Archer Review 2t

A licensed practical/vocational (LPN/VN) nurse assists the behavioral health unit's registered nurse (RN). Which task can the RN appropriately delegate to the LPN/VN? A. Alcohol withdrawal screening on a client going through detoxification [6%] B. Medication administration to a client with a nasogastric tube [91%] C. Suicide assessment on a newly admitted client [0%] D. Educating a client on newly prescribed citalopram [1%]

Explanation Choice B is correct. An appropriate task the RN may delegate to the LPN/VN would be administering medications via nasogastric tube. This task is within the scope of the LPN/VN. Choices A, C, and D are incorrect. All of these tasks require the RN to complete. An alcohol withdrawal screening requires assessment and completion by the RN. Assessment is also required for a client requiring suicide screening. Finally, education about newly prescribed medications originates from the RN. Additional Info

The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L. Which of the following signs and symptoms can be attributed to the client's sodium level? Select all that apply. A. Lethargy [24%] B. Dry mucous membranes [28%] C. Tachypnea [19%] D. Cyanosis [3%] E. Excessive thirst [25%]

Explanation Choices A, B, and E are correct. Sodium plays a very important role in the brain, so imbalances in the serum sodium level can cause major neurological changes. The patient who is hypernatremic, or has a sodium level greater than 145 mEq/L, is at risk for changes in their level of consciousness ranging from restlessness and agitation to lethargy (Choice A), stupor, and coma. A patient who has a high sodium level will often have dry mucous membranes. Hypovolemic hypernatremia is the most common form of hypernatremia. Other causes include renal losses of free water (osmotic diuresis, post obstructive diuresis) or extrarenal losses (diarrhea, sweating, increased insensible losses). Therefore, the patient is often dehydrated and this fluid volume deficit is manifested by dry mucous membranes (Choice B) and excessive thirst (Choice E). Dry mucosa may also be secondary to the relationship sodium has with water. Water follows sodium, so where there is an increased level of sodium in the extracellular space, water leaves the cells and follows the sodium into the extracellular space. This causes dry mouth and mucous membranes. Choice C is incorrect. Tachypnea, or an increased respiratory rate, is not a symptom of hypernatremia. Sodium plays a very important role in the brain and nerves as well as for water balance. The major symptoms to monitor for will be neurological, not respiratory. Choice D is incorrect. Cyanosis, or bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood, is not a symptom of hypernatremia. Sodium imbalance can cause many devastating neurological symptoms, but will not result in cyanosis. NCSBN Client Need: Topic: Reduction of Risk Potential; Subtopic: Laboratory Values

The nurse observes a patient clutching her abdomen and complaining of cramping, which is accompanied by sharp pain. Which of the following types of pain is the client experiencing? A. Cutaneous or superficial somatic [15%] B. Visceral [42%] C. Deep somatic [32%] D. Radiating

Explanation Choice A is correct. Cutaneous or superficial somatic pain arises in the skin or subcutaneous tissue. Such pain is described as sharp, aching, gnawing, or cramping. It is often localized. The client is experiencing "sharp" pain, which goes more in favor of cutaneous pain. Physical pain is either nociceptive or neuropathic. These two types of pain differ in the way they affect the patient as well as in how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to stimuli that are potentially damaging, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur as a result of trauma, surgery, or inflammation. Two types of nociceptive pain are visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue). Choice B is incorrect. Visceral pain is caused by the stimulation of deep internal pain receptors. It is most often experienced in the internal organs of the abdominal cavity, skull, or thorax. Visceral pain is not well localized and can be described as tight, pressure, deep squeezing, or aching pain. Choice C is incorrect. Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. It is localized and can be described as achy or tender. A fracture or sprain, arthritis, and bone cancer can cause deep bodily pain. Choice D is incorrect. Radiating pain starts at the origin but extends to other locations. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic Care & Comfort

The nurse notices a unlicensed assistive personnel (UAP) passing by several call lights during the shift. What is the nurse's best initial action? A. Confront the UAP about the behavior. [67%] B. Report unsafe behavior to the charge nurse. [21%] C. File an incident report due to safety risk. [1%] D. Ask another UAP to help cover this UAP's patient load. [10%]

Explanation Choice A is correct. Ignoring call lights (or not responding in a timely manner) puts patients at increased risk of falls and injury. The chain of command says the nurse should address issues/conflicts with the peer (if another nurse) or subordinate (UAP), as long as the situation is not illegal or dangerous. This nurse should first address issues with the UAP to determine the reason for this behavior (i.e. negligence versus work overload) and collaborate to find a solution. If the interaction is not effective, the nurse would then bring the issue up the chain of command (charge nurse) to determine the next steps. Choice B is incorrect. The nurse should address the UAP first before reporting. If the behavior continues, the issue should be brought up the chain of command to determine if it is due to factors such as negligent behavior, alarm fatigue, or improper staffing. Choice C is incorrect. Filing an incident report would not be appropriate. Although patient safety is at risk, according to the given information, no incident/accident has occurred. Choice D is incorrect. Asking another UAP to cover additional clients does not address the problem and increasing the number of patients for the second UAP would put the safety of additional patients at risk. Assignments should be set by the unit charge nurse and based on patient acuity.

The nurse is caring for a female client who is receiving prescribed isotretinoin. Which laboratory data is essential prior to the initiation of this therapy? A. Pregnancy test [77%] B. C-Reactive Protein [6%] C. BUN and Creatinine [14%] D. Prothrombin time (PT) [4%]

Explanation Choice A is correct. Isotretinoin is indicated in the treatment of moderate to severe acne vulgaris. This medication is highly teratogenic, and a negative pregnancy test is essential prior to the initiation of therapy. Choices B, C, and D are incorrect. A C-Reactive Protein, BUN and Creatinine, and Prothrombin time (PT) are all laboratory data not relevant to isotretinoin. This medication is highly hepatotoxic, and the liver function tests are laboratory data that should be monitored before and during the course of treatment. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Adverse Effects/Contraindications/Side Effects/Interactions Question type: Knowledge/comprehension Additional Info Isotretinoin may also be utilized in the treatment of moderate to severe acne vulgaris as it has demonstrated its ability to shrink the sebaceous glands. This medication is highly teratogenic, and the client should be counseled on reliable contraception. A negative pregnancy test is required prior to the start of treatment. Laboratory monitoring of the client's liver function tests and triglycerides is essential. This medication may cause a liver injury and raise triglyceride levels.

The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit. A. Levofloxacin 750 mg IVPB Q12 hours [29%] B. 0.9% Saline 125 ml/hr [24%] C. Metoclopramide 10 mg IV Push Q8 hours [38%] D. Ketorolac 15 mg IV Push Q8 hours [9%]

Explanation Choice A is correct. Levofloxacin should be promptly administered for this client with pneumonia. Critical pathways call for prompt initiation of antibiotics for pneumonia as the condition may worsen to acute respiratory distress syndrome (ARDS) and/or sepsis. The diagnosis of pneumonia is also prioritized as it is a breathing impediment and requires prompt follow-up. Choices B, C, and D are incorrect. Gastroenteritis consists of symptoms such as nausea, vomiting, diarrhea, and fever. All of which leads to dehydration. While this is important to initiate fluid repletion, this is a circulation issue that does not prioritize antibiotic administration for pneumonia. Metoclopramide is commonly used in DKA because of its amelioration on gastroparesis. This does not prioritize the respiratory need of the client with pneumonia. Urolithiasis requires prompt pain control with anti-inflammatories such as ketorolac. This medication helps with the urinary colic that the client experiences. Additional Info Prompt initiation of antibiotics for CAP is essential to ensure positive patient outcomes. Other medications that may be used in the management of community-acquired pneumonia (CAP) include bronchodilators and fluids. The nurse should encourage coughing and deep breathing. Incentive spirometry may be utilized as well.

The nurse prepares to suction a tracheostomy tube to help clear a patient's secretions. After opening the package, filling the cup with sterile water, and putting on sterile gloves, the nurse uses one hand to connect the catheter to the suction. What action would be most appropriate for the nurse to take next? A. Use the contaminated hand to preoxygenate the patient prior to suction. [46%] B. Use the sterile hand to slowly insert the catheter while applying intermittent suction. [24%] C. Restart the procedure due to contamination after applying sterile gloves. [17%] D. Assess the patient's baseline oxygenation status. [13%]

Explanation Choice A is correct. Open suction of a tracheostomy tube requires an aseptic technique. After setting up a sterile field and applying sterile gloves, the nurse would designate one hand as contaminated and ensure the other remains sterile. The contaminated hand should be used to connect/disconnect the catheter tubing, use the resuscitation bag, and operate the suction control. If preoxygenation is indicated, the nurse would use the contaminated hand to administer it. Choice B is incorrect. The sterile hand would be the correct choice for advancing the catheter, but suction should never be applied during insertion. Intermittent suction would only be used while withdrawing the catheter. Choice C is incorrect. The nurse has performed the procedure steps correctly so far and has not taken any action that would compromise the sterile field or require re-starting the procedure. Choice D is incorrect. The nurse should assess the patient's oxygenation status prior to setting up the sterile field and starting the procedure to use as a baseline for monitoring the patient's response to the procedure.

The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication? A. Ondansetron [46%] B. Methimazole [19%] C. Omeprazole [9%] D. Methylphenidate [27%]

Explanation Choice A is correct. Prophylactic nausea and vomiting prevention is essential following this surgery. If the client were to vomit, this would put pressure on the operative site and cause wound disruption. Following this surgery, the client is instructed not to cough, blow their nose, or sneeze. Vomiting should be avoided because it exerts pressure on the operative site, which is detrimental. Choices B, C, and D are incorrect. Methimazole is an antithyroid medication used for hyperthyroidism. This is not indicated following hypophysectomy. Omeprazole is a PPI and indicated in the treatment of peptic ulcer disease. Methylphenidate is a psychostimulant indicated in the treatment of ADHD. Additional Info After hypophysectomy, the client should be monitored closely for increased intracranial pressure, headaches, urine output, and vital signs. The client should be instructed to avoid blowing their nose, coughing, or straining. The most serious adverse effect of this surgery is CSF leakage, increased intracranial pressure, infection, and diabetes insipidus. Perioperative and postoperative steroids are routinely prescribed to prevent diabetes insipidus.

The nurse is reviewing a client's laboratory data. Based on the laboratory result, the nurse should take which action? See the image below. A. Review the medication administration record (MAR) [50%] B. Plan to initiate daily fluid restrictions [17%] C. Clarify the prescribed chest radiograph (x-ray) [5%] D. Insert an indwelling urinary catheter to monitor urinary output [28%]

Explanation Choice A is correct. The client's creatinine is elevated (normal is 0.6-1.2 mg/dL). Elevations in creatinine may be caused by exposure to nephrotoxic substances (toxins, medications, IV contrast). A decrease in renal perfusion may also cause an elevation in creatinine. Most cases of elevated creatinine are caused by exposure to nephrotoxic substances. The nurse should review the client's MAR to determine if the client is taking any nephrotoxic medication. Choices B, C, and D are incorrect. Initiating fluid restrictions would be unhelpful in this case. At times fluid repletion may help the offending agent clear the client's system. A chest x-ray is fine with this creatinine level since it does not involve contrast dye. It is procedures that involve contrast dye that should be questioned. Inserting a urinary catheter is invasive and premature; thus, it would not be indicated unless the client is experiencing a shock where urinary output measurement is essential. Additional Info Serum creatinine is produced when muscle and other proteins are broken down. Because protein breakdown is usually constant, the serum creatinine level is a good indicator of kidney function. No common pathologic condition other than kidney disease increases the serum creatinine level. Several substances may insult the kidneys, thus, raising the creatinine. These substances and medications include - Metformin Aminoglycosides IV Contrast Sulfonamides NSAIDs Heavy metals

The nurse is caring for a client immediately following the administration of prescribed sumatriptan. Which clinical finding would require follow-up by the nurse? A. Blood Pressure 189/98 mm Hg [78%] B. Headache pain 4/10 [4%] C. Client's skin appears flushed [14%] D. Reports of nausea [4%]

Explanation Choice A is correct. This is significantly elevated blood pressure and requires follow-up. Vasoconstriction may occur with this medication, and thus, the client with a medical history of coronary artery disease, uncontrolled hypertension, and a previous stroke should not take this medication. Choices A, B, and D are incorrect. The medication is indicated for migraine headaches, and a headache would not be of significant concern. Flushing of the skin immediately after administering this medication is a common effect. Nausea and abdominal cramping may be a side-effect associated with this medication.

A newly registered nurse is buddying up with a senior nurse in the delivery room. During their shift, the nurse asks the senior nurse regarding the prevention of cold stress immediately after delivery. Which is the most appropriate response by the senior nurse? A. The nurse should dry the neonate and place the baby under a radiant warmer for 2 hours immediately after birth. [65%] B. The nurse should give oxygen for the first 30 minutes after birth. [1%] C. The nurse should decrease integumentary stimulation after birth. [3%] D. The nurse needs to make sure that the environmental temperature is maintained at a constant level. [31%]

Explanation Choice A is correct. To prevent cold stress, the nurse needs to stop heat loss from the newborn. Drying the infant and placing the baby in a radiant warmer ensures that the newborn does not lose any heat through conduction, evaporation, or convection. Choice B is incorrect. Oxygen does not have any effect in preventing cold stress in the newborn. Choice C is incorrect. Decreasing integumentary stimulation does not affect preventing cold stress. Choice D is incorrect. Maintaining environmental temperature does not prevent heat loss via conduction, evaporation, and convection.

The nurse is caring for a client who sustained full-thickness burns to their entire torso and back. The nurse plans to take which priority action? A. Assess the client's respiratory status [80%] B. Prepare an infusion of lactated ringers [18%] C. Insert an indwelling urinary catheter [0%] D. Obtain an accurate weight [1%]

Explanation Choice A is correct. When caring for a client with a significant thermal burn (greater than 10% TBSA), the priority is assessing respiratory status. Smoke inhalation injuries and carbon monoxide poisoning are immediate concerns that must be addressed. Choices B, C, and D are incorrect. Fluid resuscitation is a central part of the emergent care of a major thermal burn. An isotonic solution, such as lactated ringers, is commonly utilized because of its fluid volume expanding properties. An indwelling catheter is necessary to determine the effectiveness of fluid resuscitation. However, this intervention does not prioritize airway patency. An accurate weight is necessary to determine the amount of fluid needed to restore circulating volume. Additional Info The emergent (resuscitation) phase of a burn injury begins at the onset of injury and continues for about 24. The type of burn determines the type of care along with the percentage of body surface affected. The priorities of care during the emergent phase include: Securing the airway Supporting circulation and perfusion through volume repletion Maintaining body temperature Providing adequate pain control Rendering emotional support

The nurse is caring for a client who has nephrogenic diabetes insipidus. Which of the following medications should the nurse expect to be prescribed for the client? A. Prednisone [35%] B. Hydrochlorothiazide [45%] C. Verapamil [17%] D. Lithium [3%]

Explanation Choice B is correct. Hydrochlorothiazide is a thiazide diuretic and has a paradoxical effect when prescribed for individuals with diabetes insipidus. While commonly HCTZ causes a diuretic effect, when used for nephrogenic DI, it can increase the proximal sodium and water reabsorption, thereby reducing the urine output. Choices A, C, and D are incorrect. Prednisone is indicated in the management of adrenal insufficiency. Verapamil is a calcium channel blocker and is efficacious for migraine headache prophylaxis and hypertension management. Lithium would be contraindicated as lithium may cause nephrogenic diabetes insipidus. Additional Info DI is a condition that may be central or nephrogenic. The client is at risk for fluid volume deficit because the client may experience polyuria. This may manifest as tachycardia, hypotension, and a thread pulse. Common laboratory findings for an individual with DI include hypernatremia, decreased urine specific gravity (it is dilute), and increased hematocrit (hemoconcentration). Treatment for central diabetes insipidus is through the administration of desmopressin (intranasal or tablet). Nephrogenic diabetes insipidus is treated by withdrawing the offending agent (such as lithium) and the administration of thiazide diuretics or NSAIDs.

The mother of a 2-month old infant tells the nurse that her mother-in-law said to her that picking her baby up immediately when she cries, "spoils her baby". What would be the nurse's best response? A. "You can let your baby wait a while before picking her up." [7%] B. "Babies need to be cuddled and comforted; this does not spoil your child." [85%] C. "You need to feed her right away because crying means that she is hungry." [8%] D. "You can just let your baby cry; she will stop once she gets tired." [0%]

Explanation Choice B is correct. Infants need to have their security needs met by being held and cuddled. Choice A is incorrect. Not picking up the baby after she has cried does not meet the baby's need for security. Choice C is incorrect. Infants cry for many reasons. Assuming that the child is hungry and feeding each time they cry may cause overfeeding problems such as obesity. Choice D is incorrect. Letting the baby cry to sleep does not meet the baby's security needs.

The nurse is caring for a client two weeks postpartum with reports of flu-like symptoms, headache, and tenderness to the left breast. On examination, the nurse assesses enlarged axillary lymph nodes. The client is demonstrating manifestations of A. Endometritis [2%] B. Mastitis [94%] C. Pelvic inflammatory disease [1%] D. Cystitis [2%]

Explanation Choice B is correct. Mastitis commonly occurs 2-4 weeks postpartum. The client often experiences flu-like symptoms (fever, malaise, and axillary lymphadenopathy). The affected breast usually is tender, has erythema, and is swollen. The client's manifestation classically coincides with this infection. Choices A, C, and D are incorrect. These manifestations are not consistent with these disorders. If the client were to have any of these infections, the pain or discomfort would be localized to this area which is not in the client's complaint. Additional Info Mastitis is often caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. The bacteria are most often carried on the skin of the mother or in the mouth or the nose of the newborn. The organism enters through an injured area on the nipple, such as a crack or blister. The primary medical treatment is antibiotics and continued emptying of the breast. Comfort measures during mastitis include applying moist heat or ice packs, breast support, bed rest, fluids, and analgesics.

The nurse is caring for a client receiving mechanical ventilation. Which prescription from the primary healthcare physician (PHCP) should the nurse anticipate? A. Hydroxyzine [25%] B. Pantoprazole [40%] C. Rivastigmine [16%] D. Verapamil [19%]

Explanation Choice B is correct. Mechanical ventilation may cause a stress ulcer. A proton pump inhibitor (PPI) or a histamine-2 receptor antagonist (H2 blocker) may be utilized to prevent this ulcer which may lead to a gastrointestinal bleed. Choice A, C, and D are incorrect. Hydroxyzine is an anticholinergic utilized in allergic reactions and anxiety. Rivastigmine increases acetylcholine in the central nervous system and is indicated for dementia. Verapamil is a calcium channel blocker indicated for hypertension and migraine headache prophylaxis. These medications have no relevance to mechanical ventilation management. Additional Info Mechanical ventilation poses a risk for a stress ulcer to form. This is caused by hypersecretion of gastric acid and impaired protection of the gastric mucosa. Stress ulcers pose a serious risk as they may cause gastrointestinal bleeding. This bleeding may lead to perforation and then shock. PPIs such as pantoprazole or H2 blockers famotidine may be used to mitigate this risk. Manifestations of stress ulcers include hematemesis, melena, anemia, and shock.

A nurse is instructing a patient about a newly prescribed medication, phenytoin. Which statements, if made by the patient, indicate effective teaching? A. "If my gums get irritated and large, I can stop this medication." [11%] B. "I will need laboratory work to monitor the medication level." [80%] C. "It is okay for me to increase this medication if I have a seizure." [4%] D. "I should take this medication with low protein foods." [5%]

Explanation Choice B is correct. Phenytoin is an anticonvulsant and is indicated for epilepsy. Therapeutic levels must be maintained to ensure the effectiveness of the drug. The therapeutic drug levels of phenytoin are 10-20 mcg/mL. Choices A, C, and D are incorrect. Phenytoin is an anticonvulsant medication that requires adherence to prevent seizure activity. The client should not stop the drug because of the side-effect of gingival hyperplasia; instead, the client should report this effect. The client's self-discontinuing the medication increases the risk of a seizure. The client should not increase the drug if they have a seizure. Phenytoin can be taken with or without food. This medication does not have any dietary restrictions. Additional Info Phenytoin is an anticonvulsant that requires follow-up drug monitoring. For female clients, education should be provided to utilize appropriate contraception because it may cause fetal defects. Manifestations of phenytoin toxicity include ataxia, nystagmus, and blurred vision.

The nurse is preparing to administer prescribed bumetanide to a client. Which clinical finding would indicate the desired outcome? A. Increase in central venous pressure [8%] B. Reduced cardiac preload and wall tension [65%] C. Decreased glomerular filtration rate [18%] D. Increase in systemic vascular resistance

Explanation Choice B is correct. The desired outcome for a loop diuretic is the following - Reduction of blood pressure Reduction of pulmonary vascular resistance Reduction of systemic vascular resistance Reduction of central venous pressure Reduction of left ventricular end-diastolic pressure Choices A, C, and D are incorrect. It is not desired for a diuretic to increase CVP. CVP is the measurement of right ventricular end-diastolic pressure. Diuretics reduce blood volume, thereby reducing this pressure. The goal of a diuretic is to reduce the CVP. It is not desired for a client to have their GFR reduced. The goal for all clients is to have a high GFR, as this is an indicator of renal health. Prolonged exposure to loop diuretics may reduce the GFR, especially at aggressive doses. An increase in systemic vascular resistance is also not the desired effect of diuretics. SVR is the amount of force exerted on circulating blood by the body's vasculature. Less blood volume by the diuretic = a decrease in SVR. Additional Info Loop diuretics act primarily along the thick ascending limb of the loop of Henle, blocking chloride and, secondarily, sodium resorption. Loop diuretics are also thought to activate renal prostaglandins, which dilate the blood vessels of the kidneys, the lungs, and the rest of the body (i.e., reduction in renal, pulmonary, and systemic vascular resistance). The hemodynamic effects of loop diuretics are a reduction in both the preload and central venous pressures (which are the filling pressures of the ventricles). These actions make them useful in treating the edema associated with heart failure, hepatic cirrhosis, and renal disease. Examples of loop diuretics include - bumetanide, ethacrynic acid, furosemide, and torsemide

The nurse is talking to an elderly client with osteomalacia regarding ways to strengthen his bones. Which statement by the client would necessitate further teaching by the nurse? A. "I've started to walk more frequently under the sun." [7%] B. "I don't like dairy products so I've stopped eating them." [88%] C. "I've enrolled myself in an exercise program for seniors at the community center." [2%] D. "I've been taking Vitamin D supplements lately."

Explanation Choice B is correct. The patient needs to be reinforced regarding a calcium-rich diet and calcium-rich foods. Milk and dairy products are some of the most common sources of dietary calcium. If the patient does not like milk or any other dairy product, the nurse should talk to him about different foods that are rich in calcium. Choice A is incorrect. Clients with osteomalacia need vitamin D to stimulate calcium absorption and mineralization. Vitamin D, exercise, and a calcium-rich diet are recommended. Walking under the sun stimulates vitamin D production in the body. Choice C is incorrect. Clients with osteomalacia need vitamin D to stimulate calcium absorption and mineralization. Vitamin D, exercise, and a calcium-rich diet are recommended. Enrolling in an exercise program indicates that the client understands the treatment regimen for osteomalacia. Choice D is incorrect. Clients with osteomalacia need vitamin D to stimulate calcium absorption and mineralization. Vitamin D, exercise, and a calcium-rich diet are recommended. Taking vitamin D supplements indicates that the client understands the treatment regimen for osteomalacia.

You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a "wrong surgery" because this possible error was caught in time. What is your priority action as the nurse manager? A. Praise the staff for catching these near misses before a surgical error occurs. [5%] B. Investigate and explore this near miss. [69%] C. Investigate and explore this medical error. [22%] D. Report the nature and frequency of these medical errors to the State Department of Health. [4%]

Explanation Choice B is correct. You, as the nurse manager of this surgical unit, should investigate and explore this near miss to prevent further medical errors in the future. This is your priority action. It's important to conduct near-miss investigations within 24 to 48 hours of the incident while memories are fresh about what happened and how the incident could have been prevented. Know these definitions: Near miss: A near miss is defined as "any event that could have had adverse consequences but did not and was indistinguishable from fully-fledged adverse events in all but outcome." In a near miss, an error was committed, but the patient did not experience clinical harm, either through early detection or sheer luck. In the above question, the clients have not undergone the wrong surgery and therefore, it's a near miss. Sentinel event: An unexpected occurrence involving death or serious physical/psychological injury. These events are called "sentinel" because they signal the need for immediate investigation and response. In the above question, the harm has not occurred. Therefore, it's not a sentinel event. Note that the terms "sentinel event" and "error" are not synonymous. Not all sentinel events occur because of an error and not all errors result in sentinel events. Choice A is incorrect. Although you should praise the staff for catching these near misses before a surgical error occurs, the priority is to investigate what led to the near miss. Choice C is incorrect. These near misses are not an actual medical error. Choice D is incorrect. These near misses are not an actual medical error, so it does not have to be reported to the State Department of Health.

The nurse assesses a client with schizophrenia who appears to be demonstrating neologisms in their speech. Which of the following would be the expected finding? A. Words that rhyme or have a similar beginning sound [16%] B. Reduction in speech; short-worded replies [4%] C. Words or phrases with meaning only for the client [72%] D. Going off on tangents and never reaching the point

Explanation Choice C is correct. A neologism is when a client invents words or phrases that only have meaning for themselves. This is a positive symptom associated with schizophrenia. Choices A, B, and D are incorrect. Words that rhyme or have a similar beginning sound are a clang association (example - 'She went to the bar, and saw some tar'). A reduction of speech with short-worded replies is alogia (poverty of speech). This is a negative symptom associated with schizophrenia. Going off on tangents and never reaching the point is the classic definition of tangentially. Additional Info Schizophrenia symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include: Hallucinations: Experiences involving the apparent perception of something not present. They can include any of the five senses: touch, taste, smell, sight, or hearing. Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia. Delusions: Fixed, false beliefs that conflict with reality. Types of delusions include persecution, grandeur, and jealousy Thought and speech disorganization Negative symptoms are things that take something away from the client. They include: Apathy: A lack of interest, enthusiasm, or concern. Alogia: Also known as 'poverty of speech,' alogia is difficulty with speaking or the tendency to speak little due to brain impairment. Anhedonia: The inability to feel pleasure. Avolition: A total lack of motivation that makes it hard to get anything done Flattened affect

The nurse is caring for a client receiving assist-control (AC) via mechanical ventilation. The nurse understands that this setting is used to do which of the following? A. Allow spontaneous breaths at the client's tidal volume. [29%] B. Deliver additional pressure at the end of exhalation. [12%] C. Deliver a preset tidal volume during spontaneous breaths. [39%] D. Provide inspiratory pressure during ventilations. [20%]

Explanation Choice C is correct. Assist-control (AC) is a volume mode on a mechanical ventilator that senses a client's ability for a spontaneous breath. When the client takes a spontaneous breath, it will deliver the tidal volume preset on the ventilator. This is in addition to the client receiving the ventilated breaths preset in the rate. For example, if the client is at a preset rate of 12 and taking 4 spontaneous breaths, each breath of the 16 will receive 515 mL of gas (the tidal volume preset). Choices A, B, and D are incorrect. AC differs from SIMV (synchronized intermittent mandatory ventilation); in SIMV, the client may trigger a spontaneous breath and their own tidal volume. Pressure added at the end of exhalation to prevent alveoli collapse would be a description of PEEP (positive end-expiratory pressure). Inspiratory pressure during ventilation would be a description appropriate for pressure support ventilation. Additional Info When caring for a client on a ventilator, you should be familiar with the following settings: Mode (Volume [SIMV, A/C] or Pressure [PSV]) Rate (Number of breaths per minute) Tidal volume (the amount of gas delivered to the client) Fraction of inspired oxygen (FiO2 - the percentage of oxygen given per breath) PEEP (pressure added at exhalation to keep the small airways open and mitigate atelectasis) Pressure support (PS - provides added pressure when the client takes a spontaneous breath)

A 42-year-old female client reports colicky abdominal pain that worsens after eating a high-fat meal. The nurse anticipates that this client has which diagnosis? A. Gastric ulcer [36%] B. Appendicitis [2%] C. Cholecystitis [59%] D. Liver cirrhosis [2%]

Explanation Choice C is correct. Cholecystitis occurs most commonly in women older than age 40 who haven't gone through menopause. Its manifestations include episodic, colicky pain in the epigastric area that radiates to the back and shoulder. Pain in cholecystitis resembles indigestion or chest pain after eating fatty or fried foods. Choice A, B, and D are incorrect. A gastric ulcer is an ulceration of the mucosal lining that extends to the submucosal layer of the stomach. Its manifestations include a gnawing, sharp pain in the left mid-epigastric region 30-60 minutes after a meal. Appendicitis is the inflammation of the appendix. It is manifested by pain in the periumbilical area that descends to the right lower quadrant. Cirrhosis is a chronic hepatic disease characterized by diffuse destruction of hepatic cells, replaced by fibrous cells. The symptoms presented by the patient do not indicate liver cirrhosis. Additional Info Risk factors for cholecystitis include: • Women of all ages (risk of calculi increases with aging) • American Indian, Mexican American, or Caucasian • Obesity • Rapid weight loss or prolonged fasting; low-fat diet • Increased serum cholesterol and lipids • Women on hormone replacement therapy (HRT) Manifestations of cholecystitis include: Constant pain in the right upper abdominal quadrant. It may radiate to the right shoulder or scapula. Nausea, vomiting, and reports of indigestion.

The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up? A. Active range of motion in both arms [6%] B. Scant drainage on the dressing [9%] C. Difficulty swallowing liquids [81%] D. Soreness at the operative site [3%]

Explanation Choice C is correct. Difficulty swallowing liquids indicates nerve damage that requires immediate follow-up. Following cervical spinal surgery, the client is likely placed in a cervical collar for a prescribed period. Manifestations that need to be reported following cervical spinal surgery include numbness and tingling in the upper extremities, difficulty swallowing, decreased motor strength, and respiratory depression. Choices A, B, and D are incorrect. These findings after this procedure are normal and do not require follow-up. The nurse would be concerned if active range of motion would be reduced, and scant drainage on the dressing does not concern for any hemorrhage. Following this procedure, it is likely that the client would experience soreness at the operative site. Additional Info The upper cervical spinal nerves innervate the diaphragm to control breathing. Monitor all clients following cervical spinal cord surgery for any reduction in respiratory rate. Additionally, if a client has difficulty swallowing, diminished sensation in the extremities, and movement in the upper extremities, this should be reported.

The nurse is caring for a client experiencing an episode of vertigo. The nurse should plan to take which essential action? A. Avoid sudden movement changes [54%] B. Provide additional pillows to support the client's head [3%] C. Raise the upper side rails of the bed [27%] D. Instruct the client to move the head slowly

Explanation Choice C is correct. Many actions should be taken for a client experiencing vertigo, but protecting the client's safety is essential. If a client is experiencing vertigo, this raises the risk of a fall. Interventions to prioritize include adequate lighting to the bathroom, raising the upper side rails on the bed, and providing the client with the call bell coupled with instructing the client to use it before getting out of bed. Choices A, B, and D are incorrect. These are appropriate actions for a client experiencing vertigo; however, they do not prioritize the client's safety. Additional Info Vertigo is characterized as a sense of whirling or turning in space. Many conditions may cause vertigo, including dehydration and inner ear disorders. A client with vertigo has a significant fall risk, and the nurse should mitigate this risk with fall precautions and frequent reinforcement to call for assistance before the client gets out of bed. Interventions for a client experiencing vertigo include - Fall precautions Propping the client's head up with additional pillows (may decrease the sensation) Avoid any sudden or jerky movements, especially with the head Administer medications, such as anticholinergics, as prescribed

The nurse assesses the following telemetry strip for a client on a medical-surgical unit. Based on the rhythm, what is the first priority action for the nurse to take? See the exhibit. A. Prepare for synchronized cardioversion [36%] B. Administer Atropine via IV push [15%] C. Review the most recent labs [30%] D. Ask the patient about palpitations [19%]

Explanation Choice C is correct. The EKG strip shows normal sinus rhythm with occasional premature ventricular contractions (PVCs). A PVC produces wide, bizarre complexes, with the P wave hidden within the QRS complex (not visible). Choice A is incorrect. Cardioversion would not be appropriate for this rhythm. Synchronized cardioversion delivers a timed electrical current to reset the heart's electrical activity and is indicated in tachydysrhythmias such as atrial fibrillation or atrial flutter. Choice B is incorrect. Atropine is indicated for increasing the heart rate, such as in the case of symptomatic bradycardia. This client's rhythm is 80 BPM, so it is within the normal rate and does not require adjustment. Choice D is incorrect. This client may notice or feel palpitations due to the intermittent irregular beats, but this assessment data would not be an important aspect of determining the need for treatment and would not be a high priority. Additional Info PVCs are the most common type of arrhythmia, can occur in healthy individuals, and are typically not concerning in an otherwise normal rhythm. However, they can be a warning sign of electrolyte imbalance (hypokalemia, hypomagnesemia), hypoxemia, acid-base imbalances, or myocardial ischemia. PVC may also be triggered by excessive stress, caffeine use, nicotine, and sleeplessness. The nurse should assess the client's presentation and review the most recent lab values to determine if there is any apparent physiological cause for the arrhythmia. If the client presents without symptoms and if no abnormal labs are noted, the nurse should continue to monitor for any symptom development or changes in the rhythm.

The nurse encounters an infant with irritability from acute otitis media while working in the pediatric clinic. The nurse should know that the infant is at much higher risk than an adult for otitis media due to which of the following? A. Immature cardiac sphincter [2%] B. Feeding in a semi-Fowler position [4%] C. Introduction of solid foods [1%] D. Narrower, shorter, and more horizontal Eustachian tubes [92%]

Explanation Choice D is correct. Infants have more horizontal, shorter, and narrower eustachian tubes, which makes them more prone to otitis media. The eustachian machine is a conduit from the middle ear to the nasopharynx. An inflammatory swelling in the eustachian tube can cause it to be blocked, trapping the fluid in the middle ear and eventually leading to infection. Several factors, such as allergies, common cold, viral flu, sinus infection, enlarged adenoids, and drinking while lying down (in infants), may predispose to swelling/ blockage of the eustachian tube. In an adult, the eustachian tube typically measures 36 mm and is angled at 45 degrees. In infants, it is shorter (18 mm) and has a more horizontal (angle at 10 degrees). Such a shorter tube predisposes to infection via reflux of bacteria from the nasopharynx Choice A is incorrect. An immature cardiac sphincter causes vomiting, not otitis media. Choice B is incorrect. Feeding in a semi-Fowler position helps decrease the risk of otitis media because the infant is not lying flat. Choice C is incorrect. The introduction of solid foods has no bearing on the incidence of otitis media.

The patient has been experiencing inflammation of the eye and maybe experiencing a retinal detachment. Which of the following signs and symptoms are NOT associated with retinal detachment? A. Seeing "floaters" in the field of vision [19%] B. A sense of having a curtain drawn over the eyes [16%] C. Flashes of light [22%] D. Intense pain in the affected eye [44%]

Explanation Choice D is correct. Intense pain is not generally associated with retinal detachment. Retinal detachment may present with floaters in the field of visions, partial loss of sight, and increasingly blurred images. Some patients report feeling as though a curtain has been drawn over their eyes. Choice A is incorrect. Floaters in the field of vision, all common symptoms associated with retinal detachment. Patients may also lose sight in a portion of the visual field and have increasingly blurred vision. Choice B is incorrect. A sense of having a curtain drawn over the eyes is a commonly reported symptom of retinal detachment. Choice C is incorrect. Seeing flashes of light is a common symptom associated with retinal detachment. Patients may also lose sight in a portion of the visual field and have increasingly blurred vision. NCSBN client need Topic: Physiological integrity, alterations in body systems

When caring for a client with a documented history of aggressive and violent behavior. What is the first thing the nurse should do to help prevent an extreme event toward others? A. Restrain the client [3%] B. Place the client in seclusion [10%] C. Get an order for a sedating medication [3%] D. Establish trust with the client [83%]

Explanation Choice D is correct. The first thing that you should do to prevent violence towards others is to establish trust with the client. The first step in the nurse-client relationship is to build confidence in this therapeutic relationship. Without trust, future collaboration, interventions, and client outcomes then it is difficult to facilitate appropriate and safe behaviors. Nurses can be prepared to intervene and perhaps even prevent violence if they recognize risk factors and early warning signs. Nurses should assess for factors that increase the risk for aggression, such as mental disorders, being under the influence of alcohol or other drugs, withdrawal from alcohol or other drugs, and history of violence. Clinical conditions such as high fever, epilepsy, head trauma, and hypoglycemia may also lead to violent outbursts. Choices A and B are incorrect. Restraints and seclusion are not indicated until others are in imminent danger because of this client's current violent behaviors and not a history of it. Choice C is incorrect. Sedating medications to prevent violence are also not the first things that are done. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Nurse-Patient Relationships

The nurse is caring for a client who has a prescribed subcutaneous (SQ) regular insulin sliding scale. The client's current blood glucose level is 360 mg/dL. Which of the following actions should the nurse take? See the below exhibit. Select all that apply. A. Notify the primary health care provider (PHCP). [38%] B. Administer 8 units of regular insulin. [2%] C. Administer 10 units of regular insulin. [37%] D. Recheck the client's blood glucose in one hour. [18%] E. Administer the insulin intravenous (IV) push. [4%]

Explanation Choices A and C are correct. The client's blood glucose of 360 mg/dL is indicative of hyperglycemia. The healthcare provider should be notified and the client should receive ten units of regular insulin subcutaneously. Choices B, D, and E are incorrect. The blood glucose level requires prescribed 10 units of insulin and not 8 units. Checking the blood glucose in one hour would not be useful as the peak of regular insulin is within 2 to 4 hours. Finally, regular insulin may be administered intravenously, but the prescription is for subcutaneous administration. Additional information: A sliding scale is a prescribed set of parameters utilized to guide the correction of insulin. The sliding scale utilizes the blood glucose ranges to determine the appropriate amount of insulin to administer. The sliding scale may guide the amount of rapid or short-acting insulin that is necessary based on the blood glucose. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Expected Actions/Outcomes

The nurse is developing a plan of care for a patient who has a borderline personality disorder (BPD). Which of the following would be an expected finding? Select all that apply. A. Self-mutilating behaviors [23%] B. Hypervigilance [15%] C. Emotional detachment [20%] D. Social inhibition [16%] E. Impulsivity [26%]

Explanation Choices A and E are correct. Borderline personality disorder (BPD) is a common personality disorder that features extreme emotional lability, impulsivity, self-mutilative behaviors, and manipulative mannerisms. Choice B is incorrect. Hypervigilance is an expected finding with a paranoid personality disorder. Choice C is incorrect. Emotional detachment is compatible with a schizoid personality disorder. Choice D is incorrect. Social inhibition is consistent with an avoidant personality disorder.

The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply. A. Topiramate [26%] B. Risperidone [15%] C. Prazosin [10%] D. Hydroxyzine [12%] E. Lorazepam [36%]

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

The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply. A. A visitor refusing to wear personal protective equipment (PPE). [23%] B. A visitor activating a patient's patient-controlled analgesia (PCA) device. [37%] C. A visitor requesting that their family member get pain medication. [2%] D. A visitor assisting their family member with brushing their teeth. [1%] E. A visitor stating that they fell while using the bathroom. [37%]

Explanation Choices A, B, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any type of activity deviates from the norm. Incident reporting may be completed for visitors. Events that would warrant reporting would include the refusal of wearing PPE, activating a patient's PCA device, and stating that they fell while they used the bathroom. Choices C and D are incorrect. A visitor advocating for a patient to receive pain medication is not something requiring reporting—the same for a visitor assisting a patient with oral hygiene. Additional information: Incident (sometimes termed occurrence or event) reporting is a tool to mitigate future risks. Incident reporting should also be completed for events involving visitors. Such events include: Verbal and physical displays of aggression Tampering with medical devices Falls or injuries Complaints Interfering with patient care The incident should not be logged in the medical record or nursing notes.

The nurse is caring for a 14-year-old who is scheduled to go to the OR for an appendectomy later in the day. What is the nurse's role in obtaining informed consent before surgery? Select all that apply. A. Explain the procedure to the patient in terms they can understand. [12%] B. Review the risks and benefits of the surgery. [11%] C. Validate that the parents are competent to provide consent for the patient. [36%] D. Witness the signature on the informed consent [40%]

Explanation Choices C and D are correct. Since the patient is 14-years-old, they are a minor and their parents will be responsible for signing informed consent. The nurse is accountable for validating that the parents are competent to provide consent for the patient (Choice C). The nurse will serve as the witness for the informed consent. This is one of the primary responsibilities of the nurse when a patient is getting a procedure and signing a consent. The other primary responsibility will be to serve as the patient's advocate and ensure that the parents have received sufficient information to make an informed decision. If they have not, the nurse must call the surgeon to return and speak further with the parents (Choice D). Choice A is incorrect. It is not within the nurses' scope of practice to explain the procedure to the patient. It is the surgeon's responsibility to do this and they should use words/terms that the patient and family can easily understand. If the family does not speak English, a medical language interpreter should be utilized. Choice B is incorrect. It is not within the nurses' scope of practice to review the risks and benefits of the surgery with the patient. It is the surgeon's responsibility to do this. If the family does not speak English, a medical language interpreter should be used. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Pediatrics - Gastrointestinal

The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? Select all that apply. A. Bran [18%] B. Fresh peaches [13%] C. Cucumber salad [21%] D. Cooked broccoli [22%] E. Cabbages [25%]

Explanation Choices C, D, and E are correct. The client with diverticulitis should avoid foods with seeds. Additionally, they should avoid eating gas-forming foods that increase abdominal discomfort. When the colon must repeatedly move highly compacted fecal material, over time the longitudinal and circular muscles enlarge. This increases the force on the mucosal tissues, causing them to "balloon" out between the muscles and to form pouches in which fecal matter becomes trapped. The development of these outpouchings is called diverticulosis. In some cases, the bags become infected, which is a condition called diverticulitis. People whose diets are low in fiber or consist mainly of refined foods are at high risk for developing diverticulosis. Education about appropriate foods is a critical nursing intervention to help patients manage the disease. Choices A and B are incorrect. Bran cereal and fruits will help prevent constipation. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse is developing a plan of care for a client with a wet-suction chest tube prescribed wall suction. Which interventions would be appropriate to include? Select all that apply. A. Apply clamps to the tubing to secure it to the bed. [31%] B. Strip the tubing at least once every eight hours. [5%] C. Report any bubbling in the suction control chamber. [34%] D. Ambulate the client with the device below the insertion site. [18%] E. Palpate around the insertion site for any crackles or popping. [12%]

Explanation Choices D and E are correct. Ambulation with a chest tube is not contraindicated. If the nurse has an order from the primary healthcare provider (PHCP) and it is safe for the client to ambulate, the nurse should ambulate the client with the device distal to the insertion site. Palpating around the insertion site should be done and any crackles or popping should be reported to the PHCP because that indicates an air leak. Choices A, B, and C are incorrect. The tubing should not be clamped to the bed as this would cause an obstruction. It would be appropriate to keep extra tubing loose on the bed. Stripping the tubing would be inappropriate because it would increase the intrathoracic pressure, counterproductive to chest tube therapy. Continuous bubbling in the suction control chamber is normal because wall suction is prescribed for this client. Additional Info The nurse is responsible for assessing the patency of a chest tube by assessing each chamber. The nurse should always ensure client safety by having the appropriate emergency equipment at the bedside. This equipment includes occlusive sterile gauze, a bottle of sterile water, and clamps.

The nurse is determining the total intake for a client diagnosed with acute kidney injury. The client received 650 mL of intravenous fluid, 6 ounces of water, and 8 ounces of chicken broth during the shift. The client's urinary output for the shift is 820 mL. What is the total intake the nurse will record for this client? mL

Explanation The value of the client's urinary output is not necessary to determine the total intake. The nurse must know the conversion of 1 ounce = 30mL. The nurse will add the intravenous fluids and the oral fluids to determine the total fluid intake: 6 ounces of water (6 ounces x 30 mL) → 180 mL of water 8 ounces of chicken broth (8 ounces x 30 mL) → 240 mL of chicken broth 650mL IV fluid 1070mL total fluid intake Additional Info When calculating intake, the nurse should consider the amount of volume the client consumes intravenously and by mouth. While intake and output (I&O) help determine a client's condition, I&O is a crude way of a client's status. Weight is the best way to determine fluid volume status as one kilogram equates to 2.2 lb which is one liter of fluid.

While working in a pediatric cardiac intensive care unit, you are caring for a child diagnosed with tetralogy of Fallot. Upon entering the room in the morning for your first assessment you find the child crying, cyanotic, and tachycardic. You recognize this as a hypercyanotic tet spell. Place the following actions in order of priority: -Administer 100% oxygen -Place the infant in the knees to chest position -Administer an IV fluid bolus -Administer morphine sulfate -Document the event

Place the infant in the knees to chest position Administer 100% oxygen Administer morphine sulfate Administer an IV fluid bolus Document the event Explanation Correct answer: The priority in a hypercyanotic tet spell is to place the child in a knee to chest position. Tet spells occur when the infant with tetralogy of Fallot becomes acutely cyanotic due to infundibular spasm usually associated with feeding or crying. When this spasm occurs, there is decreased flow from the right ventricle due to the obstruction, resulting in severe hypoxia. Putting the child in a knee-chest position increases the intrathoracic pressure and increases blood flow to the lungs, therefore increasing oxygenation to body tissues. The next priority action is to administer 100% oxygen to assist in meeting the child's oxygenation requirements and relieving the hypoxia quickly. The following priority action is to administer morphine sulfate. This is the drug of choice for tet spells because it helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and, therefore, the hypercyanotic tet spell. The next priority nursing action is to administer an IV fluid bolus. This increases preload and consequently, cardiac output, helping to increase perfusion and oxygenation to the tissues. Lastly, the nurse should document the event, actions taken, and the patient's response. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies, Cardiovascular

The nurse is caring for a client receiving intravenous (IV) alteplase for a cerebrovascular accident (CVA). The nurse understands that this medication has reached its therapeutic effect when the client is assessed to have A. increase in the Glasgow Coma Scale. [60%] B. unintelligible speech. [1%] C. bleeding at their gum line. [8%] D. increase in pulse and decrease in blood pressure. [31%]

Explanation Choice A is correct. An increase in the Glasgow Coma Scale (GCS) is a favorable finding when tPA is administered (intravenous alteplase) for an ischemic stroke. The highest score on a GCS is 15. Choices B, C, and D are incorrect. Intravenous alteplase is a potent thrombolytic indicated for ischemic strokes and adversely may cause angioedema or severe bleeding. While slight bleeding at the gum line is not necessarily a reason to stop the infusion, it is not a therapeutic finding. Unintelligible speech would also be a consistent manifestation of a CVA that is not therapeutic when tPA is administered. An increase in pulse and decrease in blood pressure would suggest internal bleeding, which requires immediate follow-up by the nurse. Additional Info Alteplase is a thrombolytic indicated in the treatment of an ischemic stroke. To administer alteplase, the nurse must ensure that all invasive procedures are completed before the infusion to avoid bleeding. Two peripheral vascular access devices are needed, along with close monitoring of the client's vital signs and neurological status.

A client is diagnosed with a spontaneous pneumothorax which results in the need to insert a chest tube. What is the best explanation for the nurse to provide this client? A. "The tube will prevent you from having chest pains." [1%] B. "The tube will remove excess air from your chest." [87%] C. "The tube controls the amount of air that enters your chest." [10%] D. "The tube will seal the hole in your lung." [3%]

Explanation Choice B is correct. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space. Choice A is incorrect. Chest tubes do not prevent chest pain. Many patients complain of pain and discomfort because of the tube. However, the necessity of removing air is paramount. Choice C is incorrect. The purpose of the chest tube is to remove air that has accumulated, not control the amount of air entering the lung. Choice D is incorrect. The chest tube does not seal a hole in the lung. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

You are a nurse in the local childcare facility. You are feeding an infant from a bottle containing expressed breast milk from the mother, halfway through the feeding, you realize that the breastmilk you are supplying is not for this child. You have mistakenly picked up the breastmilk that was for another woman's child. You should: Select all that apply. A. Inform the parent of the child that you are feeding. [25%] B. Inform the mother of the child whose milk you fed to the child. [21%] C. Complete an incident report per facility policy. [29%] D. Inform the providers who are caring for the infants. [24%]

Explanation Choices A, B, C, and D are correct. All of these actions are appropriate and expected in this situation. Also, the team should assess both of the mothers for any infectious process. Additionally, the nurse should educate both sets of parents that the risk of transmission of the disease is small. The mother may have concerns about exposure to hepatitis B and C; however, these infections cannot be spread from a woman to an infant through breastmilk. Probably the most critical intervention is to put processes in place to prevent mix-ups of milk from happening again. NCSBN Client Need Topic: Safety and Infection Control, Sub-topic: Reporting of Incident, Newborn

A 16-year-old female client has been recently diagnosed with Grave's disease and is being admitted. The primary health care provider prescribes a few medications. Which of the following prescriptions, if ordered, should the nurse question? A. Atenolol [31%] B. Propylthiouracil (PTU) [13%] C. Radioactive iodine (I131) [36%] D. Methimazole (Tapazole) [20%]

Explanation Choice C is correct. The nurse should question the prescription for radioactive iodine therapy (RAI) in this 16-year old woman of childbearing potential. A woman of childbearing potential is defined as any woman or adolescent who has begun menstruation and can conceive. RAI works by being taken up into the thyroid gland and destroys the cells that concentrate it. RAI is highly effective and is the treatment of choice in Grave's disease in almost all patients except in pregnant patients and breastfeeding women. RAI can cross the placenta and affect the developing thyroid gland of the unborn baby. Therefore, in any woman of childbearing potential, the American Thyroid Association strongly recommends obtaining a beta-hCG to rule out pregnancy before initiation of RAI therapy. A pregnancy test must be obtained in this 16-year-old woman before initiating RAI. Choice A is incorrect. Atenolol is a beta-blocker and can be prescribed to this 16-year-old patient with hyperthyroidism to control high blood pressure and tachycardia-related symptoms ( palpitations). Choice B is incorrect. Propylthiouracil (PTU) is one of the most commonly used anti-thyroid medications. PTU works by impairing thyroid hormone synthesis and can be prescribed for patients below 18 years of age. Choice D is incorrect. Methimazole blocks the action of thyroid hormones in the body and is safe to be given to pregnant women and women of childbearing potential. Learning Objective Understand that ionizing radiation can be harmful to the fetus. Therefore, a pregnancy test is mandatory before administering radioactive drugs (e.g., RAI) to women of childbearing potential. Additional Info A woman of childbearing potential is defined as any woman or adolescent who has begun menstruation and can conceive ( typically, 12 to 49 years of age, but slight alterations in the age cut-offs may occur depending on the age of menopause). The procedures that produce ionizing radiation include CT scans, plan x-rays, fluoroscopy, and administering radioactive medications. Ionizing radiation is harmful to the fetus. Because of these harmful effects, healthcare professionals must adhere to the following strict guidelines before administering ionizing radiation of any form:- The woman should be questioned about pregnancy status, contraception use, sexual activity, and whether the pregnancy is being sought. Before administering radioactive medications like RAI, a serum beta-HCG ( blood pregnancy test) must be obtained. A urine pregnancy test is not acceptable here. Before subjecting the woman to CT scans and plain x-rays, a urine pregnancy test to exclude pregnancy is usually acceptable. Where possible, non-ionizing alternatives (e.g.: ultrasound, MRI without contrast) should be pursued if they are equally effective

A client complaining of dysuria was prescribed phenazopyridine (Pyridium). As part of client teaching, the nurse should inform the client on which of the following? A. His urine will be greater in volume [14%] B. His urine will turn orange in color [73%] C. His urine will be pungent in odor [4%] D. His urine will appear concentrated [9%]

Explanation Choice B is correct. Phenazopyridine is prescribed to relieve pain, irritation, discomfort, or urgency caused by UTI, surgery, or any injury to the urinary tract. Phenazopyridine causes the urine to have an orange color. Choices A, C, and D are incorrect. Phenazopyridine doesn't cause higher urine volume, a pungent urine odor, or concentrated urine.

The nurse is caring for an 18-month-old toddler with a cough and fever. Which is the most appropriate play activity for the nurse to offer the toddler? A. Toy puzzles [23%] B. Miniature cars [32%] C. Finger painting [41%] D. Comic book reading

Explanation Choice C is correct. Toddlers enjoy feeling different textures. They are sensorimotor learners at this point. Finger paints would be an appropriate choice. Choice A is incorrect. Puzzles may be too difficult to manipulate and some pieces may be small enough to be aspirated. Choice B is incorrect. Miniature cars have a high potential for aspiration. Choice D is incorrect. Comic books are too advanced for toddlers. Although they are enjoyable to look at because of the pictures, the toddler cannot fully appreciate the comic book yet.

The nurse reviews the procedure of obtaining blood pressure with unlicensed assistive personnel (UAP). It would indicate effective teaching if the UAP states which client finding would not be appropriate for an electronic blood pressure measurement? The client A. having coarse tremors. [76%] B. wearing a watch. [9%] C. who has excessive tattoos. [3%] D. requiring a chest radiograph. [13%]

Explanation Choice A is correct. Coarse tremors would cause the blood pressure reading to be inaccurate. The nurse should not use electronic blood pressure monitoring if the client has these tremors. Choices B, C, and D are incorrect. These client findings would not alter blood pressure measurement. Wearing a watch is not advised if the client has a fistula for dialysis. Tattooing would not alter blood pressure results, and a chest radiograph would not alter the results. Additional Info Client Conditions Not Appropriate for Electronic Blood Pressure Measurement • Irregular heart rate • Known hypertension • Peripheral vascular obstruction (e.g., clots, narrowed vessels) • Shivering • Seizures • Excessive tremors • Inability to cooperate • Blood pressure less than 90 mm Hg systolic

The nurse is caring for a client who reports excessive flatulence and abdominal cramping. The nurse anticipates a prescription for A. simethicone. [52%] B. omeprazole. [26%] C. ferrous sulfate. [6%] D. cimetidine. [15%]

Explanation Choice A is correct. Simethicone is intended to treat excessive flatulence and its discomforts. The drug works by releasing the gas via the mouth or rectum, thus, relieving the cramping sensation. Choices B, C, and D are incorrect. Omeprazole is a proton pump inhibitor indicated in the management of GERD and peptic ulcer disease. Ferrous sulfate is iron and is indicated in the management of iron deficiency anemia. Cimetidine is a medication indicated in the treatment of GERD as well. It is an H2 blocker and works by blocking the histamine receptors in the stomach, therefore, decreasing the secretion of gastric acid. Additional Info For a client with flatulence, another measure they may take is limiting the amount of gas-forming foods such as legumes (beans) and cruciferous vegetables (e.g., cauliflower, broccoli).

The nurse is researching evidence-based practice and needs related literature. The nurse understands that the best source of reliable writing is: A. Systematic review and meta-analysis studies [49%] B. Expert opinions [1%] C. Qualitative studies [17%] D. Case studies [33%]

Explanation Choice A is correct. Systematic reviews and meta-analysis studies provide current, recently summarized evidence, making them the most reliable form of evidence for studies. Choice B is incorrect. Expert opinions may involve bias on the subject, making them unreliable sources of data. Choice C is incorrect. Qualitative studies involve interpretation of the database on the author's understanding of the subject, making these types of literature unreliable sources of data. Choice D is incorrect. Case studies may also involve bias from the authors, making them unreliable sources of data as well.

The client in the ICU is experiencing an increased difficulty of breathing. ABGs for the client return showing PaO2 49 mmHg and oxygen saturation is 68%. The patient is on oxygen via facemask at 10 liters per minute. What should be the next action by the nurse? A. Prepare to intubate the client. [64%] B. Apply manual ventilations with a bag/mask device. [23%] C. Call a code blue and do CPR. [8%] D. Insert an 18-gauge IV catheter and start IV infusion.

Explanation Choice A is correct. The client is having respiratory distress and requires immediate assistance in ventilation. The nurse should prepare the client for intubation right away to prevent further deterioration of his status. Choice B is incorrect. Immediate preparations for intubation and mechanical ventilation should be carried out by the nurse while the client is still breathing. If an arrest occurs, the nurse needs to ventilate the client via a bag/mask device. Choice C is incorrect. If the nurse does not intervene immediately, an arrest situation will occur; at that time, a code blue would be called and CPR initiated. Choice D is incorrect. If the client does not have a patent IV, the nurse should start one, but not before preparing for intubation.

While caring for an 8-month-old child admitted for dehydration, the nurse prepares to administer an IV fluid bolus. She knows that the appropriate amount of fluid bolus is based on the child's weight. Which of the following is appropriate? A. 10 mL/kg [39%] B. 20 mL/kg [44%] C. 30 mL/kg [13%] D. 40 mL/kg [4%]

Explanation Choice B is correct. A child that is admitted for dehydration usually needs IV hydration. Mild to moderate dehydration is often treated with oral rehydration therapy (ORT) solutions as an outpatient. Whereas if a child is requiring inpatient admission, it often means the child is severely dehydrated or not responding to oral rehydration. Severe dehydration should be treated with intravenous fluids until the child is stabilized (i.e. circulating blood volume is restored). Patients with severe dehydration often present with hypovolemic shock, acute renal failure, and altered mental status. Fluid resuscitation with intravenous fluid boluses should be administered followed by maintenance intravenous fluids. The bolus portion of the fluid is the one that is given over 10 to 15 minutes. In children, the bolus fluid is calculated using the formula 20 mL per kg of the child's weight. Only an isotonic crystalloid (normal saline or lactated Ringer solution) must be used in treating dehydration. Frequent reevaluation of the client's vital signs, pulse strength, capillary refill time, mental status, and urine output will guide the nurse on whether further boluses are needed. Rapid delivery is the key in fluid resuscitation. Repeat boluses are administered as necessary. Often, up to 60 mL per kg of fluid (around 3 boluses) may be needed within an hour to achieve stabilization. After initial resuscitation is completed and electrolytes are restored to normal, the child should receive 100 mL per kg of oral rehydration therapy solution over four hours, followed by maintenance fluids. However, if ORT fails following initial resuscitation in a child with severe dehydration, intravenous hydration should be reinitiated. In such cases, continuous hydration with 100 mL per kg of isotonic fluid is given over four hours, followed by maintenance fluids. This same method of fluid resuscitation is also used when ORT fails in a child with moderate dehydration. Choices A, C, and D are incorrect. 10 mL per kg of fluid (Choice A) is considered inadequate for initial IV fluid bolus in a child with dehydration whereas an initial fluid bolus of 30 to 40 mL per kg (Choices C and D) is considered very high for a bolus in a child and is not recommended. The nurse should administer 20 mL of fluid per kilogram of the child's weight.

The nurse is caring for a client who has newly prescribed fondaparinux. The nurse understands that this medication is intended to treat which condition? A. Hemophilia [23%] B. Venous thromboembolism [51%] C. Sickle Cell Anemia [11%] D. Pernicious Anemia [15%]

Explanation Choice B is correct. Fondaparinux is a selective inhibitor of factor Xa, which is indicated for prophylaxis or treatment of DVT or PE. Choices A, C, and D are incorrect. Fondaparinux is not indicated in treating sickle cell anemia, hemophilia, or pernicious anemia. Additional Info Key monitoring parameters for a client receiving fondaparinux include renal function as prolonged exposure may be harmful and reflect increased creatinine. A dose adjustment (or a new anticoagulant) will be required for a client with renal impairment. Monitoring of the aPTT and the platelet count is not necessary with this medication.

Which of the following lipid levels are out of range and should be reported to the physician? A. Triglycerides: 75 mg/dL [16%] B. Total cholesterol: 6.5 mmol/L [46%] C. High-density lipoprotein (HDL): 60 mg/dL [14%] D. Low-density Lipoprotein (LDL): 95 mg/dL

Explanation Choice B is correct. Lipid profile helps physicians determine the patient's risk of developing heart disease. It is recommended that individuals have a lipid profile done at least every five years as part of a regular medical exam. 6.5 mmol/L exceeds the "high normal" total cholesterol level. The average total cholesterol level is 3.5 to 5.0 mmol/L. In milligrams, total cholesterol of 200 milligrams per deciliter (mg/dL) or less is considered desirable for adults Choices A, C, and D are incorrect. The normal lipid levels for these tests include: Triglycerides: 50-150 mg/dL High-density lipoprotein (HDL): 40-80 mg/dL Low-density lipoprotein (LDL): 85-125 mg/dL NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential

A nurse is caring for a client who has Lyme disease. The nurse should anticipate a prescription for which medication? A. Finasteride [9%] B. Doxycycline [62%] C. Valacyclovir [18%] D. Diphenhydramine

Explanation Choice B is correct. Lyme disease is a disease that is caused by the bacteria, Borrelia burgdorferi, which is carried by deer ticks. Symptoms of Lyme disease include a localized rash progressing to generalized symptoms. Doxycycline is one of the antibiotics used to treat this infection. Choice A is incorrect. Finasteride is indicated for benign prostatic hypertrophy. Choice C is incorrect. Valacyclovir is an anti-viral indicated for herpes infections Choice D is incorrect. Diphenhydramine is indicated for seasonal allergies. Additional Info Lyme disease is a tick-borne illness causing the client to have B. burgdorferi. Symptoms may begin one month after a client was exposed to the bacteria via the tick. The symptoms start with the classic bullseye rash progressing to lymph node enlargement, arthralgias, malaise, fatigue, and encephalopathy. The mainstay treatment is antibiotics such as doxycycline. The client can reduce their risk of being exposed by wearing long sleeve clothing, tick repellent, and avoiding high grass and wooded areas without the recommended attire.

The RN provides teaching to a patient with epilepsy who has just been started on carbamazepine to control seizure activity. Which information would be important for the nurse to include regarding this medication? A. Take this medication with 8 ounces of water or juice. [15%] B. Avoid taking this medication on an empty stomach. [24%] C. Discontinue immediately if any vision changes occur. [23%] D. Avoid strenuous activity if drowsiness occurs. [37%]

Explanation Choice B is correct. The nurse should instruct this patient that carbamazepine should be taken with meals. The patient should avoid taking this medication on an empty stomach in order to reduce the risk of experiencing side effects. Choice A is incorrect. The nurse should instruct this patient that carbamazepine should not be taken with grapefruit juice due to the risk of a chemical found naturally in grapefruit potentiating this medication's effects. Choice C is incorrect. The nurse should instruct this patient to notify their practitioner if vision issues occur, as this is a potential side effect of the medication. However, this medication should not be discontinued abruptly due to a risk of increased seizures. Choice D is incorrect. The nurse should instruct this patient to notify their practitioner if excessive drowsiness, weakness, or a change in mental status occurs while taking this medication.

The nurse is assessing a client with ulcerative colitis. Which of the following would be an expected finding? A. Projectile vomiting [10%] B. Frequent bloody stools [80%] C. Absent bowel sounds [6%] D. Periumbilical bruising [4%]

Explanation Choice B is correct. Ulcerative colitis has clinical features such as frequent bloody stools, iron deficiency anemia, colicky abdominal pain, fever, fatigue, and weight loss. Choices A, C, and D are incorrect. Ulcerative colitis does not cause a client to have projectile vomiting. This would be a feature most associated with pyloric stenosis. The bowel sounds associated with ulcerative colitis are high-pitched. Periumbilical bruising is a problematic feature of necrotizing pancreatitis. NCLEX Category: Physiological Adaptation Activity Statement: Alterations in Body Systems Question type: Knowledge/comprehension Additional Info Ulcerative colitis is an inflammatory bowel disorder that may cause an individual to have classic colicky abdominal pain that may produce multiple bloody stools. This, in turn, may cause an individual to become dehydrated and anemic. Nursing care is aimed at symptom management and providing prescribed medications such as steroids during exacerbations and immunomodulators to reduce flares.

The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication? A. Passive range of motion [2%] B. Sequential compression devices (SCDs) [3%] C. Early ambulation [77%] D. Prophylactic antibiotics [18%]

Explanation Choice C is correct. Early ambulation is beneficial because it prevents venous thromboembolism (VTE) and respiratory complications such as hypostatic pneumonia. Ambulation increases ventilation and mobilizes secretions, both of which help prevent the development of pneumonia. Choices A, B, and D are incorrect. Passive range of motion would help with joint mobility but would not mobilize respiratory secretions. The client needs early ambulation. SCDs would be helpful to prevent VTE - not pneumonia. Prophylactic antibiotics are invasive, expensive, and could lead to resistance. This is not an effective remedy for preventing pneumonia. Surgical clients may get antibiotics, but they intend to prevent surgical site infections. Additional Info Early ambulation in the post-operative period is highly effective in the prevention of venous thromboembolism and pneumonia. Other measures that should be implemented include frequent hand hygiene and incentive spirometry.

Which client will most likely get this device for intravenous therapy? A. A 26-year-old client who has appeared in the emergency department with a sprain. [14%] B. A hospitalized client who will be receiving intravenous fluids and electrolytes for 3 days. [16%] C. A burn client in the burn unit who has fragile skin secondary to severe burns. [39%] D. A 26-year-old client in the emergency department who has uncomplicated acute dehydration. [32%]

Explanation Choice D is correct. A 26-year-old client in the emergency department who has uncomplicated acute dehydration is the most likely to get this butterfly catheter. Butterfly catheters are used for short-term intravenous therapy for less than 24 hours, as can be anticipated for this client who most likely will get short-term fluid replacements and monitoring in the emergency department. Butterfly catheters are also used for drawing blood specimens and IV push medications. Choice A is incorrect. A 26-year-old client who has appeared in the emergency department with a sprain will most likely not get intravenous therapy; therefore, this device would not be used for this client. Choice B is incorrect. A hospitalized client who will be receiving intravenous fluids and electrolytes for three days will not get this device. Another intravenous device will be needed. Choice C is incorrect. A burn client in the burn unit who has fragile skin secondary to severe burns is not a candidate for this device. Burn clients need multiple intravenous lines, and this would not be one of them.

The nurse is reviewing the diet of the patient with hypoparathyroidism. The nurse understands that the client should be on what type of diet? A. High calorie, low calcium diet [8%] B. Low calcium, low phosphorus diet [4%] C. High phosphorus, low calcium diet [10%] D. High calcium, low phosphorus diet [78%]

Explanation Choice D is correct. A client with hypoparathyroidism should receive a diet that is high in calcium and low in phosphorus. A high calcium diet may increase the client's serum calcium levels. A low phosphorus diet ensures that his phosphorus levels are reduced enough so that it will not interfere with his calcium levels. Calcium and phosphorus have an inversely proportional relationship. Choice A is incorrect. It does not matter whether the client is eating a high-calorie diet, as long as the client adheres to a diet high in calcium and low in phosphorus. Choice B is incorrect. A client with hypoparathyroidism should receive a diet that is high in calcium and low in phosphorus. Choice C is incorrect. A client with hypoparathyroidism should receive a diet that is high in calcium and low in phosphorus. Additional Info

You are caring for a newborn born at term. On your assessment. You note that central cyanosis is present and persistent at five minutes after birth. You attach a pulse oximeter to the newborn. When determining whether or not the infant requires supplemental oxygen, you know that the expected oxygen saturation at 5 minutes after birth is: A. 65-70% [5%] B. 70-75% [7%] C. 75-80% [19%] D. 80-85%

Explanation Choice D is correct. At five minutes after birth, the expected SpO2 is in the 80-85% range. Regardless of the cyanosis, if the oxygen saturation is within this range, the infant probably does not need supplemental oxygen at this point. The American Heart Association and American Academy of Pediatrics suggest the following table for Target Pre-ductal Oxygen Saturation levels following birth. Choices A, B, and C are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Hemodynamics, Newborn

The nurse is assessing a patient with Guillain Barré syndrome. Which of the following would be an expected finding? A. Hyperreflexia [13%] B. Perseveration [2%] C. Dystonia [26%] D. Paresthesia

Explanation Choice D is correct. Guillain Barré is a polyneuropathy that is manifested by paralysis, paresthesia, autonomic disturbances, and depressed or absent reflexes. The paresthesia is typically found in the peripheral extremities and may persist for quite some time even after the return of motor function. Choices A, B, and C are incorrect. Depressed or absent reflexes are a hallmark of this disease process. Perseveration is when and the individual continues to repeat something such as a phrase. This is commonly seen in Alzheimer's disease. This is not a feature in Guillain-Barré. Dystonia is an adverse effect associated with dopaminergic drugs such as haloperidol. This muscle repetitive muscle contraction is not related to Guillain Barré. Additional information: The nurse should recognize Guillain Barré quickly and ensure a patent airway as the ascending paralysis may impact the diaphragm. The cause of Guillain Barré can be certain pathogens such as Campylobacter jejuni, which may induce massive peripheral nerve demyelination. Other causes include certain immunizations and bone marrow transplantation.

Your client is affected by nightmares, flashbacks to a previous event, as well as unyielding intrusive and threatening thoughts. Which disorder is this client most likely affected with? A. A panic disorder [1%] B. A phobia [1%] C. An anxiety disorder [1%] D. Post-traumatic stress disorder [97%]

Explanation Choice D is correct. Post-traumatic stress disorder is characterized by ongoing and unyielding nightmares, flashbacks to a previous event, as well as intrusive and threatening thoughts. Post-traumatic stress occurs primarily among those who have witnessed and have been exposed to a severe traumatic event like rape or acting as a soldier when observing or participating in the killing of others during warfare. Choice A is incorrect. A panic disorder is characterized by severe generalized anxiety, fear, discomfort, and dread; not nightmares, flashbacks to a previous event, or unyielding intrusive and threatening thoughts. Choice B is incorrect. Phobias are an unwarranted and irrational fear of an object or situation that is harmless; not nightmares, flashbacks to a previous event, or unyielding intrusive and threatening thoughts. Choice C is incorrect. Anxiety disorders are characterized by varying degrees of generalized anxiety from mild to severe; not nightmares, flashbacks to a previous event, or unyielding intrusive and threatening thoughts.

You are triaging a new patient in the antepartum unit. They tell you that they started bleeding this morning and were told to come in by their OB. They deny any pain or other symptoms. Which of the following nursing interventions do you anticipate initiating? Select all that apply. A. Bed rest [39%] B. Pad counts [41%] C. Emergency vaginal delivery [5%] D. Vaginal exam [14%]

Explanation Choices A and B are correct. The nurse suspects a placenta previa based on the client's complaint of painless bleeding. With a placenta previa, bed rest is indicated to prevent further bleeding. This is an appropriate nursing intervention to initiate for both the safety of the mother and fetus and should be done right away (Choice A). Pad counts are a way of monitoring the quantity of blood loss. Since the nurse suspects placenta previa and the patient is reporting vaginal bleeding, pad counts are an appropriate nursing intervention to initiate. When obtaining pad counts, they can be done in two ways. If the exact quantity of blood loss is not indicated, the nurse can just count the number of pads saturated with blood. If the health care provider orders strict monitoring, the pads will be weighed to obtain the exact amount of milliliters of blood lost. When considering pads, 1 gram is 1 milliliter of blood lost. Pad counts at a minimum should be initiated for any suspected placenta previa, so this is an appropriate nursing intervention (Choice B). Choice C is incorrect. An emergency vaginal delivery is contraindicated for a patient with suspected placenta previa. Since we believe that the placenta is either partially or fully covering the cervix of this patient, a cesarean section will need to be performed. This may be distressing for some mothers, so be sure to provide education about why this is the safest option for them and their baby's health. Vaginal deliveries with a placenta previa can cause serious harm to the mother and fetus and are contraindicated. Choice D is incorrect. Vaginal exams are contraindicated for a patient with a suspected placenta previa. In this patient, we suspect that the placenta is either partially or fully covering the cervix. That means that if a vaginal exam were to be performed, the hand of the examiner would touch the placenta. We do not want to cause this irritation and exacerbate the bleeding that is already occurring. Vaginal exams are always contraindicated in patients with either confirmed or suspected placenta previa. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery Additional Info

Which of the following statements regarding pressure ulcers are true? Select all that apply. A. In a stage II pressure ulcer, part of the dermis and epidermis are lost. [31%] B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only. [21%] C. In a stage III pressure ulcer, there is a deep tissue injury that can expose fat. [33%] D. In a stage IV pressure ulcer, the base of the wound is covered by eschar. [15%]

Explanation Choices A and C are correct. Stage II pressure ulcers occur when the epidermis is lost as well as part of the dermis (Choice A). Stage III pressure ulcers expose subcutaneous fat but do not extend deep enough to expose the bone and muscle. That would be considered a Stage IV pressure injury (Choice C). Choice B is incorrect. Stage I pressure ulcers do not involve any loss of tissue. The epidermis remains intact, but it is reddened and does not blanch. Choice D is incorrect. Stage IV pressure ulcers expose bone and muscle. If the base of the wound is covered by slough or eschar, the nurse can't assess how deep the pressure injury goes. Therefore the pressure ulcer is considered unstageable. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Integumentary

The nurse is teaching a client about congestive heart failure (CHF). Which of the following information should the nurse include? Select all that apply. A. "Foods such as canned vegetables and luncheon meat should be avoided." [33%] B. "Weigh yourself daily and notify the physician when weight gain is more than ten pounds in a week." [24%] C. "You may continue to take ibuprofen for your aches and pains." [8%] D. "Annual immunizations such as the influenza vaccine are recommended." [30%] E. "If you feel sick, you will need to check your urine for ketones." [4%]

Explanation Choices A and D are correct. Congestive heart failure (CHF) is a chronic condition that causes a decrease in cardiac output. The client will need to maintain a low sodium diet, so processed foods such as luncheon meat should be avoided. Annual immunizations are recommended because of the increased risk of complications from influenza. Complications from influenza are higher in those with co-morbidities such as CHF. Choice B is incorrect. The client should be taught to weigh themselves daily and to report a weight gain of five pounds or more within one week. The client must not wait until he/she gains 10lbs/week. Choice C is incorrect. NSAIDs such as ibuprofen may contribute toward fluid retention and should not be used in clients with CHF. Choice E is incorrect. Assessing the urinary ketones is only done for those with hyperglycemia secondary to diabetes mellitus. This is done to check for the potential development of ketoacidosis. Additional Info For a client with heart failure, self-management strategies include following the MAWDS approach. Medications • Take medications as prescribed and do not run out. • Know the purpose and side effects of each drug. • Avoid NSAIDs to prevent sodium and fluid retention. Activity • Stay as active as possible but don't overdo it. • Know your limits. • Be able to carry on a conversation while exercising. Weight • Weigh each day at the same time on the same scale to monitor for fluid retention. Diet • Limit daily sodium intake to 2 to 3 g as prescribed. • Limit daily fluid intake to 2 L. Symptoms • Note any new or worsening symptoms and notify the health care provider immediately.

The nurse is assisting a client in choosing food choices that are appropriate for hypertension. Which food items would be appropriate to select? Select all that apply. A. Grilled chicken [30%] B. Bacon [1%] C. Scrambled eggs [22%] D. Smoked salmon [16%] E. Boiled lentils [32%]

Explanation Choices A, C, and E are correct. Hypertension is best managed with a low sodium diet. Choices A, C, E are low sodium foods. Choices B and D are incorrect. Bacon and smoked salmon contain a high content of sodium. The client should be instructed to avoid these foods. Additional information: Clients with hypertension should avoid foods that are high in sodium. A diet high in sodium increases fluid accumulation thereby raising the client's blood pressure. The client should be educated to avoid foods that are processed, cured, or canned. The client should use natural seasonings over table salt to flavor food. NCLEX Category: Basic Care and Comfort Related Content: Nutrition and Oral Hydration Question Type: Application

Which of the following are symptoms of true labor? Select all that apply. A. Contractions that dissipate with walking [2%] B. Contractions that come in regular intervals [38%] C. Lower back pain [27%] D. Contractions of consistent intensity [33%]

Explanation Choices B and C are correct. Contractions that come in regular intervals are a sign of actual labor. You should educate mothers to seek care for contractions that occur at regular intervals, become stronger, and closer together with time. These contractions will also not go away with a change in position or activity (Choice B). Lower back pain is a sign of actual labor. Both lower back pain and pelvic pain indicate real labor, so mothers should be educated to seek treatment when such symptoms present. 'False' labor, or Braxton hicks, do not present with these symptoms. They are much weaker than contractions and typically subside with a change in position or by going on a short walk (Choice C). Choice A is incorrect. Contractions that fade away with activity, a change in position, or rehydration are not a sign of actual labor. These are more likely Braxton Hicks contractions, which do not indicate labor. They are 'practice contractions' for the uterine muscle. Real contractions will not fade with activity; they come in regular intervals, become closer together, and get more intense as time goes on. Choice D is incorrect. Contractions of consistent intensity indicate Braxton hicks or 'false' labor. When a mother is in real labor, her contractions will increase in intensity over time. Education should be provided on the difference between Braxton hicks and actual labor so that mothers know when to call their OB and seek treatment. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery

The nurse is teaching a new graduate about nutrition screening and assessment for a newly admitted client with chronic obstructive pulmonary disease (COPD). He weighs 150 lbs but reports unintentional weight loss of 18 lbs in the last six months. Which of the following statements by the nurse indicates the further need for teaching? Select all that apply. A. "Client's weight loss indicates he is at risk of malnutrition." [14%] B. "Client's COPD by itself does not put him at risk of malnutrition." [26%] C. "Client's labs including serum albumin are needed for full nutritional assessment." [16%] D. "Fluid accumulation is one of the criteria in diagnosing malnutrition." [26%] E. "Client's mid-arm circumference is a good indicator of muscle mass." [18%]

Explanation Choices B and C are correct. These statements by the new nurse are not exact and indicate a need for additional teaching. Choice B (Client's COPD by itself does not put him "at-risk" of malnutrition) is not a valid statement by the new nurse and needs further teaching. Any chronic disease significantly increases the risk of malnutrition. Malnutrition is seen in about 35% of patients with COPD and is associated with poor outcomes and more extended hospitalization. Identifying these patients at the time of admission provides for addressing their nutritional needs appropriately. A nurse must be aware of nutrition screening to identify at-risk patients, components of nutritional assessment, and criteria for diagnosing malnutrition. Nutrition screening: must be performed for all hospitalized patients within 24 hours of admission. The purpose of this is to identify those who are malnourished or at risk of malnutrition. If the client is found to be "at-risk," a detailed nutrition assessment should then be undertaken. Adult clients with any of the following are considered "at-risk" for malnutrition: Unintentional weight loss of 10% or more within six months (Choice A) Unintentional weight loss of 5% or more within one month Unintentional weight loss or gain of 10 lb within six months Chronic disease (i.e. COPD, Ulcerative colitis) Inadequate nutrient intake (not receiving food for more than seven days) BMI (body mass index) below 18.5 kg/m2 or above 25 kg/m2. Alteration in dietary intake or dietary schedule Increased metabolic requirements (i.e. COPD, Hyperthyroidism) Nutrition assessment: Once the patient is determined to be "at-risk" for malnutrition, a detailed nutritional assessment must be carried out. This comprehensive assessment may incorporate: Information from patient history (weight-loss or weight-gain history, medication history, nutrition history, chronic disease history). Physical exam findings such as trouble chewing, swallowing disorders, hand-grip strength, skin integrity, fluid accumulation such as edema/ascites. Anthropometric measurements such as height and weight measurement, body mass index, measurements limb circumferences, and skin folds. Diagnosis of malnutrition: In 2009, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) set six criteria to diagnose malnutrition in adults. The presence of two or more of the below mentioned six characteristics is diagnostic of Malnutrition: According to ASPEN's evidence-based analysis, serum albumin and pre-albumin are not included as defining criteria of malnutrition (Choice C). This is because the serum albumin may not genuinely indicate nutritional status, but rather indicate the severity of current illness and chronic illness. It must be noted that no laboratory test is both sensitive to and specific for protein-calorie malnutrition. Therefore, Choice C (Client's serum albumin is needed for full nutritional assessment) is not a valid statement by the new nurse and needs further teaching. In monitoring nutritional outcomes for patients on total parenteral nutrition (TPN), pre-albumin and albumin can be used - this is not for initial assessment but for tracking whether the client is responding to TPN. Choices A, D, and E are incorrect. These are true statements and reflect correct understanding by the new nurse. The client lost 10% weight in the last six months, which puts him at risk for malnutrition (Choice A). The mid-arm circumference is indeed an excellent indicator of muscle mass (Choice D). Fluid accumulation such as pedal edema, ascites, and anasarca is one of the six criteria proposed by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) to diagnose malnutrition. NCSBN Client Need Topic: Basic Care and Comfort; Sub-Topic: Nutrition and Oral hydration

You are working in the emergency department. Your adult patient has an endotracheal tube (ETT) in place and a team member is providing assisted ventilation. Which of the following medications can be instilled in the ETT? Select all that apply. A. Morphine [16%] B. Lidocaine [26%] C. Epinephrine [29%] D. Atropine [29%]

Explanation Choices B, C, and D are correct. According to the American Heart Association, lidocaine, epinephrine, and atropine can all be given via the ETT. It is essential to know that the dosage of a medication given via the endotracheal tube will usually be higher than if provided via the IV or IO routes. An easy way to remember what medications you can give via the ETT is by remembering the NAVEL mnemonic: N = Naloxone, A = Atropine, V = Vasopressin, E = Epinephrine, and L = Lidocaine. In the pediatric population, do not give vasopressin via an ETT. Choice A is incorrect. Medications other than these can damage the airways if instilled into the tube. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Medication Administration

Which of the following is least likely to develop trust in the nurse-client relationship? Select all that apply. A. Using consistency in approaching the client [7%] B. Encourage the client to use "testing" behaviors [28%] C. Tell the patient how she should behave [37%] D. Avoid setting limits [27%]

Explanation Choices B, C, and D are correct. Avoiding limit setting, encouraging testing behaviors, and telling the client how they should behave does not instill trust. Therefore, these are the correct answers to the question. Choice A is incorrect. One of the essential elements of trust is consistency. The client learns to trust that the nurse will follow through and do what is promised. Therefore, this is the incorrect answer to the question. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: The Helping Relationship

Which of the following findings may indicate a change in mental status? Select all that apply. A. Asymmetrical movements [20%] B. Lethargy [32%] C. Disheveled appearance [23%] D. Rapid speech [24%]

Explanation Choices B, C, and D are correct. Changes in appearance, speech, and alertness may indicate a change in mental status and require further evaluation. An alteration in mental status refers to general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, disorientation (not conscious of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception, psychomotor skills, and practice. While an altered mental status is characteristic of several psychiatric and emotional conditions, medical conditions and injuries that cause damage to the brain, including alcohol or drug overdose and withdrawal syndromes, can also cause mental status changes. Confusion, lethargy, delirium, dementia, encephalopathy, and organic brain syndrome are all terms that have been used to refer to conditions hallmarked by mental status changes. Choice A is incorrect. Asymmetrical movements may indicate a stroke and a specific change in neurological status. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Mental Status

A client in the medical ward developed a sudden drop in blood pressure, difficulty of breathing, and cyanosis after receiving intravenous penicillin. With the nurses' understanding of anaphylactic reactions, what can the nurse conclude is the cause of this reaction? A. Potent antibodies were formed when the antibiotic was being infused into the patient. [42%] B. The client was previously exposed to penicillin which enabled his body to produce antibodies. [34%] C. Passive immunity to penicillin was developed by the client. [9%] D. Atopic sensitization occurred. [15%]

Explanation Choice B is correct. Hypersensitivity reactions occur when antibodies are formed through previous exposure to an allergen. Choice A is incorrect. Antibodies were formed in the prior exposure to penicillin, not during the current exposure. Choice C is incorrect. A hypersensitivity reaction is an active immune response. Choice D is incorrect. A hypersensitivity reaction has occurred, not an atopic sensitization.

The nurse is assessing a client who has developed cardiac tamponade. Which of the following findings would the nurse expect to observe? Select all that apply. A. Bibasilar crackles [14%] B. A systolic murmur [17%] C. Bradycardia [13%] D. Jugular Venous Distention [30%] E. Hypotension [26%]

Explanation Choices D and E are correct. Classic manifestations of cardiac tamponade include tachycardia, tachypnea, pericardial rub, jugular venous distention, and hypotension with a narrowed pulse pressure. Choices A, B, and C are incorrect. Bibasilar crackles, a systolic murmur, and bradycardia would not be consistent with cardiac tamponade. The client with cardiac tamponade would have tachycardia to increase cardiac output, coupled with a pericardial friction rub if the tamponade is caused by inflammation. NCLEX Category: Physiological Adaptation Activity Statement: Alterations in Body Systems Question type: Knowledge/comprehension Additional Info Cardiac tamponade may be caused by an array of infectious and noninfectious reasons. Immediate treatment of cardiac tamponade would be pericardiocentesis. A needle is inserted to aspirate the pericardial fluid in this ultrasound-guided procedure. The provider may elect to leave a temporary catheter in place in the pericardium to drain more fluid. Nursing care involves reporting any suspicion of cardiac tamponade promptly to the provider.

Which of the following statements regarding the hormone atrial natriuretic peptide (ANP) are true? Select all that apply. A. ANP is found in the brain. [15%] B. ANP causes the excretion of sodium. [29%] C. ANP works to increase fluid volume. [25%] D. ANP works synergistically with aldosterone. [30%]

Explanation Choice B is correct. Atrial natriuretic peptide (ANP) works to cause sodium excretion and, therefore, the excretion of water. This is to lower the fluid volume through diuresis. Choice A is incorrect. The atrial natriuretic peptide is found in the atria of the heart. There are stretch receptors present there, which will sense an increase in fluid in the center, releasing ANP when the fluid volume is high. Choice C is incorrect. ANP works to decrease the fluid volume, not increase, through the excretion of sodium and water. Choice D is incorrect. ANP works opposite of aldosterone, not synergistically with it. Aldosterone causes the retention of sodium and water, therefore increasing fluid volume, whereas ANP causes sodium and water excretion, thus decreasing fluid amount. Note: Some have the misconception that select all that apply should always have more than one option. NCSBN clearly states that SATA can just be one option or more than one or all options. To help you practice such kinds of questions, the Qbank has some questions where SATA has only one correct response. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Fluid & Electrolytes

When epinephrine is administered to a client, the nurse should expect this agent to rapidly affect: A. Adrenergic receptors [69%] B. Muscarinic receptors [3%] C. Cholinergic receptors [27%] D. Nicotinic receptors [1%]

Explanation Choice A is correct. Epinephrine rapidly affects both alpha and beta-adrenergic receptors, eliciting a sympathetic response. Epinephrine is a hormone secreted by the medulla of the adrenal glands. Strong emotions such as fear or anger cause epinephrine to be released into the bloodstream, which causes an increase in heart rate, muscle strength, blood pressure, and sugar metabolism. Choice B is incorrect. Muscarinic receptors are cholinergic receptors and are primarily located at parasympathetic junctions. Choice C is incorrect. Cholinergic receptors respond to acetylcholine stimulation. Cholinergic receptors include muscarinic and nicotinic receptors. Choice D is incorrect. Nicotinic receptors are cholinergic receptors activated by nicotine and found in autonomic ganglia and somatic neuromuscular junctions. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse is caring for a 16-year-old client with cystic fibrosis. The client develops a temperature of 101.2 degrees F (38.4C). Which medication does the nurse administer with top priority? A. IV antibiotic [69%] B. Pancreatic enzyme [15%] C. Fat soluble vitamin [2%] D. Albuterol [13%]

Explanation Choice A is correct. Administering the IV antibiotic is the top priority in a client with cystic fibrosis (CF) that develops a fever. Due to the excessively thick mucus that builds up in their bronchi and bronchioles, children with CF are incredibly susceptible to respiratory infections. A fever is an indication of infection and aggressive management is the top priority. Choice B is incorrect. Pancreatic enzymes are administered to children with CF within 30 minutes of any meal and snack. These are given to aid in digestion since the excessive, sticky mucus clogs up the pancreatic duct in these clients. This is a standard medication given every day, but is not the top priority when a child with CF develops a fever. Choice C is incorrect. Fat soluble vitamins are a daily medication for children with CF. Due to the buildup of excessive, sticky mucus in their bile duct, children with CF do not absorb fat normally. This leads to a deficiency in fat soluble vitamins, which are vitamins A, D, E, and K. This is a standard medication given every day, but is not the top priority when this client develops a fever. Choice D is incorrect. Albuterol is a bronchodilator frequently given as a nebulizer treatment to clients with CF. Although this medication might be given top priority if the client was experiencing respiratory difficulty, the question states they have developed a fever. Due to this finding, the IV antibiotics are the top priority as CF clients are very susceptible to infections. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatric - Respiratory

The nurse is preparing a staff in-service regarding conductive hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. A. Presbycusis [12%] B. Prolonged exposure to noise [21%] C. Foreign body [24%] D. Ototoxic substance [21%] E. Cerumen [21%]

Explanation Choices C and E are correct. Conductive hearing loss is typically reversible and caused by cerumen, foreign body, tumor, edema, and acute infection. Choices A, B, and D are incorrect. These are all causes of sensorineural hearing loss, which is often irreversible. Additional Info Hearing loss is divided into sensorineural or conductive. Conductive hearing loss is caused by obstruction. Causes of this type of hearing loss include cerumen, foreign body, water, edema, infection, or tumor. This type of hearing loss may be reversible. Impairments of the nerve fibers cause sensorineural hearing loss. Causes of this type of hearing loss include prolonged exposure to noise, ototoxic substances (aminoglycosides), diabetes mellitus, and presbycusis (age-related hearing loss). This type of hearing loss is often not reversible.