Archer Review 3b

You have been asked to witness informed consent with your signature and title. What does this signature signify and mean? A. It means that you have taught the client about the procedure or treatment. [2%] B. It means that you can validate the client's signature and identity. [26%] C. It means that you can confirm and validate that the client is fully informed. [69%] D. It means that you have taught the client and you can confirm their knowledge. [3%]

Choice B is correct. When you, as a nurse, witness an informed consent with your signature and title, this signature signifies and means that you can validate the client's name and identity. It does not say that you taught the client about the procedure or treatment or confirm their understanding of the process or treatment. Choice A is incorrect. When you, as a nurse, witness an informed consent with your signature and title, this signature does NOT signify or mean that you have taught the client about the procedure or treatment. It means something else. Choice C is incorrect. When you, as a nurse, witness an informed consent with your signature and title, this signature does NOT signify or mean that you can confirm and validate that the client is fully informed about the procedure or treatment. It means something else. Choice D is incorrect. When you, as a nurse, witness an informed consent with your signature and title, this signature does NOT signify or mean that you have taught the client and you can confirm their knowledge about the procedure or treatment. It means something else.

While precepting a new nurse in the emergency department, you know she understands the steps for adult CPR when she places the following actions in which order? Determine that the patient is unconscious. Initiate chest compressions. After 30 compressions, open the airway with the head tilt-chin lift maneuver. Deliver 2 rescue breaths. Check for a pulse for no longer than 10 seconds at the carotid artery.

Determine that the patient is unconscious. Check for a pulse for no longer than 10 seconds at the carotid artery. Initiate chest compressions. After 30 compressions, open the airway with the head tilt-chin lift maneuver. Deliver 2 rescue breaths. Explanation According to the American Heart Association (AHA), the first step to CPR is determining that the patient is unconscious. Next, the nurse should check for a pulse at the carotid. Take no longer than 10 seconds, and if no vibration is felt proceed to initiate chest compressions. Compression is delivered at a depth of 2 inches of the anterior-posterior diameter and at a rate of 100-120 compressions/minute, or once every 5-6 seconds. After doing 30 high-quality compressions, the airway should be opened with the head tilt-chin lift maneuver. Lastly, two rescue breaths should be given with a visible chest rise noted. The nurse will continue delivering 30 compressions and two rescue breaths until help arrives, pending further interventions. NCSBN Client Need Topic: Physiological AdaptationSubtopic: Medical Emergencies

The emergency department nurse is caring for a client with an abdominal aortic aneurysm at risk of rupturing. The nurse will anticipate the primary healthcare provider (PHCP) to prescribe A. esmolol. [52%] B. dexamethasone. [14%] C. heparin. [23%] D. pantoprazole. [11%]

Explanation Choice A is correct. For a client with a suspected ruptured (or rupturing) abdominal aortic aneurysm, tight blood pressure control is essential. Esmolol is a beta-blocker and will exert antihypertensive effects. Having tight blood pressure control decreases the pressure on the aneurysm. For a client with an unstable abdominal aortic aneurysm, the nurse should provide close monitoring of their vital signs and adequate pain control. Choices B, C, and D are incorrect. These medications are not indicated in the management of abdominal aortic aneurysms. Heparin would be contraindicated for a client with an abdominal aortic aneurysm because if the client needs surgery, this could cause a delay.

The nurse cares for a client who sustained full-thickness thermal burns to 30% of their total body surface area (TBSA). Which of the following initial laboratory values would be expected? A. Potassium 5.6 mEq/L [73%] B. Hematocrit 30% [18%] C. BUN 14 mg/dL [5%] D. Glucose 89 mg/dL [3%]

Explanation Choice A is correct. Hyperkalemia is an expected finding for a client with a major burn (any full-thickness burn > 10% TBSA). This results from significant cellular damage, which allows intracellular potassium to leak. Choices B, C, and D are incorrect. Vascular dehydration would result immediately following a burn, so the hematocrit would be elevated - not low. This dehydration would also cause an increase in the BUN. Thus, the BUN would be greater than 20 mg/dL. Hyperglycemia is likely because of the stress of the burn. Additional information: Following a major thermal burn, the nurse should immediately: Assess airway patency Administer supplemental oxygen, as indicated Keep the client NPO Initiate IV line and telemetry monitoring Provide prescribed fluid resuscitation Keep the burns covered with sterile dressings NCSBN Client need: Topic: Physiological Adaptation; Subtopic: F&E Imbalances

You are taking care of a 7-year-old female in the pediatric bone marrow transplant unit. She has been in the hospital for about a year and is working on her school work with the hospital teacher. You note that she is growing increasingly frustrated with her math homework. You know that her successful completion of academic demands is vital to her psychosocial development, as she is in which stage of psychosocial development? A. Industry vs. Inferiority [66%] B. Autonomy vs. Shame and Doubt [16%] C. Trust vs. Mistrust [1%] D. Initiative vs. Guilt [17%]

Explanation Choice A is correct. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in inferiority. Choice B is incorrect. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure, and it results in shame and self-doubt. Choice C is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop a sense of confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust. Choice D is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds. In Initiative vs. Guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Development

According to the American Liver Foundation, the maximum dosage of acetaminophen with long-term use should be limited to no more than: A. 3,000 mg per day [49%] B. 4,000 mg per day [41%] C. 5,000 mg per day [6%] D. 6,000 mg per day [4%]

Explanation Choice A is correct. Long-term acetaminophen use may be defined as using acetaminophen for more than 5-7 days. According to the American Liver Foundation, the maximum dosage of acetaminophen with long-term use should be limited to no more than 3,000 mg per day. For short-term use ( less than five days), healthy individuals may take acetaminophen up to a daily maximum of 4000 mg. The American Liver Foundation also limits the short-term daily dosage of acetaminophen to no more than 3,000 mg when the client is at risk for hepatic damage. An even lower threshold of 2000 mg per day maximum dose should be applied in clients with pre-existing liver disease. Choice B, C, and D are incorrect. Acetaminophen overdoses are common. Historically, the maximum recommended daily adult dose of acetaminophen has been 4000 mg per day. This is safe if acetaminophen is prescribed for short-term use. However, it has been found that toxicity had occurred even when the doses were slightly higher than 4000 mg/ day with long-term use. Therefore, a safer risk-benefit balance is achieved with long-term use when doses can be limited to 3000 mg per day. Learning Objective Understand that a safer maximum daily dosage limit of acetaminophen with long-term use is 3000 mg per day.

You are working in the intensive care nursery and are assigned to take care of an infant withdrawing from cocaine. At your first assessment, you appreciate the following: a high-pitched cry, no tremors, increased muscle tone, sleeping for 3 hours in between feedings, no congestion, respiratory rate = 42, excessive sucking on the pacifier, poor nutrition, no vomiting, and no loose stools. What is the neonatal abstinence score (NAS) for this patient? A. 7 [36%] B. 12 [20%] C. 2 [6%] D. 8 [38%]

Explanation Choice A is correct. Neonatal abstinence syndrome (NAS) occurs due to sudden withdrawal of the fetus due to the discontinuation of substances used/abused by the mother during pregnancy. The Finnegan scoring system is commonly used to assess the severity of NAS. The NAS score uses 21 symptoms that are mostly seen in opiate-exposed infants. A numerical score is assigned to each sign and its corresponding severity. The total abstinence score is determined by the sum of the numerical score attached to each sign. This scoring can help guide initiation, monitoring, and cessation of treatment in the newborn. The initial treatment of NAS includes nonpharmacological methods. If improvement is not noted with nonpharmacological measures or if the infant develops severe withdrawal symptoms, pharmacological agents are used. NAS score helps in assessing the severity. The most common agent used in the treatment of NAS secondary to opioids is morphine. The infant may breastfeed unless the mother is involved in polysubstance abuse or has HIV. Each of these observations gives you a part of the NAS score for this infant: High pitched cry = 2 points No tremors = 0 points Increased muscle tone = 2 points Sleeping for 3 hours in between feedings = 0 points No congestion = 0 points RR = 42 = 0 points Excessive sucking on the pacifier = 1 point Poor feeding = 2 points No vomiting = 0 points No loose stools = 0 points This adds up to a total of 7 points for the NAS score for this patient. A score of 7 is in the moderate range. Less than five is mild, 5-8 is average, 8-12 is severe, and greater than 12 is very critical. For a score of 7, a breakthrough dose of morphine may not be appropriate, but the infant may not be ready to wean down on their methadone further.

The nurse is caring for a client with the below laboratory result. Which early vital sign change would the nurse expect to support this finding? See the image below. A. Tachycardia [55%] B. Bradycardia [7%] C. Hypotension [29%] D. Bradypnea [9%]

Explanation Choice A is correct. The hemoglobin and hematocrit are critically low in this client. When critically low hemoglobin is evident, the nurse will likely see the client demonstrate tachycardia as a compensatory mechanism for the low blood volume. Tachycardia is the most reliable and earliest sign of hypovolemic shock. Choices B, C, and D are incorrect. Hypotension is not an early sign of hypovolemic shock. The first changes in vital signs seen in hypovolemic shock include increased diastolic blood pressure with narrowed pulse pressure. As volume status continues to decrease, systolic blood pressure drops. Bradypnea is a late sign of shock. Additional Info The first changes in vital signs seen in hypovolemic shock include restlessness, tachycardia, and increased diastolic blood pressure with narrowed pulse pressure. As volume status continues to decrease, systolic blood pressure drops. In the case of hypovolemic shock caused by blood loss, the nurse would expect a prescription for packed red blood cells. One unit of packed red blood cells will raise the hemoglobin by 1 g/dL.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse should anticipate a prescription for which medication? See the image below. A. Adenosine [54%] B. Atropine [11%] C. Labetalol [10%] D. Amiodarone [25%]

Explanation Choice A is correct. The tracing reflects supraventricular tachycardia (SVT). The preferred medication for individuals experiencing SVT includes the rapid administration of adenosine followed by a rapid flush of 0.9% saline. Adenosine slows the electrical conduction time through the AV node. Choices B, C, and D are incorrect. Atropine is indicated for the treatment of symptomatic sinus bradycardia. Labetalol is indicated for a hypertensive emergency and sinus tachycardia. While labetalol lowers heart rate, it would not treat the underlying cause of SVT. Amiodarone may be utilized for refractory SVT, but this drug is not the initial drug of choice for SVT. Amiodarone is a preferred drug for AFIB and VTACH. Additional Info During SVT, P waves may not be visible, because the P waves are embedded in the preceding T wave. A client with SVT may be asymptomatic. If the client is symptomatic, they may exhibit manifestations such as palpitations, dizziness, dyspnea, and nervousness. Treatment includes vagal maneuvers. Vagal maneuvers include having the beardown, blowing through a straw, having the primary healthcare provider (PHCP) perform a carotid massage, and, if the client is an infant, applying a bag filled with ice and water to the face above the nose and mouth for 15 to 30 seconds. If that is not effective, another vagal maneuver would be pressing the infant's knees to the chest for 15-30 seconds. If these measures are ineffective, the nurse should prepare to administer the prescribed adenosine by rapid intravenous push (IVP) that is followed by a flush of 0.9% saline. When adenosine is administered, the emergency (code) cart should be nearby, and the nurse should always have additional personnel in the room.

The nurse has instructed a client who is being discharged with crutches about using stairs. Which statement by the client would indicate a correct understanding of the teaching? A. "I should hold the handrail for support with one hand." [46%] B. "Going up the stairs, I should lead with my crutch and weaker leg." [16%] C. "Going down the stairs, I should lead with my crutch and strong leg." [34%] D. "I should remove the rubber tip when going up and down the stairs." [4%]

Explanation Choice A is correct. This statement is correct and indicates an understanding of using crutches. The client should hold the handrail for support with one hand and have their strong leg next to the railing. Choices B, C, and D are incorrect. These statements are incorrect and require follow-up. When a client is ascending stairs, the client leads with the stronger leg. When the client is descending the stairs, the client should lead with the affected leg. The client must always have a rubber tip on the crutch to ensure appropriate traction. Additional Info When a client is using crutches and has to use stairs, the nurse should emphasize the following points: Have the client hold the handrail for support with one hand, and their strong leg should be next to the railing. The client places a crutch under the axilla of the affected side. Have the client transfer body weight to the crutch while holding the handrail with one hand. Then, have the client support the weight evenly between the handrail and crutch. Next, the client places some weight on the crutch and then steps up the first step with an unaffected leg. Have the client balance by leaning forward with the weight on the unaffected leg. Then ask the client to straighten the good knee, push down on crutches and lift body weight, bringing the affected leg and then the crutch up the stair. The crutch tip is entirely on the stair.

You are preparing to administer a unit of packed red blood cells to your client. Which of the following items should you gather in preparation for this blood transfusion? A. 250 mL of normal saline for infusion [87%] B. 250 mL of D5W for infusion [2%] C. A 22 gauge catheter [9%] D. An EKG machine [2%]

Explanation Choice A is correct. You would gather 250 mL of normal saline for infusion, among other things, in preparation for this blood transfusion. Other items that you would pick and prepare include an 18 or 20 gauge catheter for the infusion (preferably an 18 gauge), blood administration set, IV pole, intravenous pump or controller, and other supplies. Blood is transfused, preferably using the 18 G because smaller catheters such as 22 G or 24 G may predispose to mechanical hemolysis. Choice B is incorrect. You would not gather 250 mL of D5W for infusion in preparation for this blood transfusion because D5W is not compatible with blood or blood products. Another intravenous solution, such as isotonic saline, is used. 0.9% normal saline is isotonic and, therefore, preferred. Choice C is incorrect. You would not gather a 22 gauge catheter in preparation for this blood transfusion because a 22 gauge catheter is too small for a blood transfusion and is predisposed to mechanical hemolysis. Choice D is incorrect. You would not routinely gather an EKG machine for blood transfusion procedures. Arrhythmias during transfusion are not a common occurrence. Rapid bleeding of cold blood (> 100 mL/min) may cause cardiac arrhythmias and blood warmers are often used if such early transfusions are needed.

The nurse is caring for a client with akathisia. The nurse should anticipate a prescription for which medication? A. Modafinil [27%] B. Propranolol [22%] C. Venlafaxine [25%] D. Duloxetine [25%]

Explanation Choice B is correct. Akathisia is the most common extrapyramidal side effect (EPS) associated with antipsychotic medications. Propranolol is an effective treatment for akathisia as this helps with treating the internal sense of restlessness characterized by this effect. Choices A, C, and D are incorrect. Modafinil is a psychostimulant used in the treatment of narcolepsy. This would likely make akathisia worse and would not be indicated. Venlafaxine and duloxetine are serotonin-norepinephrine reuptake inhibitors (SNRIs) and are not used to manage akathisia. Additional Info Akathisia is a sense of motor restlessness and is one of the most common EPS. The individual feels a compelling urge to move and could be mistaken as an individual being aggressive or agitated. Medications that can cause EPS include: antipsychotics (haloperidol, fluphenazine) and other dopamine-modulating medications such as metoclopramide. Prior to administering propranolol, the nurse must obtain the client's blood pressure and pulse. Hypotension and bradycardia would be contraindicated to administering this medication.

Which of the following labs for a client with acute renal failure should be reported immediately? A. Blood urea nitrogen 50 mg/dL [19%] B. Serum potassium 6mEq/L [78%] C. Venous blood pH 7.30 [2%] D. Hemoglobin of 10.3 mg/dL [1%]

Explanation Choice B is correct. Although all of these findings are abnormal, elevated potassium is a life-threatening finding and must be reported immediately. Acute renal failure can cause a significant imbalance in lab values. Although all of the lab results listed are abnormal, the elevated potassium level is a life-threatening finding. Choices A, C, and D are incorrect. Each of these lab values is abnormal. However, they don't pose a life-threatening finding like answer choice B. A: The average BUN level should be 7 to 20 mg/dL. C: Venous blood pH should be 7.31 to 7.41. D: Normal hemoglobin levels differ based on age, sex, and general health. The normal range for hemoglobin is 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 grams per deciliter for women. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential - Urinary Elimination, Acute Renal Failure

In the ICU, the low-pressure ventilator alarm goes off. The nurse attends to the patient, checks the ventilator, and attempts to determine the cause of the signal. She is unable to identify the cause. Which action would the nurse initiate next? A. Give oxygen to the patient. [6%] B. Assess the client's vital signs. [46%] C. Ventilate the client manually. [47%] D. Start CPR immediately. [1%]

Explanation Choice B is correct. Checking the client's vital signs is the priority action among the options given. If the patient is unstable and struggling for air and if no problem has been found with a ventilator, the nurse needs to disconnect the patient from the ventilator and manually ventilate until the problem can be identified. While the question indicates that the nurse attended to the patient, it does not mention if the nurse evaluated the vitals and if the patient is stable. In the absence of such information in the question, it is crucial to assess the vitals and determine if they are stable. Whenever an alarm activates on a ventilator, the nurse first should make sure the patient is adequately ventilated and oxygenated. The nurse should assess the patient's level of consciousness, use of accessory muscles, and chest wall movements; determine whether bilateral breath sounds are present as well as evaluate the heart rate and SpO2. If the ventilator is intact, the client should never breathe at a rate less than that set on the ventilator. Causes of Low-pressure ventilator alarm sounding: A leak or disconnect in the ventilator tubing most often causes low-pressure alarms to sound. Causes include: The patient self-extubates or gets disconnected from the ventilator. Inadequate inflation of the tracheostomy tube cuff Poorly fitting noninvasive masks or nasal pillows/prongs Loose circuit and tubing connections The patient demands higher levels of air than the ventilator is putting out. Responding to Low-pressure alarms: While responding to this alarm, please follow this sequence: Always evaluate the patient before checking the ventilator, i.e. always start at the patient and then work your way towards the ventilator checking for loose connections. Assess the patient's vitals, assess consciousness, chest wall movements, accessory muscles, and oxygen saturation. Look for leaks at the site where the tracheostomy tube enters the neck. Look for loose connections in the rest of the ventilator tubing. If the cause of the alarm sounding is still not identified, disconnect the circuit from the patient and manually ventilate with a resuscitation bag (Ambu bag) and then call for help. Choice A is incorrect. Oxygen may be helpful, but it may not be enough to address the cause of the low-pressure alarm. Choice C is incorrect. After checking the patient's vitals and if no immediate cause for the ventilator alarm can be identified, the nurse needs to disconnect the patient from the ventilator and administer manual ventilation until the problem can be identified and solved. While this option can be a distractor here, please note that it does not take priority over "assessing the patient" unless such information is clearly presented in the question's vignette. Choice D is incorrect. There is no indication for CPR at this moment. It is essential to assess the vitals first. High-Yield Tip: Know the causes of low pressure and high-pressure ventilator alarms thoroughly as these are often tested on NCLEX. It is important to know the sequence of responses to such signals.

The registered nurse is working together with the LPN in a psychiatric ward. In a busy day, the nurse understands that it is necessary to delegate tasks to LPNs. Which job would the RN delegate to the LPN? A. Escorting a client with a serum lithium level of 2.2 mEq/L to the ER. [8%] B. Accompanying a bulimic client for an hour after lunch. [49%] C. Conducting art therapy to a group of clients in the day room. [12%] D. Accompany the client who is talking to her mother on the phone. [31%]

Explanation Choice B is correct. Clients with bulimia need someone to prevent them from purging and letting the LPN sit with her for one hour after her lunch precludes the client from inducing vomiting. Choice A is incorrect. A client in this case has lithium toxicity. This client is unstable; thus, the RN must accompany this client to the ER. Choice C is incorrect. The LPN is not trained in this type of activity. The registered psychiatric nurse should be the one conducting this. Choice D is incorrect. The LPN should not be tasked to listen to the client's phone conversation. This is a violation of the client's right to privacy.

The nurse is providing education to a schizophrenic patient prescribed clozapine. Which of the following lab results should be closely monitored in this patient to prevent infection? A. Platelet counts [5%] B. White blood cell counts [85%] C. Glomerular filtration rate [6%] D. Blood sugar levels [4%]

Explanation Choice B is correct. Clozapine may cause agranulocytosis, which can be monitored by looking at white blood cell counts. This condition should be watched closely because agranulocytosis can be fatal. Choice A is incorrect. Platelet counts, while sometimes affected by clozapine use, are not associated with infection. Choice C is incorrect. Glomerular filtration rate measures kidney function and is not generally affected by clozapine. Choice D is incorrect. Blood sugar levels are most frequently drawn in patients with diabetes. Blood glucose monitoring is not a priority in a patient taking clozapine. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral Therapies

Which phenomena is defined as "a subjective human experience that is what the client says it is, exists when the client says it is present, and it alerts humans to actual or potential bodily tissue damage"? A. Anxiety [5%] B. Pain [77%] C. Fear [6%] D. Perception [13%]

Explanation Choice B is correct. Pain is defined as a subjective human experience that is what the client says it is, exists when the client says it is present, and alerts humans to actual or potential bodily tissue damage. It is an unpleasant and distressing experience that has both physical and emotional components. Choice A is incorrect. Anxiety is a psychological and emotional response to an anticipated threat to self that leads to unpleasant feelings such as feelings of dread. Choice C is incorrect. Fear is defined as the emotional response to actual and present danger. Choice D is incorrect. Perception is defined as the human being's ability to interpret the environment exterior to the person as interpreted by the person's senses, including hearing, vision, and tactile sensation.

The nurse identifies that one of her clients will need education on caring for their stoma and education on how to self-catheterize by three weeks post-op. Based on this information, which of the following urinary diversion methods does this client have? A. Vesicostomy [7%] B. Kock Pouch [27%] C. Ileal Conduit [22%] D. Condom Catheter [43%]

Explanation Choice B is correct. Postoperatively, the client will have an indwelling urinary catheter in place to drain urine continuously until the pouch has healed. This catheter will require irrigation. Clients will then perform self-catheterization every 4 to 6 hours for urinary diversion. Choice A is incorrect. Clients do not perform self-catheterization with a vesicostomy. Instead, urine empties through a stoma into an externally placed collection pouch. Choice C is incorrect. Clients do not perform self-catheterization with an ileal conduit. Instead, an externally placed collection pouch is used for urinary diversion, as urine flows into the conduit and is continually propelled out through the stoma by peristalsis. Choice D is incorrect. Clients do not perform self-catheterization with a condom catheter. A condom catheter is a non-invasive device placed externally on the male penis. When the man urinates, gravity propels the urine through a tube to a collection bag. Learning Objective Utilize the objective information provided to determine which urinary diversion method the client has in place. Additional Info The urinary diversion methods contained within the table above may be utilized due to bladder removal (usually from cancer), interstitial cystitis, painful bladder syndrome, incontinence after trauma or surgery, neurogenic bladder, congenital anomalies, strictures, bladder trauma, chronic bladder inflammation, etc.

The nurse is evaluating a patient three days post-operative for signs and symptoms of infection. Which of the following is not a sign of infection from a surgical wound? A. Pus and clear drainage from the site [10%] B. Some redness along the edges of the site [48%] C. Increasing warmth from the wound [4%] D. Red streaks from the site [38%]

Explanation Choice B is correct. Some redness at the surgical site is a normal finding three days after surgery. Signs of infection include pus, excess wound drainage, increasing warmth from the wound, and red streaks from the site. Choice A is incorrect. While light, clear drainage is an expected finding three days post-operatively, pus drainage is not. Pus indicates a developing infection. Choice C is incorrect. While some heat is normal, an increase in temperature produced by the wound indicates infection at the site. Choice D is incorrect. Red streaks indicate a potentially dangerous infection at the wound and could mean the development of a disease and even sepsis. NCSBN client need Topic: Physiological Integrity, Reduction of risk potential

The nurse educator is giving a lecture on the different types of arthritis. Which of the following should the nurse educator emphasize distinguishes rheumatoid arthritis from gouty arthritis and osteoarthritis? A. Crepitus with range of motion [15%] B. Symmetry of joint involvement [49%] C. Elevated serum uric acid levels [26%] D. Dominance in weight bearing joints [10%]

Explanation Choice B is correct. The distinguishing factor in all three types of arthritis is the symmetry of joint involvement. Rheumatoid arthritis is symmetrical and bilateral, while osteoarthritis and gout are unilateral. Choices A, C, and D are incorrect. Osteoarthritis is characterized by crepitus. Gout is manifested by elevated serum uric acid levels, while osteoarthritis is characterized by the involvement of dominant weight-bearing joints.

An advanced practice psychiatric nurse is preparing to conduct a group therapy session. What is the optimum number of clients to be scheduled for the group session? A. 4 clients [28%] B. 8 clients [63%] C. 15 clients [8%] D. 30 clients [0%]

Explanation Choice B is correct. The ideal number of clients for a therapeutic group session should be 6 to 8 people. This allows for maximum therapeutic exchange and participation. Choices A, C, and D are incorrect. A group of 5 or fewer would be inhibited due to self-consciousness and insecurity. Participants of more than eight people would be too many to the point that there will no longer be participation and exchange among other members.

Which of the following is the most accurate education for injury prevention in the home of elderly clients? A. Use the handrail when going up and down the stairs, ensure robes or pants are held up if flowy, and wear comfortable slippers. [4%] B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable/non-skid footwear. [83%] C. Use solid chairs without armrests, keep walkways clear, and use cordless phones. [0%] D. Install raised toilet seats, ensure that all sinks have throw rugs to prevent slipping on water, and use grab bars in the shower/bathroom. [12%]

Explanation Choice B is correct. Throw rugs, furniture in walkways, and slippery footwear are all fall risks for patients. Choice A is incorrect. Clients should be instructed to wear well-fitting shoes with non-skid soles. Choice C is incorrect. Solid chairs with armrests should be used. Choice D is incorrect. All throw rugs should be removed from the home. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Preventing Falls

The nurse is caring for a client with schizophrenia, who is speaking words and phrases that are unrelated to one another. The nurse should document this communication pattern as A. pressure speech. [1%] B. word salad [80%] C. neologism. [8%] D. clang association. [11%]

Explanation Choice B is correct. Word salad is a type of language and communication disturbance in which the client says words and phrases that are not indeed related to one another. Choices A, C, and D are incorrect. Pressured speech is a universal language disturbance in clients with anxiety, bipolar disorder, and schizophrenia. It appears as though the client is forcefully putting the words out. Neologism uses words that are made up of the client and have specific meanings. Clang association is a universal language disturbance where the patient speaks in rhymes or with words that sound similar but have no real meaning when strung together. 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

While working in the emergency department, the nurse sees each of the following clients. As a mandated reporter, the nurse knows which client is at highest risk for elder abuse? A. A 70-year old female with orthostatic hypotension. [1%] B. An 86-year old female with glaucoma. [8%] C. A 92-year old male with late-stage Alzheimer's disease. [90%] D. A 75-year old male with leukemia. [1%]

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

A nurse is taking care of a client with severe burns. Because of fluid shifting, the nurse knows that the focus of attention is preventing hypovolemic shock. Which is the best intervention to address this? A. Administer dopamine as ordered [2%] B. Apply medical anti-shock trousers [1%] C. Infuse IV fluids as indicated [93%] D. Infuse fresh frozen plasma [4%]

Explanation Choice C is correct. An expected event during the early post-burn period is fluid shifting, where large amounts of plasma fluid extravasate into interstitial spaces. To address the fluid loss, the best intervention would be to administer crystalloid and colloid solutions. Choices A, B, and D are incorrect. Fresh frozen plasma may achieve this, but this is expensive and carries a slight risk of disease transmission. Medical anti-shock trousers are applied when the client is already in hypovolemic shock. It is not used for prevention. Dopamine causes vasoconstriction and raises blood pressure but does not prevent hypovolemia in burning clients.

The nurse administers succinylcholine to a patient prior to electroconvulsive therapy. Which action would be the nurse's highest priority after administering this medication? A. Observe for teeth clenching during the procedure [6%] B. Assess the level of oral secretions [44%] C. Monitor for muscle twitching [40%] D. Ask patient about headache [10%]

Explanation Choice C is correct. During electroconvulsive therapy, electric currents are passed through the brain to improve symptoms of depression and other mental illnesses (typically after other treatment attempts are unsuccessful). Succinylcholine is a muscle relaxant used prior to this procedure to diminish the patient's motor response to the induced seizure from ECT, so decreased or absent muscle twitching would indicate this medication has been effective. Choice A is incorrect. Jaw muscles will be directly stimulated during the procedure, so teeth clenching is expected despite the use of muscle relaxant medication. The nurse should place a bite-block before the procedure to prevent tooth, tongue, or gum damage. Choice B is incorrect. Diminished oral secretions would be the expected effect of an anticholinergic medication given prior to the procedure (ie. atropine). Choice D is incorrect. The patient may experience a headache following this procedure, but this medication would not be used to prevent or address this side effect. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Pharmacological and Parenteral Therapies

The nurse is caring for an 88-year-old client who is fifteen minutes post-operative following total hip arthroplasty. It would be a priority to assess which of the following? A. Range of motion [2%] B. Urine output [5%] C. Vital signs [83%] D. Incision [10%]

Explanation Choice C is correct. Immediately following a surgical procedure, the client is at risk for complications, including shock. The nurse should assess vital signs to determine a client's stability. The other assessments are not as essential because they do not help determine the hemodynamic stability of the client. Choices A, B, and D are incorrect. Following a total hip arthroplasty, the client will work with physical therapy to guide them on using ambulatory aids and completing daily activities. The range of motion is not a critical assessment, nor is the incision. Urine output must be assessed because older adult clients are sensitive to the anticholinergic effects found in certain anesthesia. Learning Objective NCSBN Client need: Topic: Reduction in Risk Potential; Subtopic: Potential for Complications of Diagnostic Tests/Treatments/ Procedures Additional Info Immediately following a surgical procedure (such as total hip arthroplasty), immediate assessments should include: Vital signs Lung sounds Cardiac rhythm Incision status Pain Nausea and vomiting Older adults are more at risk for complications, including suboptimal thermoregulation, urinary retention, wound disruption, and delirium.

A nurse is evaluating an 83-year-old client who has been hospitalized after a fall. He has not had a bowel movement for five days, and a possible fecal impaction is suspected. Which assessment finding would be most indicative of fecal impaction? A. Rigid, board-like abdomen [43%] B. The client has lost the urge to defecate [8%] C. Liquid stool [30%] D. Complaints of abdominal pain [19%]

Explanation Choice C is correct. In a client with fecal impaction, the client has the urge to defecate but is unable to do so. A liquid stool is usually observed as it is the only thing that will be able to pass around the impacted site. Choices A, B, and D are incorrect. A rigid, board-like abdomen is associated with a perforated bowel, not fecal impaction. Abdominal pain without enlargement is also not associated with fecal impaction.

Which of the following infection control activities should be delegated to an experienced nursing assistant? A. Asking clients about the duration of antibiotic therapy. [1%] B. Demonstrating correct handwashing techniques to client and family. [15%] C. Disinfecting blood pressure cuffs after clients are discharged. [81%] D. Screening clients for upper respiratory tract symptoms. [3%]

Explanation Choice C is correct. Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. In nursing, delegation refers to indirect care. The intended outcome is achieved through the work of someone supervised by the nurse. It involves defining the task, determining who can perform the job, describing the expectation, seeking agreement, monitoring performance, and providing feedback to the delegate regarding performance. While some nursing assistants may be proficient in tasks or be familiar with symptoms of diseases or disorders, clinical tasks such as assessments and education should always be assigned to a licensed nurse. Choice A, B, and D are correct. These should be carried out by a licensed nurse. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control, The Nurse as a Delegator

The nurse is checking the tray of a patient with Celiac disease. Of the following, which meal would be most appropriate for this patient? A. Macaroni and cheese [6%] B. A ham sandwich on a wheat roll [4%] C. Salmon over roasted beets [76%] D. Turkey, potatoes, and garlic bread

Explanation Choice C is correct. Of these options; the best meal is the meal without any gluten-containing substances. Salmon and beets are both gluten-free. Other gluten-free foods include meat, fish, eggs, some dairy, vegetables, corn, fruit, rice, and gluten-free flours. Choice A is incorrect. Macaroni noodles are generally made of wheat unless otherwise stated. Individuals with Celiac disease must avoid all wheat-containing products. This meal would not be the best choice for this patient. Choice B is incorrect. Wheat rolls contain gluten and should, therefore, be avoided in patients with Celiac disease. Choice D is incorrect. Flour-based bread contains gluten and is harmful to individuals with Celiac disease, and therefore, garlic bread should be avoided. NCSBN client need Topic: Physiological Integrity, Nutrition, and Oral Health

The nurse is caring for a patient who has recently had a femoral vein catheter placed. The nurse would be most correct in advising the patient to do which of the following? A. Refrain from drinking more than 500 mL per day [2%] B. Perform toe touch stretches in bed every morning [16%] C. Refrain from sitting up more than 45 degrees [76%] D. Remove the dressing if it becomes itchy [6%]

Explanation Choice C is correct. Patients who have undergone a femoral vein catheter should refrain from sitting up more than 45 degrees because this could kink the catheter, thus interfering with treatment. Choice A is incorrect. This patient does not need to be on a fluid restriction unless specifically indicated by the physician. Choice B is incorrect. Toe touches require that the patient bend more than 45 degrees and may damage or kink the femoral vein catheter. Choice D is incorrect. The patient should leave their occlusive dressing on while the femoral vein catheter is inserted. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition? A. Peripheral artery disease [11%] B. Accelerated hypertension [7%] C. Migraine headache [76%] D. Angina [5%]

Explanation Choice C is correct. Sumatriptan is a 5-hydroxytryptamine (5-HT))-receptor agonist indicated for abortive migraine headache treatment. Sumatriptan stops headaches after they have begun ( abortive therapy), but it does not prevent them. Choices A, B, and D are incorrect. These conditions are all contraindications to the administration of this medication. Sumatriptan has been linked to the development of sudden myocardial infarction following its administration in at-risk individuals. Sumatriptan may induce vasoconstriction. A client with severe hypertension, coronary artery disease, history of stroke, and peripheral vascular disease should not take this medication. Learning Objective Recognize that 5HT receptor agonists such as Sumatriptan are used in abortive therapy of migraine headaches. Additional Info Sumatriptan is a medication indicated to abort migraine headaches. It is not a prophylactic treatment. Sumatriptan is commonly administered intranasally or subcutaneously. The nurse should educate the client that if they receive this medication as an injection, a warm and tingling sensation is normal and temporary. Contraindicated for clients with uncontrolled hypertension, coronary artery disease, and those who have sustained a stroke or myocardial infarction. The nurse should monitor the client's blood pressure, autonomic instability, altered mental status, and manifestations similar to serotonin syndrome. Common side effects include flushing, tingling, warmth, dizziness, gastric upset, nausea, and vomiting.

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report. the leading risk factor for the development of chronic obstructive pulmonary disease (COPD) is: A. Genetics [1%] B. Gender [0%] C. Cigarette smoking [95%] D. Socioeconomic factors [4%]

Explanation Choice C is correct. The GOLD report identifies cigarette smoking as the leading risk factor for the development of COPD. Any or all of the others may also be contributing factors. "Never smokers" may develop COPD, but they typically do not have an increased risk of lung cancer or cardiovascular problems compared to smokers with COPD. Choice A is incorrect. Genetics does seem to play a part in the development of COPD. Choice B is incorrect. Gender may play a role in the development of COPD since it may influence occupation choice which may increase exposure to environmental toxins. Choice D is incorrect. Low birth weight influenced by socioeconomic status may hurt lung development. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Alterations in Body Systems, Respiratory

A nurse is working in a pediatric clinic. A 14-year old child's parents inquire about the Measles/Mumps/Rubella (MMR) vaccination. The child has never had the MMR vaccination. The child is on chronic high-dose steroids for juvenile arthritis. You know that the parents understand your teaching when they say: A. "We shouldn't have our child vaccinated if she has an egg allergy." [12%] B. "If our daughter has immunity, she is at risk for an allergic reaction if she is revaccinated." [2%] C. "The MMR vaccine contains live virus." [72%] D. "She needs one dose of the vaccine since she is an older child who has never been immunized." [13%]

Explanation Choice C is correct. The MMR vaccine is a live attenuated vaccine, and this is important to know when determining whether to vaccinate immunocompromised individuals or pregnant women. The child is likely immunosuppressed, and it is crucial to consult the child's rheumatologist before recommending any live vaccine. In general, live vaccines are contraindicated in: Severely immunocompromised individuals: Prolonged courses of high-dose corticosteroids may cause immunosuppression and predispose the child to infections. Other conditions that can lead to immunocompromised status include hematological malignancies (lymphoma, leukemia), use of chemotherapy, and immunodeficiency disorders. In severely immunocompromised adults, the vaccine virus by itself may lead to the illness. Pregnant women: Current studies support the idea that it is possible that a pregnant woman could pass the virus to the fetus; therefore, use during pregnancy is not recommended. Choice A is incorrect. The MMR vaccine does not contain egg proteins and is not contraindicated in individuals with an egg allergy. The CDC does not recommend restricting MMR or Influenza vaccines to those with egg allergies. The yellow fever vaccine is the only vaccine that is contraindicated in severe egg allergy. Choice B is incorrect. Giving the vaccine to an individual with a previous immunity does NOT increase the risk of an allergic reaction. The vaccination is very safe, with only rare reports of any reaction post-immunization. They mainly involve localized redness/swelling at the injection site or an occasional sore throat when reactions occur. Choice D is incorrect. The ideal immunization schedule is two doses of the MMR vaccination. The first dose should be given between 12 and 15 months, and the second dose should be given between 4 and 6 years. In the scenario where an older child was not immunized early in life, they should receive two immunizations a month apart. This two-dose schedule can also be used when the immunization history is unknown; repeat immunizations with MMR are safe. Regardless, it is essential to consult the rheumatologist and the pediatrician before recommending a live vaccine to this immunocompromised child.

While working in the emergency department, the nurse is assigned a 5-year-old client with a chief complaint of sore throat. The father states that the client has been complaining of throat pain for 2 days and when he looks in the child's throat it appears red with white patches. The nurse confirms the red throat with white patches during the throat assessment. Based on these findings, the nurse expects which of the following diagnostic tests to be ordered? A. Basic metabolic panel [1%] B. Extended respiratory virus panel [7%] C. Throat culture [82%] D. Complete blood count [10%

Explanation Choice C is correct. The nurse expects that a throat culture will be ordered to confirm a diagnosis of bacterial tonsillitis. A throat culture will assess for the presence of bacteria on the pharynx and guide the team in making decisions about treatment/antibiotics for this patient. If the suspected diagnosis of bacterial tonsillitis is not confirmed, other tests may be necessary. Choice A is incorrect. A basic metabolic panel (BMP) is a very common laboratory test that evaluates a client's electrolyte levels, kidney function, blood glucose level, metabolism, and acid/base balance. This test is ordered for many different reasons, but it would not be helpful in the client suspected of having tonsillitis. There is another test that the nurse expects to be ordered. Choice B is incorrect. The extended respiratory virus panel is a test sent to evaluate for the presence of some of the most common respiratory viruses, including influenza, RSV, adenovirus, parainfluenza, and rhinovirus. While it is possible that this client has a virus, the nurse suspects bacterial tonsillitis based upon his symptoms and expects another diagnostic test to be ordered first. Choice D is incorrect. A complete blood count (CBC) is a test done to evaluate the different components present in a patient's blood such as their red blood cells, white blood cells, and platelets. It can show if a patient is anemic, has markers of infection, and much more. While this test could be ordered for many different reasons, it is not the test that will help confirm the suspected diagnosis of bacterial tonsillitis. The nurse expects another diagnostic test to be ordered first. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Coordinated care, Pediatric - HEENT

The ICU nurse is caring for a patient who is receiving intermittent bolus feeds via a PEG tube. The nurse checks gastric residual volume (GRV) and finds that it is 220 mL. Which nursing action is appropriate? A. Administer metoclopramide and reassess GRV in 30 minutes. [2%] B. Decrease rate of bolus feeds. [5%] C. Administer bolus as ordered. [33%] D. Hold feeding and assess the patient for signs of bloating, pain, or distention. [60%]

Explanation Choice C is correct. The nurse should administer the bolus feed as ordered. In critically ill clients on enteral nutrition, the safe range for gastric residual volume (GRV) is less than or equal to 500mL. GRV refers to the amount of fluid aspirated from the stomach following administration of an enteral feed. Originally, GRV monitoring at every six hourly intervals was designed to decrease the risk of aspiration pneumonia. Still, there is no evidence to support the claim that GRV is associated with aspiration or ventilator-associated pneumonia. Many institutions have incorrectly used GRV thresholds as low as 200 to 250 ml to hold enteral feeding for an extended period. The assumption was that elevated GRV above that threshold increased the risk of aspiration and predicted intolerance to feeding. However, several studies indicate that feeding intolerance is better denoted by gastrointestinal symptoms and signs ( vomiting, abdominal distension) than GRV. High GRV is a primary reason leading to the cessation of enteral nutrition, thereby exacerbating the critically ill's malnutrition problem. The REGANE study in ventilated patients found no differences in using a GRV limit of 500mL versus a GRV limit of 200mL regarding the incidence of gastrointestinal complications and ICU-acquired pneumonia. Based on all this evidence, the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) recommend not holding enteral nutrition for GRVs less than 500 mL in the absence of other signs of intolerance. When using GRV, intolerance of enteral feeding is defined as GRV > 500mls. Choice A is incorrect. Should the first GRV be higher than 500 ml, the nurse should notify the physician, administer a prescribed prokinetic agent such as metoclopramide, hold feeding, and recheck the GRV after 2 hours. If GRV recheck is < 500mL and there are no clinical signs of feeding intolerance, the nurse should restart feeding. A prokinetic/ promotility agent can be considered even at a GRV of 250 to 300ml. Choice B is incorrect. A GRV of 220ml is within the expected range for an ICU patient, so the nurse should continue feeding at the defined rate. Choice D is incorrect. If the patient's GRV is greater than 500ml or any clinical signs of intolerance, the nurse should hold feeding and notify the physician. NCSBN Client Need Topic: Critical Care Concepts, Subtopic: nutrition and oral hydration, system-specific assessments, alterations in body systems

Which of these color codes is the highest priority for medical and nursing care? A. The yellow color code [1%] B. The green color code [1%] C. The red color code [97%] D. The black color code [1%]

Explanation Choice C is correct. The red-colored triage tag indicates that the clients in this triage group have serious life-threatening injuries. Therefore, this group of clients is the highest priority for medical and nursing care. Choice A is incorrect. The yellow-colored triage tag indicates that the clients in this triage group have injuries that are not life-threatening, so this group of clients is not the highest priority for medical and nursing care. Choice B is incorrect. The green-colored triage tag indicates that the clients in this triage group have only minor injuries, so this group of clients is not the highest priority for medical and nursing care. Choice D is incorrect. The black-colored triage tag indicates that the clients in this triage group have died, so this group of clients is not the highest priority for medical and nursing care. NCSBN Client need: Topic: Safety and Infection Control Sub-Topic: Emergency Response Plans

A 52-year-old man is admitted to the burn unit after surviving a house fire. Both of his arms, anterior and posterior, are burned along with his face and chest. According to the "rule of 9's", what percentage of his body was burned? A. 9% [0%] B. 18% [5%] C. 31.5% [59%] D. 35.5% [35%]

Explanation Choice C is correct. The rule of 9's is a way to divide the body up into sections to estimate the total body surface area burned of the patient. The body is divided into the following sections: For this patient, the total TBSA burned equals 31.5% The front of the right arm = 4.5% The back of the right arm = 4.5% The front of the left arm = 4.5% The back of the left arm = 4.5% The face = 4.5% The chest = 9% 4.5 + 4.5 + 4.5 + 4.5 + 4.5 + 9 = 31.5% An important point to remember is to pay close attention to the wording of the question. For example, while the entire anterior torso = 18%, this question specifies the chest. The chest = 9% and the abdomen = 9%. The entire posterior torso is also 18%; the upper back = 9% and the lower back = 9%. The same thing is important for the wording regarding the head. The entire head is 9%, but this question specifies the face. The face = 4.5% and the back of the head = 4.5%. NCSBN Client Need Topic: Safe and Effective Care Environment; Sub-topic: Care Management

During a physical assessment, the nurse inspects the patient's abdomen. What assessment technique would the nurse perform next? A. Percussion [6%] B. Palpation [9%] C. Auscultation [85%] D. Whichever is most comfortable for the patient [1%]

Explanation Choice C is correct. When performing a physical assessment, the most often used sequence is: Inspection Palpation Percussion Auscultation However, palpation and percussion can alter bowel sounds. Therefore, for abdominal assessments, the steps should be: Inspect Auscultate Percuss Palpate Choices A, B, and D are incorrect. When assessing the abdomen, auscultation should occur after inspection. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Types of Assessments

The nurse is assisting a client of the Orthodox Jewish faith while serving lunch. A kosher meal has been delivered to the client. What is the next appropriate action to perform with this client? A. Substitute plastic utensils with metal utensils [6%] B. Unwrapping the eating utensils for the client [3%] C. Carefully transferring the food from a styrofoam tray to a ceramic plate [6%] D. Allow the client to unwrap the utensils and prepare his own meal [85%]

Explanation Choice D is correct. A person of the Orthodox faith should be able to unwrap the utensils and prepare his meal. Choices A, B, and C are incorrect. The nurse should not assist or touch the kosher meal in any way. NCSBN client need Topic: Fundamentals; SubTopic: Culture and Spirituality

An example of a healthcare environment that provides tertiary prevention care and services is a(n): A. Acute care facility [15%] B. Primary care outpatient clinic [8%] C. Outpatient surgical center [4%] D. Physical rehabilitation center in the community [72%]

Explanation Choice D is correct. An example of a healthcare environment that provides tertiary prevention care and services is a physical rehabilitation center in the community. Choice A is incorrect. An acute care facility provides primary prevention care and services, not tertiary prevention care and services. Choice B is incorrect. A primary care outpatient clinic provides primary prevention care and services, not tertiary prevention care and services. Choice C is incorrect. An outpatient surgical center provides secondary prevention care and services, not tertiary prevention care and services.

The client is admitted to a long term care facility. The nurse in charge is encouraging autonomy in the client. Which activity should the nurse introduce to the client? A. Have the client plan her meals. [15%] B. Let the client decorate her room. [16%] C. Make the client in charge of setting her appointment with the hair dresser. [9%] D. Let the client choose social activities she would like to join. [60%]

Explanation Choice D is correct. Choosing social activities in the facility promotes the client's freedom of choice and does not risk her safety. Choice A is incorrect. The client cannot do meal planning on her own and needs the assistance of a nutritionist or dietician. Choice B is incorrect. Having the client decorate her room may pose a risk to both the client and others as the client may arrange things in a way that is conducive to trips and falls. Choice C is incorrect. The client may find it difficult to contact the hairdresser and set an appropriate appointment.

The nurse is assigned to care for a client with pneumonia and the physician has prescribed amoxicillin potassium (Augmentin) 500 mg q8h as treatment. The medication comes in 250-mg tablets. After calculating dosing, the nurse finds that the client will receive two tablets every 8 hours for a total of 6 tablets in 24 hours. When verifying client understanding, the client states, "I should take the medication with food, and if I feel fine before I finish the prescription, I can stop it and save the rest of the pills for next time I get pneumonia." After rechecking the dosage calculation, the nurse decides to do which of the following? A. Hold medication administration and clarify with the physician first [9%] B. Administer 1 tablet only instead of the calculated dosage [0%] C. Administer the medication as prescribed and monitor the patient's cardiac function [5%] D. Reinforce client teaching and administer the medication as prescribed [86%]

Explanation Choice D is correct. Further client teaching is needed, as the medication should be taken on an empty stomach with a full glass of water. The entire course of medication should be completed even if the client is feeling better to ensure the bacterial organism is erradicated and prevent the occurrence of superinfection. Choice A is incorrect. Since the medication is indicated and the dosage is appropriate/safe. Choice B is incorrect. Since the calculated dosage is two tablets every 8 hours. Choice C is incorrect. Since the client's liver, blood, and renal studies should be monitored, not cardiac studies.

The nurse witnessed a patient fall in the bathroom who is now on the floor, conscious. The nurse takes a look at the patient and immediately suspects that her hip is fractured. Which of the following nursing interventions should the nurse initiate first? A. Helping the patient back to bed. [2%] B. Notifying the family of the fall. [0%] C. Arranging for an x-ray. [3%] D. Immobilizing the patient's leg before moving the patient. [94%]

Explanation Choice D is correct. Immobilizing the patient's leg before moving her minimizes bleeding, edema, pain and prevents further injury to the tissues and structures surrounding the fracture. This also decreases the patient's risk for the development of other complications such as fat embolism and shock. Choice A is incorrect. Helping the patient back to bed produces more damage to the surrounding area of the fracture, causing more pain, and increasing the patient's risk for embolism. Choice B is incorrect. The nurse can notify the family of the situation after the patient has been stabilized. Choice C is incorrect. The nurse can arrange the x-ray to assess further damage of the fall after the patient has been stabilized.

What is the correct sequence when performing an abdominal assessment? A. Auscultation, inspection, palpation, percussion [4%] B. Inspection, palpation, percussion, auscultation [6%] C. Palpation, percussion, inspection, auscultation [1%] D. Inspection, auscultation, percussion, palpation [89%]

Explanation Choice D is correct. Inspection is always performed first. Auscultation of the abdomen must be performed before percussion and palpation to prevent the alteration of bowel sounds. Choices A, B, and C are incorrect. Performing percussion and palpation before auscultation may cause falsely increased bowel sounds by stimulating bowel activity. An inspection does not interfere with the rest of the abdominal exam. Therefore, inspection should be performed first, followed by auscultation, percussion, and palpation. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Abdominal Assessment Learning Objective The correct abdominal examination sequence differs from other areas, such as the lungs. The auscultation component in an abdominal exam should precede percussion and palpation.

The nurse is assessing a child for intussusception. Which assessment parameter would hold the least importance to the nurse? A. Abdominal girth [9%] B. Quality of vomitus [9%] C. Pain pattern [4%] D. Family history [77%]

Explanation Choice D is correct. Intussusception does not have any familial tendencies. The nurse would need to concentrate on physical examination and pain patterns. Choice A is incorrect. Children with intussusception display abdominal distention due to intestinal obstruction. Choice B is incorrect. Vomitus in intussusception contains bile because the obstruction occurs below the ampulla of Vater, the point in the intestine where bile empties into the duodenum. Choice C is incorrect. Children with intussusception can experience pain.

Which of these interventions is the priority when caring for a patient experiencing an exacerbation of inflammatory bowel disease who is to receive total parenteral nutrition and lipids? A. Infuse the solution in a large peripheral vein [7%] B. Monitor urine specific gravity every shift [3%] C. Change the administration set every 72 hours [6%] D. Monitor the patient's blood glucose per protocol [84%]

Explanation Choice D is correct. TPN can cause hyperglycemia, so blood glucose levels should be closely monitored. Parenteral nutrition, or intravenous feeding, is a method of getting food into the body through the veins. Depending on which thread is used, this procedure is often referred to as either total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN). Parenteral nutrition is used to help people who can't or shouldn't get their core nutrients from food. It's often used for people with: Irritable Bowel or Crohn's disease Cancer Short bowel syndrome Ischemic bowel disease It also can help people with conditions that result from low blood flow to the bowels. Parenteral nutrition delivers nutrients such as sugar, carbohydrates, proteins, lipids, electrolytes, and trace elements to the body. These nutrients are vital in maintaining high energy, hydration, and strength levels. The most common side effects of parenteral nutrition are mouth sores, poor night vision, and skin changes. You should speak with your doctor if these conditions don't go away. Other less common side effects include: changes in heartbeat confusion convulsions or seizures difficulty breathing fast weight gain or weight loss fatigue fever or chills increased urination jumpy reflexes memory loss muscle twitching, weakness, or cramps stomach pain swelling of your hands, feet, or legs thirst tingling in your hands or feet vomiting Choice A is incorrect. Due to the hypertonicity of the TPN solution, it must be administered via a central venous catheter. Choice B is incorrect. This is not the primary nursing intervention. Choice C is incorrect. The high glucose and lipids make the TPN an excellent medium for bacterial growth, so administration sets should be changed every 24 hours if the TPN contains fats. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort, Enteral Nutrition

The nurse is assessing a client immediately following a thoracentesis. The nurse understands that the most common complication following this procedure is a A. Pleural effusion [11%] B. Pneumonia [3%] C. Pulmonary embolism [10%] D. Pneumothorax [75%]

Explanation Choice D is correct. The most common complication associated with thoracentesis is a pneumothorax. The nurse should assess the client for this adverse reaction which includes the client experiencing tachypnea, coughing, decreased or absent lung sounds on the affected side, and decreased blood oxygen levels. Choices A, B, and C. These complications are not directly linked with thoracentesis as pneumothorax is much more likely to occur. Additional Info Thoracentesis is the needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes. This test can be performed at the bedside and typically involves using ultrasound to guide the needle. Nursing considerations for this procedure involve witnessing the informed consent, positioning the client over a bedside table, and supporting the client during the procedure. The provider will insert a needle (after the skin has been anesthetized) attached to a syringe and will slowly aspirate fluid. This fluid may be sent for laboratory analysis. A sterile pressure dressing will be applied, and a follow-up chest x-ray will be performed. The most common complication following this procedure is a pneumothorax.

The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The client reports dyspnea and dizziness. The nurse should obtain a prescription for which medication? See the image below. A. Diltiazem [8%] B. Amiodarone [16%] C. Labetalol [5%] D. Atropine [72%

Explanation Choice D is correct. This tracing reflects sinus bradycardia. Atropine would be clinically indicated if the client was experiencing symptomatic bradycardia. If the client has bradycardia and concurrent dizziness, hypotension, or dyspnea, this calls for treatment with atropine. Atropine must be administered while an emergency (code) cart is nearby. Choices A, B, and C are incorrect. These options would be highly detrimental if a client had bradycardia because these medications decrease the heart rate, and doing so would be catastrophic. Diltiazem is commonly utilized in the management of atrial fibrillation Amiodarone is an umbrella drug used in the treatment of ventricular tachycardia, ventricular fibrillation, and atrial fibrillation Labetalol is one of the drugs of choice for a client experiencing a hypertensive crisis. This medication lowers both heart rate and blood pressure. Additional Info Sinus bradycardia is a regular rhythm with a rate of less than sixty. Sinus bradycardia is only concerning if the client is symptomatic. Pathological causes of bradycardia include severe hypothyroidism, hypothermia, anorexia nervosa, and prolonged hypoxia. For a client receiving intravenous atropine, the nurse should monitor the heart rate and rhythm after administration. An increased heart rate is expected.

The doctor has ordered NPH 5 units and regular insulin 4 units in the same subcutaneous injection stat. You should: A. Call the doctor because NPH insulin and regular insulin cannot be mixed in the same syringe. [2%] B. Administer the NPH insulin first and then administer the regular insulin. [3%] C. Administer the regular insulin first and then administer the NPH insulin. [18%] D. Inject air into the NPH insulin vial first and then prepare the regular insulin in the same syringe. [77%]

Explanation Choice D is correct. You would inject air into the NPH insulin vial first and then prepare the regular insulin in the same syringe. NPH insulin and regular insulin are compatible with each other in the same needle using the correct procedure. The first step of this procedure is to inject air into the NPH insulin vial first and then do the other stages of this procedure, which includes preparing the regular insulin dosage. Choice A is incorrect. You would not call the doctor because NPH insulin and regular insulin can be incorporated in the same needle using a particular procedure. Choice B is incorrect. You would not administer the NPH insulin first and then apply the regular insulin because these insulin dosages can be mixed in the same syringe using a particular procedure. Choice C is incorrect. You would not administer the regular insulin first and then apply the NPH insulin because these insulin dosages can be mixed in the same syringe using a particular procedure.

You are providing education to the parents of a toddler suffering from gastroesophageal reflux disease (GERD). You know they understand your teaching when they make which of the following statements. Select all that apply. A. "We should feed him 6 small meals a day instead of a few big ones." [40%] B. "Making sure he is sitting upright while eating may help the reflux." [41%] C. "He should try to sleep on his left side so that his stomach can empty more easily." [13%] D. "There are no medications that can help with this disease so we will have to make lifestyle changes." [5%]

Explanation Choices A and B are correct. A is correct. Small, frequent meals are an excellent recommendation to help alleviate GERD symptoms. This will ensure the stomach does not overfill and helps to decrease the amount of reflux the patient is experiencing. B is correct. The upright position is very important for GERD patients while they are eating. This is good education. Upright positioning will help to prevent or decrease the passage of gastric contents into the esophagus. Choice C is incorrect. Left-side lying is not the recommended position overnight for patients suffering from GERD. These parents do not understand your teaching. You should teach them to encourage an upright position to help with GERD overnight. This can be accomplished in the hospital by elevating the head of the bed, or at home by using pillows to prop the head up. Choice D is incorrect. This is not true. While the healthcare provider will likely recommend lifestyle changes before prescribing any medications, there are a variety of pharmacological interventions that can be tried if severe symptoms persist. These include medications such as omeprazole and ranitidine. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Gastrointestinal

The nurse is assessing a client with peripheral arterial disease (PAD). Which of the following findings would the nurse expect to observe? Select all that apply. A. Decreased peripheral pulses [32%] B. Pain with ambulation [27%] C. Reddish-brown ankle discoloration [16%] D. Bilateral dependent edema [15%] E. Protruding veins in the leg [9%]

Explanation Choices A and B are correct. Peripheral arterial disease (PAD) is characterized by atherosclerosis in the lumen of the peripheral arteries. PAD symptoms include pain in the extremities that may be exacerbated by walking and is relieved by rest (claudication). Decreased peripheral pulses are a consistent manifestation of PAD. Choices C, D, E are incorrect. Hyperpigmentation of the ankles with edema is a finding consistent with venous insufficiency. Other features of venous insufficiency include protruding veins in the leg and telangiectasias. Peripheral pulses are typically normal in venous insufficiency. Additional information: Nursing care for those with PAD include: · Mitigation of the contributing factors such as appropriate blood pressure control, avoiding atherogenic foods, and smoking cessation. Having the legs dependent helps facilitate blood flow. · The client should be educated to avoid the application of heat to the affected extremity. The client should also avoid the application of any constrictive clothing garments or devices. Medical management includes pharmacotherapy, including cilostazol, clopidogrel, and pentoxifylline. NCSBN Client Need: Topic: Physiological Adaptation; Subtopic: Alterations in Body Systems

When educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following are considered early signs of heart failure? Select all that apply. A. Diaphoresis [28%] B. Sudden weight gain [30%] C. No wet diapers [17%] D. Hypoxia [25%]

Explanation Choices A and B are correct. The parents of children with congenital heart defects need to be aware of the "early" signs of heart failure, so they can report them to the healthcare provider before it is too late. Diaphoresis (Choice A), or excessive sweating is a common early sign of heart failure. Parents should be taught to look out for excessive sweating, especially at rest. Sudden weight gain (Choice B) is due to fluid retention and edema. This indicates decreased cardiac output, increased venous congestion, and is an early sign of heart failure. Choice C is incorrect. An infant or child having "no wet diapers" would mean he/she is severely oliguric. Oliguria is due to decreased kidney perfusion that occurs during untreated heart failure. This degree of damage to the kidneys takes time and is a late sign of heart failure, not an early warning. Choice D is incorrect. Hypoxia is also a late sign of heart failure, not an early warning. Hypoxia is typically secondary to pulmonary edema that develops during untreated heart failure.

There has been an increased incidence of SIDS in your hospital, and many of the new mothers delivering babies at your hospital are asking for more information about the syndrome. As a nurse on the Mother-Baby floor, you are placed in charge of creating a teaching handout for new mothers about SIDS prevention. It is important to include which of the following points? Select all that apply. A. 'Back-to-sleep' is the safest position for infants to sleep; place them supine in their crib for all naps and at night. [43%] B. Risk factors for SIDS include a hard crib mattress and hypothermia. [14%] C. Cigarette smoking in the house can be a risk factor, so all family members should be encouraged to quit. [40%] D. It is okay to leave stuffed animals and toys in the crib as long as they are away from the infant's face. [4%]

Explanation Choices A and C are correct. 'Back-to-sleep' is the safest position for infants to sleep and should be included in the teaching handout. Smoking is a known risk factor for SIDS, and family members should be given information to help them quit to prevent SIDS. Choice B is incorrect. There are many risk factors for SIDS. A soft mattress or bedding is a risk factor rather than a hard crib mattress. This is because if an infant rolls over onto his stomach and cannot turn back over, a soft mattress can suffocate them. A hard mattress will not conform to their face as quickly and be easier for them to breathe around. Hypothermia is also not a known risk factor for SIDS; however, slightly overheating and thermal stress can be a cause. Choice D is incorrect. It is not safe for stuffed animals and toys to be in the crib when the infant is asleep due to the risk of suffocation. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Alterations in Body Systems

Which of the following signs and symptoms may lead the nurse to suspect hypovolemia? Select all that apply. A. Decreased skin turgor [43%] B. Increased urine output [10%] C. Dry mucous membranes [44%] D. Weight gain [2%]

Explanation Choices A and C are correct. A decrease in skin turgor may indicate hypovolemia or a fluid volume deficit. Healthy skin turgor is a rapid recoil; it is most commonly checked on the back of the hand. When the skin is pinched up, it recoils to its normal position very quickly. If it recoils slowly, then it is a sign that the surface is dehydrated and is a good indicator of a fluid volume deficit (Choice A). Dry mucous membranes are an indication of hypovolemia. When the body has a fluid volume deficit or is dehydrated, the mucous membranes are one of the first places to dry out. This is an excellent assessment to monitor for fluid status; if the mucous membranes appear well hydrated, the patient is probably not dehydrated (Choice C). Choice B is incorrect. Decreased urine output, not increased, would be indicative of hypovolemia. When the body is in a fluid volume deficit, the kidneys will try to retain water to correct the imbalance and will make less urine. If there is an increase in urine output, it is more likely that the patient is hypervolemic. Choice D is incorrect. Weight loss, not gain, would be an indication of hypovolemia. If the body has a fluid volume deficit, there would be a decrease in fluid all over the body, which would lead to an acute reduction in patient weight. Any sudden weight gain would indicate hypervolemia or fluid volume excess. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Fluid & Electrolytes

Your client is a patient with low potassium levels and accelerated hypertension. The physician has listed the cause as "hyperaldosteronism." Which of the following endocrine disorders cause an increased amount of aldosterone? Select all that apply. A. Cushing's disease [41%] B. Addison's disease [13%] C. Conn's syndrome [23%] D. Pheochromocytoma [22%]

Explanation Choices A and C are correct. Cushing's disease (choice A) is caused by an increased secretion of adrenocorticotropic hormone (ACTH) from the pituitary gland. Increased ACTH causes increased stimulation and hyperplasia of the adrenal cortex. This leads to increased levels of both glucocorticoids (cortisol) and mineralocorticoids (aldosterone). The physician may order ACTH and cortisol levels to establish the diagnosis of Cushing's disease. Clinical symptoms include abdominal obesity, moon facies, neck hump, abdominal striae, increased blood glucose, secondary diabetes, hypertension, and hypokalemia. Other manifestations include osteoporosis and increased risk of fractures. Clients are prone to increased risk of infections because excess steroids (cortisol) cause immunosuppression. Cushing's disease accounts for 65 to 70 percent of all Cushing's syndrome. It is important not to confuse Cushing's disease with Cushing's syndrome (Cushing's syndrome can be ACTH-dependent or ACTH-independent. It includes Cushing's disease as well as other causes of increased cortisol and non-pituitary causes of increased ACTH. In non-pituitary, ACTH-independent Cushing's syndrome cases, aldosterone levels may be low instead of high). Another entity called iatrogenic Cushing's syndrome refers to a condition resulting from prolonged and excessive use of exogenous steroids. This is quite common due to the widespread use of steroids in many autoimmune diseases like Lupus, Rheumatoid arthritis, etc. Iatrogenic Cushing's is associated with decreased ACTH due to negative feedback on the pituitary gland. Conn's disease (choice C), or primary hyper-aldosteronism, is a disease where increased secretion of aldosterone occurs due to hyperplasia or aldosterone-secreting tumors involving the cortex. See the adrenal anatomy in the diagram below to understand the zones of hormone production. Hyperplasia of the entire adrenal cortex would produce both glucocorticoids (cortisol) and mineralocorticoids (aldosterone) whereas, hyperplasia/tumor of zona glomerulosa alone would cause an increase in aldosterone without affecting cortisol levels. 24-hour urinary aldosterone levels help make the diagnosis of Conn's syndrome. The above two conditions (Cushing's disease and Conns' syndrome) lead to secondary hypertension because the aldosterone hormone increases sodium and water retention in the body. While retaining sodium, aldosterone causes loss of potassium via the kidneys. Hyperaldosteronism is, therefore, associated with hypokalemia. Hypertension and hypokalemia may indicate to the physician to suspect hyperaldosteronism. Choice B is incorrect. Addison's disease is autoimmune destruction of the adrenal cortex. The resulting adrenal insufficiency would cause low levels of cortisol and aldosterone. There is a reflex increase in ACTH due to feedback from the adrenal gland. Clinical manifestations of Addison's disease include fatigue, diarrhea, hyperpigmentation, and hypotension (opposite of hyperaldosteronism). Hypoaldosteronism can be associated with hyperkalemia (elevated potassium levels), hyponatremia (low sodium levels), and mild metabolic acidosis. Choice D is incorrect. Pheochromocytoma is a tumor of the adrenal medulla. Since the medulla produces catecholamines, cancer involving this area is associated with high levels of adrenaline and noradrenaline. The adrenal medulla does not produce aldosterone. Therefore, secondary refractory hypertension in pheochromocytoma is mediated by catecholamine excess, not by aldosterone excess. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation

Which of the following are required for a nonstress test to be considered reactive? Select all that apply. A. Two increases in the fetal heart rate of 15 beats per minute. [40%] B. Two decreases in the fetal heart rate of 15 beats per minute. [11%] C. Two increases in the fetal heart rate for 15 seconds. [38%] D. Two decreases in the fetal heart rate for 15 seconds. [11%]

Explanation Choices A and C are correct. For a nonstress test to be reactive, there must be two accelerations. Acceleration is defined as an increase in fetal heart rate by 15 beats per minute for at least 15 seconds with movement (Choice A). For a nonstress test to be reactive, there must be two accelerations. Acceleration is defined as an increase in fetal heart rate by 15 beats per minute for at least 15 seconds with movement (Choice C). Choice B is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a nonreassuring sign. Slowdowns would lead to a nonreactive nonstress test. Choice D is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a nonreassuring sign. Slowdowns would lead to a nonreactive nonstress test. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Antepartum

You are providing discharge teaching for a 3-year-old patient with CHF. She is going home on digoxin. Which instructions are essential to teaching her parents regarding the administration of this medication? Select all that apply. A. Administer digoxin one hour before or two hours after meals. [36%] B. Mix the medication with milk or applesauce to ensure she drinks it all. [12%] C. If the child vomits after administering a dose then repeat the dose. [5%] D. Call the doctor if the child starts eating poorly and vomiting frequently. [48%]

Explanation Choices A and D are correct. This is the appropriate instruction to ensure proper absorption of digoxin. It is best to advise the parents to create a schedule and administer it at the same time each day, often before breakfast in the morning (Choice A). Poor feeding and frequent vomiting are signs of digoxin toxicity. This should be taught to the parents at discharge so that they can monitor their child for these symptoms and call the health care provider if they occur. This is the result of a timely lab test to determine the serum digoxin level and early treatment if toxicity has occurred (Choice D). Choice B is incorrect. This is not an appropriate action when administering digoxin. For the medication to be absorbed correctly, it must be taken on an empty stomach. Never administer digoxin with food. Choice C is incorrect. This is not an appropriate action when administering digoxin. A second dose should not be delivered, even if the child vomited after their first dose. Digoxin toxicity is severe and overdosing the child should always be avoided. Due to the potential toxicity, it is not advisable to administer a second dose, even if the child vomited. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Cardiovascular

The nurse is assessing a patient with Antisocial Personality Disorder. Which of the following would be an expected finding? Select all that apply. A. Lack of empathy [36%] B. Grandiosity [10%] C. Preoccupation with orderliness [10%] D. Excessive attention-seeking [9%] E. Disregard for the right of others [35%]

Explanation Choices A and E are correct. Individuals with Antisocial Personality Disorder have clinical features such as a disregard for others, deception, lack of empathy, and a failure to conform to societal norms. Choices B, C, and D are incorrect. Grandiosity is a clinical feature central to narcissistic personality disorder. A preoccupation with orderliness is a key feature associated with an obsessive-compulsive personality disorder. Excessive attention-seeking is a cardinal feature associated with a histrionic personality disorder. Additional information: Antisocial personality disorder has clinical features such as superficial charm, deceit, failure to follow societal norms, and the inability to demonstrate empathy. Patient management involves setting limits and maintaining a structured environment. The nurse should ensure that the environment is safe because an individual with an antisocial personality disorder may be impulsive and act out with anger.

The nurse is teaching individuals at a health fair about the human immunodeficiency virus (HIV). It would be correct for the nurse to state that which of the following risk factors indicate the need for HIV testing? Select all that apply. A. Pregnancy [9%] B. Engaged in sex work [24%] C. Have a sexually transmitted infection [22%] D. The use of injection drugs [23%] E. Men who have sex with men (MSM) [22%]

Explanation Choices A, B, C, D, and E are correct. Recommendations for human immunodeficiency virus (HIV) testing Adolescents and adults aged 15 to 65 years (at least one time) Individuals with a sexually transmitted infection Pregnancy The use of injection drugs Engaging in sex work Men who have sex with Men (MSM) Housed in a correctional institution such as jail and prison Please note: Multiple response items require a candidate, regardless of the number of options, to select a single response, multiple responses, or all responses as correct to answer the item. Additional Info Modes of transmitting HIV include - • Sexual: genital, anal, or oral (low risk) sexual contact with exposure of mucous membranes to infected semen or vaginal secretions • Parenteral: sharing of needles ("sharps") or equipment contaminated with infected blood or receiving contaminated blood products • Perinatal: from the placenta, from contact with maternal blood and body fluids during birth, or from breast milk from an infected mother to child HIV is not transmitted by casual contact in the home, school, or workplace. Sharing household utensils, towels and linens, and toilet facilities does not transmit HIV. HIV is not spread by mosquitos or other insects.

Which forms of nonverbal communication can be viewed differently among members of different and diverse cultures? Select all that apply. A. Silence [20%] B. A smile [12%] C. Eye contact [26%] D. Touch [23%] E. Bodily posture [19%]

Explanation Choices A, C, D, and E are correct. Silence, eye contact, touch, and bodily posture are all forms of nonverbal communication that can be viewed and perceived differently among members of different and diverse cultures. Some cultures can see silence to be a lack of attention, while others can perceive silence as a compassionate way that understanding is conveyed. Some view eye contact as aggressive and hostile while other cultures see eye contact as connectedness with others. Some cultures perceive touch as inappropriate and invasive while others recognize touch as a sign of caring and compassion. Lastly, many bodily postures and gestures differ significantly among various cultures. A smile is a relatively universal sign of joy and happiness. Choice B is incorrect. A smile is a relatively universal sign of joy and happiness among all, if not most, cultures. Therefore this is the incorrect answer to the question.

You are administering a transfusion of 1 unit of PRBCs to a 63-year-old client with hemoglobin of 8.9%. Listed in the exhibit provided are his vital signs pre-transfusion, 5 minutes into the transfusion, and 10 minutes into the transfusion. What should the nurse do after 10 minutes of administering the transfusion? See the exhibit. Select all that apply. A. Continue to monitor the patient's response to the transfusion. [7%] B. Notify the health care provider. [38%] C. Stop the transfusion. [45%] D. Take another set of vital signs at the next 10-minute interval. [10%]

Explanation Choices B and C are correct. As shown in the exhibit, there is an increase in temperature and a drop in blood pressure following the blood transfusion. Based on the vital signs the nurse has obtained, she expects that the patient is having a transfusion reaction. Transfusion reactions are adverse reactions that happen as a result of receiving a blood transfusion. Signs and symptoms of a transfusion reaction include fever, chills, diaphoresis, muscle aches, back pain, rashes, dyspnea, pallor, headache, nausea, apprehension, tachycardia, and hypotension. (Most common symptoms can be remembered by the mnemonic - "REACTION" - Rash, Elevated temperature, Aching, Chills, Tachycardia, Increased pulse, Oliguria - low urine output and Nausea). Most transfusion reactions occur during the first 15 minutes. While initiating blood transfusion, it should be started slowly at a rate of 2 mL/min (120 mL/hr) for the first 15 minutes - the idea here is to minimize the volume of the blood infused if the patient were to develop a reaction. The nurse should use an 18 gauge or larger cannula to infuse because a smaller cannula may lead to mechanical lysis of red blood cells. The nurse should remain at the patient's bedside for the first 15 minutes and if the blood is tolerated for 15 minutes without a reaction, the infusion rate can be increased. Blood transfusion units are usually at 250 cc to 300 cc in volume. Transfusion must be completed within 4 hours. As per the blood transfusion protocol used in most centers, vitals must be obtained at 5 minutes, 15 minutes, 30 minutes from the start of the infusion, 1 hour before the infusion is completed, and then at 1 hour after the transfusion is complete. Even if the patient is not complaining of the typical signs and symptoms, if their vital signs indicate a possible transfusion reaction, the transfusion should be stopped. In this client, the heart rate is trending up, blood pressure is trending down, and the temperature is trending up. At 10 minutes, he is tachycardic, hypotensive, and febrile. The patient is having a transfusion reaction. This requires immediate intervention. Therefore, the nurse should immediately stop the transfusion (Choice C); disconnect blood tubing from the intravenous site and notify the health care provider (Choice B). Choice A is incorrect. It is inappropriate to continue monitoring the patient's response to the transfusion. Their vital signs are out of normal limits and an intervention is required. Choice D is incorrect. The nurse will begin continuously monitoring vital signs now that she suspects a transfusion reaction. It would be inappropriate for her to wait 10 minutes to take another set of vitals. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies Subtopic: Blood and Blood Products.

Which of the following are substantial nursing interventions for a patient who is one-hour post-op from a cardiac catheterization? Select all that apply. A. Administer their regularly scheduled metformin on time. [6%] B. Assess the pulse of the extremity distal to the puncture site. [37%] C. Position them supine with the head of bed at 45 degrees. [21%] D. Monitor for hematoma formation at the puncture site. [35%]

Explanation Choices B and D are correct. The nurse must perform a thorough assessment of the perfusion status of the extremity distal to where the puncture was. In a cardiac cath, a sheath is inserted through an artery and snaked up into the heart. This sheath occluded blood flow during the procedure. So, we must monitor the extremity through which they placed the sheath to ensure perfusion returns properly. This includes assessing the pulse, capillary refill, the color of the extremity if there is any pain or numbness, and movement of the extremity. Usually, a femoral artery is used, so we must monitor the perfusion of the foot on the leg that was accessed (Choice B). Monitoring for hematoma formation over the access site is a critical nursing intervention. The most common complication after a cardiac catheterization is bleeding, and the creation of a hematoma shows bleeding under the skin. The nurse should notify the health care provider if she notes a hematoma forming so that they may evaluate the patient. Be sure to monitor for other signs of bleeding as well, especially around the access site (Choice D). Choice A is incorrect. If the patient who is postoperative from a cardiac catheterization has metformin scheduled, the dose should be held for 48 hours post-op. Iodinated contrast used for cardiac catheterization may cause kidney failure. Should such acute kidney failure occur, metformin metabolites can accumulate and cause lactic acidosis. Therefore, metformin should always be held for 48 hours after any procedure that involves iodinated contrast. Choice C is incorrect. Positioning is critical after a cardiac catheterization. For 4 to 6 hours post-op, the head of the bed should be flat or slightly elevated but no more than 30 degrees. Such positioning prevents bleeding and helps the access site from the cardiac catheterization ultimately heal. It is also essential to educate the patient about this so that they will be still and not try to stand up on their own before they are allowed to. NCSBN Client Need: Topic: Health Promotion and Maintenance; Subtopic: Cardiac

The registered nurse (RN) is assigning patient care. Which of the following should the RN assign to the licensed practical/vocational nurse (LPN/VN)? Select all that apply. A. A patient requiring an assessment of their current medications [3%] B. A patient needing a nasogastric tube (NGT) for enteral feedings [35%] C. A patient with an insulin pump and is unsure of how to load the insulin [11%] D. A patient requesting additional teaching on their discharge prescriptions [12%] E. A patient requiring airborne isolation and bronchodilators via an inhaler [38%

Explanation Choices B and E are correct. Skills such as the insertion of an NGT are within the scope of an LPN/VN. The RN can delegate this to the LPN/VN. Further, LPN/VN's may care for a patient in isolation as well as administer bronchodilators via an inhaler. Practical/vocational nurses should get the most stable patient assignment. Choices A, C, and D are incorrect. Assessment of a patient's medication regimen is the responsibility of the RN, as well as teaching a patient who is unsure about their insulin pump. Finally, the patient requesting additional teaching on their medications falls to the responsibility of the RN. Additional information: The scope of practice for the RN includes assessment, teaching, and evaluation. An LPN may reinforce teaching, but any initial teaching must come from the RN. Unstable patients and patients with unpredictable outcomes should be assigned to the RN. Patients who are stable and have predictable outcomes should be assigned to the LPN.

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. What foods should the nurse include in dietary teaching with the client that are good sources of phosphorus? Select all that apply. A. Leafy greens [23%] B. Garlic [15%] C. Nuts [31%] D. Butter [14%] E. Turkey [15%]

Explanation Choices B, C, and E are correct. B is correct. Garlic is a food rich in phosphorus and would be an appropriate recommendation for a client that needs to incorporate more phosphorus in their diet. C is correct. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of this important mineral. Cashews, almonds, and brazil nuts are all very high in phosphorus. E is correct. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, more than 40% of the recommended daily intake (RDI). Choice A is incorrect. While leafy greens are good choices for many vitamins and minerals, they do not contain a lot of phosphorus. Therefore, this would not be a good choice to recommend to a client that needs a diet rich in phosphorus. Choice D is incorrect. Butter does not have a lot of phosphorus. This would not be an appropriate recommendation.

The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply. A. Carotid pulse check should not take more than 20 seconds. [12%] B. The rate of chest compressions should be 100-120 per minute. [28%] C. Chest compression depth should be 2 inches on the center breastbone. [29%] D. Chest tube insertion should be prepared after five minutes of CPR. [2%] E. Early defibrillation is essential in the survival of ventricular fibrillation. [29%]

Explanation Choices B, C, and E are correct. High-quality CPR involves a compression depth of two inches on the center breastbone. The rate of the compressions should be 100-120 per minute. The nurse should utilize early defibrillation as it is the most effective treatment of ventricular fibrillation. Choices A and D are incorrect. A carotid pulse check should not exceed ten seconds. Poor quality CPR has been linked to prolonged pulse checks and pulse checks occurring too frequently. A chest tube is not in the BLS algorithm and would only be utilized for chest trauma causing injuries such as a pneumothorax. Additional information: The key to successful basic life support is high-quality CPR and prompt defibrillation. When responding to a confirmed cardiac arrest, the nurse should immediately initiate an emergency response (call a code blue or 911). Start chest compressions at a rate of 30 compressions to 2 rescue breaths. A request for an AED should be given as soon as possible; it should be applied and used immediately. The key to effective CPR is to minimize interruptions. The prompt utilization of an AED greatly enhances the survival of ventricular dysrhythmias. Auditory cues from the AED should be followed precisely to ensure the minimization of CPR interruptions. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Medical Emergencies

You have a 25-year-old patient who has sustained multiple long-bone fractures in a motor vehicle accident. While waiting for the OR to be available, they lose one-third of their blood volume and become hypotensive. The patient blood type is B+. You are sent to the blood bank to pick up two units of PRBCs for the patient. Which of the following blood types would be appropriate for transfusion? Select all that apply. A. A+ [6%] B. B- [22%] C. O- [26%] D. AB- [9%] E. O+ [37%]

Explanation Choices B, C, and E are correct. These are appropriate blood types for transfusion in this patient. Because this patient has only B antigens on their RBCs, any other antigens will be marked as foreign, and the body will mount an immune response. Choice A is incorrect. A+ blood would have A antigens and thus cause a transfusion reaction. Choice D is incorrect. This is wrong for the same reason: the A antigens from the AB- blood would cause a transfusion reaction. A patient with B+ blood can receive blood that is B+, B-, O+, or O-. NCSBN Client need: Topic: Pharmacological and Parenteral TherapiesSubtopic: Blood and Blood Products

You are educating a 25-year-old obese client with a body mass index (BMI) of 31 at 12 weeks gestation, who presents for a routine antenatal check-up. She gained 3 pounds compared to pre-pregnancy weight. Which of the following statements by the client reflect correct understanding regarding recommended weight changes in pregnancy? Select all that apply. A. "Since I am obese, I should try to lose weight now to limit my risk of gestational diabetes." [14%] B. "Typically, there is 3 to 6 pounds of weight gain during the first trimester of pregnancy." [23%] C. "In the third trimester, a weight gain of 2 pounds or more each week is considered high." [25%] D. "I should aim to gain a total of 25 to 35 pounds during this pregnancy." [18%] E. "Going forward in my pregnancy, I should aim to gain ½ pound per week." [20%]

Explanation Choices B, C, and E are correct. Weight gain is considered crucial during pregnancy. A pregnant woman should be educated regarding what is deemed to be reasonable in terms of pregnancy weight gain and the implications of gaining too much or too little weight. The client needs to keep track of the rate of weekly weight gain. Guidelines have been proposed to assist with determining the rate of healthy weekly weight gain. Weight gain of 3 to 6 pounds during the entire first trimester (first three months) is considered normal and healthy (Choice B). Gaining 2 pounds or more per week at any time (Choice C) during pregnancy would be abnormally high and such a client should focus on limiting the further rate of weight gain. The client in the question has already gained 3 pounds, which is healthy. Going forward, she should aim to gain about 8 to 17 pounds in the next six months (about half a pound per week for the rest of her pregnancy). This is based on the recommended weight gain of 11-20 pounds during the entire pregnancy for someone with a BMI of 30 or above (obese). Recommended weight gain is based on pre-pregnancy BMI and is shown in the table below: Choices A and D are incorrect. Weight-loss is dangerous during pregnancy. Regardless of their pre-pregnancy weight, every woman is expected to gain weight during pregnancy. The amount of recommended weight gain, however, is based on their pre-pregnancy BMI. A weight gain of 25 to 35 pounds (Choice D) is an ideal range recommended for those clients with healthy pre-pregnancy BMI (18.5 to 24.9). For an obese client, gaining 11 to 20 pounds during the entire pregnancy is considered ideal. Gaining more than the recommended weight will put the clients at risk for maternal hyperglycemia, reduced glucose tolerance, and increased risk of fetal complications. Fetal complications include increased risk of preterm delivery, having a newborn who is large for gestational age (LGA), and requiring a cesarean delivery. Gaining less than recommended weight increases the risk for small for gestational age (SGA) babies. The following table gives recommendations for a healthy rate of weekly weight gain:

The local community health nurse is teaching a course to nursing students on biological terrorism. When discussing anthrax, the nurse should inform their students that this agent is transmitted via: Select all that apply. A. Mosquito bites [6%] B. Breathing in bacterial spores [34%] C. Sexual contact with an infected person [4%] D. Ingestion of contaminated animal products [27%] E. Through an open wound or scratch on the skin [29%]

Explanation Choices B, D, and E are correct. Anthrax is caused by a bacteria known as Bacillus anthracis. It is spread by inhaling bacterial spores, eating raw or contaminated meats, or through open wounds and scratches on the skin. Anthrax is not spread person to person or animal to person. Choices A and C are incorrect. These are not the way anthrax is spread. NCSBN client need Topic: Safety and Infection Control: Emergency Response Plan

The primary healthcare provider prescribes 30 mL/kg of 0.9% saline to a client with suspected sepsis. The client weighs 236 pounds. How many mL will the nurse infuse into the client? Fill in the blank. Round your answer to the nearest whole number. 5218 mL

Explanation First, convert the pounds to kilograms by dividing the weight in pounds by 2.2 236 / 2.2 = 107.27 kg Next, multiply the prescribed amount of fluid by the client's weight in kilograms 30 mL x 107.27 kg = 3218.1 mL Finally, round the amount of fluid to a whole number 3218 mL

What is the sequence of action when you are mixing two insulins, such as NPH insulin and regular insulin, together in the same syringe? Place these steps in the correct order. Select the first step and then place that choice as the first letter of a series of letters in your response. For example, if the X choice is the first step; the Y choice is the second step, and the Z step is the last step of this procedure, you would fill "X, Y, and Z" in that sequential order in the blank space below. Inject an amount of air equal to the regular insulin. Inject an amount of air equal to the ordered dosage of the NPH insulin. Withdraw the ordered dosage of the regular insulin. Withdraw the ordered dosage of the NPH insulin. Prep the top of the vials with an alcohol pad.

Explanation The correct answer sequence is 5, 2, 1, 3, and 4. When you mix regular insulin with another type of insulin, always draw the regular insulin into the syringe first. When you combine two types of insulins other than regular insulin, it does not matter in what order you bring them into the syringe. The correct procedure for drawing up and mixing two different insulins like NPH insulin and regular insulin, in the correct sequential order, is: A. Prep the top of the vials with an alcohol pad. B. Inject an amount of air equal to the ordered dosage of the NPH insulin C. Inject an amount of air equivalent to the ordered dosage of the regular insulin. D. Withdraw the ordered dosage of the regular insulin. E. Withdraw the ordered dosage of the NPH insulin. This sequencing prevents the contamination of regular insulin with the longer-acting NPH insulin.

The primary healthcare provider (PHCP) prescribes 100 mg of amoxicillin oral suspension by mouth, four times a day. The medication label reads amoxicillin 250 mg per 5 mL. The nurse prepares to administer how many milliliters per dose? Fill in the blank. 2 mL

Explanation The formula of dose ordered / dose on hand x volume will be utilized to solve this problem. Divide the prescribed amount of medication by what is on hand 100 mg / 250 mg = 0.4 mL Next, take the amount of the medication and multiply it by the volume 0.4 mL x 5 mL = 2 mL Additional Info Amoxicillin is an antibiotic utilized in various infections such as otitis media. When administered to a child, the nurse should use a syringe over a spoon to deliver the precise amount.

The primary healthcare provider (PHCP) prescribes 4 mg of morphine intramuscular (IM). The medication vial reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters to administer the appropriate dose? Fill in the blank. 0.4 mL

Explanation The formula of dose ordered / dose on hand x volume will be utilized to solve this problem. First, divide the prescribed amount of medication by what is on hand 4 mg / 10 mg = 0.4 mL Finally, multiply it by the volume. If none is listed, multiply the answer by one (1) 0.4 mL x 1 mL = 0.4 mL Additional Info Morphine is an opioid utilized for moderate to severe pain. It can be given intravenously, intramuscular, and by mouth. Prior to administering the medication, the nurse should obtain vital signs and pay close attention to the client's respiratory rate and blood pressure, as this medication may lower both. Fall precautions will be necessary after administering this medication.

The primary healthcare provider prescribes 6,000 units of heparin subcutaneously. The vial reads 10,000 units/1 mL. How many milliliter(s) should the nurse administer? Fill in the blank. 0.6 mL

Explanation To solve this problem, the formula of dose ordered / dose on hand x volume will be utilized. 6,000 units / 10,000 units x 1 mL = 0.6 mL Additional Info It is important to remember that when inputting responses that have a decimal, to start the response with a leading zero (example - .5 is incorrect / 0.5 is correct)

A pregnancy-related spinal change that can alter mobility is known as: A. Ankylosing spondylosis [17%] B. Lordosis [62%] C. Scoliosis [9%] D. Kyphosis [11%]

xplanation Choice B is correct. The spinal change that is common in pregnancy is lordosis. This is the result of the increasing weight of the enlarging uterus and the effect of gravity. As a fetus grows, a variety of changes appear in a pregnant woman's body. The thoracic and lumbar spine curvature change, pain in the low back, and pelvic region can increase, and the balance and gait pattern also changes. Some studies report that the center of gravity of pregnant women moves towards the abdomen, resulting in an increase in lumbar lordosis, posterior tilt of the sacrum, and movement of the head to the back to compensate for the increased weight as the fetus grows. Choice A is incorrect. Ankylosing spondylosis is a form of arthritis that primarily affects the spine, although other joints can become involved. It causes inflammation of the spinal bones (vertebrae) that can lead to severe, chronic pain, and discomfort. Choice C is incorrect. Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. Choice D is incorrect. Kyphosis is an exaggerated, forward rounding of the back. It can occur at any age but is most common in older women. Age-related kyphosis is often due to weakness in the spinal bones that causes them to compress or crack. Other types of kyphosis can appear in infants or teens due to malformation of the spine or wedging of the spinal bones over time. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort, Musculoskeletal Changes in Pregnancy