Archer Review 14a

The nurse is caring for a client who is a Native American. Which of the following actions would be necessary for the nurse to take? A. Avoid excessive direct eye contact. [53%] B. Ensure that the nurse is of the same gender. [19%] C. Refer healthcare decisions to the male. [22%] D. Allow time for meditation to a shrine of Buddha. [5%]

Explanation Choice A is correct. Caring for a client who is Native American requires the nurse to be culturally competent and sensitive. One of the cultural norms is avoiding direct eye contact, as excessive eye contact may be seen as disrespectful. Choices B, C, and D are incorrect. Cultural norms for Native Americans do not require the nurse to be the same gender as the client. A patriarchal family structure is consistent with the Amish culture - not Native American. Healthcare decisions are made independently. Allowing time for meditation in a shrine of Buddha is a religious practice for Buddhism. Additional Info When caring for a client who is Native American, the nurse should practice cultural competence and sensitivity. Cultural norms for Native Americans include utilizing silence as a sign of respect, avoiding direct eye contact, and providing ample personal space.

A client is brought to the emergency department due to vomiting, fever, and a severe headache. The physician suspects meningitis; then assesses the client for meningeal irritation and spinal nerve root inflammation. The nurse documents a positive Kernig's sign when: A. The client complains of pain when his knee is extended with his hip flexed. [52%] B. The client has a stiff neck when the neck is flexed towards the chest. [33%] C. The client's forearm spasms when a blood pressure cuff is inflated on the upper arm. [7%] D. The client feels pain in the calf when his foot is dorsiflexed. [8%]

Explanation Choice A is correct. Kernig's sign is positive if pain occurs upon extension of the knee. When meninges are inflamed (meningitis), movement of the spinal cord or nerves against the inflamed meninges results in pain. With the patient placed supine and hip flexed at 90 degrees, an extension of the knee stretches the hamstring and triggers pain by pulling tissues surrounding an inflamed spinal canal and meninges. Choice B is incorrect. Brudzinski's sign is also a sign of meningeal irritation/inflammation. Brudzinski's is positive when severe neck stiffness occurs after the neck is flexed towards the chest, causing the patient's hips and knees to flex. Choice C is incorrect. The appearance of a carpopedal spasm (flexion of the wrist, thumb, and metacarpophalangeal joints along with hyperextension of the interphalangeal joints) is referred to as Trousseau's sign. Such carpopedal spasms result from ischemia secondary to compression by the inflated sphygmomanometer cuff on a client's arm. Trousseau's sign signifies latent tetany; this is seen in hypocalcemia and hypomagnesemia. A positive Trousseau helps the clinician to detect the early presentation of hypocalcemia. Choice D is incorrect. When a client experiences pain in the calf upon sharp dorsiflexion of the foot with the knee extended, it refers to a Homan's sign. A positive Homan's indicates that the patient may have a deep vein thrombosis (DVT). However, Homan's by itself is considered an unreliable sign for diagnosing DVT and must be used in conjunction with diagnostic imaging and/or other physical assessment findings (Well's score). Learning objective: Meningitis refers to inflammation of the meninges, and certain signs such as Kerning's and Brudzinski's help detect meningeal inflammation on physical exam. NCSBN Client need: Topic: Physiological Integrity; Sub-Topic: Physiological adaptation/Infectious diseases

The client admitted to the gynecology ward for premature labor is given terbutaline to arrest labor. The nurse should monitor which parameter when administering this medication? A. Breath sounds [45%] B. Urine output [14%] C. Pain [6%] D. Level of consciousness [34%]

Explanation Choice A is correct. One of the most common side effects of terbutaline is pulmonary edema. The nurse should monitor the client's breath sounds as well as assess for respiratory crackles and difficulty of breathing to detect if pulmonary edema is present. Choice B is incorrect. Terbutaline does not have any effect on urine output. Choice C is incorrect. Terbutaline is a tocolytic agent; it arrests labor and uterine contractions; it may decrease the client's pain levels during contractions, but it is not the nurse's priority assessment. Choice D is incorrect. Terbutaline does not have any effect on the client's level of consciousness.

The nurse is caring for a client who has septic shock. Which of the following findings would indicate that the client is meeting the treatment goals? A. Mean arterial pressure (MAP) 67 mmHg [79%] B. Urine output (UOP) 20 ml/hr [9%] C. Capillary blood glucose 253 mg/dL [2%] D. Serum pH level of 7.33 [9%]

Explanation Choice A is correct. Septic shock is a life-threatening illness that may cause a client to have decreased perfusion. A client having a MAP of 65 mmHg or greater is one of the desired goals of septic shock. Thus, a MAP of 67 mmHg would be a favorable finding. Choices B, C, and D are incorrect. A urine output (UOP) of 20 mL/hr would not be a positive finding in an individual with septic shock. This low UOP would be further evidence that the client has decreased renal perfusion. Hyperglycemia is an expected finding in shock, but it also is a detrimental finding. Hyperglycemia stunts healing and has been linked to a plethora of complications. A pH of 7.33 is indicative of acidosis and is not a reassuring finding. The acidosis will need to be corrected depending on its etiology. Additional information: Treatment goals for a client with septic shock include the following: · Optimal perfusion as demonstrated by a MAP ≥ 65 mmHg. · Normal respiratory rate, pulse, temperature, pulse oximetry, mentation, and urine output. · Clearance of lactic acid. A falling lactic acid indicates a favorable response to fluids and oxygenation. Lactic acid is produced when tissue is not being perfused. A serum lactic acid level of 2 mmol/L or greater may indicate the severity of sepsis. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Illness Management

Which of the following best describes the reflex of a newborn, which includes: hand opening with abducted and extended extremities following a jarring motion? A. Moro reflex [74%] B. Grasp reflex [14%] C. Babinski reflex [10%] D. Rooting reflex [2%]

Explanation Choice A is correct. The Moro reflex occurs in response to a slight drop, sudden movement of the crib, or a loud noise, the newborn quickly makes a symmetrical abduction of the extremities and places the index fingers and thumbs into a "C" shape. The newborn's neurological system is immature at birth. The nurse may notice periodic jerking or twitching, which is considered normal. Tremors are not considered a normal finding in a newborn. The newborn's cry can provide information about the neurological status. A high-pitched scream can indicate an increase in intracranial pressure. When assessing the reflexes, the nurse needs to consider the gestational age, not the birth weight. Premature infants will have a reduced response to the reflex evaluation. The nurse should document and report the following warning signs: Tremors A high-pitched cry Abnormal pupil responses Hypertonic or hypotonic positions Absent newborn reflexes Choice B is incorrect. The grasp reflex occurs when the newborn wraps the fingers around the examiner's finger when it is placed in the newborn's palm. Choice C is incorrect. When the sole of the foot is stroked, the newborn's big toe moves upward toward the top surface of the foot and the other toes fan out. This is known as the Babinski reflex. Choice D is incorrect. The rooting reflex occurs as the newborn turns his/her head to the side on which the cheek is stroked. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Newborn Reflexes

A client arrives at the emergency department for substernal chest pain. ECG shows ST-segment elevations and a cardiac troponin level is elevated. Which of the following should the nurse focus on? A. Reducing cardiac workload and improving myocardial oxygenation [83%] B. The confirmation of the suspected diagnosis and preventing complications [7%] C. Pain relief and reduction of anxiety [7%] D. Providing a quiet, non-demanding environment and reducing anxiety [3%]

Explanation Choice A is correct. The client is manifesting signs and symptoms of myocardial infarction (MI), so it is essential to focus on improving myocardial oxygenation and reducing cardiac workload. These measures will reduce the further expansion of an infarct. Choices B, C, and D are incorrect. Confirming the diagnosis, preventing complications, pain relief, and anxiety reduction are secondary to improving myocardial oxygenation and cardiac workload reduction. Stressors can only be reduced, not eliminated.

While in a maternity clinic, the client complains of experiencing leg cramps at night. The nurse educates the client to eat more of which kind of food? A. Milk, broccoli, cheese [42%] B. Almonds, sweet potato, avocado [32%] C. Lentils, peas, nuts [14%] D. Carrots, tomatoes, squash [12%]

Explanation Choice A is correct. The client's presentation of leg cramps may indicate inadequate calcium or magnesium intake. Milk, broccoli, and cheese are foods rich in calcium and should be recommended. Choice B is incorrect. Almonds, sweet potatoes, and avocadoes are Vitamin E rich foods. The client needs to eat calcium-rich food to address leg cramps. Choice C is incorrect. Lentils, peas, and nuts are high in folic acid. Folic acid helps in neural tube growth; however, it does not help in reducing the leg cramps of the client. Choice D is incorrect. Squash, carrots, and tomatoes are high in beta-carotene. Beta-carotene aids in fetal growth; however, it does not prevent muscle cramps.

The Maternal Serum Screen 4 (MMS4) of an obstetrics client shows decreased maternal serum alpha-fetoprotein and estriol, The hCG was increased. What strategy should the nurse include in the plan of care? A. Refer to the physician [44%] B. Tell the woman to increase her folic acid intake [31%] C. Refer for amniocentesis [20%] D. Order a plasma glucose level [5%]

Explanation Choice A is correct. The combination of results presented in this situation may be the result of a fetus with Down syndrome. The physician needs to be notified of the results and the nurse would anticipate a referral for an amniocentesis. The Maternal Serum Screen 4 (MSS4) is a blood test performed during pregnancy to help identify potential risks to the developing fetus. Its purpose is to screen for possible neural tube defects, Down syndrome, or trisomy 18 in the developing baby. Four substances in the blood are measured: Alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), estriol, and inhibin A. AFP is a substance made by the baby that enters the amniotic fluid and the mother's bloodstream. A small amount of AFP is usually found in amniotic fluid and the mother's blood. When the amount is high, it is a signal to the physician to look further for the possibility of a neural tube defect. Estriol, hCG, and inhibin A come from the developing baby and placenta and can be measured in the mother's blood. A woman who is carrying a baby with Down syndrome may have lower blood levels of AFP and estriol and higher blood levels of hCG and inhibin A than women with an unaffected baby. A woman who is carrying a baby with trisomy 18 may have lower blood levels of AFP, estriol, hCG, and inhibin A than women with unaffected babies. The MSS4 detects the same number of neural tube defects and trisomy 18 cases as other currently available maternal serum prenatal screens. When inhibin A is used with AFP, hCG, estriol, and the mother's age, approximately 10-15% more babies with Down syndrome can be detected before birth. Remember that not even the MSS4 can detect all babies with Down syndrome before they are born. Choice B is incorrect. A neural tube defect can be detected with MSAFP, but once the error has occurred, an increase in folic acid will not change it. Taking folic acid before becoming pregnant and continuing through the pregnancy can be beneficial to prevent neural tube defects. Choice C is incorrect. The physician will order an amniocentesis if needed, not the nurse. Choice D is incorrect. Checking the plasma glucose level is not indicated based on these test results. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Maternal Laboratory Monitoring

The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling? A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia. [77%] B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide. [10%] C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone. [9%] D. 28-year-old admitted with bacteremia, is receiving intravenous fluids via central line, and is diaphoretic. [3%]

Explanation Choice A is correct. This client has advanced age, has a medical device that impedes their mobility, and has cognitive impairments. Thus, all these risk factors make this client at a very high risk for falls. Choices B, C, and D are incorrect. All these clients have risk factors for falls; however, none of these clients have advanced age or have a cognitive impairment. Thus, universal fall precautions should be instituted, but it is the 88-year-old client who requires aggressive fall reduction measures. Additional Info Risk factors for falls include Advanced age Cognitive impairments (delirium, dementia) History of previous falls Medical/Assistive device(s) (chest tube, peripheral IV, cane) Medications (anticholinergics, benzodiazepines) Urinary frequency Universal fall precautions include Hourly rounding that addresses needs such as toileting Thorough room orientation and frequent reminders Adequately lit room with appropriate markings Accessible call light that is within reach Pathways clear of clutter and grab bars in the bathroom Additional measures that may be taken include relocating the client closer to the nursing station, enhanced observation, and using a bed alarm.

The nurse is caring for a patient diagnosed with acute symptomatic hypernatremia. Which maintenance IV fluid would the nurse expect to hang for this patient? A. 5% Dextrose [23%] B. Lactated Ringers [28%] C. 0.45% Saline [28%] D. 0.9% Saline [21%]

Explanation Choice A is correct. This patient has high sodium levels and should avoid any additional sodium-containing fluids. Additionally, this is acute hypernatremia and he is symptomatic from it. 5% Dextrose is used to replace water losses due to hypernatremia and would be an appropriate maintenance fluid for this patient because it is isotonic, contains free water with no added sodium or other electrolytes, and promotes renal solute excretion. Choice B is incorrect. Lactated Ringer's solution is used to treat mild metabolic acidosis and water losses from burns or lower gastrointestinal tract issues. It would not provide free water to promote renal excretion of excess sodium. Choice C is incorrect. This patient should avoid any additional sodium-containing fluids at this time. In patients with acute hypernatremia, rapid correction of sodium improves prognosis without the risk of cerebral edema and convulsions. Dextrose has no additional sodium and will correct the sodium faster. However, while 0.45% saline solution is hypotonic and contains free water, it also has sodium and chloride. Hence, 0.45% NS would not be the best choice for this patient who is currently symptomatic from acute hypernatremia. 0.45% NS is a preferred fluid in patients who have "chronic" hypernatremia where a more gradual decrease in sodium is desired. Choice D is incorrect. This patient should avoid any additional sodium-containing fluids. 0.9% saline is an isotonic solution used to expand the intravascular volume and replace extracellular fluid losses. It contains sodium and chloride, which may result in intravascular overload or hyperchloremic acidosis. NCSBN Client Need Topic: Fluid/Electrolytes (Endocrine/Hematology/Renal), Subtopic: medication administration, IV therapies, fluid and electrolyte imbalances, hemodynamics

What EKG rhythm represents a third-degree heart block?

Explanation Choice A is correct. This rhythm represents a 3rd-degree heart block because there is no QRS complex after every other p wave. This is because the AV node has no conduction during a 3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with each other. Choice B is incorrect. This rhythm represents a 1st-degree heart block. This rhythm occurs when the AV conduction is slowed, therefore creating a more extended time between the p wave and the QRS complex. Choice C is incorrect. This rhythm represents a 2nd-degree heart block or Mobitz type 2. This occurs when the AV node is taking longer to conduct. The PR interval may be regular or lengthened. This rhythm indicates problems in the Purkinje system. Choice D is incorrect. This rhythm is sinus tachycardia, which is a heart rate over 100 bpm. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Diagnostic Tests, Dysrhythmias

Chemotherapy induces vomiting by: A. Stimulating neuroreceptors in the medulla. [39%] B. Inhibiting the release of catecholamines. [20%] C. Autonomic instability. [6%] D. Irritating the gastric mucosa. [35%]

Explanation Choice A is correct. Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to the expulsion of gastric contents. Choice B is incorrect. Catecholamine inhibition does not induce vomiting. Choice C is incorrect. Chemotherapy does not induce vomiting from autonomic instability. Choice D is incorrect. Chemotherapy, especially oral agents, may have an irritating effect on the gastric mucosa, which could result in afferent messages to the solitary tract nucleus. Still, these pathways do not project to the vomiting center. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Drugs for Neoplasia

Which of the following clients is at greatest risk for toxicity to lithium? A. A 35-year-old male client who is taking theophylline [26%] B. A 25-year-old female client who is taking ibuprofen [17%] C. A 45-year-old male client who is taking methazolamide [29%] D. A 55-year-old female client who is taking mannitol [28%]

Explanation Choice B is correct. A 25-year-old female client who is taking ibuprofen is the client who is at the highest risk for lithium toxicity. Lithium is excreted through the kidneys, and any medication that can decrease glomerular filtration rate can therefore cause increased retention of lithium, increasing the serum levels of the drug and potentially causing toxicity. The most common medications which can do this are ACE inhibitors, angiotensin II receptor antagonists (sartans), diuretics, and non-steroidal anti-inflammatory drugs (NSAIDs). Ibuprofen is an NSAID that can decrease the glomerular filtration rate causing retention of lithium and increased serum levels of the medication. It should therefore not be prescribed with lithium due to the increased risk for toxicity. Choice A is incorrect. The 35-year-old male client who is taking theophylline is not the client who is at the greatest risk for lithium toxicity. Theophylline increases the excretion of lithium through the proximal consulted tubule of the nephron. When theophylline and lithium are taken together, theophylline, therefore, increases the amount of lithium output in the urine. This can then lead to a decrease in the amount of lithium in the blood, causing low lithium levels. Choice C is incorrect. The 45-year-old male client who is taking methazolamide is not the client that is at the highest risk for lithium toxicity. Methazolamide is a carbonic anhydrase inhibitor. these medications are used to treat glaucoma, altitude sickness, congestive heart failure, and epilepsy. They work by promoting diuresis in the proximal tubule of the kidney. Because they promote diuresis in the proximal tubule of the kidney, they cause the excretion of lithium. As lithium is excreted in the urine, the amount remaining in the blood is decreased and serum lithium levels are lower. Carbonic anhydrase inhibitors include acetazolamide, methazolamide, dorzolamide, brinzolamide, diclofenamide, ethoxzolamide, and zonisamide. Choice D is incorrect. The 55-year-old female client who is taking mannitol is not the client that is at the highest risk for lithium toxicity. Mannitol is an osmotic diuretic. Osmotic diuretics primarily inhibit water reabsorption. They do so in the proximal convoluted tubule, as well as in the descending loop of Henle and the collecting duct. All of these regions of the kidney are highly permeable to water, which is what makes osmotic diuretics so useful for inhibiting water reabsorption. When water reabsorption is inhibited, urine output is increased. With this increase in urine output, lithium is also excreted. Just as with answer choice C, mannitol will also cause serum lithium levels to be lower due to the increased excretion of lithium in the urine. Osmotic diuretics include drugs such as Mannitol, Glycerin, Isosorbide, and Urea. Additional Info Lithium is excreted almost entirely by the kidneys. Lithium is freely filtered by the glomerulus since it is not bound to serum proteins. In the proximal tubule, lithium is handled similarly to sodium. Thus, factors that decrease GFR or increase proximal tubule reabsorption, such as volume depletion, will increase serum lithium levels. Conversely, factors that decrease proximal tubule sodium reabsorption, such as carbonic anhydrase inhibitors, aminophylline, or osmotic diuretics, will increase lithium excretion and decrease serum lithium levels. Lithium has a narrow therapeutic index, with therapeutic levels between 0.6 and 1.2 mEq/L. Because toxicity can occur at levels >1.5 mEq/L, lithium levels must be carefully monitored and lithium dosage adjusted as necessary. This is especially true following changes in other medications that alter renal function, such as angiotensin-converting enzyme (ACE) inhibitors or nonsteroidal anti-inflammatory drugs (NSAID).

The nurse is teaching a patient about a scheduled contraction stress test (CST). Which of the following statements should the nurse include? A. "You will need to consume a liquid with 50 grams of glucose." [6%] B. "You may need to stimulate your nipples during this test." [38%] C. "A positive result means your baby has had no late decelerations." [33%] D. "A negative result means your baby has had variable decelerations." [23%]

Explanation Choice B is correct. A CST is indicated for high-risk patients who are in the third trimester. CST requires the patient to have contractions either through oxytocin administration or nipple stimulation. Choices A, C, and D are incorrect. The patient consuming a liquid with concentrated glucose is not indicated for a CST. This is appropriate for a glucose tolerance test. The results for a CST are interpreted as follows - Positive (abnormal) indicates that late decelerations were present in the FHR in more than 50% of the contractions. Negative (normal) indicates that no late or variable decelerations were evident during the contractions. Learning Objective Understand that contractions during a contraction stress test can be induced by intravenous administration of oxytocin or by nipple stimulation. Additional Info A contraction stress test is indicated for patients with high-risk pregnancies. This test is completed in the third trimester. Relative contraindications to a CST include placenta previa and patients at risk for preterm delivery as this test may hasten delivery or at minimal cause rupture of the membranes.

Informed consent mostly upholds the client's right to: A. Beneficence [14%] B. Self-determination [69%] C. Nonmaleficence [9%] D. Confidentiality [8%]

Explanation Choice B is correct. An informed consent mostly upholds the client's right to self-determination and autonomy. Self-determination, or independence, simply described, is the right of a person to make their own decisions without the undue influences of others. Choice A is incorrect. Although we fulfill our ethical responsibility of beneficence when we facilitate informed consent, this is not the client's right that we are primarily upholding. Choice C is incorrect. Although we fulfill our ethical responsibility of nonmaleficence when we facilitate informed consent, this is not the client's right that we are primarily upholding. Choice D is incorrect. Although we maintain the confidentiality of informed consent in addition to all other medical information, this is not the client's right that we are upholding.

The nurse performs a physical assessment on a client and observes the following finding while the client has their arms extended. The nurse understands that this finding is consistent with which of the following? See the image below. A. Rheumatic fever [11%] B. End-stage renal disease [19%] C. Neuroleptic Malignant Syndrome (NMS) [69%] D. Human Immunodeficiency Virus (HIV) [1%]

Explanation Choice B is correct. Asterixis is a hand flapping tremor that may be elicited by having the client close their eyes, extend their arms, dorsiflex their wrist, and spread their fingers. End-stage renal disease causes azotemia and may trigger this unilateral or bilateral tremor in end-stage renal disease. While this tremor is poorly understood, it is likely the accumulation of nitrogenous waste that contributes to the development of this action. This tremor has also been associated with moderate to severe hepatic encephalopathy. Choices A, C, and D are incorrect. Neuroleptic Malignant Syndrome is an insidious autonomic reaction that adversely causes muscle rigidity, tachycardia, and pyrexia. NMS is commonly triggered by antipsychotics and causes hyporeflexia; thus, it would not cause asterixis. HIV is an infectious disease that does not produce asterixis. Rheumatic fever is a condition characterized by arthritis, carditis, and chorea. While an individual with rheumatic fever may have motor disturbances, the Sydenham chorea produces a dance-like motion overtly seen during gross motor movements. Additional Info These brief shock-like movements may be associated with conditions such as hepatic encephalopathy, end-stage renal disease, and drug intoxication with phenytoin. Most asterixis is bilateral but unilateral asterixis may develop because of pathology in the brain.

A nurse in the surgical ICU is taking care of a young man that was involved in a four-wheeling accident 4 hours ago. He was diagnosed with a grade two renal laceration, multiple rib fractures, and a concussion upon arrival. While performing the last head-to-toe assessment before the transfer, the nurse notices a small amount of bruising around the patient's umbilicus. What should the nurse do? A. Administer pain medication for rib fractures [0%] B. Notify the trauma surgeon of bruising immediately [77%] C. Perform serial abdominal exams and keep monitoring the umbilicus [16%] D. Assess pupillary reaction [6%]

Explanation Choice B is correct. Bruising around the umbilicus is called Cullen's sign. This is important to identify after trauma because it indicates bleeding into the abdomen. The nurse needs to notify the surgeon immediately so the patient can be further assessed. The surgeon may monitor the patient medically or take him back into surgery. Choice A is incorrect. The patient may need pain medication, but the most important intervention at this time is to notify the trauma surgeon of the Cullen's sign that was noted. Choice C is incorrect. The trauma surgeon may order serial abdominal exams after assessing the patient, but he needs to be called to evaluate the patient first. Choice D is incorrect. This assessment is not warranted at this time. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: System-specific Assessments, Critical Care

A nurse is conducting medication teaching on a client receiving a monoamine oxidase inhibitor (MAOI). The client has demonstrated understanding by stating, "I should avoid tyramine-containing foods, or I may go into hypertensive crisis." When asked to list specific tyramine-containing foods, the client would be correct to include which of the following? A. Cream cheese [17%] B. Swiss cheese [72%] C. Milk [8%] D. Ice cream [3%]

Explanation Choice B is correct. Fermented, aged, or smoked foods are high in tyramine and should be avoided; thus, swiss cheese. Choices A, C, and D are incorrect. Cream cheese, milk, and ice cream are unfermented milk products and may be taken by patients on MAOIs without incident.

The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first? A. Administer prescribed ibuprofen. [5%] B. Place the client on droplet precautions. [78%] C. Notify the public health department. [2%] D. Obtain prescribed blood cultures. [14%]

Explanation Choice B is correct. Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. Protecting the other clients and staff from disease transmission is essential for the nurse. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing a surgical mask in the client's presence. Choices A, C, and D are incorrect. Medications to lower fever, such as acetaminophen or ibuprofen, would be helpful for a client with bacterial meningitis. If bacterial meningitis is confirmed, the public health department must be notified to initiate contact tracing. However, these do not prioritize the safety and infection control of the clients and staff within the ED. Additional Info Neisseria meningitidis is a common cause of bacterial meningitis in children and adolescents. Symptoms classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias. The nurse's immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions. The other actions do not reflect an immediate priority. Treatment for N. meningitidis includes prompt initiation of antibiotics such as ceftriaxone.

A nursing student in the pediatric hospital asks the clinical nurse educator about the nurse's legal responsibilities in case of child abuse. What would be the nurse educator's most appropriate response? A. The nurse needs to collect additional data to support her suspicion and then take further action. [27%] B. The nurse should directly report her suspicions to the local child protection agency. [67%] C. The nurse should talk to the child's parents. [1%] D. Talk to the physician regarding suspicions of child abuse. [5%]

Explanation Choice B is correct. It is the nurse's legal responsibility to report any suspected cases of child abuse to relevant authorities right away. Choice A is incorrect. The data that has led the nurse to suspect child abuse should be sufficient to report to the authorities. The nurse does not need additional data. Choice C is incorrect. This step might result in aggravating the parents and taking the child out of the hospital. It might also worsen the situation and lead to more abuse. Choice D is incorrect. Discussion with the physician does not guarantee that the authorities will be notified of the case.

The nurse is caring for a patient who has recently undergone a gastric bypass procedure. All of the following are appropriate nursing instructions to prevent dumping syndrome, except : A. Avoid sugars and milk [16%] B. Avoid high-protein foods [58%] C. Eat small meals [8%] D. Avoid drinking fluids with meals [18%]

Explanation Choice B is correct. Patients who have undergone gastric bypass surgery do not need to avoid high-protein diets and should instead intake meals that incorporate high-protein foods. Patients can also eat high-fat foods that are low in carbohydrates and eat small meals. Choice A is incorrect. The nurse should encourage patients to avoid sugars and milk. Too much sugar or dairy may cause "Dumping Syndrome," a complication of gastric bypass surgery, which results in rapid gastric emptying. Choice C is incorrect. Patients who have had gastric bypass surgery should eat small meals. Choice D is incorrect. Those who have had gastric bypass surgery should avoid drinking fluids with meals. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse in the psychiatric unit is administering fluoxetine (Prozac) together with tranylcypromine (Parnate). The nurse should watch out for which symptoms signifying an adverse reaction from the combination of both drugs? A. Low blood pressure and urinary retention [26%] B. Muscle rigidity and hyperthermia [51%] C. Shortness of breath and pink frothy sputum [8%] D. Weakness and diaphoresis [15%]

Explanation Choice B is correct. Serotonin syndrome is a result of too much serotonin in the body due to the use of SSRI's and MAOI's. Serotonin syndrome is characterized by high body temperature, agitation, muscle rigidity, tremor, sweating, dilated pupils, and diarrhea. Upon noticing these symptoms, the nurse must report this to the physician to initiate medical intervention. Choice A is incorrect. These symptoms are not associated with serotonin syndrome. Choice C is incorrect. These symptoms are related to pulmonary edema, not serotonin syndrome. Choice D is incorrect. Weakness and diaphoresis are symptoms associated with hypoglycemia, not serotonin syndrome.

The obstetric nurse is reading the prenatal client's chart. The nurse notes that the patient is suffering from preeclampsia and knows to observe for which complications in the newborn? A. Shaking and agitation [24%] B. Low birth-weight [54%] C. Abnormal kidney function [14%] D. Blurred vision [9%]

Explanation Choice B is correct. The nurse with this patient should expect an infant born with low birth weight. Preeclampsia often results in blood being shunted away from the fetus; growth restriction is commonly found in infants born to these women. Choice A is incorrect. Shaking and agitation aren't commonly connected with preeclampsia. These symptoms may be related to drug abuse or gestational diabetes. Choice C and D are incorrect. Blurred vision and abnormal kidney function affect mothers who are suffering from preeclampsia, not their infants. NCSBN client need Topic: Health Promotion and Maintenance

Which term best describes the nurse's role as the nurse actively upholds and protects the rights of individual clients and groups of clients? A. Deontological ethical practice [4%] B. Advocacy [79%] C. Utilitarian ethical practice [7%] D. Autonomy [10%]

Explanation Choice B is correct. The term that best describes the role of the nurse as the nurse actively upholds and protects the rights of individual clients and a group of clients is advocacy. Choice A is incorrect. Deontological ethics is a school of ethical thought. It does not relate to the rights of individual clients and groups of clients. Choice C is incorrect. Utilitarian ethics is a school of ethical thought. It does not relate to the rights of individual clients and groups of clients. Choice D is incorrect. Autonomy is defined as the individual's right to make independent, informed decisions without any coercion. It does not reflect the nurse's upholding and protecting the rights of individual clients and groups of clients.

Which phase of the nursing process is most foundational for delivery of care? A. Evaluation [4%] B. Assessment [75%] C. Planning [17%] D. Diagnosis [4%]

Explanation Choice B is correct. This assessment determines which diagnoses will be the focus of care, the interventions that will be initiated, and those that will be reevaluated. In this way, the assessments drive care, whereas the reassessments loop back into the further assessments and revision of care planning. Choices A, C, and D are incorrect. All aspects of the nursing process are essential. However, without proper assessment, the other steps in the process are ineffective. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; The Nursing Process

A woman comes into the emergency department complaining of insomnia, anxiety, difficulty breathing, and a sense of impending doom. After being assessed by the physician, no physiological abnormalities were found. However, the client is still anxious and apprehensive. What is the most appropriate statement from the nurse to the patient? A. "Don't worry, you're safe here. Just try to relax." [2%] B. "Can you think of anything that happened recently or in the past that might have triggered these feelings?" [74%] C. "We gave you something that should calm you down." [1%] D. "Take slow, deep breaths, and try to relax. Nothing bad will happen to you here." [22%]

Explanation Choice B is correct. This is an appropriate response from the nurse because it offers reassurance to the client while providing an opportunity for the nurse to gain insight into the client's anxiety. Choice A is incorrect. This statement disregards the client's feelings and offers false reassurance. This is an inappropriate response by the nurse. Choice C is incorrect. Telling the client that you gave her some medication disregards her feelings and does not allow her to discuss those feelings. This statement also offers some form of false reassurance to the client. Choice D is incorrect. This statement disregards the client's feelings and offers false reassurance. This is an inappropriate response by the nurse.

The nurse is working with a woman who is five months pregnant and attending her first prenatal appointment after completing the client's history. The nurse suspects that she is a victim of domestic violence. Which of the following is not a sign of domestic violence? A. Depression [1%] B. Weight gain [83%] C. Unexplained bruising [7%] D. Late initiation of prenatal care [8%]

Explanation Choice B is correct. Weight gain is an expected finding in pregnancy and is not a symptom that requires investigation into possible abuse. A woman's risk of becoming a victim of domestic violence increases when pregnant. The health care team should be diligent in watching for signs of violence and abuse in the prenatal client. Choices A, C, and D are incorrect. Depression, unexplained bruising, and late initiation of prenatal care are all signs of possible abuse. Other symptoms include drug or alcohol abuse, chronic pain, and isolation. NCSBN Client need Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care

You have offered one of your newly admitted clients a partial bed bath. The client states, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." How should you respond to this client? You should respond by saying: A. "Would it be okay with you if I teach you about the benefits of and the need for daily bathing?" [46%] B. "That is fine. At what time of the day do you prefer to bathe and do you prefer a shower or tub bath?" [39%] C. "A once a week bath is not good. You have to bathe at least every other day to protect against infection." [14%] D. I am sorry but we have rules here. All clients must be bathed at least every other day. Let's start the bath." [1%]

Explanation Choice B is correct. You would respond with, "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" when one of your newly admitted clients refuses a partial bed bath by stating, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." This response acknowledges the fact that the frequency of bathing, bathing routines, and practices vary among individuals and cultures. Clients should be assessed for their bathing needs in preferences of their type of bathing and time of bathing. Additionally, a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Choice A is incorrect. You would not respond with, "Would it be okay with you if I teach you about the benefits of and the need for daily bathing?" because a daily bath is not always necessary and a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Choice C is incorrect. You would not respond with, "A once a week bath is not good. You have to bathe at least every other day to protect against infection" because a daily bath is not always necessary, and a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Choice D is incorrect. You would not respond with, "I am sorry, but we have rules here. All clients must be bathed at least every other day. Let's start the bath" because a daily bath is not always necessary, and a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Additionally, you're saying, "Let's start the bath," which indicates that you are violating this client's right to choose and refuse all care and treatments.

Which of the following healthcare providers are responsible for documenting care provided to a patient? A. The LPNs should document the care that they provided and the care that was given by unlicensed assistive staff. [1%] B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care. [13%] C. All staff members should document all of the care that they have provided. [71%] D. All staff should document all of the care that they have provided but since the registered nurse is the only independent practitioner, the RN signs it. [15%]

Explanation Choice C is correct. All staff members, including unlicensed assistive staff like nursing assistants, document and sign all of the care that they have personally provided. For example, the nursing assistants will document the vital signs that they have taken; the licensed practical nurses will document all of the treatments and medications that they have given to the patient, and the registered nurse will document nursing diagnoses and assessments that they have completed. There is an old saying among healthcare professionals that have been passed on to new generations. The saying is, "I don't care what you did; if you didn't document it, you didn't do it." Documentation is an essential part of patient care. A patient's complete medical record is a legal document. Proper documentation means 1. The person who provided care should document what care/treatment/medication was given and how the patient responded. 2. If care is delegated to another person, it should be noted to whom the responsibility was assigned; proper documentation AND follow-up should be done. Choice A is incorrect. Each person providing care should personally document the attention that he/she provided. Choice B is incorrect. Although the RN or charge nurse is responsible for making sure tasks are delegated to the appropriate personnel, only the person who performs the care should document the care that was provided. Choice D is incorrect. The person providing care should document the care followed by his/her signature. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Roles and Functions of the Nurse

The nurse is caring for a 7-year-old child who is continuously anxious in the pediatric ward. The nurse plans to initiate therapeutic play to help the child's anxiety. During the therapeutic game, all of the following activities should be included, except: A. Encourage manipulation of equipment. [53%] B. Constantly monitor the child's anxiety levels throughout the activity. [12%] C. Provide structure for the play. [28%] D. Continue play sessions regularly. [6%]

Explanation Choice C is correct. All the other statements are accurate except option C. Therapeutic play should be unstructured. The child should use the equipment, however, or whenever he/she wants it. Choice A, B, and D are incorrect. These statements are accurate. The nurse should encourage the expression of the child's feelings through the manipulation of equipment. This action also lets the child share her feelings, knowledge, and perceptions throughout the activity. The nurse should continuously observe the child's anxiety levels throughout the activity to determine if intervention by the nurse is needed or not. The nurse should always remember that the event is designed to decrease the client's anxiety, not increase it. Therapeutic play should be done regularly once it is initiated.

The nurse administers bumetanide to a client with pulmonary edema. Which assessment would indicate that the client is experiencing an adverse response? A. Distended neck veins [13%] B. Adventitious lung sounds [16%] C. Leg cramps [62%] D. Increase in urine output [9%]

Explanation Choice C is correct. Bumetanide is a loop diuretic, and leg cramping may occur because loop diuretics may cause potassium depletion. Hypokalemia is a common complication of loop diuretics. Choices A, B, and D are incorrect. Distended neck veins may indicate fluid overload, CHF, or cardiac tamponade. Fluid overload and CHF may be indications for drug administration, but it is not a complication. Adventitious lung sounds such as crackles and rhonchi are manifestations of pulmonary edema and fluid in the alveoli. Diuretics may be administered to relieve these symptoms, but these are not complications of the drug. An increase in urine output is the desired effect of the medication, not its complication. Additional Info Loop diuretics act primarily along the thick ascending limb of the loop of Henle, blocking chloride and, secondarily, sodium resorption. Loop diuretics are also thought to activate renal prostaglandins, which dilate the blood vessels of the kidneys, the lungs, and the rest of the body (i.e., reduction in renal, pulmonary, and systemic vascular resistance). The hemodynamic effects of loop diuretics are a reduction in both the preload and central venous pressures (which are the filling pressures of the ventricles). These actions make them useful in treating the edema associated with heart failure, hepatic cirrhosis, and renal disease. Examples of loop diuretics include - bumetanide, ethacrynic acid, furosemide, and torsemide.

The son of a client with early Alzheimer's disease states, "I'm so tired of hearing Dad talk about the past all the time." What is the nurse's best response? A. "You should be more patient with your father and accepting of his disease." [7%] B. "He is quite anxious at this stage. Reliving the past helps him become calm again." [23%] C. "He has lost his short-term memory but can still remember events from long ago." [61%] D. "Just remind him when he repeats himself and that will reinforce better behavior." [9%]

Explanation Choice C is correct. Family members can become frustrated when clients with Alzheimer's disease lose short-term memory. The nurse should explain to the family member that it's the "short-term memory" that is declining and encourage the client to talk about things that he/she can remember. Choice A is incorrect. During the early stages of Alzheimer's, family members are still trying to learn about and cope with the changes that their loved ones are experiencing. Patience with the family will be more beneficial than the scolding tone that this answer choice portrays. Choice B is incorrect. Early Alzheimer's symptoms are not usually reflective of anxiety. Also, the client is not reliving past experiences because it makes him calm again. Instead, his behavior is expected as Alzheimer's first affects short-term memory. Choice D is incorrect. Reminding an Alzheimer's patient that he is repeating himself will not improve the behavior as his short-term memory is affected. The hippocampus is the structure responsible for creating new memories from experiences. When it is damaged, short-term memory is not possible. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Promoting Health in Older Adults, Cognitive Abilities and Aging

The nurse has received the following prescriptions for newly admitted patients. The nurse should first administer which of the following? A. Subcutaneous (SubQ) epoetin for anemia [5%] B. By-mouth (PO) oxycodone pain [13%] C. Intravenous (IV) fluids for sepsis [76%] D. Intramuscular (IM) hydroxyzine for anxiety [7%]

Explanation Choice C is correct. IV fluids indicated for sepsis are crucial to administer. The nurse must understand that sepsis protocol includes timely fluid and antibiotic administration. This patient is the most critical based on their diagnosis and the nurse should prioritize this medication. Choices A, B, and D are incorrect. The other choices are not a priority as epoetin will take weeks for full therapeutic benefit. Further, by-mouth pain control will take some time for onset. Finally, the diagnosis of anxiety will not prioritize over the physiological threat of sepsis. Additional information: Sepsis can be life-threatening and may progress to shock if the patient is not treated promptly. Isotonic fluid boluses are a staple in sepsis treatment along with appropriate antibiotics. The nurse must implement these interventions quickly to avoid clinical deterioration.

A client with acute myocardial ischemia was given oxygen and sublingual nitroglycerin. Which part of the ECG indicates that therapy has been effective? A. Widening QRS complex [5%] B. Frequent ectopic beats [1%] C. ST-segment has returned to baseline [92%] D. A significant Q-wave [3%]

Explanation Choice C is correct. In myocardial ischemia, the ST-segment may appear elevated or depressed. If treatment has been successful, the ST-segment will return to baseline. Choices A, B, and D are incorrect. Widening QRS complex, presence of a Q wave, and frequent ectopic beats are not directly associated with myocardial ischemia.

Which of the following infection control activity should be delegated to an experienced nursing assistant? A. Asking clients about the duration of antibiotic therapy. [1%] B. Demonstrating correct handwashing techniques to client and family. [15%] C. Disinfecting blood pressure cuffs after clients are discharged. [80%] D. Screening clients for upper respiratory tract symptoms. [4%]

Explanation Choice C is correct. Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. Nurses must know not only their scope of practice but also the scope of practice of the UAP (Unlicensed Assistive Personnel), which may vary depending on a facility's policies and procedures. Thus, the nurse must know the employer's policies and procedures for delegation, the UAP's job description, and the UAP's skill level. The NCSBN has provided "five rights of delegation" to help nurses make delegation decisions. It is important to remember that the nurse may delegate a task to a UAP; however, the responsibility for action or inaction by the UAP remains on the nurse. Choices A, B, and D are incorrect. These actions should be carried out by a licensed nurse. NCSBN Client Need Topic: Safe and Effective Care Environment; Subtopic: Coordinated Care

The nurse in the pediatric unit is caring for a 5-year old child diagnosed with dehydration. The child is reluctant to drink water because she is afraid of vomiting. Which action by the nurse would be most effective in ensuring her fluid intake? A. Call the physician to insert a nasogastric tube. [4%] B. Ask the help of the child's parents to force her to drink. [1%] C. Offer the child a popsicle. [93%] D. Offer her bubbles. [2%]

Explanation Choice C is correct. Offering the child a popsicle is one way of increasing fluid intake as popsicles are also fluids but are more enjoyable for children. Choice A is incorrect. Inserting a nasogastric tube to a client who can drink is unnecessary. Nasogastric tubes are only inserted in clients that are unable to eat or drink and are at high risk for aspiration. Choice B is incorrect. Asking the help of the child's parents to force her to drink may increase the child's anxiety and make her more resistant to drinking fluids. Choice D is incorrect. Blowing out bubbles is a way to increase the child's lung expansion. This does not, in any way, improve her fluid status.

The Three-Step Analgesic Ladder was developed by: A. National Institutes of Health (NIH) [32%] B. Centers for Disease Control and Prevention (CDC) [9%] C. World Health Organization (WHO) [45%] D. American Hospital Association (AHA) [14%]

Explanation Choice C is correct. The Three-Step Analgesic Ladder was developed by the World Health Organization (WHO). The Three-Step Analgesic Ladder describes the stepwise approach to pain management according to the intensity of pain. Choice A is incorrect. Although the National Institutes of Health (NIH) develops and publishes many health/healthcare-related research and guidance, a different organization developed the Three-Step Analgesic Ladder. Choice B is incorrect. Although the Centers for Disease Control and Prevention (CDC) develops many health/healthcare-related regulations and guidance, a different organization developed the Three-Step Analgesic Ladder. Choice D is incorrect. Although the American Hospital Association (AHA) develops many health/healthcare-related regulations and guidance, a different organization developed the Three-Step Analgesic Ladder.

You are caring for a patient in a medical unit. You have an order to administer medication via the buccal route. How will you administer the medication? A. Into the ear [1%] B. Under the tongue [8%] C. In the mouth toward the cheek [90%] D. Into the nasal sinus [1%]

Explanation Choice C is correct. The buccal route is into the mouth toward the cheek. Choice A is incorrect. Administration of medications into the ear is referred to as auricular or otic administration. Choice B is incorrect. Administration of drugs under the tongue is referred to as sublingual administration. Choice D is incorrect. Administration of medicines into the nasal sinus is referred to as endosinusial administration. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Medication Administration

The nurse is preparing to administer a prescribed dose of lactulose 20 grams orally QID to a client with portal-systemic encephalopathy. The medication is available at 3.33 grams per 5 mL oral solution. She plans to administer 30 mL per dose to the client QID. When the nurse approaches the client, the client states, "I understand that I cannot take other laxatives with lactulose." Which of the following should the nurse do next? A. Withhold the lactulose [18%] B. Give only 3 mL of lactulose instead of 30 mL [2%] C. Give 30 mL of lactulose with juice and monitor blood ammonia [48%] D. Give 30 mL of lactulose and correct the client's statement by telling him he may take additional laxatives [32%]

Explanation Choice C is correct. The client has been prescribed lactulose for portal-systemic encephalopathy (PSE), not for constipation. The prescribed dose is 20 grams every 4 hours. Since every 5 mL has 3.33 grams in it, the accurate dosage to be administered is 30 mL every 4 hours. Lactulose does not have a palatable taste; therefore, it can be mixed with fruit juice, water, or milk to improve flavor. The nurse should monitor blood ammonia levels and watch for any side effects. Side effects include belching, flatulence, or abdominal cramping. Lactulose belongs to the class of "osmotic laxatives" and may be used to treat constipation. Being an osmotic laxative, it draws water into the colonic lumen and softens the stool. Lactulose is also used in hepatic (portal-systemic) encephalopathy because it inhibits intestinal ammonia production. Lactulose is metabolized by intestinal bacteria and converted to lactic acid. Because of lactic acid, the pH in the colonic lumen is reduced (acidified), and this promotes the conversion of ammonia (NH3) to ammonium (NH4+). This ionized form of ammonia is unable to diffuse across the gut membrane into the blood, and thereby, blood ammonia levels decrease. Additionally, the acidic pH suppresses the urease-producing gut bacteria involved in the production of ammonia. Decreasing blood ammonia levels results in improved mental status in PSE. When used in hepatic encephalopathy, the lactulose dose needs to be carefully adjusted so the client averages 2 to 3 loose stools per day. This is the dose at which lactulose is expected to show good benefit in PSE. If other laxatives are used in conjunction, it gets challenging to determine the optimal dose of lactulose using the above definition of 2-3 loose stools/day. Therefore, the client should be educated not to use additional laxatives. Choice A is incorrect. The client needs his prescribed dose of lactulose for his portal-systemic encephalopathy. Choice B is incorrect. The prescribed dose is 20 grams, which is equivalent to 30 mL as per the calculation above. Administering 3 mL instead of 30 mL is inappropriate. Choice D is incorrect. The client has a correct understanding already. It is inappropriate to tell the client with hepatic encephalopathy to take additional laxatives while on lactulose. The lactulose dose needs to be carefully adjusted, so the client averages 2 to 3 loose bowel movements per day. If other laxatives are used in conjunction, it gets challenging to determine the optimal dose of lactulose.

The nurse is planning care for a client with a newly diagnosed fractured pelvis. Which action would lessen the risk of fat embolism syndrome (FES)? A. Request a prescription for enoxaparin. [24%] B. Alternate with the application of ice and heat. [3%] C. Educate the client on pelvic immobilization. [37%] D. Encourage passive range of motion of the lower legs. [36%]

Explanation Choice C is correct. The most effective way to prevent fat embolism syndrome (FES) is aggressive immobilization. This also reduces the risk of internal injuries as pelvic fractures may cause significant internal bleeding. Choices A, B, and D are incorrect. Enoxaparin is an effective prescription for the prevention of venous thromboembolism (VTE) - but not a fat embolism. Ice and heat to the pelvis would be contraindicated until internal injuries have been ruled out, and the nurse obtains a prescription for such therapy. The client should be encouraged to have pelvic immobilization. Passive range of motion exercises during an acute injury would be contraindicated, raising the risk for FES. Additional information: Pelvic fractures are quite serious. They may cause significant internal bleeding and pain for the client. FES has been implicated in long bone and pelvic fractures. Manifestations may include dyspnea, tachypnea, hypoxemia, and altered mental status. A petechial rash may appear on the thorax or in the mouth. FES is likely in the first 24-72 hours; prevention consists of aggressive immobilization. For a pelvic fracture, this may be accomplished with a pelvic sling. NCSBN Client need: Topic: Reduction of Risk Potential; Subtopic: Potential for Alternation in Body Systems

The nurse comes into the client's room to check on her and her newborn child. The client tells the nurse that another nurse just came and took the baby back to the nursery. What would be the initial action of the nurse? A. Alert security personnel about an infant abduction and call a code. [19%] B. Ask the mother what the nurse who took her baby looked like. [7%] C. Call the nursery to ask if the baby was returned to the nursery. [64%] D. Ask the mother if she asked the nurse for a code word. [9%]

Explanation Choice C is correct. The nurse should always confirm first whether another staff member returned the baby to the nursery. The nurse should not cause a false alarm in the institution. A Code Pink notifies all hospital staff of a possible infant abduction. Choice A is incorrect. When the nurse is sure that the infant is not in the nursery, a Code Pink can be started. This notifies all hospital staff of a possible infant abduction. Choice B is incorrect. This will be done if the infant was not returned to the nursery, but this is not the initial action of the nurse. Choice D is incorrect. There are many safety precautions to prevent infant abductions. For example, most facilities have a code word that is changed daily. The mother must ask anyone who wants to take the infant out of the mother's room for the code word. This is not the nurse's first intervention.

The nurse is giving a lecture on the complications of positive pressure ventilation. Which should be included as a potential cause of alveolar hypoventilation? A. Incorrect respiratory rate in ventilator settings. [14%] B. Air leakage from endotracheal tube. [34%] C. Excessive lung secretions. [37%] D. High tidal volume in ventilator settings. [15%]

Explanation Choice C is correct. The presence of excessive lung secretions is associated with alveolar hypoventilation. Choice A is incorrect. A low respiratory rate in ventilator settings is associated with alveolar hyperventilation. Choice B is incorrect. Air leakage from the ET tube results in decreased delivered tidal volume. Choice D is incorrect. The high tidal volume setting is associated with mechanical over-ventilation and alveolar hyperventilation. NCSBN Client Need Topic: Critical care, Subtopic: potential for complications of treatments/procedures

A nurse is conducting pre-operative teaching to a client who will undergo surgery in 1 week. Which response by the client would prompt the nurse to give additional teaching? A. "Aspirin can possibly cause bleeding even after surgery." [4%] B. "Aspirin can adversely affect my clotting ability" [5%] C. "I should stop aspirin one day prior to my surgery." [80%] D. "It is important that I talk to my physician about the possibility of stopping aspirin before the surgery." [10%]

Explanation Choice C is correct. This statement by the client ("I should stop aspirin one day before my surgery.") needs further education and is, therefore, the correct answer to this question. Stopping Aspirin one day before surgery is not usually appropriate since platelet function would not recover enough in 1 day. Aspirin is an anti-platelet drug and can alter the platelet's ability to aggregate and may increase the risk of bleeding after surgery. Aspirin irreversibly affects the platelet function, therefore one should be aware that the effects of aspirin last for the duration of the life of the platelet (which is close to 10 days). After a single dose of aspirin, total body platelet activity recovers by 10% per day as a result of new platelets being produced - so approximately, by 5-7 days after the last aspirin dose, the majority of platelet activity would have recovered. Because of this, anti-platelet therapy is usually stopped 5 to 7 days before the scheduled surgery but should be done as directed by the physician. The client should, therefore, discuss this with the physician so that the client will be properly guided as to when the medication should be stopped before surgery. In this case, the nurse needs to reinforce teaching to correct the client's notion. Choices A, B, and D are incorrect. These statements reflect accurate understanding by the client regarding aspirin, and these ideas do not need additional teaching. It is true that the client needs to consult his physician for guidance regarding stopping Aspirin (Choice D). It is true that Aspirin may increase post-operative bleeding risk (Choice A) and can adversely affect the clotting ability (Choice B).

The school nurse has performed an assessment on a 6-year-old child who has been sent to the office after a teacher developed concerns for his safety. Which findings will lead the nurse to investigate other signs of neglect? A. The child has a difficult time paying attention during class. [4%] B. The child always finishes his meal at lunch time and is hungry again a few hours later. [7%] C. The child is more shy than many of his classmates. [2%] D. The child is frequently absent from school and is tired when he does attend. [87%]

Explanation Choice D is correct. A child who is frequently absent from school and fatigued should be further investigated for neglect at home. Other signs may be poor dental hygiene, lack of appropriate seasonal clothing, or a tendency towards theft. Choice A is incorrect. Many children have difficulty paying attention to their teachers at this age and are not necessarily being neglected. Choice B is incorrect. Children at this age will need to eat every few hours. Eating their lunch and finding themselves hungry a few hours later is an expected finding. Choice C is incorrect. Shyness is not necessarily a sign of neglect. All children have different personalities and will express themselves differently in the classroom. NCSBN client need Topic: Psychosocial Integrity, Abuse/Neglect

A nurse is assigned to care for a client with an internal radiation implant. All of the following should be included in the plan of care, except? A. Wearing gloves when handling the client's bedpan [3%] B. Keeping all of the client's linens in the room until the implant is removed [10%] C. Wearing a lead apron when direct care is provided to the client [7%] D. Placing the client in a semi-private room at the end of the hallway [81%]

Explanation Choice D is correct. A client with an internal radiation implant must be placed in a private room with a private bath to prevent accidental exposure of other clients to radiation. Choices A, B, and C are incorrect. These are appropriate interventions for a client with a radiation implant and should be included in the plan of care. Therefore, these are incorrect answers to the question being asked.

The nurse is caring for a prenatal client with some vaginal bleeding. The nurse knows that this client could be experiencing a spontaneous abortion or miscarriage if it is occurring before ________ weeks of gestation. A. 14 [21%] B. 16 [12%] C. 18 [4%] D. 20 [63%]

Explanation Choice D is correct. A spontaneous abortion or miscarriage occurs before 20 weeks. Choices A, B, and C are incorrect. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

The nurse is caring for a patient with Helicobacter pylori. The nurse should anticipate a prescription for which of the following medications? A. Dicyclomine [12%] B. Metoclopramide [15%] C. Valacyclovir [13%] D. Amoxicillin [59%]

Explanation Choice D is correct. Amoxicillin is an antibiotic that is commonly used to treat Helicobacter pylori infections. Choices A, B, and C are incorrect. Dicyclomine is an antispasmodic medication used to treat gastrointestinal spasms, which is common in individuals with irritable bowel syndrome. Metoclopramide is a medication that causes gastric emptying and is used for nausea and vomiting. Valacyclovir is an antiviral indicated for herpes infections. Additional information: H. pylori is a gram-negative bacterium spread via the oral-oral route or oral-fecal. This bacterium may cause an individual to develop a gastrointestinal ulcer. Antibiotic therapy consisting of one or two antibiotics is often the treatment.

The nurse is educating a new graduate about alterations in cortisol levels. Which of the following conditions does she explain cause an increased cortisol levels in a client? A. Addison's disease [17%] B. Congestive heart failure [1%] C. Renal failure [2%] D. Cushing's disease [80%]

Explanation Choice D is correct. Cushing's disease produces elevated cortisol levels. Cortisol is best known for helping support the body's natural "fight-or-flight" instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance. Choice A is incorrect. Addison's disease produces decreased cortisol levels. Choices B and C are incorrect. Neither of these conditions is associated with cortisol levels. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Endocrine System Responses

A nurse is assessing a patient for possible domestic violence. The nurse should know that all of the following are warning signs of the presence of violence except: Select all that apply. A. Stating that everything is "just fine" [16%] B. Expressing sadness over a previous loss [30%] C. Displaying mood and behavior changes [12%] D. Wanting to have family involved [41%]

Explanation Choice D is correct. In most cases of abuse/violence, the victim does not want the family involved. Many times the perpetrator of violence will try to control the victim by threatening his/her family with harm. If the client wants the family to be involved, it is often "not" a warning sign of the presence of violence. Recognizing signs of the possible presence of violence are essential nursing skills, as many victims will not immediately report abuse. Often victims will seem dismissive of what the nurse feels is a sign of violence. The victim may state, "everything is fine" or "we have good days and bad days." Being observant of mood and behavior changes will give the nurse a sense of when there are changes in a patient. Suspicion of violence is not something that should be taken lightly or second-guessed. It's always best to observe and identify warning signs rather than wait for the patient to complain first. Choices A, B, and C are incorrect. Warning signs of violence include behavior changes, withdrawal, depression, agitation, hyperarousal, a new display of anger, noncompliance, sexualized behavior, bowel or bladder problems, sleep problems, and unexplained/curious injuries.

The nurse is working at the triage desk in the emergency department when a client arrives and begins speaking in Spanish. The nurse asks if the client would like an interpreter, and the client says, "No." What is the most appropriate action for the nurse to take? A. Ask around to see if anyone nearby knows Spanish. [1%] B. Call the receptionist who speaks Spanish to translate. [3%] C. Pull up Google translate on the internet. [5%] D. Request an interpreter from the hospital's interpreter service despite the client's refusal. This is the safest option and will lead to the best outcome for the client. [90%]

Explanation Choice D is correct. It is most appropriate to request an interpreter from the hospital's interpreter service. A certified medical interpreter has the proper training to quickly and accurately translate the conversation as well as protect client confidentiality. This is the appropriate action by the nurse. Choice A is incorrect. It is not appropriate to ask around to see if anyone nearby knows Spanish. This person would not be a certified medical interpreter and have the necessary training to properly interpret the conversation. Choice B is incorrect. It is not appropriate to call the receptionist who speaks Spanish to translate. This does not respect patient privacy, nor does the receptionist have the necessary training to properly interpret the conversation like a certified medical interpreter does. Choice C is incorrect. It is not appropriate to pull up Google translate on the internet to interpret the conversation. Not only would this be inaccurate, but it would take far too long to figure out what the patient needs. This is not an acceptable action. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Fundamentals - Ethics

The RN is caring for a patient recovering from cardiac catheterization via the right femoral artery. One hour after the procedure, the nurse notes stable vitals but is unable to palpate the patient's left pedal pulse. Which action would be the nurse's highest priority? A. Assess bilateral lower extremity capillary refill [25%] B. Notify the physician [26%] C. Place bed in Trendelenburg [2%] D. Recheck pedal pulse with doppler [46%]

Explanation Choice D is correct. Peripheral pulses may be diminished following cardiac catheterization, but the complete absence of a pulse indicates a serious complication. If unable to palpate the patient's pulses, the nurse's first action should be to attempt to locate it with a doppler. Choice A is incorrect. This assessment data would not be a priority for treatment/intervention. If the pulse remains absent upon doppler examination, the nurse can expect the patient's circulation will be compromised. Choice B is incorrect. Pulses may be diminished following this procedure, but non-palpable pulses may be heard with the doppler. In the absence of patient distress, the nurse should first evaluate the pulse distal to the incision site with a doppler before notifying the physician. Choice C is incorrect. This position (supine with both feet elevated 15-30 degrees above head) is appropriate for patients with a low pulse due to vagal nerve stimulation. This action would not address this patient's problem of a non-palpable pulse. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential

The patient has just been diagnosed with hyperlipidemia. Aside from the prescribed atorvastatin, she is advised to lose weight and implement some dietary changes. The nurse talks to her about possible nutritional modifications. All of the following are accurate, except: A. Replace vegetable oil with canola oil when cooking. [13%] B. Eat fish like tuna and salmon more often. [3%] C. Eat more fruits and vegetables. [4%] D. Eat red meats more often. [79%]

Explanation Choice D is correct. Red meats are rich in saturated fat. It should be eaten less frequently because it contributes to high cholesterol levels. Choice A is incorrect. Replacing vegetable oils high in polyunsaturated fats with canola oil (monounsaturated fats) is more beneficial in reducing cholesterol levels. Choice B is incorrect. Fish like tuna and salmon are rich in omega 3 fatty acids, which help in reducing harmful cholesterol levels. Choice C is incorrect. Fruits and vegetables contain fiber, which promotes a healthy cholesterol level.

A teenager is diagnosed with anorexia nervosa. Upon interviewing her friends, the nurse would expect them to describe the patient to be which of the following? A. An under achiever [24%] B. Disorderly [14%] C. Independent [29%] D. Obedient [33%]

Explanation Choice D is correct. Teens with anorexia nervosa try their best to do what is expected of them at home and school. Choice A is incorrect. Teens with anorexia nervosa tend to do well in school. Choice B is incorrect. Anorexic teens are orderly and obedient. They try their best to do what is expected of them. Choice C is incorrect. Anorexic clients are dependent on others.

Calculate the body mass index (BMI) for a 43-year-old client who is 5' 11" and weighs 190 pounds. A. 18 [9%] B. 48 [8%] C. 38 [25%] D. 26 [58%]

Explanation Choice D is correct. The body mass index (BMI) can be calculated by dividing the weight of the client in kg by the height of the client in terms of meters squared. For example, the BMI for a client who is 5' 11" and weighs 190 pounds is as follows: 190 pounds = x kg 190/2.2 = 86 kg 5' 11" = x meters 71 " = x meters 71 "/ 39.6 = 1.8 meters 86 kg/1.8 x 1.8 meters = 86/3.24 = 26.5 or a BMI of 26 Choice A is incorrect. This client's BMI is not 18. The BMI is calculated by dividing the client's weight in kilograms by the client's height in terms of meters squared. Try this calculation again. Choice B is incorrect. This client's BMI is not 48. The BMI is calculated by dividing the client's weight in kilograms by the client's height in terms of meters squared. Try this calculation again. Choice C is incorrect. This client's BMI is not 38. The BMI is calculated by dividing the client's weight in kilograms by the client's height in terms of meters squared. Try this calculation again.

The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric patients around him are getting angry. What is the most appropriate action of the nurse? A. Restrain the client [1%] B. Escort the other clients from the day room [28%] C. Give Haloperidol IM [3%] D. Approach the client calmly accompanied by two other staff [67%]

Explanation Choice D is correct. The first intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not contact the agitated client alone but should be accompanied by other personnel. Choice A is incorrect. Restraining the client should be the last approach for the nurse. The first intervention should be to talk to the client to remove him from the day room. Choice B is incorrect. The nurse should not try to remove the other clients from the room. The nurse should first remove the disruptive client from the place. Choice C is incorrect. An IM injection of Haldol will take 30 minutes to become active. The nurse needs to remove the disruptive client before the situation escalates.

The nurse is reinforcing discharge instructions to the parents of a 6-year-old child with chickenpox. The nurse knows that the parents understand the discharge instructions when they make which of the following statements? A. "Once she has been without a fever for a day, she can go back to school." [1%] B. "She will still be infectious for 14 days, so we should let the school know she will be out for 2 weeks." [22%] C. "After antibiotics have been started, she can go back to school in 48 hours." [7%] D. "Once all of her sores are crusted over, it will be safe for her to go back to school." [70%]

Explanation Choice D is correct. This statement demonstrates understanding by the parents. Chickenpox is considered infectious until all of the lesions have crusted over. For most children, this occurs 6-7 days after the last of the rash presents but can be up to 10 days. Choice A is incorrect. The child could still be infectious after 24 hours of being afebrile, so she should not return to school until all the lesions are crusted over. Choice B is incorrect. The child will not necessarily be infectious for 14 days after going home. With chickenpox, children remain infectious until all of the lesions have crusted over. Typically, all the lesions crust over within 6-7 days. Therefore, staying home for 2 weeks is unnecessary. Choice C is incorrect. Chickenpox (or varicella) is a viral infection for which antibiotics will not be prescribed. This statement by the parents would indicate that they do not understand the treatment plan for their child, nor do they understand when she can go back to school. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Infection control and safety

Your client has consumed an 8 ounce can of ginger ale, a 4-ounce container of apple sauce, and 6 ounces of lean meat for lunch. You will document this client's fluid intake as: A. 80 mL or cc [4%] B. 160 mL or cc [7%] C. 180 mL or cc [16%] D. 240 mL or cc [73%]

Explanation Choice D is correct. You will document this client's fluid intake as 240 mL or cc because the client has consumed a total of 8 ounces of fluid and because each ounce has 30 mL or cc, it is calculated as follows: 30 x 8 = 240 mL or cc. The apple sauce and lean meat do not count as fluid. Choice A is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 80 mL or cc. Try this calculation again. Choice B is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 160 mL or cc. Try this calculation again Choice C is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 180 mL or cc. Try this calculation again

Which of the following gross motor skills should be developed in a 9-month-old infant? Select all that apply. A. Sitting without support [44%] B. Rolling over [38%] C. Standing without support [11%] D. Taking their first steps [7%]

Explanation Choices A and B are correct. A is correct. Sitting without support is a gross motor skill that should be developed by 8 to 9 months. Indeed, a 9-month-old infant should already be able to sit up without support. If they have not yet met this milestone by 9 months of age, follow up is warranted to further evaluate the infant. They may be missing other milestones and need help, such as physical therapy. B is correct. Rolling over is a milestone that should be developed in a 9-month-old infant. Rolling completely over should be accomplished by the time the infant is six months old. If they have not met this milestone by nine months of age, follow-up is warranted to evaluate the infant further. They may be missing other milestones and need help, such as physical therapy. Choice C is incorrect. Standing without support is a gross motor skill that should be developed by 10-12 months, not by nine months. Choice D is incorrect. A 9-month-old infant may not be taking their first steps yet, which is appropriate, and no follow-up is necessary. Taking their first steps is a milestone that should be achieved by 12 months. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Development

While reinforcing education with a family who has a 1-year-old son diagnosed with phenylketonuria (PKU), the mother states. "I think we should just stick to the formula. I am too scared to feed him other foods." The LPN should review which of the following foods for this family to avoid? Select all that apply. A. Pork tenderloin [41%] B. Green beans [13%] C. Cheese omelets [40%] D. Pears [6%]

Explanation Choices A and C are correct. It is appropriate for the LPN to advise the mother to avoid pork tenderloin. In phenylketonuria (PKU), there is impaired metabolism of an essential amino acid named phenylalanine. When patients eat foods that contain this amino acid, they cannot break it down, and levels of this amino acid can then become toxic to the patient. Foods that are high in protein have this amino acid and therefore should be avoided. Since pork tenderloin is high in protein, and therefore phenylalanine, the LPN should advise the family to avoid this food (Choice A). It is appropriate for the LPN to advise the family to avoid foods with eggs, such as cheese omelets. Foods that are high in protein have this amino acid and therefore should be avoided. Since eggs are high in protein, and therefore phenylalanine, the LPN should advise the family to avoid omelets (Choice C). Choice B is incorrect. Green beans are not high in protein and, therefore, do not have high levels of phenylalanine. Such food is appropriate for patients with PKU. Choice D is incorrect. Pears are not high in protein and, therefore, do not have high levels of phenylalanine. These are appropriate for patients with PKU. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Pediatric nutrition

Which of the following are potential causes of metabolic alkalosis? Select all that apply. A. Vomiting [42%] B. Diarrhea [17%] C. Antacids [29%] D. Starvation [12%]

Explanation Choices A and C are correct. Vomiting is a cause of metabolic alkalosis. There are a lot of acids in stomach contents, so losing those acids through vomiting leads to alkalosis (Choice A). Antacids used in excess are a cause of metabolic alkalosis. Antacids have a lot of base in them, so taking too much leads to alkalosis (Choice C). Choice B is incorrect. Diarrhea is a cause of metabolic acidosis. There are a lot of bases (bicarbonate) in diarrhea, so losing them leads to acidosis. Choice D is incorrect. Starvation is a cause of metabolic acidosis. This is because when the cells are starving, the body starts to break down fat. The breakdown of fat leads to ketone production, and ketones are acid. So, too many ketones lead to acidosis. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Acid-Base

Which of the following would cause an increase in cardiac output? Select all that apply. A. 2 L normal saline fluid bolus [36%] B. Furosemide [14%] C. Propranolol [15%] D. Dopamine [35%]

Explanation Choices A and D are correct. Any increase in volume will cause an increase in cardiac output. When you increase the amount of mass in circulation, you increase the patient's stroke volume. Since the formula for cardiac output is CO = HR x SV, there are two ways to increase CO - by increasing the HR or increasing the SV. One sure way to increase the stroke volume, or amount of blood that the heart is pumping out with each beat, is to increase the amount circulating. Fluid boluses are commonly used to increase cardiac output (Choice A). Dopamine will increase cardiac output. Dopamine is an inotrope that improves the contractility of the heart. This means that the center will contract harder and pump out more blood with each contraction. This is an increase in stroke volume and because CO = HR x SV, an increase in SV causes an increase in CO. Any inotrope that improves the contractility of the heart will cause an increase in CO. This includes dopamine, dobutamine, and milrinone, to name a few (Choice D). Choice B is incorrect. Furosemide administration would decrease cardiac output. Furosemide is a potent loop diuretic, which induces diuresis and therefore reduces the amount of fluid in the vasculature. With reduced volume, preload in the heart is decreased. With decreased preload, there is diminished contractility due to Starling's law ("The greater the stretch on the myocardium before systole (preload), the stronger the ventricular contraction"). With decreased contraction, there is reduced stroke volume, and therefore decreased cardiac output. Choice C is incorrect. The administration of propranolol will decrease cardiac output. This is due to propranolol decreasing the heart rate. Propranolol is a beta-blocker used to control the pulse of the heart and therefore reduces the heart rate. Since CO = HR x SV, any decrease in the heart rate will decrease cardiac output; this is why the administration of any beta-blocker will lower cardiac output. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Cardiac

The nurse is assisting with monitoring a client that has a chest tube and documents the appropriate assessments. Which of these assessments are expected findings? Select all that apply. A. Drainage system at a level below the patient's chest. [42%] B. Vigorous bubbling in the water-seal chamber. [7%] C. Stable water in the tube of the water-seal chamber during inhalation and exhalation. [15%] D. Occlusive dressing over the chest tube. [35%]

Explanation Choices A and D are correct. It is expected that the drainage system will be at a level below the client's chest. This is what allows gravity to help drain fluid from the pleural space. If the drainage system was above the client's chest, the chest tube would not work properly (Choice A). An occlusive dressing placed over the chest tube is appropriate. This is important to ensure that air does not enter the pleural space causing a pneumothorax. The nurse should check the dressing to ensure that it is airtight (Choice D). Choice B is incorrect. Gentle bubbling in the water chamber is an appropriate finding, but the bubbling should not be vigorous. Gentle bubbling indicates that air is draining from the client, but if vigorous or excessive bubbling is noted, there may be an air leak, which will need to be addressed quickly. Choice C is incorrect. It is not expected for the water in the tube of the water-seal chamber to be stable during inhalation and exhalation. The water in the tube of the water-seal chamber should fluctuate during inhalation and exhalation. If it does not, the chest tube could be occluded, the lung could have re-expanded, or there could be air leaking into the pleural space. The nurse will need to notify the physician of this finding to investigate the cause and take appropriate action. NCSBN Client Need: Topic: Potential for Complications of Diagnostic Test/Treatments/Procedures, Reduction of Risk Potential; Subtopic: Chest tubes, Respiratory

Which of the following interventions are appropriate for a pediatric patient experiencing contact dermatitis? Select all that apply. A. Diphenhydramine [36%] B. Hydrocortisone [42%] C. Cyclosporine [14%] D. Tacrolimus [8%]

Explanation Choices A, B, C, and D are all correct. A is correct. Diphenhydramine is a first-generation oral antihistamine that is commonly prescribed for dermatitis or eczema. These antihistamines, including diphenhydramine and Chlor-Trimeton, have a side effect of drowsiness and can help the child itch less. B is correct. Topical hydrocortisone cream is commonly prescribed to help relieve itching associated with dermatitis. Hydrocortisone can be purchased OTC and is often one of the first treatments used with contact dermatitis. C is correct. Cyclosporine is a calcineurin inhibitor. It inhibits the enzyme calcineurin in immune cells to decrease the number of inflammatory substances that the body produces. This, therefore, reduces overall inflammation, helping with contact dermatitis. D is correct. Tacrolimus is a calcineurin inhibitor. It inhibits the enzyme calcineurin in immune cells to decrease the number of inflammatory substances that the body produces. This, therefore, reduces overall inflammation, helping with contact dermatitis. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Pediatrics - Integumentary

The nurse is caring for an 82-year-old male in end-stage renal failure. Upon assessment, she notes dyspnea auscultates crackles and rales in his lungs. Which of the following signs and symptoms does she also expect? Select all that apply. A. Distended neck veins [31%] B. Weight gain [31%] C. Bounding pulses [28%] D. Hypotension [10%]

Explanation Choices A, B, and C are correct. A is correct. A patient in end stage renal failure often experiences fluid volume excess due to their kidney dysfunction. The kidneys are unable to concentrate urine as they should and therefore large volumes of fluid are retained causing a fluid volume excess. The nurse has appreciated dyspnea, rales, and crackles on her assessment, which are all signs of fluid volume excess due to increased fluid in the lungs. Distended neck veins are another sign of fluid volume excess that she would expect to find. With the increased fluid volumes, veins of the neck appear distended. This can also be appreciated in the veins on the back of the hands. B is correct. Weight gain is another sign of fluid volume excess that the nurse would expect to find. Due to fluid accumulation with end stage renal failure, large amounts of weight can be gained due to fluid. C is correct. Bounding pulses are another sign of fluid volume excess that the nurse would expect to find. Due to the fluid retention that occurs in end stage renal failure, there are larger than normal quantities of fluid in the vascular system leading to bounding pulses. Choice D is incorrect. Hypotension would not be expected in a patient with fluid volume excess. Where there are larger than normal volumes of fluid in the vascular system the patient is more likely to experience hypertension. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Fundamentals of care - Fluids & Electrolytes

Which of the following is not a rationale for the nurse to reassess the patient's pain after treatment? Select all that apply. A. To measure the duration of pain [29%] B. To pinpoint the location of pain [33%] C. To make changes to the patient's pain goal [26%] D. To establish the efficacy of medication [12%]

Explanation Choices A, B, and C are correct. A: Duration is how long the patient experiences pain. The rationale for the 30-60 minute timeframe for reassessment is to allow the pain medication to take effect. B: Location refers to where the patient is experiencing pain. This is not expected to change in a reassessment. C: The pain goal is negotiated on admission, not during readmission or reassessment. Choice D is incorrect. Reassessment is performed to assess the efficacy of the treatment. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort; Reassessing and Documenting Pain

You are preparing to discharge a patient with a history of sickle cell anemia. Which of the following points are important to include in your discharge teaching? Select all that apply. A. Keep a water bottle with you at school so that you can stay hydrated. [39%] B. Follow a high-calorie, high-protein diet. [30%] C. Do not receive the annual influenza vaccination due to lowered immunity. [4%] D. Avoid flying on an airplane. [27%]

Explanation Choices A, B, and D are correct. Remaining hydrated is one of the most important points to teach the family. Sickle cell crises occur when the child is dehydrated, febrile, or under stress. Avoiding these situations will help avoid a crisis. Following a high-calorie, high-protein diet is necessary for the child with sickle cell anemia to promote optimal nutrition. Supplementation with folic acid may also be needed. Avoiding flights is necessary to teach the family as high altitudes can precipitate a crisis due to the body's increased demand for oxygen. Choice C is incorrect. Children with sickle cell anemia do have lowered immunity due to secondary functional asplenia, but this is precisely why it is important for them to receive the annual influenza vaccination. The nurse should include in her discharge teaching the importance of getting vaccinated.

The nurse is assessing a client with opioid withdrawal. Which of the following would be an expected finding? Select all that apply. A. Diaphoresis [26%] B. Bradycardia [8%] C. Irritability [25%] D. Hypotension [10%] E. Rhinorrhea [13%] F. Abdominal cramps [19%]

Explanation Choices A, C, E, and F are correct. A client experiencing opioid withdrawal will experience symptoms such as abdominal cramping, diarrhea, nausea, rhinorrhea, piloerection, shivering, tachycardia, hypertension, insomnia, and agitation. Choices B and D are incorrect. Bradycardia and hypotension are expected findings during opioid intoxication. Opioids are central nervous system (CNS) depressants and may cause life-threatening hypotension, bradycardia, and bradypnea. Additional information: Opioid withdrawal is typically not life-threatening but highly uncomfortable for the client. Treatment is symptomatic, including encouraging hydration if the client is experiencing vomiting or diarrhea. The nurse should advocate for treatment options to promote abstinence from opioids such as pharmacotherapy (methadone, naltrexone, etc.) and/or psychotherapy. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Alterations in Body Systems

What health issues might you expect to find in a client that is a victim of domestic violence? Select all that apply. A. Upper respiratory infections [2%] B. Bruises and broken bones [26%] C. Unintended pregnancies [15%] D. Repetitive strain injuries [19%] E. Alcoholism [16%] F. Depression [22%]

Explanation Choices B, C, E, and F are correct. Domestic violence (including physical, emotional, and sexual abuse) occurs throughout society. It is present among all racial, social, and economic groups. Health issues related to domestic violence include physical injury from the assault and chronic health problems that may emerge, either as a complication of traumatic injury or as a physical response to ongoing stress from violence or neglect. Health issues related to domestic violence include physical injury from the assault itself, such as bruises and broken bones (Choice B). Families experiencing domestic violence/ physical abuse have more unintended pregnancies, miscarriages, abortions, and low-birth-weight babies (Choice C). Families experiencing domestic violence have higher rates of substance abuse and depression (Choices E and F). Choice A is incorrect. While stress may affect immunity, upper respiratory infections are not particularly associated with physical abuse. Choice D is incorrect. Repetitive strain injuries are not particularly associated with physical abuse. They are seen with repetitive tasks performed over long periods, such as typing and using a computer mouse or assembling parts in a factory line. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Challenges Related to Family Health

The nurse is educating community members on the signs and symptoms of substance abuse intoxication. Which information should the nurse include? Select all that apply. A. Cocaine may cause increased pulse, low blood pressure, and paranoia. [16%] B. Inhalants may cause slurred speech, loss of motor coordination, and nausea. [18%] C. Heroin may cause increased alertness, paranoia, and increased respirations. [14%] D. Alcohol may cause drowsiness, slurred speech, and difficulty with walking. [30%] E. Marijuana may cause a slowed reaction time and problems with balance and memory. [23%]

Explanation Choices B, D, and E are correct. Depending on the inhalant, an individual may experience a loss of inhibition, headache, nausea, poor muscle coordination, and slurred speech. Alcohol may cause drowsiness, loss of inhibition, and difficulty walking. Marijuana may cause a slowed reaction time, difficulty with learning and memory, and hallucinations. Choices A and C are incorrect. Cocaine is a stimulant and produces significant blood pressure and pulse increases. Psychotic symptoms such as paranoia are also common. Heroin has depressant effects during intoxication and may produce drowsiness, euphoria, sedation, and worse respiratory arrest from decreased respiration. NCLEX Category: Psychosocial integrity Related Content: Chemical and Other Dependencies/Substance Abuse Disorder Question type: Knowledge/comprehension

The nurse cares for a client with a potassium of 5.7 mEq/L. The nurse understands that this potassium level may be caused by which condition? Select all that apply. A. Cushing's disease [18%] B. Nasogastric tube suctioning [11%] C. Salt Substitutes [22%] D. Hyperinsulinism [17%] E. Adrenal insufficiency [31%]

Explanation Choices C and E are correct. The client's high potassium level, 5.7 mEq/L is concerning. Salt substitutes contain potassium which makes them more palatable. Excessive intake may lead to hyperkalemia. Adrenal insufficiency causes hyperkalemia because of the insufficient amount of aldosterone, which causes potassium elimination. Less aldosterone, and less potassium elimination, equates to hyperkalemia. Choice A, B, and D are incorrect. Cushing's disease is likely to cause hypokalemia, not hyperkalemia. In this disease, the adrenal glands produce too much aldosterone. Aldosterone causes the body to excrete potassium, putting patients with Cushing's disease at risk for excessive potassium losses leading to hypokalemia. The patient with an NG tube to continuous suction is likely to experience hypokalemia, not hyperkalemia. NG tube suction removes all of the gastric contents, which are rich in potassium. With those excessive potassium losses, the patient becomes hypokalemia. Hyperinsulinism is likely to experience hypokalemia, not hyperkalemia. Insulin is a hormone secreted by the pancreas that facilitates the movement of insulin into cells. With it comes potassium, and therefore when there is too much insulin as there is in hyperinsulinism, too much potassium is moved into the cells and the serum potassium level drops causing hypokalemia. Additional Info The normal potassium level is 3.5 mEq/L to 5.0 mEq/L. Cardiovascular changes are the most severe problems from hyperkalemia and are the most common cause of death in patients with hyperkalemia. The nurse should obtain a 12-lead electrocardiogram and establish continuous telemetry monitoring. Treatment for hyperkalemia includes regular insulin, albuterol breathing treatments, and/or sodium polystyrene.

The nurse places a patient with hypovolemia in the position depicted in the Exhibit. Which of the following positions does it represent? A. The prone position. [0%] B. The supine position. [1%] C. The Trendelenburg position. [97%] D. The Sims' position. [1%]

Explanation Correct Answer is C. This picture shows the Trendelenburg position. In this position, the body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. This position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. It is also used to improve the effects of spinal anesthesia and also to prevent air embolism during central venous cannulation. Choice A is incorrect. The prone position is when a patient is placed in a horizontal position with the face oriented down. A prone position is often used during surgical procedures, especially for those needing access to the spine and the back. It is also used to increase oxygenation in patients with respiratory distress. A Prone position is depicted in the image below: Choice B is incorrect. The supine position is when a patient is placed in a horizontal position with the face oriented up. A supine position is often used during surgical procedures, especially for those needing access to the thoracic area/ cavity. A Supine position is depicted in the image below: Choice D is incorrect. A Sim's position is when a patient lies on his/her left side, left hip and lower extremity straight, and right hip and knee bent. It is also called a lateral recumbent position. Sim's status is usually used for rectal exams, treatments, and enemas. A Sims position is shown below: Additional Info Fowler's position is another position an RN needs to be aware of since it has many implications during nursing care. This is when a patient is seated in a "semi-sitting" position when the head of the bed is elevated at a 45 to 60 degrees angle. There are variations in Fowler position: Low ( 15-30 degrees), Semi-Fowler (30-45 degrees), Standard (45-60 degrees), and High Fowler's (60-90 degrees). Fowler's position is depicted in the image below: Fowler has been used as a way to help with peritonitis. Fowler's can be used:- To promote oxygenation during respiratory distress because it allows maximum chest expansion and relaxation of abdominal muscles. E.g., infants with respiratory distress. To increase comfort during eating and other activities. To improve uterine drainage in post-partum women. To minimize the risk of aspiration in patients with oral or nasal gastric feeding tubes. Fowler's position aids Peristalsis and swallowing by the effect of gravitational pull.

Your elderly female client has just begun a new medication for their impaired cardiac function. Which of the following is a high-priority nursing intervention, and what is the rationale for this client? A. You should closely monitor this client for the side effects of this medication because she is elderly. [8%] B. You should closely monitor this client for the side effects because this drug classification has more side effects than other drugs. [4%] C. You should closely monitor this client for adverse effects of this cardiac medication and dehydration. [15%] D. You should closely monitor this client for the adverse effects because she is elderly and adverse effects most commonly occur when a new medication is begun. [73%]

Explanation Correct Answer is D. You should carefully monitor this client for the adverse effects of this cardiac medication because they are elderly and adverse effects most commonly occur when a new drug is begun. This is the correct reasoning for the nurse's priority action of monitoring. Choice A is incorrect. Although you should closely monitor this client for the side effects of this medication because they are elderly, a more comprehensive rationale ( Choice D) exists among the options. The side effects may be more in this client because of the older age and this being a new medication. Choice B is incorrect. Although you should closely monitor this client for the side effects of this cardiac medication, it is not because this classification has more side effects than other drugs. This monitoring is necessary for the reason explained in Option D. Choice C is incorrect. Although you should closely monitor this client for the side effects of this cardiac medication, it is not indicated only because the client may be dehydrated. This monitoring is necessary for another reason, and there is no evidence in this question that the client is dehydrated. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb's Fundamentals of Nursing: Concepts, Process, and Practice.

The nurse is preparing to administer penicillin V potassium to a child with pneumonia. The child weighs 18.5 kg. The prescription is for 50 mg/kg/day PO divided doses every six hours. How many milligrams should the child receive with each dose? Round your answer to the nearest whole number. Fill in the blank. 231 mg per dose

Explanation First, determine the total daily dose for this child 50 mg x 18.5 = 925 mg Next, determine the individual dose. The drug is given every six hours, so the child will receive four individual doses each day. Divide the daily dose by the frequency of dosing 925 mg/day / 4 doses/day = 231.25 Finally, round the dose to the nearest whole number 231.25 = 231 mg Additional Info Common side effects of penicillin V potassium include: Nausea Vomiting Mild diarrhea

The nurse is caring for a patient receiving a blood transfusion. On assessment, the nurse notes that the patient's respirations are rapid, the face is flushed, and the patient is complaining of itching. The nurse suspects the patient is having a transfusion reaction. The nurse should accomplish the following actions: Take vital signs Stop the transfusion Administer oxygen Obtain a urine specimen. The nurse should complete the tasks in the following order: Stop the transfusion Administer oxygen Obtain a urine specimen Take vital signs

Stop the transfusion Administer oxygen Take vital signs Obtain a urine specimen Explanation Correct ordered sequence: The most crucial step in the process is to stop the transfusion and begin to treat the symptoms. In this case, the patient is short of breath, so the nurse should start oxygen and raise the head of the patient's bed. Vital signs will help the nurse to determine what other processes might be going on and will give the nurse information to provide to the physician. A urine specimen will help to determine if there is hemoglobin in the urine. Also, the nurse should keep an IV open with normal saline and keep the blood bag to return to the blood bank. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Blood and Blood Products

You are caring for a client who states they have a health care proxy. Which of the following most accurately describes a health care proxy? A. The client's legal designation to their spouse or significant other allowing them to have a voice in health care treatment options as the client ages [7%] B. An individual designated by the client to assist in medical decision-making who also becomes responsible for a minimum of one-half of all medical bills accrued by the client [3%] C. An agent who the client legally designates to make medical decisions when the client is no longer capable of doing so [81%] D. A specific designation specifying who can receive and discuss the client's privileged healthcare information [8%]

You are caring for a client who states they have a health care proxy. Which of the following most accurately describes a health care proxy? A. The client's legal designation to their spouse or significant other allowing them to have a voice in health care treatment options as the client ages [7%] B. An individual designated by the client to assist in medical decision-making who also becomes responsible for a minimum of one-half of all medical bills accrued by the client [3%] C. An agent who the client legally designates to make medical decisions when the client is no longer capable of doing so [81%] D. A specific designation specifying who can receive and discuss the client's privileged healthcare information [8%] Incorrect Correct Answer(s): C 82% of peers have answered correctly. 77 s Time Spent 07-08-2022 Last Updated Explanation Choice C is correct. A health care proxy is an agent named in a written legal document designated to make medical decisions for the person signing the document (the principal) when he or she is unable to make decisions for themself. Therefore, Choice C is correct. Choice A is incorrect. Although a client may (and often does) designate their spouse or significant other as their health care proxy, an official health care proxy requires completion of legal paperwork and a copy of the documents to be provided to the hospital. Without doing so, the significant other or spouse cannot be the designated health care proxy. Therefore Choice A is incorrect. Choice B is incorrect. Health care proxies make decisions about healthcare and only healthcare. So long as the health care proxy follows the client's prediscussed wishes, there are no financial implications for the health care proxy. Therefore, Choice B is incorrect. Choice D is incorrect. All people are entitled to confidentiality unless they provide consent for disclosure. The Health Insurance Portability and Accountability Act (i.e., HIPAA) applies to most health care practitioners and details rules regarding privacy, access, and disclosure of individually identifiable health information (also referred to as protected health information). Although a healthcare proxy must comply with HIPAA like any other individual, this is not the best answer for this question. Therefore, Choice D is incorrect. Learning Objective Identify which option best describes a health care proxy. Additional Info A health care proxy is an agent named in a written legal document designated to make medical decisions for the person signing the document (the principal (i.e., the client)) when he or she is unable to make decisions for himself or herself. The health care proxy follows the client's wishes, typically laid out in a health care declaration (although this document goes by various names depending on the state in which the client resides). The health care proxy's authority usually includes making medical decisions not mentioned in a health care declaration (i.e., authorizing medical and surgical procedures, hiring and firing medical staff to provide treatment, accessing medical records, visiting, etc.). Health care proxies make decisions about healthcare and only healthcare. A health care proxy may be known by other names, such as attorney-in-fact, agent, or patient advocate. In most states, the document specifying one's health care proxy becomes legally effective when the principal (i.e., client) loses the clinical capacity to make health care decisions. Some states recognize the document as immediately effective, which in theory means that the designated agent can make health care decisions immediately, but as a practical matter, the principal (i.e., client) can direct and override anything the agent does as long as the client retains the capacity to make health care decisions. Two sample health care proxy forms are shown below: