Archer Review 10a

The nurse is caring for a client with acute respiratory failure in the Intensive Care Unit (ICU). The nurse should expect which arterial blood gas (ABG) results? A. pH: 7.29; PCO2: 56; PaO2: 83; HCO3: 22 [78%] B. pH: 7.38; PCO2: 40; PaO2: 92; HCO3: 25 [2%] C. pH: 7.49; PCO2: 34; PaO2: 96; HCO3: 28 [7%] D. pH: 7.40; PCO2: 65; PaO2: 85; HCO3: 16 [13%]

Explanation Choice A is correct. A client in respiratory distress should be expected to exhibit acidosis, hypoxemia, and hypercapnia (respiratory acidosis) on ABG. Choice B is incorrect. This is indicative of a normal arterial blood gas result. Choice C is incorrect. This arterial blood gas result shows respiratory alkalosis. Respiratory alkalosis commonly occurs in hyperventilation wherein more carbon dioxide is eliminated. Choice D is incorrect. This is an example of compensated respiratory acidosis.

You have an adult client who has abnormally heightened responses to minor pain like the pain from sitting on a bedpan or a small skin tear. What would you suspect that this client is affected by? A. Hyperpathia [57%] B. Drug seeking behavior [9%] C. Equianalgesia [14%] D. Dysesthesia [21%]

Explanation Choice A is correct. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is most likely affected with hyperpathia. Hyperpathia is synonymous with hyperalgesia and is defined as the abnormal pain processing that can lead to the appearance of neuropathic pain. Choice B is incorrect. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is most likely affected with a disorder other than drug-seeking behavior. Choice C is incorrect. Equianalgesia is the mathematically calculated relationship between different opioid medications and parenteral morphine. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is not affected with equianalgesia. Choice D is incorrect. Dysesthesia is a cutaneous symptom; i.e. pruritis, burning, stinging, tickling, crawling, cold sensation, tingling, etc. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is not affected with dysesthesia.

The nurse is caring for a patient with a spinal cord injury. Which diagnostic test would be the most precise for determining the degree of damage/spinal compromise? A. CT scan [27%] B. Cervical x-rays [8%] C. MRI [45%] D. Vertebral angiography [19%]

Explanation Choice A is correct. CT scan is the gold standard for determining the stability, location, degree of injury, and spinal cord compromise. Choice B is incorrect. A cervical x-ray may be used to visualize the injury if a CT scan is not readily available, but it is not the most precise method due to the limited visibility of some parts of the spine. Choice C is incorrect. MRI is useful in visualizing soft tissue damage and neural changes for patients who present with a neurological deficit. MRI would not be the best test to assess the degree of the injury. Choice D is incorrect. Vertebral angiography is used to rule out vertebral artery damage when a patient presents with altered mental status. It would not be appropriate to determine the degree of spinal cord injury. NCSBN Client Need Topic: Critical Care Concepts (spinal injury); Subtopic: diagnostic tests

The nurse suspects that one client, a woman diagnosed with bulimia nervosa, may also have a substance abuse disorder. Which drug should the nurse ask the client about? A. Amphetamines [57%] B. Hallucinogens [5%] C. Sedatives [14%] D. Cannabis [24%]

Explanation Choice A is correct. Clients with bulimia nervosa would usually resort to amphetamine use as an additional way to control weight. Choices B, C, and D are incorrect. These clients are generally not into sedatives, hallucinogens, or cannabis for weight control.

The nurse is developing a plan of care for a patient who had bariatric surgery. Which of the following should the nurse include? A. Pneumatic compression devices [58%] B. Insertion of an indwelling urinary catheter [9%] C. Strict bed rest [9%] D. Fluid restrictions [24%]

Explanation Choice A is correct. Following bariatric surgery, the patient faces an array of complications, including hemorrhage, wound disruption, pneumonia, and wound infection. Venous thromboembolism is a significant complication and may be mitigated using pneumatic compression devices as well as chemical prophylaxis. Choices B, C, and D are incorrect. Insertion of a urinary catheter is not standard of care for a patient recovering from bariatric surgery. This could cause bacterial cystitis, which may complicate healing. Strict bed rest is not recommended because this increases the risk for pneumonia and venous thromboembolism. Patients are often expected to ambulate several hours after surgery. Fluid restrictions are not in the plan of care as the patient will initially be prescribed a clear liquid diet. Additional information: Bariatric surgery is major surgery with many complications such as venous thromboembolism, nutritional deficiencies, dumping syndrome, pneumonia, and infection. Venous thromboembolism may be mitigated by early ambulation, compression devices, and chemical prophylaxis.

The nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following would indicate the client is achieving the treatment goals? A. Mean arterial pressure (MAP) 67 mmHg [42%] B. Potassium 3.3 mEq/L [15%] C. Blood glucose 255 mg/dL [27%] D. Serum pH 7.33 [16%]

Explanation Choice A is correct. For a client with DKA, hypovolemia and hyperglycemia are the primary problems. Hyperglycemia contributes to acidosis and hypovolemia. A normal MAP would indicate effective tissue perfusion and, thus, would be a favorable finding indicating that the hypovolemia has resolved. Normal MAP is between 70 and 100 mm Hg. Choices B, C, and D are incorrect. Hypokalemia is a common complication associated with DKA treatment. Regular insulin lowers blood glucose and potassium, and the nurse must be aware of hypoglycemia and hypokalemia risks. Blood glucose of 255 mg/dL is hyperglycemia and would not be a therapeutic finding. A serum pH of 7.33 indicates acidosis and warrants further treatment. Additional Info The treatment goals for a client with DKA include repleting critically lost volume and normalizing the blood glucose. Achieving both would help correct the underlying metabolic acidosis. Isotonic saline replacement is utilized initially, and then once the blood glucose approaches 250 mg/dL to 300 mg/dL, the fluids change to 5% dextrose and 0.45 saline with potassium additive. Monitoring parameters include hourly blood glucose and the client's potassium.

The nurse is preparing a patient for scheduled total knee arthroplasty (TKA). Which action by the nurse would be most important to reduce this patient's risk for experiencing emergence excitement after this procedure? A. Ask the patient about any concerns regarding the procedure. [52%] B. Monitor for changes in the patient's respiratory status. [18%] C. Reassure the patient that this is a simple, minor procedure. [1%] D. Ask the patient about any recent alcohol and drug use. [28%]

Explanation Choice A is correct. Patients who are anxious prior to anesthesia are at higher risk of experiencing postoperative emergence excitement or delirium. The nurse should focus on actions that aim to reduce the patient's anxiety to reduce this patient's risk of emergence excitement. The nurse should provide reassurance, explain the purpose of procedure, and allow the patient to express concerns/ask questions. Choice B is incorrect. This action would be appropriate in the post-operative phase as the patient comes out of general anesthesia, but would not be a preventative action in the pre-operative phase to reduce the risk of emergence excitement. Choice C is incorrect. This action is dismissive and does not offer the patient a chance to voice concerns. The TKA procedure would likely require general anesthesia and it would be false for the nurse to reassure the patient that it is simple or minor. Choice D is incorrect. Patients with a history of recent drug or alcohol use may be at increased risk of post-operative emergence excitement, but this action would only identify the risk factor, not actively reduce the patient's risk of experiencing this problem.

Which of these patient room assignments would the nurse be appropriate to question? A. Placement of an 89-year-old patient with acute delirium at the end of the hallway. [70%] B. Placement of a 79-year-old patient with C. difficile in the same room with a 26-year-old patient with C. difficile. [4%] C. Placement of a 56-year-old patient with HIV and bronchitis in a private room. [23%] D. Placement of a 39-year-old patient with mild head trauma after a car accident in the same room with a 40-year-old patient with an arm fracture. [3%]

Explanation Choice A is correct. Patients with delirium and those who are at high risk for safety events should be roomed close to the nurse's station to accommodate close monitoring. In addition to the acute delirium, this client's age poses a risk for injury related to falls. Choices B, C, and D are incorrect. All of these room assignments are appropriate, given the patients' ages and diagnoses. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; The Nursing Process for Infection Prevention and Control

The RN prepares a presentation on dietary recommendations for patients with inflammatory bowel disease (IBD). Which information would be important for the nurse to include? A. Avoid raw fruits [33%] B. Focus protein intake from nuts, seeds, and whole grains [21%] C. Limit intake of white bread and refined pasta [35%] D. Reduce dairy products to four servings per day [11%]

Explanation Choice A is correct. Patients with inflammatory bowel disease should be instructed to follow a low-residue, low-fiber diet in order to reduce the risk of obstruction when the intestines are narrowed due to scarring or inflammation, or when gastrointestinal motility is slowed. Raw fruits, with the exception of bananas, should be avoided. Choice B is incorrect. Nuts, seeds, whole grains, vegetables, and plant fiber are high in fiber and can result in obstruction when the gastrointestinal tract is narrowed. These foods should be avoided for a patient with inflammatory bowel disease. Choice C is incorrect. Foods high in carbohydrates, such as white bread and refined pasta, are typically low in residue and would be recommended for this patient. Choice D is incorrect. Dairy products can increase inflammation in the intestines and should be limited to two servings per day or less.

The nurse is taking the history and physical of a woman who has just discovered that she is pregnant. This nurse knows that the purpose of asking a prenatal client about her history with rheumatic fever has the most to do with: A. Cardiac stress related to a possible valvular lesion. [43%] B. Preventing transmission of this teratogenic condition to her infant. [32%] C. Preparing to deliver preventative antibiotics during labor and post-birth. [20%] D. Monitoring lung sounds for reoccurrence of the disorder. [5%]

Explanation Choice A is correct. Rheumatic fever can cause the formation of valvular lesions, which can lead to cardiac stress during pregnancy. Choice B is incorrect. A prenatal client with a history of rheumatic fever will not be at risk for passing on rheumatic fever to her infant. Choice C is incorrect. Preventative antibiotics would not be needed in this circumstance. Choice D is incorrect. Lung sounds are not relevant to a woman with a history of rheumatic fever. NCSBN Client need Topic: Health Promotion and Maintenance / Ante / Intra and Postpartum Care

A client comes to the outpatient clinic complaining of abdominal pain, diarrhea, shortness of breath, and epistaxis. What should the nurse's first action be? A. Ask the client about any recent travel to Asia or the Middle East. [54%] B. Screen clients for upper respiratory tract symptoms. [14%] C. Review the client's history of recommended immunizations. [3%] D. Call an ambulance to take the client immediately to the hospital. [29%]

Explanation Choice A is correct. The client's clinical symptoms suggest possible avian influenza (bird flu). If the client has traveled recently to Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. Nursing priority is always patient safety. This includes not only the patient the nurse is assessing but those who are present within the facility and the staff as well. Determining where a patient has been and any activities he or she has been involved with will help pinpoint the possible source of illness/infection. Choices B, C, and D are incorrect. While these actions may be appropriate, they are not the initial action to take for the client who may transmit the infection to other patients or staff. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control

The nurse is attending to a newly admitted patient with a diagnosis of hyponatremia. Which of the following should the nurse expect to assess in this patient? A. Orthostatic hypotension [38%] B. Blood serum sodium level of 148 mEq/L [3%] C. Muscle twitching [40%] D. Increased thirst [19%]

Explanation Choice A is correct. The nurse should assess the client for the presence of orthostatic hypotension. Orthostatic hypotension is often seen in association with hyponatremia. The presence of orthostatic hypotension usually indicates hypovolemic status. The nurse must assess the volume status while evaluating a client with hyponatremia because it helps to differentiate between hypovolemic, euvolemic, and hypervolemic hyponatremia. Separating these will help in planning the nursing and treatment interventions. Orthostatic or postural hypotension refers to a significant decrease in systolic blood pressure of greater than 20 mmHg or a reduction of at least 10 mmHg in diastolic pressure upon 3 to 5 minutes of standing. Often, it indicates hypovolemia. Hyponatremia refers to a sodium level lower than 135 mEq/L. Hyponatremia may be secondary to several causes; however, it is possible to get clues regarding the cause of hyponatremia by determining the type of hyponatremia. Sodium and water go together. Sodium tends to draw and keep water with it—the decrease in sodium relative to free water results in hyponatremia. Hyponatremia is classified into three types: By knowing the type of hyponatremia, appropriate treatment intervention can be planned. Hypovolemic Hyponatremia: Correct hypovolemia with isotonic (0.9%) normal saline. In severe cases of symptomatic hypovolemic hyponatremia, 3% (hypertonic) saline is used. Euvolemic Hyponatremia: Ask the client to restrict free water. Physicians may order medications such as demeclocycline or tolvaptan. Hypervolemic hyponatremia: Ask the client to restrict free water intake. Diuretics may be administered to clear retained fluid. Choice B is incorrect. Normal sodium is 135-145 mEq/L. A sodium level of 148 mEq/L would be a result found in hypernatremia (high sodium), not hyponatremia. Choice C is incorrect. Muscle twitching would be found more commonly in hypernatremia, not hyponatremia. Muscle twitches are likely due to excess sodium leading to irregular contraction of muscles. Hypernatremia often involves dehydration, and acute hypernatremia may be associated with confusion, muscle twitches, and seizures. Hyponatremia is typically asymptomatic unless it is acute or severe (<120 mEq/L). A sharp fall in serum sodium may cause a free water shift from the intravascular to the interstitial space, resulting in cerebral edema. In such cases, patients may present with symptoms of increased intracranial pressure such as nausea, vomiting, headache, agitation, lethargy, seizures, coma, or death. Choice D is incorrect. Increased thirst occurs in hypernatremia due to the body's attempt to increase fluid intake and balance sodium levels. This is not a common finding in hyponatremia.

A nurse is assigned to care for a 2-year-old who is newly diagnosed with acute lymphocytic leukemia. Which action should be included in the client's plan of care that is directed to facilitate growth and development in the acutely ill toddler? A. Focus on educating parents to minimize anxiety over the parenting of the child. [52%] B. Make sure that the toddler is informed in advance of what is to take place in a procedure. [23%] C. Isolate child from parents, especially if there are temper tantrums. [1%] D. Encourage regression to a previous developmental level for familiarity and comfort. [24%]

Explanation Choice A is correct. When a toddler is acutely ill, it is best to have parents who are not overly anxious and can work well with hospital personnel. It is, therefore, best to exert effort in educating the parents in this case. Choices B, C, and D are incorrect. Choice B is not an appropriate action because a toddler's thinking is concrete and tangible, and the toddler cannot think beyond the observable. Preparation should be done immediately before the procedure. Temper tantrums are a standard developmental characteristic of a 2-year-old, and the parents must hold her to alleviate fear. Isolating the toddler from her parents is not a therapeutic approach. Choice C is, therefore, incorrect. A toddler may regress during hospitalization but will not facilitate comfort. Choice D is an inappropriate action.

Your client has been taking medication to promote sleep for the last 19 days. This medication was discontinued three days ago. The client is now complaining about their insomnia ever since the drug was discontinued. You would respond to this client's concern by stating: A. "It is likely that you are affected with insomnia rebound which often occurs when a sleeping medication is discontinued." [61%] B. "It is likely that you are affected with REM rebound which often occurs when a sleeping medication is discontinued." [22%] C. "I am going to talk with your doctor about re-ordering your medication because this insomnia will, again, interfere with your necessary sleep." [8%] D. "I am going to talk with your doctor about re-ordering another sleeping medication because this insomnia will, again, interfere with your necessary sleep." [9%]

Explanation Choice A is correct. You would respond to this client's concern by stating, "It is likely that you are affected with insomnia rebound, which often occurs when a sleeping medication is discontinued." This rebound typically affects clients, therefore sleeping medications should be used for only a brief period and only when alternatives have been tried but failed. Choice B is incorrect. You would not respond to this client's concern by stating, "It is likely that you are affected with REM rebound, which often occurs when a sleeping medication is discontinued" because REM rebound can affect the client's increased dreaming, but does not induce insomnia. Choice C is incorrect. You would not respond to this client's concern by stating, "I am going to talk with your doctor about re-ordering your medication because this insomnia will, again, interfere with your necessary sleep" because this rebound will only occur again, therefore sleeping medications should be used for only a brief period and only when alternatives have been tried but failed. Choice D is incorrect. You would not respond to this client's concern by stating, "I am going to talk with your doctor about re-ordering another sleeping medication because this insomnia will, again, interfere with your necessary sleep" because this rebound will only occur again, therefore sleeping medications should be used for only a brief period and only when alternatives have been tried but failed.

The nurse is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up? A. Venlafaxine [13%] B. Hydrochlorothiazide [60%] C. Gabapentin [14%] D. Verapamil [13%]

Explanation Choice B is correct. A client taking lithium should be instructed to avoid dehydration and hyponatremia. Lithium is a salt, and when the client has decreased fluid volume, the drug will accumulate and raise the lithium level. HCTZ is a thiazide diuretic and is contraindicated for a client taking lithium because of its ability to decrease fluid and sodium levels. Choices A, C, and D are incorrect. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor and has no contraindication with lithium. Further, gabapentin and verapamil have no contraindications as gabapentin is indicated for neuropathy, and verapamil is indicated for hypertension. Additional Info Key teaching points for a client taking lithium include the avoidance of dehydration, adhering to the dosing schedule to maintain a therapeutic level of 0.6-1.2 mEq/L, and reporting signs of toxicity such as nausea, vomiting, and ataxia. The client should be instructed that the drug level should be obtained twelve hours after the last dose to avoid a falsely elevated level.

A patient is about to get a Salem sump NG tube inserted. Which position should the nurse place the patient in? A. Supine, with the head of the bed elevated at 30° - 45° [43%] B. Supine, with the head of the bed elevated at 60° - 90° [56%] C. Knee-chest position [1%] D. Prone position [0%]

Explanation Choice B is correct. A supine position with a 60° - 90° elevation facilitates swallowing of the patient and lets gravity help in the movement of the tube down the GI tract. Choice A is incorrect. The nurse should position the patient so that the insertion of the NG tube is facilitated. An elevation of 30° - 45° is not enough to facilitate the movement of the tube down the GI tract. Choice C is incorrect. A knee-chest position does not facilitate the movement of the tube down the GI tract. Choice D is incorrect. A prone position does not facilitate the insertion of the NG tube.

A post-coronary artery bypass graft patient developed a fever of 38.8° C. The nurse notifies the physician of the elevated temperature because: A. The elevated temperature may lead to profuse sweating. [7%] B. It may increase cardiac output. [47%] C. It is a sign of cerebral edema. [12%] D. It is indicative of hemorrhage. [34%]

Explanation Choice B is correct. An increase in temperature leads to increased metabolism and cardiac workload. Choice A is incorrect. Although there can be diaphoresis during an increase in temperature, it is not going to be a reason to call the physician. Choice C is incorrect. Fever is not an early sign of cerebral edema. Choice D is incorrect. When there is significant blood loss, there is no increase in temperature. Instead, there will be a decrease in temperature.

The nurse is precepting a new graduate who will be caring for a patient with bacterial cystitis. Which of the following statements by the new graduate requires follow-up? A. "The patient should be counseled to increase their fluid intake." [4%] B. "A 24-hour urine sample will be needed to confirm the diagnosis." [52%] C. "Risk factors include frequent intercourse and douching." [17%] D. "Cranberry concentrate may be used to prevent future infections." [28%]

Explanation Choice B is correct. Bacterial cystitis may be diagnosed based on urine analysis. A simple, clean-catch midstream urine sample is sufficient for diagnosing bacterial cystitis. A 24-hour urine is utilized for diagnosing conditions such as pheochromocytoma and abnormal protein quantification in multiple myeloma - not bacterial cystitis. The presence of leukocyte esterase, nitrite, red blood cells ( hematuria), an abnormal number of white blood cells ( pyuria, ≥10 wbcs/microliter), and bacteria in the urinalysis are indicative of an acute bladder infection ( cystitis). Choices A, C, and D are incorrect. Teaching points for a patient diagnosed with bacterial cystitis should include increasing their fluid intake of non-caffeinated and non-alcoholic beverages ( Choice A). Increased hydration promotes increased urination and natural flushing of the bacteria. The patient should be advised of the risk factors of bacterial cystitis, such as douching, frequent intercourse, inappropriate perianal hygiene, and invasive devices such as indwelling catheters ( Choice C). Cranberry concentrate has shown efficacy in preventing recurrent bacterial cystitis in some clients ( Choice D). While cranberry helps protect against recurrent urinary tract infections ( UTI), there is no clear evidence to support its use in treating an active UTI episode. Therefore, educate the clients that cranberry can be used for UTI prevention, not UTI treatment. Learning Objective Understand the tests used to diagnose acute cystitis and relevant patent education concepts. Additional Info Cystitis refers to inflammation of the bladder. When bacteria cause inflammation, it is called bacterial cystitis. Diagnosis: Acute bacterial cystitis can easily be recognized by demonstrating pyuria in the urinalysis. In the absence of pyuria, the presence of bacteria alone does not mean an active infection and could merely represent colonization. Generally, clinically significant pyuria refers to greater than or equal to 10 leucocytes per microliter. Urine sample collection: Ideally, a clean-catch, midstream sample of the first urine of the day is the best specimen. However, this is not always feasible, and there is no clear evidence it is more accurate than the specimen collected at the time of clinical evaluation. Therefore, a clean catch and midstream urine sample is sufficient. The nurse should educate the client regarding the specimen collection - the initial portion of the urine stream should be discarded since the urethral area contaminants may potentially contaminate it. The subsequent midstream sample should be collected in a sterile container. Treatment: A patient with bacterial cystitis will be prescribed an antibiotic, to which the nurse should educate the patient on adherence. Not taking the antibiotics for the optimal duration can lead to recurrence and antibiotic resistance. Commonly used antibiotics for treating uncomplicated UTIs include trimethoprim/ sulfamethoxazole, nitrofurantoin, and ciprofloxacin. Recurrences: Recurrent bacterial cystitis may require reinforcement of teaching, such as hygiene measures and adequate fluid intake. Cranberry products are beneficial in preventing recurrences but not for treating active infection.

Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit? A. Bowel sounds of 14 per minute [4%] B. High-pitched bowel sounds at a rate of 4 per minute [46%] C. Bowel sounds greater than 60 per minute [39%] D. Low-pitched bowel sounds at a rate of 30 per minute [11%]

Explanation Choice B is correct. Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult. Choice A is incorrect. Bowel sounds of 14 per minute are considered normal. Choice C is incorrect. Although bowel sounds more significant than 30 per minute are considered hyperactive, it is not as immediate a concern as choice B. Choice D is incorrect. Bowel sounds usually are high-pitched. However, the rate of bowel sounds here is more normal than choice B. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

Which of the following medications is not typically recommended for the elderly population? A. Allegra [18%] B. Cimetidine [30%] C. Claritin [7%] D. Ativan [45%]

Explanation Choice B is correct. Cimetidine is not typically recommended for the elderly population because it interacts with several drugs. Cimetidine can lead to confusion among the elderly. Instead, another H2-agonist is preferred over cimetidine. Choice A is incorrect. Allegra is preferred over other antihistamines such as diphenhydramine and promethazine because it is less prone to sedation; therefore it can be recommended for the elderly population. Choice C is incorrect. Claritin is preferred over other antihistamines such as diphenhydramine and promethazine because it is less prone to sedation; therefore it can be recommended for the elderly population. Choice D is incorrect. Ativan is preferred over other sedatives such as diazepam, benzodiazepines, and meprobamate because it is shorter acting, not as prone to addiction or long periods of sedation; therefore it can be recommended for the elderly population.

Which position is the most appropriate to prevent foot drop for a patient who is on bed rest following a spinal injury? A. Supination [21%] B. Dorsiflexion [56%] C. Hyperextension [9%] D. Abduction [14%]

Explanation Choice B is correct. Dorsiflexion is the most appropriate position to prevent foot drop in a patient on bed rest following a spinal injury. Choices A, C, and D are incorrect. None of these positions would be used to prevent foot drop. A: Supination involves lying patients on their back or facing a body part upward. B: Hyperextension is a state of exaggerated extension. D: Abduction involves the lateral movement of a body part away from the midline of the body. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Spinal Cord Injuries

he RN is caring for a patient with a new medication order of amiodarone. Which intervention is not appropriate for this patient? A. Monitor ECG [10%] B. Check BP every 4 hours [36%] C. Report shortness of breath [10%] D. Avoid ingesting grapefruit [44%]

Explanation Choice B is correct. Hypotension is an adverse effect of amiodarone. A decrease in blood pressure usually occurs within the first several hours of administration, so BP should be checked more frequently than every 4 hours initially. Choice A is incorrect. Amiodarone may cause QT prolongation, which can lead to worsening arrhythmias. Choice C is incorrect. Shortness of breath should be reported as it may indicate ARDS related to the new medication. Choice D is incorrect. Grapefruit and grapefruit juice may interfere with amiodarone. NCSBN Client Need Topic: Cardiovascular, Subtopic: Medication administration, adverse effects/contraindications/side effects/interactions

The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment? A. 74-year-old with several heavily bleeding wounds who is lethargic and pale. [33%] B. 37-year-old who appears anxious and is using neck muscles to breathe. [46%] C. 16-year-old who is confused, holding her head, and complaining of nausea. [15%] D. 65-year-old who rates his pain at 10/10 and is guarding his right leg. [5%]

Explanation Choice B is correct. In the setting of a mass casualty or disaster, triage systems are essential to prioritize patients. Triage deals with the appropriate allocation of limited resources during a disaster. In a disaster, the highest priority is given to the person with life-threatening injuries who has a high chance of survival if stabilized. The client in option B presents with symptoms highly suspicious of traumatic pneumothorax, using accessory muscles for breathing, and anxiety (due to difficulty getting enough air). Use of accessory muscles indicates severe respiratory distress. This patient would be the nurse's highest priority and requires rapid chest decompression to allow lung expansion. A needle thoracostomy and subsequent tube thoracostomy could be life-saving in this situation. Choice A is incorrect. This person is likely in hypovolemic shock due to blood loss. The chance of survival is low compared to the patient with a suspected pneumothorax, so this person would not be the highest priority for treatment. Choice C is incorrect. This person presents with signs of a concussion, and the chance of survival is high, but the injuries are not as severe or emergent as the patient with suspected pneumothorax. Choice D is incorrect. This person likely has a minor injury such as a broken bone. The chance of survival is high, but the damage would not require the most immediate attention and could be delayed until the more severely injured are stabilized. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential

Parenting styles are most similar to whose theory of leadership? A. Bass [6%] B. Lewin [55%] C. House [14%] D. Fiedler [25%]

Explanation Choice B is correct. Kurt Lewin's theory of leadership is the most similar to the styles of parenting. Lewin describes the leadership styles as the autocratic, participative, democratic, and laissez-faire styles of leadership, which are the same as the different parenting styles. All these styles of leadership and parenting styles have their distinct advantages and disadvantages. Choice A is incorrect. Bass developed the transformational leadership style, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting. Choice C is incorrect. House developed the Path-Goal situational leadership theory, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting. Choice D is incorrect. Fiedler is credited with the Contingency situational leadership theory, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting.

Your newly assigned client has a history of chronic obstructive pulmonary disease (COPD). When you enter his room, you find his oxygen is running at 6 L/min, his color is flushed, and his respirations are 8/min. What should you do first? A. Place client in high Fowler's position [51%] B. Lower the oxygen rate [45%] C. Take baseline vital signs [3%] D. Obtain an EKG [1%]

Explanation Choice B is correct. Low oxygen level stimulates respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe. This can lead to increased hypoventilation and possibly the development of or worsening of respiratory acidosis can occur. Left untreated, this can result in a patient's death. Individuals with COPD experience lowered oxygen tension and increased carbon dioxide retention during sleep, especially during REM sleep, when neuromuscular control usually is depressed. This can result in pulmonary spasms and transient pulmonary hypertension. Choice A is incorrect. Although High-Fowler's position is recommended, it is not the first action that should be taken. Choice C is incorrect. Baseline vitals are taken on admission to the unit. Choice D is incorrect. While an EKG may be ordered if symptoms do not resolve, the first nursing action should be to lower the O2 rate and see if there is an improvement in the patient's status. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

Which of these medications can be mixed in the same syringe without the risk of any incompatibility? A. Morphine and furosemide [12%] B. Metoclopramide and dexamethasone [45%] C. Lignocaine and ampicillin [18%] D. Promethazine and furosemide [25%]

Explanation Choice B is correct. Metoclopramide and dexamethasone can be mixed in the same syringe because these two medications are compatible with each other. Choice A is incorrect. Morphine and furosemide cannot be mixed in the same syringe because they are not compatible. However, morphine and other medications such as ketamine can be mixed in the same syringe. Choice C is incorrect. Lignocaine and ampicillin cannot be mixed in the same syringe because they are not compatible. However, lignocaine and other medications such as metoclopramide are compatible and can be mixed in the same syringe. Choice D is incorrect. Promethazine and furosemide cannot be mixed in the same syringe because they are not compatible. However, promethazine and other medications such as atropine can be mixed in the same syringe.

The nurse receives an order to infuse 500 mL of normal saline over 8 hours. The drop factor of the available IV tubing is 10. The drip rate per minute is: A. 5.2 [6%] B. 10.4 [81%] C. 20.8 [7%] D. 26 [6%]

Explanation Choice B is correct. The drip rate per minute is 10.4. Convert 8 hours to minutes: 8 hr X 60 minutes/hr = 480 minutes. Use the formula (Amount ordered X drip factor)/ # minutes = Drops/minute. (500 X 10)/ 480 = 10.4 drops/minute. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Dosage Calculation; Medication administration

What is the first assessment the nurse should make when a patient reports he hurt his knee playing baseball and the knee appears swollen? A. Feel the knee for warmth [11%] B. Compare the swollen knee with the other knee [53%] C. Palpate for crepitus in the knee [8%] D. Assess active range of motion in the knee [28%]

Explanation Choice B is correct. The first step of any assessment is always inspection. The first step the nurse should take is to compare the knees for symmetry. Choices A, C, and D are incorrect. These answer choices are procedures for assessing joints, which may be indicated, but do not represent the first step the nurse should take. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Musculoskeletal Assessment

Which of the following statements best describes the cardiovascular system? A. It has a heart with six chambers, strong vessels, and valves. [9%] B. It is a double-pump circulating blood out to the lungs and the body. [56%] C. It includes concepts of precontractility, postcontractility, and load. [24%] D. It functions with a conduction system and starts in the ventricles. [11%]

Explanation Choice B is correct. The heart is a double pump with four chambers, four valves, and a conduction system with a pacemaker originating in the atrium. Choice A, C, and D are incorrect. These are incorrect statements about the cardiovascular system. The heart has four chambers, not six. These chambers include two atria (right and left) and two ventricles (right and left). Blood from the entire body returns to the heart's right atrium through the superior and inferior vena cavaes. Blood circulates through the right atrium, then to the right ventricle, gets oxygenated in the lungs, moves on to the left atrium, then left ventricle, and is pumped back to the systemic circulation via the aorta. The conduction system of the heart begins in the right atrium, not the ventricle. The heart's conduction system includes pacemaker cells (SA node, AV node, Bundle of His, bundle branches, and Purkinje fibers) plus contractile cells. The sinoatrial node (SA node), located in the right atrium, is the pacemaker that sets the heart rate and is the starting point of the conduction system. The effectiveness of the pumping action of the heart is described in concepts of preload, afterload, and contractility. Preload (end-diastolic volume) is the amount of initial stretching of the ventricles before the contraction (systole) begins. Preload is determined by the venous return to the heart and is directly related to ventricular filling. Afterload refers to the resistance/load against which the left ventricle pumps out the blood. Afterload is directly determined by aortic pressure (systemic vascular resistance, SVR). Finally, contractility (inotropy) refers to the innate ability of heart muscle to contract at a given afterload and preload. Preload, afterload, and contractility determine the stroke volume and ejection fraction. Therefore, understanding these concepts is important to understand the pathophysiology of heart failure and the rationale for using certain medications in heart failure. Several medications are used in heart failure and they work by different methods. Diuretics and nitrates reduce the preload. Anti-hypertensive medications such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) work by reducing both the preload and afterload. ACEI and ARBs are the drugs of choice in the long-term management of congestive heart failure. Positive inotropic drugs such as digoxin, dopamine, dobutamine, and milrinone directly increase contractility and are often used in acute heart failure. NCSBN Client Need - Topic: Physiological Integrity; Subtopic: Physiological Adaptation

Select the skin disorder that is appropriately paired with an independent nursing intervention that can correct it or prevent it from getting worse. A. Erythema: The application of an antiseptic spray [4%] B. Excessive dryness: Using limited mild soap for bathing [50%] C. Abrasions: The application of an antimicrobial cream [36%] D. Hirsutism: Washing the area carefully and gently [10%]

Explanation Choice B is correct. The skin disorder that is appropriately paired with an independent nursing intervention that can correct it or prevent it from getting worse is the use of limited mild soap to help with excessive dryness. Choice A is incorrect. Although the application of an antiseptic spray to correct or prevent erythema from getting worse may be indicated, the use of any antiseptic spray is a dependent and not independent nursing intervention. Dependent nursing interventions need a doctor's order and because an antiseptic topical skin spray contains a medication, you must have a doctor's prescription to use it for erythema. Choice C is incorrect. Although the application of an antimicrobial cream to correct or prevent abrasions may be indicated, the use of any antimicrobial cream is a dependent and not independent nursing intervention. Dependent nursing interventions need a doctor's order and because antimicrobial topical skin creams contain a medication, you must have a doctor's prescription to use it for erythema. Choice D is incorrect. Hirsutism is a skin disorder that is characterized by the abnormal growth of unwanted hair on areas such as a female client's face; washing the area carefully and gently will not correct or prevent it. Shaving and tweezing the unwanted hair, however, are two independent nursing interventions that can be implemented to correct hirsutism.

While performing cardiac auscultation on a client. The nurse notes a whooshing and blowing sound over the heart valves. The nurse knows that this sound can be identified as a: A. Pericardial friction rub [18%] B. Heart murmur [57%] C. Normal lub-dub sounds [10%] D. S3 [15%]

Explanation Choice B is correct. The whooshing or blowing sound sometimes heard upon cardiac auscultation is known as a heart murmur and may indicate valve incompetency. Choice A is incorrect. Pericardial friction sounds like a scratching sound, caused by the conflict between the heart and pericardium. Choice C is incorrect. Whooshing and blowing do not indicate normal lub-dub sounds. Choice D is incorrect. S3 is a third heart sound sometimes referred to as a gallop. This gallop is not the same thing as a murmur. NCSBN client need Topic: Physiological Integrity, alterations in body function Additional Info

The nurse is caring for a patient that has just undergone left-sided thoracentesis. All of the following should be included by the nurse in his/her care plan, except: A. Document the amount of fluid withdrawn from the patient. [1%] B. Have the client turn on his left side. [51%] C. Have the client turn on his right side. [39%] D. Palpate the area around the site for a crackling sensation. [9%]

Explanation Choice B is correct. This is not an appropriate intervention, therefore the correct answer to the question. Following thoracentesis, the nurse should place the client on his unaffected side (right side in this case) for one hour to facilitate lung expansion. Placing on the left side is inappropriate in a client who just underwent left-sided Thoracentesis. Choices A, C, and D are incorrect. These are appropriate interventions that should be included in the nursing care plan post-Thoracentesis. The nurse should document the amount of fluid drained from the patient (Choice A) to ascertain how much residual fluid may be left in the pleural space. This documentation is also necessary so that it can be sent to the lab for analysis if needed. The nurse should place the client on his unaffected side (Choice C) for one hour to facilitate lung expansion. Subcutaneous emphysema is defined as a condition where the air gets into soft tissues under the skin. Often, it manifests as painless swelling of tissues. The characteristic clinical sign is a crackling sensation (Choice D) upon touch (like touching a sponge beneath the fingers). Subcutaneous emphysema is a common occurrence during a Thoracentesis and should be assessed by the nurse. Although it does not cause any problem, clients need to be reassured to prevent anxiety.

The RN develops a care plan for an 86-year-old patient with a medical diagnosis of diabetes mellitus. Nursing Diagnosis: Ineffective peripheral tissue perfusion related to compromised blood flow secondary to diabetes mellitus as evidenced by bilateral lower extremity edema and nonhealing wound to left lower extremity. Which collaborative nursing intervention would be appropriate for the RN to include in this patient's plan of care? A. Encourage frequent ambulation. [18%] B. Refer patient for physical therapy consultation. [36%] C. Inspect lower extremities for redness, pain, and edema. [44%] D. Provide a heating pad to warm the lower extremities. [2%]

Explanation Choice B is correct. This question is focusing on collaborative interventions, which are therapies that involve partnership and cooperation between multiple health care professionals. Of the options provided, referring the patient for a physical therapy consultation is the only one considered as a collaborative intervention. Choice A is incorrect. This patient should avoid prolonged sitting and should be encouraged to walk frequently in order to promote venous return. This would be appropriate for the nurse to include but is not an example of a collaborative intervention. Choice C is incorrect. Redness, pain, and edema in the leg are possible signs of a clot or DVT. This would be appropriate for the nurse to include but is not an example of a collaborative intervention. Choice D is incorrect. Patients with diabetes mellitus may have impaired peripheral sensation and should not use heating pads or hot water bottles to warm up cool extremities due to the risk of excessive temperatures damaging the skin.

A patient has been marked as "confidential" due to safety concerns. Which of these actions would be inappropriate of the nurse? A. Keep the patient's name/information out of public areas such as the nurse's station. [17%] B. Tell the patient's mother he is okay when she calls to ask if he is still on the unit. [54%] C. Deny that the patient is on the unit when visitors come to visit or call. [16%] D. Remove the patient from confidential status when he asks to be removed. [12%]

Explanation Choice B is correct. When a patient has asked to be flagged as confidential, no medical personnel can give out any information, including verifying the patient's presence in the hospital. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Legal Factors Related to Patient Safety

The nurse on the medical floor receives a report on four patients. Which patient should the nurse see first? A. A client with a pulmonary embolism that has dyspnea and a pCO2 of 30 mmHg, who is on anticoagulation. [39%] B. A client with atrial fibrillation on Warfarin with a history of prior rectal bleeding and an INR of 6.0. [49%] C. A client with congestive heart failure and brain natriuretic peptide of 640 pg/mL. [7%] D. A client with acute pancreatitis and serum calcium of 8.9 mg/dL. [5%]

Explanation Choice B is correct. While answering prioritization questions, it is essential to determine which findings are unexpected and which pose an immediate risk of complications to the client. The target international normalized ratio (INR) for atrial fibrillation is 2.0-3.0. A supra-therapeutic INR of 6.0 is too high for this patient and puts the patient at high risk for bleeding. Additionally, given his prior history of gastrointestinal bleeding, he is more prone to recurrent bleeding in the setting of coagulopathy. The nurse should hold warfarin, assess the patient for signs of bleeding and notify the physician of abnormal results to determine if vitamin K should be administered to counter the effects of warfarin. Choice A is incorrect. The client has an established diagnosis of Pulmonary Embolism (PE) and is on therapeutic anticoagulation. Dyspnea and elevated D-dimer are expected results in patients with known PE. D-dimer reflects thrombin and plasmin activity; it is usually positive in hospitalized patients with thrombotic events. Low pO2 (Hypoxia) and low pCO2 (Respiratory alkalosis) are expected findings in patients with PE. Normal PCO2 is 35-45 mmHg, so 30 mmHg is small but not critical (<20 mmHg). Choice C is incorrect. Brain natriuretic peptide is a marker for congestive heart failure (CHF) because it correlates with left ventricular pressure. High left ventricular pressures and high BNP levels are expected findings in patients with heart failure. A BNP of more than 100 pg/mL is abnormal. The client has an established diagnosis of CHF and a report of BNP at 640 pg/mL does not require immediate action. Choice D is incorrect. Acute pancreatitis can cause decreased calcium levels (hypocalcemia). Severe hypocalcemia may be seen in acute pancreatitis and can present with neurological as well as cardiovascular manifestations. However, since the normal range for serum calcium level is 8.6-10.2 mg/dL, this patient's result of 8.9 mg/dL is within the normal range and would not warrant any intervention. NCSBN Client Need Topic: Leadership/management; Subtopic: Prioritization

Which of the following expected outcomes is appropriate for a client with heart disease who is complaining of chest pain? A. The client will be free of neuropathic pain related to angina. [12%] B. The client will be free of hyperalgesia pain related to angina. [12%] C. The client will be free of visceral pain related to angina. [51%] D. The client will be free of somatic pain related to angina. [25%]

Explanation Choice C is correct. "The client will be free of visceral pain related to angina" is an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is an example of visceral pain. Other cases of physical pain are cramping secondary to irritable bowel syndrome and labor pain. Choice A is incorrect. "The client will be free of neuropathic pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not neuropathic pain. Choice B is incorrect. "The client will be free of hyperalgesia pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not hyperalgesia. Choice D is incorrect. "The client will be free of somatic pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not bodily pain.

The nurse is performing a visual acuity test on a client that states she has myopia. Which result should the nurse expect to find? A. 20/20 [8%] B. 20/15 [45%] C. 20/55 [42%] D. 20/27 [6%]

Explanation Choice C is correct. 20/55 means that the client can read at 20 feet what a person with normal vision can see at 55 feet or less. A result of 20/30 or higher indicates myopia or nearsightedness. Choice A is incorrect. 20/20 means a typical visual acuity result. It means that the client can read at 20 feet what a person with normal vision can see at 20 feet. Choice B is incorrect. 20/15 means that the client can read at 20 feet what a person with normal vision can see at 15 feet or less. This is indicative of hyperopia or farsightedness. Choice D is incorrect. 20/27 can still be considered normal visual acuity.

The nurse is caring for a patient who is receiving prescribed acamprosate. Which of the following statements, if made by the patient, would indicate a therapeutic response? A. "I no longer hear voices." [15%] B. "I have more motivation during the day." [18%] C. "I am not drinking alcohol anymore." [46%] D. "My anxiety has lessened in public." [21%]

Explanation 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 be used to 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. Additional information: 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 patient should be encouraged to seek counseling to help enhance their chances of abstinence.

A nurse is assigned to care for a client with acquired immunodeficiency syndrome. The client is to receive didanosine in tablet form. When administering the medication, the nurse knows that: A. The tablets should be crushed and mixed with fruit juice [4%] B. The client should be asked to swallow the tablets whole with a full glass of water [77%] C. The client should be instructed to chew the tablets thoroughly before swallowing [15%] D. The tablets should be dissolved in fruit juice [4%]

Explanation Choice C is correct. Didanosine is an antiretroviral drug (reverse transcriptase inhibitor) prescribed to patients with human immunodeficiency virus. Stomach juices are acidic and can cause degradation of Didanosine. Didanosine tablets have buffers that increase the pH levels in the stomach to the point that prevents degradation of the active drug. Chewing the tablets releases the buffers. The nurse must ensure that the pills are chewed thoroughly before swallowing, or they should be crushed and mixed with water, not fruit juices or other acidic liquids. Choices A and D are incorrect. Fruit juices are acidic and may cause degradation of Didanosine. The tablets may be chewed or crushed and dissolved in a non-acidic liquid for administration. Choice B is incorrect. Didanosine may also come in capsules which must be swallowed as a whole. However, the tablets must be chewed. The question refers to the tablet forms, not capsules.

The home health nurse is discussing environmental safety with a 74-year-old patient who lives with her son. Which of the following statements by the patient would indicate that additional teaching is needed? A. "My son will install grab bars in the bathroom." [2%] B. "I will wear my indoor shoes while walking inside the house." [27%] C. "The furniture is arranged so that I can hold onto something if I need it." [62%] D. "We will remove all small rugs." [9%]

Explanation Choice C is correct. Furniture should be arranged so that there are clear paths, free of rugs, cords, or other obstacles. It is not safe for the patient to be using furniture for support during walking. The nurse should discuss the risks associated with this action and evaluate the patient's need for a mobility aid such as a walker or cane. Choice A is incorrect. Falls frequently occur in the bathroom setting. Grab bars, elevated toilet seats, and shower chairs are examples of safety precautions to reduce the risk of falls. Choice B is incorrect. The patient should wear sturdy, properly fitting footwear when ambulating, even when inside the home. Choice D is incorrect. Rugs should be taped down at the edges or removed from the floors to reduce the risk of falls. NCSBN Client need Topic: Safety, Subtopic: Home safety

During nursing hand-off, the nurse was informed that a patient's serum potassium is critically low at 2.8 mEq/L. During rounds, the first thing that the nurse should assess in this client should be which of the following? A. Ability to balance while walking [7%] B. Quality of peripheral pulses [30%] C. Respiratory status looking out for shallow respirations [58%] D. Frequency of bowel movements [5%]

Explanation Choice C is correct. Hypokalemia affects the musculoskeletal, cardiovascular, neurologic, and respiratory systems. The skeletal muscles become weak, causing the patient to collapse while ambulating; the peripheral pulses are expected to be thready and weak, making palpation difficult. May also cause decreased peristalsis, which can lead to constipation. However, it is the respiratory system that is severely affected by hypokalemia through the weakness of the muscles needed for breathing. This may lead to shallow respirations and cause respiratory insufficiency, which is a major cause of death. Thus, respiratory status should be assessed first in any client with hypokalemia. Choices A, B, and D are incorrect. These assessments should also be included but are not the utmost priority.

A client with benign prostatic hyperplasia (BPH) is post-operative from transurethral resection of the prostate and is now on continuous bladder irrigation. Upon assessment, the nurse notes that the drainage from the catheter has stopped. Which intervention is most appropriate? A. Reinsert a new catheter [4%] B. Increase the infusion rate of the irrigation [17%] C. Attempt to dislodge a clot [45%] D. Contact the urologist [34%]

Explanation Choice C is correct. Initially, the nurse should inspect the catheter for a possible clot. If present, the nurse may remove the clot by either gentle aspiration of the lump or irrigation through the out-port. Choices A, B, and D are incorrect. It is not necessary to replace the apparatus at this point. Increasing the flow may lead to bladder distention and pain. The nurse should not contact the physician without exhausting independent intervention first.

Select the phase of the therapeutic nurse-client relationship process that is most accurately paired with a nursing skill that is essential to its success in terms of meeting the client's needs. A. The termination phase: The collection of assessment data [4%] B. The introductory phase: The summarization of outcomes [3%] C. The working phase: Mutual goal setting with the client and others [47%] D. The introductory phase: Mutual goal setting with the client and others [46%]

Explanation Choice C is correct. Mutual goal setting and decision-making with the client and others, such as family members and other members of the healthcare team, are essential to the working phase of the therapeutic nurse-client relationship process. This mutual goal setting and decision-making are critical to the success of care planning and optimal client outcomes. The phases of the nurse-client relationship in the correct sequential order are: The preinteraction phase The introductory phase The working phase The termination phase Choice A is incorrect. The termination phase of the therapeutic nurse-client relationship is characterized as the end of this relationship with the client, and, as such, the nursing skill that is essential to this phase in terms of meeting the client's needs is a summarization and not the collection of assessment data. After this relationship, the nurse will summarize the relationship, decisions that were made, and the outcomes that were or were not achieved. Choice B is incorrect. The summarization of outcomes is not done during the introduction/ interaction phase. Instead, the nursing skill that is necessary during this phase is the collection of assessment data, which is also the second phase of the nursing process. Choice D is incorrect. The nursing skills that are essential to the introductory phase of the therapeutic nurse-client relationship process are the ability to establishing participant expectations and to delineate the roles and responsibilities of both the nurse and the client as this relationship continues. Mutual goal setting and decision-making with the client and others, such as family members and other members of the healthcare team, are essential to another phase of this therapeutic nurse-client relationship process.

This nurse is caring for a client who is receiving prescribed oprelvekin. Which of the following findings would indicate a therapeutic response? A. Hemoglobin (Hgb) 14 g/dL [20%] B. White Blood Cell (WBC) 6,500 mm3 [21%] C. Platelets 155,000 mm3 [41%] D. Prothrombin Time (PT) 11 seconds [18%]

Explanation Choice C is correct. Oprelvekin is a hematopoietic agent used to stimulate the production of platelets. This platelet count is normal (150-400 mm3 is the optimal range) and thus, is a therapeutic finding. Choices A, B, and D are incorrect. Oprelvekin is a hematopoietic agent used to stimulate the production of platelets. While all of these laboratory values are normal, they are not relevant to the therapeutic benefit of oprelvekin. Additional Info Oprelvekin is indicated to prevent chemotherapy-induced severe thrombocytopenia and avoid the need for platelet transfusions. This medication takes 5-9 days to be efficacious. Once oprelvekin is discontinued, counts remain increased for about 7 days and return to baseline within 14 days. The normal laboratory values are as follows: Normal Hemoglobin: Male: 14-18 g/dL; Female: 12-16 g/dL Normal Hematocrit: Male: 42-52%; Female: 37-47% Normal White Blood Cell count: 5-10 mm3 Normal Platelet Count: 150-400 mm3

The nurse is preparing to administer prochlorperazine maleate 10 mg IM and butorphanol 2 mg IM to a patient. Which is the most appropriate nursing action? A. Check the client's respirations and temperature [30%] B. Dilute the medications in 5 mL of normal saline [2%] C. Draw the medications in separate syringes [61%] D. Draw both medications in the same syringe [6%] Correct Answer 61%

Explanation Choice C is correct. Prochlorperazine should not be mixed with other medications as it is not compatible. Choice A is incorrect. The nurse does not need to check the respiration and temperature of the patient. Instead, the nurse should monitor the blood pressure and heart rate of the patient. Choice B is incorrect. These medications do not need to be diluted with normal saline. Choice D is incorrect. Prochlorperazine should not be mixed with other medications as it is not compatible.

The nurse is taking care of a client in the fourth stage of labor. She notes that her fundus is firm but she is still bleeding profusely. What should be the nurse's first action? A. Document the findings. [2%] B. Massage the client's fundus. [43%] C. Notify the physician. [44%] D. Put the client in Trendelenburg position. [11%]

Explanation Choice C is correct. Profuse bleeding may indicate a laceration of the birth canal or cervix, which needs the attention of a doctor to initiate appropriate interventions. Choice A is incorrect. The nurse should document the findings; however, the nurse should notify the physician first. Choice B is incorrect. The nurse should massage the client's fundus if it is still soft to stimulate contraction. Massaging the fundus if it is already firm does not help in controlling the bleeding. Profuse bleeding may indicate a laceration of the birth canal or cervix, which needs the attention of a physician. Choice D is incorrect. Putting the client in the Trendelenburg position compromises the patient's respiratory and cardiac functioning.

When discussing the Denver II test with the parents of a preschooler, which of these statements would indicate that they correctly understood the teaching? A. "This test will tell me whether or not my child's Intelligence Quotient (IQ) is normal." [14%] B. "This test will tell me about the motor developmental tasks my child can do today." [20%] C. "This test will measure my child's development." [46%] D. "This test will let me know if my child's development is normal or not." [20%]

Explanation Choice C is correct. The Denver Developmental Screening Test (DDST) was devised to provide a simple screening method for evidence of slow development in infants and preschool children. The test covers four functions: gross motor, fine motor adaptive, language, and personal-social. It has been standardized on 1,036 presumably healthy children (two weeks to six years of age) whose families reflect the occupational and ethnic characteristics of the population of Denver. Choice A is incorrect. The Denver Test does not measure a child's Intelligence Quotient (IQ). Wechsler Intelligence Scale for Children is one of the methods used to assess IQ. Choice B is incorrect. The Denver Test does not give information just on the "motor" developmental tasks that the child can perform "today." Instead, it is an instrument comprising several studies covering four functions: gross motor, fine motor adaptive, language, and personal-social. Choice D is incorrect. The Denver II is not used to define "normal" vs. "abnormal." Instead, it is used to provide evidence of slow or delayed development. The preschooler in the question is expected to attain the following milestones. Development milestones of a preschooler: NCSBN Client Need Topic: Psychosocial Integrity; Sub-Topic: Growth and Development

The nurse notices some bright red blood on the residual limb dressing of a client that had a below-the-knee amputation. The nurse suspects an arterial bleed. What should be the nurse's first action? A. Increase the IV rate. [2%] B. Take the client's vital signs. [20%] C. Apply a tourniquet above the amputation. [57%] D. Notify the physician. [20%]

Explanation Choice C is correct. The nurse should apply a tourniquet above the client's residual limb to stop the bleeding. This should be the nurse's first intervention. Choice A is incorrect. The nurse may increase the client's IV but not after implementing measures that can stop the bleeding. Choice B is incorrect. The nurse should assess the client's vital signs but not until after stopping the bleeding. Choice D is incorrect. The nurse needs to notify the physician but only after stopping the bleeding.

What does the area labeled 12 in the picture below represent? A. The anterior horn [18%] B. The dorsal root ganglion [24%] C. The posterior root [40%] D. The anterior root [18%]

Explanation Choice C is correct. The posterior or dorsal root is labeled as 12 in the picture, and cell bodies of the dorsal root nerves are located in the dorsal root ganglion (marked 13). These dorsal anatomical structures shown in the image play a role in pain and pain perception. Choice B is incorrect. The dorsal root ganglion is labeled 13 in the picture. A ganglion is a collection of cell bodies of the neurons outside the central nervous system. This cluster of cell bodies in the dorsal root ganglion gives rise to all the fibers in the spinal nerve's dorsal root, which carries afferent ( sensory) information to the spinal cord. The dorsal/ posterior root nerve fibers sense painful and noxious stimuli that can be chemical or thermal. Choices A and D are incorrect. Dorsal ( posterior) roots and ventral ( anterior) roots are the components of spinal nerves. The anterior horn is labeled 1, whereas the anterior root is marked 11 in the image. The ventral ( anterior) roots carry the motor( efferent) impulses from the spinal cord to the organ.

According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS), which of the following is mandated at all times in respect to restraints? A. A written order from the client's physician. [52%] B. A written order from the client's licensed independent practitioner. [1%] C. The use of the least restrictive restraint possible. [46%] D. The monitoring of the restrained client at least every 6 hours. [1%]

Explanation Choice C is correct. The use of the least restrictive restraint possible is mandated at all times, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS). Restraint orders can be written by the client's physician, the client's licensed independent practitioner, and by the registered nurse in an emergency situation or by using an established protocol. Choice A is incorrect. A written order from the client's physician is NOT mandated at all times, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS). There are other ways that restraints can be initiated. Choice B is incorrect. A written order from the client's licensed independent practitioner is NOT mandated at all times, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS). There are other ways that restraints can be initiated. Choice D is incorrect. The monitoring of the restrained client is required more frequently than every 6 hours, according to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS).

Which of the following is a critical and necessary component of a malpractice case? A. An act of omission [17%] B. An act of commission [8%] C. An intentional act [28%] D. A breach of duty [47%]

Explanation Choice D is correct. A breach of duty is a critical and necessary component of a malpractice case. Other vital and essential elements of a malpractice case include an act of commission or omission, an intentional or unintentional act, damages to the client, causation, foreseeability, and causation. Choice A is incorrect. A malpractice case can occur as the result of both acts of omission and commission. Therefore, the commission is not a necessary component of a malpractice case. Choice B is incorrect. A malpractice case can occur as the result of both acts of omission and commission. Therefore, failure is not a necessary component of a malpractice case. Choice C is incorrect. A malpractice case can occur due to intentional and negligent, or unintentional acts; therefore, the intention is not a necessary component of a malpractice case.

A nurse caring for an HIV positive client is preparing to administer an IV gamma globulin to the client. The client asks the nurse, "What is that you are giving me?" The nurse's most appropriate response would be: A. "This medication will help stimulate production of red blood cells in your body." [9%] B. "This is intravenous gamma globulin. This will increase the proteins circulating in your blood, helping to increase your blood pressure." [15%] C. "This medication will slow down the replication of the virus." [27%] D. "This is gamma globulin. This will help you against infection." [49%]

Explanation Choice D is correct. Gamma globulins or immunoglobulins are given to boost the clients' immunity, protecting him from infection. Choice A is incorrect. Drugs that stimulate RBC production in the body include erythropoietin (EPO). IV gamma globulins do not increase RBC production. Choice B is incorrect. The nurse may be referring to albumin. Albumin is used to elevate the blood pressure in cases of shock and can be used to treat hypoalbuminemia in clients with liver failure. Choice C is incorrect. The nurse is referring to antiretroviral drugs. Antiretrovirals stop HIV from multiplying inside the body.

You are treating a postpartum patient with subinvolution. The nurse receives orders for each of the following medications. Which of these medications should the nurse question the order form? before administering? Select all that apply. A. Oxytocin [21%] B. Methylergonovine [19%] C. Carboprost tromethamine [25%] D. Magnesium sulfate [35%]

Explanation Choice D is correct. Magnesium sulfate is not an appropriate medication to administer for a patient with subinvolution. The nurse needs to question this order. Magnesium sulfate is a tocolytic agent that inhibits contractions of myometrial smooth muscle cells. This is given to prevent preterm labor, or relax the uterus during hypertonic contractions. It would be contraindicated in the case of subinvolution. Choice A is incorrect. Oxytocin would be an appropriate medication to administer for a patient experiencing subinvolution. The nurse does not need to question this order, so this answer is incorrect. Oxytocin, also known as Pitocin, causes contraction of the uterus. This will help in the case of subinvolution because the uterus is not clamping down as needed to prevent bleeding after the delivery. Choice B is incorrect. Methylergonovine would be an appropriate medication to administer for a patient experiencing subinvolution. The nurse does not need to question this order, so this answer is incorrect. Methylergonovine affects the smooth muscle of the uterus, causing increased muscle tone. This will also help with bleeding due to uterine atony that occurs during subinvolution. Choice C is incorrect. Carboprost tromethamine would be an appropriate medication to administer for a patient experiencing subinvolution. The nurse does not need to question this order, so this answer is incorrect. Carboprost tromethamine is a prostaglandin that causes smooth muscle contraction. It, therefore, causes the uterus to contract, clamp down, and stop the bleeding associated with subinvolution. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery

Which Jewish religious practice relating to death is accurate? Members of the Jewish religion: A. Bury the dead within 24 hours of the death regardless of the day. [16%] B. Bury the dead within 48 hours of the death except on Saturdays. [18%] C. Prohibit organ donations. [45%] D. Sit Shiva rather than have a wake. [21%]

Explanation Choice D is correct. Members of the Jewish religion sit Shiva rather than have a wake. The shiva period lasts for seven days following the burial. Sitting Shiva is somewhat similar to a wake in that Shiva pays respect for the deceased, and it offers loved ones a time to mourn among friends and family after the death of a loved one. Choice A is incorrect. Members of the Jewish religion bury the dead within 24 hours of the death but not on the Sabbath, which is Saturday. Choice B is incorrect. Members of the Jewish religion bury the dead within 24 hours, not 48 hours, of the death but not on the Sabbath, which is Saturday. Choice C is incorrect. Members of the Jewish religion do not prohibit organ donations after death.

The nurse is caring for a 48-hour old newborn. Based on the previous shift's report, the newborn has not yet passed stools since it was delivered. The nurse would suspect which condition? A. Celiac disease [3%] B. Cystic fibrosis [12%] C. Intussusception [31%] D. Hirschsprung's disease [54%]

Explanation Choice D is correct. Most healthy infants will pass meconium (first stool) by 24 hrs, and almost 100% of normal full-term neonates will pass meconium by 48 hours. Failure to pass meconium within the first 48 hours of life may indicate Hirschsprung's disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility (aganglionosis) in an intestinal segment. Choice A is incorrect. Celiac disease is a disease in which the small intestine is hypersensitive to gluten, leading to difficulty digesting food. Celiac disease is characterized by diarrhea, malabsorption, and iron deficiency anemia. Not passing stools for the first 24 hours of life is not a manifestation of Celiac disease. Choice B is incorrect. Cystic fibrosis is a generalized dysfunction of the exocrine glands leading to increased mucus secretions, particularly in the pancreas and lungs. Meconium ileus (small bowel obstruction) by thickened meconium is one of the earliest manifestations of cystic fibrosis. Meconium ileus must be differentiated from other conditions that cause the delayed passage of meconium (e.g. Hirschsprung's disease). Often, meconium ileus presents within few hours of birth with bilious emesis after the first feeding is initiated. Certainly, these infants can also present with delayed passage of meconium, but more often, obstructive ileus symptoms are present within hours after birth rather than at 48 hours. Choice C is incorrect. Intussusception is the invagination of one portion of the intestine into another. A characteristic manifestation of this condition is severe abdominal pain.

The nurse attends to a client with shortness of breath, bilateral lung crackles, weak pulses, and frothy pink sputum. Which of the following orders should the nurse question for this client? A. Supplemental oxygen via nasal cannula or mask [7%] B. Losartan [38%] C. Fowler's position [7%] D. Diltiazem [47%]

Explanation Choice D is correct. The client is exhibiting symptoms and signs of left ventricular heart failure. Decreased cardiac output associated with acute systolic heart failure results in reduced blood pressure, weak pulses, and acute pulmonary edema ( dyspnea, frothy pink sputum, lung crackles). Diltiazem and other calcium channel blockers ( CCBs) produce a negative inotropic effect ( reduced myocardial contractility) and are contraindicated in acute systolic heart failure. CCBs may exacerbate systolic dysfunction and cause heart failure symptoms to worsen. The nurse should question this order to determine if there is a more appropriate medication to accomplish the intended therapeutic effect with a lower risk of complications. Choice A, B, and C are incorrect. These orders are appropriate for a client presenting with acute heart failure and pulmonary edema. The nurse should administer supplemental oxygen to promote adequate tissue oxygenation ( Choice A). Losartan is an angiotensin receptor blocker ( ARV). Afterload is increased in systolic heart failure due to RAAS ( Renin-Angiotensin- Aldosterone-System) mediated increased peripheral vascular resistance. By blocking angiotensin II receptors, losartan causes vasodilation and decreases afterload. Losartan is indicated in systolic heart failure because it reduces mortality and morbidity. Fowler's position ( Choice C) is indicated for patients with heart failure symptoms. Fowler's position promotes oxygenation by allowing maximum chest expansion. NCSBN Client Need Topic: Adult health - Cardiovascular, Subtopic: Illness management, the potential for alterations in body systems, system-specific assessments, expected actions/outcomes Learning Objective Recognize acute heart failure symptoms and understand that the drugs that reduce myocardial contractility ( negative inotropics) are contraindicated in this setting. Additional Info Heart failure is associated with reduced cardiac output and reduced blood flow to organs, including the kidneys. Reduced renal blood flow stimulates renin release. Renin converts Angiotensinogen to Angiotensin I, which is further activated to Angiotensin II by the angiotensin-converting enzyme in the lungs. Angiotensin II is a vasoconstrictor, and it increases peripheral vascular resistance (afterload). When medications are used to reduce afterload, the heart pumps better and cardiac output increases. Losartan is an angiotensin receptor blocker ( ARB). It reduces the systemic blood pressure (afterload) by countering the angiotensin II. Losartan does not have direct inotropic action on the heart, but it helps the cardiac output by decreasing the afterload. Losartan improves the morbidity and mortality in heart failure, and hence it's an important drug in treating heart failure.

The defining characteristic that separates and differentiates palliative care from curative care is that curative care: A. Focuses on medical outcomes and care; whereas palliative care focuses on nursing outcomes. [3%] B. Focuses on the care of medical symptoms; whereas palliative care focuses on nursing care needs. [11%] C. Aims to correct chronic and acute disorders; whereas palliative care aims to provide comfort only. [46%] D. Aims to correct chronic and acute disorders; whereas palliative care aims to manage symptoms. [40%]

Explanation Choice D is correct. The defining characteristic that separates and differentiates palliative care from curative care is that curative care aims to correct chronic and acute disorders whereas palliative care aims to manage symptoms such as the end of life symptoms and pain using both pharmacological and non-pharmacological pain interventions, in addition to the provision of comfort at the end of life. Choice A is incorrect. Although curative care focuses on medical outcomes and care, it also focuses on nursing outcomes so this is not the defining characteristic that separates and differentiates palliative care from curative care. Choice B is incorrect. Although curative care focuses on the care of medical symptoms, it also focuses on nursing care needs so this is not the defining characteristic that separates and differentiates palliative care from curative care. Choice C is incorrect. Although curative care aims to correct chronic and acute disorders, palliative care entails more than the provision of comfort only.

Which of the following is an example of the appropriate care of a client with neutropenia? A. Usual hand washing [47%] B. Offer a semi-private room [3%] C. Provide fresh fruits and vegetables [2%] D. Have the patient wear a mask when outside of their room [49%]

Explanation Choice D is correct. The neutropenic patient should wear a mask when leaving their hospital room to prevent exposure to any airborne pathogens that may cause infection. Neutropenia is a condition associated with a low neutrophil count, which is a type of white blood cell. Neutrophils are made in the bone marrow and fight off infections. When the neutrophil count is low, the patient is more susceptible to infections, and preventive measures must be implemented. The single most important preventive measure is hand washing. Before any contact with a neutropenic patient, caregivers and others should wash their hands. Infections often develop from endogenous bacteria, so patients should maintain good personal hygiene, including handwashing and oral care. Patients should avoid crowds and others who are ill. Avoiding uncooked meats, seafood, eggs, and unwashed fruits and vegetables may be prudent, though the effectiveness hasn't been established. Procedures that break the skin, such as venipunctures, biopsies, and I.V. therapy, may also introduce infection. Such procedures should be delayed if possible. Common infection sites include the mucosa of the GI, urinary, and respiratory tracts. Since trauma to the mucous membranes increases the risk of disease, catheters, enemas, rectal suppositories, or rectal thermometers should be avoided. Choice A is incorrect. Handwashing should be meticulous and frequent to help decrease the patient's risk of exposure to pathogens. A simple/ usual hand washing is not sufficient. Meticulous hand washing involves following the CDC recommended hand washing steps and washing the hands with soap and water for at least 20 seconds: Choice B is incorrect. A neutropenic patient should have a private room. Choice C is incorrect. Fresh fruits, vegetables, and flowers can contain pathogens that may infect the patient. All food should be thoroughly cooked. Plants and flowers are not allowed in the patient's room. Learning Objective Recognize that the neutropenia increases the risk of infection and various preventive measures must be implemented. Additional Info Neutropenia can lead to life-threatening infections. Generally, the longer the neutropenia lasts, and the more severe it is, the more likely the patient will develop a disease. The National Cancer Institute has a grading scale correlating a patient's ANC and the risk of infection. A neutrophil count between 1000 to 1500/ul is mild where as the count less than 500/ul is considered a severe neutropenia.

The nurse is caring for a 4-day post-abdominal surgery client. The nurse notes a temperature of 37 °C, no complaints of pain at the incision site, dry wound dressing, and hypoactive bowel sounds on all quadrants. Which conclusion can the nurse make based on all the assessment data? A. The client's wound is getting infected. [2%] B. The nurse should implement pain relief measures. [1%] C. There are no present problems for the client. [40%] D. The nurse should perform an additional GI assessment. [56%]

Explanation Choice D is correct. The nurse should use all the data gathered to analyze the situation. The client had abdominal surgery and has hypoactive bowel sounds. The nurse needs to do a further assessment to determine if there are any impending GI problems for the client and if any treatments need to be initiated. Choice A is incorrect. The client's wound dressing is dry and intact. The client is not hysterical. There is no sign of infection. Choice B is incorrect. The client states that he is not in pain; there is no need for pain relief. Choice C is incorrect. The client is four days post-op; the client is already expected to have normoactive bowel sounds. However, the client is exhibiting hypoactive bowel sounds, which signifies a problem.

A 62-year-old man with right shoulder pain starts noticing that his stool is clay-colored. He's never been a heavy drinker and has no known liver issues. What test should the nurse expect the doctor to order first while waiting for an ultrasound? A. Creatinine and BUN blood levels [17%] B. Serial abdominal exams [9%] C. ERCP [14%] D. Bilirubin level [60%]

Explanation Choice D is correct. The physician will want to know the patient's bilirubin level since it will be elevated. Increased bilirubin levels are associated with liver disease because the liver creates bilirubin. When it's not able to filter it out of the blood, it builds up. Choice A is incorrect. These lab values are helpful in kidney disease, not liver disease. Choice B is incorrect. Serial abdominal exams will not be a practical assessment in the care of this patient at this time. Choice C is incorrect. An ERCP (endoscopic retrograde cholangiopancreatography) may be warranted, but the doctor will want a more definitive diagnosis before sending the patient to surgery. NCSBN Client Need Topic: Safe and Effective Care Environment, Sub-topic: Care Management, Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

Which reimbursement principle are you employing when you appropriately transfer a client from an acute healthcare facility to a subacute healthcare facility along the continuum of care? A. The principle of retrospective reimbursement. [16%] B. The principle of rehabilitation care. [52%] C. The need to limit lengths of stay. [6%] D. The need for medical necessity. [26%]

Explanation Choice D is correct. The reimbursement principle that you are employing when you appropriately transfer a client from an acute healthcare facility to a subacute healthcare facility along the continuum of care is the need for medical necessity. Healthcare facilities are not reimbursed for care and services that are not medically necessary in an acute care facility when these services and care can be effectively and appropriately provided in a different setting such as a subacute care facility. Choice A is incorrect. The principle of retrospective reimbursement is not employed when you appropriately transfer a client from an acute healthcare facility to a subacute healthcare facility along the continuum of care because prospective rather than retrospective reimbursement is used in contemporary healthcare facilities (i.e. retail clinics, assisted living facilities). Choice B is incorrect. The principle of rehabilitation care is not employed when you appropriately transfer a client from an acute healthcare facility to a subacute healthcare facility along the continuum of care because rehabilitation is not a principle associated with reimbursement. Choice C is incorrect. The need to limit lengths of stay is a principle of reimbursement; however, the appropriate transfer of a client from an acute healthcare facility to a subacute healthcare facility along the continuum of care is not based on the need to limit client length of stay but instead, the client's needs. NCSBN Client Need: Topic: Management of Care; Subtopic: Establishing Priorities

Which statement should the nurse use during client education regarding a vasectomy as a permanent method of contraception? A. If you change your mind in the future, it's simple to reverse the procedure. [10%] B. You will need to return for an annual follow-up visit and sperm count. [13%] C. If you have a history of cardiac disease. we won't be able to do the vasectomy. [8%] D. You'll need to use another type of birth control until your sperm count is zero. [69%]

Explanation Choice D is correct. The second method of birth control is necessary until the sperm count is zero. A vasectomy is a form of male birth control that cuts the supply of sperm to your semen. It's done by cutting and sealing the tubes that carry sperm. Vasectomy has a low risk of problems and can usually be performed in an outpatient setting under local anesthesia. Although vasectomy reversals are possible, vasectomy should be considered a permanent form of male birth control. Vasectomy offers no protection from sexually transmitted infections. Vasectomy is a safe and effective birth control choice for men who are sure they don't want to father a child in the future. Vasectomy is nearly 100 percent effective in preventing pregnancy. Vasectomy is an outpatient surgery with a low risk of complications or side effects. The cost of a vasectomy is far less than the price of female sterilization (tubal ligation) or the long-term value of birth control medications for women. Choice A is incorrect. Although reversal is possible, it is often difficult, requiring microsurgery. Also, results may be unsuccessful. Choice B is incorrect. Once the sperm count is zero, there is no need for follow-up exams. Choice C is incorrect. There is no correlation between having a vasectomy and cardiac disease. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Altered Sexual Function

Which of the following are invasive procedures not routinely done on all pregnant women? Select all that apply. A. Contraction stress test [23%] B. Amniocentesis [46%] C. Nonstress test [8%] D. Nitrazine test [23%]

Explanation Choices A and B are correct. In a contraction stress test, contractions are induced with oxytocin. This is only done if a nonstress test is nonreactive, or there are other concerns (Choice A). An amniocentesis is a sampling of amniotic fluid that is sent for genetic testing. This is only done if indicated (Choice B). Choice C is incorrect. A nonstress test is noninvasive and done as routine antepartum testing. Choice D is incorrect. While a nitrazine test is not routinely done on all pregnant women, it is not invasive. Please note the question is asking to name the "non-routine" and "invasive" tests. The nitrazine test refers to the testing of the pH of vaginal secretions to determine if it is amniotic fluid and there has been a rupture of membranes. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological adaptation

While working in the neonatal intensive care nursery, you are assigned to take care of a baby who is 31 weeks gestation. Which of the following complications must you know to monitor given the baby's gestational age? Select all that apply. A. Hypoglycemia [35%] B. Hypothermia [39%] C. Birth injuries [10%] D. Fat wasting [16%]

Explanation Choices A and B are correct. Infants born before 37 weeks gestation have low stores of glucose and therefore hypoglycemia is a common complication of prematurity. Blood glucose should be monitored closely (Choice A). Preterm infants are at risk for poor thermoregulation and hypothermia due to decreased stores of muscle and fat. Their body temperatures should be regulated via incubator, radiant warming, bundling, or other methods of temperature control, as indicated (Choice B). Choice C is incorrect. Birth injuries are not a common complication for preterm infants as they are typically small and don't experience issues during vaginal delivery. This would be a complication to monitor for an infant that is large for gestational age. Choice D is incorrect. Fat and muscle wasting are not a common complication of preterm infants. They do not have large muscle and fat stores to begin with. This is common in a baby born post-term, who has wasted fat and muscle stores while in utero. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Newborn

Which of the following statements are true regarding hyperparathyroidism? Select all that apply. A. Patients with hyperparathyroidism have increased serum calcium levels. [40%] B. Patients with hyperparathyroidism have decreased serum phosphate levels. [31%] C. Hyperparathyroid patients are typically irritable and extremely agitated. [23%] D. There is no cure for hyperparathyroidism. [5%]

Explanation Choices A and B are correct. The parathyroid secretes parathyroid hormone. Parathyroid hormone causes calcium from the bones to be released, increasing serum calcium levels. An excessive parathyroid hormone, causes clients to experience hypercalcemia. Calcium and phosphorus have an inverse relationship. Due to increased levels of PTH increasing serum calcium, the phosphorus will then be decreased. Therefore, these clients will have hypophosphatemia. Choices C and D are incorrect. Hyperparathyroidism leads to increased serum calcium, which leads to clients being more sedated and lethargic, not agitated and irritable. The cure for hyperparathyroidism is a partial parathyroidectomy, or the removal of 2 of the parathyroids to decrease the amount of parathyroid hormone secretion.

Which of the following neurological assessments would be considered abnormal in a newborn? Select all that apply. A. High pitched cry [37%] B. Pupils are 2mm, equal, round, and react briskly to light. [8%] C. Lethargy [49%] D. Sleeping between each feeding [6%]

Explanation Choices A and C are correct. A high, pitched cry is an irregular finding in a newborn. It can be a sign of withdrawal in neonatal abstinence syndrome, or a sign of increased ICP if there is birth trauma (Choice A). For the level of consciousness, lethargy is not a normal finding. We expect the newborn to be alert. Lethargic, obtunded, stuporous, or comatose are all abnormal findings (Choice C). Choice B is incorrect. This is the usual pupil assessment. 2-3 mm, equal in size, round in shape, and briskly reactive to light are the expected findings for a pupil assessment in a newborn. Choice D is incorrect. For behavior, an infant is expected to be sleeping between their feedings. This is considered appropriate for the age and is a reasonable assessment finding. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn

Which of the following are preventable risk factors for developing cancer? Select all that apply. A. Low fiber diet [28%] B. Decreased red meat [30%] C. Obesity [38%] D. Increased age [4%]

Explanation Choices A and C are correct. A low fiber diet is a dietary cause of cancer and can be prevented (Choice A). Obesity is a preventable cause of cancer (Choice C). Choice B is incorrect. Increased, not decreased, consumption of red meat is a preventable cause of cancer. Choice D is incorrect. Increased age is a cause of cancer, but it is not preventable. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Oncology

Your client is being scheduled for cardiac catheterization. His medications include amlodipine for hypertension and metformin for diabetes. Which of the following are essential nursing interventions for the client before he proceeds to cardiac catheterization? Select all that apply. A. Verify if the client has any allergies. [37%] B. Check client's blood urea nitrogen (BUN) and creatinine. [28%] C. Hold the client's metformin. [32%] D. Administer acetaminophen. [3%]

Explanation Choices A, B, and C are correct. It is essential to verify if a patient has any allergies before a procedure in order to protect the patient. It is an especially important step for a cardiac catheterization to make sure the patient is not allergic to iodine because an iodine-based dye is used during cardiac catheterization to visualize the vessels. Should you discover that the patient is allergic to iodine, contact the health care provider immediately, and do not administer the dye. Physicians may order diphenhydramine and prednisone per protocol to minimize the risk of allergy with the iodinated contrast. Checking the patient's blood urea nitrogen and creatinine (Choice B) is essential before cardiac catheterization. Contrast-induced nephropathy (contrast-induced acute tubular necrosis) is a condition where the iodinated contrast damages renal tubules. Clients with pre-existing renal insufficiency are more prone to comparison associated renal damage. Therefore, it is crucial to make sure the client's renal function is not too low before a contrast agent is given. If the client's renal function is low, the physician may order intravenous hydration before the procedure to minimize the chances of renal damage. Metformin (Choice C) can cause lactic acidosis in patients with chronic renal failure and acute kidney injury. Since severe kidney injury is a possibility with iodinated contrast, the FDA recommends holding Metformin on the day of administration of contrast and 48 hours after. Choice D is incorrect. Acetaminophen is not usually prescribed for patients before cardiac catheterization. It does not minimize the risk of contrast-induced nephropathy. The most useful strategy to decrease the risk of contrast-induced neuropathy in those with baseline chronic kidney disease is per-procedural hydration. This is accomplished by initiating intravenous (IV) fluid with 0.9% normal saline at 1 ml/kg/hr about 6 to 12 hours before the procedure and continuing after the process. NCSBN Client Need: Topic: Reduction of Risk potential, Subtopic: Cardiac

Which of the following foods should the nurse educate the patient to avoid while they are taking warfarin? Select all that apply. A. Peanut butter [4%] B. Spinach [46%] C. Kale [45%] D. Almonds [5%]

Explanation Choices B and C are correct. Spinach should be avoided while taking warfarin. Vitamin K is a natural antagonist to warfarin as it helps the body form clots. So the amount of vitamin K will need to be controlled while taking warfarin. Spinach has 444 mcg per half cup, making it incredibly high in vitamin K (Choice B). Kale should be avoided while taking warfarin since vitamin K is a natural antagonist to warfarin as it helps the body form clots. So the amount of vitamin K will need to be controlled while taking warfarin. Kale has 565 mcg per half cup, making it incredibly high in vitamin K (Choice C). Choice A is incorrect. Peanut butter does not need to be avoided while taking warfarin. Vitamin K is a natural antagonist to warfarin as it helps the body form clots. So the amount of vitamin K will need to be controlled while taking warfarin. Peanut butter only has about 0.05 mcg of vitamin K per 1 tbsp, so it does not need to be avoided. Choice D is incorrect. Almonds do not need to be avoided while taking warfarin. Vitamin K is a natural antagonist to warfarin as it helps the body form clots. So the amount of vitamin K will need to be controlled while taking warfarin. Almonds have virtually no vitamin K, so they do not need to be avoided when taking warfarin. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Medication Administration

Which of the following are signs and symptoms of renal failure? Select all that apply. A. Metabolic alkalosis [12%] B. Metabolic acidosis [34%] C. Hyperkalemia [41%] D. Hypomagnesemia [13%]

Explanation Choices B and C are correct. The signs and symptoms of renal failure include metabolic acidosis and hyperkalemia, among many other signs and symptoms. Choice A is incorrect. Metabolic alkalosis can occur as the result of vomiting, Cushing's syndrome, and other causes, not including renal failure. Choice D is incorrect. Hypomagnesemia can occur as the result of diarrhea, pancreatitis, and burns, among other causes, not including renal failure.

The student nurse obtains a diastolic blood pressure that is much lower than the patient's typical reading and the patient denies any symptoms supporting the abnormal result. The precepting nurse should reinforce that which of the following factors may contribute to a falsely low diastolic blood pressure reading? Select all that apply. A. Leg crossing during the blood pressure reading [20%] B. The arm is positioned higher than heart level [27%] C. The cuff size too narrow for the patient's arm [22%] D. Pressing the stethoscope down too forcefully [16%] E. Deflating the cuff too slowly [13%]

Explanation Choices B and D are correct. B: Positioning the patient's arm higher than the level of the heart is likely to give a falsely low diastolic (and systolic) reading due to reduced hydrostatic pressure. D: Pressing the stethoscope down too forcefully is likely to give a falsely low diastolic reading due to obstruction or distortion of the brachial artery. Choice A is incorrect. A patient crossing their legs during a blood pressure reading is likely to give a falsely high diastolic and systolic blood pressure reading due to blood moving from the lower extremities to the thoracic area. Choice C is incorrect. Applying a cuff that is too narrow for the patient's arm is likely to give a falsely high diastolic blood pressure reading. Choice E is incorrect. Deflating the blood pressure cuff too slowly after inflation is likely to give a falsely high diastolic blood pressure reading due to venous congestion in the forearm making sounds less easily auscultated.

You are the nurse caring for a 4-month-old infant status post cleft lip repair. Which of the following nursing actions are appropriate for this patient? Select all that apply. A. Position prone [12%] B. Position supine [34%] C. Clean the suture line with hydrogen peroxide [12%] D. Apply elbow restraints [42%]

Explanation Choices B and D are correct. Supine or side-lying positions ( Choice B) are recommended following the cleft lip repair. The nurse must be cognizant of the suture line and protect the integrity of the sutures. Prone positioning may cause increased pressure/friction near the suture line and put the surgical site at risk in the post-operative cleft "lip" scenario. Applying elbow restraints (Choice D) is appropriate for a 4-month-old infant status post cleft lip repair. The nurse must protect the integrity of the suture line. Applying elbow restraints will restrict the necessary mobility for the infant to reach the sutures, thereby protecting the suture line. Choice A is incorrect. Prone positioning is not the recommended postoperative position for "cleft lip" repairs because of the risk to the suture line on the lip. Back or side-lying positions are the recommended positioning following cleft lip repair. The prone position is the preferred post-operative position for the "cleft palate" repair, not the cleft lip. Choice C is incorrect. Cleaning the suture line with hydrogen peroxide is not advisable. This chemical is too strong and could damage the suture line. The nurse should clean the suture line with saline. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics

While providing discharge teaching instructions for a parent with an 8-year-old newly diagnosed with type 1 diabetes mellitus, you review what to do when the child is sick. Which of the following are important points to teach the parent? Select all that apply. A. Check the blood glucose levels every 2 hours. [25%] B. Check for urinary ketones each time the child voids. [25%] C. Do not force the child to eat if they have no appetite. [17%] D. Continue to administer insulin even if the child does not have an appetite. [33%]

Explanation Choices B and D are correct. It is vital to check for urinary ketones each time the child voids to monitor for the development of ketosis and provide early treatment (Choice B). It is especially important when the child is ill to continue administering insulin. Because of the increased cortisol level present in the body during times of stress, such as illness, the child will be persistently hyperglycemic. Holding their insulin could lead to DKA (Choice D). Choice A is incorrect. The parent does not need to check the blood glucose every 2 hours, instead, every 4 hours would be appropriate. Choice C is incorrect. Children with diabetes need to follow their regular meal plan as best as they can. Modifying it to accommodate illness is appropriate, but they must still eat as close to their daily meals as possible. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Reduction of risk potential, endocrine

Which of the following may be causes for disciplinary action taken by the Board of Nursing? Select all that apply. A. Asking visitors to leave the room when preparing to assess a patient. [1%] B. Testing positive on a routine drug test. [34%] C. Refusal to provide care to a client based on personal beliefs. [27%] D. Committing a breach of patient confidentiality. [38%]

Explanation Choices B, C, and D are correct. The language used to describe the types of disciplinary actions available to the Board of Nursing (BON) varies according to state law. Although the terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Board actions may include: Fine or civil penalty Referral to an alternative discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other mental or physical conditions) Public reprimand or censure for a minor violation of the nurse practice act often with no restrictions on the license The imposition of requirements for monitoring, remediation, education, or other provision tailored to the particular situation Limitation or restriction of one or more aspects of practice (e.g. probation with certain limits, limiting role, setting, activities, hours worked) Separation from practice for some time (suspension) or loss of license (revocation or voluntary surrender) Remediation (various educational content or exercises) Other state-specific remedies Informing your superior that you cannot assume nursing duties until sufficient preparation for the specific task has been provided Conduct that is unprofessional and could affect the health of the public adversely They are abusing a patient physically or verbally They are falsifying a patient's record It is important to remember that a patient does not need to be injured for a discipline to be imposed against a nurse when his or her clinical practice is under question. Instead, it is the risk to the patient, potential or real, that is the basis of any discipline that might be imposed by the board of nursing. Choice A is incorrect. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Disciplinary Action

The nurse is caring for a client who is receiving prescribed mirtazapine. Which of the following statements, if made by the client, would indicate a therapeutic response? Select all that apply. A. "I am not smoking cigarettes anymore." [15%] B. "My blood glucose has decreased." [4%] C. "My depression has gotten better." [33%] D. "I am sleeping eight hours a night." [35%] E. "My blood pressure is back to normal." [13%]

Explanation Choices C and D are correct. Mirtazapine is a tetracyclic antidepressant that causes an increase in serotonin and norepinephrine. This medication is used for depressive and anxiety disorders. Mirtazapine is quite sedating and is often used for insomnia associated with depressive disorders. Choices A, B, and E are incorrect. Mirtazapine does not affect the craving for nicotine or decrease blood glucose. This medication also has no impact on blood pressure. Additional Info Additional information: Mirtazapine is an agent used to treat depressive and anxiety disorders. This medication causes sedation and is dosed at night. This may be helpful for those with depressive disorders and who suffer from concomitant insomnia. Mirtazapine has the following side effects - Increased appetite Weight gain Sedation Dizziness Confusion