mynclex set 11- 35

A nurse is caring for a client with a diagnosis of fibromyalgia. During care, the client reports having suicidal thoughts. What currently prescribed medication should the nurse question in regard to this new finding? 1. Amitriptyline (52%) 2. Celecoxib (16%) 3. Cyclobenzaprine (22%) 4. Hydrocodone (8%) OmittedCorrect answer 1 52%Answered correctly

Fibromyalgia is a chronic, nonspecific pain disorder. Common sequelae include fatigue, sleep disturbances, emotional distress (eg, anxiety, depression), and even mild cognitive impairments (eg, forgetfulness, difficulty concentrating). Treatment is focused on symptom management and often includes: Muscle relaxers (eg, cyclobenzaprine) Narcotic analgesics (eg, tramadol, hydrocodone) Nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen, celecoxib) Neuropathic pain relievers (eg, pregabalin, gabapentin) Antidepressants such as selective serotonin reuptake inhibitors (eg, fluoxetine, duloxetine) and tricyclic antidepressants (eg, amitriptyline). Antidepressants can cause suicidal ideation and behaviors, especially during the initial few weeks of therapy. This risk is even higher for young adults (age 18-24). The nurse must assess for this adverse effect and alert the provider (Option 1). (Options 2, 3, and 4) Celecoxib, cyclobenzaprine, and hydrocodone are not known to cause suicidal ideation. Educational objective:Fibromyalgia is treated using a variety of medications. Nurses must be aware of the risks associated with medications, specifically antidepressants that may increase suicidal behaviors during the first few weeks of therapy. Any indication of such effects requires immediate intervention by the nurse (eg, alert health care provider).

The nurse in a clinic is obtaining a developmental history of an 18-month-old during a well-child visit. Which activities should the child be able to perform? Select all that apply. 1. Calls self by name 2. Goes up stairs while holding a hand 3. Stacks 6 blocks in a tower 4. Turns 2 pages in a book at a time 5. Twists doorknob to open doors OmittedCorrect answer 2,4 11%Answered correctly

A toddler's development centers on both fine and gross motor skills. By 18 months, the toddler can manage stairs while holding a hand and turn 2 or 3 pages in a book. The direction in development is on improving the skill of locomotion (Options 2 and 4). (Options 1, 3, and 5) A 24-month-old should be able to build a tower of 6 or 7 blocks, call self by name, and use a doorknob to open a door. Educational objective:An 18-month-old is developing both fine and gross motor skills, which include going up stairs while holding a hand and turning 2 or 3 pages in a book.

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? 1. Absent bowel sounds (83%) 2. Borborygmi sounds (8%) 3. High-pitched and gurgling sounds (5%) 4. Swishing or buzzing sounds (3%) OmittedCorrect answer 1 83%Answered correctly

Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds. (Option 2) Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. (Option 3) High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery. (Option 4) A swishing, humming, or buzzing sound (bruit) may be cardiovascular in origin; a bruit indicates turbulent blood flow as with artery dilation (aneurysm) or narrowing (obstruction). A bruit can best be auscultated with the bell of the stethoscope. Educational objective:Bowel sounds following abdominal manipulation may be absent for 24-48 hours. Any disease process that causes an increase in peristalsis may cause borborygmi (loud, gurgling sounds). Swishing and humming sounds heard best with the bell of the stethoscope may be indicative of turbulent blood flow. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription? 1. Furosemide 20 mg IV push twice daily (12%) 2. Maintenance IV line of 0.9% normal saline at 85 mL/h (46%) 3. Potassium chloride 20 mEq orally twice daily (12%) 4. Sodium-restricted diet (28%) OmittedCorrect answer 2 46%Answered correctly

Chronic heart failure involves the inability of the heart to fill and pump blood effectively to meet the body's oxygen demands. As a result, clients can develop dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]), an electrolyte disturbance caused by an excess of total body water in relation to total sodium content. The nurse should question the prescription for the maintenance IV line. An infusion of an isotonic solution of 0.9% normal saline at 85 mL/h is contraindicated in this client as it would increase the circulating extracellular fluid volume, worsen the symptoms, and exceed the <2 L/day fluid restriction (ie, 85 mL × 24 hours = 2040 mL). Converting the running IV line to a lock for medication administration would be appropriate. (Option 1) Furosemide (Lasix) is a fast-acting loop diuretic prescribed to decrease preload in clients with heart failure who are fluid overloaded and experiencing manifestations of pulmonary congestion (eg, crackles, dyspnea). Appropriate diuresis in this client would remove excess free water and correct dilutional hyponatremia. (Option 3) Potassium chloride is administered to clients receiving furosemide to prevent or treat diuretic-associated hypokalemia. The nurse should not question this prescription. (Option 4) Fluid restriction is prescribed to correct dilutional hyponatremia (sodium <135 mEq/L [135 mmol/L]) in a client with heart failure. In addition, all heart failure clients require a low-salt diet. Excess salt causes retention of more water. This client's low sodium is due to excess free water and not to low dietary sodium. Educational objective:Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of diuretics and fluid/salt restriction.

The nurse assesses a newborn with skin discoloration in the lumbar area, as shown in the exhibit. What would be an appropriate action for the nurse to complete? Click the exhibit button for additional information. 1. Assess the infant's hemoglobin, hematocrit, and platelet levels (10%) 2. Measure and document the size and location of the markings (77%) 3. Notify the health care provider of the markings immediately (4%) 4. Review the delivery record for evidence of a traumatic birth (8%) OmittedCorrect answer 2 77%Answered correctly

Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin most often seen in newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian). Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health care assessments. (Option 1) Mongolian spots are common birthmarks and are not associated with abnormal laboratory values. (Option 3) Mongolian spots are benign, so immediately notifying the health care provider is not indicated. (Option 4) Although often mistaken for bruises, mongolian spots are normal skin variations and are not due to trauma. Educational objective:Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin typically found on the back or buttocks. It is most often seen in newborns of ethnicities with darker skin tones. The spots are usually bluish gray and may be misidentified as bruising in future health care assessments. Proper documentation is essential to avoid misinterpretation of findings.

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful? 1. "I am busy right now but can stay for a few minutes." (29%) 2. "I can call the clergy to come sit with you." (7%) 3. "I can stay and sit with you if you would like." (60%) 4. "I don't think I should interrupt your family time." (2%) OmittedCorrect answer 3 60%Answered correctly

During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes. (Option 1) Telling family members that a nurse is busy is not a helpful response. They may feel guilty about asking for the nurse's time and attention. If needed, the nurse can ask coworkers to help with other assigned clients. (Option 2) Although calling clergy members may be appropriate, it may take several hours for them to arrive. This is not the most helpful response. (Option 4) Family members who ask the nurse to stay for a few minutes may have questions or need emotional support. In such cases, it is not helpful for the nurse to decline. Educational objective:During the end-of-life process, the client and family members typically go through several emotional stages, each requiring therapeutic communication techniques by the nurse. The nurse can help the client and family by providing a few minutes of time and attention. The nurse should validate the family's needs by providing emotional support.

The nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first? 1. Client with a history of thyroidectomy who needs a refill for levothyroxine (8%) 2. Client with Addison disease who is taking corticosteroids and reports new mood swings (18%) 3. Client with diabetes who reports blood sugars of 250-300 mg/dL (13.9-16.7 mmol/L) in the past week (17%) 4. Client with hyperthyroidism who has a new temperature reading of 101.5 F (38.6 C) (55%) OmittedCorrect answer 4 55%Answered correctly

Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). (Option 1) The post-thyroidectomy client who needs a refill of the thyroid replacement medication should be contacted third. Without thyroid replacement therapy, this client would experience signs and symptoms of hypothyroidism (eg, extreme fatigue, bradycardia). (Option 2) Clients on corticosteroids may report moods swings and irritability; these are common side effects. (Option 3) The client with diabetes who is asymptomatic but has elevated blood sugars should be contacted second as prolonged hyperglycemia may lead to dehydration and acidosis. Educational objective:Clients with hyperthyroidism are at risk for developing thyroid storm, a life-threatening condition. Symptoms include fever, tachycardia, cardiac dysrhythmias, nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise. Additional Information Management of Care NCSBN Client Need

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle this situation? 1. Call security to escort the family member to the waiting room (2%) 2. Have the family member stand or sit in an area that is not in the staff's way (33%) 3. Inform the family member that relatives are not allowed in rooms during emergency situations (17%) 4. Let the family member stay and assign a staff person to explain what is happening (47%) OmittedCorrect answer 4 47%Answered correctly

If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The charge nurse should be prepared to escort family members from the room if they become disruptive. (Option 1) Calling security is appropriate only if the family member is disruptive or abusive to the staff. (Option 2) This could increase the family member's anxiety and result in a traumatizing experience if this person does not understand what is occurring during the resuscitation effort. (Option 3) Many professional organizations support allowing a family member to stay during emergency situations, in accordance with specific hospital policy. Educational objective:The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

/A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick? 1. Apply adhesive urine collection bag around the genital area and wait for the child to void (40%) 2. Intermittently catheterize the child every morning to avoid contaminating the specimen (21%) 3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick (32%) 4. Place urine dipstick in the child's diaper overnight and check result in the morning (5%) OmittedCorrect answer 3 32%Answered correctly

Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result. (Options 1 and 4) Children with nephrotic syndrome often have significant edema of the scrotum or labia. Placing a urine dipstick in the child's diaper or applying a standard adhesive urine collection bag around the genital area would cause further irritation and increased risk for skin breakdown. (Option 2) Children with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections. Urine cultures are the only specimen requiring sterile collection techniques (eg, clean catch, catheterization). Educational objective:Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags or dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place cotton balls in a dry diaper and later squeeze urine onto a dipstick. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse should consider which of the following client reports as an indication of an allergic reaction? 1. "I can't eat broccoli or cabbage when I take my warfarin." (0%) 2. "I get a headache when using my nitroglycerine patch." (0%) 3. "My feet swell when I take felodipine." (0%) 4. "My lips swell when I eat bananas or avocados." (98%) OmittedCorrect answer 4 98%Answered correctly

People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: Allergic contact dermatitis (rash, itching, vesicles) developing 3-4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include:Glove useProcedures involving balloon-tipped catheters (eg, arterial catheterization)Blowing up toy balloonsUse of bottle nipples, pacifiersUse of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid. (Option 1) Foods rich in vitamin K reduce the effects of warfarin (which works by inhibiting vitamin K-dependent clotting factors). Consumption of these foods decreases the effectiveness of warfarin; clients must be taught to eat the same amount of or avoid dark, green, leafy vegetables. (Option 2) Nitroglycerine is a vasodilator and a headache from dilating cerebral vessels is an expected finding. The side effect is treated with acetaminophen (Tylenol). (Option 3) Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. This is an expected, frequent side effect and is not an allergic reaction. Clients are advised to elevate the legs when lying down and to use stockings. Educational objective:Latex allergy is suspected when there is a food allergy to banana, kiwis, or avocados. Peripheral edema is an expected side effect of peripherally acting calcium channel blockers. Headache is an expected side effect of nitroglycerine. Clients taking warfarin (Coumadin) should consume the same amounts of food high in vitamin K.

//The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? 1. Face shield/goggles (15%) 2. Gloves (52%) 3. Gown (25%) 4. Mask/respirator (6%) OmittedCorrect answer 2 52%Answered correctly

Personal protective equipment (PPE) is necessary when a client is on contamination precautions (eg, droplet, airborne, contact). A gown is not normally required in an airborne precaution room; however, if contamination is probable (eg, dressing change, contact with bodily fluids), a gown is necessary. The proper removal of PPE limits self-contamination. The exact procedure for donning and removing PPE varies with the level of precautions and location of nursing practice. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials (Option 2). To remove gloves: Grasp the first glove by its palmar surface and pull off inside out. Next, slide fingers of the ungloved hand under the second glove at the wrist and peel off over the first glove. Discard gloves in an infectious waste container. (Options 1, 3, and 4) Face shield/goggles, gown, and mask/respirator can be removed after gloves, which are considered the most contaminated piece of PPE. Educational objective:The proper removal of personal protective equipment limits self-contamination. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials. Additional Information Safety and Infection Control NCSBN Client Need

/As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse? 1. Administer an analgesic (10%) 2. Assess the child's level of pain using a numeric rating scale (87%) 3. Come back later in the day (0%) 4. Tell the child, "Get up and walk if you want to go home soon." (0%) OmittedCorrect answer 2 87%Answered correctly

Postoperative pain control is a priority intervention for a child of any age. However, the nurse needs to first perform an assessment of the child's pain to determine the appropriate pharmacological or non-pharmacological measure to implement. This assessment will also provide a baseline against which the effectiveness of the chosen pain relief method can be evaluated. A numeric pain scale can be used with most children who can count and understand the concept of numbers, generally at around age 5. The scale uses a straight line with divisions marked in units from 0-10; 0 is identified as no pain, 5 as moderate pain, and 10 as worst pain. (Option 1) Analgesics (opiates and nonsteroidal antiinflammatory drugs), along with adjuvant analgesics, are appropriate pain control measures in children. However, pain should be assessed before medications are administered. (Option 3) Returning later in the day allows the child to rest but does nothing to relieve current pain. (Option 4) This non-therapeutic response ignores the child's expressed pain and poses a threat that could be upsetting to the child. Educational objective:When a client is in pain, assessment is the first necessary nursing action. The pain assessment helps to determine the appropriate relief measure and serves as a baseline for evaluating the effectiveness of the chosen pharmacological or non-pharmacological measure. Additional Information Basic Care and Comfort NCSBN Client Need

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used. Your Response/ Incorrect Response 5. Measure, mark, and lubricate tube 2. Ask client to flex head forward and swallow 1. Advance tube to the marked point 6. Verify tube placement and anchor 4. Instruct client to extend neck back slightly 3. Gently insert tube just past nasopharynx . Correct Response 5. Measure, mark, and lubricate tube 4. Instruct client to extend neck back slightly 3. Gently insert tube just past nasopharynx 2. Ask client to flex head forward and swallow 1. Advance tube to the marked point 6. Verify tube placement and anchor OmittedCorrect answer 5,4,3,2,1,6 53%Answered correctly

Steps for inserting a nasogastric tube for gastric decompression include the following: Perform hand hygiene and apply clean gloves (no need for sterile gloves) Place client in high Fowler's position Assess nares and oral cavity and select naris Measure and mark the tube Curve 4-6" tube around index finger and release Lubricate end of tube with water-soluble jelly Instruct client to extend neck back slightly Gently insert tube just past nasopharynx, aiming tip downward Rotate tube slightly if resistance is met, allowing rest periods for client Continue insertion until just above oropharynx Ask client to flex head forward and swallow small sips of water (or dry if NPO) Advance tube to marked point Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration. Educational objective:Key steps when inserting a large-bore nasogastric tube include using clean gloves; inspecting nares; measuring, marking, and lubricating tube; instructing client to extend the neck back slightly; inserting tube past the nasopharynx and continuing advancement until just above oropharynx; asking the client to flex the head forward and swallow; advancing tube to marked point; and verifying tube placement using abdominal x-ray and anchoring.

///A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply. 1. Administer morphine only if the pain is >8 on a 1-10 pain scale 2. Ambulate within 8 hours after surgery, if possible 3. Have client cough with splinting every hour 4. Have client deep breathe and use the incentive spirometer every hour 5. Maintain pneumatic compression devices when client is in bed 6. Place client in Fowler's position OmittedCorrect answer 2,3,4,6 34%Answered correctly

Strategies to prevent postoperative pneumonia include the following: Adequate pain control is a priority so that the client can move, deep breathe, and cough more effectively and comfortably. Opioids are effective for relieving postoperative pain, but because they depress respirations and the cough reflex, assessing the client's response to the medication and level of sedation is important. Ambulate within 8 hours after surgery, if possible. Mobilization/early ambulation decreases atelectasis and hypoventilation, and promotes coughing, deep breathing, and lung expansion. Usually, it can be initiated within 4-8 hours after surgery. Coughing with splinting every hour. Splinting of the incision and adequate pain management are useful for promoting an effective cough (huff, cascade) that clears the airway of secretions. Deep breathing and use of the incentive spirometer every hour. Deep breathing in conjunction with the use of the incentive spirometer promotes ventilation and oxygenation. It opens the pores of Kohn that permit air from well-ventilated alveoli to move into collapsed alveoli, and it helps to prevent/decrease atelectasis and hypoventilation caused by the effects of anesthesia, analgesia, and pain. Place in Fowler's position. Elevating the head of the bed 45-60 degrees helps to promote oxygenation and prevent aspiration. Turn and reposition the client at least every 2 hours. Swab mouth with chlorhexidine swabs every 12 hours. Mouth care prevents ventilator-associated and postoperative pneumonia. Use hand hygiene (all personnel) to decrease transmission of microorganisms. (Option 1) Adequate pain control is a priority. The decision to hold opioids is usually based on sedation level. Giving pain medicine only for severe pain is not appropriate. If the client is awake and complains of pain, adequate analgesia should be provided (oral or IV). (Option 5) Use of pneumatic compression devices promotes venous return and helps to prevent venous thrombosis, not pneumonia. Educational objective:Strategies to prevent postoperative pneumonia include adequate pain management, positioning, coughing and deep breathing, mobilization and early ambulation, twice daily chlorhexidine mouth care, and precautions for limiting the transmission of microorganisms.

/The nurse is educating a group of parents about ways to decrease the risk of sudden infant death syndrome. Which of the following recommendations should the nurse suggest? Select all that apply. 1. Breastfeed the infant 2. Cosleep with the infant in the parent's bed 3. Ensure the infant's vaccinations are updated 4. Maintain a smoke-free environment 5. Place the infant to sleep in a side-lying position 6. Provide a firm sleep surface for the infant OmittedCorrect answer 1,3,4,6 56%Answered correctly

Sudden infant death syndrome (SIDS) is the unexpected, unexplained death of an infant age <1 year, occurring most frequently in those age <6 months during sleep/naps. The nurse should recommend that parents place their infant to sleep on the back in a safe place (eg, crib). The sleep surface (eg, mattress) should be firm with no loose or soft items (eg, blankets, toys, stuffed animals) to prevent suffocation (Option 6). Environmental factors such as smoking may also increase the infant's risk for SIDS; therefore, parents should maintain a smoke-free environment (Option 4). In addition, breastfeeding and updated vaccinations help to keep infants healthy and are protective against SIDS (Options 1 and 3). (Option 2) Parents should avoid cosleeping with their infant (ie, bed sharing) because it increases the infant's risk for suffocation and falls. Encouraging room sharing without bed sharing is appropriate, however. (Option 5) Due to the infant's body shape (ie, barrel chest; flat, uncurved spine), side-lying positions facilitate rolling over to a prone position. Instead, the nurse may recommend supervised time during the day for the infant to lay on the stomach while awake (ie, tummy time) to promote muscle development and prevent positional plagiocephaly. Educational objective:To reduce the incidence of sudden infant death syndrome (ie, the unexpected, unexplained death of an infant age <1 year), the nurse should teach parents to avoid cosleeping and prone/side-lying sleeping positions and encourage safe sleep practices (eg, firm sleeping surface); breastfeeding; a smoke-free environment; and updated vaccinations.

The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the primary health care provider? 1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ratio (INR) of 1.3 (43%) 2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL (190 g/L) (27%) 3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 (15 × 109/L) (12%) 4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L) (16%) OmittedCorrect answer 1 43%Answered correctly

The client with atrial fibrillation is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize and lead to an ischemic brain attack. The INR (normal 0.75-1.25) is a measurement used to assess and monitor coagulation status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin (Coumadin) to treat atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to report to the health care provider (HCP) as the client is at increased risk for a stroke and dose adjustment is needed. (Option 2) A client with chronic obstructive pulmonary disease and chronic bronchitis has chronic alveolar hypoxia, which stimulates erythropoiesis (red blood cell production) and leads to polycythemia (hematocrit >53% [0.53] in males, >46% [0.46] in females; hemoglobin >17.5 g/dL [175 g/L] in males, >16 g/dL [160 g/L] in females). Increased hematocrit and hemoglobin are expected in this client and are not the most important results to report to the HCP. (Option 3) Leukocytosis (white blood cells >11,000/mm3 [11 × 109/L]) is expected in a client with C difficile infection and is not the most important result to report to the HCP. (Option 4) A client receiving gentamycin, a nephrotoxic drug, has a normal creatinine level (0.6-1.3 mg/dL [53-115 µmol/L), which is not the most important result to report to the HCP. Educational objective:The therapeutic INR range is 2-3 for a client receiving warfarin to treat atrial fibrillation. Subtherapeutic INR increases the risk for atrial thrombus formation, with subsequent embolization and stroke. Excess anticoagulation (INR >3-4) increases the risk for bleeding. Additional Information Management of Care NCSBN Client Need

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action? 1. Cut the wires (18%) 2. Elevate the head of the bed (37%) 3. Notify the health care provider (0%) 4. Suction the mouth and oropharynx (43%) OmittedCorrect answer 4 43%Answered correctly

The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent airway. If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway by suctioning via the oral or nasopharyngeal route. If this intervention is ineffective, cutting the wires may be necessary. (Option 1) Cutting the wires can cause collapse of the fractured jaw and exacerbate the airway problem. This action is not the first priority unless the situation is an emergency (eg, acute respiratory distress, cardiopulmonary arrest requiring intubation). A wire cutter must be taped to the head of the client's bed at all times, including during travel. (Option 2) Elevating the head of the bed is a preventive measure. Because the client is choking, the priority is suctioning secretions to clear the airway. The nurse should also turn the client to the side if the client has excessive oral secretions or begins to vomit to decrease the risk of aspiration. (Option 3) The nurse should intervene to maintain the airway before calling the health care provider. A prescription for nasogastric suction to decompress the stomach may be indicated to reduce the risk of vomiting. Educational objective:Maintaining a patent airway is the priority for clients with mandibular fractures who are unable to open their mouths. If choking occurs, the immediate intervention is to suction the mouth and oropharynx. If this is ineffective, cutting the wires may be necessary. Additional Information Reduction of Risk Potential NCSBN Client Need Copyrigh

The nurse cares for a client with type 2 diabetes mellitus. The client is alert and oriented but also shaky, pale, and diaphoretic. The client's fingerstick blood glucose is 50 mg/dL (2.8 mmol/L). Which of the following is the best next step the nurse can take? 1. Administer dextrose 50 mg IV push (7%) 2. Give client 6 oz of orange juice or low-fat milk (85%) 3. Inject the client with glucagon 2 mg intramuscularly (5%) 4. Verify fingerstick blood glucose with serum blood draw (1%) OmittedCorrect answer 2 85%Answered correctly

This client is exhibiting signs and symptoms of a hypoglycemic reaction (evidenced by low blood glucose <70 mg/dL [3.9 mmol/L]). The client who is alert enough to ingest food/liquids orally should be given 15 grams of a simple carbohydrate such as orange juice or low-fat milk (Option 2). The fat in whole milk slows the absorption process and will not treat hypoglycemia quickly enough. For this reason, low-fat milk is recommended. Fingerstick blood glucose should be checked 10-15 minutes after this (Option 4). If the client shows no improvement, the simple carbohydrate can be readministered orally. (Options 1 and 3) Dextrose (D50 IV push), a highly concentrated sugar, and glucagon (intramuscular, subcutaneous, intravenous/gel), a hormone that stimulates glycogenolysis (conversion of glycogen to glucose), are administered to hypoglycemic clients who are unable to ingest a simple oral carbohydrate. These can cause rebound hypoglycemia by stimulating additional insulin release from the body in response to increased serum glucose levels. Educational objective:A client who experiences a hypoglycemic reaction (evidenced by low blood glucose <70 mg/dL [3.9 mmol/L]) and is alert enough to ingest food/liquids orally should be given a simple carbohydrate (eg, orange juice, low-fat milk).

A 2-year-old child is brought to the emergency department for a severe sore throat and fever of 102.9 F (39.4 C). The nurse notes that the child is drooling with distressed respirations and inspiratory stridor. What action should the nurse take first? 1. Assess an accurate temperature with a rectal thermometer (1%) 2. Directly examine the throat for the presence of exudates (18%) 3. Obtain intravenous access for anticipated steroid administration (9%) 4. Position the child in tripod position on the parent's lap (70%) OmittedCorrect answer 4 70%Answered correctly

This is a classic description of epiglottitis (supraglottitis). It is an inflammation by bacteria of the tissues surrounding the epiglottis, a long, narrow structure that closes off the glottis during swallowing. Edema can develop rapidly (as quickly as a few minutes) and obstruct the airway by occluding the trachea. There has been a 10-fold decrease in its incidence due to the widespread use of the Hib (Haemophilus influenzae type B) vaccine. The classic symptoms include a high-grade fever with toxic appearance, severe sore throat, and the 4 Ds—dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling, and distressed respiratory effort. The tripod position opens the airway and helps air flow. The child should be allowed to assume a position of comfort (usually sitting rather than lying down). The priority nursing response is to protect the airway. (Option 1) No invasive procedure should be done that could cause the child to cry until the airway is secure. Knowing the temperature is not a priority. (Options 2 and 3) When drooling is present, the airway becomes the primary concern. No visual inspection, invasive procedure, or anxiety-provoking activity should be done until the airway is secure due to the risk of laryngospasm and respiratory arrest. Educational objective:Children with potential epiglottitis should be allowed a position of comfort without any invasive or anxiety-provoking procedures (eg, phlebotomy, pharyngeal examination, epiglottal cultures) until the airway is secure with intubation or a surgical airway.

/SEE EX A health care provider prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 34 lb. Based on the available concentration of cefuroxime, how many mL would the nurse administer per dose? Click the exhibit button for additional information. Record your answer using one decimal place. Answer: (mL)

Using dimensional analysis, the following steps are performed to calculate the volume of cefuroxime per dose in milliliters: Identify the prescribed, available, and required medication information Prescribed: 30 mg cefuroximekg/day Available: 250 mg cefuroxime5 mL Required: mLdosePrescribed: 30 mg cefuroximekg/day Available: 250 mg cefuroxime5 mL Required: mLdose Convert the prescription to the volume needed for administration using dimensional analysis Prescription×available data=mL per dosePrescription×available data=mL per dose OR (mg cefuroximekg/day)(kglb)(lb )(daydose)(mLmg cefuroxime)=mL cefuroximedosemg cefuroximekg/daykglblb daydosemLmg cefuroxime=mL cefuroximedose OR ⎛⎝30 mg cefuroximekg/day⎞⎠⎛⎝kg2.2 lb⎞⎠(34 lb )⎛⎝day2 doses⎞⎠⎛⎝5 mL250 mg cefuroxime⎞⎠=4.6363¯ mL cefuroximedose 30 mg cefuroximekg/daykg2.2 lb34 lb day2 doses5 mL250 mg cefuroxime=4.6363¯ mL cefuroximedose Round to the first decimal place 4.6363¯ mLdose=4.6 mLdose4.6363¯ mLdose=4.6 mLdose Educational objective:To calculate the volume of cefuroxime in milliliters per dose, the nurse should first identify the prescribed dose (eg, 30 mg/kg/day) and available medication (eg, 250 mg/5 mL) and then convert to volume in milliliters per dose (eg, 4.6 mL). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? Select all that apply. 1. Arrange furniture to allow for free movement 2. Keep frequently used items within easy reach 3. Lock doors leading to stairwells and outside areas 4. Place an identifying symbol on the bathroom door 5. Provide a dark room free of shadows for sleeping OmittedCorrect answer 1,2,3,4 50%Answered correctly

When a client with Alzheimer disease is being cared for in the home, the caregiver should be instructed regarding safety modifications to ease the burden of caregiving and promote the client's independence and dignity. Injury-prevention modifications include: Arrange furniture to allow for free movement to prevent falls (Option 1). Place frequently used items within easy, visible reach of the client (Option 2). Place locks on stairwells and outside doors to decrease the client's risk of falls and becoming lost during periods of wandering (Option 3). Label the doors to the bathroom and other commonly used rooms to assist with environment interpretation and promote independent functioning (Option 4). (Option 5) Providing a night light in the sleeping area can prevent falls, aid in orientation, and decrease illusions. Educational objective:Caregivers of clients with Alzheimer disease should be taught safety modifications for the home, such as placing frequently used items within reach, arranging furniture to allow for free movement, labeling doors to commonly used rooms, providing a night light, and locking stairwell and outside doors. Additional Information Safety and Infection Control NCSBN Client Need

The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information? 1. "I will get this notarized as soon as I can." (14%) 2. "I will give a copy of this to my daughter, who is listed as my health care proxy." (65%) 3. "I'll put this on my refrigerator, so no one will give me cardiopulmonary resuscitation (CPR)." (6%) 4. "You and my daughter can witness this for me." (13%) OmittedCorrect answer 2 65%Answered correctly

When the advance directive is completed, a copy should be placed in the client's medical record and copies should be given to everyone listed as health care proxies. The client should also keep a copy in a safe place. (Option 1) The advance directive form does not need to be notarized, and so it can be completed in the health care setting if there are 2 witnesses. (Option 3) The advance directive is used to document a client's wishes, but it is not a medical order. It will not prevent from performing CPR on a client when necessary. If this client does not want CPR, a portable "do not resuscitate" (DNR) order should be used to ensure that the DNR order is followed outside the hospital setting. Types of portable orders include a POLST (Portable Orders for Life Sustaining Treatment) form, an out-of-hospital DNR, and a DNR bracelet. (Option 4) Two witnesses are required for completion of the advance directive form. The witnesses cannot be health care providers involved in the care of the client or individuals named as health care proxies in the document. Educational objective:An advance directive is placed in the client's medical record and copies are given to health care proxies. Two witnesses are required for completion of the advance directive, but they should not be the health care proxies listed in the document. Additional Information Management of Care NCSBN Client Need

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply. 1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision 4. Obtain a signed informed consent from the client 5. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order OmittedCorrect answer 1,2,3 36%Answered correctly

Advance care planning is a process that includes: Considering treatments that may be needed in the future Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record (Option 1) Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future (Option 3) Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client (Option 2) The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are communicated and documented appropriately so that the health care proxy and health care team will have the necessary information. (Option 4) An informed consent is necessary for the client or surrogate decision maker to approve certain treatments, procedures, and surgeries. The nurse's role in obtaining informed consent is to obtain and witness a signature once the HCP has explained the procedure, its risks and benefits, and answered any questions. This client is not providing consent for any procedure at this time. (Option 5) A DNR order is used to prevent resuscitation in someone with a life-limiting illness. A DNR order does not provide direction for nutrition supplementation. Educational objective:An advance directive is used to communicate a client's wishes when the client is not able to communicate them him/herself. The nurse can advocate for the client by ensuring that expressed wishes are communicated in the advance directive and medical record and by encouraging the client to share this information with the appointed health care proxy.

The nurse receives report on 4 clients. Which client should be seen first? 1. Client with amyotrophic lateral sclerosis experiencing increased dysarthria (24%) 2. Client with chronic obstructive pulmonary disease reporting increasing leg edema (40%) 3. Client with strep throat and fever of 102 F (38.9 C) on antibiotics for 12 hours (11%) 4. Client with urolithiasis reporting wavelike flank pain and nausea (24%) OmittedCorrect answer 1 24%Answered correctly

Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with ALS and worsening ability to speak (dysarthria) may also have dysphagia and respiratory distress; this client should be seen first (Option 1). (Option 2) The client with chronic obstructive pulmonary disease and peripheral edema may have cor pulmonale, or right-sided heart failure, from vasoconstriction of the pulmonary vessels. Cor pulmonale is treated with long-term, low-flow oxygen; bronchodilators; and diuretics. This client should be seen second. Right-sided heart failure (peripheral edema) is not as dangerous as left-sided heart failure (pulmonary edema). (Option 3) Fever often occurs with strep throat and may persist for ≥24 hours after initiation of antibiotics. This client should be seen last and should receive an antipyretic. (Option 4) Wavelike flank pain is characteristic of urolithiasis (urinary stones). This client needs pain medication and, possibly, further treatment (eg, lithotripsy) and should be seen third. Educational objective:Amyotrophic lateral sclerosis causes progressive loss of motor neurons, resulting in muscle weakness and spasticity. Muscles involved in respiration and swallowing are affected, leading to aspiration and, ultimately, respiratory failure. Treatment focuses on maintaining respiratory function, adequate nutrition, and quality of life.

//The nurse receives report on 4 first-trimester pregnant clients. Which client should the nurse assess first? 1. Client with hydatidiform mole reporting dark brown vaginal discharge (4%) 2. Client with hyperemesis gravidarum reporting excessive vomiting and weight loss (7%) 3. Client with suspected ectopic pregnancy reporting abdominal and shoulder pain (79%) 4. Client with threatened miscarriage who says, "I am a Jehovah's Witness." (8%) OmittedCorrect answer 3 79%Answered correctly

An ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterine cavity, frequently in the fallopian tubes. Clients with ectopic pregnancies may report a positive pregnancy test, vaginal spotting/bleeding, and/or abdominal pain. If untreated, continued growth can lead to fallopian tube rupture, resulting in hemorrhage and hemodynamic compromise. Intra-abdominal bleeding can lead to referred shoulder pain, a classic sign of diaphragm irritation. Ruptured ectopic pregnancy requires emergency surgical intervention and hemodynamic support (eg, IV fluids, blood transfusion) (Option 3). (Option 1) In clients with hydatidiform mole or "molar pregnancy," the fetus is replaced by edematous, cystic chorionic villi. Clients experiencing molar pregnancy should anticipate intermittent, dark brown vaginal discharge until the pregnancy is evacuated. (Option 2) Clients with hyperemesis gravidarum have excessive nausea and vomiting and weight loss, often requiring fluid replacement and antiemetic therapy. The condition is not usually life-threatening and does not take priority over ruptured ectopic pregnancy. (Option 4) Clients who are Jehovah's Witnesses do not allow blood transfusions due to religious beliefs. Clients with threatened miscarriage usually report spotting but have a closed cervical os. Heavier bleeding requiring a blood transfusion may be more common with inevitable or incomplete miscarriages. Educational objective:Ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterus, often in the fallopian tubes. Rupture of an ectopic pregnancy results in hemorrhage and requires emergency surgery. Shoulder pain in a client with ectopic pregnancy indicates intra-abdominal bleeding from a rupture. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time? 1. Administer albuterol nebulizer (16%) 2. Assist the client in identifying the trigger and ways to avoid it (6%) 3. Coach the client through controlled breathing exercises (73%) 4. Continue to monitor oxygen saturation (3%) OmittedCorrect answer 3 73%Answered correctly

Anxiety is an emotional reaction to a perceived threat. For the client with COPD, the fear of having difficulty breathing can actually trigger difficulty breathing, which worsens as the client's anxiety increases. This client is stable, with no obvious cause of shortness of breath. The nurse should intervene by calmly coaching the client through breathing exercises, which will promote relaxation and help alleviate the anxiety that is causing the client to feel short of breath. (Option 1) The client's lung sounds are clear bilaterally and so albuterol, a bronchodilator used for wheezing, will not be helpful. Its action as an adrenergic agonist may cause tachycardia and tremulousness and actually worsen the client's anxiety. (Option 2) Trigger avoidance and problem solving are appropriate strategies for long-term control of anxiety and shortness of breath. However, these are not appropriate at this time as the client has acute symptoms that need to be controlled. (Option 4) This client has normal oxygen saturation. Constant monitoring is not likely to alleviate the symptoms unless the client is reassured by this knowledge. However, the client's anxiety may actually be worsened by worrying about the saturation results and the alarms that are likely to be triggered by monitoring. Educational objective:Anxiety is common in clients with COPD and can contribute to difficulty breathing. In the client with acute shortness of breath and normal assessment findings, appropriate interventions are controlled breathing and relaxation.

A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time? 1. "Avoid strenuous activity before the surgery." (71%) 2. "Continue to exercise, even if angina occurs. It will strengthen your heart muscles." (0%) 3. "Take short walks 3 times a day." (18%) 4. "There are no activity restrictions unless angina occurs." (9%) IncorrectCorrect answer 1 71%Answered correctly

Aortic stenosis is the narrowing of the orifice between the left ventricle and aorta. Many clients with aortic stenosis are asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot pump enough blood to meet the body's demands due to aortic obstruction (stenosis). These include dyspnea, angina, and, in severe cases, syncope (reduced blood flow to the brain). Clients usually do not experience symptoms at rest. (Options 2 and 4) This client already developed syncope and angina (exertional chest pain) and is at high risk for sudden death with exertion. (Option 3) The client should restrict activity. The incidence of sudden death is high in this population, and it is therefore prudent to decrease the strain on the heart while awaiting surgery. Educational objective:Clients with severe aortic stenosis are at risk for developing syncope and sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body's demands due to the valve stenosis.

/A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply. 1. Audible gurgling 2. Heart rate 105/min 3. Increased irritability 4. Oxygen saturation 88% 5. Respiratory rate 30/min OmittedCorrect answer 1,3,4 56%Answered correctly

Artificial airways (eg, tracheostomies, endotracheal tubes) impair the cough mechanism and ciliary function, causing an increase in thick secretions that may occlude the airway. Focused respiratory assessments are critical to determine the need for suctioning and to maintain a patent airway. To decrease the risks associated with the procedure (eg, atelectasis, hypoxemia, trauma, infection), suctioning should be performed only when necessary. Assessment findings that indicate a need for suctioning include: Decreased oxygen saturation (Option 4) Altered mental status (eg, irritability, lethargy) (Option 3) Increased heart rate (normal infant range: 90-160) Increased respiratory rate (normal infant range: 30-60) Increased work of breathing (eg, flared nostrils, use of accessory muscles) Adventitious breath sounds (eg, crackles, wheezes, rhonchi) (Option 1) Pallor, mottled, or cyanotic skin coloring (Options 2 and 5) Respiratory rate of 30/min and heart rate of 105/min are within normal limits for an infant and would not indicate distress or a need for suctioning. Educational objective:Assessment findings that indicate the need to suction a client's tracheostomy or endotracheal tube include decreased oxygen saturation, altered mental status (eg, irritability), increased heart rate or respirations, increased work of breathing, and adventitious breath sounds. Additional Information Physiological Adaptation NCSBN Client Need

The health care provider (HCP) has told a client to take over-the-counter (OTC) supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse give the client? 1. Monthly calcium levels will need to be drawn (31%) 2. Stop vitamin D supplements when taking calcium (5%) 3. Take calcium at bedtime (15%) 4. Take calcium in divided doses with food (47%) Correct 47%Answered correctly

Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elemental calcium of OTC products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions. Calcium carbonate and calcium acetate (PhosLo) are used to reduce serum phosphorous levels in clients with chronic kidney disease. In such cases, calcium should remain in the intestine and bind the phosphorous present in food; the calcium phosphorus product would then be excreted in stool. Therefore, these clients should take calcium supplements before meals. (Option 1) Calcium levels may need to be checked periodically, but it is not necessary to do so monthly. (Option 2) Vitamin D also increases calcium absorption and is important for treatment of osteoporosis. There is no need to stop it. (Option 3) Calcium does not need to be taken at any particular time of day. Educational objective:The nurse should encourage the client with osteoporosis to take supplemental calcium with food to increase its absorption. Vitamin D will also enhance absorption. Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose. Constipation is a frequent side effect of calcium supplementation.

The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1. Chest tube output of 175 mL in past hour (40%) 2. International Normalized Ratio (INR) of 1.5 (14%) 3. Temperature of 100.3 F (37.9 C) (14%) 4. Total urine output of 85 mL over past 3 hours (30%) OmittedCorrect answer 1 40%Answered correctly

Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products. (Option 2) Clients who receive a mechanical valve replacement will be started on anticoagulants. A therapeutic INR is 2.5-3.5. This client just had surgery and so has not received enough anticoagulation to get the INR to a therapeutic level. (Option 3) Although this is an abnormal temperature, it is not as high a priority as the blood loss. The nurse should continue to monitor and administer prescribed postoperative antibiotics. (Option 4) Normal urine output is 30 mL/hr. This urine level is just 5 mL below normal. The nurse should continue to monitor. Educational objective:Postoperative blood loss >100 mL/hr should be reported to the HCP immediately. The client may have a compromised suture site and can rapidly become hemodynamically unstable.

//Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? 1. Bladder scan showing 500 mL urine (32%) 2. Hemoglobin of 11 g/dL (110 g/L) (9%) 3. History of cataracts (32%) 4. Reporting frequent diarrhea today (25%) OmittedCorrect answer 1 32%Answered correctly

Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed. (Option 2) Anticholinergic drugs do not affect the blood count. The normal reference range for hemoglobin is 11.7-15.5 g/dL (117-155 g/L) for females and 13.2-17.3 g/dL (132-173 g/L) for males. (Option 3) The common eye contraindication is narrow-angle glaucoma as it could worsen the condition. Cataracts are a clouding of the lens and are not related to drainage flow. (Option 4) Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason for the drug to be prescribed. Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and further relaxation of the intestines could worsen these conditions. Educational objective:Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

//A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital? 1. Client at 8 weeks gestation with spotting and pulse of 90/min (6%) 2. Client with a compound femoral fracture and an oozing laceration (15%) 3. Client with fixed and dilated pupils and no spontaneous respirations (10%) 4. Client with paradoxical chest movement throughout respirations (67%) OmittedCorrect answer 4 67%Answered correctly

Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with flail chest (ie, paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise, which requires immediate treatment (Option 4). (Option 1) Spotting at 8 weeks gestation may indicate complications of pregnancy (eg, miscarriage, ectopic pregnancy, hydatidiform mole). With stable vital signs, this client would be classified as nonurgent as the fetus is not at the age of viability and there is no evidence of risk to the mother's life. (Option 2) The client with a compound fracture and oozing laceration would be classified as urgent and require care within 2 hours to prevent life-threatening complications (eg, hemorrhagic shock). (Option 3) Absent respirations and fixed pupils indicate severe neurologic damage or death. Therefore, this client would be classified as expectant. Educational objective:During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant). Additional Information Safety and Infection Control NCSBN Client Need

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply. 1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 3. "Go to the emergency department every time a seizure occurs." 4. "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a nonhormonal birth control method." OmittedCorrect answer 1,2,4,5 42%Answered correctly

Epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication. The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake, sleep deprivation, and stress (Option 1). Practicing relaxation techniques (eg, biofeedback) may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency (Option 4). Phenytoin (Dilantin), a hydantoin anticonvulsant, may decrease the effectiveness of some medications (eg, oral contraceptives, warfarin) due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral contraceptives (Option 5). Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal abnormalities (eg, cleft palate, heart malformations, bleeding disorders). Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure (Option 2). (Option 3) For a client with epilepsy, it is not necessary to go to an emergency department after a seizure, unless status epilepticus (ie, prolonged, repeated seizures) occurs or the client is injured. Educational objective:Clients prescribed phenytoin should receive education about the potential need for nonhormonal birth control as well as the importance of good oral hygiene and not abruptly stopping anticonvulsants. Other teaching for epilepsy includes avoiding seizure triggers and wearing a medical identification bracelet. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

//The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority? 1. Ask the UAP to stop compressions and check for a pulse (22%) 2. Establish additional IV access with large-bore IVs (3%) 3. Obtain the defibrillator and apply the pads to the client's chest (43%) 4. Prepare to administer 100% O2 with a bag valve mask (31%) OmittedCorrect answer 3 43%Answered correctly 01 secTime Spent 03/31/2020Last Updated

For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Effective chest compressions are essential for maintaining perfusion to vital organs. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest (Option 3). (Option 1) Interruptions in compressions should be kept to a minimum. Pulse checks are performed every 2 minutes per basic life support (BLS) guidelines or if a rhythm change is noted. (Option 2) Additional large-bore IVs may be needed for emergency medication administration (eg, epinephrine, amiodarone) but can be completed when more help arrives to the client's room. (Option 4) Bag valve mask breaths with 100% oxygen should be initiated after obtaining the defibrillator. Educational objective:For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest.

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. "I need to raise the head of my bed on blocks by at least 6 inches." (11%) 2. "I will remain sitting up for several hours after I eat any food." (11%) 3. "If my reflux and abdominal pain don't improve, I might need surgery." (5%) 4. "Losing weight may reduce my reflux, so I plan to take a weight-lifting class." (71%) OmittedCorrect answer 4 71%Answered correctly

Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option 4). (Options 1 and 2) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux. (Option 3) If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning after meals), surgical revision of the diaphragm may be required to prevent organ movement. Educational objective:Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply. 1. African American ethnicity 2. Diabetes mellitus type 2 3. Frequent stress at work 4. LDL of 94 mg/dL (2.43 mmol/L) 5. Smoking of 1 pack of cigarettes daily OmittedCorrect answer 1,2,3,5 60%Answered correctly

Hypertension is referred to as the "silent killer" as many clients are asymptomatic. Untreated chronic hypertension can result in damage of various organs and tissues and increases the risk for renal failure, coronary artery disease, stroke, and heart failure. Appropriate client screening based on risk factors is key to preventing complications. This client has both nonmodifiable (eg, African American ethnicity) and modifiable (eg, diabetes mellitus type 2, chronic stress, smoking) risk factors (Options 1, 2, 3, and 5). To prevent future comorbidities, the nurse should educate the client on smoking cessation, appropriate diabetes management, and therapeutic strategies for stress management at work. (Option 4) Clients should be screened for potential hyperlipidemia. An LDL laboratory value of 94 mg/dL (2.43 mmol/L) is within recommended parameters (<100 mg/dL [<2.6 mmol/L]). Educational objective:Key risk factors for developing hypertension include African American ethnicity, increasing age, positive family history, smoking, excessive sodium and alcohol use, diabetes mellitus, obesity, hyperlipidemia, chronic stress, and sedentary lifestyle. Untreated hypertension increases client risk for coronary artery disease, stroke, heart failure, and renal failure. Additional Information Health Promotion and Maintenance NCSBN Client Need

Exhibit ////A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Click on the exhibit button for additional information. 1. Atrial fibrillation (27%) 2. Atrial flutter (11%) 3. Mobitz II (7%) 4. Torsades de pointes (53%) OmittedCorrect answer 4 53%Answered correctly

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate. (Option 1) Characteristics of atrial fibrillation (AF) include an irregularly irregular rhythm and replacement of P waves by fibrillatory waves. Although electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening. (Option 2) Atrial flutter is characterized by sawtooth-shaped flutter waves. There is no clinical evidence suggesting that hypomagnesemia leads to atrial flutter, which is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale). (Option 3) Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers). Educational objective:In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1. A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling (9%) 2. A 7-year-old has had a high fever, cough, and sore throat for the past 2 days (35%) 3. A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral white patches (5%) 4. A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain (49%) OmittedCorrect answer 4 49%Answered correctly

Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16-year-old client should be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery. (Option 1) Skin peeling is expected in the subacute stage of Kawasaki disease; the new skin might be tender. This client is not the priority. (Option 2) Fever, cough, and a sore throat in a 7-year-old must be evaluated. However, the client's condition is not immediately life-threatening; this client should be treated after the client with infectious mononucleosis. (Option 3) Corticosteroid inhalers can cause oral thrush. Clients must perform proper oral care (rinsing after use) and may use a nystatin oral suspension (swish throughout the mouth as long as possible before swallowing). This client is not the priority. Educational objective:A serious complication of infectious mononucleosis is a ruptured spleen, which would cause sudden onset of severe abdominal pain in the left upper quadrant.

///The nurse is performing the initial assessment of a newborn. Which of the following findings should the nurse report to the health care provider? Select all that apply. 1. Cyanosis of the hands and feet 2. Decreased muscle tone 3. Heart rate of 150/min 4. Sacral dimple with a 0.4 in (1 cm) skin tag 5. Single artery in the umbilical cord OmittedCorrect answer 2,4,5 48%Answered correctly

Nurses caring for newborns must be able to distinguish between normal physiologic variations and unexpected findings that require further intervention. Unexpected findings in newborns include: Decreased muscle tone (ie, hypotonia), which may indicate a congenital neurological abnormality (eg, Down syndrome) or spinal injury (Option 2). Newborns normally have increased muscle tone and should resist movement of the extremities. Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally (Option 4). Presence of a single umbilical artery, which is sometimes associated with congenital defects, particularly of the kidneys and heart (Option 5). Normal umbilical cords contain 2 arteries and 1 vein. (Option 1) Bluish discoloration of the hands, feet, and around the mouth (ie, acrocyanosis) is a common, harmless finding during the first 24 hours after birth and through the first week of life when exposed to cold. (Option 3) The normal heart rate for a newborn is 110-160/min when awake and calm. However, the heart rate may further range from 80/min during rest to 180/min when crying or agitated. Educational objective:Nurses assessing newborn clients should monitor closely for abnormal findings that may require further intervention. Some abnormal findings in a newborn include decreased muscle tone, sacral dimple, and a single artery in the umbilical cord. Bluish discoloration of the hands, feet, and lips and heart rate of 110-160/min are normal physiologic variations in newborns.

A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching? 1. "I have started taking a daily multivitamin with my dinner-time dose of medication." (39%) 2. "I may have oily stools and fecal incontinence when taking this medication." (24%) 3. "I will consume a low-fat diet in which no more than 30% of my calories are from fat." (11%) 4. "I will take my medication with, or within 1 hour of, meals that contain fat." (25%) OmittedCorrect answer 1 39%Answered correctly

Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine. This medication is prescribed to clients with obesity who have difficulty losing weight or a comorbidity that makes weight loss therapeutically essential (eg, diabetes, heart disease). Orlistat should always be used with diet modification and an exercise regimen. Because orlistat blocks the absorption of fats, it also interferes with fat-soluble vitamin uptake. Clients should offset this effect by taking a multivitamin that contains vitamins A, D, E, and K. To be most effective, multivitamins should be taken >2 hours after taking orlistat (Option 1). (Option 2) Clients may experience fecal incontinence, flatulence, oily stools, and oily spotting because unabsorbed fat is eliminated through defecation. (Option 3) A low-fat diet is an essential component of weight loss when a lipase inhibitor has been prescribed. (Option 4) The nurse should teach the client to take orlistat with, or within 1 hour of, meals that contain fat. If the client selects foods that do not contain fat, the dose may be skipped. Educational objective:Orlistat, a lipase inhibitor, prevents the absorption of fat from the gastrointestinal tract and is used with diet (eg, low-fat) and exercise to promote weight loss. Because orlistat blocks the absorption of fats, it also interferes with the uptake of fat-soluble vitamins. Clients should take a daily multivitamin with vitamins A, D, E, and K >2 hours after taking orlistat to prevent nutrient deficiencies.

/The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply. 1. Assess for abdominal distention and constipation 2. Contact the client's health care provider 3. Examine the catheter for kinks and obstructions 4. Flush the tubing with 100 mL of dialysate 5. Place the client in a side-lying position OmittedCorrect answer 1,3,5 48%Answered correctly

Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) (Option 1). The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation (Options 3 and 5). The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location. (Options 2 and 4) The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider. Educational objective:Insufficient outflow from peritoneal dialysis commonly results from constipation; bowel movements should be monitored and stool softeners administered as prescribed. Additional nursing measures include checking the tubing for kinks or clots; maintaining the drainage bag below the abdomen; and placing clients in a side-lying position or assisting with ambulation. Additional Information Physiological Adaptation NCSBN Client Need

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that treatment for this condition will consist of which of the following? 1. Blood transfusion (26%) 2. Fluid bolus (22%) 3. Phlebotomy (42%) 4. Steroid injection (9%) OmittedCorrect answer 3 42%Answered correctly

Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client develops blood clots—due to the increased viscosity of the blood, which makes the circulation sluggish—and decreased tissue perfusion. Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary. (Option 1) A blood transfusion is contraindicated in a client with PV because this would have the opposite of the desired effect, further increasing the RBC count and clotting. (Option 2) Although an IV fluid bolus may be helpful in the short term to reduce blood viscosity, it is not a maintenance treatment for PV. Instead, the client should be encouraged to drink >3 L of fluid daily and avoid dehydration. (Option 4) Steroid injections are not typically used to treat PV. Educational objective:A client with polycythemia vera requires periodic therapeutic phlebotomy treatments to reduce the RBC count and risk of blood clotting associated with increased blood viscosity. Additional Information Physiological Adaptation NCSBN Client Need Copyright © UWorld. All rights reserved.

///The nurse is performing the initial assessment of a newborn. Which finding should the nurse report to the health care provider? 1. A sudden jarring of the client's crib does not produce a Moro reflex. (78%) 2. The client has swollen labia and a thin, white vaginal discharge. (9%) 3. The posterior fontanel is triangular and smaller than the anterior fontanel. (6%) 4. There are pearly, white pinpoint papules on the client's face and nose. (5%) OmittedCorrect answer 1 78%Answered correctly

Primitive newborn reflexes help determine the client's neurological status and development. The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib. Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position. Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be reported to the health care provider (Option 1). (Option 2) Swollen labia and a thin, white vaginal discharge are normal findings in the first few weeks of life, probably related to maternal hormones. These will subside spontaneously. (Option 3) The posterior fontanel is located at the intersection of the sagittal and lambdoid sutures. It is triangle-shaped and smaller than the anterior fontanel, which is diamond-shaped and located at the intersection of the frontal and parietal sutures. (Option 4) White pinpoint papules on the newborn's face (milia) are caused by sebaceous material in the follicles. These are normal and will disappear spontaneously within the first month of life. Educational objective:The Moro (startle) reflex is elicited in newborns by simulating a falling sensation; the infant extends and raises the arms and then curls into the fetal position. An absent Moro reflex may indicate brain or spinal cord underdevelopment or damage.

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale? 1. The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain." (30%) 2. The nurse asks the client what day it is and the client says "banana." The nurse scores verbal response as "confused." (21%) 3. The nurse speaks with client and then the client's eyes open. The nurse scores eye opening as "spontaneous." (43%) 4. The nurse walks in the room and the client states "Hi honey. How are you?" The nurse scores verbal response as "oriented." (5%) OmittedCorrect answer 1 30%Answered correctly

The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response. For the best motor response score, the nurse first verbally asks the client to obey a command. If there is no response, the nurse next uses noxious stimuli (eg, nail bed pressure) and records the physical response. If the client tries to remove the painful stimulus, it is recorded as "localizing" or moving toward the pain; whereas if the client retracts from the stimulus, it is recorded as "withdrawal" (Option 1). (Option 2) To ensure an accurate score in the verbal response category, the nurse must differentiate if the client is confused (eg, answers "1955" when asked the year) or if a client uses inappropriate words. (Option 3) To ensure an accurate eye opening score, the nurse must determine whether the client's eyes open spontaneously (eg, no prompting) or if a stimulus (eg, sound, pain) is needed. (Option 4) A social, verbal client is not necessarily oriented. The nurse must assess orientation by specifically asking clients to state their name, the time, and their location. Educational objective:The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response. Additional Information Reduction of Risk Potential NCSBN Client Need

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required? 1. "I should supplement my potassium intake." (19%) 2. "I should weigh myself daily." (2%) 3. "Moderate exercise may be helpful in my condition." (3%) 4. "Potato chips are an acceptable snack in moderation." (74%) OmittedCorrect answer 4 74%Answered correctly

The client is likely dealing with some level of denial regarding his diagnosis of congestive heart failure. Glossing over the importance of salt avoidance is missing an important opportunity to help them avoid further hospitalizations for the same condition. (Option 1) Adding potassium to a diet, especially when substituting it for sodium, can decrease blood pressure and fluid retention. Some diuretics, such as furosemide (Lasix), may also cause low levels of potassium. (Option 2) Tracking the level of fluid retention with daily weigh-ins is the easiest way for clients and health care providers to monitor the effects of medication on congestive heart failure. (Option 3) Physical activity is very important in preserving cardiac function. Educational objective:In congestive heart failure, large changes in clients established dietary habits are necessary to avoid the repeated hospitalizations caused by salt overload.

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate? 1. "I don't know because I am off duty right now." (1%) 2. "Let's step away from the crowd to discuss it." (73%) 3. "Mrs. Jones was fine when I last checked on her during rounds." (1%) 4. "You will have to talk with the nurse caring for her while I am on break." (23%) OmittedCorrect answer 2 73%Answered correctly

The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privileged health care information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately (Option 2). (Option 1) This response is neither accurate nor helpful because the nurse knows how the client was earlier in the day. It is best to make the conversation private so that the nurse can respond to the question appropriately. (Option 3) Although vague, this response in a public area (ie, cafeteria) violates the client's privacy by acknowledging the client's presence in the hospital, where the response may be overheard by others. In addition, it does not provide accurate information. (Option 4) It is appropriate to direct questions about the client to the currently assigned nurse; however, this response violates the client's privacy by confirming the client's presence in the hospital. It is best to make the conversation private before sharing any information. Educational objective:The nurse must protect clients' privacy and ensure that their medical information remains confidential. Conversations about the client with other staff, ev

A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first? 1. Auscultate breath sounds (81%) 2. Check for peripheral edema (2%) 3. Measure the client's vital signs (12%) 4. Review the client's weight log over the past several days (4%) OmittedCorrect answer 1 81%Answered correctly

The nurse should start assessment based on the ABCs (Airway, Breathing, Circulation). This client is at risk for acute decompensated heart failure and pulmonary edema. Pulmonary edema is an acute, life-threatening situation in which the lung alveoli become filled with serosanguineous fluid. Auscultation may include crackles, wheezes, and rhonchi if fluid has moved into the lungs. The next priority is for the nurse to measure vital signs (Option 3). This would identify if the client's heart rate or respiratory rate is elevated and if the oxygen saturation is compromised. Checking for peripheral edema (Option 2) and review of the client's weight over the past several days (Option 4) are appropriate assessments that may indicate fluid volume overload. However, they do not take priority over auscultation of the lungs. Educational objective:The nurse should follow the ABCs of assessment with the heart failure client who is short of breath and coughing. Airway, breathing, and circulation should be assessed, including auscultation of breath sounds, measurement of respiratory rate, and oxygen saturation. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate? 1. Assign the same nurses and caregivers to the child each day (17%) 2. Avoid mentioning the loved one's death in the child's presence (45%) 3. Explain the importance of being with the child to the parents (16%) 4. Schedule time each day for age-appropriate play (20%) OmittedCorrect answer 2 45%Answered correctly

The preschool-age (3-5 years) child's view of death is related to their developmental stage. They believe death is temporary and reversible, similar to a prolonged nap. The child may ask repeatedly when the deceased individual will return, or they may feel guilty and responsible for the death because of their wishes or thoughts (magical thinking). Talking about the death in simple, accurate terms as often as needed helps the preschool-age child to process their loss. Avoiding discussion of the loved one's death is not therapeutic and may increase anxiety or cause confusion (Option 2). (Option 1) Familiar faces are comforting to the child, and consistently assigning the same nurses and caregivers promotes therapeutic relationships and trust. (Option 3) When considering the idea of death, preschool-age children have significant fear of separation from their parents. Therefore, it is appropriate to explain the importance of remaining with the child as much as possible to the parents. (Option 4) Play allows the child to cope with grief and provides an outlet to express or work through feelings/experiences that the child may not be able to vocalize. Educational objective:Therapeutic interventions for preschool-age children who are experiencing the death of a loved one include providing familiarity (eg, same nurses, parental presence), ensuring that time each day is devoted to play, and speaking openly to the child about the death as often as needed. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used. Your Response/ Incorrect Response .4. Identify the client using 2 identifiers 5. Validate tube placement 1. Administer the prescribed feeding solution 2. Elevate the head of the bed 30-45 degrees 3. Flush the tube with 30 mL of water Correct Response 4. Identify the client using 2 identifiers 2. Elevate the head of the bed 30-45 degrees 5. Validate tube placement 3. Flush the tube with 30 mL of water 1. Administer the prescribed feeding solution OmittedCorrect answer 4,2,5,3,1 49%Answered correctly

The steps for administering a continuous enteral feeding include: Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) (Option 4) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. Elevate the head of the bed ≥30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration (Option 2). Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation (Option 5). Check gastric residual volume. Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration (Option 3). Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump (Option 1). Educational objective:The general steps for administering a continuous enteral feeding include identifying the client, elevating the head of bed at least 30 degrees, validating tube placement, flushing the tube with 30 mL of water, and administering the prescribed enteral feeding solution. Additional Information Basic Care and Comfort NCSBN Client Need

Several graduate nurses tell the nurse manager that they are unfamiliar with the various cultural practices of the clients on their assigned unit. Which leadership strategy is best for the nurse manager to implement to assist the graduate nurses in developing cultural competency? 1. Assign the graduate nurses to a unit without cultural diversity until cultural competency is achieved (2%) 2. Provide the graduate nurses with a workshop designed to teach about cultures encountered at work (67%) 3. Request that the charge nurse assign the graduate nurses 2 culturally diverse clients each shift (9%) 4. Suggest that the graduate nurses research various cultures and provide an in-service to the staff (21%) OmittedCorrect answer 2 67%Answered correctly

The transformational nurse manager provides a supportive culture in which learning is valued and best practices are implemented to ensure the appropriate skill level and experience of each staff member. A workshop would provide the graduate nurses with an opportunity to learn and ask questions about the cultures represented on their unit. It would also help develop cultural awareness and sensitivity, leading to respect for the diverse cultures represented on the unit. (Option 1) Cultural diversity is present in every clinical unit; therefore, it is not feasible to assign the graduate nurses to a unit without cultural diversity. (Option 3) To provide culturally competent care, the graduate nurses must know about the various cultures represented on their unit. Culturally competent care is first attained through education. Afterward, the graduate nurses are ready to implement best practices in the care of clients from diverse cultures. (Option 4) Although researching various cultures would assist the graduate nurses in learning, the new graduates are novices and have not fully developed cultural competency; therefore, they are not the best individuals to provide an in-service on this topic. Educational objective:Nurse managers must ensure that the nursing staff can provide quality care to clients on the unit through development of the necessary skills, including cultural competency. Nurse managers can find mentoring and continuing education programs and Internet resources useful in developing the cultural competencies of staff nurses. Additional Information Management of Care NCSBN Client Need

/Laboratory results pH 7.31 PaO2 76 mm Hg (10.11 kPa) PaCO 254 mm Hg (7.18 kPa) HCO3⁻24 mEq/L (24 mmol/L) The nurse is caring for a client with a pulmonary contusion. Assessment reveals restlessness, chest pain on inspiration, diminished breath sounds, and oxygen saturation of 86%. Which acid-base imbalance does the nurse correctly identify? Click on the exhibit button for more information. 1. Metabolic acidosis (4%) 2. Metabolic alkalosis (1%) 3. Respiratory acidosis (86%) 4. Respiratory alkalosis (7%) OmittedCorrect answer 3 86%Answered correctly

This client's arterial blood gas analysis reveals respiratory acidosis, with a low pH (<7.35), low PaO2, and high PaCO2 (>45 mm Hg [>5.98 kPa]). Any condition that causes a decrease in respiratory rate or tidal volume (eg, chronic obstructive pulmonary disease, chest trauma, over-sedation, sleep apnea) increases the risk of developing respiratory acidosis. This client's breathing is likely shallow due to pain, impairing gas exchange and leading to buildup of acidic carbon dioxide in the blood. (Option 1) In metabolic acidosis, pH would be decreased (<7.35) and HCO3- would be decreased (<22 mEq/L [<22 mmol/L]). (Option 2) In metabolic alkalosis, pH would be increased (>7.45) and HCO3- would be increased (>26 mEq/L [>26 mmol/L]). (Option 4) In respiratory alkalosis, pH would be increased (>7.45) and PaCO2 would be decreased (<35 mm Hg [<4.7 kPa]). Educational objective:Buildup of acidic carbon dioxide from hypoventilation causes a decrease in pH, creating a state of respiratory acidosis.

//The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. "I am having problems extending my fingers since this morning." (37%) 2. "I can't take any of the pain medicine because it makes me feel sick." (0%) 3. "I have to scratch under the cast with a nail file because of the itching." (8%) 4. "I noticed a warm spot on my cast, and a bad smell is coming from it." (53%) OmittedCorrect answer 1 37%Answered correctly

Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy). (Option 2) The nurse should educate the client about ways to prevent medication-related nausea, or the HCP may consider switching pain medications. This would be addressed last. (Option 3) The client must be instructed to never stick anything inside the cast; this can lead to altered skin integrity and infection. This would be addressed third. (Option 4) A warm spot on the cast with a foul odor can indicate infection under the cast, especially if the client has been sticking objects inside to scratch the skin. This would be addressed second. Educational objective:Volkmann contracture (wrist contracture, inability to extend the fingers) occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention.

//The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? Select all that apply. 1. Applying bilateral sequential compression devices 2. Encouraging splinting of the incision with a pillow when coughing 3. Keeping the client NPO until bowel sounds return 4. Maintaining supine positioning at all times 5. Repositioning and irrigating a clogged nasogastric tube PRN OmittedCorrect answer 1,2,3 30%Answered correctly

A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following partial gastrectomy, clients should remain NPO until bowel sounds return (Option 3). Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid emptying of stomach contents into the small intestine). Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and require VTE prophylaxis (eg, sequential compression devices, compression hose) (Option 1). Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of atelectasis (Option 2). (Option 4) In the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating. (Option 5) Clients may have a nasogastric tube postoperatively for gastric decompression. Clogged nasogastric tubes should be reported to the surgeon. Attempting to manipulate or flush the device may disrupt the surgical site, causing hemorrhage or gastric perforation. Educational objective:Postoperative care of a client with gastroduodenostomy includes initiation of thromboembolism prophylaxis; turning, coughing, and deep breathing; and aspiration precautions (eg, elevating the head of the bed). The nurse should keep clients NPO until bowel sounds return and should not manipulate clogged nasogastric tubes.

A nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer. Which intervention would be the priority? 1. Assess for signs of alcohol withdrawal (55%) 2. Assess the need for alcohol rehabilitation referral (1%) 3. Let the client sleep off the alcohol intoxication (1%) 4. Monitor blood glucose levels during the night (42%) OmittedCorrect answer 4 42%Answered correctly

Alcohol is a toxin that causes central nervous system depression. Acute alcohol intoxication can cause confusion, coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions. Alcohol can also cause hypoglycemia, especially in clients with diabetes mellitus. Although the client is intoxicated, it is difficult to determine if the confusion is caused by alcohol or hypoglycemia or both. The priority is to monitor blood glucose during the night to watch for hypoglycemia, which would require immediate intervention. (Option 1) Alcohol withdrawal generally starts within 8 hours after the last drink and peaks at 24-72 hours. (Option 2) Alcohol rehabilitation referral can be addressed when the client is sober and is not a priority. (Option 3) The client should be allowed to sleep, but monitoring glucose levels is the priority. Educational objective:Alcohol can cause hypoglycemia, but intoxication can make it difficult to differentiate between the effects of alcohol and hypoglycemia. Clients with acute alcohol intoxication, especially those who have diabetes mellitus, should have their blood glucose levels monitored.

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1. Difficult to awaken 2. Dry skin 3. Frequent, loose stools 4. Hoarse cry 5. Tachycardia OmittedCorrect answer 1,2,4 44%Answered correctly

Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. Screening occurs after birth for all infants in the United States and Canada to prevent disability and encourage early treatment (ie, levothyroxine). TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include: Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1) Dry skin due to alterations in skin function (Option 2) Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4) Constipation due to slowed metabolism Bradycardia due to the effect of TH on cardiac function (Options 3 and 5) Hyperthyroidism (Graves disease) is an autoimmune condition related to increased production of TH. Neonatal Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes. Educational objective:Congenital hypothyroidism is a partial or complete loss of thyroid function that affects growth, development, and regulation of bodily functions. Clinical manifestations in affected infants may include dry skin, hoarse cry, or difficulty awakening beginning a few months after birth. If untreated, intellectual disability may occur.

The school nurse is teaching a class of 10-year-old children about prevention of dental caries. Which recommendations would be part of the nurse's teaching plan? Select all that apply. 1. Chew sugar-free gum 2. Drink fruit drinks/juices instead of sugary, carbonated beverages 3. Include milk, yogurt, and cheese in dietary intake 4. Minimize consumption of sweet, sticky foods 5. Rinse mouth with water after meals when brushing is not possible OmittedCorrect answer 1,3,4,5 31%Answered correctly

Dental caries (ie, cavities) form when bacteria (eg, Streptococcus mutans) digest carbohydrates in the mouth, producing acids that break down tooth enamel and cause mineral loss. Oral hygiene and dietary intake are significant factors contributing to the development of caries. Clients should increase intake of cariostatic foods, which have an inhibitory effect on the progression of dental caries (eg, dairy products, whole grains, fruits and vegetables, sugar-free gum containing xylitol) (Options 1 and 3). Cariogenic foods increase the risk for cavities and should be avoided. These include refined, simple sugars; sweet, sticky foods such as dried fruit (eg, raisins) and candy; and sugary beverages (eg, colas and other carbonated beverages, fruit drinks/juices) (Option 4). Additional practices to prevent dental caries include: Brushing after meals Flossing at least twice a day Rinsing the mouth with water after meals or snacks (Option 5) Drinking tap water rather than bottled water (most tap water sources add fluoride to promote dental health, whereas most bottled water does not contain fluoride) Finishing meals with a high-protein food (Option 2) Fruit drinks/juices contain high amounts of simple sugars; substituting these for other sugary beverages does not prevent dental caries. Whole fruits are better choices. Educational objective:Risk for dental caries can be reduced by avoiding highly cariogenic foods (eg, refined, simple sugars; sugary beverages; sweet, sticky foods), increasing intake of cariostatic foods (eg, dairy products, whole grains, fruits and vegetables), and maintaining oral hygiene (eg, brushing teeth, rinsing after meals). Additional Information Health Promotion and Maintenance NCSBN Client Need Copyright © UWorld. All rights reserved.

A client with type 1 diabetes mellitus is on intensive insulin therapy. The client is of the Islamic faith and insists on fasting during Ramadan. What is the most important nursing action? 1. Advise the client of the risks of fasting when diabetic (22%) 2. Assess the client's clinical stability and glycemic control (47%) 3. Refer the client to the health care provider for adjustment of the insulin therapy (25%) 4. Refer the client to the registered dietitian for meal planning (5%) OmittedCorrect answer 2 47%Answered correctly

Diabetic clients whose religious practices require them to change their current diet (eg, fasting) and glycemic management regimen should be assessed for clinical stability (eg, comorbidities) and glycemic control, including: History of hyperglycemia, hypoglycemia, and ketoacidosis Dosage and timing of medications Knowledge of meal planning Ability to perform blood glucose monitoring during the fast Fasting during Ramadan is one of the Five Pillars of Islam. Observance of Ramadan and daytime fasting occurs throughout the ninth month of the lunar calendar. During this time, Muslim clients are required to refrain from food and drink from dawn to sunset. Clients who are sick, children, pregnant women, and the elderly are exempt from fasting; however, some clients who fall into these categories may insist on fasting, creating challenges for their health care team. (Option 1) Clients with diabetes who are at lower risk for adverse events while fasting based on risk assessment need to receive instruction on adjusting their meal planning, physical exercise, and insulin therapy. Those at high risk for complications should be discouraged from fasting. (Options 3 and 4) These are appropriate nursing actions after the client has been assessed for risk of diabetic complications from fasting. Educational objective:Clients with diabetes who insist on fasting for religious reasons need to be assessed for risk of adverse events. Key assessment areas include clinical stability and glycemic control (eg, history of hyper-/hypoglycemic episodes, medication regimen, and the ability to self-monitor blood glucose during the fast). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

//The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding (42%) 2. Absence of tears in crying child with IV start (16%) 3. Blood-streaked mucous stool in diaper (13%) 4. Sausage-shaped right-sided mass on palpation (26%) OmittedCorrect answer 1 42%Answered correctly

Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly. (Option 2) Absence of tears in a painful procedure during which the client is crying is a sign of dehydration. This is very common in clients with intussusception and should be treated. IV fluids should be started, and the client's hydration status (vital signs, mucus membranes, capillary refill) should be assessed frequently. (Option 3) A classic sign of intussusception is blood-streaked mucous stool, sometimes referred to as "currant jelly-like" stool. This is expected with intussusception. Treatment is an enema of either air or barium to unfold the intestine. (Option 4) A "sausage-shaped" right-sided mass is commonly felt on palpation in clients with intussusception. This is an expected finding for this condition. Educational objective:Intestinal perforation and peritonitis are common complications of intestinal obstruction (eg, intussusception). Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness and is a surgical emergency.

/The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm3 (154 × 109/L) (12%) 2. Losartan for client with hypertension who is 8 weeks pregnant (61%) 3. Prednisone for client with herpes simplex lesions and Bell palsy (17%) 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease (8%) OmittedCorrect answer 2

Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril, enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE inhibitors have black box warnings that indicate contraindication in pregnancy. The nurse should not give an ARB to a pregnant client (Option 2). The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa). (Option 1) Antiplatelet agents (eg, clopidogrel) are prescribed to prevent thromboembolic events in clients with increased risk for stroke or myocardial infarction. Laboratory values are monitored periodically as these drugs increase bleeding time (normal, 2-7 minutes [120-420 seconds]) and, rarely, may lower platelet count (normal, 150,000-400,000/mm3 [150-400 × 109/L]) (Option 3) Bell palsy presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus). Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset. (Option 4) Tiotropium is an inhaled anticholinergic drug that inhibits receptors in the smooth muscles of the airways. It is prescribed daily for the long-term management of bronchospasm in clients with chronic obstructive pulmonary disease. Educational objective:Angiotensin II receptor blockers and ACE inhibitors are teratogenic, causing fetal injury or death, and are contraindicated in pregnany

/A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority? 1. Activity intolerance related to imbalance between oxygen supply and demand (6%) 2. Acute pain related to inspiration and inflammation of pleura (1%) 3. Anxiety related to fear of the unknown, chest pain, and dyspnea (5%) 4. Impaired gas exchange related to ventilation-perfusion imbalance (86%) OmittedCorrect answer 4 86%Answered correctly

Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation, becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung. The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis, pO2 <80 mm Hg, restlessness, dyspnea, and tachycardia). Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis. It addresses the most basic physiologic need—oxygen. Clients will not survive without adequate oxygenation. (Options 1, 2, and 3) Activity intolerance, acute pain, and anxiety elicit autonomic responses (exertional discomfort, dyspnea, tachycardia) and are all appropriate nursing diagnoses. However, none are the highest priority or pose the greatest threat to survival. Educational objective:Activity intolerance, anxiety, acute pain, and impaired gas exchange are all appropriate nursing diagnoses to include in the plan of care for a client with PE. The highest priority nursing diagnosis is the one that poses the greatest threat to the client's survival.

The nurse is assigned to care for a client who had a thyroidectomy 24 hours ago. On initial assessment, which finding requires the most immediate action by the nurse? 1. Calcium 8.8 mg/dL (2.20 mmol/L) (7%) 2. Heart rate 110/min (4%) 3. Laryngeal stridor (85%) 4. Pain rated 8 out of 10 (2%) OmittedCorrect answer 3 85%Answered correctly

Stridor is a high-pitched, vibratory, harsh sound during inspiration or expiration that indicates partial airway obstruction. When stridor occurs after a thyroidectomy, a delicate surgery involving a highly vascularized area, the most immediate concern is airway compromise secondary to hemorrhage or laryngeal edema. This is a life-threatening complication requiring immediate intervention. The nurse should ensure that suctioning devices, oxygen, and a tracheostomy tray are readily available in the recovery room as immediate tracheostomy may be necessary. Respiratory stridor, also observed in epiglottitis, is very different from the minor laryngeal edema that commonly occurs after intubation and results in transient hoarseness in the postoperative period. Persistent hoarseness and the inability to raise one's voice more than 24 hours postoperatively may indicate damage to the laryngeal nerve, a frequent complication of thyroid surgery. (Option 1) This calcium level is normal (8.6-10.2 mg/dL [2.15-2.55 mmol/L]). However, hypocalcemia is a potential complication of a thyroidectomy as the parathyroid glands that regulate calcium levels in the blood are often inadvertently removed or damaged during surgery. The nurse should ensure that calcium gluconate is available. (Options 2 and 4) Although the pain and tachycardia warrant action by the nurse, these are not as high a priority as the life-threatening complication of airway obstruction. Educational objective:Stridor indicates airway obstruction, and abrupt onset is a medical emergency. Stridor after thyroidectomy requires immediate action by the nurse to maintain airway patency. Suctioning devices, oxygen, and a tracheostomy tray should be available for rapid surgical intervention.

The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the best response by the nurse? 1. "Are you still going to take your business trip?" (2%) 2. "It sounds like you are having a difficult time coping with your partner's behavior." (39%) 3. "Your partner is most likely doing it for attention, so it's best to just ignore it." (1%) 4. "Your partner needs to be seen in the clinic today." (56%) OmittedCorrect answer 4 56%Answered correctly

Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior. (Options 1 and 3) The priority is for the client to be evaluated at the clinic due to the diagnosis and risk for suicide. The partner's response to the client's behavior can be discussed later. (Option 2) This is not the priority response; it focuses on the partner's needs rather than the client's. Educational objective:Clients with borderline personality disorder are at very high risk for suicide. Suicidal gestures and attempts must be taken seriously and evaluated for suicidal intent. Additional Information Psychosocial Integrity NCSBN Client Need

The home health nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the nurse to report to the health care provider? 1. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm3 (15.0 x 109/L) (7%) 2. Client with liver cirrhosis has an International Normalized Ratio of 1.5 (19%) 3. Client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL (13.9 mmol/L) (39%) 4. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm3 (14.0 x 109/L) (33%) OmittedCorrect answer 4 33%Answered correctly

Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately. (Option 1) This client with Clostridium difficile infection will have an elevated white blood cell count. The client is receiving appropriate therapy (eg, metronidazole, oral vancomycin). The nurse will need to monitor the white cell count and, if it keeps increasing, report it. (Option 2) The liver produces most blood clotting factors. Clients with liver cirrhosis will lose this ability and are at risk for bleeding. This client's International Normalized Ratio is mildly elevated (normal 0.75-1.25), which is expected with cirrhosis. (Option 3) Corticosteroids increase blood glucose. This is expected, and the client may need treatment if the glucose levels are markedly increased for a prolonged period. Most clients with asthma exacerbation are expected to take a 5- to 7-day course of steroids. Educational objective:Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) are common tumor necrosis factor inhibitor, biologic disease-modifying antirheumatic drugs. Major adverse effects include immunosuppression and infection. Additional Information Management of Care NCSBN Client Need Copyright

The nurse is caring for a client with advanced Alzheimer disease. Which techniques are appropriate when speaking with this client? Select all that apply. 1. Ask open-ended questions 2. Face the client while speaking 3. Speak in a loud voice 4. Turn off the television and close the door 5. Use simple statements and questions OmittedCorrect answer 2,4,5 67%Answered correctly

Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (dementia) in older individuals (most commonly age >60). Conversation becomes progressively more difficult, and the client experiences word-finding difficulty. The best way for the nurse to obtain information and communicate is to use simple statements and questions (Option 5). Facing the client allows the client to visualize the speaker's face and helps reduce distraction (Option 2). Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting stimuli (Option 4). (Option 1) Asking open-ended questions is a valuable communication technique for collecting information from most clients, but it may confuse the client with AD. The nurse should instead ask simple, direct questions. (Option 3) AD results in a reduction in cognitive function. Speaking loudly does not improve comprehension and may increase anxiety and confusion. Educational objective:When speaking with a client with Alzheimer disease, the nurse should face the client and use clear, simple statements and questions. Facing the client allows the client to visualize the speaker's face and helps reduce distraction. The nurse should also maintain a quiet environment to reduce competing or distracting stimuli.

The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to report to the health care provider? 1. Client at 24 weeks gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29% (41%) 2. Client at 26 weeks gestation whose 1-hour (50 g) oral glucose challenge test result is 120 mg/dL (6.7 mmol/L) (4%) 3. Client at 36 weeks gestation with blood pressure of 125/85 mm Hg and trace protein detected on urine dipstick (29%) 4. Client at 37 weeks gestation with a WBC count of 13,000/mm3 (13.0 x 109/L) (23%) OmittedCorrect answer 1 41%Answered correctly

Anemia is a common complication of pregnancy, sometimes due to iron deficiency. During the second half of pregnancy, the fetus begins to store iron in preparation for extrauterine life and depletes maternal iron stores. Hemoglobin <11 g/dL (110 g/L) in the first or third trimester or <10.5 g/dL (105 g/L) in the second trimester is considered low. The nurse should evaluate a client with a hemoglobin of 9 g/dL (90 g/L) for symptoms of anemia (eg, fatigue, shortness of breath) and notify the health care provider because the client may require additional testing (eg, complete blood count, serum ferritin) and iron supplementation (Option 1). (Option 2) A 1-hour (50 g) oral glucose challenge test screens clients for gestational diabetes and is considered abnormal if blood glucose is ≥130-140 mg/dL (7.2-7.8 mmol/L). (Option 3) Protein is not normally detected in the urine, but large amounts of protein in the urine (eg, ≥300 mg/24 hours, ≥1+ on urine dipstick) along with elevated blood pressure (eg, ≥140/90 mm Hg) may indicate preeclampsia. Trace protein is likely due to specimen contamination or recent illness. (Option 4) During pregnancy, it is normal for the WBC count to increase, even in the absence of infection. Educational objective:Anemia during pregnancy occurs when hemoglobin is <11 g/dL (110 g/L) in the first or third trimester or <10.5 g/dL (105 g/L) in the second trimester. The nurse should evaluate clients with low hemoglobin for symptoms of anemia and anticipate additional testing and/or iron supplementation. Additional Information Reduction of Risk Potential NCSBN Client Need

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? Select all that apply. 1. Administers the prescribed analgesic 30 minutes before irrigating the wound 2. Cleanses the wound from the most to the least contaminated area 3. Obtains a 10-mL syringe and a 27-gauge needle 4. Reviews the child's most recent immunization record 5. Uses continuous pressure to irrigate and repeats until drainage is clear OmittedCorrect answer 2,3 35%Answered correctly

Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil or dirt greatly increases the risk of infection. To perform wound irrigation: Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option 1). Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. Use continuous pressure to flush the wound, repeating until drainage is clear (Option 5). Dry the surrounding wound area to prevent skin breakdown and irritation. Immunization history is reviewed to determine tetanus vaccination status (Option 4). Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound. (Option 2) Wounds should be cleaned from the least to the most contaminated area to prevent recontamination. (Option 3) A 10-mL syringe would require frequent refilling; a larger syringe is more appropriate. The narrow lumen of a 27-gauge needle would provide excessive irrigation pressure. Educational objective:Open wounds must be free of dirt and bacteria prior to closure to reduce the risk of infection. Wound irrigation requires surgical asepsis.

The nurse auscultates the lung sounds of a newly admitted client. The nurse understands that the lung sounds heard are consistent with which health condition? Listen to the audio clip. (Headphones are required for best audio quality.) 1. Bronchitis (32%) 2. Croup (17%) 3. Pleurisy (34%) 4. Pneumothorax (14%) OmittedCorrect answer 1 32%Answered correctly

Bronchitis is inflammation of the upper airways (bronchi) often precipitated by a viral infection. Rhonchi (ie, sonorous wheeze) are continuous, low-pitched adventitious breath sounds that occur when thick secretions or foreign bodies (eg, tumors) obstruct airflow in the upper airways. The resulting sound resembles moaning or snoring and is heard primarily during expiration but may also be present during inspiration. Rhonchi are commonly heard in bronchitis, cystic fibrosis, or some types of pneumonia, and may clear with coughing or suctioning (Option 1). (Option 2) Croup often manifests with stridor, a high-pitched inspiratory breath sound that can often be heard without using a stethoscope. Stridor is caused by partial obstruction of the upper airway and is often louder over the throat. (Option 3) Pleurisy manifests with pleural friction rub, a loud, rough rubbing or grating sound heard throughout inspiration and expiration that is caused by the pleural surfaces rubbing together. Pleural friction rub sounds similar to crackles, but crackles are typically heard only during inspiration. (Option 4) Lung sounds are diminished or absent with pneumothorax due to compression of lung tissue by air in the pleural space. Educational objective:Rhonchi are continuous, low-pitched adventitious breath sounds similar to moaning or snoring that occur when thick secretions or foreign bodies (eg, tumors) obstruct airflow in the upper airways, as in bronchitis. Additional Information Reduction of Risk Potential NCSBN Client Need Copyright © UWorld. All rights reserved.

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with acute cholecystitis who reports right shoulder pain (19%) 2. Client with gastroparesis who reports persistent nausea and vomiting (18%) 3. Client with intractable lower back pain who reports new urinary incontinence (44%) 4. Client with Ménière disease who reports increasing tinnitus (17%) OmittedCorrect answer 3 44%Answered correctly 05 secsTime Spent 03/02/2020Last Updated

Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome (ie, incontinence); therefore, the nurse should assess this client first. (Option 1) Clients with acute cholecystitis may experience referred pain to the right shoulder due to irritation of the diaphragm from the inflamed gallbladder. Although the client's pain should be addressed, this client is not the priority. (Option 2) Clients with gastroparesis have delayed gastric emptying and often report persistent nausea and vomiting. Treatment includes antiemetics, but this client is not the priority. (Option 4) Ménière disease is an inner ear disorder. Expected symptoms include episodic vertigo, tinnitus, and muffled hearing. Treatment during an acute attack includes antihistamines, anticholinergics, and benzodiazepines. As long as the client is safe from falling, treatment is not emergent. Educational objective:Signs and symptoms of cauda equina syndrome (eg, acute spinal/back pain, inability to walk, saddle anesthesia, bowel/bladder incontinence) require emergency attention to prevent permanent damage.

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply. 1. Choose foods that are low in fat 2. Do not consume any foods containing dairy 3. Eat three large meals a day and minimize snacking 4. Limit or eliminate the use of alcohol and tobacco 5. Try to avoid caffeine, chocolate, and peppermint OmittedCorrect answer 1,4,5 71%Answered correctly

Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter (LES) normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the LES (eg, caffeine, alcohol), delays gastric emptying (eg, fatty foods), or increases gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may prevent GERD and associated symptoms include: Weight loss, as excessive abdominal fat may increase gastric pressure Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals (Option 3) Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1, 4, and 5) Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated Refraining from eating at bedtime and/or lying down immediately after eating (Option 2) Clients with GERD generally do not need to minimize or eliminate dairy products from the diet; however, they should choose low-fat or nonfat products. Educational objective:Lifestyle and dietary measures that help prevent or minimize symptoms of gastroesophageal reflux disease include avoiding dietary triggers such as alcohol, caffeine, chocolate, peppermint, and high-fat foods. Clients should consume small, frequent meals and discontinue the use of tobacco products. Additional Information Basic Care and Comfort NCSBN Client Need

///The nurse is performing assessments of several clients during routine prenatal visits. Which client should the nurse discuss with the health care provider first? 1. Client at 30 weeks gestation with darkened patches of skin on the face (6%) 2. Client at 32 weeks gestation with painless, flesh-colored bumps on the perianal area (54%) 3. Client at 34 weeks gestation with intense itching on the hands and feet that worsens at night but no rash (31%) 4. Client at 38 weeks gestation with stretch marks on the abdomen that have become reddened and pruritic (6%) OmittedCorrect answer 3 31%Answered correctly

Intrahepatic cholestasis of pregnancy is a liver disorder exclusive to pregnancy that manifests with intense, generalized itching but no rash. Itching often involves the hands and feet and worsens at night. This condition increases the risk of intrauterine fetal demise and requires priority assessment by the health care provider (Option 3). Management includes laboratory testing (eg, elevated bile acids), fetal surveillance (eg, biophysical profile, nonstress test), medication (ie, ursodeoxycholic acid), and labor induction around 37 weeks gestation. Intrahepatic cholestasis of pregnancy begins to resolve after birth. (Option 1) Chloasma (ie, melasma, mask of pregnancy) is a hormonally stimulated increase in pigmentation over the bridge of the nose and cheeks that usually appears in the second trimester; it is benign and fades postpartum. (Option 2) Fleshy, nontender bumps on genital/anal areas are characteristic of condylomata acuminata (ie, anogenital warts) caused by human papillomavirus. Treatments (eg, trichloroacetic acid) are available for removal of warts in pregnancy, but it is not a priority. (Option 4) Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a dermatologic complication that causes discomfort but is not harmful to the client. Pruritic, raised lesions form within abdominal striae, spare the umbilicus, and may spread to the thighs, arms, legs, and back. Educational objective:Intrahepatic cholestasis of pregnancy is a liver disorder exclusive to pregnancy that manifests with intense, generalized itching but no rash. The condition requires priority assessment and intervention (eg, bile acid testing, fetal surveillance, ursodeoxycholic acid) due to an increased risk of fetal demise. Additional Information Physiological Adaptation NCSBN Client Need

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? 1. Continue at the current dosage (77%) 2. Decrease the dosage (9%) 3. Discontinue the medication (3%) 4. Increase the dosage (10%) OmittedCorrect answer 1 77%Answered correctly

Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia). (Options 2, 3, and 4) No dose adjustment is needed as this client's lithium level is therapeutic. Educational objective:Lithium levels should be checked frequently given the narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). A level >1.5 mEq/L (1.5 mmol/L) is considered toxic. Chronic toxicity manifests with neurologic symptoms (eg, confusion, tremor, ataxia) and/or diabetes insipidus (eg, polyuria, polydipsia).

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take? 1. Anticipate the scheduling of a biopsy (66%) 2. Apply ice to the node (3%) 3. Reassure the client that it is an expected finding (28%) 4. Request an antibiotic (2%) OmittedCorrect answer 3 28%Answered correctly

Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference. A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard or fixed nodes could indicate malignancy. (Option 1) A biopsy is performed for an abnormal lymph node finding that could suggest malignancy. (Option 2) The swelling is caused by inadequate lymph drainage or inflammation, not localized edema. Ice is not recommended for this normal finding. (Option 4) There is no indication of lymphangiitis requiring antibiotics. This may produce a red streak with induration following the course of the lymphatic collecting duct. Infected skin lesions may also be present. Educational objective:A lymph node that is superficial, palpable, small (≤1 cm ), mobile, firm, and nontender is a normal finding. Hard and fixed nodes are most concerning as they are likely due to malignancy. Tender nodes usually indicate inflammation/infection. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance? 1. Black tarry (84%) 2. Bright red bloody (11%) 3. Light gray "clay-colored" (2%) 4. Small, dry, rocky-hard masses (1%) OmittedCorrect answer 1 84%Answered correctly

The nurse would expect a client experiencing an upper gastrointestinal (GI) bleed to have black tarry stools (melena). As blood passes through the GI tract, digestion of the blood ensues, producing the black tarry appearance. (Option 2) Bright red bloody stool (hematochezia) would indicate a lower GI hemorrhage. (Option 3) Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay-colored" stool. (Option 4) Small, dry, rocky-hard masses are an indication of constipation. Inactivity, slow peristalsis, low intake of fiber in the diet, decreased fluid intake, and some medications (eg, anticholinergics) may contribute to constipation. Educational objective:Clients with upper gastrointestinal (GI) bleed tend to have black tarry stools (melena). Lower GI bleeding will have bright red bloody stool. Blood present on surface of stool indicates hemorrhoids.

///An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply. 1. Assess the client for a carotid pulse 2. Determine the client's Glasgow Coma Scale score 3. Maintain airway with head-tilt/chin-lift maneuver 4. Place a hard cervical collar on the client 5. Remove the client from the car onto a backboard OmittedCorrect answer 1,2,4,5 24%Answered correctly

he transference of kinetic energy to the client's body from an opposing force during sudden deceleration (eg, fall, motor vehicle collision) causes bodily injury. If the client is not wearing a seatbelt during an automobile crash, the client may strike (or be propelled through) the windshield, causing blunt-force trauma to the head, neck, or spine. The unconscious client should first be assessed for adequate breathing and the presence of a pulse (using the rule of airway, breathing, and circulation [ABCs]) (Option 1). Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury (Option 4). The client should be removed and placed on a backboard after the cervical spine has been stabilized (Option 5). The nurse should also perform Glasgow Coma Scale scoring to determine the level of neurological impairment (Option 2). (Option 3) If a client with possible spinal injuries is not breathing, or if the airway is occluded, the nurse should use the jaw-thrust technique. The head-tilt/chin-lift maneuver may hyperextend the neck, compromising the cervical spine. Educational objective:After sudden deceleration with blunt-force head injury, the nurse first checks if the client is breathing and has a pulse (using the rule of airway, breathing, and circulation [ABCs]). Spinal injury should be presumed, and the cervical spine should be stabilized (eg, cervical collar). The jaw-thrust maneuver may be used to open the airway.