect. Incision site pain is not uncommon, especially one-day post-op. Choice B is incorrect. Stomach discomfort is not an immediate cause of concern and is not a priority among the available answer choices. Choice C is incorrect. An expected symptom of hypertension is a headache. This client complaint is not the most urgent. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Integration of Critical Thinking and Clinical Reasoning

Which lab value alteration is likely a result of corticosteroid treatment in a type 1 diabetic patient diagnosed with pneumonitis? A. Potassium 5.1 mEq/L (5.1 mmol/L) [14%] B. Sodium 138 mEq/L (138 mmol/L) [2%] C. Albumin 3.5 g/dL (5.07 µmol/L) [5%] D. Glucose 200 mg/dL (11.1 mmol/L) [79%]

Explanation Choice D is correct. Type 1 diabetes is characterized by hyperglycemia secondary to the body's inability to create insulin. Corticosteroids cause a rise in blood sugar even in a non-diabetic patient by increasing insulin resistance and triggering the liver to release additional glucose. Prednisone and other steroids can cause a spike in blood sugar levels by making the liver resistant to insulin. Steroids can make the liver less sensitive to insulin because they cause it to keep releasing sugar, even if the pancreas is also releasing insulin. This continued release of sugar triggers the pancreas to stop producing the hormone. Choices A, B, and C are incorrect. Changes in sodium, albumin, and potassium would not be expected findings in this scenario. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort, Disturbances in Fluid Volume, Electrolyte, and Acid-Base Balances

Steroids have many different effects on the body. Which of the following are potential effects of glucocorticoids? Select all that apply. A. Psychosis [15%] B. Immunosuppression [44%] C. Hypoglycemia [14%] D. Hyperkalemia [27%]

Explanation Choices A and B are correct. Glucocorticoids can have severe effects on your patient's mood. Some of the potential mood changes you may observe in your patient are depression, psychosis, euphoria, and insomnia. It is essential to know your patient's baseline and warn them of the potential changes they will experience while taking these medications (Choice A). Glucocorticoids do alter the body's defense mechanism, making them immunosuppressed. This puts them at risk for infections. While your patient is taking glucocorticoids, it is essential to monitor them for infection by watching their temperature, WBCs, and CRP. Any indications of infection should be taken seriously, as it is common for these patients to develop infections quickly (Choice B). Choice C is incorrect. Hyperglycemia, not hypoglycemia, is a potential effect of glucocorticoids. This is because glucocorticoids inhibit insulin. With insulin inhibited, glucose is not transported from the serum into the cells for metabolism and there is an increased level of glucose in the plasma, making the client hyperglycemic. Always monitor your patient's blood glucose levels while they are receiving glucocorticoids. Choice D is incorrect. Glucocorticoids will not affect your patient's potassium levels, but mineralocorticoids will. The mineralocorticoid aldosterone can cause hypokalemia when it is elevated and hyperkalemia when it is decreased. This is due to the fluid volume changes that occur with aldosterone. Glucocorticoids, however, do not have this effect. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Endocrine

The registered nurse is asked to assist the physician with removal of a chest tube. Which steps does the nurse anticipate will occur during the procedure? Select all that apply. A. Placing an occlusive dressing over the site. [41%] B. Asking the client to bear down as the tube is removed. [38%] C. Clamping the chest tube for 30 minutes prior to removal. [11%] D. Placing the drainage system near the head of the bed. [9%]

Explanation Choices A and B are correct. The nurse anticipates placing an occlusive dressing over the site immediately after the chest tube is removed. It is necessary for this dressing to be airtight to prevent any re-entry of air into the pleural space while the chest tube site is healing (Choice A). The nurse anticipates that the client will be instructed to take a deep breath, exhale, and bear down as the physician quickly removes the chest tube. This helps to ensure no air is inhaled into the pleural space while the chest tube is pulled out and occlusive dressing is placed (Choice B). Choice C is incorrect. It is not typical that the chest tube is clamped prior to removal, so the nurse does not anticipate this. A chest tube is considered ready for removal once the lung has fully re-expanded and there is little to no drainage into the chest tube. Once these criteria are met the physician may decide to remove the tube. Choice D is incorrect. It is not appropriate to place the drainage system near the head of the bed. The drainage system should always be placed below the level of the chest tube site to allow gravity to drain contents into the drainage system. If the nurse placed the chest tube drainage system near the head of the bed, contents could flow back into the chest tube site causing issues such as a pleural effusion. NCSBN Client Need: Topic: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures; Subtopic: Adult Health - Respiratory

The nurse is reviewing the concept of third spacing with a new graduate nurse. Which of the following conditions put patients at risk for the development of third-spacing? Select all that apply. A. Burns [45%] B. Gastroenteritis [21%] C. Pediatric patients [9%] D. Alcoholism [25%]

Explanation Choices A and D are correct. Burns are a major cause of third-spacing. In third-spacing, fluid shifts into the interstitial space and remains there. This occurs in burns due to an increased capillary membrane permeability of the injured tissue (Choice A). Alcoholism puts patients at risk for the development of third-spacing. When an injury occurs to the tissue of a patient with chronic alcoholism, they are more likely to develop third spacing into their abdomen, pleural cavity, peritoneal cavity, and pericardial sac when an injury occurs to these tissues. This fluid is then useless because it is not circulating and is unable to provide nutrients to the cells (Choice D). Choice B is incorrect. Gastroenteritis is not a cause of third-spacing. This is a gastrointestinal illness that can cause severe vomiting and diarrhea, but there is no tissue injury leading to third-spacing. Examples of risk factors for third-spacing are kidney disease, major trauma, burns, and sepsis. Choice C is incorrect. Pediatric patients are not more at risk for the development of third-spacing. Geriatric patients on the other hand are indeed at a higher risk for the development of third-spacing into their abdomen, pleural cavity, peritoneal cavity, and pericardial sac when injury occurs to these tissues. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk potential reduction - Fluids & Electrolytes

Which of the following arrhythmias are fatal without immediate intervention? Select all that apply. A. Ventricular fibrillation [39%] B. Ventricular tachycardia with a pulse [15%] C. Wenckebach phenomenon [9%] D. Asystole [37%]

Explanation Choices A and D are correct. Ventricular fibrillation, or v-fib, is a fatal rhythm without immediate intervention. The priority is to defibrillate the patient and initiate CPR between shocks. In this rhythm, the ventricles are just quivering, and there is no productive diastole or systole. This means there is really no cardiac output and the body will be quickly deprived of oxygen if action is not taken (Choice A). Asystole is a fatal rhythm without immediate intervention. It is characterized by a flat line with no rhythm or electrical activity. Since there is no electrical activity present, this is not a shockable rhythm. Instead, CPR should be initiated immediately with high-quality compressions (Choice D). Choice B is incorrect. Ventricular tachycardia is divided into two different rhythms: v-tach with a pulse and pulseless v-tach. As surprising as it may sound, some patients tolerate ventricular tachycardia with a pulse. When you see this rhythm on the monitor, your first action should be to assess your patient and determine if they have a pulse. Pulseless v-tach is fatal without immediate intervention. Choice C is incorrect. Wenckebach Phenomenon is another name for AV Block 2nd degree, or Mobitz type I. This type of heart block is characterized by a PR interval that is progressively longer and longer until there is a beat that is dropped entirely. While this type of heart block does need to be addressed, it is not fatal without immediate intervention. The only kind of heart block that is considered a deadly rhythm is a 3rd-degree heart block. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Cardiac

The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by: Select all that apply. A. Fever [29%] B. Alzheimer's disease [15%] C. Mild to moderate hyperglycemia [18%] D. Vascular disease [7%] E. Infection [30%]

Explanation Choices A and E are correct. Delirium is an alteration in mental status that occurs abruptly. Delirium, unlike dementia, is reversible with treatment. Contributing factors for delirium include fever, hypoglycemia, and infection. Choice B is incorrect. Alzheimer's disease is a form of dementia, not delirium. Choice C is incorrect. Hypoglycemia is often associated with delirium, not hyperglycemia. Mild to moderate hyperglycemia does not cause delirium. However, severe hyperglycemia ( blood glucose > 600 mg/dl) can cause a hyperosmolar state ( non-ketotic hyperosmolar syndrome) which can result in altered mental status and coma. Choice D is incorrect. Vascular disease contributes to vascular dementia, not delirium. Learning Objective Understand the common causes of delirium. Additional Info Delirium is an altered sensorium. It is characterized by acute changes in the patient's level of consciousness. Hyperactive delirium is characterized by agitation, restlessness, and emotional lability. Hypoactive delirium is characterized by flat affect, apathy, lethargy, or decreased responsiveness. Many causes of delirium include medications (dexamethasone, opioid toxicity), nicotine withdrawal, dehydration, uncontrolled pain, constipation, urinary retention, infection, hypoxia, renal failure, hyponatremia, hypercalcemia, hyperglycemia, and emotional distress. Initially, non-pharmacological interventions should be attempted to identify and address reversible etiology and relieve terminal agitation/delirium. For example, address the reversible causes such as treating constipation or discontinuing medications such as dexamethasone, modifying precipitating factors such as sensory deprivation or uncontrolled pain, etc. If no rapidly reversible factors are identified or if the patient is terminal, dopamine antagonists must be used.

A nurse is educating a student nurse about blood transfusion and transfusion reactions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply. A. "Most common cause of fever during transfusion and transfusion reactions is hemolysis." [23%] B. "Transfusion related Graft Versus Host disease occurs in immuno-suppressed patients." [21%] C. "Transfusion Associated Circulatory Overload (TACO) is more common in patients with baseline renal failure." [16%] D. "It is important to ask the patient about history of previous blood transfusions." [9%] E. "Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion." [31%]

Explanation Choices A and E are correct. These two statements indicate that the student nurse needs further teaching on transfusion reactions. Choice A does not reflect correct understanding by the student nurse because the most common cause of fever during transfusion is "Febrile Non-hemolytic transfusion reaction" and not hemolysis. Physicians may decide to give pre-medication with diphenhydramine and acetaminophen only if the patient has a history of such febrile reactions or prior blood transfusions. Pre-medications are, therefore, not always required (Choice E does not reflect correct understanding by the student nurse). Choice B is incorrect. Graft-versus-host-disease (GVHD) is a rare transfusion reaction that occurs mostly in severely immunocompromised patients (post-bone-marrow transplant, Hodgkin disease, non-Hodgkin lymphoma, and acute myeloid and acute lymphoid leukemias). Choice B reflects a correct understanding of student nurses. In this condition, the donor's T lymphocytes cause an immune response in the recipient by engrafting in the marrow of the recipient and attacking the recipient's tissues/ blood cells. Under normal circumstances, donor T-cells are killed by the recipient's immune system but in severe immunodeficiency, donor T-cells remain causing GVHD. Transfusion-related GVHD presents with fever, rash all over including feet and hands, diarrhea, nausea, and elevated Liver function tests. Such reactions can be limited by a process called "Cytoreduction" where the T-cells are removed from the donor blood products. Choice C is incorrect. Transfusion Associated Circulatory Overload (TACO) is more common in patients with baseline cardiac and renal disorders. Choice C reflects a correct understanding by the student nurse. Fluid overload can happen during transfusion if the patient already has underlying congestive heart failure. If the patient is felt to be at risk for circulatory overload, a loop diuretic such as furosemide may be ordered before, after, or in between PRBC units. Choice D is incorrect. Hemolysis also causes fever but it's not common and often happens when there's mismatching with the donor blood product. On the other hand, febrile non-hemolytic reactions are due to recipient antibodies reacting with donor leucocytes. Often, these patients have been sensitized with prior transfusions and develop antibodies. Therefore, it is important to get a history of any previous blood transfusions. Choice D reflects a correct understanding by the student nurse. Transfusion reactions are adverse reactions that happen as a result of receiving a blood transfusion. The most common symptoms of transfusion reactions can be remembered by the mnemonic - "REACTION" - Rash, Elevated temperature, Aching, Chills, Tachycardia, Increased pulse, Oliguria - low urine output, and Nausea. Transfusion reactions are various types and can include the allergic, hemolytic, and febrile type of reactions as well as GVHD (graft-versus-host-disease). Other transfusion-related complications include circulatory overload which is more common in cardiac/renal patients and septicemia due to contaminated blood products. Allergic type transfusion reactions occur when certain types of proteins (eg: IgA) interact with antibodies in the recipient. For example, recipients with IgA deficiency may develop anaphylaxis if given a transfusion from a normal donor with normal IgA levels. Such anaphylactic reactions may present with hives, rashes, wheezes, respiratory distress, abdominal pain, and angioedema (lip/oral swelling). Hemolytic type reaction can be occurring when the blood products are mistyped. Antibodies in the recipient's blood destroy the donor's blood cells. This can manifest as fever, chills, anxiety, back pain, chest pain, hemoglobinuria, increased heart rate, low blood pressure, disseminated intravascular coagulation, renal failure, and death. Febrile reactions can occur without hemolysis (non-hemolytic). This is the most common type. It manifests with fever, chills, headaches, and tachycardia. Often, these patients have received blood in the past with antibodies in their blood against WBCs. The recipient's antibodies react with leucocytes within the donor blood products. An increase in temperature by 1 degree C or 1.8 degrees F from baseline can be noted. Such febrile reactions may be minimized by a process called "leukodepletion" (removing WBCs from donor blood products). Graft-versus-host-disease (GVHD) is a rare transfusion reaction that occurs mostly in severely immunocompromised patients (post-bone-marrow transplant, Hodgkin disease, non-Hodgkin lymphoma, and acute myeloid and acute lymphoid leukemias). Choice B reflects a correct understanding of student nurses. In this condition, the donor's T lymphocytes cause an immune response in the recipient by engrafting in the marrow of the recipient and attacking the recipient's tissues/blood cells. Under normal circumstances, donor T-cells are killed by the recipient's immune system but in severe immunodeficiency, donor T-cells remain causing GVHD. Transfusion-related GVHD presents with fever, rash all over including feet and hands, diarrhea, nausea, and elevated liver function tests. Such reactions can be limited by a process called "cytoreduction" where the T-cells are removed from the donor blood products. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies, Subtopic: Blood and Blood Products

A patient that has suffered a third-degree burn injury a few hours ago involving 27% of total body surface area (TBSA) a few hours ago has been rushed to the emergency room. Which of the following should the nurse expect to find in this patient? Select all that apply. A. Hyponatremia [22%] B. Hyperkalemia [20%] C. Hypotension [23%] D. Increased urinary output [2%] E. Severe hypophosphatemia [11%] F. Edema in burned areas [22%]

Explanation Choices A, B, C, and F are correct. The client has suffered a significant burn. A burn penetrating from the epidermis to the dermis and down into the subcutaneous tissue is classified as a third-degree or full-thickness burn (they grasp the full thickness of the skin). A full-thickness wound involving 10% or greater of the total body surface area (TBSA) or a partial thickness burn involving 25% or greater of TBSA is considered a significant injury. A nurse involved in the care of the burn patient must be aware of fluid and electrolyte imbalances so the client can be monitored accordingly. Electrolyte and fluid imbalances vary depending on three periods of time since the initial burn injury. Initial resuscitation period: This refers to a period between 0 to 36 hours from the time of burn injury. Due to the damage of the tissues and vessels in major burns, capillary/vascular permeability is significantly increased, and fluid/electrolyte shifts occur between the body compartments. Significant edema in the burn area occurs due to fluid accumulation in the burned tissues due to increased vascular permeability and increased interstitial osmotic pressure (Choice F). Due to changes in cellular permeability, sodium ions enter the cellular compartment resulting in low levels of intravascular sodium (Hyponatremia, Na < 135 mEq/L) (Choice A). Extensive tissue necrosis and cell lysis in major burns also lead to the exit of potassium ions from the cell into the intravascular compartment resulting in hyperkalemia (K > 5.1 mEq/L) (Choice B). Restoring sodium losses by using appropriate fluid and correcting severe hyperkalemia is necessary during this period. The body's initial response in a major burn is to shunt blood toward the brain and heart and away from peripheral vasculature and other organs, resulting in a low circulating volume (Choice C). This often manifests with reduced urinary output, not increased urinary output (Choice D is incorrect). Hypotension progresses to shock and organ failure if fluid resuscitation is not accomplished immediately. The goals of fluid resuscitation in an adult are to maintain an adequate urinary output of 30 to 50 cc/hr. Fluid resuscitation is crucial - under-resuscitation can be life-threatening due to shock. Over-resuscitation may lead to compartment syndrome. So, the nurse needs to understand and calculate fluid deficits based on the accepted formulas. For fluid resuscitation, the modified Brooke formula or Parkland formula is used to calculate the amount of fluid the client is going to need during the first 24 hours. Lactated Ringer's solution is the fluid of choice in resuscitating burn patients because of its close resemblance to the body's extracellular fluid composition. The liquid is often warmed to prevent hypothermia—no colloids in the first 24 hours. The Modified Brooke formula is 2 mL x total body surface areas burned (TBSA) x total kg body weight. The Parkland formula is 4 mL x % total body surface areas burned (TBSA) x total kg weight. The nurse should be aware of the "Rule of 9s" to calculate the TBSA. Both formulas will give an estimate of the first 24-hour fluid requirements from the time of the burn, with half the amount given in the early 8 hours and the remaining half given over the next 16 hours. Early post-resuscitation period: Refers to the period from day 2 to day 6 from the time of burn injury. This phase is characterized by hypernatremia, hypokalemia, hypocalcemia, hypomagnesemia, and fluid shifts back to intracellular and intravascular compartments. Shock improves, blood pressure is restored to normal. It is important to remember that with successful resuscitation and resolution of burn shock, one will see the opposite effects in an intravascular compartment for sodium (Hypernatremia, Na > 145 mEQ/L) and potassium (Hypokalemia K< 3.5Meq/L) compared to those seen in the initial phase. Increased urinary output (diuretic phase) is seen in this period, not in the first 24 hours (Choice D is incorrect). Urine output may rise to 100 cc/hr. D51/2NS is the usual fluid of choice to correct hypernatremia and fluid imbalances during this second phase post burn injury. Severe hypophosphatemia (phosphate less than 1 mg/dl) may appear around day 3 post-burn and is most prevalent on day 7. It is not seen in a few hours post-burn. (Choice E is incorrect). Inflammation-infection period: (also known as the hypermetabolic period) is seen after the first week and lasts until wounds are healed. Nutritional support, rehabilitation, and prevention of infection are crucial during this phase. NCSBN client need Topic: Physiological Adaptation; Sub-Topic: Fluid-electrolyte balance

Which of the following are functions of parathyroid hormone (PTH)? Select all that apply. A. Moves calcium from bones to the bloodstream [32%] B. Promotes renal tubular reabsorption of calcium [32%] C. Enhances renal production of vitamin D metabolites [19%] D. Promotes renal tubular reabsorption of phosphorus [17%]

Explanation Choices A, B, and C are correct. All of these options are functions of parathyroid hormone. Electrolytes are present in all body fluids and fluid compartments. Just as maintaining fluid balance is vital to normal body functioning, so is maintaining electrolyte balance. Although the concentration of specific electrolytes differs between fluid compartments, a balance of cations (positively charged ions) and anions (negatively charged ions) always exists. Electrolytes are essential for maintaining fluid balance that contributes to acid-base regulation, facilitating enzyme reactions, and transmitting neuromuscular reactions. Most electrolytes enter the body through dietary intake and are excreted in the urine. Some electrolytes, such as sodium chloride and potassium, are not stored by the body and must be consumed daily to maintain healthy levels. Other electrolytes, such as calcium, are stored in the body; when serum levels drop, ions can shift out of storage into the blood to maintain adequate serum levels for normal functioning, at least in the short term. Choice D is incorrect. Parathyroid hormone depresses renal tubular reabsorption of phosphorus. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Body Fluids and Electrolytes

While reviewing congenital heart defects with a senior nurse in the PICU, she asks you which errors have increased pulmonary blood flow. You respond by listing which of the following? Select all that apply. A. Atrial septal defect (ASD) [28%] B. Atrioventricular canal defect [23%] C. Ventricular septal defect (VSD) [30%] D. Aortic stenosis [18%]

Explanation Choices A, B, and C are correct. An ASD is an abnormal opening between the atria. It causes an increased flow of oxygenated blood into the right side of the heart, which therefore increases pulmonary blood flow. An atrioventricular canal defect (AV canal) is the incomplete fusion of the endocardial cushions leading to an open 'canal' between both atriums and ventricles. Oxygenated and deoxygenated blood mix in the open canal and cause increased pulmonary blood flow. A VSD is an opening between the two ventricles. Blood shunts from the left ventricle where there is higher pressure and then to the right ventricle where there is lower pressure, causing the increased pulmonary blood flow. Choice D is incorrect. Aortic stenosis is the narrowing of the aortic valve. This causes resistance to systemic blood flow and is characterized as an obstructive congenital heart defect. It does not create increased pulmonary blood flow. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Alterations in Body Systems

The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled? Select all that apply. A. Tachypnea [26%] B. Bradycardia [9%] C. Nausea [23%] D. Mydriasis [18%] E. Increased blood glucose [24%]

Explanation Choices A, C, D, and E are correct. A client experiencing acute pain will have activation of the sympathetic nervous system, therefore, causing signs and symptoms such as: Nausea, vomiting Diaphoresis Increased pulse Tachypnea Increased blood glucose Increased blood pressure Dilated pupils (mydriasis) Choice B is incorrect. The activation of the sympathetic nervous system is associated with acute pain. Bradycardia is not a finding consistent with this system's activation as tachycardia would be the likely finding. Additional information: Pain is a subjective symptom that must be taken seriously. A thorough assessment of a client's pain includes the location, intensity, quality, onset and duration, aggravating factors, and the effects that pain has caused, such as psychosocial distress. Client self-report is the most reliable indicator of pain, but the nurse must be aware of the non-verbal assessment findings supporting the presence of pain.

The nurse assesses an infant who sustained a traumatic brain injury (TBI). Which assessment finding requires follow-up? Select all that apply. A. Bulging fontanel [35%] B. Tachycardia [7%] C. Bradycardia [24%] D. Ptosis [24%] E. Distended scalp veins [10%]

Explanation Choices A, C, and E are correct. A tense, bulging fontanel is a classic sign of increased ICP in an infant. Associated symptoms that are concerning include bradycardia and distended scalp veins. Choices B and D are incorrect. Tachycardia is a clinical manifestation of shock but not for increased ICP. The client would exhibit triad symptoms such as bradycardia, bradypnea, and widening pulse pressure. Ptosis is drooping of the eyelid and is not associated with increased ICP. Pupillary changes would be assessed as a late sign of increased ICP, which would be nonreactive on an assessment. Additional Info For an infant with a TBI, the nurse must assess the newborn for increased intracranial pressure. Manifestations of increased ICP in newborns and infants include a high-pitched cry, bulging fontanels that may also have distended scalp veins, irritability, bradycardia, and an irregular breathing pattern.

You are providing education to a group of parents about toilet training their toddler age children. Which of the following educational points should you include? Select all that apply. A. Most children are ready to begin toilet training between 12 and 18 months old. [17%] B. Stay with the child while they are trying to use the toilet. [40%] C. Limit sitting on the toilet to 5-8 minutes at a time. [30%] D. A child should be able to stay dry throughout the night before you begin toilet training. [14%]

Explanation Choices B and C are correct. B is correct. This is a good educational point. Parents should stay with the child while they are trying to use the toilet. Toilet training may be scary for some toddlers; it is a new and unfamiliar activity when they are learning about their bodies and how to control something that they have not controlled before. It is important to their psychosocial development that the toddler feels safe and supported and therefore providing education to stay with the child while they are using the toilet is a good tip. C is correct. This is a good educational point. Parents should limit sitting on the toilet to 5-8 minutes at a time. Toilet training can be a frustrating task for toddlers and it is important to foster their autonomy instead of increasing their frustration. If they have not been able to use the toilet after 5-8 minutes, it is unlikely that they will be able to do so. They may just not have a full bladder and they should not be forced to keep sitting on the toilet if it is not going to be successful. Limiting the time on the toilet to 5-8 minutes will limit frustrations for the toddler and foster autonomy and success in the task of toilet training. Choice A is incorrect. This statement is incorrect. It is not true that most children are ready to begin toilet training between 12 and 18 months old. The development of control of the sphincter muscles occurs between 18 and 24 months. This is when children will be ready to begin toilet training. Signs that they may be ready are waking up dry from their naps, telling you that they need to go, and the ability to stay dry for at least 2 hours during the daytime. Choice D is incorrect. This statement is incorrect. It is not true that a child should be able to stay dry throughout the night before you begin toilet training. Remaining dry throughout the night often does not occur until 4 to 5 years of age. Children are typically ready to begin potty training long before that; around 18-24 months of age. Signs that they may be ready are waking up dry from their naps, telling you that they need to go, and the ability to stay dry for at least 2 hours during the daytime. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Development

Which of the following patients should have their temperature measured orally? Select all that apply. A. A 61-year-old woman who had oral surgery. [1%] B. A 44-year old man with chest pain on oxygen via nasal canula. [24%] C. An 83-year-old woman with diarrhea. [39%] D. A 29-year-old patient with an earache. [35%]

Explanation Choices B, C, and D are correct. There is no contraindication for oral temperature measurement in any of these patients. The oral temperature is measured with the probe placed under the tongue and the lips closed around the instrument. Oxygen delivered by nasal cannula does not affect the accuracy of the measurement. Choice A is incorrect. Oral surgery may falsely increase the local temperature by causing surgery-related inflammation. Oral temperature measurement is contraindicated in: Patients who have altered mental status because they may not cooperate fully. Those who are mouth breathers. Mouth breathing can affect the accuracy of oral temperature. Those who have had a recent oral intake of cold or hot foods/drinks Those who have recently smoked Those who have recently undergone oral surgery NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Temperature

The nurse is developing a plan of care for a client diagnosed with Kawasaki disease. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Initiate contact precautions [12%] B. Obtain a 12-lead electrocardiogram [27%] C. Offer soft foods and liquids [28%] D. Implement fluid restriction [7%] E. Administer aspirin, as prescribed [26%]

Explanation Choices B, C, and E are correct. Kawasaki disease is an autoimmune disorder that occurs primarily in individuals younger than five. This disease process may consequently cause inflammation of the coronary arteries leading to aneurysms. Thus, an electrocardiogram should be performed along with an echocardiogram. Soft foods and liquids should be offered because of the chapping of the lips. Fluids would be encouraged because of the fever commonly associated with Kawasaki disease. Finally, treatment for this disease includes either medium to high dose aspirin or intravenous immunoglobin. Choices A and D are incorrect. Kawasaki disease is an inflammatory condition causing systemic vasculitis. Thus, standard precautions are applicable for this disease. Fluid restrictions are not helpful in an individual with Kawasaki disease, and the nurse should encourage more fluids because of the fever associated with this syndrome. Additional Info Kawasaki disease is an inflammatory syndrome commonly found in individuals younger than five, affecting males more than females. Classic symptoms include fever, chapped lips, bilateral conjunctivitis, and polymorphous rash. Prompt treatment with aspirin or intravenous immunoglobin is needed to prevent injury to the coronary arteries. It is important to note that Kawasaki disease is the one time that aspirin is administered in the pediatric population. Usually, it is avoided due to the risk of Reye's syndrome. However, Kawasaki disease is the exception to this rule, and aspirin is routinely used in this case.

The nurse documents the presence of a skin lesion as a "palpable solid mass measured at 1 cm." What types of skin lesions might this describe? Select all that apply. A. Macule [24%] B. Patch [4%] C. Plaque [9%] D. Nodule [32%] E. Bulla [11%] F. Pustule [19%]

Explanation Choices C and D are correct. Plaque and nodules are palpable, elevated, solid masses that may measure 1 cm. Choices A and B are incorrect. Macules and patches are circumscribed, flat, nonpalpable changes in skin color. Macules are less than or equal to 1 cm, and patches are more significant than 1 cm. Choices E and F are incorrect. Bulla and pustules are circumscribed, superficial skin elevations formed by free liquids in a cavity with skin layers. Bulla is higher than 0.5 cm, whereas pustules are filled with pus. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Assessing the Skin, Hair, and Nails

The nurse is preparing to transfuse platelets to a client. Which of the following actions would be appropriate for the nurse to take? Select all that apply. A. Obtain the client's weight [4%] B. Ensure ABO type compatibility [21%] C. Infuse the platelets within 30-60 minutes [17%] D. Verify completed consent for platelet transfusion [28%] E. Obtain pre-transfusion vital signs [29%]

Explanation Choices C, D, and E are correct. When administering platelets to a client, the nurse should ensure that a completed blood product consent from the client is obtained before transfusion. Further, the nurse will obtain pre-transfusion vital signs and infuse platelets over 30-60 minutes. Choices A and B are incorrect. Platelets are pooled from as many as ten donors, and ABO compatibility is not required. The nurse should obtain pre-transfusion vital signs, but weight is not necessary. Additional information: Platelets are indicated for severe thrombocytopenia, typically when the platelet count is less than 25,000. The nurse will need to verify consent prior to transfusion and verify the blood product with another nurse prior to initiation. Platelets are infused over 30-60 minutes. Following the transfusion, the nurse should obtain post-transfusion vital signs. Platelets are not required to be ABO compatible; while compatibility is preferred, this is not always available. Clinically significant hemolytic transfusion reactions secondary to transfusion of ABO-incompatible platelet products (e.g., group O platelets given to group A client) are uncommon, but they do occur.

The primary healthcare provider (PHCP) prescribes 0.5 grams of cefaclor by mouth, twice a day. The medication label reads cefaclor 500 mg capsule. The nurse prepares to administer how many capsules per dose? 1 capsule(s)

Explanation To solve this multi-step problem, the formula of dose ordered / dose on hand x volume will be utilized. First, the nurse must convert the prescription to the same units as the medication label (grams → milligrams) 0.5 grams → 500 mg Next, take the dose ordered and divide it by the dose on hand and multiply by its volume 500 mg / 500 mg x 1 capsule = 1 capsule Additional Info Cefaclor is a cephalosporin antibiotic indicated for bacterial infections. Common side effects include nausea, vomiting, and mild diarrhea.

The primary healthcare provider (PHCP) prescribes lidocaine at 2 mg/min. The medication label reads lidocaine 1 gram in 500 mL of 0.9% saline. How many mL per hour will be administered to the client? Fill in the blank. 60 mL/hr

Explanation To solve this multistep problem, the formula of dose ordered / dose on hand x volume will be used First, determine the hourly dosage 2 mg x 60 mins = 120 milligrams Next, convert the milligrams to grams so the units align 120 milligrams / 1000 = 0.12 grams Finally, divide the dose ordered by the amount on hand x the volume 0.12 grams / 1 gram x 500 mL = 60 mL/hr

While working in the ICU, you suspect that your patient's central venous catheter has become infected. Place the following actions in the correct order of nursing priorities: Notify the health care provider. Remove the catheter. Obtain blood cultures. Prepare to administer antibiotics as ordered. Document the incident.

Notify the health care provider. Remove the catheter. Obtain blood cultures. Prepare to administer antibiotics as ordered. Document the incident. Explanation It is essential to first notify the health care provider, as they will need to prepare for the insertion of a new central venous catheter quickly to ensure medication administration interruptions are minimized. Next, the nurse needs to remove the catheter. Removing the source of the infection is a nursing priority and should be completed as quickly as possible to prevent any further spread of disease. Next, the nurse should obtain blood cultures. This will identify the type of organism causing the infection so that the health care provider can choose an appropriate antibiotic. It is essential to obtain blood cultures before administering antibiotics. The next action is administering medicines to treat the infection, but only after blood cultures have been received. Lastly, the nurse should document the incident. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies Subtopic: Central Venous Access Devices