NCLEX EAQ module 8 Care Competencies
A client with chronic renal failure stops responding to the treatment. On examination, the primary health care provider determines that the client is terminally ill. Which is the correct nursing intervention in this situation? 1 Suggest that the family members get a second opinion. 2 Suggest that the family members continue to try different treatments. 3 Encourage the family members to provide palliative care to the client. 4 Inform the family members that the disease is no longer curable and the client will die shortly.
3 Encourage the family members to provide palliative care to the client. Clients who are terminally ill and no longer respond to treatment are in need of palliative care. Palliative care promotes client comfort and provides important interventions to support the client and family at the end of life. There is no need to get a second opinion from another primary health care provider, because the client is terminally ill. Continuing to attempt different treatments until the death of the client may cause more client suffering. It is not advisable to inform the family members that the client will die soon because it may lead to emotional stress. The palliative care team will help prepare the family for the client's death.
Which nursing action is appropriate when terminating exposure for a toddler who presents to the emergency department (ED) after eating a lily? 1 Emptying the mouth 2 Monitoring vital signs 3 Questioning the parents 4 Placing in a side-lying position
Correct1 Emptying the mouth To terminate exposure, the nurse would empty the toddler's mouth of any plant remnants. Monitoring vital signs is an assessment action. Questioning the parents helps identify the poisonous substance. Placing the child in a side-lying position is a nursing action that prevents further absorption or prevents aspiration with emesis.
A client receives intrathecal morphine to control severe postoperative pain. Which action will the nurse include as part of the client's initial 24-hour postoperative care plan? 1 Monitoring of respiratory rate hourly 2 Assessing the client for tachycardia 3 Administering naloxone every 3 to 4 hours 4 Observing the client for signs of central nervous system (CNS) excitement
Correct1 Monitoring of respiratory rate hourly Intrathecal morphine can depress respiratory function depending on the level it reaches within the spinal column; hourly assessments during the first 12 to 24 hours will allow for early intervention with an antidote if respiratory depression needs to be corrected. Bradycardia, not tachycardia, and hypotension occur. Administering naloxone every 3 to 4 hours is too infrequent if the client's respirations are depressed. The recommended adult dosage usually is 0.4 to 2 mg every 2 to 3 minutes, if indicated. CNS depression occurs secondary to hypoxia.
The nurse uses a visual analogue scale to rate the pain experienced by a client receiving oxycodone therapy. Which terminology would the nurse use to enter the visual analogue scores in the client's electronic health record (EHR)? 1 Omaha system 2 Nursing Interventions Classification (NIC) 3 American Medical Informatics Association (AMIA) 4 North American Nursing Diagnosis Association (NANDA) International
Correct1 Omaha system The American Nurses Association recognized the Omaha system as standardized terminology to support nursing practices. It includes codes for entering the data obtained from a problem-rating scale in the EHR. The nurse would use the Omaha system to enter the client's score in the EHR. The NIC assigns codes for entering the various interventions followed by the nurse to reduce the client's illness. The AMIA is a professional organization developing nursing informatics competencies. It does not provide codes for entering clients' data in the EHR. NANDA International gives codes for entering nursing diagnoses.
Which medication would the nurse instruct a client to avoid while taking alprazolam? Select all that apply. One, some, or all responses may be correct. 1 Opioids 2 Alcohol 3 Barbiturates 4 Antidepressants 5 First-generation antipsychotics
Correct1 Opioids Correct2 Alcohol Correct3 Barbiturates Respiratory depression can occur if a client combines benzodiazepines with opioids, alcohol, or barbiturates. Antidepressants and first-generation antipsychotics are safe to take with benzodiazepines.
While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures. These episodes are longer than 24 hours. Which fever pattern would the nurse anticipate? 1 Relapsing 2 Sustained 3 Remittent 4 Intermittent
Correct1 Relapsing Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38 oC with little fluctuations. In a remittent fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in 24 hours, the fever is termed intermittent.
Which would the nurse do first if an allergic reaction to a blood transfusion occurs? 1 Shut off the infusion. 2 Slow the rate of flow. 3 Administer an antihistamine. 4 Call the health care provider (HCP).
Correct1 Shut off the infusion. The child is experiencing an allergic reaction, and the infusion must be stopped immediately to prevent serious complications. Slowing the rate of infusion will not halt the allergic reaction to the transfused blood. Administering an antihistamine is dangerous as an initial action because the degree of allergic reaction cannot be determined at this time. Also, it requires an HCP's prescription. The HCP should be notified after the infusion has been stopped.
After surgery, an adolescent has a patient-controlled analgesia (PCA) pump that is set to allow morphine delivery every 6 minutes. Which statement indicates to the nurse that the family understand instructions about the PCA pump? 1 "I'll make sure that she pushes the PCA button every 6 minutes." 2 "She needs to push the PCA button whenever she needs pain medication." 3 "I'll have to wake her up on a regular basis so she can push the PCA button." 4 "I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping."
Correct2 "She needs to push the PCA button whenever she needs pain medication." Morphine, an opioid analgesic, relieves pain; when control of pain is given to the adolescent, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the adolescent should press the PCA button. Having the adolescent press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the adolescent is sleeping, the pain is under control; waking the adolescent will interfere with rest. If the adolescent is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.
Which term would the nurse use to describe a female client who states that she no longer enjoys any of the activities that she once found fun and pleasurable? 1 Anergia 2 Anhedonia 3 Grandiosity 4 Tangentiality
Correct2 Anhedonia The term to use is anhedonia. Anhedonia is the inability to experience pleasure in events or activities that once were enjoyable. Anergia is lethargy and a decreased level of energy. Grandiosity is a symptom seen during manic episodes in which an individual displays an inflated self-esteem. Tangentiality is speaking about subjects unrelated or tangent to the main discussion topic or responding to questions without answering the question.
After a surgical thyroidectomy a client exhibits carpopedal spasm and tremors. The client reports tingling in the fingers and around the mouth. The nurse suspects a deficiency in which mineral? 1 Potassium Correct2 Calcium 3 Magnesium 4 Sodium
Correct2 Calcium The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia. Deficits in potassium, magnesium, and sodium do not cause these classic manifestations.
Which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction? 1 Back blows 2 Chest thrusts 3 Suprapubic thrusts 4 Abdominal thrusts
Correct2 Chest thrusts Chest thrusts are performed for an obstetrical client with a foreign airway body obstruction. Back blows, suprapubic thrusts, or abdominal thrusts are not used to dislodge a foreign body causing airway obstruction.
A 15-year-old plans to go to a nightclub without informing his or her parents but is afraid of being caught. Which behavior would this indicate? 1 Seriation 2 Invulnerability 3 Personal fable 4 Imaginary audience
Correct2 Invulnerability When an adolescent goes to a club but fears getting caught by his or her parents, this action shows a sense of invulnerability. Feelings of invulnerability frequently lead to risk-taking behaviors. Seriation is the ability to mentally classify objects according to their quantitative dimensions. Personal fable is when adolescents think that their thoughts and feelings are unique. Adolescents have a belief that an imaginary audience constantly scrutinizes their actions.
Which is the etiological factor of nephrogenic diabetes insipidus (DI)? 1 Meningitis 2 Lithium therapy 3 Graves disease 4 Sulfonamide therapy
Correct2 Lithium therapy Lithium therapy is the etiological factor of nephrogenic DI. Central nervous system infections such as meningitis are etiological factors of central DI. Goiter, an enlarged thyroid gland, is commonly seen in clients with Graves disease. Sulfonamide is a goitrogen that can cause goiter.
Which cation regulates intracellular osmolarity? 1 Sodium Correct2 Potassium 3 Calcium 4 Calcitonin
Correct2 Potassium A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity. A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.
Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? 1 Hazy 2 Yellow 3 Brown 4 Colorless
Correct2 Yellow The yellow color of CSF can be attributed to the hemolysis of the red blood cells, which leads to increased production of bilirubin. Other causes include subarachnoid hemorrhage, jaundice, increased CSF protein, hypercarotenemia, or hemoglobinemia. Hazy or unclear CSF is indicative of an elevated white blood cell count as a result of infection. If the CSF has a brown color, it is indicative of the presence of methemoglobin, indicating a previous meningeal hemorrhage. Colorless CSF indicates a normal finding.
Which is most important for the nurse to emphasize during discharge planning for a child after a sickle cell vasoocclusive crisis? 1 A high-calorie diet 2 A rigorous exercise regimen 3 An increased intake of fluids 4 An increase in hours spent sleeping
Correct3 An increased intake of fluids Dehydration promotes the sickling of erythrocytes. Increased fluid intake minimizes the chance that sickle cell pain will recur. A high-calorie diet is not necessary or helpful for a child with sickle cell anemia. Rigorous exercise is contraindicated because the decrease in oxygenation may cause sickling. An increase in the hours spent sleeping is not necessary.
Which are extrinsic factors responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct. 1 Impaired vision 2 Cognitive impairment 3 Environmental hazards 4 Inappropriate footwear 5 Improper use of assistive devices
Correct3 Environmental hazards Correct4 Inappropriate footwear Correct5 Improper use of assistive devices Environmental hazards, inappropriate footwear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.
While teaching a nursing student, the registered nurse says, "This is a study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable." Which type of research is described in the above statement? 1 Historical research 2 Evaluation research 3 Exploratory research 4 Experimental research
Correct4 Experimental research In experimental research, the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable. In historical research, studies are designed to establish facts and relationships concerning past events. In evaluation research, studies test how well a program, practice, or policy is working. Exploratory research is an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena.
An 8-year-old child is being prepared for surgery the next day. How would the nurse present preoperative instructions to this child? 1 Be sure to repeat instructions often. 2 Provide time for needle play. 3 Use several abstract examples. 4 Focus on simple anatomical diagrams.
Correct4 Focus on simple anatomical diagrams. According to Piaget, an 8-year-old child's level of development is in the stage of concrete operations; the child will benefit from simple, concrete examples. The preschooler and younger child, not the school-age child, require repetition. Therapeutic needle play is more appropriate if and when the child is to receive an injection. The child who is in the period of concrete operations cannot think in the abstract; the ability to do this develops during adolescence.
In which order do the events of antidiuretic hormone (ADH) secretion stimulated by plasma osmolarity occur? 1. Osmoreceptors are activated. 2. Extracellular fluid is decreased. 3. Plasma osmolarity is increased. 4. Water is reabsorbed from renal tubules. 5. Antidiuretic hormone (ADH) is released.
1. Extracellular fluid is decreased. 2. Plasma osmolarity is increased. 3. Osmoreceptors are activated. 4. Water is reabsorbed from renal tubules. 5. Antidiuretic hormone (ADH) is released. Decrease in extracellular fluid increases the plasma osmolarity. This increased plasma osmolarity activates the osmoreceptors. These osmoreceptors stimulate the release of ADH. The water is reabsorbed from the renal tubules and urine becomes more concentrated when ADH is released.
Which intervention related to restraint use is appropriate to delegate to nursing assistive personnel (NAP)? Select all that apply. One, some, or all responses may be correct. 1 Appropriate use of restraints 2 Determination of the need for restraints 3 Assessment of the client's behavior Correct4 Routine checks of the client while in restraints 5 Orientation of the client to the environment
4 Routine checks of the client while in restraints NAP can perform routine checks of the client in restraints. Determination of appropriate use of restraints and the need for restraints; assessment of a client's behavior; and orientation of the client to the environment are not tasks that can be delegated to NAP.
Which statement by a new mother observing her preterm infant in the neonatal intensive care nursery indicates that she has not yet begun the bonding process? 1 "It's such a tiny baby." 2 "Do you think he'll make it?" 3 "Why does he need to be in an incubator?" 4 "My baby looks so much like my husband."
Correct1 "It's such a tiny baby." By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.
Which is the nurse's most therapeutic response for the child who is about to have an intravenous (IV) line inserted and cries out that he is afraid of IVs? 1 "Tell me what frightens you." 2 "It's just a little prick in the arm." 3 "You're a big boy; this will hardly hurt." 4 "Come on—there's no reason to be afraid."
Correct1 "Tell me what frightens you." Allowing the child to talk about what is frightening him provides an opportunity for him to express feelings and fears. It is not therapeutic to belittle the child's fears.
Arrange the stages of Freud's psychoanalytical model of personality development in the correct order. Correct1.Oral Correct2.Anal Correct3.Phallic or oedipal Correct4.Latency Correct5.Genital
The first stage of Freud's theory is the oral stage, from birth to 12 to 18 months. The anal stage is the second stage, from 12 to 18 months to 3 years of age. Children between the ages of 3 and 6 years are considered to be in the phallic or oedipal stage. The latency stage lasts from age 6 years to age 12 years. The genital stage is the sixth stage; it starts in puberty and continues to adulthood.
Which manifestation is an adverse effect of intravenous lorazepam? Select all that apply. One, some, or all responses may be correct. 1 Amnesia 2 Drowsiness 3 Sleep driving 4 Blurred vision 5 Respiratory depression
Correct1 Amnesia Correct2 Drowsiness Correct3 Sleep driving Correct4 Blurred vision Correct5 Respiratory depression Benzodiazepines such as lorazepam have a range of side effects, many of which are related to central nervous system depression. Anterograde amnesia, drowsiness, sleep driving, blurred vision, and respiratory depression are all potential adverse effects of lorazepam.
Based on an electrocardiogram (ECG), a client is suspected to have hypokalemia. Which test will be used to confirm hypokalemia? 1 Complete blood count 2 Serum potassium level 3 Arterial blood gas panel 4 Urine osmolality test
Correct2 Serum potassium level Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and urine osmolality testing have no significance in diagnosing a potassium deficit.
Why is 15 g of a simple sugar administered when a client with diabetes experiences hypoglycemia? 1 Inhibits glycogenesis 2 Stimulates release of insulin 3 Increases blood glucose levels 4 Provides more storage of glucose
Correct3 Increases blood glucose levels A simple sugar provides glucose to the blood for rapid action. It does not inhibit glycogenesis. It does not stimulate the release of insulin. It does not stimulate the storage of glucose.
Which statement by the nursing student indicates understanding of the precautions needed in the provision of care to a child who is human immunodeficiency virus (HIV) positive? 1 "I'll put on a mask." 2 "I'll put on an N-95 mask." 3 "I'll put on a gown and gloves." 4 "I'll put on gloves if I'm going to be in contact with body fluids."
Correct4 "I'll put on gloves if I'm going to be in contact with body fluids." The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) recommends standard precautions for the care of individuals with HIV infection or acquired immune deficiency syndrome (AIDS) without opportunistic infections. Droplet precautions are not necessary because HIV is not transmitted in large-particle respiratory droplets. Contact precautions are not necessary unless the HIV infection or AIDS is complicated by the presence of disease or infection, necessitating the addition of these precautions to standard precautions. Airborne precautions are unnecessary because HIV is not spread in airborne droplet nuclei; these precautions are used in addition to standard precautions if an opportunistic infection such as Mycobacterium tuberculosis is present.
Which average daily caloric intake is appropriate in preschoolers? 1 400 Incorrect2 700 3 1000 Correct4 1800
Correct4 1800 The average daily intake of calories required in preschoolers is 1800 calories. Four hundred, 700, and 1000 would be too low.
Which medication acts as an antidote to benzodiazepine? 1 Zolpidem 2 Temazepam 3 Suvorexant 4 Flumazenil
Correct4 Flumazenil Flumazenil is a benzodiazepine receptor antagonist and is used to reverse conscious sedation induced by benzodiazepines. Temazepam, suvorexant, and flumazenil are benzodiazepines.
