NCLEX-PN Practice Questions

Which of the following clients should the LPN/LVN attend to first? A. A client who is newly diagnosed with Hepatitis A that is reporting stomach pain and itchy skin. B. A patient in an arm cast that is 2 days post-op and reports feeling numbness and tingling in his affected arm. C. A post-op prostatectomy patient complaining of bladder spasms and blood in his foley bag. D. A patient with a newly placed NG tube complaining of pain around the face and a "plugged" nose.

Choice B is correct. Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a doctor right away. Choices A, C, and D are incorrect. These are all expected or typical symptoms related to the diagnosis. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care - Prioritizing Care

Which of the following are correct statements about the proper administration of polyethylene glycol prescribed for constipation? Select all that apply. Mix the powder with any beverage that the patient enjoys. Administer at the same time every day. Administer with meals. Dilute the powder with 8 oz of water. Instruct that the medication can take 1-3 days to work

A is correct. This statement is correct. It is appropriate to mix polyethylene glycol with any beverage the patient enjoys. Soda and juice are common choices due to their ability to mask the flavor better than water. B is correct. It is preferable to administer polyethylene glycol at the same time every day. This promotes a bowel regimen and routine, which maximizes the success of the medication. It is also useful to help the client remember to take their medication with a routine established. E is correct. Polyethylene glycol can take 1-3 days to produce a bowel movement, and it is important to continue taking it as directed until a bowel movement occurs. Choice C is incorrect. It is not necessary to administer polyethylene glycol with meals. The client may choose to do this, but there is no increased effectiveness related to the time of day or if the medication is taken with or without food. Choice D is incorrect. It is not necessary to dilute polyethylene glycol with water unless that is what the client chooses. The amount of liquid used to dilute will depend on the dose. The package will indicate the quantity of liquid to use depending on the dose of polyethylene glycol. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Pediatrics Gastrointestinal ✓Polyethylene glycol 3350 comes in a powder form, which can be mixed with a liquid such as water, juice, or soda. The powder should be completely dissolved before administration. ✓The recommended dose for adults is one capful (17 grams) of polyethylene glycol 3350 mixed with 8 ounces of liquid, once daily or as directed by the healthcare provider. ✓For children, the dose is usually based on weight and age, and the healthcare provider should be consulted. ✓Polyethylene glycol 3350 can take 1-3 days to produce a bowel movement, and it is important to continue taking it as directed until a bowel movement occurs. It is essential to drink plenty of fluids when taking polyethylene glycol 3350 to avoid dehydration. ✓Polyethylene glycol 3350 should not be used for more than two weeks without consulting a healthcare provider. ✓If there is no bowel movement after three days of polyethylene glycol 3350 use, or if there is rectal bleedin

The nurse is caring for a client with acute renal failure. Which of the following labs should be reported immediately to the primary healthcare provider (PHCP)? A. Blood urea nitrogen 50 mg/dL (Both Sexes: 10-20 mg/dL) B. Serum potassium 6 mEq/L (Both Sexes: 3.5-5 mEq/L, 3.5-5.1 mmol/L) C. Venous blood pH 7.30 (pH 7.31 - 7.41) D. Hemoglobin of 10.3 mg/dL (Male: 14-18 g/dL Female: 12-16 g/dL, Female 115-155 g/L Male 125-170 g/L)

Acute renal failure can cause a significant imbalance in lab values. Although all of the lab results listed are abnormal, the elevated potassium level is a life-threatening finding. Choice B is correct. Hyperkalemia can occur in acute renal failure due to the kidneys' inability to excrete potassium properly. Hyperkalemia can lead to life-threatening cardiac arrhythmias, making it a critical concern. Choice A is incorrect. Elevated blood urea nitrogen (BUN) levels can indicate impaired kidney function, but it is not an immediate life-threatening condition. In acute renal failure, BUN levels often rise, but an isolated high BUN value without other critical symptoms does not require an immediate report. Choice C is incorrect. A venous blood pH of 7.30 is indicative of acidosis, which can occur in acute renal failure due to the accumulation of metabolic waste products. Choice D is incorrect. A hemoglobin level of 10.3 mg/dL is indicative of anemia, which can be a complication of chronic kidney disease. While anemia is a concern and requires monitoring and treatment, it is not an immediately life-threatening condition in most cases. ✓ Work closely with the interdisciplinary healthcare team, including nephrologists, dietitians, pharmacists, and social workers, to provide comprehensive care and support for the client. ✓ Electrolyte imbalances can be exacerbated by fluid imbalances. Careful monitoring of input and output, along with daily weights, is crucial. Nurses should be aware of signs of both dehydration and fluid overload. ✓ Regular electrocardiogram (ECG) monitoring is essential, especially in cases of hyperkalemia. ECG changes, such as peaked T-waves and widened QRS complexes, necessitate immediate intervention.

The nurse is calculating intake for a client. The client received 0.9% saline at 125 mL/hr for six hours, three cups of cranberry juice, one cup of coffee, and one cup of water. The nurse should calculate the client's total intake as how many mL? Fill in the blank.

1950 To calculate the client's total intake, the nurse must recall that one cup is eight ounces, equating to approximately 240 mL. The client received a 0.9% saline infusion at 125 mL/hr for six hours → 750 mL total Three cups of cranberry juice → 720 mL One cup of coffee → 240 mL One cup of water → 240 mL When added up, the total intake was 1950 mL When calculating intake, the nurse should consider the amount of volume the client consumes intravenously and by mouth. While intake and output (I&O) help determine a client's condition, I&O is a crude way of a client's status. Weight is the best way to determine fluid volume status as one kilogram equates to 2.2 lb which is one liter of fluid.

The primary healthcare provider (PHCP) prescribes 150 mL of sterile water to be administered over one hour. The drop factor is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Round your answer to the nearest whole number. Fill in the blank.

38 To solve this problem, the nurse will use the formula of total volume x drop factor / time in minutes First, take the prescribed volume and multiply it by the drop factor 150 mL x 15 gtt = 2250 mL Next, divide the total volume by the minutes 2250 mL / 60 minutes = 37.5 gtts Finally, perform appropriate rounding (if needed) 37.5 gtts = 38 gtts/minute Although rare, sterile water may be administered short-term as it is a hypotonic solution. This is likely to be administered when the client has significant diabetes insipidus.

While caring for a client who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention? A. "The pain doesn't feel as bad now, I think it was just a stomach ache." B. "Would you mind getting me an ice pack?" C. "I know I'm not supposed to eat anything right now, but I'm hungry." D. "I wonder if I can play in the basketball game on Monday."

Choice A is correct. A client suspected of having appendicitis that suddenly feels better has likely experienced a rupture of the appendix. This situation warrants immediate attention since surgery will be necessary. Choice B is incorrect. The client may want an ice pack because he feels like it will ease his pain. Choice C is incorrect. Stating that he feels hungry is not an example of non-compliance, nor is it an emergency. Choice D is incorrect. This statement is not a reason for concern. ✓ Maintain the client's NPO status until appendicitis is definitively ruled out or confirmed by the healthcare provider. ✓ If appendicitis is confirmed, or a rapid deterioration is suspected, be prepared to assist with surgical consultation/intervention if necessary. ✓ Collaborate closely with the healthcare team, including surgeons, physicians, and other healthcare providers, to ensure comprehensive care and timely interventions.

The nurse reviews prescriptions for assigned clients. Which prescription should the nurse clarify with the primary healthcare provider (PHCP)? A. Albuterol via nebulizer for a patient with hypokalemia. B. Clozapine for a patient with severe schizophrenia. C. Lisinopril for a patient with congestive heart failure. D. Verapamil for a patient with migraine headaches.

Choice A is correct. Albuterol is a bronchodilator that is used for asthma exacerbations. Adversely, this medication may lower serum potassium levels. The nurse should question this order as this medication may decrease the potassium further. Choices B, C, and D are incorrect. Clozapine is an atypical antipsychotic used in the treatment of severe schizophrenia. Lisinopril is an ACE inhibitor indicated for heart failure and hypertension. Verapamil is commonly used as prophylaxis for migraine headaches; this medication may also be used for individuals with hypertension. ✓ Albuterol is a short-acting bronchodilator. Common side effects of albuterol include tremors, tachycardia, palpitations, and metabolic disturbances such as hypokalemia and hyperglycemia. ✓ This medication is emergently indicated for asthma exacerbations.

The licensed practical/vocational nurse (LPN/VN) collects data on a client who has overdosed on aspirin. Which clinical finding would be most concerning? A. Pulmonary edema B. Tinnitus C. Nausea and vomiting D. Tachycardia

Choice A is correct. All of these manifestations are associated with an aspirin overdose. Pulmonary edema is the most concerning and is caused by a lung injury induced by aspirin. A treatment for aspirin overdose is an infusion of sodium bicarbonate to correct metabolic acidosis. During the infusion, the nurse must be sensitive to the potential lung injury caused by aspirin; thus, auscultating lung sounds and assessing for pulmonary edema will be essential. Manifestations of pulmonary edema include tachypnea, tachycardia, and crackles in the lung fields. Choices B, C, and D are incorrect. All of these clinical manifestations are associated with an aspirin overdose. Tinnitus (humming, buzzing, or ringing in the ear) may be transient and is not life-threatening. Nause and vomiting are expected and are concerning because they may lead to hypovolemia. Treatment is parenteral fluids and prescribed anti-emetics. Tachycardia is likely with ASA poisoning because of the electrolyte shift and fluid volume depletion. Cardiac monitoring is the standard of care for this diagnosis. ✓ Aspirin (ASA) overdose is highly concerning because it causes many serious effects ✓ The Poison Control Center should always be consulted with ASA overdoses for guidance on the client's care ✓ Manifestations of ASA overdose include Tinnitus Nausea and vomiting Tachypnea Metabolic acidosis Respiratory alkalosis (they may be in a mixed state of both) Tachycardia Hypovolemia Life-threatening pulmonary edema ✓ Treatment includes correcting the acid-based imbalance with sodium bicarbonate infusion(s), cardiac monitoring, parenteral fluid replacement to correct hypotension, and glucose replacement

The nurse is caring for a client diagnosed with Lyme disease. The nurse anticipates the primary healthcare provider (PHCP) prescribe which medication? A. Doxycycline B. Enalapril C. Simvastatin D. Famotidine

Choice A is correct. Doxycycline is an effective treatment for Lyme disease. Lyme disease is an infectious disease caused by the Borrelia bacterium, spread by ticks. The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans, that appears at the tick bite site about a week after it occurred. The rash is typically neither itchy nor painful. The rash is classically referred to as a bullseye rash. Choices B, C, and D are incorrect. Enalapril is an ACE inhibitor prescribed for hypertension and congestive heart failure. Simvastatin is a statin prescribed to reduce total cholesterol, triglycerides, and low-density lipoproteins (LDL). Famotidine is a histamine receptor antagonist for gastrointestinal disorders like GERD and peptic ulcer disease. Doxycycline is a commonly used tetracycline antibiotic that effectively treats various bacterial infections, including acne, pelvic inflammatory disease, and Lyme disease. Because dairy products contain calcium, doxycycline should not be concomitantly administered with milk. This also includes avoiding antacids containing calcium, aluminum, and magnesium. Doxycycline intake and ingestion of these products must be separated by 2-3 hours. Doxycycline is recommended to be taken on an empty stomach. Oral contraception and doxycycline: Current literature suggests no evidence of increased contraceptive failure when doxycycline is used concurrently with estrogen-containing oral contraceptives. Older literature recommended additional birth control methods (e.g., barrier methods) during concomitant use of estrogen-based oral contraceptives and doxycycline due to the theoretical risk of decreased contraceptive effect. However, this theory remains unproven. Pregnancy and breast-feeding: Doxycycline crosses the placenta and is excreted in breast milk—doxycycline chelates with calcium in the bones and the teeth. If given to pregnant women, it may lead to skeletal growth retardation and permanent teeth discoloration in the fetus. Doxycycline in breastfed infants and children under eight causes permanent teeth discoloration, tooth enamel damage, skeletal growth retardation, and photosensitivity. Therefore, it should be avoided in these populat

The nurse is caring for a client who is prescribed enoxaparin. Which of the following findings in the medical history would require follow-up with the primary healthcare physician (PHCP)? A. Recent spinal surgery B. Diabetes mellitus C. Osteoarthritis D. Venous thromboembolism

Choice A is correct. Enoxaparin is an anticoagulant medication used to prevent blood clots. Clients who have recently undergone spinal surgery may be at risk for spinal epidural hematomas if they receive anticoagulation therapy like enoxaparin. This condition can lead to compression of the spinal cord and neurological deficits, necessitating consultation with the primary healthcare physician (PHCP) to assess the appropriateness of enoxaparin. Choice B is incorrect. Diabetes mellitus, on its own, does not typically require follow-up with the PHCP when prescribing enoxaparin. Choice C is incorrect. Osteoarthritis is a chronic joint condition and is not a contraindication for enoxaparin. Choice D is incorrect. This finding supports the use of enoxaparin, as it is commonly prescribed to prevent or treat venous thromboembolism. However, follow-up should still consider the specific context and needs of the client. ✓ Enoxaparin comes in prefilled syringes to prevent dosing errors. The bubble should not be expelled before administration. If the drop is expelled, part of the dose would be wasted. ✓ Enoxaparin is administered subcutaneously. It should be injected at either a 90 or 45-degree angle. This medication should only be administered in the abdomen and not rubbed afterward. ✓ Enoxaparin is a low molecular weight-based heparin that does not require monitoring the activated partial thromboplastin time (aPTT). ✓ The nurse still needs to monitor the client for bleeding as well as heparin-induced thrombocytopenia (HIT). HIT would manifest as a reduction of platelets and may seriously cause thrombosis elsewhere. ✓ Contraindications to administering enoxaparin include recent spinal surgery, epidural, peptic ulcer disease, thrombocytopenia, and uncontrolled hypertension. ✓ The antidote for enoxaparin is protamine sulfate.

The nurse is caring for a client with human immunodeficiency virus (HIV). It would be appropriate for the nurse to assign the client to a room with the client diagnosed with A. infectious mononucleosis. B. mycoplasma pneumonia. C. gastroenteritis (rotavirus). D. mumps (infectious parotitis).

Choice A is correct. Infectious mononucleosis (IM) requires standard precautions. Disease transmission is spread by prolonged exposure to human saliva and is difficult to spread. Often IM is referred to as the 'kissing disease' because prolonged kissing may transmit this pathogen. It is appropriate to place a client with HIV in the same room as a client with IM. HIV requires standard precautions. Choice B is incorrect. A client with mycoplasma pneumonia requires droplet precautions. It would be inappropriate to place this client in the same room with a client with HIV because there is a potential for disease transmission. A client with HIV requires standard precautions. Choice C is incorrect. A client with rotavirus requires contact precautions. The nurse should not place this client in the same room with a client with HIV. Rotavirus can be prevented through childhood vaccination starting at two months of age. Choice D is incorrect. Mumps (infectious parotitis) requires droplet precautions. The nurse should not place this client in the same room as a client with HIV. Mumps can be prevented through vaccination starting at twelve months of age. ✓ Standard precautions require the use of hand hygiene and additional personal protective equipment as needed ✓ Common diseases/disorders requiring standard precautions include AIDS, HIV, Hepatitis A*, B, and C * For those with hepatitis A and incontinent of stool or diapered, they will need to be placed in contact precautions

The nurse is caring for a 10-year-old client with a tracheostomy tube. The nurse notes that the client has a large volume of secretions and prepares to suction the client. Which of the following actions should she take first? A. Hyperoxygenate the client B. Ask the client to take a deep breath C. Place the client supine D. Notify the RN

Choice A is correct. It is necessary to hyperoxygenate the client prior to taking any of the other actions. This is one of the first steps in suctioning a tracheostomy. The nurse hyperoxygenates the client to prepare them for the procedure and prevent desaturations. The nurse then inserts the suction catheter without suctioning to the pre-measured depth, applies intermittent suction and rotates the suction catheter as it is removed from the tracheostomy. Choice B is incorrect. It is unnecessary to ask the client to take a deep breath prior to suctioning their tracheostomy. The nurse should hyperoxygenate the client first. Choice C is incorrect. Placing the client supine is not specifically necessary for suctioning a tracheostomy. The client can be in any position of comfort where the tracheostomy can easily be accessed. For some clients, they may be sitting up in bed or up in a chair. For pediatric clients it can be helpful to place a roll under their shoulders, hyperextending the neck so that you may better reach the tracheostomy. Choice D is incorrect. It is unnecessary to notify the RN if the client needs suctioning. The nurse may proceed with this intervention. ✓ Explain procedures and interventions to the 10-year-old client in an age-appropriate manner. Use simple and clear language to ensure they understand what is happening. ✓ Empower the child by allowing them to make simple decisions about their care, such as choosing when to suction (if possible). ✓ Suctioning can be uncomfortable for the client. Ensure they are as comfortable as possible during the procedure and provide emotional support.

The nurse is collecting data on a client with Paget's disease. Which of the following would be an expected finding? A. Bone deformities B. Berry aneurysm C. Heberden's nodes D. Janeway lesions

Choice A is correct. Paget's disease is a disease caused by a bone becoming weakened and remodeled, which may result in deformities. The most common area this inappropriate bone remodeling affects is the skull, pelvis, and spine. Choices B, C, and D are incorrect. Berry aneurysm is an aneurysm that may cause an individual to have a hemorrhagic stroke. This is a common finding for an individual with polycystic kidney disease. Heberden's nodes are a physical feature associated with osteoarthritis. Janeway lesions are an expected finding associated with bacterial endocarditis. These lesions are commonly found on the soles of the feet and the hands. ✓ Paget's disease is a disease characterized by accelerated bone remodeling ✓ The may cause an individual to be asymptomatic or have pain in the affected bone(s) ✓ The client will be at a higher risk for fracture during this disease process and may eventually develop bone deformities

What complication should the nurse monitor for during the immediate postoperative time following a thoracentesis? A. Pneumothorax B. Infection C. Dyspnea D. Aspiration

Choice A is correct. The most immediate postoperative risk factor is pneumothorax. Symptoms of pneumothorax include dyspnea, chest pain, shortness of breath, and pain. Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove pleural effusion (excess fluid) from the pleural space to ease breathing. Some conditions, such as lung disease/infections, heart failure, and tumors, may cause pleural effusion. All procedures have some risks. The risks of this procedure may include the following: air in the space between the lung covering (pleural space) that causes the lung to collapse (pneumothorax), bleeding, infection, and liver or spleen injury (rare). Choice B is incorrect. Infection would not be evident during the immediate postoperative period. Choice C is incorrect. Dyspnea is a sign of pneumothorax. Choice D is incorrect. Aspiration is not a complication related to thoracentesis NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Aspiration/Biopsy

Which of the following statements correctly outlines the proper flow of blood through the heart? A. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → pulmonary valve → pulmonary artery → lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation. B. Superior and Inferior vena cavas → Right atrium → mitral valve → Right ventricle → pulmonary valve → pulmonary artery → lungs → pulmonary veins → left atrium → tricuspid valve → left ventricle → aortic valve → aorta → systemic circulation. C. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → pulmonary valve → pulmonary veins→ lungs → pulmonary artery → left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation. D. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → aortic valve → pulmonary veins→ lungs → pulmonary artery → left atrium → mitral valve → left ventricle → pulmonary valve → aorta → systemic circulation

Choice A is correct. This is the proper flow of blood through a healthy heart with normal anatomy. The superior and inferior vena cavae are the large veins that bring back deoxygenated blood from the body to the heart's right atrium. The blood enters the right atrium, passes through the tricuspid valve into the right ventricle, and is then pumped into the lungs through the pulmonary artery. In pulmonary circulation, the deoxygenated blood drops off its carbon dioxide plus waste products and picks up fresh oxygen to deliver to the body. Blood is now oxygenated. The blood returns to the left atrium through the pulmonary veins that pass through the mitral valve to enter the left ventricle which is then pumped out to the body through the aorta. Oxygenated blood is now in the systemic circulation, where it can deliver oxygen to all the tissues of the body. Choice B is incorrect. In this sequence, the mitral and tricuspid valve locations are switched. Remember, the mitral valve is between the left atrium and ventricle, and the tricuspid valve is between the right atrium and ventricle. Choice C is incorrect. In this sequence, the pulmonary artery is switched with the pulmonary vein. The pulmonary artery carries deoxygenated blood away from the heart to the lungs. It is the only artery in the body that carries deoxygenated blood. The pulmonary vein brings oxygenated blood back from the lungs to the left atrium. Choice D is incorrect. In this sequence, the pulmonary and aortic valves are switched. This should be easy to remember, as the valves are named after which vessel they open into. The pulmonary valve is located at the opening of the pulmonary artery, and the aortic valve is located at the opening of the aorta. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Risk of a potential reduction - Cardiac

The nurse is performing medication administration for four clients. Which client and medication should be administered first? Client One: prednisone 10 mg PO daily for asthma exacerbation Client Two: acetaminophen 500 mg PO one dose for fever Client Three: magnesium oxide 250 mg PO daily for chronic alcoholism Client Four: glargine insulin 15 units SubQ daily for diabetes mellitius A. Client one B. Client two C. Client three D. Client four

Choice A is correct. This medication is prescribed for a client with an asthma exacerbation which is an acute problem. Additionally, this acute problem is dealing with the client's breathing status, prioritizing a fever, diabetes, and chronic alcoholism. Choices B, C, and D are incorrect. The client with a fever prescribed acetaminophen will require treatment but does not prioritize over the acute respiratory ailment of an asthma exacerbation. Diabetes and alcoholism are chronic medical problems that would not require immediate administration of the prescribed medications when competing with a client an acute asthma exacerbation. Acute problems prioritize over chronic problems. Further, when faced with multiple acute problems using the approach of ABC (airway, breathing, circulation) is an additional framework that can be used to determine which client situation should be addressed first.

The licensed practical/vocational nurse (LPN/VN) reinforces teaching a client about newly prescribed isoniazid (INH) for pulmonary tuberculosis. Which of the following statements by the client would require follow up? A. "I will have to take this medication for three months." B. "I will need to have my blood drawn periodically to see if I am having an adverse effect to this medication." C. "I will not be considered infectious if I have three consecutive negative sputum samples." D. "This medication may make my hands and feet have numbness and tingling sensations."

Choice A is correct. This statement requires follow-up because it is not accurate. Antitubculin medications must be taken for six to nine months to complete treatment and prevent resistance. If the client is at risk of poor treatment adherence, they may be ordered directly observed therapy where an individual supervises the client to take their medication. Choice B is incorrect. This statement is accurate and does not require follow-up because INH may cause hepatic injury and blood dyscrasias. The client will need periodic blood specimen collections to determine if they are experiencing anemia, transaminitis, or thrombocytopenia. Choice C is incorrect. The client will be considered noninfectious if they have three consecutive negative sputum tests for acid-fast bacilli (AFB). One of the sputum specimens must be collected in the morning. Choice D is incorrect. INH may cause a client to experience peripheral neuropathy, described as a pins and needles sensation. This is why a client is prescribed pyridoxine to attenuate these sensations. ✓ INH is the first-line therapy for pulmonary tuberculosis. ✓ This agent is often combined with another antitubercular medication because of emerging drug resistance. ✓ Hepatotoxicity is the most common adverse effect of most antitubercular drugs. ✓ The client should immediately report signs of hepatotoxicity, such as jaundice and clay-colored stools. ✓ INH may cause a client to develop peripheral neuropathies. Pyroxidine (vitamin B6) is commonly prescribed to prevent this occurrence.

While working in the emergency department, you triage a 29-year-old female who states, "I am going to kill myself. They are coming for me!" Which of the below responses utilizes therapeutic communication? A. You are safe here; can you tell me more about what is happening? B. Please don't try to kill yourself; we will sedate you if we have to. C. Why would you kill yourself? D. Who is coming for you?

Choice A is correct. This statement uses therapeutic communication by helping the client feel safe and asking open-ended questions to gather more information. Choice B is incorrect. Telling the client not to kill themselves will not work for this client. Instead, it will increase the likelihood of them trying to do so. Furthermore, it is never therapeutic to threaten to sedate a client. Choice C is incorrect. Asking 'why' questions are never therapeutic communication. This can seem judgmental and make the client defensive rather than open to you. Choice D is incorrect. This question endorses the client's thought that someone is coming for them by asking them who they are. This is also a closed-ended question that will not promote further conversation. In therapeutic communication, you should use open-ended questions. ✓ Ensure the individual's immediate safety by closely monitoring and providing a safe environment, including removing any potential means of self-harm. ✓ Engage in active listening, allowing the person to express their feelings and thoughts without interruption or judgment. ✓ Collaborate with the healthcare team, including mental health professionals, to develop a comprehensive care plan.

The nurse is caring for a client who is receiving prescribed varenicline. Which of the following statements, if made by the client, would indicate a therapeutic response? A. "I am not smoking cigarettes anymore." B. "My depression has gotten better." C. "I am sleeping eight hours a night." D. "I can focus on one task at a time."

Choice A is correct. Varenicline is a medication intended to reduce nicotine withdrawal symptoms and cravings. Following the initiation of varenicline, the client's comments that they are not smoking cigarettes anymore indicate varenicline has been therapeutically effective. Clients go back to resuming tobacco smoking if the withdrawal symptoms are not appropriately treated. Choices B, C, and D are incorrect. Varenicline may cause depression and suicidal ideation. It does not therapeutically assist with depressive symptoms, insomnia, or focus. Another medication used for smoking cessation called bupropion assists with depression. ✓ A combination of medications and behavioral therapy works best for smoking cessation rather than either treatment alone ✓ Most smoking cessation medications work by reducing nicotine withdrawal and cravings ✓ Medicines for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion ✓ Varenicline is a preferred option for most clients. Varenicline is administered as an oral pill ✓ It works by relieving nicotine withdrawal symptoms and blocking the smoking-related reward feeling. ✓ For a client taking varenicline, starting the medication one week before quitting cigarettes is recommended ✓ The client may continue the treatment for up to twelve weeks. ✓ The most common side effect of varenicline is nausea. Neuropsychiatric effects such as vivid dreams, depression, and suicidal ideation have been reported.

The nurse is collecting data on a child with bilateral lower extremity chemical burns. The nurse suspects that the child may have been abused. The nurse should take which initial action? A. Cover the affected area with sterile dressing B. Irrigate the affected area with saline C. Report the suspected abuse D. Document the findings

Choice B is correct. A common mnemonic to remember is "the solution to pollution is dilution." When a client has a chemical burn, the highest priority is to copiously irrigate it (dilute it) with saline or water. Prompt irrigation of the area exposed to caustic substances ( acid, alkali) dilutes the chemical, attempts to neutralize the pH change in the skin, and decreases the extent of the dermal injury. Additionally, dilution lessens the risk of the caregiver getting burned by the chemical. Choices A, C, and D are incorrect. All of these actions are appropriate, but the nurse should not prioritize these actions over caring for the client's immediate physical needs ( applying Maslow's hierarchy while answering priority questions, one should address the physical needs first). Before suspected abuse should be reported ( Choice C), the nurse should stabilize the client. Irrigation to decrease further damage to the client's integument is the highest priority with any chemical burn.

The nurse reviews prescriptions for packed red blood cell (PRBC) transfusions. Which PRBC transfusion should the nurse question with the primary healthcare provider (PHCP)? A client A. with a febrile illness. B. with pulmonary edema. C. receiving mechanical ventilation. D. with a chest tube for a hemothorax.

Choice B is correct. A unit of PRBCs will add fluid volume, and if the client has pulmonary edema, the unit of blood should be questioned with the PHCP until the edema has resolved. Giving a unit of PRBCs may worsen pulmonary edema. Clients at risk for transfusion-associated circulatory overload (TACO) will need to receive their unit of PRBCs slower and may require diuretics after the blood has been administered. Choices A, C, and D are incorrect. A febrile illness is not a contraindication for a blood transfusion. It may make recognizing a febrile reaction more difficult. Still, it can be done by using the client's baseline temperature and looking for other clinical features such as chills, tachycardia, and tachypnea. Mechanical ventilation is not a contraindication to a client receiving blood products. The nurse must recognize other reaction manifestations, such as pallor, fever, tachycardia, and hypotension. A client with a chest tube for a hemothorax is not a contraindication for administering a blood product. If the hemothorax causes that much bleeding, a transfusion is much more likely to prevent shock. ✓ The nurse should remain with the client during a transfusion's first fifteen to thirty minutes to observe for a hemolytic or allergic reaction. ✓ The universal blood donor type is O negative; the universal blood type for recipients is AB positive. ✓ A unit of PRBCs should be transfused over 2-4 hours using Y-type tubing. ✓ 20-gauge intravenous (IV) catheter should be used to administer a blood product. ✓ The nurse should verify the client's identification, blood product, and compatibility with a second nurse prior to transfusion.

Which nursing diagnosis would be the highest priority for a patient with a medical diagnosis of Bell's palsy? A. Risk for infection B. Risk for disturbed sensory perception C. Risk for disturbed body image D. Risk for ineffective tissue perfusion

Choice B is correct. Bell's palsy causes acute facial paralysis or weakness in the muscles supplied by cranial nerve VII, which can result in difficulty closing the eyelid, increased sound sensitivity, altered sense of taste, difficulty chewing/swallowing, and pain. Choice A is incorrect. Bell's palsy may be caused by inflammation and viral infections, but the patient would not be at a higher risk for developing an infection due to facial muscle weakness. Choice C is incorrect. This patient would be at risk for disturbed body image, but this would be a psychological nursing diagnosis and would not be a higher priority than disturbed sensory perception. Choice D is incorrect. Bell's palsy would not put this patient at increased risk for impaired tissue perfusion. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse is collecting data on a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory test requires careful monitoring? A. Potassium B. Sodium C. Glucose D. Magnesium

Choice B is correct. Dilutional hyponatremia may occur from SIADH from the excess water caused by the antidiuretic hormone. The hyponatremia may be so severe that it may cause neuromuscular weakness and seizure activity. Choice A is incorrect. While potassium levels are important to monitor, they are not typically as directly affected by SIADH as sodium levels. Choice C is incorrect. Glucose levels are not directly affected by SIADH. Choice D is incorrect. While magnesium levels are important, they are not typically affected by SIADH as directly as sodium levels. ✓ SIADH is characterized by excessive antidiuretic hormone release. ✓ The most common cause of SIADH is small-cell lung cancer. Other causes include traumatic brain injuries and medications (carbamazepine, fluoxetine). This excess of ADH causes the client to retain water without peripheral edema. ✓ Other clinical features of SIADH include hyponatremia, oliguria, excessive thirst, and hemodilution. ✓ A good memory device is recalling that the SI in SIADH stands for soaked inside because the client is soaked inside with water. ✓ Keep a close track of the client's fluid intake and output. SIADH leads to water retention, and excessive fluid intake can worsen hyponatremia. Document any changes in urinary output and report them to the registered nurse or healthcare team. ✓ Observe the client for signs of neurological changes, such as confusion, lethargy, headache, seizures, or altered consciousness. Hyponatremia can affect the brain, and prompt intervention is crucial.

After reporting to her usual adult medical-surgical floor, the LPN is told she must float to the mother-baby unit. The LPN has never cared for this patient population before. Which of the following actions is most appropriate? A. Refuse the assignment. B. Float to the mother-baby unit and identify tasks within her training that she can safely perform. C. Call the nurse manager. D. Float to the mother-baby unit and ensure no one knows her inexperience.

Choice B is correct. Floating to the mother-baby unit and identifying tasks within her training that she can safely perform is the correct action. This promotes patient safety and benefits both the nurse and the unit. Choice A is incorrect. It is inappropriate to refuse the assignment. Nurses may be asked to float to another unit, depending on the hospital census, and it is not beneficial to refuse to take an assignment if asked to float. Choice C is incorrect. It is not appropriate to call the nursing manager. Floating is an acceptable legal practice used by the hospital to solve understaffing. Choice D is incorrect. Floating to the mother-baby unit and ensuring not to let anyone there know she does not have experience in this area is inappropriate and does not promote patient safety. The nurse should identify tasks that she can safely perform. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Fundamentals of care - Ethical & Legal Issues

The nurse knows that Hemophilia is an X-linked recessive disorder. If an unaffected man and a woman who is a carrier have a baby, what percent of their male offspring would be expected to have hemophilia? A. 25% B. 50% C. 75% D. 100%

Choice B is correct. If an unaffected man and a woman who is a hemophilia carrier have a baby, their male offspring have a 50% chance of getting hemophilia. To complete this problem, you should use a Punnett square. The nurse knows that the allele for hemophilia is X-linked. "H" is the normal allele, and "h" is an abnormal allele. An unaffected male has the genotype XHY, and a carrier woman has the genotype XHXh. She is a carrier because she does not have hemophilia (remember it is recessive, so her 'H' normal allele is what her phenotype will show), but she can pass down the 'h' abnormal allele to her offspring. The question asks about the probability of the male offspring having hemophilia. The male offspring will receive a Y chromosome from their father and either an XH normal allele or an Xh abnormal allele from their mother. This means their possible genotypes are XHY or XhY. There is a 50% chance that they will be unaffected (XHY) and a 50% chance that they will have hemophilia (XhY). Choice A, B, and C are incorrect. In this scenario, there is a 50% chance of male offspring having hemophilia. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Risk of the potential reduction

The nurse reviews a client's medication record who takes prescribed sildenafil. Which medication should the nurse clarify with the primary healthcare provider (PHCP)? A. Lisinopril B. Isosorbide C. Atorvastatin D. Losartan

Choice B is correct. Isosorbide is a nitrate medication and should not be taken concurrently with phosphodiesterase inhibitors such as sildenafil. The combination of the two may result in profound hypotension. Choices A, C, and D are incorrect. Lisinopril is an ACE inhibitor and has no adverse interaction with Isosorbide. Lisinopril is indicated for hypertension and congestive heart failure. Atorvastatin is indicated for hyperlipidemia and has no interaction with isosorbide. Losartan is an ARB and is indicated for congestive heart failure or hypertension. It has no adverse interaction with isosorbide. Phosphodiesterase inhibitors such as sildenafil, tadalafil, and vardenafil are indicated to treat erectile dysfunction and pulmonary hypertension. The client should not take these medications concurrently with nitrates.

The nurse is caring for a client who has sickle cell disease (SCD). Which of the following laboratory findings would require follow-up? A. Hemoglobin 11.2 mg/dL B. Creatinine 2.5 mg/dL C. BUN 19 mg/dL D. Platelet count 150,000 mm3

Choice B is correct. One of the many complications associated with sickle cell disease is renal injury. The significantly elevated creatinine requires follow-up because this is evidence of significant renal insufficiency. Choices A, C, and D are incorrect. The hallmark of sickle cell disease is anemia. Hemoglobin of 11.2 mg/dL illustrates the cardinal sign of this disease (normal hemoglobin for males 14-18 g/dL; 12-16 for females). The BUN is normal (10 mg/dL-20 mg/dL) and does not require follow-up. The platelet count is normal (150,000 - 400,000 mm3) and does not require follow-up. Sickle cell disease (SCD) is a serious genetic disorder that causes abnormalities in hemoglobin. The client has an increased presence of hemoglobin S compared to a decreased hemoglobin A. Several complications with SCD may occur and include: Stroke Pulmonary hypertension Myocardial infarction Infection Priapism Venous thromboembolism

The nurse is assessing a client with post-traumatic stress disorder (PTSD). Which assessment finding would be expected? A. Delusions of grandeur B. Hypervigilance C. Circumstantial speech D. Flight of ideas

Choice B is correct. PTSD is characterized by an individual who has experienced (or witnessed) a traumatic event such as sexual assault, combat, violence, or medical illness. The client then experiences significant cognitive, affective, and behavioral responses to stimuli reminding them of the trauma they experienced. This chronic psychiatric condition causes a client to experience manifestations such as night terrors, avoidance of anything that may trigger trauma memories, being easily startled, decreased concentration, hypervigilant, and sleep disturbances. This may cause the client to feel 'always on edge.' Dissociative symptoms may occur with PTSD, such as derealization or depersonalization. Choices A, C, and D are incorrect. Delusions of grandeur (false self-inflated view of themselves), circumstantial speech (speech pattern that takes a long time to get to the point), and flight of ideas (flood of unrelated ideas) are all manifestations associated with mania that may be found in bipolar disorder. These are not features of PTSD as the client may become more affectively constricted and socially retract. ✓ PTSD is a condition that requires trauma leading to intrusive symptoms, avoidance of particular stimuli, alterations in mood, and hyperactivity. ✓ Clinical features include hyperarousal, social retraction, hypervigilance, night terrors, and potentially dissociative symptoms. ✓ This is a chronic disorder that responds favorably to psychotherapy. ✓ Other treatments include prazosin for night terrors and SSRIs (such as citalopram) for mood symptoms. ✓ Nursing care aims to build and maintain a therapeutic rapport with the client, encourage the verbal expression of feelings, and provide opportunities for therapeutic group therapy.

The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)? A. Loratidine B. Saw Palmetto C. Furosemide D. Pantoprazole

Choice B is correct. Saw Palmetto is an over-the-counter supplement purported to decrease symptoms of benign prostatic hyperplasia. This medication should be used with caution if it is administered with warfarin. Warfarin is an anticoagulant; if the client takes both concurrently, it may potentiate the anticoagulant effect. The primary healthcare provider (PHCP) must be made aware of this interaction. Choices A, C, and D are incorrect. Loratidine is a histamine antagonist used for allergies. Furosemide is a loop diuretic used for edema and hypertension. Pantoprazole is used for peptic ulcer disease and GERD. None of these medications interact with warfarin. ✓ Saw palmetto is purported to treat benign prostatic hyperplasia and alopecia ✓ Saw palmetto is believed to inhibit dihydrotestosterone and 5-alpha reductase ✓ This medication should be used with the prescriber's approval if the client is taking anticoagulants or medications for erectile dysfunction, as the medication may potentiate the anticoagulant effects

The nurse is monitoring a 10-year-old patient status post-tonsillectomy. Which of the following observations should be immediately reported to the healthcare provider? A. Drooling B. Frequent swallowing C. Sneezing D. Moaning

Choice B is correct. Swallowing is a sign of hemorrhage and should be immediately reported to a healthcare provider. If the patient has a hemorrhage at the surgical site in the back of their throat there will be blood running down the back of their throat causing them to constantly swallow. The nurse must monitor closely for this complication. Choice A is incorrect. Drooling in a patient who has just had a tonsillectomy is not uncommon and does not need to be immediately reported to a healthcare provider. Drooling would likely indicate inflammation around the surgical site at the back of the throat making it painful to swallow. The painful swallowing causes drooling. Since this is to be expected, it does not need to be reported immediately. Choice C is incorrect. Sneezing is not a sign of any postoperative complication. It does not need to be closely monitored for nor reported immediately to a healthcare provider. Choice D is incorrect. Moaning would likely indicate pain, which is to be expected in a child who has had surgery. They should have orders for PRN pain medications that the nurse may administer. Moaning would not be a reason that the nurse must immediately notify the healthcare provider. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Risk potential reduction; Pediatric - HEENT

Which advice is most appropriate for a client on neutropenic precautions who wants to learn ways to prevent infection? A. Only brush your teeth once a day or every other day. B. Avoid the use of tampons for menstrual periods. C. Do not let visitors within 10 feet. D. Wash hands after handling pets.

Choice B is correct. Tampons may cause tears in the vagina that could lead to infection. Tampons can introduce harmful bacteria into the vaginal canal, especially during insertion and removal. This risk is significant for neutropenic clients, as their weakened immune system may not be able to fight off infections effectively. Choice A is incorrect. Teeth should be brushed twice daily with a soft toothbrush to help prevent infection. Choice C is incorrect. Healthy visitors are usually okay. However, it may be best for them to wear a mask, gown, or gloves when in close contact in some circumstances. Choice D is incorrect. People with low WBCs should avoid cleaning up after pets and have others take on this task. ✓ Toxic Shock Syndrome (TSS): TSS is a rare but serious condition associated with tampon use, which can lead to life-threatening complications. Neutropenic clients may be at higher risk of severe infections, including TSS, due to their compromised immune response. ✓ Emphasize the importance of practicing proper hand hygiene. Encourage the client to wash their hands frequently with soap and water for at least 20 seconds or to use alcohol-based hand sanitizers when soap and water are not available. ✓ Instruct the client to avoid consuming uncooked or raw foods, as they may carry harmful bacteria. Encourage them to focus on a well-balanced diet with cooked, pasteurized, or properly prepared foods. ✓ Remind the client to stay away from individuals who have known infections or illnesses, especially respiratory infections.

A client has been marked as "confidential" due to safety concerns. Which of these actions would be inappropriate for the nurse? A. Keep the client's name/information out of public areas such as the nurse's station. B. Tell the client's mother he is okay when she calls to ask if he is still on the unit. C. Deny that the client is on the unit when visitors come or call. D. Remove the client from confidential status when he asks to be removed.

Choice B is correct. When a client has asked to be flagged as confidential, no medical personnel can give out any information, including verifying the client's presence, in the hospital. This option violates the principle of confidentiality. Choice A is incorrect. This action is appropriate and necessary to maintain the client's confidentiality. Public areas should not display any information that could identify the client to unauthorized individuals. Choice C is incorrect. The nurse should follow the facility's policies and procedures for handling inquiries about a "confidential" client. When a client is at risk of harm or in a "confidential" status due to safety concerns, there are circumstances where healthcare providers, including nurses, may need to use therapeutic deception or withhold specific information from callers or visitors if disclosing such information could jeopardize the client's safety. Choice D is incorrect. This option is inappropriate without appropriate evaluation and a valid reason. The decision to label a client as "confidential" due to safety concerns is made based on a careful assessment of potential risks and threats. ✓ Healthcare professionals must ensure that they maintain the confidentiality of all client information, both in written and electronic formats. ✓ Use secure communication methods when discussing a client's personal or medical information. Avoid discussing sensitive details in public areas where unauthorized individuals may overhear. Use password-protected electronic devices and ensure that computer screens are not visible to others when accessing client records. ✓ Limit access to the client's medical records and information to only those healthcare professionals directly involved in their care. Nurses should not share confidential information with colleagues or family members who are not part of the healthcare team.

The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication? A. valacyclovir B. zidovudine C. amphotericin b D. metronidazole

Choice B is correct. Zidovudine (ZDV) is an antiretroviral medication that may be administered intrapartum to further reduce vertical transmission of HIV. This medication is commonly indicated for women who have a scheduled cesarean delivery or, in the rare instance of a vaginal delivery. This medication is preferred because it may be administered intravenously and can provide pre-exposure prophylaxis to the fetus. Whether this medication is prescribed and administered intrapartum depends on the mother's viral load. The lower the viral load, the less likely of transmission to the fetus. Choice A is incorrect. Valacyclovir is an antiviral indicated in the treatment of herpes simplex. This medication may be used during pregnancy, despite the limited safety profile. Choice C is incorrect. Amphotericin b is an antifungal drug indicated in treating systemic fungal infections. Choice D is incorrect. Metronidazole is an effective antibiotic indicated for bacterial and parasitic infections such as vaginosis and trichomonas. ✓ Women should continue taking their antiretroviral therapy (ART) regimen as much as possible during labor and delivery or scheduled cesarean delivery ✓ Zidovudine is an intravenous antiretroviral that is administered intrapartum to reduce vertical transmission further ✓ To further reduce HIV transmission during labor and delivery, avoid fetal scalp electrode monitoring when possible ✓ To identify HIV infection in infants and young children (less than 18 months), HIV viral load (VL) testing must be performed using assays that detect HIV deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) ✓ Antibody tests are not accurate because the infant acquires maternal antibodies, which may cause a false positive ✓ Cord blood should not be used for testing because of the possibility of contamination of the sample with maternal blood

Your client is receiving a non-steroidal anti-inflammatory drug (NSAID) in addition to a narcotic analgesic. The client wonders why an NSAID is necessary since the narcotic analgesic offers better pain relief. How would you respond to the client's question? A. I don't know and I suggest that you ask your doctor when you see her the next time. B. You are getting the NSAID because we are trying to wean you off the narcotic analgesic for moderate to severe pain. C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective. D. You are getting the NSAID because it is a placebo, and it is proven to be effective for severe pain.

Choice C is correct. "You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective" is an appropriate response to the client's query. An NSAID is an "adjuvant" medication used in combination with narcotic analgesics to treat moderate to severe pain. Adjuvant pain medications are used to enhance pain relief provided by other analgesics. The primary function of NSAIDs is to reduce inflammation. Therefore, NSAIDs are helpful in treating the pain caused by inflammation. Choice A, B, and D are incorrect. This response ( Choice A) is inappropriate because the nurse is expected to address the client's question without referring the client to the physician. The nurse is expected to have basic understanding of various types of analgesics or be able research why the NSAID is being given. If the nurse is unable to find the information herself, she should ask the physician and attempt to address the client's concern before simply referring the client to the physician. Narcotic analgesic with or without an NSAID is an appropriate intervention for moderate to severe pain. While weaning the client off the opioid analgesic should be definitely considered, there is no information in the question regarding adequate pain control before considering weaning (Choice B). If the client's pain is adequately controlled on non-opioid medications, then opioid weaning can be attempted. Weaning opioids may take 6 months or more depending on the total baseline opioid dose and the individual client's response to the opioid wean. NSAID is not a placebo ( Choice D). NSAIDs can be used primarily to treat inflammatory pain or as an adjuvant analgesic.

While working in the emergency department, the nurse sees the following clients, and recognizes which of them is at highest risk for elder abuse? A. A 70-year-old female with orthostatic hypotension B. An 86-year-old female with glaucoma C. A 92-year-old male with late-stage Alzheimer's disease D. A 75-year-old male with leukemia

Choice C is correct. A 92-year-old male with late-stage Alzheimer's disease is at very high risk for elder abuse. This can include both physical and psychological abuse. Elders with late-stage Alzheimer's disease are at very high risk because of the memory loss and confusion that occurs with this disease. Choice A is incorrect. A 70-year-old female with orthostatic hypotension may be at risk for elder abuse as it is a widespread issue that can occur to any elder, but there is another answer choice with a higher risk individual. Choice B is incorrect. An 86-year-old female with glaucoma may be at risk for elder abuse as it is a widespread issue that can occur to any elder, but there is another answer choice with a higher risk individual. Choice D is incorrect. A 75-year-old male with leukemia may be at risk for elder abuse as it is a widespread issue that can occur to any elder, but there is another answer choice with a higher risk individual. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Geriatrics - Mental Health

The nurse is caring for a patient who is experiencing acute mania. Which of the following actions should be prioritized by the nurse? A. Plan structured solitary activities B. Redirect the patient's speech and ideas C. Provide high-calorie, small, frequent meals D. Initiate a psychiatry referral

Choice C is correct. A client experiencing acute mania manifests symptoms such as inflated self-esteem, flight of ideas, psychomotor agitation, and an expansive effect. The client experiencing mania often has difficulty sleeping and exerts excessive physical energy. Thus, the nurse needs to focus on ensuring that the client's need for nutrition is met by offering high-calorie, small, frequent meals. This is the priority based on Maslow's Hierarchy of Needs. Choices A, B, and D are incorrect. Structured solitary activities are recommended for a client experiencing mania because group activities may trigger conflict. The nurse should redirect the patient's fragmented speech and ideas as well as consult psychiatry. However, this is not the priority over the patient's physical need for appropriate nutrition. ✓ Assess the immediate environment for potential hazards, remove any objects that could be used to harm oneself or others, and ensure the client's physical safety. ✓ Use a calm and non-confrontational approach when communicating with the client. Maintain a respectful and empathetic attitude to establish trust. ✓ Building a therapeutic relationship is crucial. Take the time to listen actively, validate their feelings, and demonstrate understanding.

The nurse is caring for a client who is receiving prescribed acamprosate. Which of the following statements, if made by the client, would indicate a therapeutic response? A. "I no longer hear voices." B. "I have more motivation during the day." C. "I am not drinking alcohol anymore." D. "My anxiety has lessened in public."

Choice C is correct. Acamprosate is a medication intended to treat alcohol use disorder. This medication may be combined with naltrexone to increase the chance of sobriety. Choices A, B, and D are incorrect. Acamprosate is a medication that may decrease the craving for alcohol. This medication is not an antipsychotic and does not enhance motivation. Further, this medication is not intended for those with anxiety. ✓ Acamprosate is a prescribed treatment for alcohol use disorder. ✓ This medication decreases an individual's craving for alcohol. ✓ It is typically dosed three times a day, with the most common side effect being diarrhea. ✓ The client should be encouraged to seek counseling to help enhance their chances of abstinence.

The LPN is working on the pediatric floor caring for a 2-year-old who receiving 100% FiO2 via a nasal cannula. At the end of her shift, the hospital receives a tornado warning. Which of the following actions should the nurse take to best protect her patient? A. Clock out, her shift is over and she is not responsible. B. Remove the nasal cannula and carry the child to a tornado shelter. C. Move the patient as close to the interior of the room as possible. D. Close all of the doors.

Choice C is correct. During a tornado warning, the appropriate nursing action is to move patients away from windows and as close to the interior of the room as they can safely be moved. This best protects them in the event of a tornado. Choice A is incorrect. It is inappropriate to clock out because her shift is over. The nurse will always be responsible for the safety of her patients. This answer choice does not best protect her patient. Choice B is incorrect. It would never be appropriate to remove the nasal cannula. This could result in serious harm and even death if the child is dependent on oxygen therapy. This answer choice does not best protect the patient. Choice D is incorrect. Closing all of the doors will not protect the patient during a tornado. This is the appropriate action in the case of some fire events depending on the location of the fire, but never for a tornado. This answer choice does not best protect the patient. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Infection control and safety; Pediatrics - Safety

The nurse is conducting presurgical assessments on clients at an ambulatory care center. In which scenario should the nurse report to the surgeon, as it may necessitate postponing surgery? A. A 20-year-old client who is a vegan. B. An elderly client who intakes daily nutritional drinks. C. A 40-year-old client who takes ginkgo biloba and aspirin daily. D. An infant who is breastfeeding.

Choice C is correct. Ginkgo biloba (herbal), aspirin, and vitamin E all have anticoagulant properties. It is vital to notify the surgeon about these medications to decrease the client's risk of excessive bleeding. Choice A is incorrect. Being a vegan, or following a plant-based diet, does not in itself pose a contraindication for surgery or require immediate reporting to the surgeon. Choice B is incorrect. An elderly client consuming daily nutritional drinks does not raise any immediate red flags for surgery postponement. Nutritional drinks are often used to supplement the diet and can be beneficial for providing essential nutrients to maintain overall health, including perioperative nutritional support. Choice D is incorrect. Breastfeeding in itself does not usually require postponement of surgery. ✓ Educate clients about the potential risks and benefits of herbal supplements and the importance of discussing their use with healthcare providers. Conduct a thorough assessment of the client's herbal supplement usage, including specific products, dosages, and duration of use. ✓ Recognize that the available information on herbal supplements may be limited and sometimes conflicting. Refer clients to reliable sources of information and encourage them to consult with their healthcare provider for evidence-based guidance. ✓ Advise pregnant or breastfeeding clients to exercise caution with herbal supplements, as their safety during these periods is often not well established. Some herbs can have adverse effects on pregnancy outcomes or breastfed infants.

The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is A. to attending scheduled group therapy. B. adhere to the medication regimen. C. gain one pound (half a kilogram) a week. D. demonstrate increased self-esteem.

Choice C is correct. Physical needs always prioritize over other needs. For the client with anorexia nervosa, the priority is to stabilize and increase the client's weight. Anorexia nervosa may lead to life-threatening electrolyte disturbances if it goes untreated. Choices A, B, and D are incorrect. Group therapy helps treat anorexia nervosa but having the client attend is not essential compared to weight gain. Medication plays little role in treating anorexia because no approved medication is available directly for anorexia. However, medications may be used off-label such as mirtazapine, to treat depressive symptoms and to promote weight gain. A decrease in self-esteem is common with anorexia nervosa but does not prioritize over the client's physical needs, which is dangerously low weight.

The nurse assists a registered nurse in developing a care plan for a client with psychosis associated with schizophrenia. Which of the following interventions would be appropriate? A. Provide therapeutic touch B. Set limits on splitting behavior C. Establish a trusting, non-threatening relationship D. Immediately restrain the client for verbal aggression

Choice C is correct. The most crucial goal for a person with schizophrenia is establishing a trusting relationship. This therapeutic rapport may help clients decrease their paranoia, which is commonly found in individuals with schizophrenia. Choice A is incorrect. Providing therapeutic touch for a client experiencing perceptual disturbances would be unhelpful because the client could misinterpret the touch as something negative. Choice B is incorrect. Splitting (seeing things or people as either all good or all bad) is a characteristic found in individuals with borderline personality disorder Choice D is incorrect. Restraints may be used for a client experiencing psychosis to protect the client from self-injury or from injuring others. However, it is absolutely inappropriate for the nurse to utilize restraints as a first-line intervention. Measures such as verbal descelation should be initially used. ✓ Schizophrenia is a psychiatric syndrome that impacts an individual's cognition, perception, mood, and affect. Positive (hallucinations, delusions), negative (apathy, alogia, anhedonia), and cognitive (problems with math and speech) symptoms vary by severity. ✓ Treatment is prescribed antipsychotics and psychotherapy. ✓ The treatment goals include stabilizing the client, minimizing residual psychotic symptoms, and maximizing the client's social function.

The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate? A. "Stop, you will kill your baby." B. "That is a nice, tight swaddle. It will help soothe your new baby." C. "May I help you? We will need to be careful with their intestines and we do not want the swaddle to push them back inside." D. "Swaddling is not allowed for these babies. Please stop."

Choice C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very loosely and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It also promotes bonding with the infant, as it encourages the parent to touch and care for their baby. Choice A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to promote the parent bonding with their infant, so phrases like this will scare the parent and make them afraid to touch the baby, which is not therapeutic. Choice B is incorrect. It is inappropriate to tightly swaddle an infant with an omphalocele. This would place pressure on their exposed intestines and push them back inside the baby, which we do not want. Choice D is incorrect. This is inappropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed intestines, but if it is done loosely and avoids placing pressure on the defect, it can certainly be done. Telling the parent to stop will not promote bonding and will decrease their interaction with the baby. The nurse should educate the parent on the necessary precautions when traveling and develop a positive relationship with their new baby. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Pediatrics - Gastrointestinal

The nurse is caring for a newborn. Which of the following actions would be appropriate for the nurse to take? A. Perform APGAR assessment at five and ten minutes B. Suctions the nose then the mouth C. Administer RhoGAM intramuscularly D. Obtain the first outfit from the warmer

Choice D is correct. A newborn is at risk of cold stress during the first few hours of post-intrauterine life. To prevent cold stress, the nurse should place the newborn skin-to-skin with a parent, obtain the first outfit out of a warmer, and dry the newborn thoroughly. Choices A, B, and C are incorrect. The APGAR assessment is completed at one and five minutes. If suctioning is indicated, the nurse should suction the mouth than the nose. Finally, medications administered to a newborn include intramuscular Vitamin K and erythromycin eye ointment. RhoGAM is indicated for Rh-negative mothers - not newborns. ✓ When caring for a newborn, the nurse should perform an APGAR assessment at one and five minutes. The higher the score, the more stable the newborn. Scores 7 to 10 are reassuring. The assessment evaluates a newborn's color, heart rate, reflexes, muscle tone, and respiration. ✓ Familiarize yourself with the specific newborn screening program in your area. Ensure appropriate tests are conducted, and follow up on any abnormal results or referrals. ✓ Support breastfeeding by providing guidance to the mother on proper latch and positioning techniques.

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

Choice D is correct. Consulting with a dietician is of the utmost importance for the patient who is suspected of having Celiac disease. The dietician is the expert in this area and will provide support, education, and a dietary plan for this patient. Learning to avoid gluten can be difficult for the family, and the dietician is the best resource to help them navigate this. Choice A is incorrect. A pharmacist may be involved in the intradisciplinary team, but there is another specialist of particular importance in the options (a dietician) for the patient with Celiac disease. Choice B is incorrect. It is not necessary to consult with a pulmonologist for a patient with Celiac disease. They should not be experiencing respiratory issues, as Celiac disease is a gastrointestinal disorder. Choice C is incorrect. It is not necessary to consult with an occupational therapist for a patient with Celiac disease. Celiac disease is a gastrointestinal disorder that should not affect the normal functioning and ADLs of this patient. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatrics Gastrointestinal

The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema? A. Assess for skin tenting over the sternum B. Weigh the patient at the same time daily C. Obtain a baseline BNP level D. Record the calf circumference daily

Choice D is correct. Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema. Choice A is incorrect. Checking for tenting is a technique to assess skin turgor for dehydration, not to monitor peripheral/dependent edema. Additionally, assessing for the turgor does not provide an accurate measure of dehydration in older patients due to loss of skin elasticity with age. Choice B is incorrect. Weighing the patient daily would be an appropriate method of monitoring for alterations in overall fluid status, but does not specifically address peripheral edema. Choice C is incorrect. BNP (B-type natriuretic peptide) reflects left ventricular presence/severity of heart failure. This value may be abnormal due to cor pulmonale, but would not specifically reflect the patient's level of edema. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

What is the highest priority nursing goal for a client whose hemoglobin is 10 g/dL(Male: 14-18 g/dL / Female: 12-16 g/dL) and hematocrit is 30%(Male: 42-52% / Female: 37-47%)? A. Encourage mobility B. Promote skin integrity C. Prevent constipation D. Conserve the client's energy

Choice D is correct. These test results indicate anemia. The impaired oxygen-carrying capacity of red blood cells causes cellular hypoxia which results in fatigue. Conserving energy limits oxygen expenditure and minimizes fatigue. The hematocrit, also known by several other names, is a blood test that measures the volume percentage of red blood cells in the blood. The measurement depends on the number and size of red blood cells. It usually is 40.7% to 50.3% for men and 36.1% to 44.3% for women. Hemoglobin, abbreviated Hb or Hgb, is the iron-containing oxygen-transport metalloprotein in the red blood cells of almost all vertebrates and the tissues of some invertebrates. Hemoglobin in the blood carries oxygen from the lungs or gills to the rest of the body. Choice A is incorrect. Increased mobility increases the oxygen demand and contributes to fatigue. Choice B is incorrect. Although hypoxic tissues are more vulnerable to breakdown, protecting the integumentary system is not as high a priority as promoting the body's overall oxygenation. Choice C is incorrect. Constipation is not a problem in anemia. NCSBN Client Need Topic: Physiological Integrity Subtopic: Reduction of Risk Potential; Blood Tests

The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication? A. 19 gauge, 1 1/2" (3.8 cm) needle B. 18 gauge, 1" (2.5 cm) needle C. 20 gauge, 1" (2.5 cm) needle D. 25 gauge, 5/8" (1.6 cm) needle

Choice D is correct. This needle size and gauge are appropriate for a neonate. When administering IM medications to a neonate or young child, the vastus lateralis is the preferred site. For the volume to be administered in an IM, it is recommended to be 0.5 mL or less for infants; up to 2 mL for children. Choices A, B, and C are incorrect. These needle sizes are not recommended for infants as they can cause excessive pain and trauma to the muscle. ✓ A key advantage of using the vastus lateralis is that an intramuscular (IM) injection may be given if the client is supine, side-lying, or sitting. ✓ Aspiration for routine injections into deltoid or vastus lateralis is not indicated because there are no large blood vessels in these locations. ✓ To locate the vastus lateralis, the nurse should palpate to find greater trochanter and knee joints; divide vertical distance between these two landmarks into thirds; inject into middle third.

The LPN is reviewing laboratory data for a client scheduled for surgery. Which laboratory data requires follow-up with the primary healthcare physician (PHCP)? Select all that apply. Calcium 7.9 mg/dl Potassium 3.3 mEq/l Sodium 143 mEq/l BUN 17 mg/dl Creatinine 0.9 mg/dl

Choices A and B are correct. A Calcium of 7.9 mg/dl is critically low (normal 9.0 - 10.5 mg/dl) and requires the nurse to follow up with the PHCP. Finally, potassium of 3.3 mEq/dl is low (normal 3.5 - 5.0 mEq/dl), and the PHCP should also be notified of this finding. Choices C, D, and E are incorrect. The laboratory values for the sodium (normal 135-145 mEq/dl), BUN (normal 10-20 mg/dl), and creatinine (0.6-1.2 mg/dl) are all within normal limits and do not require notification to the PHCP. When preparing a client for surgery, the nursing responsibilities include - Ensuring that all pre-procedure paperwork is completed, including consent and corresponding checklists. Nothing by mouth (NPO) status, if appropriate, was maintained. Appropriate attire and hygiene, including preprocedural bath with specified soap, clean gown, and anti-embolism stockings or sequential compression devices (SCDs). Recent laboratory data, including CBC, CMP, UA, clotting factors (PTT, PT/INR), and HCG if the patient is a female.

The nurse is collecting data on a child admitted with erythema infectiosum (Fifth disease). Which of the following would be an expected finding? Select all that apply. Erythema on face Headache Nuchal rigidity Hepatosplenomegaly Photophobia

Choices A and B are correct. Erythema infectiosum (Fifth disease) characteristically causes a child to develop erythema on the face (slapped face appearance). It also causes the appearance of maculopapular red spots distributed on the upper and lower extremities. Finally, the client will have mild flu-like symptoms such as a fever, headache, and malaise. Choices C, D, and E are incorrect. Nuchal rigidity and photophobia are characteristic of bacterial meningitis. Hepatosplenomegaly is an assessment found in mononucleosis. Erythema infectiosum (Fifth disease) The causative agent is Parvovirus B19 Mode of transmission for this pathogen is respiratory secretions and blood, blood products Isolation is not necessary unless the child is immunosuppressed (standard/droplet will then be used) Manifestations include erythema on the face (slapped face appearance). It also causes the appearance of maculopapular red spots distributed on the upper and lower extremities. Finally, the client will have mild flu-like symptoms such as a fever, headache, and malaise Treatment is primarily supportive (antipyretics and analgesics) A blood transfusion may be needed for transient aplastic anemia

The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply. Topiramate Risperidone Prazosin Hydroxyzine Lorazepam

Choices A and E are correct. Epilepsy is an idiopathic condition that requires maintenance treatment by using anticonvulsants. Topiramate is an anticonvulsant that may be used in the prevention of seizures. Lorazepam is also indicated for epilepsy in the event of a client experiencing an acute tonic-clonic or complex partial seizure. Topiramate should be used for maintenance purposes, and lorazepam would be indicated for an acute seizure. Choices B, C, and D are incorrect. Risperidone is indicated for psychotic disorders such as schizophrenia. Prazosin is an antihypertensive that may be used for high blood pressure. This medication also may be indicated for psychiatric illnesses such as PTSD. Hydroxyzine is indicated for anxiety disorders as well as allergic rhinitis. ✓ Epilepsy is an idiopathic condition that requires management with anticonvulsants such as topiramate, valproic acid, or phenytoin ✓ Acute seizures are managed with benzodiazepines such as lorazepam or diazepam ✓ During an acute tonic-clonic or complex partial seizure, the nurse should place the client on their side, loosen restrictive clothing, and anticipate a prescription for a parenteral benzodiazepine such as diazepam or lorazepam ✓ If a client is experiencing a tonic-clonic or complex partial seizure in the chair, they should be lowered to the ground and placed on their side

The nurse knows that which of the following are possible causes of constipation in the pediatric client? Select all that apply. Hirschsprung disease Spina bifida Iron supplements Psychosocial factors Changes in routine

Choices A, B, C, D and E are correct. A is correct. Hirschsprung disease can be a structural cause of constipation. In Hirschsprung disease, there is a lack of innervation in the colon's nerve cells, leading to an inability for the child to pass stool. B is correct. Spina bifida can be a structural cause of constipation. In Spina bifida, there is a loss of tone and sensation in the bowel, making them prone to constipation. C is correct. Iron supplements are a medication that commonly causes constipation. It is one of their most common side effects. Clients should be educated about this side effect and measures to prevent constipation. Sometimes a bowel regimen may be necessary. D is correct. Several psychosocial factors can cause constipation in pediatric clients. For example, a fear of using the toilet in public, a change in routine, difficult experiences passing stool, or painful stooling can cause constipation. E is correct. Changes in routine can contribute to constipation in children.

You are completing a health history of a 4-year-old male at the primary care office. When checking with his mother about fine motor development milestones, what do you expect that the 4-year-old can do? Select all that apply. Complete a puzzle with 5 or more pieces. Copy a triangle onto a piece of paper. Brushing teeth. Use a fork to eat dinner. Climbs stairs alternating feet without support Skip on 1 foot

Choices A, B, C, D, E, and F are all correct. These are all fine and gross motor skills that are expected in preschool-age children, 3 to 5 years old. Other motor developmental milestones include: pasting things onto paper, completing puzzles with 5 or more pieces, cutting out simple shapes with scissors, self-feeding, and brushing his teeth. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Pediatrics Development

Which of the following food choices would be suitable for a client with iron deficiency anemia? Select all that apply. Quinoa Liver Spinach Baked beans Dairy product

Choices A, B, C, and D are correct. A is correct. Quinoa is a good source of iron and an excellent recommendation for a client with iron deficiency anemia. In one cup of quinoa, there is about 3 mg of iron. B is correct. The liver is a good source of iron and an excellent recommendation for a client with iron deficiency anemia. In 3 oz of the liver, there are about 15 mg of iron. C is correct. Spinach is a good source of iron and an excellent recommendation for a client with iron deficiency anemia. In 100 grams of spinach, there is about 3 mg of iron. D is correct. Beans are a good source of iron and an excellent recommendation for clients with iron deficiency anemia. There is about 5 mg of iron in one cup of baked beans. Choice E is incorrect. E is incorrect. While dairy products contain essential nutrients, including calcium and protein, they can inhibit iron absorption. It is generally recommended to avoid consuming dairy products with iron-rich meals or iron supplements to maximize iron absorption. Here are some sources of iron-rich foods for children: ✓Lean meats: Beef, pork, lamb, or poultry (chicken, turkey). These meats provide heme iron, which is more easily absorbed by the body. ✓Fish and seafood: Particularly shellfish like clams, oysters, and shrimp, as well as fish such as salmon, tuna, and sardines. These are good sources of heme iron. ✓Legumes: Including beans, lentils, chickpeas, and soybeans. Legumes provide non-heme iron, which is still a valuable source of iron for children. ✓Dark leafy greens like spinach, kale, and Swiss chard. These greens contain non-heme iron and are also rich in other nutrients. ✓Fortified cereals: Certain breakfast cereals fortified with iron can conveniently supplement iron intake. Look for whole-grain options with added iron. ✓Seeds and nuts: For example, pumpkin seeds, sunflower seeds, sesame seeds, and cashews. These can contribute to iron intake and provide healthy fats and other nutrients. ✓Iron-fortified foods: Including iron-fortified bread, pasta, and rice. These products have added iron to increase their nutritional value. ✓Dried fruits: Particularly raisins, apricots, and prunes. Dried fruits are a good source of non-heme iron. Remember that incorporating

The nurse is assigned to care for a patient with hypophosphatemia. Which of the following complications of this electrolyte imbalance should she monitor? Select all that apply. Rhabdomyolysis Seizures Osteopenia Fractures Hypocalcemia

Choices A, B, C, and D are correct. A is correct. Rhabdomyolysis is a serious complication of hypophosphatemia. When a patient is suffering from severe hypophosphatemia, the available phosphorus is used to generate ATP. Consequently, the muscle cells are unable to maintain membrane integrity, and rhabdomyolysis can form. B is correct. Seizures are a serious complication of hypophosphatemia. This only occurs with very severe, or acute, hypophosphatemia where there is neurologic instability. Other findings can include numbness and reflexive weakness. C is correct. Osteopenia is a serious complication of hypophosphatemia. This is because hypophosphatemia leads to incomplete bone mineralization and, therefore, over time, can cause osteopenia if it goes untreated. It also leads to calcium being mobilized away from bones and results in hypercalcemia. D is correct. Fractures are a serious complication of hypophosphatemia. This is because hypophosphatemia leads to incomplete bone mineralization, which can cause fractures to patients' bones under normal stress. Choice E is incorrect. Hypercalcemia, not hypocalcemia, is a complication of hypophosphatemia. In the presence of very low phosphorous, calcium can be mobilized out of the bone into the blood and leads to hypercalcemia. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Risk of potential reduction; Fundamentals of care - Fluids & Electrolytes

The nurse is providing care to a postpartum client who delivered a healthy newborn. Which of the following interventions should the nurse include in the plan of care to promote thermoregulation? Select all that apply. Encourage skin-to-skin contact Keep the room warm Swaddle the newborn Place an electric heating pad on the mother Use an incubator when needed, for a newborn that isn't clothed

Choices A, B, C, and E are correct. Encourage and facilitate skin-to-skin contact between the mother and newborn. This allows for direct warmth transfer from the mother's body to the baby, helping the newborn maintain a stable body temperature. Providing a warm environment also helps prevent heat loss and supports the newborn's ability to maintain a stable body temperature. Swaddling the newborn, when skin-to-skin contact is not taking place, helps keep the baby warm and reduces heat loss by minimizing exposure of the body to the environment. Wrapping the baby snugly in a blanket or using a hat helps preserve body heat. The healthy, full-term infant dressed and under blankets can maintain a stable temperature within a wider range of environmental temperatures. The use of an incubator is one of the three main methods for helping maintain thermoregulation in a newborn. Choice D is incorrect. Placing an electric heating pad on the mother's abdomen or body may increase her body temperature, but it does not directly promote thermoregulation in the newborn. ✓ In the healthy newborn collect data regarding the temperature shortly after birth and then according to agency policy. Generally, the temperature is checked every half hour until it has been stable for 2 hours. ✓ Routine data collection and care can be performed while the infant is on the mother's abdomen. ✓ Dry the wet infant quickly with warm towels to prevent heat loss by evaporation. Pay particular attention to drying the hair because the head has a large surface area and hair that remains damp increases heat loss. ✓ Skin-to-skin contact should be encouraged. It provides physiological stability, promotes maternal attachment behaviors, protects from negative effects of separation, supports optimal brain development, and increases breastfeeding rates and duration

Which of the following is not an example of an inspection? Select all that apply. A. Heart rate and rhythm irregular B. Abdomen tympanic C. Lungs clear D. Skin is clear

Choices A, B, and C are correct. Each of these answer choices is an example of auscultation. Inspection is the first technique of the overall general survey and should be done for each body part because it generally provides a wealth of information. The purpose of gathering data during the initial phase is to gain an overall impression of the client and assess for severity. Observing for cues that might indicate a position that needs immediate attention is essential. The nurse should first consciously see the client for physical characteristics, behaviors, and note any odors. The client should be seen for overall attributes, including gender, level of alertness, body size and shape, skin color, hygiene, posture, and level of discomfort or anxiety. Global observation is called the general survey and is done intentionally. With experience, gathering information from inspection becomes automatic. Choice D is incorrect. Assessing that the skin is clear is achieved by inspecting the skin. ✓ The nurse begins by visually inspecting the skin, looking for any changes in color, texture, temperature, and integrity. They assess the entire body, paying attention to areas that are commonly prone to skin problems, such as bony prominences, pressure points, and areas covered by medical devices or dressings. ✓ Ensure the client's privacy and maintain their comfort during the skin inspection. Provide a warm and well-lit environment for the assessment. ✓ Collaborate with other healthcare team members, such as registered nurses, wound care specialists, or physicians, as needed, to share findings and develop a comprehensive care plan.

Which of the following are potential complications of cleft lip and cleft palate in the infant? Select all that apply. Ear infections Feeding difficulties Weight gain Speech delay

Choices A, B, and D are correct. A is correct. When a child has a cleft lip and cleft palate, the tissue and bone inside their mouth are not appropriately fused. This means there is a space between their upper lip and palate. Ear infections will be a frequent complication for these patients due to the dysfunction of the eustachian tube, which connects the middle ear and the throat. B is correct. Feeding issues are a common complication of cleft lip and cleft palate because it is harder for these infants to eat with the abnormality in their palate. The space in the roof of the mouth makes it very hard to suck and get a good seal around the bottle or nipple. D is correct. Speech delays and language delays are both common complications of cleft lip and cleft palate. This is because the roof of the mouth and lip have spaces where they should not, which decreases muscle function and leads to delayed or abnormal speech. Many of these infants will require consultation with a speech-language pathologist. Choice C is incorrect. Weight gain is not a common complication of cleft lip and cleft palate. With these abnormalities, it is much more difficult for the infant to eat, and they commonly experience feeding issues. This, therefore, leads to weight loss or failure to thrive, not weight gain. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Risk potential reduction; Pediatrics - Gastrointestinal

The nurse is caring for a client who has a serum calcium level of 13.2 mg/dL(9-10.5 mg/dL). Which of the following medications would be expected orders for this condition? Select all that apply. Phosphorus Calcitonin Vitamin D IV calcium gluconate Glucocorticoids

Choices A, B, and E are correct. A is correct. The normal serum calcium level is 8.4-10.2 mg/dL. This client has a high serum calcium level (hypercalcemia). Phosphorus is a medication that the nurse would expect to administer to treat hypercalcemia. Phosphorus and calcium have an inverse relationship, so by increasing the serum level of phosphorus the nurse can decrease the serum level of calcium. Oral phosphate is the preferred method of administering phosphorus. If given IV, calcium phosphate forms and precipitates in the tissues. This "precipitation phenomenon" reduces serum calcium levels very quickly. B is correct. Calcitonin is a medication that the nurse would expect to administer to treat hypercalcemia. Calcitonin is a thyroid hormone that decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration. E is correct. Glucocorticoids are steroids that can be used to treat a variety of conditions, including hypercalcemia associated with certain cancers. Glucocorticoids work by inhibiting the activity of cells that break down bone and release calcium into the blood. Choice C is incorrect. Vitamin D should be avoided in hypercalcemia. Vitamin D enhances the absorption of calcium and can therefore increase the level of serum calcium, which we do not want to do when the client's level is already high. Choice D is incorrect. IV calcium gluconate is given to clients that are hypocalcemic, not hypercalcemic. It can treat the tetany that occurs when a client is severely hypocalcemic. It can also be given to protect the cardiac muscle if a client has severe hyperkalemia or hypermagnesemia. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Fundamentals of care - Fluids & Electrolytes There are several medications that may be ordered to treat hypercalcemia, or high levels of calcium in the blood. The choice of medication may depend on the underlying cause of the hypercalcemia, the severity of the condition, and other individual factors. ✓Bisphosphonates: These drugs are used to treat osteoporosis and other bone diseases, but they can also help to lower blood calcium levels by inhibiting bone resorption. ✓Calcitonin: Calcitonin is a

The nurse is reinforcing teaching with the parents of a child diagnosed with eczema. Which of the following information should the nurse include? Select all that apply. Avoid harsh soaps and detergents. Wash the affected areas 4-5 times per day. Apply lotion immediately after bathing. Keep nails short. "Baths with hot water are preferred."

Choices A, C, and D are correct. A is correct. It is appropriate education to teach your client to avoid using harsh soaps and detergents. This can irritate the skin and exacerbate eczema. Common irritants include soaps, detergents, perfumes, cosmetics, jewelry, and fragrances. You should educate the client to avoid these harsh chemicals. C is correct. This is an appropriate education. Applying lotion immediately after a bath will help the client keep moisture over the affected areas and decrease the itching and irritation associated with eczema. D is correct. Keeping nails short is a critical piece of education for a child diagnosed with eczema. Their skin will be very itchy, but we need to teach them how to control this itching and avoid irritation from scratching. We also don't want any papules to be broke open or compromise tissue integrity due to prolonged itching from sharp nails. Young children that aren't able to stop scratching may need to wear mittens. Choice B is incorrect. Teaching the client to wash the affected area 4-5 times a day is inappropriate because this would cause excessive dryness. Bathing may need to be performed 1-2 times daily with applying emollients immediately afterward. Choice E is incorrect. Hot water is inappropriate because it contributes to the drying of the skin. A tepid bath is recommended with mild soap. ✓ Infantile eczema may occur as early as 2 to 6 months with manifestations such as lesions that appear as papules, weeping, oozing, crusting, and scaling ✓ Childhood eczema may follow the infantile form and include clusters of small erythematous or flesh-colored papules ✓ Adult form may continue from childhood and may last indefinitely ✓ Treatment of eczema includes topical emollients, tepid baths, and topical steroids during flares ✓ If appropriate, demonstrate proper skin care techniques, such as applying moisturizers and avoiding scratching. Visual aids or practical demonstrations can enhance understanding. ✓ Emphasize the importance of adhering to the prescribed treatment plan, including medications and skin care routines, to achieve the best outcomes. ✓ Provide written materials or reputable resources for parents to refer to between healthcare visits.

You are assessing a 4-year-old preschooler and note the following vital signs: Pulse: 146 RR: 42 BP: 72/48 Which of the following actions are appropriate given these vital signs? Select all that apply. Continue your assessment. Notify the healthcare provider. Administer IVF as ordered by your health care provider. Document the vital signs. Reinforce teaching on normal findings for mom

Choices B and C are correct. B is correct. This is an appropriate action. The health care provider should be notified immediately. The nurse has identified that the child is in shock and should immediately notify the healthcare provider. C is correct. This is an appropriate action. The nurse has identified that the child is in shock due to their hypotension and tachycardia. She notifies the health care professional and is expecting an order for IV fluids. This will help to increase the blood pressure, beginning the process of addressing the shock by increasing the blood pressure to provide profusion to the vital organs. This is an appropriate action. These vital signs are not within the normal limits for a preschooler. Typical vital signs for a preschooler are: Pulse: 80-120 RR: 20-30 BP: 95/65 This 4-year-old is tachycardic, tachypneic, and hypotensive. The blood pressure should jump out at you as a significant concern. Hypotension is a late sign of distress in children - this client is in shock. Their heart rate is increasing above normal, trying to compensate for the decreasing cardiac output and perfusion to the rest of the body. They are breathing faster to exhale as much carbon dioxide as possible - they are almost surely in a state of acidosis and need to get rid of that acid. They are trying to compensate, but their body is getting tired and becoming hypotensive. With a blood pressure this low in a 4-year-old, they do not perfuse their vital organs, and immediate action is warranted. Choice A is incorrect. This is not appropriate. The nurse should not continue their assessment, as they have already identified that the child is in shock, and another action listed is more appropriate. Remember, on the NCLEX, if there is an action you can take to help the client at that moment, do it. Do not delay care by continuing your assessment. Choice D is incorrect. It is not appropriate to simply document the vital signs for this client. The nurse has identified that all of these vital signs are out of the normal limits for a preschooler and that the hypotension paired with tachycardia and tachypnea is suspicious for shock. She needs to notify her healthcare provider and take immediate action before completing any

The nurse is counseling a client with opioid use disorder. The nurse understands that treatment choices for opioid use disorder include which of the following? Select all that apply. Selegiline Naltrexone Methadone Buprenorphine Bupropion

Choices B, C, and D are correct. Naltrexone, Methadone, and Buprenorphine are three agents approved for the management of opioid use disorder. These medications have various mechanisms of action. Naltrexone is an opioid receptor antagonist and may be administered as a single-dose injection. Buprenorphine is a partial agonist and is available in preparations such as sublingual tablets or film. Methadone is a full agonist that may be used daily. Choices A and E are incorrect. Selegiline is a monoamine oxidase inhibitor and is used in depression and Parkinson's disease. Bupropion is indicated in the treatment of depressive disorders. This medication may be useful in the management of nicotine addiction. ✓ Medications used in opioid use disorder are efficacious when combined with appropriate counseling. ✓ The nurse should advocate for appropriate treatment choices such as buprenorphine, methadone, or naltrexone. ✓ Caution must be taken with methadone and buprenorphine as these two medications may cause respiratory depression when combined with other CNS depressants.

Which of the following interventions would be appropriate for a practical nurse caring for a toddler diagnosed with phenylketonuria? Select all that apply. Initiation of a keto diet IV iron dextran treatments Elimination of dairy, meat, and eggs from the diet Strict avoidance of aspartame Foods must be measured to provide the prescribed amount of phenylalanine.

Choices C, D, and E are correct. C is correct. Elimination of dairy, meat, and eggs from the diet is an essential intervention for a toddler with phenylketonuria (PKU). In phenylketonuria, there is impaired metabolism of an essential amino acid named phenylalanine. When patients eat foods that contain this amino acid, they cannot break it down, and levels of this amino acid can then become toxic to the patient. Dairy, meat, and eggs are high in protein and therefore have a large amount of the amino acid phenylalanine. Therefore, eliminating these items from the diet is essential for children with PKU. D is correct. Strict avoidance of aspartame is an essential intervention for a toddler with PKU. In phenylketonuria (PKU), there is impaired metabolism of an essential amino acid named phenylalanine. When patients eat foods that contain this amino acid, they cannot break it down, and levels of this amino acid can then become toxic to the patient. The artificial sweetener aspartame has a large amount of the amino acid phenylalanine. Therefore, eliminating it from the diet is essential for children with PKU. E is correct. Foods must be measured to provide the prescribed amount of phenylalanine. The phenylalanine requirement must be recalculated if the toddler has a decreased appetite or refusal to eat. Choice A is incorrect. A ketogenic diet is a high-fat, adequate-protein, low-carbohydrate diet used to treat hard-to-control epilepsy in children. In this diet, because the body has so few carbs to use for energy, it burns fat, which produces ketones. This diet is not used in children with PKU. Choice B is incorrect. Iron dextran is used to treat iron deficiencies and iron deficiency anemia. It is essential for oxygen transport within the body and affects the oxygen-carrying capacity. Administration of IV iron dextran would not be useful in a child with PKU. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic care, comfort; Maternity Nursing - Problems with Labor and Delivery ✓Phenylketonuria (PKU), a genetic disease inherited as an autosomal recessive trait, is caused by an absence of the enzyme phenylalanine hydroxylase needed to metabolize the essential amino acid phenylalanine. ✓The clinical prese

The nurse is caring for a client diagnosed with schizophrenia with catatonia History And Physical A 22-year-old female was admitted from the emergency department (ED) after wandering in the local park. The client was disheveled, completely mute during the assessment, and did not respond to external stimulation. The client had a fixed stare at the ceiling and a marked reduction in purposeful movements. The physical exam noted flaky skin with tenting and dry mucous membranes. Medical records reveal that this client has a history of schizophrenia. Which prescriptions should the nurse anticipate from the primary healthcare provider (PHCP) based on the history and physical? Levodopa-Carbidopa Methylprednisolone Lorazepam Intravenous fluids Venlafaxine Levothyroxine

Options C, D - Correct - Catatonia is a serious psychiatric syndrome that may occur with psychiatric and medical conditions. The gold standard treatment for catatonia is benzodiazepines such as lorazepam. Lorazepam is preferred because of its modulating effects on the neurotransmitter GABA. The nurse should also request a prescription for intravenous fluids because the clinical data suggests dehydration (skin tenting and dry mucous membranes) which is a likely consequence of catatonia. Options A, B, E, F - Incorrect - Dopaminergic medications (both agonists and antagonists) should be avoided. Agonists should be avoided because they would trigger psychosis, therefore, levodopa-carbidopa would be contraindicated. Antagonists may worsen catatonia and complicate treatment. Therefore, antipsychotics and levodopa-carbidopa are avoided in the treatment of catatonia. Further, steroids (methylprednisolone), serotonergic agents (venlafaxine), and thyroid hormone (levothyroxine) have no role in the treatment of catatonia. Catatonia is a syndrome that may co-occur with bipolar disorder or schizophrenia. This condition may cause symptoms such as mutism, stupor, negativism, waxy flexibility, hypokinesia, staring, and bizarre speech patterns such as echolalia. Medical treatment includes parenteral benzodiazepines and electroconvulsive therapy (ECT) in severe cases. Depending on the degree of catatonia, nursing care aims to prevent complications of immobility such as venous thromboembolism and skin breakdown. Intravenous hydration is often used when the client does not drink.

The nurse is caring for a female client who is incontinent of urine. The MD orders an indwelling Foley catheter to be placed. Place the following actions in the order that the nurse takes to correctly insert the Foley catheter: Secure the catheter to the client, and initial the securement device with the date and time. Spread the labia and hold them open. Cleanse the meatus from front to back on the right side, then the left side, and down the center. Insert the catheter and inflate the balloon. Perform hand hygiene, identify the client, explain the procedure, and wear sterile gloves.

Perform hand hygiene, identify the client, explain the procedure, and wear sterile gloves. Spread the labia and hold them open. Cleanse the meatus from front to back on the right side, then the left side, and down the center. Insert the catheter and inflate the balloon. Secure the catheter to the client, and initial the securement device with the date and time. First, the nurse should perform hand hygiene, identify the client using 2 client identifiers, explain the procedure to the client, and wear sterile gloves. Second the nurse uses her non-dominant hand to spread the labia and hold them open. Third the nurse uses her dominant hand to cleanse the meatus from front to back on the right side, then left side, then down the center. Fourth the nurse will insert the catheter and inflate the balloon. Lastly, the nurse will secure the catheter to the client, and place their initials, date, and time on the securement device. ✓ Maintain the client's privacy by ensuring that the procedure is conducted in a private and well-draped area. Provide emotional support and communicate with the client to ensure they feel respected and comfortable throughout the procedure. ✓ If possible and if no contraindications are present, assist the client into a comfortable supine position with their knees bent and feet flat on the bed. ✓ Accurately document the procedure, including catheter size, type, amount of balloon inflation, client's tolerance, and urine output. ✓ Regularly collect data regarding the client's urine output, catheter patency, and the condition of the catheter insertion site. Provider orders and/or policies at your facility may dictate how frequently this should be done and documented.

The nurse performs a home safety survey for an older adult Click to specify the findings that require intervention by the nurse Living area Scatter rugs at the end of the stairs Smoke detector present without a battery Stairs present with sturdy hand rails New light fixtures installed and connected in a grounded electrical outlet Extension cord covered with an anti-skid area rug Kitchen Unlabeled household chemicals under the sink Fire extinguisher present near stove Bathroom Rubber mats in the bathtub Grab bars installed in the shower Medications mixed in various containers

The findings that require intervention by the nurse include the following - Scatter rugs at the bottom of the stairs: scatter rugs should not be used because they reduce the traction on the ground, and the edges of these rugs may cause a client to fall. Smoke detector present without a battery: the smoke detector should have a functioning battery. The battery should be tested every six months. Extension cord covered with a rug: a rug should not cover an extension or electrical cord because of the fire risk. Instead, electrical and extension cords should be against a wall behind furniture. Unlabeled household chemicals under the sink: household chemicals should be labeled to avoid accidental mixing (for example - bleach being mixed with ammonia) that may create a significant hazard. Medications mixed in various containers: medications should not be mixed in containers. This may cause a client to take the wrong medication inadvertently. Medications should be in their original labeled container, and the client may request labels that have a bigger font size. To promote home safety for the older adult, the nurse should verify the following: ✓ Remove scatter rugs and frayed carpet ✓ Ensure that hallways and steps are well lit ✓ Do not run wires under carpeting ✓ Smoke detectors are present and are tested every six months ✓ The recommendation is one smoke detector per room and one per floor ✓ Ensure fire extinguishers are readily available ✓ Add additional lighting to the bathroom ✓ Medications are clearly labeled and are reviewed periodically by a family member or healthcare provider ✓ Household chemicals are clearly labeled ✓ Rubber mats in the bathtub