Archer Review 2b

What intervention is appropriate for the nurse to teach her pregnant patient about relieving constipation? A. Increasing the consumption of fruits and vegetables [94%] B. Taking a mild over-the-counter laxative [4%] C. Lying flat on the back when sleeping [0%] D. Reduce the consumption of iron by at least ½ [1%]

Explanation Choice A is correct. Dietary roughage (or fiber) with sufficient fluids and exercise may help relieve constipation. Constipation in pregnant women is thought to occur due to hormones that relax the intestinal muscle and by the pressure of the expanding uterus on the intestines. Relaxation of the intestinal muscle causes food and waste to move slower through your system. Sometimes iron tablets may contribute to constipation. Choice B is incorrect. Over-the-counter medications should be avoided during pregnancy. Choice C is incorrect. The supine position can place additional pressure on the aorta and vena cava, leading to vena cava syndrome. Choice D is incorrect. A reduction of iron supplements during pregnancy may reduce hemoglobin production and result in a less than effective immune system. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse just completed administering an incorrect intravenous antibiotic infusion to the postoperative client. What is the nurse's first action? A. Assess the client for adverse reactions. [74%] B. Submit a completed incident report. [1%] C. Stop the current antibiotic and administer the correct antibiotic. [14%] D. Notify the client's physician. [11%]

Explanation Choice A is correct. The nurse's utmost priority is the client safety. The nurse should first assess the client for any adverse reactions to the wrong drug. Choice B is incorrect. After the nurse determines that the client is safe, the nurse can then proceed to file an incident report. Choice C is incorrect. The nurse has already completed administering the incorrect antibiotic. She/he should stop the future doses of the incorrect antibiotic but should assess the client first for any adverse reactions before administering the correct antibiotic. Choice D is incorrect. The nurse needs to assess the client first because she/he will need this assessment data to report to the physician.

The major difference between extravasation and infiltration is that infiltration occurs when: A. A non-vesicant drug enters into the subcutaneous tissue. [32%] B. A vesicant drug enters into the subcutaneous tissue. [27%] C. A non-vesicant drug enters into the intradermal tissue. [23%] D. A vesicant drug enters into the intradermal tissue.

Explanation Choice A is correct. The significant difference between extravasation and infiltration is that infiltration occurs when a non-vesicant drug enters into the subcutaneous tissue, which does not happen with extravasation. Extravasation occurs when a vesicant drug comes into the subcutaneous tissue. Choices B, C, and D are incorrect. Infiltration does not occur when a vesicant drug enters into the subcutaneous tissue; rather, it occurs when a non-vesicant comes into the subcutaneous tissue. Lastly, the affected tissue used to define infiltration and extravasation is subcutaneous tissue, not intradermal tissue.

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence the way people see and behave within the world is defined as: A. Society [9%] B. Community [4%] C. Spirituality [7%] D. Culture [81%]

Explanation Choice D is correct. Culture is defined as the customs, arts, social institutions, and achievements of a particular nation, people, or another social group. Choice A is incorrect. Society is defined as the people who live in a country or region, their organizations, and their way of life. Choice B is incorrect. A community is defined as all the people living in an area or a group or groups of people who share common interests. Choice C is incorrect. Spirituality is defined as the quality of being concerned with the human spirit or soul as opposed to material or physical things. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Cultural Assessment and Cultural Competency

The primary healthcare provider (PHCP) prescribes metronidazole to be administered over thirty minutes. The pharmacy supplies the medication in a bag labeled 500 mg of metronidazole in 100 mL of 0.9% saline. How many mL/hour should the nurse administer this medication? Fill in the blank. 200 mL/hr

Explanation To solve this problem, the nurse will use the formula of volume / time (hours) First, convert the 30 minutes to hours 30 minutes / 60 = 0.5 hr Next, divide the volume by the hour(s) 100 mL / 0.5 = 200 mL/hr Additional Info Metronidazole is an antibiotic effective for enteric infections such as C. diff and appendicitis. The client should be educated to avoid alcohol during the therapy and expect a darker color to their urine.

While volunteering at a summer camp as the RN on duty, a child playing soccer falls and breaks their arm. It appears to be a compound fracture. Place the following actions in order of nursing priority when dealing with this injury: Assess the injury while calling for help Apply ice around the injured site Cover the open wound with a clean dressing Elevate the arm

Assess the injury while calling for help Cover the open wound with a clean dressing Apply ice around the injured site Elevate the arm Explanation Compound fracture (open fracture) is a fracture with bone fragments protruding through the skin. Because there's an open wound or skin breach near the fracture site, bacteria from the contaminants can enter the wound and lead to infection. It is essential to treat the open fracture early to prevent infection. The infection can progress to osteomyelitis ( bone infection) if not addressed. The following are the steps in addressing an open fracture:- Assess: As always, the priority nursing action is to assess the injury. While assessing the injury, the nurse should also assess for any neurovascular compromise. Protect: The nurse should cover the open wound with a clean dressing to prevent infection. Apply pressure over the surrounding wound, not over the protruding bone. Apply an ice pack to the site above and around the fracture. Avoid applying ice directly to the skin because it may cause skin damage. Also, care should be taken not to contaminate the open wound. Elevate: Elevate the arm to reduce the swelling; however, this may have to be done carefully in an open fracture setting without greatly mobilizing fracture fragments. These nonpharmacological interventions will reduce swelling and pain while waiting for help. The child will need to go to the hospital for possible surgery and casting of the extremity. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation Learning Objective Recognize the complications of an open fracture and understand that the most critical risk is infection. Protect the site by covering it with a clean dressing until surgical help arrives.

When providing instructions about the use of an MAO inhibitor to a patient with clinical depression, the nurse should instruct the client to: A. Avoid chocolate and cheese [85%] B. Take frequent naps [1%] C. Take the medication with milk [4%] D. Avoid walking without assistance [10%]

Explanation Choice A is correct. Foods high in tryptophan, tyramine, and caffeine, such as chocolate and cheese, may precipitate a hypertensive crisis. Monoamine oxidase inhibitors (MAOIs) were the first type of antidepressant developed. They ease depression by affecting neurotransmitters in the brain. Although they are active, they've generally been replaced by antidepressants that are safer and cause fewer side effects. MAOIs can cause dangerously high blood pressure when taken with certain foods or medications. Because of this, diet restrictions and avoiding certain other drugs are required while on an MAOI therapy. Despite side effects, these medications are still a good option for some people. In some instances, they relieve depression when other treatments have failed. Choices B, C, and D are incorrect. None of these are necessary instructions for a patient taking an MAO inhibitor. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse is caring for a patient exhibiting signs of poor muscle coordination, stooped posture, and slow movements. The medication most likely to cause these symptoms would be which of the following? A. Haloperidol [72%] B. Nifedipine [6%] C. Venlafaxine [13%] D. Prazosin [9%]

Explanation Choice A is correct. Haloperidol is a typical antipsychotic which may adversely cause extrapyramidal side effects (EPS). These effects include akathisia, dystonia, pseudo parkinsonism, and/or tardive dyskinesia. Choices B, C, and D are incorrect. Nifedipine is a calcium channel blocker indicated for the treatment of hypertension. It also may be used as a tocolytic to mitigate preterm labor. Venlafaxine is a serotonergic drug used in the management of depressive and anxiety disorders. Prazosin is indicated for the treatment of hypertension as well as PTSD. Additional information: EPS is a concern when a patient is taking antipsychotic medication. The highest risk is associated with typical antipsychotics (haloperidol, fluphenazine, etc.) compared to atypical antipsychotics. The nurse must assess the patient for any abnormal movements during the therapy.

The nurse is caring for a client who has pertussis. Which infection control precaution should the nurse implement? Select all that apply. A. Wear a surgical mask prior to entry [32%] B. Provide disposable dishes for meals [20%] C. Keep the patient's room door closed [21%] D. Provide the patient with a portable fan [4%] E. Maintain negative air pressure [10%] F. Apply an N95 mask to the patient during transport [7%] G. Place the patient in a room near the nurse's station [6%]

Explanation Choice A is correct. Infected droplets spread pertussis. Therefore, the nurse must wear a surgical mask when providing care. Visitors must also wear the surgical mask, and during client transport, the patient should wear a surgical mask - not N95. Choices B, C, D, E, F, and G are incorrect. Disposable dishes and utensils are not necessary for any isolation precaution. Further, this client requires droplet precautions, and the door may remain open with no need for negative pressure. The nurse should not provide the client with a fan as the fan will spread the infected droplets around the room. The client doesn't need to be placed near the nurse's station as this is an intervention for a client at risk for falls. Please note, that select all that apply items may require one or all responses according to the NCSBN (the authors of the NCLEX) Additional Info Transmission-based precautions for pertussis include droplet precautions such as wearing a face mask and appropriate hand hygiene. The nurse may only room a patient with pertussis with another client with the same infection. Keeping the client's room door closed and maintaining negative air pressure are appropriate interventions for airborne isolation (unlike in this patient, with respiratory droplet precautions).

The nurse is caring for a 10-year-old client with a tracheostomy tube. The nurse notices that the client has a large amount of secretions and prepares the client for suction. Which action should the nurse take first? A. Hyperoxygenate the client [90%] B. Ask the client to take a deep breath [4%] C. Place the client in the supine position [5%] D. Notify the charge nurse [1%]

Explanation Choice A is correct. It is necessary to hyper-oxygenate the client prior to taking any of the other actions. This is one of the first steps in suctioning a tracheostomy. The nurse hyper-oxygenates the client to prepare them for the procedure and prevent oxygen desaturation. The nurse then inserts the suction catheter without suctioning to the pre-measured depth, applies intermittent suction, and rotates the suction catheter while removing it from the tracheostomy. Choice B is incorrect. It is not necessary to ask the client to take a deep breath prior to suctioning their tracheostomy. The nurse should hyper-oxygenate the client first. Choice C is incorrect. Placing the client supine is not specifically necessary for suctioning a tracheostomy. The client can be in any position of comfort where the tracheostomy can easily be accessed. For some clients, they may be sitting up in bed or up to the chair. For pediatric clients, it can be helpful to place a roll under their shoulders, hyperextending the neck so that the nurse can better reach the tracheostomy. Choice D is incorrect. It is not necessary to notify the charge nurse if the client needs suctioning. The nurse may proceed with this intervention. NCSBN Client Need Topic: Reduction of Risk Potential, Subtopic: Potential for Complications of Diagnostic Test/Treatments/Procedures; Respiratory

The nurse is caring for a client who arrives with an intentional overdose of nortriptyline. Which information is essential to obtain? A. The number of pills that were consumed. [67%] B. The indication for the medication. [6%] C. Previous suicide attempts and methods. [21%] D. Circumstances leading up to the overdose. [6%]

Explanation Choice A is correct. Nortriptyline is a tricyclic antidepressant (TCA) used in the management of depressive and obsessive-compulsive disorders. Overdoses of tricyclics can be fatal because of their cardiotoxicity. Discerning how many pills were consumed would be very helpful. The priority for this client is to complete a 12-lead electrocardiogram followed by continuous cardiac monitoring. Choices B, C, and D are incorrect. The indication for the medication, previous suicide attempts, and circumstances leading up to the overdose are not priority questions to obtain. The immediate care of this client would not change based on these questions. However, knowing that a client took three pills versus thirty would be quite helpful in determining the severity of the overdose. Additional information: Tricyclic antidepressants include medications such as nortriptyline, amitriptyline, and imipramine. These medications are utilized in the treatment of depressive and obsessive-compulsive disorders. This class of medications possesses significant anticholinergic effects and therefore would not be recommended for older adults. Overdose of a TCA is extremely serious because these medications are cardiotoxic. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Adverse Effects/Contraindications/Side Effects/Interactions

The nurse is assessing a patient with Paget's disease. Which of the following would be an expected finding? A. Bone deformities [75%] B. Berry aneurysm [5%] C. Heberden's nodes [12%] D. Janeway lesions [7%]

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

A client who has recently traveled to another country presents to the emergency department with shortness of breath and suspected severe acute respiratory syndrome (SARS). What should the nurse's first intervention be? A. Place the client on contact and airborne precautions. [88%] B. Obtain blood, urine, and sputum for culture. [5%] C. Administer methylprednisolone 1 gram/IV. [4%] D. Infuse normal saline at 100mL/hr. [2%]

Explanation Choice A is correct. Since SARS can be potentially deadly, the nurse's first action should be to place the client in isolation. If an airborne isolation room is not available in the emergency department, droplet precautions should be initiated until the patient can be moved to a negative-pressure room. SARS is a potentially deadly viral illness that quickly spread around the world in 2003. It presents with flu-like symptoms. The virus takes over cells within the body and duplicates itself within the affected cells. It is associated with the viral group known as coronaviruses, which cause the common cold. It is spread through infected droplets that may be transmitted when a person coughs, sneezes, or spits when he/she talks. Other people may get the virus by touching something that comes in contact with the droplets, then touching their nose, eyes, or mouth. Choices B, C, and D are incorrect. The other choices should also be done rapidly but are not as crucial as preventing transmission of the disease. NCSBN Client Need Topic: Safe and Effective Care Management, Subtopic: Safety and Infection Control

The nurse is caring for a client experiencing digitalis toxicity. The nurse anticipates a prescription for which medication? A. Digoxin immune fab [70%] B. Milrinone [7%] C. Amrinone [10%] D. Flecainide [12%]

Explanation Choice A is correct. The antidote for digoxin toxicity is the administration of digoxin immune fab. This drug binds digoxin, preventing it from reaching the tissues. The onset of action is rapid: less than 1 minute after the IV infusion is begun. Cardiac glycosides cause potentially dangerous adverse effects at high doses and in individual clients. The margin of safety between a beneficial dose and a toxic dose is tiny. Therefore, therapy should be closely monitored. Serum digoxin levels above 1.8 ng/mL are considered toxic. Initial side effects are GI-related and include loss of appetite, vomiting, and diarrhea. Headache, drowsiness, confusion, and blurred vision may also occur. Choices B, C, and D are incorrect. Milrinone is a phosphodiesterase inhibitor that is primarily used for short-term support of advanced heart failure. Amrinone or inamrinone is a pyridine phosphodiesterase-3 inhibitor. It is a drug that may improve the prognosis in clients with congestive heart failure (CHF). Amrinone has been shown to increase the contractions initiated in the heart by calcium-induced calcium release. Flecainide is used for severe ventricular dysrhythmias. Additional Info Digoxin is a cardiac glycoside indicated for the treatment of atrial fibrillation and congestive heart failure (CHF). This medication has lost popularity in recent decades because newer agents do not require therapeutic monitoring. For a client taking digoxin, the apical pulse needs to be obtained prior to administration. The apical pulse needs to be at least 60/minute for adults; 70/minute for children; 90/minute for infants.

The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client's clinical data. Which post-procedure data requires immediate follow-up? See the image below. A. Blood Pressure [52%] B. Glasgow Coma Scale [24%] C. Respirations [23%] D. Temperature [0%]

Explanation Choice A is correct. The client's post-procedure blood pressure is highly concerning as it reflects clinical hypotension. Medications used in moderate sedation have a vasodilating effect, and the nurse should intervene to increase the client's blood pressure via prescribed intravenous (IV) fluids. Choices B, C, and D are incorrect. The client does have a reduction in the GCS. However, immediately post-moderate sedation, it is common for a client to be lethargic because of the medications administered. The client's respiratory rate is normal, and while it is lower compared to the pre-procedure rate, the client emerging from sedation often has a respiratory rate on the lower end of normal. The client's temperature is within normal limits. Additional Info A procedure involving this type of sedation requires informed consent, and the nurse will serve as a witness. Common medications utilized for moderate (conscious) sedation include fentanyl, midazolam, or propofol. Anesthesia providers, other physicians, dentists, and oral surgeons are qualified to administer conscious sedation, and the nurse does not administer anesthesia intravenously. When this type of sedation is utilized for a closed reduction, it is a quick process that requires close monitoring of the client's vital signs, end-tidal carbon dioxide (normal is 20 and 40 mm Hg), cardiac rhythm, and level of consciousness.

While reviewing various pain scales, the nurse understands pictorial pain assessment scale, like the Wong-Baker scale, has some advantages compared to a numerical pain intensity assessment scale. One of these advantages of pictorial scale over logarithmic scale is that the logarithmic pain intensity assessment scale cannot be used when: A. A client is confused and disoriented [45%] B. A client is in severe pain because these numerical pain intensity assessment scales are only able to measure mild to moderate pain and not severe pain. [5%] C. A client is in minimal pain because these numerical pain intensity assessment scales are able to measure only mild to moderate pain and not minimal pain. [4%] D. A client is deeply lethargic and unable to follow instructions. [46%]

Explanation Choice A is correct. The primary advantage of a pictorial pain assessment scale, like the Wong-Baker scale, when compared and contrasted to a numerical pain intensity assessment scale is that the logarithmic pain intensity assessment scale cannot be used when a client is confused and disoriented. However, this type of client would be able to use a pictorial pain assessment scale like the Wong-Baker FACES range of pain assessment. Choice B is incorrect. This is inaccurate. Logarithmic pain intensity assessment scales can be used to assess the continuum of pain intensity from the absence of all suffering to the most significant and highest level of severe pain. Choice C is incorrect. This is inaccurate. Logarithmic pain intensity assessment scales can be used to assess the continuum of pain intensity from the absence of all suffering to the most significant and highest level of severe pain. Choice D is incorrect. This is inaccurate because a client who is deeply lethargic and unable to follow instructions cannot be assessed with either a numerical or pictorial pain assessment scale since they are not able to follow instructions. For these clients, the nurse should use a pain behavior assessment.

After reviewing information related to advanced directives with a patient, which statement by the patient indicates the need for further discussion and education? A. "A living will designates a person that can make decisions about my medical care if I can't do that myself." [36%] B. "The person who I choose to make decisions about my medical care if I cannot on my own is named as the durable power of attorney." [18%] C. "I can refuse to be intubated or placed on mechanical ventilation as part of a living will." [7%] D. "If I change my mind, I can revoke an advanced directive any time, just by verbally saying so."

Explanation Choice A is correct. This statement indicates that the patient requires further teaching. A 'living will' provides specific instructions to health care providers regarding the patient's preferences about life-sustaining interventions, eg: cardiopulmonary resuscitation (CPR), mechanical ventilation, dialysis, tube feeding, organ and tissue donations, body donation, and comfort care. An advance directive in which a person is designated to make decisions for the patient when he/she is unable to do so is called a durable power of attorney or a healthcare proxy and is not a part of a living will. Choice B is incorrect. This statement indicates the patient understands the purpose of a durable power of attorney. A 'living will' differs from the durable power of attorney for health care because life will delineate the patient's wishes precisely. In contrast, a power of attorney allows the patient's designated agent to make health care decisions for the patient. Choice C is incorrect. This statement indicates the patient understands the purpose of the living will. Choice D is incorrect. This statement indicates that the patient understands that they can revoke an advanced directive at any time and that this can be done either verbally or in writing. Bloom's Taxonomy - Analyzing

The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications? A. The development of an infection [5%] B. Hemorrhage [90%] C. Wound dehiscence [3%] D. Hematoma [1%]

Explanation Choice B is correct. A patient with low blood pressure and tachycardia after a surgical procedure may be experiencing an illness. Blood loss results in lowered blood pressure and the heart rate increases to compensate. Choice A is incorrect. The development of an infection after surgery usually presents with tachycardia and fever. Hypotension may or may not be present. Choice C is incorrect. Wound dehiscence occurs when the edges of a surgical site rupture. It is not categorized by tachycardia and low blood pressure. Wound dehiscence is a serious complication of surgery and needs immediate treatment. Choice D is incorrect. A hematoma, or a bruise, is a non-serious occurrence after surgery. It is caused by a collection of blood beneath the skin's surface. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse is reviewing leadership and management concepts with a student nurse. It would require further teaching if the student nurse made which of the following statements? A. "The Laissez-faire leadership style is a passive leadership approach." [14%] B. "A Registered Nurse (RN) may delegate accountability to a Licensed Practical Nurse (LPN)." [69%] C. "The rights of delegation include task, circumstance, person, direction, supervision." [11%] D. "The State Nurse Practice Act defines roles and responsibilities of nursing professionals." [7%]

Explanation Choice B is correct. An RN may delegate certain responsibilities to an LPN but cannot delegate accountability. The RN retains accountability when delegating patient assignments and tasks but maintains accountability. Choices A, C, and D are incorrect. The Laissez-faire leadership style is a passive leadership approach where the leader acts more as a consultant versus an active leader. This type of leader is hands-off. The rights of delegation do include the right task, circumstance, person, direction, and supervision. Finally, the Nurse Practice Act is unique to each state and defines the roles and responsibilities of nursing professionals. Additional information: Delegation is the process of transferring responsibility and authority to another individual. Responsibility is an obligation to complete the task. Accountability is assuming responsibility and appropriate consequences for certain actions. The RN may delegate to responsibilities, as appropriate, but maintains accountability.

A 55-year old female has a complete knee replacement on her left knee. Which symptom would be the most likely to indicate a severe adverse reaction after surgery? A. Inability to move the leg [24%] B. Capillary refill 5+ for the left foot [61%] C. Severe pain at the left knee incision site [11%] D. Ability to move the toes [3%]

Explanation Choice B is correct. Assessments after knee surgery should include the 5 P's: pain, pallor, pulse, paralysis, and paresthesia. Capillary refill should be assessed during the pallor assessment. A normal capillary refill is less than two seconds. The capillary refill, in this case, is 5 seconds, which is indicative of a problem. Choice A is incorrect. This patient may not be able to move her leg due to pain after the surgery. Choice C is incorrect. This patient will have pain at the surgery incision site. If the patient continues to have severe and uncontrollable pain in the entire leg, the nurse should worry about compartment syndrome. Choice D is incorrect. This is a normal finding. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Complications from Surgical Procedures and Health Alterations

Which of the following complaints should be first evaluated in a client with respiratory symptoms who has a history of asthma? A. An oxygen saturation of 94% [4%] B. Increased wheezing [56%] C. Sustained rhonchi [6%] D. Decreased respiratory rate [33%]

Explanation Choice B is correct. Clients with a history of asthma may be normal at the baseline. However, they exhibit symptoms and signs such as coughing, dyspnea, chest tightness, anxiety, tachypnea, and wheezing if having an asthma exacerbation. Wheezing is associated with airway inflammation and narrowing ( bronchospasm) that accompany asthma. Wheezes are high-pitched, continuous musical sounds that can be heard during inspiration and/ or expiration. Acute onset of wheezing may indicate an acute exacerbation in an asthmatic client. Bronchospasm should be treated, and often, a rescue inhaler with a short-acting bronchodilator is quickly administered to relieve symptoms. Choice A is incorrect. An oxygen saturation ( Sao2) reading at 94% is not a priority. Instead, pulse oximetry with Sao2 of less than 92% is a cause for concern. Choice C is incorrect. Rhonchi are low-pitched, continuous musical sounds heard during inspiration and/ or expiration. Bronchial rhonchi indicate secretions in the airway, such as those caused by pneumonia. Often, rhonchi are not associated with asthma. Choice D is incorrect. Should the client have an asthma exacerbation, increased respiration ( tachypnea) is expected, not decreased. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Thorax and Lung Assessment

An elderly client has just finished a total knee replacement surgery. The nurse suspects fluid overload in the client. Which of the following signs and symptoms would confirm the nurse's suspicion? A. Blood pressure of 90/55 mmHg; weak, thready pulse; slightly elevated temperature. [14%] B. Cool, clammy skin; bounding pulse; cough. [65%] C. Headache, Lethargy, and abdominal pain. [9%] D. Fever; warmth, swelling, and redness at the operative site. [11%]

Explanation Choice B is correct. Cool and clammy skin, bounding pulses, productive cough, distended neck veins, edema, and polyuria are signs of fluid overload. Choice A is incorrect. Low blood pressure, weak and thready pulse, and a slightly elevated temperature would indicate dehydration. Choice C is incorrect. These are not symptoms of fluid overload and may indicate other co-morbidities. Choice D is incorrect. Fever, warmth, swelling, and redness at the operative site indicate infection.

The patient is admitted to the ICU following a motor vehicle accident in which he sustained multiple fractures. He is scheduled to go to surgery for repair of his fractured femur. The physician has ordered famotidine 20 mg IV as one of the pre-operative medications. The nurse knows that this medication will: A. Decrease pain [12%] B. Help prevent ulcers [61%] C. Promote post-op healing [4%] D. Treat nausea [22%]

Explanation Choice B is correct. Famotidine is a histamine antagonist often referred to as an H2-blocker. This class of drugs treats and prevents duodenal and gastric ulcers caused by increased acid production in the stomach. In the pre-operative setting, it can also be used to reduce the risk of aspiration pneumonitis that can be caused by reflux from increased stomach acid. As the histamine antagonist name suggests, famotidine blocks the action of histamine in the cells of the stomach, which reduces the secretion of acid into the stomach. Choices A, C, and D are incorrect. This class of medications does not decrease pain, treat nausea, or promote post-operative healing. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies Sub-Topic: Expected Actions/Outcomes, Gastrointestinal/Nutrition

Which medical gas is in the canister on the right? See the exhibit. A. Oxygen [19%] B. Carbon dioxide [44%] C. Air [25%] D. Nitrous oxide [13%]

Explanation Choice B is correct. Gray is used on a canister of carbon dioxide so it can be readily identified. The other colors that are used to recognize other hazardous medical gases are: • Oxygen: Green or white • Air: Yellow • A combination of oxygen and helium: Green and brown • Nitrous oxide: Blue • Ethylene: Red • A mixture of oxygen and carbon dioxide: Green and gray Choice A is incorrect. Green on a medical gas canister indicates oxygen. Choice C is incorrect. Yellow on a medical gas canister indicates air. Choice D is incorrect. Blue on a medical gas canister indicates nitrous oxide.

The nurse is caring for a client with venous thromboembolism who has developed heparin-induced thrombocytopenia. After discontinuing the heparin infusion, the nurse anticipates which prescription from the primary healthcare provider (PHCP)? A. Enoxaparin [45%] B. Dabigatran [21%] C. Ketorolac [5%] D. Epoetin alfa [29%]

Explanation Choice B is correct. Heparin-induced thrombocytopenia (HIT) may be a life-threatening complication of exposure to heparinoids. The treatment for HIT Is to discontinue exposure to the heparin product immediately and to continue the anticoagulation with a non-heparin product. Agents that may be safely used include apixaban, dabigatran, or rivaroxaban. Choices A, C, and D are incorrect. Enoxaparin would be contraindicated because it is a heparinoid. Ketorolac is an antiinflammatory and not indicated in the treatment of HIT. Epoetin alfa is a colony-stimulating factor used to promote the production of red cells. This medication is not indicated in the treatment of HIT. Additional Info HIT is an adverse response to heparinoids. This autoantibody reaction causes venous (deeper vein thrombosis, pulmonary embolism) and arterial thrombosis (thrombotic strokes, myocardial infarction, arterial thromboembolism) The priority of HIT is to recognize it and stop the heparin product. The classic presentation of HIT is a reduction in the platelets by up to 50%, which is likely to occur between days four and five of heparin therapy. The nurse must report this type of platelet reduction immediately to the primary healthcare physician (PHCP). HIT treatment includes using an alternative anticoagulation agent such as fondaparinux, warfarin, rivaroxaban, dabigatran, and argatroban, inhibiting thrombin. Note that anticoagulation must be pursued in HIT despite thrombocytopenia.

The registered nurse (RN) is working with a licensed practical/vocational nurse (LPN/VN). Which client assignment should the RN delegate to the LPN? A client A. immediately post-operative following a thyroidectomy. [1%] B. with a paralytic ileus requiring the management of a nasogastric tube. [87%] C. receiving intravenous magnesium sulfate for status asthmaticus. [10%] D. with a hypertensive crisis requiring initiation of intravenous nicardipine. [1%]

Explanation Choice B is correct. Managing a nasogastric tube (NGT) is within the scope of an LPN. The other client situations lack predictability, require frequent assessments or need skills performed such as intravenous therapy that is not within the scope of an LPN. Choices A, C, and D are incorrect. These client situations require frequent assessment or skills outside the LPN's scope of practice. A client immediately post-operative needs a thorough assessment. A client receiving intravenous magnesium sulfate for status asthmatics is unstable. Finally, a client with a hypertensive emergency requiring intravenous anti-hypertensives needs the care of the RN because of the lack of predictability.

The nurse in the gynecology ward has just finished receiving the report from the previous shift. Which patient should the nurse see first? A. A client who is complaining of perineal pain while voiding. [3%] B. A client who had multiple saturated perineal pads changed during the night. [86%] C. A client who is refusing her newborn to be roomed in with her. [9%] D. A client who is upset because her baby will not latch. [1%]

Explanation Choice B is correct. Multiple peri-pads being saturated overnight indicates heavy bleeding, which may signify a hemorrhage. The nurse should see and examine this patient first. Choice A is incorrect. The pain may be related to an episiotomy or a perineal tear during delivery, but this patient should not be prioritized over a client who may be hemorrhaging. Choice C is incorrect. The patient needs to be assessed for bonding problems; however, this is a psychosocial issue. Clients with physiological issues need to be evaluated first such as a possible hemorrhaging patient. Choice D is incorrect. The patient needs coaching and instructions from the nurse regarding breastfeeding and latching. However, this should not be prioritized over a possible hemorrhaging client.

Many clients at the end of life experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life? A. Advocate for pain management unless life-threatening side effects occur. [44%] B. Advocate for pain management even if the life-threatening side effects hasten death. [50%] C. Prohibit the respiratory system from depressing drugs because this is euthanasia. [4%] D. Allow families to administer respiratory system depressing drugs to hasten death. [2%]

Explanation Choice B is correct. The American Nurses Association (ANA) advocates for pain management even if the life-threatening side effects hasten death. In the past, pain management agents like narcotic analgesics were not given if they caused a respiratory depression that could lead to the cessation of life. This administration of respiratory system depressing drugs at the end of life is not considered euthanasia. The American Nurses Association does not encourage families to administer respiratory system depressing drugs to hasten death but it does allow families to administer respiratory system depressing drugs to relieve pain at the end of life. Choice A is incorrect. The American Nurses Association does not advocate for pain management unless life-threatening side effects occur. Choice C is incorrect. The American Nurses Association does not prohibit the respiratory system depressing drugs because this is euthanasia; this association does permit respiratory system depressing medications for a specific reason. Choice D is incorrect. The American Nurses Association does not encourage families to administer respiratory system depressing drugs to hasten death. However, it does allow families to apply respiratory system depressing drugs to relieve pain at the end of life.

A nurse is assigned to care for a client with anorexia nervosa. Which intervention should the nurse apply following the patient's meals? A. Instruct the client to get some exercise or go for a walk after meals [11%] B. Restrict the client from going to the bathroom for 90 minutes after eating [70%] C. Ask the client to lie down for 2 hours after eating [17%] D. Encourage the client to start an intense exercise program [1%]

Explanation Choice B is correct. The nurse should observe the client while eating and prevent the client from using the bathroom for 90 minutes after meals to break the purging cycle. Purging is seen both with bulimia and anorexia. Anorexia nervosa consists of two types: a) restrictive type and b) binge-eating/purging type. In the restrictive type, the client significantly restricts the food intake. In the binge-eating/purging type, the client purges what he/she has eaten by vomiting or by using medications such as laxatives/diuretics. Choices A, C, and D are incorrect. Exercise is not encouraged until the client has shown adequate weight gain. Until then, training should be done in moderation. There is no need for the patient to lie down after meals.

Your new client presented with a positive home pregnancy last night. She has abdominal pain, some vaginal bleeding. and you note an adnexal mass on palpation. You order a progesterone level, which returns as 13 ng/mL. Your initial impression is: A. Early normal pregnancy [8%] B. Possible ectopic pregnancy [73%] C. Abnormal intrauterine pregnancy [13%] D. Incorrect home pregnancy test [6%]

Explanation Choice B is correct. The nurse should suspect a possible ectopic pregnancy. Abdominal pain, vaginal bleeding, and an adnexal mass are the classic triad for an ectopic pregnancy. The developing chorion produces progesterone. A normal progesterone level is > 15 ng/mL. A lower than normal progesterone level is uncommon in normal pregnancies but is very common in an ectopic pregnancy. Further testing will usually be done to confirm the diagnosis. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Alterations in Body Systems; Antepartum

Select the type of pain below that is accurately paired with one of its subjective sensory descriptors and one of its subjective affective, emotional descriptors. A. Ache: Radiating and throbbing [32%] B. Pain: Drilling and exhausting [23%] C. Hurt: Radiating and miserable [11%] D. Ache: Tender and throbbing [33%]

Explanation Choice B is correct. The type of pain that is accurately paired with one of its subjective sensory descriptors and its personal affective, emotional descriptors is "pain: drilling and exhausting." Other individual sensory descriptors of pain include "sharp, crushing, and wrenching"; other subjective affective, emotional descriptors of pain include "agonizing, unbearable, and torture." Ache is the least intense, hurt is the next level of intensity, and pain is the most intense. Choice A is incorrect. Although ache can be described with the sensory descriptor of "radiating," the ache is not related to the affective, emotional pain descriptor of "throbbing." Some useful emotional pain descriptors of ache are "annoying and tiring." Choice C is incorrect. Hurt is not related to the sensory descriptor of "radiating" or the affective, emotional pain descriptor of "miserable." Instead, hurt can be reported with the sensory descriptor of "pricking" and the affective, emotional pain descriptor of "throbbing." Choice D is incorrect. Ache is not related to the affective, emotional pain descriptor of "miserable." Instead, ache can be associated with the sensory descriptor of "cramping" and the affective, emotional pain descriptor of "tender."

The nurse in the ICU is taking a client's central venous pressure ( CVP). All of the following are appropriate actions of the nurse when taking a CVP reading, except: A. Placing the client supine with the head of the bed elevated to no more than 45°. [11%] B. Placing the transducer at the fifth intercostal space, mid-axillary line. [36%] C. Placing the transducer at the fourth intercostal space, mid-axillary line. [47%] D. Instruct the client to relax, not strain or cough during the reading. [5%]

Explanation Choice B is correct. The zero points on the transducer need to be at the level of the right atrium, which is located at the fourth intercostal space, midaxillary line, not at the 5th ICS. The question has a modifying phrase, "except" - therefore, the answer is option B. Choices A, C, and D are incorrect. These are appropriate actions. The client should be lying supine with the head of the bed elevated to no more than 45 degrees for the most accurate reading (Choice A). The zero points on the transducer need to be at the level of the right atrium, which is located at the fourth intercostal space, midaxillary line (Choice C). This is also referred to as the "Phlebostatic" axis. The client should be instructed to relax, not strain, cough, or do any activity that increases intrathoracic pressure, which causes falsely high measurements (Choice D).

A nurse is attending to a client who presents to the emergency department after suffering a burn injury. He describes the burn as extremely painful. Which zone corresponds to the area up to which the wound could extend? A. I [10%] B. II [48%] C. III [29%] D. IV

Explanation Choice B is correct. This represents the dermal layer, which is involved in the 2nd-degree burn. Second-degree burns are the most painful of all the injuries. A wound extending through both the epidermis and dermis is classified as a second-degree burn (partial thickness burn). It is different from first-degree burns because blisters do form and the skin is moist as well as red. These burns extend through the upper dermis and into the lower layer of the dermis where most pain sensory receptors are located. This makes the second-degree burns the most painful burns. Choice A is incorrect. This represents the epidermis, which is involved in the 1st-degree burn. A burn where the cuticle remains intact and only erythema is present would be classified as a first-degree burn. This is the most superficial type of injury. The skin remains intact and there is no break in the integrity of the epidermis. There are no blisters either, only erythema, or redness. These burns can be painful to the touch but are not typically life-threatening. Also, they are not as painful as second-degree burns. Choice C is incorrect. This represents subcutaneous tissue, which is affected by the third-degree burn. A burn penetrating from the epidermis to the dermis and down into the subcutaneous tissue is classified as a third-degree burn (full-thickness burns). Third-degree wounds appear either red, tan, or black and are dry and leathery. They involve nerve endings and destroy them, making them less painful than other burns. Choice D is incorrect. This represents muscle underneath the subcutaneous tissue and is affected by the 4th-degree burn. A burn involving the full thickness of the skin, plus the bone and muscle underneath, is classified as a fourth-degree burn. These burns have all the same characteristics as third-degree wounds, but also expose muscle, bone, tendons, and ligaments as they extend even more profound. These burns are dry and dull. NCSBN client need Topic: Physiological Adaptation; Sub-Topic: Burn injuries

The nurse is preparing a client for a paracentesis. All of the following nursing actions should be included in the care plan, except: A. Obtain the client's vital signs and weight before and after the procedure. [4%] B. Have the client void before the procedure. [17%] C. Apply a large pressure dressing after the procedure. [41%] D. Maintain the client on bed rest. [38%]

Explanation Choice C is correct. A dressing is applied after the procedure, but a large pressure dressing is not required. Choice A is incorrect. The nurse needs to take pre-procedure vital signs, including weight, to establish a baseline. The pressure is taken before and after the procedure to indicate the effectiveness of the system in fluid removal. Choice B is incorrect. The client is made to void before the procedure to make sure that the bladder is not full and prevents it from being punctured. Choice D is incorrect. The client is maintained on bed rest after the procedure to assess the client for any complications.

Student nursing is discussing Freud's psychosexual stages of development with a pediatric nurse. The student nurse would be correct in stating that Freud's anal stage of development is associated with which psychosocial development? A. During this stage, children learn what is pleasurable. [9%] B. The anal stage is associated with looking to satisfy the self. [8%] C. Toilet training often occurs during this stage. [75%] D. An understanding of sexuality is realized during this stage. [8%]

Explanation Choice C is correct. According to Freud's developmental stages, toilet training usually occurs during the anal phase. This theory of development believes that children in this stage derive pleasure from the elimination of body waste. Choice A is incorrect. According to Freud's theory of development, children learn self-gratification through what is pleasurable at the time during the latency period. Choice B is incorrect. This description also relates to Freud's latency period. Choice D is incorrect. Sexual realization occurs during the phallic stage. NCSBN client need Topic: Health Promotion and Maintenance, Developmental stages

The nurse is teaching a client about the proper administration of liquid iron. The teaching has been effective if the client states that he will take this medicine with which of the following? A. Milk [7%] B. Antacid [1%] C. Orange juice [85%] D. Water [7%]

Explanation Choice C is correct. Acids like orange juice facilitate iron absorption and are recommended to be taken with liquid metal. Iron is ideally given 2 hours after meals to ensure absorption but may be provided with meals if GI upset occurs. It is also offered through a straw to prevent staining of teeth. Choices A and B are incorrect. Both milk and antacids interfere with the absorption of iron. Choice D is incorrect. Water is not contraindicated in this case, but the orange juice is best taken with liquid iron for absorption.

A client presents to the emergency department (ED) with a suspected ectopic pregnancy. The nurse anticipates which diagnostic test will confirm this finding? A. Nonstress testing [2%] B. Abdominal radiograph (x-ray) [17%] C. Transvaginal ultrasound [69%] D. Doppler transducer [12%]

Explanation Choice C is correct. An ectopic pregnancy (EP) is a medical emergency. The imaging of choice is a transvaginal ultrasound, as this type of ultrasound may visualize an extrauterine gestational sac with a yolk sac or embryo (with or without a heartbeat). Choices A, B, and D are incorrect. Non-stress testing is utilized in the third trimester, where an EP is typically recognized around six or eight gestational weeks. Radiography does not provide a sufficient ability to visualize an embryo. Doppler transducer for fetal heart rate would simply discern if there is a fetal heart rate and not where the embryo is located. Additional Info An ectopic pregnancy (EP) is an extrauterine pregnancy. Almost all ectopic pregnancies occur in the fallopian tube, but other possible sites include cervical, interstitial, hysterotomy (cesarean) scar, ovarian, or abdominal. Manifestations of an EP include unilateral abdominal (pelvic) pain, vaginal bleeding, and a positive pregnancy test. Rapid management is needed because life-threatening intraabdominal bleeding may occur. For EP's that have not ruptured and the woman is stable, methotrexate may be used. If that is not the case, surgical management will be necessary.

What is the priority intervention when caring for an infant diagnosed with transposition of the great arteries? A. Administer digoxin [22%] B. Chest x-ray [12%] C. Initiate alprostadil infusion [44%] D. Make the infant NPO [23%]

Explanation Choice C is correct. Initiation of alprostadil is the priority for an infant diagnosed with transposition of the great arteries. Alprostadil will keep the ductus arteriosus from fetal circulation patent, allowing shunting of blood from left to right so that some oxygenated blood can exit the transposed aorta and be distributed to the body. Without alprostadil administration, the ductus arteriosus will begin to close, and if the infant does not have an ASD or VSD they will become profoundly hypoxic due to the lack of oxygenated blood in the systemic circulation. Choice A is incorrect. Digoxin is a cardiac glycoside administered to many children with heart failure. It may be administered at some point in the course of this infant's hospital stay, but would not be initiated right away. Remember the "ABCs" when it comes to priority questions: this infant should have an airway and be breathing, but circulation will be seriously compromised if something is not done. Choose the answer that addresses this concern. Choice B is incorrect. A chest x-ray will likely be ordered at some point in the course of this infant's hospital stay, but would not be a priority at this time. Remember the "ABCs" when it comes to priority questions: this infant should have an airway and be breathing, but circulation will be seriously compromised if something is not done. Choose the answer that addresses this concern. Choice D is incorrect. While it is likely that this infant will be NPO due to the need for cardiac surgery, the diet status of this infant will not be the priority. Remember the "ABCs: when it comes to priority questions: this infant should have an airway and be breathing, but circulation will be seriously compromised if something is not done. Choose the answer that addresses this concern. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological therapies, Pediatrics - Cardiac

Upon entering the room of a prenatal client, the nurse sees that her chart reads primigravida. As a competent health care practitioner, the nurse knows that this means that the client: A. Is experiencing a miscarriage [1%] B. Has been pregnant at least once before [7%] C. Is experiencing her first pregnancy [92%] D. Is a premium candidate for a vaginal delivery [0%]

Explanation Choice C is correct. Primagravida indicates that this woman is experiencing her first pregnancy. Choice A is incorrect. Miscarriage is charted as spontaneous abortion. Choice B is incorrect. If she has been pregnant before, this woman's chart will be considered multigravida. Choice D is incorrect. Primagravida has nothing to do with whether or not this woman will have a vaginal birth. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

The nurse is providing discharge teaching to a patient receiving sulfamethoxazole. Which of the following instructions should be given during this teaching? A. Discontinue taking this medication when symptoms are alleviated [2%] B. Restrict fluid intake to prevent hypertension [2%] C. Drink plenty of fluids [90%] D. Go to the emergency department if the urine turns a dark brown or yellow [7%]

Explanation Choice C is correct. Sulfamethoxazole (SMX) is used to treat urinary tract infections and should be taken with plenty of water. Each dose should be taken with a full glass of water. Choice A is incorrect. Antibiotics should not be discontinued until the entire prescribed course is completed. Choice B is incorrect. This medication should be taken with plenty of fluids to prevent adverse effects. Choice D is incorrect. Dark brown urine is a common side effect of using sulfamethoxazole and does not warrant a visit to the emergency department. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral therapies

A medical-surgical ward nurse is taking a floater shift in the ICU. The charge nurse would assign which patient to the nurse? A. A 2-hour post lung transplant client [10%] B. A client with a central venous pressure ( CVP) reading of 13 cm of water [7%] C. A client with pneumonia [81%] D. A client with Hantavirus pulmonary syndrome [2%]

Explanation Choice C is correct. The client with pneumonia is neither in immediate danger nor in complicated condition. The medical-surgical nurse can safely assess and administer medication to this client. This client can be assigned to the nurse. Choice A is incorrect. The client is still in critical condition and is prone to organ rejection. This client should be assigned to an experienced nurse. Choice B is incorrect. The client's increased central venous pressure ( CVP) reading indicates volume overload or right ventricular failure. This client needs to be assigned to a much more experienced nurse. Choice D is incorrect. Hantavirus pulmonary syndrome is a deadly disease with a specific treatment or cure. This client should be assigned to an experienced nurse. Test-taking strategy: Please note that the question is testing you about assignment/ delegation, not prioritization. While assigning a patient to a nurse, one should delegate it to the person trained to handle that task. Learning Objective Understand the principles of assignment/ delegation and apply them in your practice. While assigning a patient, picking the staff member trained to handle such a client is essential.

You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children? A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children. [5%] B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof. [14%] C. The cognitive development of young children impacts their understanding of death. [73%] D. The cognitive development of young children before 12 has no impact on their understanding of death. [7%]

Explanation Choice C is correct. The cognitive development of young children impacts their understanding of death. Since the meaning of death and the finality of death vary according to the age of the child, the nurse should listen to and support these children according to their level of understanding. Choice A is incorrect. Nurses should openly discuss death with children as the need arises. Young children do not view death as terrifying, they do not even see death as final. Choice B is incorrect. Children before the age of 12 do have perspectives about death, its meaning, and its finality or lack thereof. Although, these perspectives are not the same as older children and adults. Choice D is incorrect. The cognitive development of young children before 12 most definitely impacts their understanding of death and its finality.

The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up? A. "Wheezes arise from the small airways and usually do not clear with coughing." [19%] B. "A pleural friction rub causes loud, rough, scratching sounds usually during inspiration." [18%] C. "Thick, tenacious secretions that clear with coughing cause crackles." [49%] D. "Fluid or secretions in large airways typically cause coarse crackles." [13%]

Explanation Choice C is correct. This statement requires follow-up because it is incorrect. Thick, tenacious secretions that clear with coughing cause rhonchi. Choices A, B, and D are incorrect. These statements are factual and do not require any follow-up. Please see the additional information section for an overview of the adventitious lung sounds. Additional Info Wheezing creates squeaky, musical, continuous sounds associated with air rushing through narrowed airways; it may be heard without a stethoscope. Wheezes originate from the small airways and usually do not clear with coughing. Treatment for wheezing is bronchodilators and inhaled anticholinergics. Pleural friction rub is characterized by loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together, often associated with pain on deep inspirations. Stridor is a medical emergency and indicates that the upper airways (larynx or pharynx) are closing. Coarse crackles are lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways, likely to change with coughing or suctioning. Fine crackles sound like popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear. Rhonchus (rhonchi) are lower in pinch and sound like continuous snoring sound. These sounds arise from the large airways and usually can be cleared with coughing.

The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should expect the client to demonstrate which clinical manifestation in conjunction with this electrocardiogram tracing? See the image below. A. Jugular venous distention (JVD) [8%] B. Systolic murmur [11%] C. Irregular pulse [63%] D. Widened pulse pressure [19%]

Explanation Choice C is correct. This tracing shows atrial fibrillation. Atrial fibrillation is an irregularly irregular arrhythmia that produces an irregular pulse. This pulse irregularity is often a clinical indicator that a client requires a cardiac evaluation. Choices A, B, and D are incorrect. JVD is not a clinical feature consistent with atrial fibrillation. JVD would coincide with conditions such as right-sided heart failure or pulmonary hypertension. A systolic murmur is not a feature specific to atrial fibrillation. A widened pulse pressure is a clinical feature associated with increased intracranial pressure (late sign). Additional Info Atrial fibrillation is associated with atrial fibrosis and loss of muscle mass. These structural changes are common in heart diseases such as hypertension, heart failure, and coronary artery disease. Characteristically, atrial fibrillation is irregularly, irregular with no P-waves identified. The biggest complication associated with atrial fibrillation is stroke because of blood pooling in the atrium. Treatment options for atrial fibrillation include digoxin (not as commonly used), amiodarone, diltiazem, verapamil, or atenolol. The client may be prescribed an oral anticoagulant such as apixaban to prevent thrombosis. If medication is not desired, synchronized cardioversion may be prescribed.

The nurse notices a physician's order for ibuprofen 600 mg. However, the patient's chart states that he is allergic to NSAIDs. What is the appropriate nursing action? A. Administer the medication per the physician's order because they are trained to know best. [0%] B. Find out how serious the patient's reaction to NSAIDs was in the past. [14%] C. Contact the physician to verify the order and discuss concerns. [85%] D. Ask the patient if he or she feels comfortable taking the medication. [0%]

Explanation Choice C is correct. Verifying orders that seem inappropriate for a patient is a safety procedure and a way of advocating for the patient's safe healthcare delivery. Choice A is incorrect. No one is above making a mistake. Following the physician's order without verifying is not appropriate. Choice B is incorrect. Any history of allergic reactions on a patient's chart (or from patient history) should be taken seriously. Even if the first exposure only caused a minor response, subsequent exposure to an allergen could result in worse effects. Choice D is incorrect. Patients may feel pressured to take a medication if the nurse asks if he/she feels comfortable. If an allergy has been reported, the patient should not be given the option to take the medication. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Verifying Medication Orders

While rounding in the mental health unit, you are learning about specific phobias. You should be aware that ailurophobia is an unreasonable fear of: A. Social interactions [16%] B. Clowns [25%] C. Crowds [13%] D. Cats [45%]

Explanation Choice D is correct. Ailurophobia is best described as an unreasonable fear of cats. The psychiatric mental health treatment interventions for phobias are based on the specific type of phobia. For example, ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear. Choice A is incorrect. A fear of social interactions is referred to as a social phobia. Social interaction phobias are typically treated with exposure therapy, antidepressants, or beta-blockers. Choice B is incorrect. The fear of clowns, which is referred to as coulrophobia, is typically treated with exposure therapy. Choice C is incorrect. The fear of crowds, which is referred to as enochlophobia, is also typically treated with exposure therapy.

An expected outcome that is appropriate for the recipient of respite care is: A. The terminally ill client will be free of any physical, psychological, or spiritual distress. [19%] B. The terminally ill client will be free of any pain or discomfort at the end of life. [36%] C. The primary caregiver will be free of any physical, psychological, or spiritual distress. [13%] D. The primary caregiver will be physically and emotionally rested. [31%]

Explanation Choice D is correct. An expected outcome that is appropriate for the recipient of respite care is that "the primary caregiver will be physically and emotionally rested." Respite care provides time off for the primary caregiver of the ill client so that the caregiver gets to rest with the opportunity to renew and restore their strengths during this stressful period as they serve as the primary caregiver. Choice A is incorrect. An expected outcome that is appropriate for the recipient of respite care is not that "the terminally ill client will be free of any physical, psychological, or spiritual distress." This is an expected outcome of the end of life care and hospice care, but not respite care. Choice B is incorrect. An expected outcome that is appropriate for the recipient of respite care is not that "the terminally ill client will be free of any pain or discomfort at the end of life." This is an expected outcome of the end of life care and hospice care, but not respite care. Choice C is incorrect. An expected outcome that is appropriate for the recipient of respite care is not that "the primary caregiver will be free of any physical, psychological, or spiritual distress." This is not a feasible goal.

A patient tells the nurse that she is ashamed of how her hair looks and wants to wash her hair before her daily tests and appointments are performed. How should the nurse prioritize the patient's care? A. The nurse should explain to the patient that there is not enough time to wash her hair today because she has too many critical medical tests and appointments. [1%] B. The nurse should schedule the testing and meal planning first and complete hygiene as time permits. [8%] C. Perform the dressing changes first, schedule testing, counsel, and complete hygiene last. [3%] D. Arrange to wash the patient's hair first, perform hygiene, and then schedule diagnostic testing and counseling. [87%]

Explanation Choice D is correct. As long as time constraints permit, the most immediate priorities when scheduling nursing care are the priorities identified by the patient as being the most important. Choices A, B, and C are incorrect. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for a productive nurse-patient relationship. Diagnostic tests and dressing changes in a stable patient can certainly wait until after the patient-identified priorities are addressed. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic Care and Comfort

The patient experiencing an epidural tumor is exhibiting symptoms of spinal cord compression. The nurse knows that they should initiate care for this patient by: A. Assessing and controlling patient's pain. [27%] B. Monitoring for signs of urinary retention. [28%] C. Helping this patient perform personal and hygiene care. [5%] D. Upholding strict bed rest until spinal instability is ruled out. [40%]

Explanation Choice D is correct. If the nurse suspects that this patient is experiencing spinal cord compression, strict bed rest should be upheld until spinal stability is evaluated. Choices A, B, and C are incorrect. While observing for signs of urinary retention, aiding the patient in performing personal and hygiene care, and controlling pain are essential aspects of caring for a patient with spinal cord compression, these steps need not be completed until bed rest has been executed. NCSBN client need Topic: Oncology

The nurse is talking to the parents of an adolescent that had an accident and is having surgery in the operating room. The parents report that their son is having a hard time finding his identity. The nurse tells them that the failure of the teenager to develop his identity would end up in which situation? A. Shame [4%] B. Guilt [2%] C. Inferiority [12%] D. Role confusion [82%]

Explanation Choice D is correct. In adolescents, they need to develop a sense of identity and belongingness, or else they develop role confusion. Choice A is incorrect. Shame develops in toddlers when their sense of autonomy is not established. Choice B is incorrect. Guilt is developed when preschoolers do not create a sense of initiative. Choice C is incorrect. Inferiority happens when the industry is not developed in school-aged children.

The nurse is caring for a client with the following clinical data. Based on the laboratory tests, which medication would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the below exhibits. A. Bupropion 150 mg XL PO Daily [34%] B. Clonidine 0.1 mg PO Daily [18%] C. Albuterol 2.5 mg via nebulizer Daily [11%] D. Lisinopril 40 mg PO Daily [38%]

Explanation Choice D is correct. Lisinopril is an ACE inhibitor used to manage heart failure and hypertension. While this medication may be nephroprotective, it can become nephrotoxic. While a client is taking an ACE inhibitor, the creatinine and the GFR need to be watched closely. Elevations of the creatinine and a decrease in the GFR are reportable findings to the PHCP. Choices A, B, and C are incorrect. Bupropion is an antidepressant and not a nephrotoxic medication. Clonidine is indicated for hypertension and ADHD, and this medication is also not nephrotoxic. Albuterol is a beta-adrenergic agonist indicated for both acute and chronic respiratory illnesses. NCLEX Category: Pharmacological and parenteral therapies Activity Statement: Contraindications Question type: Analysis Additional Info Elevations of the creatinine (normal 0.6-1.2 mg/dl) usually are caused by an offending agent such as an NSAID (ibuprofen), antibiotic (vancomycin), ACE inhibitors (lisinopril), and sulfa-based drugs.

Which of these medications can be mixed in the same syringe without the risk of any incompatibility? A. Dexamethasone and midazolam [2%] B. Haloperidol and ketorolac [2%] C. Hydrocortisone and midazolam [2%] D. NPH and regular insulin [93%]

Explanation Choice D is correct. NPH insulin and regular insulin can and are often mixed in the same syringe without the risk of incompatibility. Choice A is incorrect. Dexamethasone and midazolam cannot be mixed in the same syringe because they are not compatible. However, dexamethasone and other medications such as metoclopramide are compatible and can be mixed in the same syringe. Choice B is incorrect. Haloperidol and ketorolac cannot be mixed in the same syringe because they are not compatible. However, haloperidol and other medications such as hydromorphone can be mixed in the same syringe. Choice C is incorrect. Hydrocortisone and midazolam cannot be mixed in the same syringe because they are not compatible. However, hydrocortisone and other medications such as metoclopramide are compatible and can be mixed in the same syringe.

The nurse in the detoxification center is caring for a 42-year-old man with a history of alcohol abuse. He has significant tremors and tachycardia. The nurse should expect to give which medication to control the tachycardia: A. Disulfiram [41%] B. Oral naltrexone [9%] C. Injectable naltrexone (Vivitrol) [13%] D. Clonidine [36%]

Explanation Choice D is correct. Research shows that clonidine can help reduce pulse and blood pressure by a reduction in catecholamine activity in the brain. Choice A is incorrect. Disulfiram is a conventional medication prescribed to prevent an individual from drinking. It does NOT stop tremors or tachycardia; it causes headache, nausea, and vomiting that may stop an alcoholic from drinking to avoid these symptoms. Choice B is incorrect. Naltrexone may prevent the urge to drink since it blocks the good feelings caused by drinking alcohol. Choice C is incorrect. The injectable version of naltrexone (Vivitrol) will not control the tremors and tachycardia. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Expected Actions/Outcomes; Cardiovascular

The primary healthcare provider (PHCP) is preparing to intubate a client. The PHCP prescribes succinylcholine. The nurse understands that this medication is intended to A. sedate the client during the procedure. [20%] B. decrease oral and airway secretions. [35%] C. increase heart rate in case of a vagal response. [3%] D. cause skeletal and smooth muscle paralysis. [42%]

Explanation Choice D is correct. Skeletal and smooth muscle paralysis is the intent of this medication. Succinylcholine is a neuromuscular blocking medication typically given immediately prior to intubation to assist with the procedure. Choice A, B, and C are incorrect. Sedation does not occur with succinylcholine as it causes paralysis. This medication may be used adjunctively with sedatives for a client receiving mechanical ventilation. This medication does have an anticholinergic effect, but it is not given to decrease oral and airway secretions or prevent a vagal response. A medication that may be used to accomplish both would be atropine. Additional Info The muscle paralysis induced by depolarizing NMBDs (e.g., succinylcholine) is sometimes preceded by muscle spasms, which may damage muscles. These muscle spasms cause the release of potassium which may lead to hyperkalemia. Prolonged exposure to this medication may lead to hyperkalemia, and this medication should not be used if the client already has hyperkalemia. Finally, this medication may cause malignant hyperthermia. If a client develops a significant fever, muscle rigidity, and tachycardia, immediate treatment must be implemented.

Which of the following terms, according to the North American Nursing Diagnosis Association, is defined as the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others at the end of life? A. Guilt [10%] B. Isolation [20%] C. Religious distress [7%] D. Spiritual distress [63%]

Explanation Choice D is correct. Spiritual distress, as defined by the North American Nursing Diagnosis Association, is the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others. Choice A is incorrect. Guilt is defined as a feeling of inner discomfort that occurs when a person believes that they have done something wrong and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others. Choice B is incorrect. Isolation may occur as a result of spiritual distress. However, separation is quite different from the lack of connectedness with self, others, and a power greater than oneself and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others. Choice C is incorrect. Religious distress is the feeling that some who are not able to feel that they have followed the mandates of their religion and its traditions and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others.

Which method of pain management would you anticipate using when your client is adversely affected by nociception in the transduction phase? A. Progressive relaxation [21%] B. Meditation [12%] C. The administration of narcotic analgesics like codeine or morphine [33%] D. The administration of a nonsteroidal anti-inflammatory medication like ibuprofen [33%]

Explanation Choice D is correct. The administration of a nonsteroidal anti-inflammatory medication like ibuprofen is the method of pain management that you would anticipate using when your client is adversely affected with nociception in the transduction phase. Nociception is the type of pain that occurs when the body has suffered an injury or inflammation, and the client has a well-functioning nervous system. Choice A and B are incorrect. Although progressive relaxation can be used to control pain and anxiety, it is not the method of pain management that you would anticipate using when your client is adversely affected with nociception in the transduction phase. Choice C is incorrect. The administration of narcotic analgesics like codeine or morphine can be used to control pain; it is not the pain management method that you would anticipate using when your client is adversely affected with nociception in the transduction phase. Additional Info Nociceptive pain occurs when noxious stimuli activate the peripheral nervous system. This could be inflammation, injury to tissue, or a disease process. There are four phases of pain signaling: Transduction, Transmission, Modulation, and Perception. Transduction is the first phase of pain signaling. it occurs when there is a stimulus that is concerted to a nerve signal. The stimulus could be pressure, heat, or chemical irritation. The sensory nerve cells recognize the stimuli and send the signal in the next phase. Transmission occurs when the signal is transferred from the peripheral nervous system to the central nervous system. Next, modulation occurs when pain is either upregulated or downregulated in the central nervous system. If the central nervous system downregulates the pain response, it may not be consciously recognized by the client. Lastly, perception of pain is the awareness of the pain signal. The perception of pain is also influenced by social and environmental cues, as well as by cultural conditioning and past personal experiences.

The nurse is caring for a client who has suffered 3rd-degree burns and is in the resuscitative phase. The nurse knows that the goal of this phase is what? A. Promoting hemodynamic stability and restoring capillary permeability [49%] B. Prevention of scars and contractures [27%] C. Achieve maximum functionality [4%] D. Initiation of fluids ends when massive fluid shifts decrease [21%]

Explanation Choice D is correct. The treatment of burns is separated into two categories. The goals of the resuscitative (emergent) phase are to maintain airway patency and initiate fluids and manage capillary permeability. The stage is complete when the massive third-spacing of fluids has nearly resolved. This phase of the burn injury lasts from the onset of the injury until fluid shifting has resolved. This typically lasts 24-48 hours after the burn injury. Choice A is incorrect. The promotion of hemodynamic stability to restore capillary permeability is known as the acute phase. The acute phase of burn injuries begins around 48 hours after the injury when the fluid shift resolves and lasts until wound closure is complete. Choice B is incorrect. Prevention of scars and contractures takes place during the rehabilitative phase. This phase focuses on restoring the patient to their highest level of functioning. Choice C is incorrect. Achieving maximum functionality takes place during the rehabilitative phase and sometimes overlaps with the acute phase. This phase of a burn injury may last for a year or a lifetime, depending on the severity of the burn. Learning Objective Interpret assessment findings for patients with a suspected or acute integumentary concern. Additional Info Source: Archer LibrarySource : Source: ArcherReview library Burn care takes place in three phases. There is the emergent phase (resuscitation), acute phase (healing), and rehabilitative phase (restorative). The resuscitation phase begins at the time of injury and continues for 24-48 hours after the injury. This is when the burn is evaluated, and priorities of care are established based on the severity. The priorities during this phase of the resuscitative process include securing the airway, supporting circulation and perfusion, maintaining body temperature, keeping the patient comfortable with prescribed analgesics, and providing emotional support. The acute phase of burn injuries begins around 48 hours after the damage when the fluid shift resolves and lasts until wound closure is complete. Nursing care during this phase focuses on continuous assessment and maintenance of the cardiac and respiratory systems with a focus on nutritional support. The nurse will be providing frequent burn dressing changes during this phase of recovery. Nursing interventions should also be targeted toward pain control and providing further emotional support and psychosocial interventions. The rehabilitation phase of burn injury technically starts at wound closure and ends when the patient achieves their highest level of functioning. Focus during this stage of the burn injury is targeted towards preventing scars or contractures and resuming the same level of activity they had before the burn injury.

What is the most appropriate instruction to give a client with osteoporosis regarding exercise? A. Avoid exercise activities that increase the risk of fractures. [38%] B. Exercise to strengthen muscles and thereby protect bones. [20%] C. Exercise to reduce weight. [2%] D. Exercise doing weight-bearing activities. [39%]

Explanation Choice D is correct. Weight bearing means a person is working against the weight of another object. Weight bearing helps with osteoporosis because it strengthens muscles and builds bone. Studies have shown that weight bearing exercise increases bone density and reduces the risk of fractures. An estimated 10 million Americans have osteoporosis. The risk increases with age and is much higher in women, mainly in relationship with hormonal changes at menopause and inadequate calcium intake. Cigarette smoking, moderate to heavy alcohol consumption, and lack of weight-bearing exercise, also increase the risk of osteoporosis. Choice A is incorrect. This is not the most appropriate choice. All people should avoid potentially dangerous activities. Choice B is incorrect. Exercise to strengthen muscles is important, but for the client with osteoporosis the emphasis should be placed on building bone density, which will reduce the risk of fractures. Weight bearing exercises are the best option for this. Choice C is incorrect. While weight loss can help reduce the stress on joints and alleviate symptoms related to arthritis or back pain, obesity is not a high-risk factor for osteoporosis. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

The nurse is caring for a client receiving lorazepam. Which of the following reported herbal supplements would require follow-up? Select all that apply. A. Kava [28%] B. Glucosamine [10%] C. Valerian [26%] D. Garlic [15%] E. Saw palmetto [20%]

Explanation Choices A and C are correct. Lorazepam is a CNS depressant, and the client should avoid potentiating the effects of this medication. Herbal products such as kava and valerian are CNS depressant medications that should not be given concurrently while a client is receiving lorazepam. Lorazepam and one of these medications may cause profound sedation. Choices B, D, and E are incorrect. Glucosamine is an herbal product that may benefit clients with osteoarthritis in the knees, waist, and hips. This medication does not cause CNS depression. Garlic may be taken to assist a client in reducing their cholesterol and should be avoided if the client is taking anticoagulants. This medication does not alter the CNS. Saw palmetto may be taken for men who have prostate hyperplasia. This herbal supplement does not alter the CNS. Additional Info Herbal products may cause serious interactions with prescribed medications. CNS depressant medications such as lorazepam should not be taken concurrently with herbal products that may cause CNS depression. The nurse should always obtain a comprehensive list of a client's medications, including over-the-counter (OTC) products.

You are providing education to a group of parents about nutrition for their toddler age children. Which of the following educational points should you include? Select all that apply. A. Offer whole milk instead of skim or 2% milk. [32%] B. Using food as a reward can be a positive incentive. [9%] C. Good iron-rich choices include whole grain bread and cheese. [29%] D. Iron deficiency anemia is common in toddlers. [29%]

Explanation Choices A and D are correct. A is correct. It is appropriate to offer full-fat milk choices instead of skim or partial fat milk to toddlers. Toddlers are usually picky eaters and parents often have trouble ensuring that they get adequate caloric intake. Offering full-fat milk, such as whole milk, is a way to ensure the toddler gets the proper amount of calories and also adequate amounts of essential fats needed for brain development. D is correct. Iron deficiency anemia is very common in toddlers. It is common that toddlers are picky eaters, and have an iron-poor diet that leads to iron deficiency anemia. Iron-rich food options that should be encouraged include leafy greens, red meats, fish, beans, and iron-fortified cereals. Choice B is incorrect. It is not advisable to use food as a reward. This manipulation can create a very poor relationship with food and create problems in the eating habits of a child as they grow up. If children view food as a positive reward, they may expect treats any time they do something right or complete a request. This can lead to poor nutrition, therefore using food as a reward is not appropriate educational advice. Choice C is incorrect. Whole grain bread and cheese are iron-poor food choices. These are often foods that toddlers will eat a lot of, and the iron-poor diet can lead to iron-deficiency anemia in a lot of toddlers. Better iron-rich options would include leafy greens, red meats, fish, beans, and iron-fortified cereals. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Development

Which of the following opportunistic conditions are potential causes of hospital admission in an immunocompromised patient? Select all that apply. A. Kaposi's sarcoma [26%] B. Tuberculosis [36%] C. Toxoplasmosis [32%] D. Transesophageal fistula (TEF) [6%]

Explanation Choices A, B, and C are correct. "Opportunistic" infections are those that take hold once the host immunity declines significantly. A is correct. Kaposi's sarcoma (KS) is a cancer that grows in the blood vessel lining and is caused by an opportunistic infection with Human Herpes Virus-8 (HHV-8). HHV-8 is also known as Kaposi Sarcoma Associated Herpes Virus (KSHV). KS can cause severe illness in an immunocompromised patient and lead to hospital admission. Pulmonary KS can present with severe hemoptysis. B is correct. Tuberculosis is a severe bacterial disease that most commonly affects the lungs. It is sporadic in most healthy individuals but is an opportunistic infection that can be devastating for an immunocompromised patient. C is correct. Toxoplasmosis is a parasitic infection most commonly occurring in immunocompromised patients. It can be severe and cause hospital admission for patients with a lowered immune system like AIDS/HIV patients. Choice D is incorrect. A transesophageal fistula, or TEF, is a congenital anomaly often associated with VACTERL syndrome. In this deformity, there is a fistula connecting the esophagus and trachea at some point, making it impossible for the infant to eat without aspirating. This is not an infection and would not cause a hospital admission in an immunocompromised patient. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Immunology

You are tasked with providing education to a 24-year-old newly diagnosed diabetic. The correct approach to providing this education is: Select all that apply. A. Assess the patient's knowledge. [38%] B. Ask the patient about their perception of barriers to controlling the disease. [35%] C. Suggest small behavior changes based on specific information. [22%] D. Provide "just-in-time" education at the time of discharge. [6%]

Explanation Choices A, B, and C are correct. Educating the patient and family is one of the primary functions of the registered nurse. The first step in this process is to assess the patient's knowledge about the disease or condition. Is the information accurate and complete? If not, one of the goals in the process is to correct or supplement the knowledge. As the nurse talks with the patient, it is essential to help the patient identify what barriers they perceive to being able to control their disease. For example, a person with diabetes might think that they cannot afford the medications necessary to treat diabetes. If the patient must give themselves injections, they might say that they won't be able to inject themselves due to fear. Once the barriers are identified, the nurse must develop a plan to overcome the obstacles. Often, this involves consulting with other team members. For example, a case manager might be called in to help with financial issues. A new diagnosis can be overwhelming. It is often helpful to suggest small behavior changes. For example, a diabetic patient may indicate that they cannot change their eating habits. This might indicate to the nurse that a dietician consult would be helpful. The dietician may be able to suggest foods that can be substituted for favorite foods. Choice D is incorrect. To provide "just-in-time education" at the time of discharge is inappropriate. Education of the patient must always begin at the time of admission, mainly if the treatment will require lifestyle changes. Part of the success of the therapy will be from the repetition of teaching and return demonstrations by the patient and family. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Health Promotion/Disease Prevention, Endocrine; Prioritization

A 3-year old boy in the pediatric unit develops a fever of 102.2 degrees Fahrenheit, a rash on his torso, and has a strawberry-red tongue as pictured in the exhibit. What should the nurse suspect the physician would order in the next few hours? See the exhibit. Select all that apply. A. Intravenous immunoglobulin (IV IG) [25%] B. Head CT scan [5%] C. Aspirin [13%] D. Antipyretic [29%] E. Fluid restriction [4%] F. IV steroids [24%]

Explanation Choices A, C, D, and F are correct. This patient has classic symptoms of Kawasaki's disease, which is most common in children ages 1-2 and mainly under the age of 5. It rarely occurs in children less than 14. Boys are diagnosed more often as well as those of Asian descent. Kawasaki's disease affects the blood vessels throughout the body. It affects the heart, lymph nodes, skin, and mucous membranes. IVIG is essential to administer early to prevent coronary artery aneurysms (Choice A). The gold standard of therapy is early IVIG and aspirin administration. Aspirin will assist in the prevention of coronary artery aneurysms and coronary artery disease (Choice C). NSAIDs should be administered for this patient to reduce inflammation in the blood vessels and decrease the patient's fever. The patient is at risk for febrile seizures if the temperature is not addressed (Choice D). Choice B is incorrect. Evidence-based practice states that the standard of care for Kawasaki's Disease is IVIG, antipyretics, aspirin, fluid therapy, and steroids. There is no reason to expose this child to radiation for a CT scan of the head. It will not tell the doctor anything meaningful about the patient's condition at this point. Choice E is incorrect. This patient needs additional IV fluids. A fluid restriction would only hinder this patient's prognosis. Usually, the doctor will order 20 mg/kg of crystalloid. Parents can also encourage oral liquids as well. The fluid will help decrease the widespread inflammation of blood vessels in the body. NCSBN Client Need Topic: Safe and Effective Care Environment, Sub-Topic: Care Management, The Child with Hematologic or Immunologic Dysfunction

You are caring for a pregnant client who has an order to be on partial bed rest with bathroom privileges. You know that the side effects of this order can include: Select all that apply. A. Deep vein thrombosis [39%] B. Fetal demise [6%] C. Alterations in mood [25%] D. Undesirable weight gain [31%]

Explanation Choices A, C, and D are correct. Prolonged bed rest can result in deep vein thrombosis (particularly of the legs), alterations in mood due to stress and anxiety, and undesirable weight gain due to inactivity. Although bed rest is not ordered often, the nurse must understand that compression stockings and ankle exercises might be requested to prevent DVT. The client should have an opportunity to talk about their feelings related to the bedrest. The nurse should consult the nutritionist to work with the client and obstetrician to ensure a healthy diet that takes into account the decreased activity. Choice B is incorrect. Unless the fetus is stressed in other ways, bedrest by itself does NOT result in fetal demise. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Alterations in Body Systems; Antepartum

The patient is diagnosed with acute pancreatitis. Which preventative intervention should the nurse implement to reduce the patient's risk of developing a respiratory infection? Select all that apply. A. Assist the patient to turn and reposition frequently. [29%] B. Document the respiratory rate and oxygen saturation. [11%] C. Place the patient in a semi-fowlers position. [28%] D. Encourage deep breathing and coughing. [33%]

Explanation Choices A, C, and D are correct. Respiratory infections are common in acute pancreatitis due to retroperitoneal fluid pushing the diaphragm upwards and causing the patient to take shallow abdominal breaths. Assisting the patient to change positions frequently, encouraging deep breathing as well as coughing exercises, and positioning patients for maximum chest expansion would all be preventative interventions to reduce the risk of respiratory infection. Choice B is incorrect. The question is looking for preventative actions to reduce the patient's risk of respiratory infection. While documentation would be indicated to recognize any changes or complications, it would not prevent disease. NCSBN Client Need Topic: Infection control, Subtopic: Potential for complications from health alterations, system-specific assessments, alterations in body systems, illness management, pathophysiology

Which of the following activities can be delegated to unlicensed assistive personnel (UAPs)? Select all that apply. A. Performing initial patient assessments [0%] B. Making patient beds [25%] C. Giving patients' bed baths [25%] D. Administering patient medications [0%] E. Ambulating clients [24%] F. Assisting clients with meals [25%]

Explanation Choices B, C, E, and F are correct. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to unlicensed assistive personnel (UAP). Due to the pressure to reduce health care costs and the increasing demand for nursing services amid a critical shortage of professional nurses, many employers of nurses have increased their use of UAP. UAPs are trained to function in an assistive role to the nurse in the provision of patient activities as delegated by and under the supervision of the nurse. Choices A and D are incorrect. A: Performing the initial patient assessment is the responsibility of the registered nurse. D: The administration of medications is carried out by registered nurses and licensed vocational/practical nurses. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care; Delegation and the Unlicensed Assistive Personnel

When assessing self-perception, the nurse should ask the client which of the following? A. "How would you describe yourself?" [82%] B. "What gives you hope when times are troubled?" [8%] C. "Is your normal way of dealing with stress helpful to you?" [7%] D. "Are you having difficulty handling any family problems?" [3%]

Explanation Choice A is correct. Assessment of self-perception focuses on how the patient thinks of himself/herself. Choices B, C, and D are incorrect. Role addresses the daily duties or tasks. Values address important big concepts of life and death. Coping is in response to a stressor. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care

The nurse is attending to a client who was just diagnosed with terminal cancer. He continues to claim the "cancer is just going to disappear on its own." Knowing that this is an acceptable response by the client, please arrange the following stages of the Kübler-Ross model of grieving in the correct ordered sequence: Denial Anger Acceptance Bargaining Depression

Denial Anger Bargaining Depression Acceptance Explanation The correct ordered sequence is Denial, Anger, Bargaining, Depression, and Acceptance ("DABDA"). Denial: Refuses to believe that loss is happening. The client is unready to deal with practical problems, i.e. prosthesis after the loss of a leg. May assume artificial cheerfulness to prolong denial. This client is currently in denial. Anger: The client or family may direct anger at nurses or staff about matters that generally would not bother them. Bargaining: Seeks to bargain to avoid loss (e.g. "let me just live until ___ and then I will be ready to die"). Depression: Grieves over what has happened and what cannot be. May talk freely (e.g. reviewing past losses such as money or a job), or may withdraw. Acceptance: Comes to terms with the loss. May have decreased interest in surroundings and support people. May wish to begin making plans (e.g. will, prosthesis, altered living arrangements). NCSBN Client Need Topic: Psychosocial Integrity; Mental health concepts, Subtopic: Loss & Grief

The primary healthcare provider (PHCP) prescribes 500 mL of 0.9 saline to infuse over four hours via intravenous micro drip tubing. The nurse sets the flow rate at how many drops per minute? Fill in the Blank. 125 drops per minute

Explanation To solve this problem, the nurse will use the formula of total volume x drop factor/time in minutes First, take the prescribed volume and multiply it by the drop factor 500 mL x 60 gtt (micro drip tubing is always 60) = 30000 Next, calculate the time in minutes by multiplying the hours by 60 4 hours x 60 = 240 minutes Further, divide the volume by the minutes 30000 mL / 240 minutes = 125 gtt/min Finally, perform appropriate rounding (if needed) Additional Info Microdrip tubing is utilized for precise fluid administration and is likely to be used for infants or children. The drop factor with this tubing is always 60 gtts/mL

A patient recovering from myocardial infarction is presenting with heart rate 110 beats per minute, blood pressure 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority? A. Administer medications to increase stroke volume. [33%] B. Provide analgesics. [3%] C. Obtain a STAT electrocardiogram and troponins. [34%] D. Administer fluid replacement to increase blood pressure. [30%]

Explanation Choice A is correct. Based on the assessment information, the nurse can determine the patient is experiencing cardiogenic shock secondary to myocardial infarction. Since cardiogenic trauma occurs as a result of the heart not pumping effectively, the highest priority is to increase cardiac output to ensure adequate tissue perfusion. Cardiac Output = Stroke volume x Heart rate. Medications that improve stroke volume will improve cardiac output in cardiogenic shock. The following agents may be used in the pharmacological management of cardiogenic shock. Inotropes: Positive inotropes strengthen the heart contractility (increase stroke volume). Dobutamine has more beta-adrenergic action than alpha activity. It causes peripheral vasodilation while increasing contractility. But in higher doses, it may increase heart rate and exacerbate myocardial ischemia. Vasopressors: In severe shock, vasopressors (Dopamine, Norepinephrine) maintain blood pressure but decrease blood flow to organs. They increase afterload and reduce cardiac output. However, they may be needed initially to provide hemodynamic support. Dopamine increases myocardial contractility and maintains blood pressure. If dopamine fails to support blood pressure, norepinephrine is added. Vasodilators: Vasodilators (Nitroglycerin) decrease venous return (preload) to the heart and decrease peripheral resistance (afterload). Although vasodilators may drop blood pressure, they sustain cardiac output and help achieve hemodynamic stability when combined with vasopressor support in cardiogenic shock. Supplemental oxygen may also be necessary to increase tissue oxygenation. Choice B is incorrect. There is no assessment information in the question that points to chest pain. If a patient in cardiogenic shock is showing signs or complaining of pain, this action would be appropriate, but not the highest priority. Choice C is incorrect. The patient recently experienced MI, so they should already be on a telemetry monitor. ECG will likely be abnormal and troponins may still be elevated. This action may be appropriate but will not change the immediate treatment of shock, so it would not be the highest priority. Choice D is incorrect. Fluid replacement is not the correct immediate action because the patient is showing signs of pulmonary edema (crackles, shortness of breath, jugular vein distention). Cardiac output needs to be improved before considering the additional fluid volume. This action might be appropriate if the patient was in hypovolemic shock, not cardiogenic. NCSBN Client Need Topic: Establishing priorities, illness management, medical emergencies, pathophysiology

The nurse is providing patient teaching in the clinic. The patient is prescribed a bisphosphonate to treat osteoporosis. Which information should the nurse inform this patient about? A. Take this medication sitting upright first thing in the morning with a full glass of water. [73%] B. Take this medication at night, just before bed. [7%] C. This medication should be taken along with a full meal. [19%] D. This medication is the best alternative if an esophageal disorder is present. [1%]

Explanation Choice A is correct. Bisphosphonates should be taken first thing in the morning with a full glass of water. Patients should also wait 30 minutes to eat any food and should remain sitting or standing during that time. This prevents esophageal damage that may occur when this medication is taken improperly. Choice B is incorrect. This medication should not be taken at night because the patient needs to remain sitting or standing for 30 minutes following medication administration. Choice C is incorrect. This medication should not be taken with a full meal. Choice D is incorrect. Bisphosphonates are contraindicated in patients with esophageal disorders. NCSBN client need Topic: Physiological Integrity, pharmacological and parenteral therapies

A nurse is assigned to care for a client who just underwent a thyroidectomy. The nurse notes that the client has developed peripheral numbness and tingling, muscle twitching, and spasms. With this, the nurse anticipates to administer: A. Thyroid supplements [13%] B. Barbiturates [2%] C. Antispasmodics [8%] D. Intravenous calcium [76%]

Explanation Choice D is correct. The removal of the thyroid gland can cause hyposecretion of parathormone that leads to calcium deficiency which is manifested by numbness, tingling, and muscle spasms. The treatment includes calcium administration. Choices A, B, and C are incorrect. Thyroid supplements are typically given post-thyroidectomy but are not directly related to the problem. Antispasmodics will not treat the cause of the problem. Barbiturates are not indicated in this situation.

Which of the following educational points are correct when teaching a patient about iron supplementation? Select all that apply. A. Take the iron supplement 30 minutes after a meal. [16%] B. Drink a glass of orange juice with your iron supplement. [41%] C. Report any black stools to your doctor. [9%] D. Drink the iron suspension with a straw. [34%]

Explanation Choices B and D are correct. Orange juice is high in vitamin C, which will help increase the absorption of iron. Also, this will make taking the supplement easier on the stomach and many say it helps with the bad taste (Choice B). If the healthcare provider orders an oral suspension iron supplementation, you should teach your patient to drink it through a straw to avoid staining their teeth. Alternatively, if you are administering the medication to a young child who cannot drink through a straw, you can pull it up in a syringe and squirt it into the back of their mouth behind their teeth (Choice D). Choice A is incorrect. Taking an iron supplement on a full stomach will not allow for proper absorption. You must educate the patient to take their iron supplement on an empty stomach. Choice C is incorrect. Black stools are an expected side effect of iron supplementation. Patients do not need to report black stools to their doctor if they are taking an iron supplement. The nurse should warn them to expect this side effect so that they are not alarmed. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Hematology

A client has been diagnosed with Parkinson's disease and was prescribed carbidopa-levodopa (Sinemet). Which objective assessment point would indicate that the treatment has been effective? A. The tremors have lessened in frequency [92%] B. The frequent swallowing has stopped [3%] C. The seizures have spaced out [3%] D. There is decreased lacrimation [2%]

Explanation Choice A is correct. The classic sign of Parkinson's disease is the "pill-rolling" tremors of the hands. Festinating gait is also present in the lower extremities. Treatment is considered valid when these tremors are lessened. Choices B, C, and D are incorrect. The condition does not involve increased swallowing and lacrimation. Seizures are also not associated with Parkinson's disease.

The nurse taking care of a malnourished patient reviews their lab results and notes that the patient is currently hypokalemic. The nurse knows that given this condition, the patient should be monitored for which changes in their EKG? A. U wave and a flat T wave [74%] B. An inverted QRS complex [12%] C. Absence of a U wave [6%] D. Exaggerated QRS complex [8%]

Explanation Choice A is correct. This patient is experiencing hypokalemia, also known as a deficiency in potassium or a blood serum potassium level of less than 3.5 mmol/L. Low potassium affects the heart's ability to repolarize, which is reflected in an EKG with a flat T wave and, occasionally, the presence of a U wave. Choices B, C, and D are incorrect. These would not be seen on EKG in this hypokalemic patient. NCSBN client need Topic: Physiologic Adaptation: Fluid and Electrolyte Imbalances