mynclex set 7- 39

An adult client with bacterial pneumonia becomes increasingly disoriented and somnolent. Which assessment findings indicate that the client may be in septic shock? Select all that apply. 1. Blood pressure of 80/50 mm Hg 2. Capillary refill of 5 seconds 3. Temperature of 96.4 F (35.8 C) 4. Urine output of 125 mL/hr 5. WBC count of 26,000/mm3 (26 x 109/L) OmittedCorrect answer 1,2,3,5 24%Answered correctly

Sepsis is an overwhelming response to infection that causes impaired organ function. Septic shock occurs when sepsis causes cardiovascular collapse and/or impairs the body's ability to maintain normal metabolic and cellular processes. Manifestations of septic shock include: Fever or hypothermia (>100.4 F [38 C]; <96.8 F [36 C]) - Either fever or low body temperature is found in sepsis and septic shock. Fever occurs in response to infection, whereas low body temperature can occur as shock worsens due to metabolic alterations and inadequate tissue perfusion (Option 3). Hypotension - Systolic blood pressure <90 mm Hg or mean arterial pressure <65 mm Hg in a client with infection may indicate septic shock. Altered perfusion from hypotension may cause lactic acid accumulation and metabolic acidosis (Option 1). Prolonged capillary refill - A refill time >3-4 seconds in adults indicates inadequate tissue perfusion as a result of altered peripheral circulation and hypotension (Option 2). Tachycardia - A resting heart rate >90/min is common in septic shock to compensate for decreased systemic vascular tone and hypotension. WBC count >12,000/mm3 (12 x 109/L) or immature neutrophils (bands) of >10% - An increased WBC count, especially with bands, indicates severe infection (Option 5). (Option 4) Clients with septic shock typically develop decreased urine output (ie, <0.5 mL/kg/hr) due to inadequate organ perfusion. Educational objective:Septic shock is a life-threatening systemic response to infection that causes impaired organ function, cardiovascular collapse, and/or impairment of normal metabolic and cellular processes. Signs of septic shock include fever or hypothermia, hypotension, tachycardia, and leukocytosis.

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply. 1. Human immunodeficiency virus (HIV) 2. Human papillomavirus (HPV) 3. Multiple sexual partners 4. Nulliparity 5. Sexual activity before age 18 OmittedCorrect answer 1,2,3,5 12%Answered correctly

Almost all cases of cervical cancer result from persistent infection due to human papillomavirus (HPV), a primary risk factor (Option 2). HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However, persistent HPV infection can cause abnormal changes in cervical epithelial tissue that slowly progress to invasive cancer if not treated. Most other risk factors for cervical cancer are related to behaviors that increase the client's risk of contracting HPV or an inability to clear the infection. Clients who have multiple sexual partners or initiate sexual activity at an early age (<18) increase their risk for exposure to HPV (Options 3 and 5). Clients with weakened immunity (eg, HIV, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection (Option 1). (Option 4) Nulliparity (ie, no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast cancer. Educational objective:Human papillomavirus is the most common sexually transmitted infection and is a primary risk factor for cervical cancer. Other cervical cancer risk factors include sexual activity at an early age (age <18), multiple sexual partners, and weakened immune system function (eg, HIV infection). Additional Information Health Promotion and Maintenance NCSBN Client Need

/Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis? 1. Metronidazole 500 mg IV every 8 hours (13%) 2. Nasogastric (NG) tube to suction (19%) 3. Nothing by mouth (NPO) (6%) 4. Prepare for barium enema in AM (59%) OmittedCorrect answer 4 59%Answered correctly

Diverticular disease of the colon occurs when saclike protrusions form in the large intestine. When diverticula become infected and inflamed, the client has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes the following: IV antibiotic therapy - to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS; Septra) or ciprofloxacin (Cipro) (Option 1) NPO status - more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3) NG suction - in severe cases of abdominal distention, nausea, or vomiting (Option 2) IV fluids - prevent dehydration Bed rest (Option 4) Any procedure or treatment that increases intraabdominal pressure (lifting, straining, coughing, bending), increases peristalsis (laxative, enema), or could lead to perforation or rupture of the inflamed diverticula should be avoided during the acute disease process. A barium enema may be used after treatment with antibiotics and the inflammation is resolved. Diagnostic examinations, such as abdominal x-rays or CT scans, may be used without risking rupture. Educational objective:Management of acute diverticulitis focuses on bowel rest (NPO status, NG suction, bed rest), and drug therapy (IV antibiotics, analgesics). Any procedure or treatment that increases intraabdominal pressure or may cause rupture of the inflamed diverticula should be avoided.

A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply. 1. Desire for adoption planning services 2. Emotional response to the pregnancy 3. Family/social support systems 4. Nutritional habits and substance abuse 5. Plan for finishing high school OmittedCorrect answer 2,3,4 61%Answered correctly

Pregnant adolescent clients are a unique population because of their increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia) and developmental needs. During an initial encounter with a pregnant adolescent, the nurse should discuss the client's emotional response to the pregnancy to build rapport and provide psychosocial support (Option 2). Discussing the client's level of family/social support or fear of social discrimination is appropriate because these factors may prevent the client from obtaining prenatal care (Option 3). Pregnant adolescents are vulnerable to poverty, dangerous living conditions, exposure to teratogens (eg, tobacco, alcohol, illicit drugs), poor nutritional status, and physical or sexual abuse, which can cause adverse fetal/maternal outcomes. Therefore, discussing these topics openly as soon as possible is appropriate to prevent harm (Option 4). (Option 1) Discussing adoption planning and parenting is not necessary at this time but should be addressed later in collaboration with a social worker. (Option 5) Young adolescents (ie, age <16) are less mature emotionally and developmentally and may resist planning for the future. Education planning may be approached during subsequent encounters, but it is not a priority for maternal and fetal health at this time. Educational objective:Pregnant adolescent clients are at an increased risk for complications during pregnancy. Factors such as emotional response to the pregnancy, family/social support, nutritional status, and substance abuse impact the pregnancy and should be discussed during an initial encounter to establish rapport and prevent harm.

The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply. 1. "How would you describe your child's usual behavior at home?" 2. "These bruises seem excessive and suspicious. How did they happen?" 3. "What forms of discipline do you use with your child?" 4. "When you are stressed, what coping mechanisms do you use?" 5. "Who watches your child when you are at work?" OmittedCorrect answer 1,3,4,5 39%Answered correctly

When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned, and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse. If possible, the interview should be done without the child present. The nurse should remain supportive and empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence." Open-ended questions are less threatening and provide more detailed responses. Information to gather includes: Caregiver's perspective on the child's behavior (Option 1) Methods of discipline used with the child (Option 3) Routine caregivers for the child Caregiver stress, coping, and support systems (Option 4) Person or persons who care for the child when regular caregivers are away (Option 5) (Option 2) Use of the words "excessive" and "suspicious" to describe the child's bruising conveys judgment. This may cause the caregiver to become defensive and limit the nurse's ability to establish trust and find the source of the abuse. Educational objective:When child abuse is suspected, the nurse should convey empathy and support when questioning a caregiver while maintaining a nonjudgmental, nonthreatening attitude. Open-ended questions are less threatening and provide more detailed responses.

/During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply. 1. Assess the client's hand movements with the arms extended 2. Compare current mental status findings with those from previous shifts 3. Contact the health care provider to request a blood draw for ammonia level 4. Encourage the client to ambulate in the hallway 5. Hold the client's morning dose of lactulose OmittedCorrect answer 1,2,3 66%Answered correctly

Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy. The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by assessing for asterixis and comparing current mental status and ammonia level to previous findings. If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and discharge should be delayed until the client is stable. (Option 4) The client with lethargy and confusion is at risk for falling. Ambulation is not an appropriate intervention at this point. (Option 5) Lactulose is the primary drug used for hepatic encephalopathy treatment. It helps to excrete ammonia through the bowels as soft or loose stools. Lactulose should not be held if the client's hepatic encephalopathy continues to worsen. Educational objective:Hepatic encephalopathy is a serious complication of end-stage liver disease caused by high levels of ammonia in the blood. Assessment findings include confusion, lethargy, and asterixis; coma and death can occur if this condition remains untreated. Pharmacologic treatments include lactulose and antibiotics (eg, rifaximin). The client with worsening encephalopathy is not stable enough for discharge.

The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? 1. Client with history of head injury whose Glasgow Coma Scale (GCS) changes from 13 to 14 (3%) 2. Client with history of myasthenia gravis who had ptosis in the evening (3%) 3. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension (91%) 4. Client with history of transverse myelitis with 2+ bilateral lower extremity muscle strength (0%) OmittedCorrect answer 3 91%Answered correctly

Autonomic dysreflexia (autonomic hyperreflexia) is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system (SNS) in a spinal injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia, piloerection (goose bumps), and flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause. (Option 1) The Glasgow Coma Scale (GCS) is an objective scale used to monitor alertness/mental functioning in an acute head injury. The best score is 15, and the worst is 3. This client has an improving trend and is not a priority. (Option 2) Myasthenia gravis is an autoimmune disease manifesting mainly as muscle weakness and ptosis. The muscle weakness increases with activity, and by the end of the day, ptosis is present. These are expected findings for this condition, and so this client is not a priority. However, clients with myasthenic crisis can have respiratory failure, which, if it occurs, would be a priority. (Option 4) Transverse myelitis (spinal cord inflammation) usually results from a recent viral infection. Classic symptoms include paralysis, urinary retention, and bowel incontinence. Some clients recover, but many have permanent disability. Normal muscle strength is 5 on a scale of 0-5. Weakened muscle strength (2+ means only able to move laterally, not able to lift up against gravity) would be an expected finding. Educational objective:Autonomic dysreflexia in a client with a spinal cord injury is a priority and requires emergency intervention. Classic triggers are distended bladder or rectum. Management includes raising the head of the bed and then treating the cause (eg, Foley catheter kinks). Additional Information Management of Care NCSBN Client Need

////Four clients with different skin alterations come to the emergency department. Which client should the nurse advise that the health care provider (HCP) see first? 1. 8-year-old client who uses corticosteroid inhaler and has white patches on the tongue (5%) 2. 50-year-old client who developed a smooth, red, pinpoint rash after taking sulfa (62%) 3. 60-year-old client with pain and crusted blisters along the back (27%) 4. 70-year-old client who has erythema with a small pustule at the hair follicle (4%) OmittedCorrect answer 2 62%Answered correctly

Petechiae (small pinpoint red/purple spots on mucus membrane or skin) and purpura (irregular purplish blotches) can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more localized dermatological presentation. (Option 1) Oropharyngeal candidiasis/thrush (moniliasis) is a fungal infection of skin or mucous membranes. It resembles curdled milk and can bleed when removed. The etiology may be due to not rinsing the mouth after steroid inhaler use. It is treated with antifungal suspensions (nystatin) and is nonurgent. (Option 3) Shingles (herpes zoster) is reactivation of dormant varicella virus. The lesions follow the nerve dermatome and can be quite painful. Incidence increases after age 50. Active chickenpox requires airborne and contact precautions, but not the shingles with crusted lesions, especially if the lesions are covered with clothes. It can be contagious to individuals who have not had varicella or who are immunocompromised. However, this is the second priority as this is a localized issue; the nurse can place this client in a private area. (Option 4) Folliculitis is usually due to the presence of staphylococci in moist areas where there is friction. It is most common in the scalp, beard, and extremities in men. It can be treated with medicated soap, topical antibiotics, and warm compresses. The systemic issue in Client 2 is a priority. Educational objective:Petechiae (small circles) and purpura (blotches) are reddish/purple rashes that do not blanch. They indicate systemic blood dyscrasias and are a priority for treatment.

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? 1. Insert a Foley catheter into the existing tract and inflate the balloon (22%) 2. Insert a small-bore nasointestinal tube to administer feedings and medications (3%) 3. Notify the health care provider who inserted the PEG tube (55%) 4. Reinsert the PEG tube into the existing tract immediately (17%) OmittedCorrect answer 3 55%Answered correctly

A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option 2) Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention. Educational objective:A PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks. Tube dislodgement <7 days from placement requires surgical or endoscopic replacement. Attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis.

After receiving the shift report, the nurse should assess which infant first? 1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min (10%) 2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2 mmol/L) (64%) 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago (21%) 4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C) (2%) OmittedCorrect answer 2 64%Answered correctly

A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first. (Option 1) A normal respiratory rate for an infant is 30-60/min. This infant is currently stable. (Option 3) It is normal to auscultate crackles in an infant during the first hour of life. This is because fluid is still being pushed out of and absorbed by the lungs. This infant is currently stable. (Option 4) A normal temperature range for an infant is 97.7-99.7 F (36.5-37.6 C). This infant is currently stable. Educational objective:The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring the blood glucose level. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia and should be treated immediately by feeding or administering a glucose bolus. Additional Information Management of Care NCSBN Client Need

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? 1. "A power of attorney (POA) is good to have in place. It sounds like you are on the right track." (7%) 2. "Great. Your POA can start to make decisions for you when you are no longer able to do so." (13%) 3. "Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order." (1%) 4. "There are many types of POAs. Let's clarify if your POA can make health care decisions for you." (77%) OmittedCorrect answer 4 77%Answered correctly

A power of attorney (POA) designates a representative to act on a person's behalf in the event that the individual becomes incapacitated. There are different types of POAs, including medical and financial. An advance directive or living will describes the client's health care decisions (eg, do not resuscitate). As part of an advance directive, the client may designate a representative to make health care decisions for the client - a durable POA for health care or POA for health care (Canada). This client's statement requires further clarification regarding what type of POA is in place (Option 4). (Option 1) The nurse should not assume that the client's affairs are in order based on this statement. Further clarification is needed to determine whether the client has made the appropriate arrangements regarding health care decisions. (Option 2) Although it is correct that the POA makes decisions for a client only when the client is no longer able to make them, the nurse first needs to determine what type of POA is in place. (Option 3) Lawyers can help with end-of-life paperwork, but the priority is to clarify whether the client has the appropriate POA in place. Educational objective:An advance directive makes clear a client's health care wishes (eg, do not resuscitate). A power of attorney (POA) designates a representative to act on a person's behalf. It is important to clarify that the client has the type of POA who can make health care decisions (durable POA for health care, POA for health care [Canada]).

/The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet. The trunk has a pink color. Which action by the nurse is appropriate? 1. Apply blow-by oxygen and count respirations (7%) 2. Auscultate heart sounds for a murmur (7%) 3. Observe the newborn for expiratory grunting (12%) 4. Place the newborn skin-to-skin with the mother (73%) OmittedCorrect answer 4 73%Answered correctly

Acrocyanosis or peripheral cyanosis of the hands and feet is a benign finding during a newborn's transition to extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold. Manifestations include a bluish discoloration of the hands and feet and sometimes the skin around the mouth. Acrocyanosis results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and stabilize temperature. Initial nursing management includes promoting thermoregulation by placing the newborn skin-to-skin with the mother or under a radiant warmer and assessing axillary temperature (Option 4). (Option 1) Acrocyanosis is considered normal during the first day of life. Therefore, supplemental oxygen is not warranted unless central cyanosis or other signs of respiratory distress (eg, tachypnea) occur. (Option 2) Transient acrocyanosis without central cyanosis in the first day of life is considered normal and not indicative of a pathologic condition (eg, murmur). (Option 3) Because peripheral cyanosis is a normal finding associated with the newborn's inability to retain heat adequately, the best action is to facilitate newborn thermoregulation and continue routine observation for any respiratory abnormalities. Educational objective:Acrocyanosis manifests as a bluish discoloration of the newborn's hands and feet; it is considered a normal finding during the first day of life or if the newborn becomes cold. The best nursing action is to promote warmth by placing the newborn skin-to-skin with the mother.

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? 1. Heating pad (46%) 2. Positioning for comfort (7%) 3. Rest from pain-aggravating activities (39%) 4. Stretching exercises (6%) OmittedCorrect answer 3 39%Answered correctly

Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities which may continue to promote inflammation and delay healing. (Option 1) Applying heat to the injured area can promote the inflammatory process (via vasodilation); therefore, this is not the best intervention at this time. However, after the acute inflammation has resolved (usually within a few days) heat application would be appropriate to reduce pain and muscle spasms. (Option 2) Although the nurse should teach the client to ensure positioning for comfort to reduce pain, this is less likely to impact the inflammatory processes causing the pain. (Option 4) Stretching exercises can also be helpful for back pain but should begin after the acute pain and inflammation have subsided. Educational objective:Rest from activities that aggravate pain and inflammation is a nonpharmacologic comfort intervention to decrease the inflammation due to acute pain. Additional Information Basic Care and Comfort NCSBN Client Need

///The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse? 1. Client reports chest pain that is worse with deep inspiration (7%) 2. Distant heart tones and jugular venous distension (35%) 3. ECG showing ST-segment elevations in all leads (47%) 4. Pericardial friction rub auscultated at the left sternal border (8%) OmittedCorrect answer 2 35%Answered correctly

Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). Increased pericardial fluid places pressure on the heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-threatening without immediate intervention. When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest. (Option 1) In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside table) to lean on for comfort. (Option 3) ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in only localized leads (depending on which vessel is occluded). (Option 4) Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium rubbing together to create a characteristic high-pitched, leathery, and grating sound. Educational objective:Nurses caring for clients with pericarditis should monitor for, and immediately report, signs of cardiac tamponade (eg, jugular venous distension, distant heart sounds, hypotension), a life-threatening complication occurring from increased pericardial fluid volume. Additional Information Physiological Adaptation NCSBN Client Need

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention? 1. Client has not been taking prenatal vitamins (13%) 2. Client is taking lisinopril to control hypertension (53%) 3. Client reports a whitish vaginal discharge (3%) 4. Client reports mild cramping pain in the lower abdomen (29%) OmittedCorrect answer 2 53%Answered correctly

Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, lisinopril, ramipril) and angiotensin II receptor blockers (eg, losartan, valsartan, telmisartan) should be avoided in clients who are planning to become pregnant. These drugs are teratogenic, leading to fetal renal and cardiac abnormalities, and are contraindicated in all stages of pregnancy. (Option 1) Prenatal supplements, especially folic acid and iron, are recommended during pregnancy. Although important, this is not a priority over discontinuing ACE inhibitors. (Option 3) Leukorrhea, a whitish vaginal discharge, is common during the prenatal period. The client should be instructed to call the health care provider if the discharge is accompanied by other signs or symptoms, such as a foul odor, redness, or itching. (Option 4) As the uterus enlarges, cramping may occur in the lower abdomen and inguinal region. This common finding can be caused by stretching of the round ligaments, and is usually not concerning in the absence of vaginal bleeding. Educational objective:Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are teratogenic and need to be discontinued when planning pregnancy.

//A client is admitted with an exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply. 1. Accessory muscle use 2. Chest tightness 3. High-pitched expiratory wheeze 4. Prolonged inspiratory phase 5. Tachypnea OmittedCorrect answer 1,2,3,5 41%Answered correctly

Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Asthma exacerbations occur due to various triggers (eg, allergens, respiratory infection, exercise, cold air), resulting in edema, hypersecretion of mucus, and bronchospasm. Narrowing of the airways culminates in increased airway resistance, air trapping, and lung hyperinflation. In severe asthma, breath sounds may be diminished due to closure of bronchioles. Absent breath sounds in a client with asthma are a medical emergency. Clinical manifestations of an asthma exacerbation include: Accessory respiratory muscle use related to increased work of breathing and diaphragm fatigue (Option 1) Chest tightness related to air trapping (Option 2) Cough from airway inflammation and increased mucus production Diminished breath sounds related to hyperinflation High-pitched expiratory wheezing caused by narrowing airways (Option 3); wheezing may be heard on both inspiration and expiration as asthma worsens Tachypnea related to inability to take a full, deep breath (Option 5) (Option 4) Clients with obstructive lung disease (eg, asthma, chronic obstructive pulmonary disease) develop prolonged expiratory phase as a physiologic response to hyperinflation and trapped air. Educational objective:Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Clinical manifestations of an asthma exacerbation include accessory respiratory muscle use, chest tightness, diminished breath sounds, high-pitched wheezing on expiration, prolonged expiratory phase, tachypnea, and cough.

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? Select all that apply. 1. Change in lacrimation on the affected side 2. Electric shock-like pain in the lips and gums 3. Flattening of the nasolabial fold 4. Inability to smile symmetrically 5. Severe pain along the cheekbone OmittedCorrect answer 1,3,4 45%Answered correctly

Bell palsy is peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (cranial nerve VII) in the absence of a stroke or other causative agent/disease. Paralysis of the motor fibers innervating the facial muscles results in flaccidity on the affected side. Manifestations of Bell palsy include: Inability to completely close the eye on the affected side Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option 1) Flattening of the nasolabial fold on the side of the paralysis (Option 3) Inability to smile or frown symmetrically (Option 4) Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue. (Options 2 and 5) Electric shock-like pain in the lips and gums and severe pain along the cheekbone are symptoms of trigeminal neuralgia (cranial nerve V). With Bell palsy, the trigeminal nerve may become hypersensitive and cause facial pain, but this is uncommon and typically more indicative of trigeminal neuralgia. Educational objective:Bell palsy is unilateral facial paralysis due to inflammation of the facial nerve that is characterized by inability to close the affected eye completely, changes in tear production, facial droop, and asymmetrical smile or frown.

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. 1. "I don't plan on eating any more frozen meals." 2. "I plan to take my diuretic pill in the morning." 3. "I will weigh myself at least every other day." 4. "I'm going to look into joining a cardiac rehabilitation program." 5. "Ibuprofen works best for me when I have pain." OmittedCorrect answer 3,5 57%Answered correctly

Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention (Option 5). To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of clothing, and on the same scale (Option 3). Weights should be recorded to allow for day-to-day comparisons to help identify early signs of fluid retention. (Option 1) Frozen meals are often high in sodium. Most heart failure clients are instructed to limit sodium intake. All foods high in sodium (>400 mg/serving) should be avoided. (Option 2) Diuretic medications cause clients to urinate more. Morning is the appropriate time to take this type of medication. Evening administration would cause nocturia and interrupted sleep. (Option 4) Exercise training, such as cardiac rehabilitation, improves symptoms of chronic heart failure. It has been found to be safe and improves the client's overall sense of well-being. It has also been correlated with reduction in mortality. Educational objective:Discharge education for the client with chronic heart failure should include daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention.

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. 1. "I don't plan on eating any more frozen meals." 2. "I plan to take my diuretic pill in the morning." 3. "I will weigh myself at least every other day." 4. "I'm going to look into joining a cardiac rehabilitation program." 5. "Ibuprofen works best for me when I have pain." OmittedCorrect answer 3,5 57%Answered correctly

Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention (Option 5). To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of clothing, and on the same scale (Option 3). Weights should be recorded to allow for day-to-day comparisons to help identify early signs of fluid retention. (Option 1) Frozen meals are often high in sodium. Most heart failure clients are instructed to limit sodium intake. All foods high in sodium (>400 mg/serving) should be avoided. (Option 2) Diuretic medications cause clients to urinate more. Morning is the appropriate time to take this type of medication. Evening administration would cause nocturia and interrupted sleep. (Option 4) Exercise training, such as cardiac rehabilitation, improves symptoms of chronic heart failure. It has been found to be safe and improves the client's overall sense of well-being. It has also been correlated with reduction in mortality. Educational objective:Discharge education for the client with chronic heart failure should include daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention. Additional Information Physiological Adaptation NCSBN Client Need

The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency? 1. "I have had some visual disturbances while driving at night." (13%) 2. "I have had trouble falling asleep over the past few months." (1%) 3. "Scaly patches of skin are developing on my elbows and knees." (20%) 4. "Sometimes my hands and feet get a tingling sensation." (64%) OmittedCorrect answer 4 64%Answered correctly

Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins (eg, meat, poultry, fish) and products (eg, dairy, eggs). Clients who are vegan are at risk for deficiency of vitamin B12 (cobalamin), which is primarily supplied by animal products. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain. Manifestations of chronic deficiency include: Peripheral neuropathy (eg, tingling, numbness) (Option 4) Neuromuscular impairment (eg, gait problems, poor balance) Memory loss/dementia (in cases of severe/prolonged deficiencies) Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological complications. In addition, clients are taught to incorporate vitamin B12-fortified foods (eg, cereals, grain products, soy and nut milks, meat substitutes). (Options 1, 2, and 3) Visual disturbances, difficulty sleeping, and scaly patches of skin are likely not complications of a nutritional deficiency related to a vegan diet. Educational objective:Clients following a vegan diet should be educated about vitamin B12 deficiency and the importance of supplementation and eating B12-fortified foods. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms (eg, peripheral neuropathy, neuromotor impairment, memory loss).

A/ child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? 1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity (13%) 2. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze (9%) 3. Place the tooth in water and transport the client to the nearest emergency department (43%) 4. Wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment (33%) OmittedCorrect answer 1 13%Answered correctly

Dental avulsion (ie, tooth separated from the mouth) of a permanent tooth is a dental emergency. The priority nursing action is to rinse and reinsert the tooth into the gingival socket and hold it in place (eg, with a finger) until stabilized by a dentist (Option 1). Reimplantation within 15 minutes of injury re-establishes blood supply, increasing the probability of tooth survival. If the tooth cannot be reinserted it should be kept moist by submerging it in commercially prepared solution (eg, Hanks Balanced Salt Solution), cold milk, sterile saline, or as a last resort—due to bacteria—saliva (eg, holding it under the tongue). (Option 2) Scrubbing the root would damage it. The tooth should be gently rinsed with sterile saline or clean, running water. (Option 3) Placing the tooth in water (a hypotonic solution) would lyse the cells, killing the tooth. (Option 4) Wrapping the tooth in sterile gauze would dry it out. In addition, the nurse should arrange for immediate transfer to a dentist rather than advise the parent to schedule an appointment that might not be available for days. Educational objective:Dental avulsion is a dental emergency. The nurse should gently rinse off debris and reinsert the tooth into the gingival socket. If reimplantation is not possible, the tooth should be placed in a commercially prepared solution, cold milk, or sterile saline. The client should see a dentist immediately.

//The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply. 1. "I need to call the health care provider (HCP) if I have trouble reading." 2. "I need to check my blood pressure before taking my medicine." 3. "I should call the HCP if I develop nausea and vomiting." 4. "I should check my heart rate prior to taking this medication." 5. "I will call the HCP if I feel dizzy and lightheaded." OmittedCorrect answer 1,3,4,5 21%Answered correctly

Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL). Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness (Option 5). Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold the medication and notify the health care provider (Option 4). Other manifestations of digoxin toxicity that clients should report include: Visual symptoms (eg, alterations in color vision, scotomas, blindness) (Option 1) Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms (Option 3) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) (Option 2) There is no need to routinely check blood pressure before taking digoxin as it does not affect blood pressure. Clients should check the pulse prior to administration. Educational objective:Cardiac glycosides (eg, digoxin) have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). Clients are instructed to check their pulse before administration and to report gastrointestinal (eg, anorexia, nausea), neurologic, and cardiac symptoms and visual changes.

The parent of a 5-year-old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? Select all that apply. 1. Apply a cold cloth to the bridge of the nose 2. Apply pressure by pinching the nostrils together 3. Attempt to keep the child calm and quiet 4. Have the child lie down and turn to the left side 5. Take the child to the emergency department OmittedCorrect answer 1,2,3 36%Answered correctly

Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury (eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home management. Home management of epistaxis includes: Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 5-15 minutes to promote clot formation (Option 2) Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding (Option 1) Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a challenge to implementing interventions and stopping bleeding (Option 3) (Option 4) Positioning a child with epistaxis in a horizontal position or with the head tilted backward promotes drainage of blood into the throat, which increases the risk of swallowing or aspirating blood. Clients with epistaxis should sit upright and tilt the head forward. (Option 5) Epistaxis is typically managed at home. However, the caregiver should seek emergency care if the client's breathing is impaired, or the bleeding is excessive or uncontrollable with home measures or resulted from a traumatic injury. Educational objective:Epistaxis (nosebleed) is a nasal condition typically occurring from local injury (eg, nose-picking) or irritation. Initial epistaxis management includes calming the client; tilting the head forward; applying direct, continuous nasal pressure for 5-15 minutes; and applying cold packs to the nasal bridge.

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver? 1. Administer the medication around the clock even if the client denies having pain (50%) 2. Avoid administering with immediate-release opioids to prevent respiratory depression (38%) 3. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs (2%) 4. Request a tapered dose from the health care provider if pain decreases to prevent tolerance (9%) OmittedCorrect answer 1 50%Answered correctly

Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours. (Option 2) Immediate-release opioids and nonopioids are coadministered with long-acting opioids for relief of breakthrough pain. Respiratory status should be monitored; however, clients who receive long-term therapy become opioid tolerant and are less likely to experience adverse effects. Because the goal of hospice care is comfort, this client should be relieved of breakthrough pain regardless of respiratory status. (Option 3) The dose and frequency cannot be changed without a prescription. Also, breakthrough pain is best treated with short-acting opioids. (Option 4) Long-term opioid therapy leads to drug tolerance and physical dependence; higher doses are eventually required for therapeutic effect. In the dying client, it is not appropriate to taper the dose. Rather, it should be titrated upward for effective pain relief. Educational objective:Long-acting controlled-release opioid drugs for chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need Copyright

A 37-weeks-pregnant woman comes to the emergency department with a fractured ankle. Which assessment finding is most concerning and requires the nurse to follow up? 1. Fetal heart rate remains 206/min (84%) 2. Fetus kicked 4 times in the past hour (2%) 3. Mother reports feeling 2 contractions every hour (5%) 4. Mother's hemoglobin is 11 g/dL (110 g/L) (7%) OmittedCorrect answer 1 84%Answered correctly

Fetal tachycardia is a baseline of >160 beats/min for >10 minutes. Tachycardia needs evaluation and continued surveillance. The most sensitive indicators of fetus health are fetal movement and fetal heart rate. (Option 2) This is an expected finding. Monitoring fetal movement/kick counts is a primary method of fetal surveillance. The reassuring finding is when the movement equals or exceeds the established baseline. In general, 4 movements/hour or 10 distinct fetal movements within 2 hours is a reassuring finding. (Option 3) Braxton-Hicks contractions are felt mid-pregnancy onward. These painless, occasional physiological contractions are normal. The contractions are a concern if they become regular and persist. (Option 4) During pregnancy, hemoglobin can drop to 11 g/dL (110 g/L), a condition known as physiological anemia of pregnancy. Due to the increased oxygen requirements of pregnancy, the red blood cell count increases 30%. However, anemia can result from an increase in the plasma volume that is relatively larger than the increase in red blood cells. This lowered maternal hemoglobin is within the expected range. Educational objective:Sustained fetal tachycardia (>160/min for >10 minutes) is a concerning finding that requires further follow-up. Additional Information Reduction of Risk Potential NCSBN Client Need

//A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? 1. Abdominal thrusts (46%) 2. Back blows and chest thrusts (36%) 3. Blind sweep of the child's mouth (13%) 4. Call 911 for an ambulance (3%) OmittedCorrect answer 1 46%Answered correctly

Foreign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected. The primary rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich maneuver. This maneuver entails applying upward thrusts with a fist to the upper abdomen just beneath the rib cage. The upward action causes the diaphragm to forcefully expel air out of the airway, carrying the foreign body out with it. If the child is conscious and able to cough or make sounds, the nurse should ask the child to forcefully cough before intervening. These signs indicate a partial obstruction still allowing airflow, which may be cleared with strong coughing. However, any signs of respiratory distress (eg, stridor, inability to speak, weak cough, and cyanosis) require immediate intervention. (Option 2) Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require abdominal thrusts to clear an obstructed airway. (Option 3) Blind sweeping a child's mouth can force a loosely obstructing object to fully block the airway or cause the object to fall farther into the airway, requiring surgical removal. (Option 4) This child is experiencing a blocked airway, which is a medical emergency that requires intervention at the skill level of a nurse. The nurse can ask a bystander to contact 911 while attempting to clear the airway. This differs from a situation such as anaphylaxis, in which the nurse would require epinephrine and would call 911 for immediate assistance. Educational objective:The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child's mouth should not be attempted. Additional Information Physiological Adaptation NCSBN Client Need

///The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. 1. Encourage adequate sodium intake 2. Place client in semi-Fowler position 3. Place client in Trendelenburg position 4. Provide alternating air pressure mattress 5. Use music to provide a distraction OmittedCorrect answer 2,4,5 62%Answered correctly

In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm (Option 2). In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours (Option 4). A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies (Option 5). (Option 1) This client has ascites and peripheral edema; higher levels of fluid or sodium intake can worsen these conditions. (Option 3) In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate shortness of breath by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion. Educational objective:The client with discomfort and shortness of breath due to ascites should be positioned in the semi-Fowler or Fowler position to promote comfort and lung expansion. Music and other methods of distraction may also promote comfort. Meticulous skin interventions (eg, specialty mattress, turning schedule) are important to prevent tissue breakdown.

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.... I can get out of anything. There could be trouble now." Which of the following is the best response to this client? 1. "How are you feeling now?" (10%) 2. "How did you manage to get out of the restraints?" (2%) 3. Say nothing but signal to other staff that assistance is needed (24%) 4. "What kind of trouble are you thinking about?" (63%) OmittedCorrect answer 4 63%Answered correctly

In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. This client's statement, "There could be trouble now," has multiple possible meanings (eg, Is the nurse "in trouble" as the restraints may not have been applied properly? Are the other clients in the unit "in trouble" as this client is out of restraints? Is this client "in trouble" due to thoughts of self-harm?). Seeking clarification of this client's statement is a therapeutic communication technique that will help the nurse determine the next steps in providing care. Mechanical restraints may be necessary only as a last resort for a client at high risk for violence, self-directed or other-directed. Clients placed in restraints must be observed and monitored frequently for: Assisting with hydration, elimination, and positioning Ensuring that circulation is not compromised Determining readiness for removal of restraints (Option 1) It is important to ask this client about current feelings. However, in this situation, the priority is to clarify this client's statement. (Option 2) This statement is immaterial; it is important to assess this client's current status. (Option 3) Assistance from another staff member may be necessary if this client is still at high risk for violence; this client needs to be assessed first. Educational objective:A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed. Additional Information Psychosocial Integrity NCSBN Client Need Copyright © UWorld. All rights reserved.

//The nurse plans care for a child admitted with measles. Which of the following interventions will the nurse include in the plan of care? Select all that apply. 1. Advise measles vaccination for susceptible family members 2. Apply calamine lotion to reduce itching 3. Place a tracheostomy tray at the bedside 4. Place the client in a negative-pressure isolation room 5. Use a N95 respirator mask during client contact OmittedCorrect answer 1,4,5 23%Answered correctly

Measles (ie, rubeola) is a highly contagious viral illness that affects people of all ages. Measles spreads when infected individuals cough or sneeze, sending the virus through the air, where it remains suspended for up to 2 hours. Widespread vaccination with the measles, mumps, and rubella (MMR) vaccine, such as in the United States, has reduced measles incidence by 99%. However, an increase in international travel and unvaccinated children have caused a resurgence of the disease. For hospitalized clients with measles, the plan of care should include the following: Recommendation of postexposure prophylaxis (ie, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family members within 72 hours of exposure to decrease the severity and duration of symptoms in case they contract the disease (Option 1) Implementation of airborne precautions, including a negative-pressure isolation room and use of an N95 respirator mask, during contact with the client by health care staff (Options 4 and 5) Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause blindness, particularly in clients in low-resource areas (Option 2) An erythematous, maculopapular, morbilliform rash is characteristic of measles, but it is not typically pruritic. Calamine lotion is effective for soothing pruritic rashes (eg, varicella [chickenpox]). (Option 3) A tracheostomy tray is not required for this client with measles because respiratory paralysis or emergency intubation is not expected. Educational objective:Clients with measles are highly contagious and require airborne precautions (eg, negative-pressure isolation room, N95 respirator). Susceptible family members should receive postexposure prophylaxis (eg, measles, mumps, and rubella vaccine). Additional Information Physiological Adaptation NCSBN Client Need

//The nurse assesses a client who is receiving methotrexate for rheumatoid arthritis. Which statement by the client is most concerning? 1. "I am nauseated and vomited three times today." (8%) 2. "I drink four large cups of coffee every day." (8%) 3. "I have small, purple spots all over my skin." (54%) 4. "I plan to stop taking birth control today." (28%) OmittedCorrect answer 3 54%Answered correctly

Methotrexate is an antirheumatic drug prescribed to treat rheumatoid arthritis. It acts by interfering with folic acid metabolism, which inhibits DNA synthesis and cell reproduction. Adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity (ie, drug-induced liver injury), and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Bone marrow suppression is a serious adverse effect that leads to anemia, leukopenia, and thrombocytopenia. Thrombocytopenia (especially platelet count <100,000/mm3 [100 × 109/L]) is characterized by petechiae (ie, small, purple hemorrhagic spots), purpura, and/or other signs of bleeding (eg, melena, hematemesis, bleeding gums) (Option 3). Bone marrow suppression is managed by dose reduction or discontinuation of the medication. (Option 1) Nausea and vomiting are the most common side effects associated with methotrexate. The nurse should notify the health care provider and request a prescription for an antiemetic; however, vomiting is not the priority concern. (Option 2) Some substances decrease the effectiveness of methotrexate (eg, caffeine, folic acid) and should be avoided. (Option 4) Methotrexate is teratogenic, so pregnancy must be prevented. Effective contraceptives must be used throughout treatment and for one ovulatory cycle after completing treatment for women (three months after completion for men). This statement requires follow-up but is not priority as the client has not yet stopped taking birth control. Educational objective:Adverse effects of methotrexate include hepatotoxicity, gastrointestinal irritation, and bone marrow suppression. Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first? 1. Client post kidney transplant who reports white spots in the oral cavity (37%) 2. Client with a history of mitral valve regurgitation who reports fatigue (25%) 3. Client with erythema and purulent drainage at the site of a spider bite (26%) 4. Client with hypertension who reports a cold and nasal congestion (10%) OmittedCorrect answer 2 25%Answered correctly

Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention. (Option 1) Kidney transplant recipients are on an immunosuppressant regimen to prevent rejection of the transplanted organ, which can leave them susceptible to infections such as candidiasis (thrush) of the oral cavity. (Option 3) The client with a spider bite is displaying signs and symptoms of infection, and further assessment is required to evaluate for conditions such as cellulitis. This client should be called second. (Option 4) Clients with hypertension who develop sinus or nasal congestion have limited options for symptom relief. Decongestants containing a vasoconstrictor (eg, pseudoephedrine) can exacerbate hypertension. Educational objective:Chronic mitral valve regurgitation is often asymptomatic, but many clients eventually develop heart failure; therefore, early recognition of symptoms is a priority. Mitral regurgitation causes a backflow of blood from the left ventricle to the left atrium, resulting in pulmonary edema (eg, dyspnea, orthopnea) and decreased cardiac output (eg, fatigue). Left atrial enlargement can also result in atrial fibrillation (eg, palpitations). Additional Information Management of Care NCSBN Client Need

/The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used. Your Response/ Incorrect Response 1. Clean the vial tops with alcohol swabs 5. Inject air into the regular insulin vial 2. Draw up the NPH insulin solution 3. Draw up the regular insulin solution 4. Inject air into the NPH insulin vial . Correct Response 1. Clean the vial tops with alcohol swabs 4. Inject air into the NPH insulin vial 5. Inject air into the regular insulin vial 3. Draw up the regular insulin solution 2. Draw up the NPH insulin solution OmittedCorrect answer 1,4,5,3,2 65%Answered correctly

Mixing insulins allows multiple insulin preparations to be delivered in a single subcutaneous injection, thereby sparing the client from multiple injections. Intermediate-acting insulins (eg, NPH) can be mixed with short-acting (eg, regular) or rapid-acting (eg, aspart, lispro) insulins. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and are typically packaged in prefilled syringes. When drawing up multiple insulins, there is a risk for contaminating the shorter-acting vials with the longer-acting insulin, which would slow the action of later doses withdrawn from the shorter-acting insulin vial. Multidose vials of regular insulin that have been contaminated with other insulins are unsafe for IV administration. When drawing up multiple insulins, the nurse should: Clean both vial tops with alcohol swabs (Option 1). Inject air into the NPH insulin vial without touching the needle to the solution (Option 4). Withdraw the needle from the NPH insulin vial and inject air into the regular insulin vial (Option 5). Invert the regular vial and withdraw the regular solution into the syringe (Option 3). Insert the needle into the NPH insulin vial and withdraw the solution (Option 2). The nurse can recall the mnemonic RN (Regular before NPH). Educational objective:When drawing up multiple insulins, there is a risk for contaminating the shorter-acting insulin vial with longer-acting insulin and slowing the action of later doses withdrawn from the shorter-acting insulin vial. The nurse should withdraw the shorter-acting insulin first, and then use the same syringe to withdraw the intermediate-acting insulin. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first? 1. Client prescribed sumatriptan who has throbbing left temple pain preceded by an aura (16%) 2. Client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position (1%) 3. Client with myasthenia gravis who has a fever and increasing difficulty swallowing (81%) 4. Client with trigeminal neuralgia who reports burning cheek pain after eating ice cream (0%) OmittedCorrect answer 3 81%Answered correctly

Myasthenia gravis is an autoimmune disease of the neuromuscular junction resulting in fluctuating muscle weakness. Autoantibodies are formed against the acetylcholine receptors, so fewer receptors are available for acetylcholine to bind. It is treated with pyridostigmine (Mestinon), which increases the amount of acetylcholine at the synaptic junction, augmenting neuromuscular signals and improving muscle strength. Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's infection and increasing difficulty swallowing indicate the need for immediate intervention. (Option 1) Sumatriptan is prescribed for moderate to severe, acute migraine headaches that are characterized by severe pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting. The client with uncontrolled migraine headaches requires a change in treatment regimen (eg, ergotamine). (Option 2) Carbidopa-levodopa is prescribed to decrease symptoms of Parkinson disease (eg, bradykinesia, tremor, rigidity). Orthostatic hypotension is an adverse effect of the drug and may also occur from disease-related autonomic nervous system dysfunction. This client should be taught to slowly change positions; this is not the priority action. (Option 4) Trigeminal neuralgia is characterized by intermittent severe, unilateral facial pain precipitated by light touch, hot or cold foods, chewing, and swallowing. This client may require a change in treatment regimen (eg, carbamazepine, gabapentin, baclofen) for improved pain relief. Educational objective:Myasthenia gravis is a chronic neurologic autoimmune disease in which acetylcholine receptors are blocked, causing muscle weakness. Infection, undermedication, and stress can lead to a myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure.

The nurse prepares a community education program about health promotion strategies for postmenopausal women. Which of the following teaching points are appropriate to include? Select all that apply. 1. Consider seeing a dietitian for help with healthy weight maintenance 2. Consult with a health care provider for cholesterol monitoring 3. Engage in a daily weight-bearing exercise regimen 4. Prioritize consumption of green, leafy vegetables and dairy products 5. Seek support to cope with any emotional symptoms OmittedCorrect answer 1,2,3,4,5 27%Answered correctly

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Loss of ovarian function during menopause causes a decrease in estrogen production, leading to reduced osteoblast activity and cardioprotective effect. Therefore, postmenopausal clients are at increased risk for osteoporosis and coronary artery disease (CAD). Other physiological changes after menopause may include weight gain, sleep disturbances, fat redistribution, and vaginal atrophy. Clients should utilize health promotion strategies to reduce the effects of decreased estrogen levels, including: Consuming optimal amounts of dietary calcium (green, leafy vegetables; dairy products) and engaging in weight-bearing exercise to promote bone health (Options 3 and 4) Closely monitoring cholesterol levels (eg, HDL, LDL, triglycerides), as increased LDL cholesterol increases risk for CAD (Option 2) Considering seeking the assistance of a dietitian, and maintaining a low-calorie diet rich in fruits and vegetables, as hormone changes may cause a predisposition to weight gain (Option 1) Seeking support to cope with any emotional symptoms (eg, depression, mood swings, sadness, difficulty concentrating) caused by changing hormone levels (Option 5) Educational objective:Postmenopausal women should consume plenty of calcium-rich foods (eg, dairy products; green, leafy vegetables), engage in weight-bearing exercise, monitor cholesterol levels, consider dietary counseling to maintain a healthy weight, eat a diet rich in fruits and vegetables, and seek support for any emotional symptoms.

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective? Select all that apply. 1. "I need to eat a diet high in calories and protein so that I avoid losing weight." 2. "I need to take multivitamins containing calcium daily." 3. "I should avoid consuming alcoholic beverages." 4. "I should drink at least 2 liters of water daily and more when I have diarrhea." 5. "I will keep a symptom journal to note what I eat and drink during the day." OmittedCorrect answer 1,2,3,4,5 11%Answered correctly

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Ulcerative colitis (UC) is a form of inflammatory bowel disease characterized by remitting periods of mucosal irritation in the large intestine, resulting in profuse, bloody diarrhea. Management of clients with UC often includes dietary interventions to reduce symptoms and prevent reoccurrence, malnutrition, and dehydration. Nutrition and hydration management: Diets consisting of high-calorie, high-protein foods are recommended to prevent weight loss and muscle wasting (Option 1). Multivitamins containing calcium are often prescribed to supplement nutrition and should be taken regardless of symptoms (Option 2). Oral hydration is critical in UC as >10 liquid stools may occur daily during flares, placing clients at risk for dehydration. Instruct clients to drink at least 2 liters of water daily (Option 4). Dietary triggers for UC vary greatly between individuals and may include dairy, nuts/legumes, cereal, alcohol, caffeine, and fatty and processed foods. Diet journaling is recommended to assist with identifying triggers (Option 5). Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided (Option 3). Educational objective:Ulcerative colitis (UC) is an inflammatory bowel disease that is managed with dietary interventions in addition to medication. Clients with UC should maintain a high-calorie, high-protein diet; drink at least 2 liters of water per day; take multivitamins as prescribed; maintain a symptom journal in relation to daily dietary intake; and avoid triggers.

The health care provider (HCP) prescribes naproxen for a client who has degenerative joint disease. What instructions regarding this drug does the nurse include in the client's discharge plan? Select all that apply. 1. Avoid driving while taking this medicine 2. Change positions slowly 3. Discontinue immediately if suicidal thoughts occur 4. Notify the HCP of tarry stools 5. Take the medicine with food OmittedCorrect answer 4,5 31%Answered correctly

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. Kidney injury - long-term use is associated with kidney injury Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet drugs as they can increase the risk of GI bleeding. (Option 1) Clients should not drive when taking sedating medications (eg, antihistamines, benzodiazepines). However, sedation is not associated with NSAID use. (Option 2) Orthostatic hypotension is common with blood pressure medications (eg, ACE inhibitors, alpha blockers) but not with NSAIDs. (Option 3) Suicidal thoughts are commonly associated with selective serotonin reuptake inhibitors (antidepressants) and varenicline (Chantix), a smoking cessation medication. Educational objective:All NSAIDs (eg, indomethacin, ibuprofen, naproxen) are associated with gastrointestinal toxicity, kidney injury, exacerbation of fluid overload/hypertension, and bleeding risk. They should be used at the lowest dose and for the shortest period possible.

//The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room? 1. Child with chickenpox for the past 14 days; all lesions are crusted and dried (6%) 2. Child with impetigo who has been on antibiotics for 3 days (2%) 3. Child with leg rash secondary to poison ivy exposure (2%) 4. Child with suspected pertussis who has paroxysms of coughing (88%) OmittedCorrect answer 4 88%Answered correctly

Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation immediately to prevent the spread of disease. (Option 1) Chickenpox is no longer contagious after the lesions have crusted and dried, but this process can take as long as 3 weeks. This client would not require isolation. (Option 2) Impetigo is no longer contagious after 24 hours of antibiotics. This client would not require isolation. (Option 3) Poison ivy rash is not considered contagious. A person develops the rash only on contact with the urushiol oil itself. The pustules do not contain this oil, and therefore the rash cannot be spread via person-to-person contact. Educational objective:Chickenpox is no longer contagious after the lesions have crusted and dried. Pertussis is a highly contagious disease that requires droplet precautions.

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? 1. Check renal function laboratory results (31%) 2. Flush tube with normal saline, not water (19%) 3. Stop the feeding for 1 to 2 hours (29%) 4. Take the blood pressure (BP) (19%) OmittedCorrect answer 3 29%Answered correctly

Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug. (Option 1) Unless clients have renal insufficiency, renal function tests are not routinely monitored during prescribed phenytoin therapy. Phenytoin is metabolized in the liver and can cause liver damage. Monitoring of liver function test during therapy is recommended. (Option 2) Flushing the tube with 30-50 mL of water before and after administering phenytoin is recommended to minimize drug loss and drug-drug incompatibility. Flushing with normal saline before and after drug administration is recommended in clients receiving intravenous (IV) phenytoin. (Option 4) BP is not usually affected in clients prescribed oral phenytoin therapy for seizure disorders. However, IV phenytoin can cause hypotension and arrhythmias. Educational objective:Phenytoin is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin.

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily. The client's child reports that the client has trouble swallowing the large KCl pill. The client's potassium level is 3.7 mEq/L (3.7 mmol/L). What action should the nurse take first? 1. Consult with the pharmacist to see if other oral forms of KCl are available (66%) 2. Crush the pill and mix it with applesauce or pudding (12%) 3. Hold the KCl until the health care provider makes rounds (9%) 4. Instruct the client to tuck the chin to the chest when swallowing the pill (12%) OmittedCorrect answer 1 66%Answered correctly

Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsules, dissolvable packets, and effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are currently available and to determine if the medication is safe to crush. If a more appropriate form (eg, liquid) is available, the nurse would then discuss that change in route with the health care provider and obtain an updated prescription. (Option 2) Some pills or capsules are sustained-release formulations, and crushing may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. (Option 3) The use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L [3.5 mmol/L]), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). (Option 4) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill. Educational objective:Oral potassium chloride comes in multiple forms: tablet or capsule, oral liquid, dissolving packets, and effervescent tablets. If a client has difficulty swallowing large pills, the pharmacist can determine availability of other medication forms, which can then be prescribed by the health care provider.

///Which client finding is most important for the nurse to follow up? 1. Client with distinct liver edge even with right costal margin (13%) 2. Client with pyelonephritis who has costovertebral angle tenderness (12%) 3. Client with rash that has purplish blotches that do not blanch (31%) 4. Client with spinal injury whose toes point downward with the Babinski test (42%) OmittedCorrect answer 3 31%Answered correctly

Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia. (Option 1) The normal finding is a soft, distinct liver edge that is even with the bottom of the right rib cage or right costal margin. An abnormal finding would be a boggy liver edge below the rib cage (hepatomegaly). (Option 2) Kidney inflammation (pyelonephritis) results in positive costovertebral angle (CVA) tenderness tenderness in the back/flank. It is an expected finding that is elicited when the examiner places the hand over the client's lower back and places the other hand on top and makes a fist to gently "thump" or tap the area. (Option 4) The Babinski sign can indicate an upper motor neuron lesion from damage to the corticospinal tract. A normal finding for an adult is for the toes to point downward. Educational objective:Purpura refers to purplish blotches indicating bleeding underneath the skin; it is a significant finding that requires further assessment.

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care? 1. Assess the client's feelings about placement at a skilled nursing facility for care (5%) 2. Educate the client on the risks of tissue death if not properly cared for at home (9%) 3. Explore the client's abilities and motivation to perform care at home (82%) 4. Provide the client with the supplies needed to change dressings as recommended (2%) OmittedCorrect answer 3 82%Answered correctly

Self care is a critical component of health. However, barriers to self care are multifactorial, and include: Knowledge (lack of experience, cognitive abilities) Skills/supplies (lack of dexterity, experience, financial barriers) Motivation (lack of assumed threat to health, denial, hopelessness) The nurse must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities (Option 3). Once the barriers have been identified, the nurse can work with the client to create an individualized plan to meet health care needs. (Option 1) Without understanding the barriers to self care, the nurse cannot identify proper resources to assist the client in meeting needs. Placement for skilled nursing may be excessive for a client who lives independently. (Option 2) Education on tissue death may be perceived as threatening and not therapeutic. (Option 4) Financial resources or supplies may not be the barrier; therefore, this intervention may not effectively assist the client in performing self care successfully. Educational objective:The nurse must assess a client's knowledge, skills, and motivation to identify barriers to self care. Through this identification, the nurse can help develop an individualized plan to meet health care needs.

An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate? 1. "Don't you know it's not morning yet?" (2%) 2. "It's time to get back to bed now." (61%) 3. "You might fall if you wander in the dark." (18%) 4. "You should not leave your room without assistance." (16%) OmittedCorrect answer 2 61%Answered correctly

Sundowning refers to the increased confusion experienced by an individual with dementia; it occurs at night, when lighting is inadequate, or when the client is excessively fatigued. Wandering is a common associated behavior. A client with mild-to-moderate dementia may need frequent reality reorientation to promote appropriate behaviors. However, with advanced dementia, reality orientation may not be effective and might cause the client to feel anxious, leading to inappropriate behaviors and aggression. In this situation, validation therapy is more appropriate and involves recognizing and exploring the client's feelings and concerns but not reinforcing or arguing with any incorrect perceptions. (Option 1) This statement calls attention to the client's memory and cognitive issues but does not provide any useful information for reorientation. In addition, this type of statement may reinforce anxieties and fears in a client who is already feeling insecure and scared about the cognitive changes, leading to anger and possible aggression. (Option 3) This option provides little reorientation information. (Option 4) This statement has a paternalistic tone and seems to penalize the client. This type of statement may cause the client to get angry, leading to escalating negative behaviors. Educational objective:Appropriate communication techniques to assist a client with dementia while avoiding anxiety and other negative behaviors include reorientation in the earlier stage of dementia and validation in the later stage of dementia.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply. 1. Administer hydromorphone IV PRN for pain 2. Administer intravenous fluids 3. Insert a nasogastric tube for nasogastric suction 4. Maintain client in a supine position, with head of bed flat 5. Provide small, frequent, high-carbohydrate, high-calorie meals OmittedCorrect answer 1,2,3 33%Answered correctly

Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include: NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces). (Option 4) The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better. (Option 5) NPO status is maintained to inhibit stimulation of pancreatic enzymes. Educational objective:The major goals in acute pancreatitis are symptom management (eg, opioids, NPO status, nasogastric suction) and monitoring and prevention of complications (eg, IV fluids), giving the pancreas time to heal. Additional Information Physiological Adaptation NCSBN Client Need

//The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? 1. 12 hours (0%) 2. 24 hours (7%) 3. 36 hours (14%) 4. 72 hours (76%) OmittedCorrect answer 4 76%Answered correctly

TST (Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: Injection of purified protein derivative solution under the first layer of skin of the forearm Evaluation of the injection site 48-72 hours later The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB. The QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB bacteria. Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is more expensive, it requires only a single visit to the health care provider and results are available in 24 hours. (Options 1, 2, and 3) The 12-, 24-, and 36-hour time frames are incorrect. Educational objective:The presence of an indurated area at the injection site 2-3 days after the tuberculin solution is administered indicates a positive TST. Additional Information Reduction of Risk Potential NCSBN Client Need

The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1. Room 1 - Client with diabetes mellitus and chronic kidney disease who is on hemodialysis and has a serum glucose level of 265 mg/dL (14.7 mmol/L) (59%) 2. Room 2 - Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 (0.2 x 109/L) (2%) 3. Room 3 - Client with cellulitis of the leg due to a spider bite who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) (2%) 4. Room 4 - Client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 (85 x 109/L) (35%) OmittedCorrect answer 4 35%Answered correctly

The best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3 [150-400 x 109/L]) as this does not place the immediate post-operative client at increased risk for infection. (Options 1, 2, and 3) The clients in these rooms place the postoperative client at increased risk for infection: Room 1: A client with diabetes mellitus and advanced chronic kidney disease may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia. In addition, hemodialysis increases the risk for infection due to invasive lines and catheters. Room 2: A low CD4+ cell count (<500/mm3 [0.5 x 109/L], normal is 500-1,200/mm3 [0.5-1.2 x 109/L]) in a client with chronic HIV infection indicates disease progression. It can also indicate progression of asymptomatic early infections to more advanced symptomatic infections. Room 3: The client with cellulitis and an increased white blood cell count (>11,000/mm3 [11.0 x 109/L]) has an infection. Educational objective:An immediate post-operative client should not be assigned a bed in a room with a client who is contagious or potentially infected as this poses an increased risk for infection. Additional Information Safety and Infection Control NCSBN Client Need

/see ex A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information. 1. Administer atropine 0.5 mg IV (19%) 2. Administer dopamine 5 mcg/kg/min IV (10%) 3. Initiate transcutaneous pacing (35%) 4. Notify the health care provider (34%) OmittedCorrect answer 3 35%Answered correctly

The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client. (Option 1) Atropine is administered to clients with symptomatic bradycardia; however, this client's symptoms are caused by failure to capture. Therefore, obtaining capture via transcutaneous pacing should resolve the client's symptoms. (Option 2) Dopamine is an inotrope used to treat hypotension due to bradycardia. This client is bradycardic and hypotensive due to failure to capture. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. (Option 4) The health care provider needs to be notified, but the nurse should first use the transcutaneous pacemaker to stabilize the client. Educational objective:Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension. The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced. Additional Information Physiological Adaptation NCSBN Client Need

Progress notes 2000 Client admitted to CCU #4, reporting vise-like chest pain and shortness of breath. Pulmonary artery (PA) catheter inserted by the health care provider via right internal jugular vein without difficulty. Central venous pressure (CVP) 18 mm Hg, pulmonary artery wedge pressure (PAWP) 25 mm Hg and coarse crackles auscultated bilaterally._________________, RN Based on the progress note documentation, which priority intervention does the nurse anticipate? Click on the exhibit button for additional information. 1. 0.9% sodium chloride, 500 mL intravenous bolus (7%) 2. Furosemide, 40 mg intravenous push (82%) 3. Metoprolol, 5 mg intravenous push (7%) 4. Vancomycin, 1 g intravenously every 12 hours (2%) OmittedCorrect answer 2 82%Answered correctly

The client's central venous pressure (CVP) is elevated (normal value 2-8 mm Hg), indicating increased systemic circulation volume and increased right ventricular preload. Pulmonary artery wedge pressure (PAWP) is also elevated (normal value 6-12 mm Hg), indicating increased left ventricular preload. In the presence of increased CVP and PAWP, coarse crackles indicate left-sided failure. The treatment goal is to decrease fluid volume and preload. Furosemide is a loop diuretic that will decrease both left- and right-sided preload. (Option 1) A fluid bolus of 500 mL of sodium chloride is contraindicated in a client with increased left and right ventricular preload as it would exacerbate fluid overload. (Option 3) Beta blockers (eg, metoprolol, atenolol, esmolol) will decrease both blood pressure and afterload. However, they will not decrease preload. (Option 4) Vancomycin is an antibiotic used to treat gram-positive bacterial infections (eg, methicillin- resistant Staphylococcus aureus); it has no effect on fluid status. Educational objective:Loop diuretics (eg, furosemide, bumetanide, torsemide) are effective in decreasing both right ventricular preload and left ventricular preload.

The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior? 1. During 1-2 hours after each meal (84%) 2. During every meal (11%) 3. During the evening meal (0%) 4. During the overnight hours (3%) OmittedCorrect answer 1 84%Answered correctly

The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 2). Clients with bulimia nervosa will often go to extreme lengths to engage in purging activity, especially at the beginning of a treatment program, as a way of gaining control. After mealtime, it may be necessary to restrict clients to the dayroom or a specified area with no bathroom privileges for a set period. Clients will also need to be monitored at all times for engaging in excessive exercise. (Option 3) Clients need to be monitored during every meal, not just during the evening meal. (Option 4) Secretive bingeing and purging during the night or before bedtime are not uncommon for a client with bulimia nervosa. However, in a structured inpatient environment, the client would not have access to excessive amounts of food. Educational objective:Clients with bulimia nervosa should be supervised during every meal. However, it is most important to monitor the postprandial activity of these clients to prevent self-induced vomiting as a way to prevent weight gain.

A graduate nurse (GN) is caring for a client who underwent a total knee replacement 1 day earlier. Which intervention by the GN would cause the supervising nurse to intervene? 1. Applies a cold pack over the operative knee (17%) 2. Initiates a continual passive motion device (20%) 3. Obtains a leg-immobilizing device for ambulation (19%) 4. Places a support pillow under the operative knee (43%) OmittedCorrect answer 4 43%Answered correctly

Total knee replacement (knee arthroplasty) is a surgery that replaces the knee joint with an artificial implant. Knee arthroplasties are primarily performed for clients with severe pain or mobility impairment from arthritis. Following a knee arthroplasty, the nurse must plan care to reduce the client's risk of complications while promoting comfort and recovery. Contracture of the operative joint is a serious complication of knee arthroplasty that impairs the client's mobility. To prevent contracture formation, the nurse should maintain the operative knee in an extended position with a knee immobilizer or pillow placed under the lower leg or heel. Placing a pillow behind the knee causes joint flexion, which increases the risk of contracture (Option 4). (Option 1) Cold packs may be applied intermittently over the operative joint to reduce postoperative swelling and pain. (Option 2) Using a continual passive motion device, if prescribed, may improve range of motion through knee flexion and extension and prevent contractures. (Option 3) Applying a leg immobilizer during ambulation provides support, maintains alignment, and prevents dislocation of unstable operative joints. Educational objective:Knee arthroplasty is the surgical replacement of the knee joint. Following a knee arthroplasty, the nurse should avoid placing a pillow behind the client's operative knee due to the risk of contracture. Proper postoperative care includes applying intermittent cold packs to reduce pain and edema, using a continual passive motion device for flexibility, and obtaining a leg immobilizer for joint stability during ambulation.

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client's care plan? 1. Encourage client to drink cold beverages (1%) 2. Encourage client to eat a high-fiber diet (12%) 3. Encourage client to perform facial massage (17%) 4. Encourage client to report any fever or sore throat (68%) OmittedCorrect answer 4 68%Answered correctly

Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: Oral care - use a small, soft-bristled toothbrush or a warm mouth wash Use lukewarm water; avoid beverages or food that are too hot or cold (Option 1) Room should be kept at an even and moderate temperature Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth. (Option 2) A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger. (Option 3) Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain. Educational objective:The primary intervention for trigeminal neuralgia includes pain control and limiting pain triggers. The drug of choice is carbamazepine. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/The nurse cares for a client who has oral candidiasis. The health care provider has prescribed nystatin oral suspension. Which of the following nursing actions are appropriate? Select all that apply. 1. Assist the client in removing dentures and soaking them in nystatin 2. Inspect the oral mucous membranes thoroughly before administering nystatin 3. Instruct the client to discontinue the medication as soon as symptoms subside 4. Instruct the client to swish the suspension in the mouth for several minutes 5. Shake the bottle of suspension thoroughly before measuring the dose OmittedCorrect answer 1,2,4,5 23%Answered correctly

Nystatin is an antifungal medication commonly used to treat mucocutaneous candidal infections (ie, oral, intestinal, vaginal, skin). When caring for a client prescribed nystatin, the nurse should: Assist clients with oral candida who wear dentures in removing them and soaking them in nystatin suspension because dentures often become a reservoir for reinfection (Option 1). Assess the appearance of the affected area (eg, oral cavity, skin lesions) frequently throughout nystatin therapy (eg, before administration, during routine assessments) to monitor treatment efficacy and identify potential side effects (eg, mucous membrane irritation) (Option 2). Instruct clients prescribed nystatin liquid suspension for oral thrush to swish the suspension in the mouth for several minutes and then swallow the medication to allow treatment of any esophageal candida (Option 4). Ensure that liquid suspension forms of nystatin are shaken well before being measured for dosing because medication precipitates and causes unequal concentrations within the liquid (Option 5). (Option 3) Clients receiving nystatin should be educated to take the medication as prescribed each day and avoid missing doses; nystatin therapy is continued for at least 48 hours after symptoms subside to prevent recurrence of the infection. Educational objective:Oral nystatin suspension is an antifungal medication used to treat oral thrush caused by candidal infections. Nurses administering nystatin should assist the client in removing and soaking dentures, if present; assess the affected area frequently; educate the client to swish the medication in the mouth before swallowing; and ensure that the suspension is well shaken before dosing. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take? 1. Apply gloves and assess perineal area (55%) 2. Initiate large-bore IV access (6%) 3. Notify anesthesia provider of client's request for epidural (2%) 4. Obtain fetal heart tones via Doppler (35%) OmittedCorrect answer 1 55%Answered correctly

Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth. Signs of imminent birth include involuntary pushing/bearing down with contractions, grunting, or report of sensations of having a bowel movement. If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part (Option 1). If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed actions (eg, contact provider, assess fetal heart tones, initiate IV access). (Option 2) Large-bore IV access (ie, 18G or larger) is helpful for administrating oxytocin in the immediate postpartum period. However, the nurse first confirms that birth is not imminent before performing other actions. (Option 3) Notifying the anesthesia provider would be appropriate after confirming that birth is not imminent and performing other nursing actions to ensure client and fetal well-being (eg, assessing fetal heart tones, initiating IV access). (Option 4) The nurse should assess fetal heart tones and perform other interventions after determining that birth is not imminent. Educational objective:Precipitous birth is defined as <3 hours of labor from contraction onset until birth. When a client arrives at the hospital in second-stage labor, the nurse rapidly assesses whether birth is imminent before performing other interventions. Additional Information Management of Care NCSBN Client Need

Which client is most appropriate for the 7:00 AM-7:00 PM charge nurse on a cardiac step-down unit to assign to a float registered nurse from a medical-surgical unit? 1. Client who just returned to the unit after coronary angioplasty and placement of a stent (8%) 2. Client with atrial fibrillation scheduled for electrical cardioversion this afternoon (8%) 3. Client with heart block scheduled for pacemaker placement this afternoon (6%) 4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin (75%) OmittedCorrect answer 4 75%Answered correctly

The most appropriate assignment for the float nurse is the client with heart failure and IV heparin. The nurse from a general medical-surgical unit should be familiar with the assessment, nursing care, nursing diagnoses, and medications administered to clients with heart failure and with the facility's protocol for administration of a continual IV heparin infusion. (Option 1) This client should be assigned to an experienced nurse who regularly works on the unit. The nurse would be familiar with monitoring for bleeding at the femoral access site, post-procedure angina (eg, coronary vasospasm, acute thrombosis), and alterations in peripheral pulses. The experienced nurse would be better able to provide education as most clients are discharged 24 hours after stent placement. (Option 2) This client's nurse should be familiar with cardioversion. The nurse could explain the procedure to the client, assist if the procedure is done on the unit, and monitor the client for post-procedure complications (eg, cardiac dysrhythmias). (Option 3) This client's nurse should be familiar with monitoring for heart block until a pacemaker is placed, pacemaker placement, and postprocedure complications. Educational objective:A stable client with the least complex problems and the most clearly defined outcomes is the most appropriate assignment for a float nurse. Additional Information Management of Care NCSBN Client Need

The nurse is assessing 4 clients in the emergency department. Which client should the nurse prioritize for care? 1. Client with liver cirrhosis and ascites who has increasing abdominal distension and needs therapeutic paracentesis (19%) 2. Client with new-onset ascites from a suspected ovarian mass who needs paracentesis for diagnostic studies (30%) 3. Client with ulcerative colitis who has fever, bloody diarrhea, and abdominal distension and needs an abdominal x-ray (36%) 4. Nursing home client with dementia who has stool impaction and abdominal distension and needs stool disimpaction (13%) OmittedCorrect answer 3 36%Answered correctly

The cervical cap is a barrier method of contraception used with spermicide (eg, nonoxynol-9). The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to die, the cap should remain in place for ≥6 hours after intercourse but should not remain for more than 48 hours (Option 3). The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert additional spermicide into the vagina each time. (Option 1) Prior to insertion, spermicide is applied to the cervical cap to maximize contraceptive effectiveness. Spermicide should be applied inside the cap, along the rim of the cap, and in the groove on the underside of the cap. (Option 2) Use of cervical caps during menses (or during the postpartum period in clients with lochia discharge) increases the risk of toxic shock syndrome; an alternate contraceptive method should be used during this time. (Option 4) Inserting the cervical cap several hours before intercourse is acceptable and may improve correct use. Before each use, the client should inspect the cap for holes, cracks, or tears to ensure its effectiveness for blocking sperm. Educational objective:The cervical cap is a barrier method of contraception used with spermicide. It can be inserted several hours before intercourse and should be left in place for at least 6 hours after. Its use during menses increases the risk of toxic shock syndrome. Additional Information Health Promotion and Maintenance NCSBN Client Need

/See ex /////The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip? 1. Atrial paced rhythm (37%) 2. First-degree atrioventricular block with bigeminy (19%) 3. Sinus rhythm with premature ventricular contractions (32%) 4. Ventricular paced rhythm with failure to sense (9%) OmittedCorrect answer 1 37%Answered correctly

The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks). (Option 2) In first-degree atrioventricular block, every impulse is conducted to the ventricles, but the time of atrioventricular conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option 3) Normal sinus rhythms do not have pacer spikes. Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option 4) Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations (eg, pacer spike on the T wave). It should not be confused with failure to capture, in which pacer spikes are located appropriately but there is no electrical response elicited from the heart (eg, no QRS complex after a pacer spike). Educational objective:An atrial paced rhythm displays a pacer spike followed by a normal or distorted P wave, then a QRS complex. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks). Additional Information Physiological Adaptation NCSBN Client Need

The nurse receives the handoff of care report on four clients. Which client should the nurse see first? 1. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago (14%) 2. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air (9%) 3. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago (13%) 4. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless (62%) OmittedCorrect answer 4 62%Answered correctly

Acute respiratory failure (ARF) is a life-threatening impairment of the lungs' ability to oxygenate blood and excrete carbon dioxide (CO2). ARF may occur from exacerbation of chronic (eg, chronic obstructive pulmonary disease, asthma) or acute (eg, pneumonia, pulmonary edema) illnesses. Nurses assessing for signs of ARF should consider both respiratory and neurological manifestations. Altered mental status (eg, confusion, agitation, somnolence) is a common and often overlooked symptom that may occur because of the brain's sensitivity to inadequate oxygenation and alterations in acid-base balance from retained CO2(Option 4). Additional signs and symptoms may include paresthesias, dyspnea, tachypnea, and hypoxemia. (Option 1) Clients recovering from recent pneumonectomy (ie, surgical removal of part or all of the lung) often experience considerable pain, which may cause respiratory distress if not adequately controlled. A client with tachypnea and severe pain should be seen promptly but only after addressing potential ARF. (Option 2) Crackles, absent or diminished breath sounds over the affected lobe, and slightly decreased oxygen saturation are expected findings in pleural effusion, in which fluid collects in the space surrounding the lung. (Option 3) Low-grade fever may occur following surgery (due to the release of inflammatory cytokines) or from postoperative atelectasis. The client should be encouraged to ambulate and deep-breathe. Educational objective:Acute respiratory failure is a life-threatening impairment of lung function that inhibits gas exchange. Common symptoms include altered mental status (eg, confusion, agitation, somnolence), paresthesias, dyspnea, tachypnea, and hypoxemia, all of which should be addressed immediately.

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? 1. Capillary refill of less than 3 seconds (4%) 2. Left hand cooler than right (77%) 3. Mean arterial pressure of 65 mm Hg (10%) 4. Pressure bag at 300 mm Hg (8%) OmittedCorrect answer 2 77%Answered correctly

Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. (Option 1) Capillary refill of less than 3 seconds is an indicator of normal arterial circulation. (Option 3) A mean arterial pressure of 65 mm Hg is adequate to perfuse the vital organs. (Option 4) To maintain patency of the arterial blood pressure monitoring system, an intravenous bag of normal saline solution is placed in a pressure infuser device. The device is set to maintain continual pressure at 300 mm Hg. The pressure drops as the volume of solution in the bag decreases and can be pumped back up. This does not pose an immediate threat to the client. Educational objective:When caring for a client with a radial, brachial, or femoral arterial line in place, the nurse must be able to assess for complications. These include hemorrhage, infection, thrombus formation, and circulatory and neurovascular impairment. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching? 1. "I can restart my paroxetine once I get back home." (58%) 2. "I can take acetaminophen for headaches." (15%) 3. "I will avoid foods and drinks that contain tyramine." (17%) 4. "I will report any increased fever or diarrhea." (8%) OmittedCorrect answer 1 58%Answered correctly

Linezolid (Zyvox) is an oxazolidinone antibiotic prescribed for vancomycin- and methicillin-resistant bacteria, pneumonia, and skin infections. Linezolid has monoamine oxidase inhibitor (MAOI)-type properties; concurrent use with selective serotonin reuptake inhibitors (SSRIs) (eg, paroxetine, fluoxetine, sertraline) increases the risk of serotonin syndrome, a potentially fatal accumulation of serotonin (Option 1). Due to this risk, SSRIs are contraindicated while on linezolid therapy. SSRIs can be resumed 24 hours after linezolid therapy has been discontinued. (Option 2) Headaches may be a side effect of linezolid therapy. Acetaminophen is not contraindicated. (Option 3) Due to the MAOI-like properties of linezolid, clients should not consume foods or beverages containing tyramine during therapy to avoid adverse effects (eg, severe hypertension). (Option 4) Diarrhea is a common adverse effect of linezolid therapy. However, increased diarrhea or fever may indicate a complication from the regimen (eg, serotonin syndrome, Clostridium difficile infection) and should be reported promptly. Educational objective:Linezolid is an antibiotic with monoamine oxidase inhibitor-type properties that is prescribed to treat vancomycin- and methicillin-resistant bacterial infections. Selective serotonin reuptake inhibitors are contraindicated during therapy due to the increased risk of serotonin syndrome. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1. Administer IV regular insulin (43%) 2. Administer normal saline infusion (42%) 3. Obtain urine for urinalysis (2%) 4. Request prescription for potassium infusion (11%) OmittedCorrect answer 2 42%Answered correctly

This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion. (Option 1) Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume expansion. (Option 3) Urinalysis is important but not a priority. (Option 4) Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result. Educational objective:Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite a low total body potassium. Potassium repletion is started once the serum potassium levels are normalized or trending low (from elevated levels).

The health care provider prescribes a continuous heparin infusion at 18 units/kg/hr for a client who has a pulmonary embolus and weighs 198 lb. The infusion bag contains 25,000 units of heparin in 500 mL of D5W. At what rate in milliliters per hour (mL/hr) does the nurse set the IV infusion pump? Record your answer using a whole number. Answer: (mL/hr) OmittedCorrect answer 32 69%Answered correctly

Using dimensional analysis, use the following steps to calculate the prescribed infusion rate of heparin: Identify the prescribed, available, and required medication information Prescribed: 18 units heparinkg|hr Available: 25,000 units heparin500 mL Required: mLhrPrescribed: 18 units heparinkg|hr Available: 25,000 units heparin500 mL Required: mLhr Convert the prescription to the unit of measure needed for administration Prescription×available medication=mLhrPrescription×available medication=mLhr OR (units heparinkg|hr)(kglb)(lb )(mLunits heparin)=mL heparinhrunits heparinkg|hrkglblb mLunits heparin=mL heparinhr OR ⎛⎝18 units heparinkg∣∣hr⎞⎠⎛⎝kg2.2 lb⎞⎠(198 lb )⎛⎝500 mL25,000 units heparin⎞⎠=32.4 mL heparinhr18 units heparinkg|hrkg2.2 lb198 lb 500 mL25,000 units heparin=32.4 mL heparinhr Round to a whole number 32.4 mLhr=32 mLhr32.4 mLhr=32 mLhr Educational objective:To calculate the infusion rate of heparin, the nurse should first identify the prescribed dose (eg, 18 units/kg/hr) and available dose (eg, 25,000 units/500 mL) and then convert to milliliters per hour (eg, 32 mL/hr). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/A pregnant client at 39 weeks gestation is brought to the emergency department in stable condition following a motor vehicle collision. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. Which action should the nurse take first? 1. Administer normal saline fluid bolus (21%) 2. Ask about any prenatal complications (0%) 3. Initiate fetal heart rate monitoring (17%) 4. Tilt the backboard to one side (59%) OmittedCorrect answer 4 59%Answered correctly 03 secsTime Spent 12/30/2019Last Updated

During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first step to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and promote blood circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client from further potential spinal injury (Option 4). Manifestations of aortocaval compression (eg, hypotension, pallor, dizziness) may mimic those of other complications of trauma. It is therefore critical to reassess blood pressure after uterine displacement to identify persistent hypotension, which may indicate hemorrhage caused by trauma (eg, placental abruption). (Option 1) An IV fluid bolus of isotonic fluids (eg, lactated Ringer solution) to correct hypotension is appropriate if position changes do not relieve symptoms or hemorrhage is suspected. Client positioning should be considered first. (Option 2) Assessing medical and obstetric history is important when planning care for a pregnant client, but immediate physical needs are the priority. (Option 3) The nurse should first reposition the client to address a potential cause of hypotension (aortocaval compression), which can affect blood flow to the fetus, and then initiate fetal monitoring. Educational objective:During stabilization of a pregnant client after trauma, uterine displacement is the first step to prevent/correct supine hypotension and promote blood circulation to the fetus. A lateral tilt of the backboard can correct aortocaval compression while protecting the client from further spinal injury

/The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Carpal tunnel syndrome (3%) 2. Diabetes mellitus (45%) 3. Sciatica (8%) 4. Small cell lung cancer (42%) OmittedCorrect answer 4 42%Answered correctly

SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH. Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine). (Options 1 and 3) Carpal tunnel syndrome is a result of aggravated tendons in the wrists causing narrow, pinched nerves. Sciatica is numbness, tingling, or pain caused by an irritation of the sciatic nerve. Both are examples of peripheral nerve disorders. SIADH is more common among clients with central nerve disorders (eg, stroke, neurosurgery). (Option 2) Diabetes mellitus is an endocrine disorder characterized by hyperglycemia and is not commonly associated with SIADH. Educational objective:ADH is sometimes produced and secreted by cancer cells, especially lung cancer cells causing SIADH, a condition in which too much ADH causes water retention, increased total water, and dilutional hyponatremia. Additional Information Reduction of Risk Potential NCSBN Client Need

/The registered nurse (RN) and licensed practical nurse (LPN) are caring for a client with an established colostomy. Which nursing actions may the RN delegate to the LPN? Select all that apply. 1. Assess perfusion of the stoma tissue 2. Assist the client in changing the ostomy pouch 3. Auscultate the client's bowel sounds 4. Develop plan of care to prevent skin breakdown 5. Monitor the color of ostomy drainage OmittedCorrect answer 2,3,5 54%Answered correctly

Scope of practice Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgment of the registered nurse (RN) and may not be delegated. The RN may delegate care of stable clients with established ostomies to the licensed practical nurse (LPN). The following actions related to ostomy care are generally within the LPN scope of practice: Provide ostomy care and observe for skin breakdown (Option 2) Perform specific assessments (eg, bowel sounds, stoma color) (Option 3) Monitor drainage characteristics (eg, color, amount) (Option 5) Reinforce education Irrigate an established ostomy Document observations and interventions (Option 1) The RN may delegate specific assessments to the LPN. The LPN focuses on data collection and determining normal versus abnormal findings. For example, the LPN may determine that a client's colostomy stoma is an abnormal color whereas the RN synthesizes assessment findings (eg, color, temperature, capillary refill) to determine the quality of tissue perfusion. (Option 4) Developing the plan of care is the responsibility of the RN and cannot be delegated. Educational objective:Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgment of the registered nurse (RN) and may not be delegated. The licensed practical nurse may perform basic care activities of the client with an established ostomy, perform specific assessments, monitor RN findings, and reinforce education.

A client is scheduled for allergy skin testing to identify asthmatic triggers. Which medications should the nurse instruct the client to withhold before the test to ensure accurate results? Select all that apply. 1. Acetaminophen 2. Albuterol 3. Diphenhydramine 4. Enalapril 5. Loratadine OmittedCorrect answer 3,5 20%Answered correctly

Allergy skin testing involves introducing common environmental and food allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Several different antigens, as well as positive and negative controls, are usually tested at the same time for accuracy. To ensure an accurate result, the client should avoid antihistamines (eg, diphenhydramine [Benadryl], loratadine [Claritin], promethazine [Phenergan]) for up to 2 weeks prior to the test (Options 3 and 5). Antihistamines block mast cell release of histamines that are responsible for allergic symptoms. Systemic corticosteroids, used to treat the inflammatory component of asthma, may also affect the accuracy of allergy skin testing; therefore, the use of these medications is assessed by the health care provider. (Option 1) Acetaminophen does not have antihistamine properties and will not interfere with allergy skin testing. (Option 2) Albuterol, an inhaled short-acting beta adrenergic agonist, will not interfere with allergy skin testing results and should not be discontinued, as it is necessary to ensure client safety during acute asthma exacerbations. (Option 4) Enalapril, an ACE inhibitor, is used to treat high blood pressure and heart failure and will not impact the results of allergy skin testing. Educational objective:Allergy skin testing involves introducing common allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Clients should avoid antihistamines as these drugs can prevent accurate results. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is discussing child safety with the parents of a 12-month-old who is just beginning to walk. Which statement by the parents indicates a need for further instruction? 1. "Our swimming pool is fenced in with a lock on the gate." (1%) 2. "We have installed childproof gates at the top and bottom of our stairs." (1%) 3. "We need to lower the mattress in our child's crib." (8%) 4. "When we can't be watching, we put our child in a mobile child walker." (88%) OmittedCorrect answer 4 88%Answered correctly

Due to the relatively high incidence of injuries associated with child walkers, the American Academy of Pediatrics has recommended a ban on the manufacture and sale of mobile infant walkers. Accidents associated with child walkers include: Rolling down stairs (the most common cause of injury) Burns - children can reach high in a walker, enabling them to grab hot pot handles, reach heaters and fireplaces, or grab a hot cup of liquid off a counter or table Drowning - a child can fall into a bathtub or pool while in a mobile walker Poisoning - the child can reach higher objects Even if a parent is close by and watching a child in a walker, an accident may not be preventable. Children can move quickly and the parent or caregiver may not be able to respond quickly enough. Safer alternatives to mobile baby walkers include stationary walkers (no wheels) and play areas. If parents or caregivers insist on using a baby walker, they should be advised to choose one that meets the American Society for Testing and Materials safety standards. Walkers with braking mechanisms stop if at least one wheel drops off the riding surface. (Option 1) This is an appropriate action; swimming pools should be surrounded by fences with childproof locks to prevent accidental drowning. Wading pools and all water containers should be emptied after each use. (Option 2) This is an appropriate action; childproof gates should be installed on stairs and at the entrances to rooms that could pose danger to a child. (Option 3) This is an appropriate action; as children grow taller and can stand, they may be able to crawl over the crib rails and fall. Educational objective:Mobile baby walkers are associated with injuries such as falls and drowning as they can easily tip over. Children can also reach higher places while in a baby walker, enabling them to pull hot objects and dangerous substances off counters and tables.

he nurse is caring for several clients in a women's health clinic. Based on the data collected, which client's history is most concerning for an increased risk of endometrial cancer? 1. 40-year-old client who has been taking hormonal birth control pills for the past 10 years (8%) 2. 45-year-old client who reports a history of an ectopic pregnancy with a ruptured ovary and two preterm births (10%) 3. 47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments (42%) 4. 60-year-old client who recently had a colposcopy after testing positive for a high-risk type of human papillomavirus (38%) OmittedCorrect answer 3 42%Answered correctly

Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) (Option 3) Obesity Tamoxifen (a medication given for breast cancer) (Option 1) Progestin-containing contraceptives (ie, birth control pills) are associated with a decreased endometrial cancer risk because progestins thin the uterine lining, therefore preventing endometrial hyperplasia. (Option 2) Ectopic pregnancy with a ruptured ovary or preterm birth is not associated with endometrial cancer, although never giving birth at term gestation may increase ovarian cancer risk. (Option 4) Infection with a high-risk type of human papillomavirus increases cervical (not endometrial) cancer risk. Educational objective:Endometrial cancer is a slow-growing malignancy that arises from the inner lining of the uterus. Major risk factors include conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility), obesity, and tamoxifen therapy.

The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. "I need to monitor the total amount of this medication that I give to my child every day." (6%) 2. "I should give this medication with or just before my child has a meal or snack." (10%) 3. "It is okay for my child to chew this medication." (61%) 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce." (21%) OmittedCorrect answer 3 61%Answered correctly

In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea. Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or snack (Option 2). These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy (Option 1). (Option 4) This is a true statement; some children have difficulty taking a whole capsule. Capsule contents can be sprinkled in acidic substances such as applesauce. Capsules should not be taken with milk as they can cause it to curdle. Educational objective:Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and proteins in a child with CF. They are taken with or just before every meal (not as needed); should be swallowed whole or sprinkled on an acidic food; and should not be crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client newly diagnosed with osteomalacia is reviewing home care instructions with the nurse. Which statements indicate the need for further instruction? Select all that apply. 1. "I will avoid foods high in calcium and phosphorus." 2. "I will avoid going outside on sunny days." 3. "I will decrease activity to prevent bone injury." 4. "I will eat foods that are fortified with vitamin D." 5. "I will use a cane to help me get around better." OmittedCorrect answer 1,2,3 41%Answered correctly

Osteomalacia is a reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft, and painful bones that can easily fracture or become deformed. In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable for calcification of bone tissue. Vitamin D deficiency is also associated with increased risk of falls, especially in elderly clients, due to muscle weakness. Nursing management focuses on: Implementing safety measures such as canes or walkers to prevent falls and injury (Option 5) Encouraging light to moderate activity, which can help promote bone strength and health (Option 3) Increasing dietary intake of:Calcium (eg, leafy green vegetables, dairy) (Option 1)Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains)Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also recommended as it synthesizes vitamin D (Options 2 and 4) Taking over-the-counter or prescription supplemental vitamin D Educational objective:Osteomalacia occurs when the body is unable to use calcium and phosphorus for bone calcification due to a vitamin D deficiency. Nursing management focuses on implementing safety measures, encouraging activity, and increasing intake of vitamin D, calcium, and phosphorus. Additional Information Physiological Adaptation NCSBN Client Need

//The clinic nurse assesses an 8-year-old client who reports a sore throat and has a bright red, pruritic rash on the chest that feels like fine bumps and looks like a sunburn. Which diagnostic tool does the nurse anticipate the health care provider will prescribe? 1. Allergy skin testing (20%) 2. Complete blood count (10%) 3. Rapid streptococcal antigen test (65%) 4. Skin biopsy (2%) OmittedCorrect answer 3 65%Answered correctly

Scarlet fever (ie, scarlatina), a complication of group A streptococcal infection (eg, streptococcal pharyngitis), is common in early childhood and is characterized by a distinctive red rash. The rash begins on the neck and chest and spreads to the extremities, resembles a bad sunburn, blanches with pressure, and has fine bumps like sandpaper. Additional manifestations of streptococcal pharyngitis (eg, exudative pharyngitis, fever, swollen anterior cervical lymph nodes) are typically present. Because the clinical presentation (ie, rash plus sore throat) is characteristic, but not diagnostic, of scarlet fever, the health care provider will prescribe a rapid streptococcal antigen test to confirm symptom etiology (Option 3). Swabbing the posterior pharynx and tonsils provides test results within minutes. Throat culture may be necessary to verify results. (Option 1) Dermatologic manifestations of an allergic reaction (eg, contact dermatitis) may necessitate allergy testing (eg, scratch or patch testing). However, the client's symptoms are characteristic of scarlet fever, not an allergic reaction. (Option 2) A complete blood count may reveal elevated WBCs in the presence of any infection, but this is not diagnostic for streptococcal pharyngitis. (Option 4) A skin biopsy involves removing skin and examining it under a microscope to detect certain dermatologic conditions (eg, infection, lupus) but is not anticipated because the client's symptoms are characteristic of scarlet fever. Educational objective:Scarlet fever (ie, scarlatina), a complication of group A streptococcal infection (eg, streptococcal pharyngitis), is characterized by a distinctive red rash. Diagnosis is based on clinical presentation, rapid streptococcal antigen testing, and possible throat culture. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which assessment findings does the nurse expect to find? Select all that apply. 1. Absent deep tendon reflexes 2. Cold, clammy skin 3. Muscle rigidity 4. Restlessness and agitation 5. Sinus tachycardia OmittedCorrect answer 3,4,5 33%Answered correctly

Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). (Option 1) The client experiencing serotonin syndrome would exhibit hyperreflexia. (Option 2) The client experiencing serotonin syndrome would exhibit warm moist skin and a fever. Educational objective:Clinical manifestations of serotonin syndrome include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? 1. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally (16%) 2. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin (13%) 3. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion (30%) 4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition (39%) OmittedCorrect answer 4 39%Answered correctly

The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the nurse to report to the health care provider (HCP). (Option 1) A CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with HIV who is receiving oral fluconazole (Diflucan) to treat oral candidiasis is within normal limits (500-1,200/mm3 [0.5-1.2 × 109/L]) and does not need to be reported to the HCP. (Option 2) A hemoglobin A1C (HbA1c) of 7.3% in a client with type 2 diabetes who is receiving IV levofloxacin to treat pneumonia is not exceptionally high; the recommended goal is <7%. A bacterial infection causes physiologic stress and increased serum glucose. This increases insulin requirements but would not affect the current HbA1c level, as it reflects glucose control over a 2-3 month period. Therefore, this finding is not the highest priority for the nurse to report to the HCP. (Option 3) Heparin can lead to thrombocytopenia. However, a platelet count of 148,000/mm3 (148 × 109/L) is just below normal limits (150,000-400,000/mm3 [150-400 × 109/L]). Therefore, this finding does not need to be reported to the HCP. Educational objective:The recommended target serum glucose range for clients receiving nutritional support is 140-180 mg/dL (7.8-10.0 mmol/L). The nurse should monitor a client receiving TPN for hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) and hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]). Hypoglycemia places the client at risk for life-threatening complications (eg, seizures, nervous system damage). Additional Information Management of Care NCSBN Client Need Copyright © UWorld. All rights reserved.

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply. 1. A visitor talking in the waiting room states that the client has alcoholism 2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home 3. The nursing assistant tells a client that the hospital roommate went for a gallbladder test 4. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions 5. Two LPNs are discussing a possible cure for AIDS on a crowded elevator OmittedCorrect answer 2,3 62%Answered correctly

The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. Clients' health information should be shared only with other health care team members directly involved in those clients' care. Report sheets used by nursing staff often include clients' private health information and must be shredded at the end of the shift (Option 2). Without the client's permission, information about the diagnosis or diagnostic tests cannot be shared with a hospital roommate (Option 3). (Option 1) Health care staff are not required to censor visitor conversation in waiting rooms. (Option 4) Nurses are obligated to help protect visitors and others by instructing visitors to wear appropriate personal protective equipment. However, the nurse should not violate the client's privacy by sharing the client's diagnosis. (Option 5) Although discussion about specific client information is not permissible, general discussion about health care topics (eg, a potential cure for AIDS) is not a violation of clients' privacy. Educational objective:The nurse must protect clients' privacy and maintain the confidentiality of their medical information. Clients' health information should be discussed only with health care team members directly involved in those clients' care. Nurses must also ensure that documents containing clients' information are shredded after use.

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? 1. Explain to the family that this is a normal physiological response to dying (21%) 2. Explore the family's thoughts and concerns about the client's refusal of food (55%) 3. Recommend a feeding tube (1%) 4. Tell the family that "force feeding" the client could cause the client to choke on the food (21%) OmittedCorrect answer 2 55%Answered correctly

When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food. The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness. (Option 1) Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family's feelings and concerns. (Option 3) Although it is not unusual for a client to be admitted to hospice with a feeding tube already in place, tubes are generally not placed after a client begins receiving hospice services. (Option 4) This is a true statement, but it is not the priority nursing action. Educational objective:It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore their fears and concerns and help them identify other ways to express how they care. Additional Information Psychosocial Integrity NCSBN Client Need

/A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? Select all that apply. 1. Black fingernail polish 2. Cold extremities 3. Elevated WBC count 4. Hypotension 5. Peripheral arterial disease OmittedCorrect answer 1,2,4,5 32%Answered correctly

A pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached to the client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO2). Normal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO2 include: Dark fingernail polish or artificial acrylic nails (Option 1) Hypotension and low cardiac output (eg, heart failure) (Option 4) Vasoconstriction (eg, hypothermia, vasopressor medications) (Option 2) Peripheral arterial disease (Option 5) (Option 3) Abnormal WBC count has no direct influence on light transmission or peripheral blood flow. Educational objective:Any factor that affects light transmission or peripheral blood flow can cause a falsely low reading for oxygen saturation on pulse oximeter. Common causes include dark nail polish, hypotension, low cardiac output, vasoconstriction (eg, hypothermia, vasopressor medications), and peripheral arterial disease.

///The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first? 1. Client who has a migraine is reporting 10/10 pain and nausea (8%) 2. Client who is postictal after a seizure is drowsy and confused (6%) 3. Client with amyotrophic lateral sclerosis is experiencing dysarthria (3%) 4. Client with a Glasgow Coma Scale score of 9 is no longer responding when called (80%) OmittedCorrect answer 4 80%Answered correctly

Declining neurological status threatens the airway and breathing; therefore, the client with the Glasgow Coma Scale (GCS) score of 9 is the highest priority according to the ABCDs and Maslow's Hierarchy of Needs. A GCS score of 8 or lower is classified as a coma. Comatose clients are usually intubated to protect the airway ("when you are 8, intubate"). (Option 1) Clients with migraine headaches have episodes of severe pain (migraine attacks). Development of new-onset headache without a known etiology would be concerning. The client with declining neurological status and a GCS score of 9 is the highest priority. (Option 2) After a tonic-clonic seizure, the client wakes up gradually. It is not unusual for the client to be confused and disoriented on awakening and then to sleep for a few hours. The key concern is safety (eg, use of padded side rails, raised side rails, suction equipment in room). The nurse can teach family members the disease process and emergency care of seizures later. For now, they should encourage the client to remain in the bed with the side rails up. (Option 3) Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) involves a progressive neurological loss of motor neurons. Typical expected symptoms are limb weakness, dysarthria (difficulty speaking), and dysphagia. Educational objective:A GCS score of 8 or less is classified as a coma. These clients are intubated for airway protection.