NCLEX STUDY QUESTIONS

The nurse is caring for a client with a phosphorus level of 5 mg/dL. They know that which of the following are possible causes of this condition? Select all that apply! A. Tumor lysis syndrome B. Hypoparathyroidism C. Hypercalcemia D. Renal failure E. Superior Vena Cava syndrome

A, B, & D

The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L. Which of the following s/s do they suspect are caused by the client's sodium level? A. Lethargy B. Dry mucous membranes C. Tachypnea D. Cyanosis E. Dry mouth

A, B, & E

The client should be taught that the overall treatment goal for HIV is to A. increase the CD4/CD8 count B. increase production of hemoglobin C. raise the level of folic acid D. lower the viral load (VL)

A, D

The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL. They know that which of the following could have caused this electrolyte imbalance? Select all that apply! A. Renal failure B. Alcoholism C. Anorexia D. Diarrhea E. Malnutrition

A

A nurse has a STAT order for a cooling or hypothermia blanket. After you call the appropriate department, the cooling blanket is delivered to your nursing care unit. What is the first thing you should do concerning the STAT order? A. Inspect and run the equipment prior to use B. Immediately use the cooling blanket for the client because it is a STAT order C. Ask the engineering department to perform preventive maintenance on it D. Inspect the blanket for any frayed cords before to protect against fire

A, you must thoroughly inspect and run the equipment before use to ensure that it is appropriately functioning BEFORE it is used. This inspection should include an overall assessment for frayed electrical cords and documented evidence that the piece of equipment has had the mandated preventive maintenance and safety inspections according to the facility's policies and procedures B is incorrect, you would not immediately use it because it is STAT C is incorrect, do not as engineering because there should be documented evidence that preventive maintenance was done on the sticker D is incorrect, you would not merely inspect the blanket for any frayed cords before use to protect against fires

The ABCDEs of melanoma identification

ABCDE stands for: asymmetry, border, color, diameter, and evolution.

A nurse is performing a visual acuity test on a client who states she has myopia. Which result would the nurse expect to find? A. +1.25 B. 20/15 C. 20/80 D. 20/27

C Myopia is often referred to as nearsightedness, as objects in the distance appear blurry to these clients A is incorrect, standard vision screenings do not detect hyperopia. B is incorrect, 20/15 indicates the client is capable of seeing at a distance of 20 ft what a person w/ 20/20 requires 15 ft or less to see D is incorrect, 20/27 is an erroneous finding. Snellen eye chart goes by increments of 5.

The nurse is evaluating their client's lab results and notes that the potassium level is 5.5 mEq/L. They review the telemetry monitor, looking for which of the following signs? SELECT ALL THAT APPLY! A. Inverted T waves B. Widened QRS interval C. Tall, peaked T waves D. Prominent U-waves E. Prolonged PR interval

B, C, & E

The nurse is caring for a client who has a chloride level of 115 mEq/L. Which of the following maintenance IV fluids do they anticipate the primary healthcare provider will order? A. 3% NS B. Normal Saline IVF C. Lactated Ringers IVF D. D5NS

C

The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). Which med should the nurse question? A. Sertraline B. Omeprazole C. Alprazolam D. Ziprasidone

C is correct, ECT is a safety therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder. If a client is taking the benzodiazepine alprazolam, this will increase the seizure threshold and may attenuate the efficacy of ECT. Benzodiazepines and anticonvulsants should therefore be avoided in clients receiving ECT. Choices A, B, and D are incorrect. Antidepressant medications (such as sertraline) and antipsychotics (such as ziprasidone) may be given concurrently with ECT. These medications may enhance the efficacy of the treatment. Proton pump inhibitors (such as omeprazole) are typically given on the day of treatment to prevent gastric reflux and aspiration.

The nurse is caring for the following assigned clients. The nurse should follow up on which client first? A client who has A. mechanical ventilation and the low-pressure alarm sounds. B. a new colostomy and refuses to participate in care. C. acute glomerulonephritis and has periorbital edema. D. atrial fibrillation and an irregular pulse.

Choice A is correct. A client receiving mechanical ventilation requires multiple assessments. The low-pressure alarm is concerning for ventilator disconnection or low cuff pressure. The high-pressure alarm is concerning for obstruction such as secretions. This client should be assessed first under the priority model of "ABCs" = airway, breathing, circulation. Choices B, C, and D are incorrect. A client with a new colostomy may be indifferent when caring for themselves as they adjust to the change in body image. Further, a client with acute glomerulonephritis will exhibit periorbital edema and high blood pressure. Finally, an irregular pulse is consistent with atrial fibrillation.

A patient presents with dizziness upon standing, bilateral hand tremors, inability to sleep, irritability, sweating, and a heart rate of 95. From what substance is the patient most likely experiencing these withdrawal symptoms? A. Alprazolam B. Nicotine C. Adderall D. Cocaine

Choice A is correct. Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia. Choice B is incorrect. Typical nicotine withdrawal symptoms include headache, nervousness, poor concentration, anger, hunger, and restlessness. Choice C is incorrect. Adderal is an amphetamine drug. Typical amphetamine withdrawal symptoms include dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation. Choice D is incorrect. Typical withdrawal symptoms of cocaine are similar to amphetamine withdrawal symptoms: dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation.

The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following? A. Atonic seizure B. Tonic-clonic seizure C. Absence seizure D. Complex partial seizure

Choice A is correct. Atonic seizures are drop attacks or drop seizures that cause a sudden loss of muscle tone and result in the client collapsing. This is quite serious as this may cause a client to sustain an injury. Choices B, C, and D are incorrect. Tonic-clonic seizures are characterized by stiffening the muscles (tonic), then the client has muscle jerking (clonic). Absence seizures feature a brief staring gaze with an impaired level of consciousness. These are common in children and may occur multiple times throughout the day. Complex partial seizures cause an impairment in consciousness, so the client may exhibit automatisms such as lip-smacking or repeating certain words/phrases.

A client was admitted for an acute exacerbation of asthma. Auscultation findings reveal nearly absent breath sounds, and an albuterol nebulization treatment was promptly administered. Thirty minutes later, upon auscultation, the nurse hears diffuse inspiratory and expiratory wheezes throughout the lung fields. This finding means: A. There is increased airflow B. There is no improvement in the airflow C. There is worsening of the condition D. The airflow issue was not addressed

Choice A is correct. Changes in breath sounds indicate that the client has responded to the albuterol nebulizer. Upon the initial auscultation by the nurse, there were nearly absent breath sounds, indicating severe airflow obstruction was present. Thirty minutes after the medication administration, diffuse inspiratory and expiratory wheezes throughout the lung fields demonstrate that airflow has improved (even though the lung fields remain partially obstructed). Choice B is incorrect. The initial auscultation of the client's lungs revealed nearly absent breath sounds. According to this finding, little to no air was moving within the client's lungs. Thirty minutes after the albuterol nebulizer, auscultation by the nurse reveals diffuse inspiratory and expiratory wheezes throughout the lung fields. Unlike the previous auscultation, lung sounds are now prominent within the lung fields, indicating improved airflow throughout the client's lungs. Choice C is incorrect. The initial auscultation of the client's lungs revealed nearly absent breath sounds. According to this finding, little to no air was moving within the client's lungs. In order for a worsening of the condition to occur, auscultation by the nurse thirty minutes after the albuterol nebulizer would need to reveal a complete lack of all breath sounds throughout the client's lungs. Choice D is incorrect. According to the question, "auscultation findings reveal nearly absent breath sounds, and an albuterol nebulization treatment was promptly administered." Albuterol sulfate is a beta2-adrenergic bronchodilator used to treat asthma, bronchospasm, and reversible obstructive airway disease. Therefore, the airflow issue was not only addressed, but addressed in a prompt, effective manner.

The nurse is caring for the following assigned clients. Which client should the nurse see first? The client A. going for an echocardiogram and is allergic to contrast dye. B. refusing to eat their meal following an injection of glargine insulin. C. scheduled for discharge in three hours and needs transportation. D. requesting diphenhydramine after starting an intravenous antibiotic.

Choice D is correct. A client requesting diphenhydramine following the initiation of an antibiotic requires immediate follow-up because the client could be experiencing an allergic reaction ranging from mild to severe. Thus, the nurse should quickly assess the client. Choices A, B, and C are incorrect. A client scheduled for an echocardiogram will not receive contrast dye, and follow-up is unnecessary. Further, for an individual receiving glargine insulin, meals are not necessary as this long-acting insulin does not peak. Finally, arranging discharge transportation is a low-priority item for the nurse.

A 16-year-old adolescent client is brought to the emergency department following an injury at a skating rink. The client's left knee is bruised and swollen. Upon interview, the nurse finds out that the client has hemophilia A. Which medication would be most appropriate for this client? A. Codeine phosphate B. Aspirin C. Ibuprofen D. Oxycodone terephthalate and acetyl-salicylate

Choice A is correct. Codeine phosphate is an analgesic medication with no aspirin components and is used for moderate to severe pain. Choice B is incorrect. Clients with hemophilia should avoid aspirin (and all other nonsteroidal anti-inflammatory drugs (NSAIDS)), as these medications inhibit proper platelet functioning. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). If given to this client, aspirin would aggravate the client's condition by inhibiting platelet aggregation, likely increasing this client's bleeding and worsening this client's current condition. Choice C is incorrect. As mentioned above, clients with hemophilia should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), as these medications inhibit proper platelet functioning. Ibuprofen is an NSAID and should therefore be avoided in clients with hemophilia. Choice D is incorrect. Oxycodone terephthalate and acetylsalicylic acid possess aspirin. Acetylsalicylic acid (ASA) is a generic name for aspirin. Similar to Choice B, the aspirin in this medication renders this choice contraindicated for this client. Hemophilia clients should avoid all aspirin-containing medications, as these medications inhibit proper platelet functioning. If given to this client, aspirin would aggravate the client's condition by inhibiting platelet aggregation, likely increasing this client's bleeding and worsening this client's current condition.

The nurse is caring for a client who has developed dystonia following the administration of fluphenazine. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe? A. diphenhydramine B. mannitol C. thiamine D. haloperidol

Choice A is correct. Diphenhydramine is an anticholinergic and is utilized for dystonic reactions associated with antipsychotic use (such as fluphenazine, a typical antipsychotic). Dystonia is one of the earliest adverse effects and should be promptly reported to the prescriber. Choices B, C, and D are incorrect. Mannitol is an osmotic diuretic indicated for increased intracranial pressure. This medication would not be used for dystonic reactions. Thiamin is a B-vitamin and can be helpful for alcohol withdrawal. This is not indicated for the treatment of dystonia. Haloperidol is a typical antipsychotic and would be detrimental in treating dystonia. Medications like fluphenazine include haloperidol which would worsen the effect.

The nurse is caring for a client who sustained an electrical burn. Which priority action should the nurse take? A. Obtain an electrocardiogram (ECG) B. Obtain an order for an arterial blood gas (ABG) C. Perform wound care D. Initiate supplemental oxygen

Choice A is correct. Electrical burns are serious and require the client to undergo cardiac monitoring because of the risk of dysrhythmias. The nurse's priority action is to obtain telemetry monitoring or perform a 12-lead electrocardiogram. Choices B, C, and D are incorrect. These types of burns cause an 'iceberg' effect where the client's external injuries appear minor, but the internal injuries may be catastrophic. Electrical burns may trigger immediate ventricular fibrillation or asystole. Thus, it is important to monitor the client's cardiovascular status immediately following this type of injury.

The nurse is assessing a client with a myxedema coma. Which of the following would be an expected finding? A. Glucose 59 mg/dL (3.2745 mmol/L) B. Sodium 155 mEq/L C. Serum pH 7.49 D. Temperature 102.4° F (39.1° C)

Choice A is correct. Hypoglycemia is one of many clinical features of myxedema coma. Myxedema coma is a severe form of hypothyroidism and warrants immediate medical attention. Choices B, C, and D are incorrect. Clinical features of myxedema coma include hyponatremia, hypoventilation which causes respiratory acidosis, and hypothermia. A sodium level of 155 mEq/L is hypernatremia, a serum pH of 7.49 is alkalosis, and a temperature of 102.4° F is pyrexia. All of which are not consistent findings associated with myxedema coma.

The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply. A. Pronounced wrinkles on the face B. Decreased size of the nose and ears C. Increased growth of facial hair D. Neck wrinkles E. Increased height

Choice A is correct. Many changes occur in the aging body. With age, the loss of adipose tissue causes sagging skin and wrinkles. This is especially noticeable around the head and face. Wrinkles on the face become more pronounced and tend to take on the general "mood" of the client over the years. For example, laugh lines or wrinkles around the lips, cheeks, and eyes are usually more noticeable. Choice B is incorrect. The nose and ears of the aging client become more extended and broader. Over time, the nose and ears appears to grow in size due to gravity. As individuals age, gravity causes cartilage in the ear and nose to break down and sag which gives these features an elongated appearance. Choice C is correct. Changes in hormone levels, especially the androgen-estrogen ratio, often cause an increase in the growth of facial hair in most older adults. As individuals age, they lose estrogen. When estrogen decreases and testosterone levels are unopposed clients will start to grow more hair where men have it, especially on the face. Choice D is correct. The aging process causes the platysma muscle to shorten, which contributes to neck wrinkles. Neck skin is very similar to facial skin. As a client ages, they lose important dermal plumping factors like collagen, elastin and glysosaminoglycans. These factors are gradually lost over time with the aging process and is also enhanced with environmental stressors like frequent exposure to UV light. Choice E is incorrect. Typically, height decreases through the aging process.

While working in a pediatric cardiac unit, you are assigned to take care of an infant with tetralogy of Fallot. During report, you are told that the infant is having frequent 'tet spells'. To prepare for your shift, which medication do you ensure is readily available in case of a tet spell? A. Morphine sulfate B. Dexmedetomidine C. Fentanyl D. Atropine sulfate

Choice A is correct. Morphine sulfate is the drug of choice for use during tet spells. It helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and therefore the hypercyanotic tet spell. Choice B is incorrect. Dexmedetomidine is a sedative. It is not used for tet spells. Choice C is incorrect. Fentanyl is a narcotic used for pain relief. Although it is similar in some ways to morphine sulfate, it is not used for tet spells. Choice D is incorrect. Atropine sulfate is an anticholinergic. It is used for several different purposes such as treating a slow heart rate or to decrease saliva production prior to surgery, but it is not used for tet spells.

Your 78-year-old client has been receiving antibiotics for ten days and tells you that he is having frequent watery stools. Which action will you take first? A. Place the client on contact precautions. B. Instruct the client about correct handwashing. C. Obtain stool specimens for culture. D. Notify the physician about the loose stools.

Choice A is correct. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be to place him on contact precautions in order to prevent the spread of C. difficile to other clients. Clostridium difficile (C. difficile), a spore-forming bacillus that infects the gastrointestinal (GI) tract following treatment of other infections with antibiotics is one of the few hospital-acquired infections (HAIs) increasing in frequency. C. difficile spores are transferred to clients mainly via the hands of health care personnel who have touched a contaminated surface or item. Choices B, C, and D are incorrect. These are appropriate actions but should be taken after the client is placed on contact precautions. The other activities are also needed and should be taken after placing the client on contact precautions.

The nurse is caring for a client with the below laboratory result. Which early vital sign change would the nurse expect to support this finding? See the image below. Hgb - 5.6 Hct - 16.8 A. Tachycardia B. Bradycardia C. Hypotension D. Bradypnea

Choice A is correct. The hemoglobin and hematocrit are critically low in this client. When critically low hemoglobin is evident, the nurse will likely see the client demonstrate tachycardia as a compensatory mechanism for the low blood volume. Tachycardia is the most reliable and earliest sign of hypovolemic shock. Choices B, C, and D are incorrect. Hypotension is not an early sign of hypovolemic shock. The first changes in vital signs seen in hypovolemic shock include increased diastolic blood pressure with narrowed pulse pressure. As volume status continues to decrease, systolic blood pressure drops. Bradypnea is a late sign of shock.

Which action taken by the school nurse will have the most impact on the incidence of infectious disease in the school? A. Ensure that students are immunized according to national guidelines. B. Provide written information about infection control to all patients. C. Make soap and water readily available in the classrooms. D. Teach students how to cover their mouths when coughing.

Choice A is correct. The incidence of once-common infectious diseases such as measles, chickenpox, and mumps have been effectively reduced by immunization of all school-aged children. School-aged children are at risk for problems such as exposure to viruses, respiratory infections, and parasitic infections (such as scabies or lice). Vaccination protects children from serious illness and complications of vaccine-preventable diseases which can include amputation of an arm or leg, paralysis of limbs, hearing loss, convulsions, brain damage, and death. Choices B, C, and D are incorrect. While these are helpful, receiving proper and timely immunizations has a great impact.

The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside? A. Trach kit B. Scissors C. Obturator D. Yanuker

Choice B is correct, scissors must be kept at the bedside of any client with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of the shift to ensure the safety of the client. A Sengstaken-Blakemore tube has esophageal and gastric balloons. If the gastric balloon ruptures or moves substantially, the entire tube might migrate proximally, resulting in airway obstruction. This is an emergency, and the nurse must act immediately to deflate the balloons. Scissors are always kept at the bedside to cut across all the tube lumens and rapidly deflate the balloons. Following this, the tube can be extracted.

The nurse is caring for a client with suspected placenta previa. The nurse anticipates a prescription for which diagnostic test to confirm this finding? A. Manual cervical exam B. Transvaginal ultrasound C. Contraction stress test D. Nonstress test

Choice B is correct. A transvaginal ultrasound is a gold standard in diagnosing placenta previa. A transvaginal ultrasound is more accurate than transabdominal ultrasound in determining the location of the placenta. Please recognize that the vagal ultrasound probe can safely be inserted a few inches from the cervix to capture the placenta alteration. Any advancement of the probe into the cervix could cause bleeding. However, if done according to the recommendations, the appropriate angle between the cervix and the vaginal ultrasound probe prevents the probe from accidentally moving into the cervical canal. Choices A, C, and D are incorrect. A manual cervical examination is contraindicated in placenta previa because this may trigger bleeding. A manual cervical exam attempts to invade the cervical canal directly, whereas a transvaginal ultrasound probe is inserted away from the cervix. While placenta previa is not an absolute contraindication for a contraction stress test, it raises the risk of bleeding. A nonstress test is safe and often performed for individuals with placenta previa. However, this test does not confirm placenta previa; instead, it evaluates fetal wellbeing.

Which statement about palliative care at the end of life is most accurate? A. Palliative care at the end of life is conducted in hospice centers. B. Palliative care at the end of life can occur in all care settings. C. Narcotic pain medications can be used in palliative care, but not in curative care. D. Narcotic pain medications can be used in curative care, but not in palliative care.

Choice B is correct. Palliative care at the end of life can occur in all care settings. Palliative care is also referred to as hospice care. It is a philosophy of care that can, and is, carried out in all healthcare settings, including in the client's home. Narcotic pain medications can be used at the end of life using the palliative/hospice care philosophy as well as with curative care. Choice A is incorrect. Palliative care at the end of life can be conducted in hospice centers as well as in other settings and environments. Choice C is incorrect. Narcotic pain medications are not restricted, and they can be used in curative care. Choice D is incorrect. Narcotic pain medications are not restricted, and they can be used in palliative care.

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

Choice D is correct. A spontaneous abortion or miscarriage occurs before 20 weeks. Choices A, B, and C are incorrect.

Which of the following conditions would not be an indication for parenteral nutrition? A. Chronic, severe diarrhea B. Dumping syndrome C. Gastrointestinal obstruction D. Enterocutaneous fistula

Choice B is correct. Parenteral nutrition delivers nutrients to the body via the bloodstream rather than the GI tract and may be indicated in conditions where absorption is impaired. Dumping syndrome is not an indicator of parenteral nutrition because it is not an absorption issue. Dumping syndrome is a potential complication after surgical removal of a large part of the stomach and pyloric sphincter. The stomach has poor control over the number of gastric contents released into the small intestine, so large amounts enter, pulling fluid into the bowels. Treatment focuses on dietary modifications: small meals of dry foods with low carbohydrates, low sugar, and moderate protein and fat. Patients should also allow for rest periods following each meal. Symptoms generally resolve within several months to a year following the surgery. Choice A is incorrect. A patient with chronic, severe diarrhea or vomiting may require parenteral nutrition due to the body's inability to keep food in the GI tract long enough to absorb nutrients. Choice C is incorrect. A patient with obstruction of the GI tract would be at risk of decreased absorption and may require parenteral nutrition, depending on the severity of the blockage. Choice D is incorrect. An enterocutaneous fistula (ECF) describes an abnormal tract between the stomach or intestines and the skin. The presence of an ECF allows for the leaking of the gastrointestinal contents, preventing normal absorption of oral intake. Temporary parenteral nutrition may be needed to provide the patient with adequate nutrients and electrolytes until the fistula is corrected.

The nurse is teaching a leadership and management course and is discussing client referrals. Which of the following statements describes the purpose of referrals? A. Allows the nurse to demonstrate their leadership abilities B. Care is appropriately routed to an individual or discipline C. Ensures that care is unilateral and cost effective D. Focuses on empowering the client's decision making

Choice B is correct. The primary purpose of referrals is to ensure the completeness and appropriateness of the client's care. A registered nurse completes a referral to ensure that an appropriate individual or discipline meets the client's needs. For example, a client with a pressure ulcer or new ostomy is referred by the registered nurse to a wound/ostomy nurse for specialized treatment and counseling. Choices A, C, and D are incorrect. The referral process effectively allows the client to receive the appropriate care necessary for their condition(s). Client autonomy is essential in healthcare; however, it does not relate to the referral process. Additionally, referrals are not about the nurse exercising their leadership abilities despite this being an option afforded to the RN. While referrals may be cost effective, they are collaborative not unilateral.

While performing cardiac auscultation on a client. The nurse notes a whooshing and blowing sound over the heart valves. The nurse knows that this sound can be identified as a: A. Pericardial friction rub B. Heart murmur C. Normal lub-dub sounds D. S3

Choice B is correct. The whooshing or blowing sound sometimes heard upon cardiac auscultation is known as a heart murmur and may indicate valve incompetency. Choice A is incorrect. Pericardial friction sounds like a scratching sound caused by the conflict between the heart and the pericardium. Choice C is incorrect. Whooshing and blowing do not indicate normal lub-dub sounds. Choice D is incorrect. S3 is a third heart sound, sometimes referred to as a gallop. This gallop is not the same thing as a murmur.

What percussion sound is heard over most of the abdomen? A. Hyperresonance B. Tympany C. Resonance D. Dullness

Choice B is correct. Tympany is the percussion sound heard over hollow organs. The small intestine and colon are hollow organs; they predominate over most of the abdominal cavity. Choice A is incorrect. Hyperresonance is the sound heard by tapping on the surface of the chest. It is an exaggerated chest resonance heard in various abnormal pulmonary conditions. Choice C is incorrect. Resonance is a low-pitched, hollow sound, is usually heard over healthy lung tissue. Choice D is incorrect. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.

While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor? A. A spinal cord injury at age 12 B. An upper respiratory infection about a month ago C. Hydrocephaly as an infant D. A joint injury as a teenager

Choice B is correct. Upper respiratory infections or stomach infections correlate with the development of Guillain-Barre syndrome. Guillain-Barre syndrome is a disorder that involves the peripheral and cranial nerves causing ascending paralysis. Choice A is incorrect. Spinal cord injuries are not generally associated with Guillain-Barre syndrome. Choice C is incorrect. Hydrocephaly, as an infant, is not associated with Guillain-Barre syndrome. Hydrocephaly refers to the enlargement of the ventricles. Choice D is incorrect. Joint injuries are not associated with Guillain-Barre syndrome.

You are caring for a patient with blood clots in his lungs. He is receiving urokinase for treating pulmonary embolism. The urokinase has been infusing for the last 10 hours. As you assess the patient, you note that his blood pressure is 102/64, heart rate is 108, and his respiratory rate is 16 breaths per minute. The patient asks to use the bedpan. When he is finished, you notice that he has passed a medium-sized bloody stool. Your best intervention is to: A. Closely monitor the patient B. Stop the urokinase and call the physician C. Administer Vitamin K intramuscularly D. Slow the administration of urokinase

Choice B is correct. You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders. Choices A, C, and D are incorrect. Slowing the intravenous infusion of urokinase will not help to control the bleeding. The nurse should anticipate the administration of Amicar, which is used to treat bleeding associated with the use of fibrinolytic. Vitamin K will not do anything to reverse the fibrinolytic.

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

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

Which of the following expected outcomes is appropriate for a client with heart disease who is complaining of chest pain? A. The client will be free of neuropathic pain related to angina. B. The client will be free of hyperalgesia pain related to angina. C. The client will be free of visceral pain related to angina. D. The client will be free of somatic pain related to angina.

Choice C is correct. "The client will be free of visceral pain related to angina" is an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is an example of visceral pain. Other cases of physical pain are cramping secondary to irritable bowel syndrome and labor pain. Choice A is incorrect. "The client will be free of neuropathic pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not neuropathic pain. Choice B is incorrect. "The client will be free of hyperalgesia pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not hyperalgesia. Choice D is incorrect. "The client will be free of somatic pain related to angina" is not an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is not bodily pain.

A client has been prescribed alendronate (Fosamax) 5 mg daily for her osteoporosis. Which teaching would the nurse include to avoid side effects? A. The client should rotate injection sites during administration of medication. B. The client should monitor liver function tests frequently. C. The client should take the medication early in the morning and not lay down until breakfast. D. The client should report any vaginal bleeding.

Choice C is correct. Alendronate is a bisphosphonate that may cause a side effect of esophagitis when the tablet is not completely swallowed. The client should take the drug early in the morning, 30 minutes before eating, and should remain upright during the 30 minutes before eating. Choice A is incorrect. Alendronate is given orally, not through injections. Choice B is incorrect. Alendronate (a type of bisphosphonate) does not cause an increase in LFTs, nor cause hepatic impairment. Choice D is incorrect. Alendronate does not cause vaginal bleeding as a side effect.

The nurse is caring for a client prescribed amphotericin b. Which laboratory data is necessary for the nurse to monitor during treatment? A. Triglycerides B. Hemoglobin A1C C. Potassium D. High-density lipoprotein (HDL)

Choice C is correct. Amphotericin b is a potent antifungal that is given intravenously. Hypokalemia is a common adverse reaction associated with amphotericin b therapy. Hypokalemia associated with this medication is caused by the kidneys leaking the potassium via the collecting ducts. Potassium supplementation may be necessary during amphotericin b therapy. Choices A, B, and D are incorrect. Significant lipid levels and hemoglobin A1C alteration is not associated with amphotericin b.

The nurse is caring for a client prescribed amphotocerin B. Which lab data is necessary for the nurse to monitor during treatment? A. Triglycerides B. Hemoglobin A1C C. Potassium D. High-density lipoprotein (HDL)

Choice C is correct. Amphotericin b is a potent antifungal that is given intravenously. Hypokalemia is a common adverse reaction associated with amphotericin b therapy. Hypokalemia associated with this medication is caused by the kidneys leaking the potassium via the collecting ducts. Potassium supplementation may be necessary during amphotericin b therapy. Choices A, B, and D are incorrect. Significant lipid levels and hemoglobin A1C alteration is not associated with amphotericin b.

During a nursing change-of-shift report, an oncoming nurse was informed that the serum potassium of a client assigned to that nurse recently resulted, indicating a critically low value of 2.8 mEq/L(3.5-5 mEq/L). Based on this laboratory finding, when evaluating this client, the nurse should prioritize the assessment of which of the following when assessing this client? A. The client's ability to balance while ambulating B. Quality of the client's peripheral pulses C. Respiratory status, specifically assessing for depth of respirations D. Frequency of bowel movements

Choice C is correct. As the nurse caring for this client, the priority should focus on assessing the client's respiratory status, as hypokalemia-related respiratory changes may occur due to respiratory muscle weakness, resulting in shallow respirations. Clients experiencing hypokalemia should have their respiratory status assessed at least every two (2) hours, as respiratory insufficiency caused by shallow respirations is a significant cause of death in individuals experiencing hypokalemia. Therefore, the nurse should ensure assessing this hypokalemic client's respiratory status is prioritized. Choice A is incorrect. The client's ability to balance while ambulating is affected by numerous hypokalemia-related issues, including, but not limited to, muscle weakness and/or cognition changes. Although this presents a fall risk and should be assessed by the nurse, the client's ability to balance while ambulating is not the priority assessment in this situation. Choice B is incorrect. In hypokalemia clients, the client's peripheral pulses are usually thready and weak. Palpation is often difficult, with pulse rates ranging from very slow to rapid. While an assessment of the peripheral pulses should be included in the nursing assessment, this is not the but are not the utmost priority. Choice D is incorrect. In hypokalemia clients, intestinal changes occur as gastrointestinal smooth muscle contractions are decreased, leading to decreased peristalsis. Bowel sounds are hypoactive, with constipation and abdominal distention relatively common in these clients. Although gastrointestinal-related assessments should be included within the nursing assessment, this type of assessment is not the priority.

A 25-year-old is found unconscious with a fever and a noticeable rash. Which of the following ordered tests is essential for the nurse to obtain right away? A. Blood sugar check B. Basic Metabolic Panel (BMP) C. Blood cultures D. Arterial blood gases

Choice C is correct. Blood cultures would be ordered to investigate the source of fever and rash. Blood cultures should be obtained as quickly as possible. As soon as the blood cultures have been obtained the client will likely be placed on broad-spectrum antibiotics to start to kill the offending pathogen in the client's blood circulation. Choice A is incorrect. Abnormal blood sugar levels may result in a client who is confused or unconscious. Low blood sugar values will not cause a fever and will not cause a skin rash. Other interventions will be the priority at this time based on those additional accompanying symptoms of fever and rash. Fever and rash are indicative of an infection. Choice B is incorrect. A Basic Metabolic Panel (BMP) will likely be ordered to show this client's electrolytes, renal, and liver function- but it will not be the priority. The nurse should be most concerned about an acute infection given the client's presentation: febrile, with a noticeable rash, and found unconscious. The concern is that this client has an infection that has travelled to their bloodstream; causing sepsis. This has likely progressed to septic shock causing the client's blood vessels to vasodilate, and decreasing their blood pressure so low that perfusion to the brain is inadequate. This is an emergency. The nurse should immediately obtain blood cultures to determine the source of the client's infection. Choice D is incorrect. ABGs are not indicated to test the source of fever or rash. An ABG would be obtained to check the pH of a client's blood along with their CO2 and HCO3- levels if respiratory failure was suspected. An ABG is a lab that is often obtained to check how well a client is tolerating their ventilator settings or if a client has been on BiPAP for respiratory failure. In this patient presenting with fever and rash, the priority interventions need to be targeted towards treating the infection.

The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern? A. Infection B. Thermoregulation C. Hemorrhage D. Altered body image

Choice C is correct. Immediately postoperative clients run the risk of airway, breathing, and circulation compromise. Surgeries often result in a client losing volume and may cause intraoperative and postoperative bleeding. The nurse must be aware that an increased heart rate and low blood pressure are classic indicators of fluid volume deficit, which, if untreated, may cause the client to develop hypovolemic shock. Hypovolemic shock may be caused by hemorrhage, a significant concern immediately post-operative. Choices A, B, and D are incorrect. Infection is not an immediate postoperative concern. Infection would manifest itself three to four days postoperatively. Operating suites are quite cold, and postoperative hypothermia may occur but would not be as concerning as circulatory collapse. If a client is cold or hypothermic, the nurse should warm the client passively with warm blankets. A newly established colostomy can cause a client to have decreased self-esteem. However, this is not life-threatening. The nurse must attend to the client's physical needs first. The client meeting with an ostomate or attending outpatient therapy may assist with their coping.

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

Choice C is correct. Many actions should be taken for a client experiencing vertigo, but protecting the client's safety is essential. If a client is experiencing vertigo, this raises the risk of a fall. Interventions to prioritize include adequate lighting in the bathroom, raising the upper side rails on the bed, and providing the client with the call bell, coupled with instructing the client to use it before getting out of bed. Choices A, B, and D are incorrect. These are appropriate actions for a client experiencing vertigo; however, they do not prioritize their safety. The client experiencing vertigo is likely to fall; thus, the nurse should maintain a safe environment.

The nurse is caring for a child who reportedly got a wood chip in their right eye. The nurse should take which appropriate action? A. Rub the eye until the object dislodges B. Irrigate the affected eye with hydrogen peroxide C. Perform a visual acuity exam D. Place a cold compress on the affected eye

Choice C is correct. Most eye injuries require a visual acuity exam which assesses a client's ability to read and identify distant objects. This is a standard assessment for any eye injury. Choices A, B, and D are incorrect. Rubbing the eye with a foreign body may cause an injury to the cornea. Hydrogen peroxide should not be used in the eye as it will cause serious injury. If the eye should be irrigated, sterile saline should be used. Placing a cold compress on the eye is an intervention for an eye contusion.

The nurse is assessing a newborn that was delivered 8 hours ago. The nurse notices hyperactivity, a persistent shrill cry, and jitteriness. The nurse suspects which condition? A. Sepsis B. Hypoglycemia C. Drug dependence D. Hypothermia

Choice C is correct. Neonates born to drug-dependent mothers exhibit jitteriness, hyperactivity, and a shrill cry. These signs usually appear within 24 hours of being delivered. Choice A is incorrect. Signs of sepsis include varying unstable temperatures and tachycardia. The symptoms presented do not indicate sepsis. Choice B is incorrect. Hypoglycemia in the neonate is manifested by low body temperature, diaphoresis, muscle twitching, and respiratory distress. The signs presented in the question are not related to hypoglycemia. Choice D is incorrect. Signs of hypothermia in the neonate include cool extremities, acrocyanosis, bradycardia, poor feeding, and respiratory depression.

Which of the following anticholinergics does the nurse recognize as appropriate for a patient diagnosed with urinary bladder urgency and incontinence? A. Dicyclomine B. Ipratropium C. Oxybutynin D. Scopolamine

Choice C is correct. Oxybutynin is used to treat urinary bladder urgency and incontinence. Anticholinergics are drugs that have actions opposite those of the parasympathetic branch. Their action mimics the fight-or-flight response. Choice A is incorrect. Dicyclomine is used to treat irritable bowel syndrome. Choice B is incorrect. Ipratropium is used to treat asthma. Choice D is incorrect. Scopolamine is used to treat irritable bowel syndrome and motion sickness

The nurse is preparing to remove a central venous catheter. It would be appropriate to place the client in which position for this procedure? A. Reverse Trendelenburg B. Left lateral C. Trendelenburg D. High-Fowler's

Choice C is correct. Placing the client supine or Trendelenburg for this procedure would be appropriate. One of these two positions is acceptable to decrease the risk of air embolism. The client should not have their head elevated for this procedure.

The nurse is performing a physical assessment on an adult client. The nurse should assess for tactile fremitus by A. placing the thumbs on the client's spine at the level of the ninth ribs. B. asking the client to breathe slowly and deeply through an open mouth while auscultating lung sounds. C. asking the client to say "ninety-nine" while palpating the intercoastal spaces beginning at the lung apex. D. tapping the chest over the distal interphalangeal joint with the middle finger of the opposite hand.

Choice C is correct. Tactile (vocal) fremitus describes the vibrations that can be palpated through the chest wall during speech. To assess tactile fremitus, the nurse would place hands over the lung apices in the supraclavicular areas and palpate from one side to the other while the client repeats "ninety-nine" to compare vibrations. If vibrations are uneven, it may indicate pneumothorax, inflamed lung tissue, or fluid build-up. Choices A, B, and D are incorrect. Placing the thumbs on the client's spine at the level of the ninth ribs while the client inhales and exhales would assess for chest expansion. As the client inhales, both sides of the chest should move upward and outward together in one symmetric movement, moving your thumbs apart. On exhalation, the thumbs should come back together as they return to the midline. Asking the client to breathe slowly and deeply through an open mouth while auscultating lung sounds are the appropriate steps for auscultating lung sounds. Tapping the chest over the distal interphalangeal joint with the middle finger of the opposite hand would describe the process of percussion.

Which of the following correctly describes the physical growth pattern from infancy into early childhood? A. Growth occurs from the distal to the proximal parts of the body B. Growth occurs from the proximal to the distal parts of the body C. Growth occurs in a head-to-toe progression D. Growth initially occurs most rapidly in the extremities

Choice C is correct. The cephalocaudal principle (also known as cephalocaudal development) refers to a general pattern of growth and development followed from infancy into toddlerhood and even early childhood whereby development follows a head-to-toe progression. Choice A is incorrect. Growth occurring from the distal to proximal portions of the body is not a recognized manner or pattern of physical growth or development for any age group, including those ranging from infancy into early childhood. Choice B is incorrect. Growth occurring from the proximal to the distal portions of the body is not a recognized manner or pattern of physical growth or development for any age group, including those ranging from infancy into early childhood. Choice D is incorrect. In children ranging in age from infancy to early childhood, growth does not initially occur most rapidly in the child's extremities. The general pattern of development occurs from the head downward through the body.

The mother is concerned about a 2 cm, red rash on her two-month-old infant's back, which blanches with pressure. What teaching should the nurse discuss with the mother regarding this type of lesion? A. Treatment is non-invasive and consists of yellow light laser ablation. B. This marking is due to excessive proliferation of mature capillaries. C. This immature hemangioma requires no intervention. D. The marking is a sign of an infected hair follicle.

Choice C is correct. The description is consistent with an immature hemangioma (capillary hemangioma, superficial hemangioma). Because of their bright-red appearance, they are often referred to as "strawberry nevi." They blanch with pressure, which can help differentiate these lesions from port-wine stains. Immature hemangiomas are common, harmless tumors of blood vessels that occur within the first year of life. They do not require any treatment and typically resolve on their own by 5-7 years of age. They commonly appear on the face, scalp, chest, or back. Occasionally, some immature hemangiomas can interfere with vision or cause other symptoms based on their location. Such hemangiomas may be treated with medications or laser surgery. Choice A is incorrect. Ablation with a yellow light laser is indicated for a port-wine stain, not for an immature hemangioma. A port-wine stain is typically a large, flat, dark, and macular patch that does not blanch with pressure. Choice B is incorrect. The proliferation of immature capillaries causes immature hemangiomas which are bright red and blanchable. A mature (cavernous) hemangioma presents as a reddish-blue colored, deep, spongy mass of blood vessels. Choice D is incorrect. The description of this lesion is not consistent with an infected hair follicle (furuncle). A furuncle would present as a localized, swollen, tender area of inflammation.

The patient tells his nurse that he has no one he trusts to make healthcare decisions if he becomes incapacitated. What should the nurse suggest he prepare? A. Combination advance medical directive B. Durable power of attorney for health care C. Living will D. Proxy for health care

Choice C is correct. The living will is a document whose precise purpose is to allow individuals to record specific instructions about the type of health care they would like to receive in particular end-of-life or incapacitated states. Choice A is incorrect. The combination advance medical directive appoints a proxy (agent) whom the client trusts to make decisions. The client has stated that he has no one he believes can make decisions for him. Choice B is incorrect. A durable power of attorney for health care appoints an agent that the person trusts to make decisions in the event of incapacity. The patient has told the nurse he has no one that he can trust. Choice D is incorrect. A proxy is an agent. The client has stated he has no one that he trusts to designate.

An LPN is working in a group home for adolescents who are recovering from substance abuse. She is assigned to work with a 16-year-old girl who is trying to quit smoking marijuana. While talking with the girl, she uses motivational interviewing to help her work towards her goals. Which of the following statements by the LPN would be the best? A. "Would it be alright if we talk about your pot use now?" B. "What good things do you have going for you in your life?" C. "What changes can you make in your marijuana use this week?" D. "Who can help you quit marijuana?"

Choice C is correct. This is a direct, open-ended question that addresses the patient's substance abuse. Motivational interviewing maintains direct communication with open items, as does this question. By using motivational interviewing, the patient should be empowered and encouraged to make positive changes. The nurse will help to facilitate the patient in seeing the need to change, but the patient will make their own decision to work for that change. Choice A is incorrect. If the LPN asks her patient if it is alright to talk about her substance abuse, it allows the patient to say no. This could prevent the LPN from having a productive conversation with her patient and will not likely be an excellent motivational interviewing conversation. Choice B is incorrect. This is an off-topic question and does not directly address the patient's substance abuse. The LPN should use open-ended questions that directly address the patient's substance abuse to begin motivational interviewing. Choice D is incorrect. This is not an appropriate statement because it does not focus on the patient. Instead, it seeks to involve another person. This will not aid in helping the patient feel empowered to make their positive changes, which is what motivational interviewing seeks to do.

The ICU nurse assesses a comatose patient with a known lesion to the medulla. Which breathing pattern would the nurse expect to assess? A. Cheyne-Stokes B. Apneustic breathing C. Central neurogenic hyperventilation D. Cluster breathing

Choice D is correct. Cluster breathing is associated with lesions of the medulla or lower pons. This breathing pattern is characterized by clusters of breaths with irregular pauses in between. Choice A is incorrect. Cheyne-Stokes is associated with bilateral hemispheric disease or metabolic brain dysfunction and commonly occurs at the end of life. This breathing pattern is associated with cycles of hyperventilation and apnea. Choice B is incorrect. Apneustic breathing is associated with lesions of the mid or lower pons. This breathing pattern is characterized by a prolonged inspiratory phase or pauses alternating with expiratory pauses. Choice C is incorrect. Central neurogenic hyperventilation is associated with lesions of the brainstem between the lower midbrain and upper pons. This breathing pattern is characterized by sustained, regular, rapid, and deep breathing.

The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who A. is being treated with acute glomerulonephritis (AGN) and has periorbital edema. B. discarded their first urine sample upon starting a 24-urine collection. C. is receiving continuous bladder irrigation and reports the need to void. D. just returned from a hemodialysis session and reports dizziness.

Choice D is correct. Hypotension is a complication associated with hemodialysis. Dizziness may explain this finding, and the nurse should immediately intervene because the client risks falling. The hypotension may be caused by too much fluid removed during the dialysis. This is a safety issue, and the nurse should prioritize this client's needs. Choices A, B, and C are incorrect. AGN has a clinical feature of periorbital edema often present in the morning. This is an expected finding and does not require follow-up. During a 24-hour urine collection, it is appropriate for the first urine to be discarded, which marks the start of the 24-hour collection. During continuous bladder irrigation, a large catheter is utilized and the client reporting that they need to urinate despite having an indwelling catheter is a normal finding not requiring follow-up.

A pregnant client is brought into an emergency department by her husband. The client reports she is currently at 37 weeks gestation and began experiencing severe abdominal pain and bright red vaginal bleeding which "runs down my legs" thirty minutes prior to arrival. She currently rates her abdominal pain 10/10. Based on this information, which assessment method should the emergency room nurse refrain from performing? A. External fetal heart rate monitoring B. Abdominal palpation C. Measurement of vital signs D. Internal vaginal examination

Choice D is correct. In the presence of vaginal bleeding, an internal vaginal examination is contraindicated unless performed inside an environment prepared to perform an emergent vaginal delivery or cesarean section (i.e., such as a labor and delivery unit). Additionally, this emergency room nurse is likely not permitted under hospital or emergency department policy to perform an internal vaginal examination on a full-term pregnant woman with vaginal bleeding and severe abdominal pain. Additionally, this emergency department nurse is likely not trained to perform an internal vaginal examination on a full-term pregnant woman, as this skill is not routinely performed or practiced in an emergency department. Choice A is incorrect. External fetal heart rate monitoring should be performed to determine the current status of the fetus. Continued fetal monitoring should continue to observe for any signs and symptoms to allow for early intervention. Choice B is incorrect. Abdominal palpation should be performed, as this can provide the nurse with valuable information regarding uterine contractions and abdominal tenderness, potentially assisting in determining the cause of the vaginal bleeding. Choice C is incorrect. The nurse should assess a complete set of vital signs on the client to ascertain the current physiological functioning of the client.

The nurse is caring for a newborn immediately following birth. Which of the following actions by the nurse will prevent radiant heat loss in the newborn? A. Drying the newborns skin with a towel B. Placing the newborn on a padded, covered surface C. Using warmed, humidified oxygen D. Positioning the bassinet away from windows

Choice D is correct. Radiation is one of the mechanisms of heat loss. Radiant heat loss occurs when heat is transferred between two objects, not in direct contact. Radiant heat loss may occur if the infant is placed near windows, air conditioner vents, or drafts. Heat is transferred from a warmer to a cooler object -the infant's warmth is lost to the cooler object (e.g., windows/ cooler window glass). Radiant heat loss can occur despite the surrounding (ambient) air. Ambient will not fix this problem. The nurse must remove the source of the radiant heat loss, not adjust the air temperature. Choices A, B, and C are incorrect. Evaporative heat loss occurs when the moisture from the body's surface is lost to the environment. Drying the infant with a towel would help prevent evaporative heat loss, not radiant heat loss (choice A). Heat loss by conduction occurs when heat is transferred by direct contact from one object to the other. Placing the newborn on a padded, covered surface would prevent conductive heat loss (choice B). Convective heat loss happens when the heat is transferred from an object/ body to the surrounding air. Warmed, humidified oxygen can prevent convective heat loss (choice C).

The nurse is on her way to the hospital for her shift when she encounters a roadside traffic accident. The nurse assists in responding to the victim and notes that the victim suffered a traumatic amputation of her fingers. Which intervention should the nurse implement when dealing with traumatic amputations? A. Apply direct pressure to the site using wet gauze. B. Remove the pressure dressing when emergency personnel arrive. C. Place the amputated fingers in a container with ice. D. Wrap the fingers in a clean cloth, put it in a plastic bag, and then place the bag in ice water.

Choice D is correct. The amputated fingers should be placed in a waterproof bag and placed in ice water, not directly on ice. Keeping these parts chilled prevents decomposition. Ice should not come directly in contact with the amputated part because it can cause ice burns, and the fingers may not be able to be sewn back. Choice A is incorrect. Direct pressure should be applied to the site using dry gauze, not wet. Choice B is incorrect. The pressure dressing should not be removed since removal can cause the dislodgement of a formed clot. Instead, the dressing should be reinforced until the victim is brought to the hospital. Choice C is incorrect. The amputated fingers should be placed in a waterproof plastic bag and placed in ice water, not directly on ice. Ice should not come directly in contact with the amputated part because it can cause ice burns, and the fingers may not be able to be sewn back.

A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take? A. Document the refusal B. Notify the primary healthcare provider (PHCP) C. Review the client's most recent platelet count D. Inquire with the client about the refusal

Choice D is correct. The appropriate and initial nursing action is to inquire with the client about their rationale for refusing the medication. Assessment is the initial part of the nursing process, and discussing the refusal with the client is a step the nurse should execute. Choices A, B, and C are incorrect. Documenting the refusal should not prioritize over inquiring with the client about their reasoning for refusing the prescription. If the client still refuses after the nurse has thoroughly educated the client on the medication and its purpose. The nurse should contact the PHCP and document the refusal accordingly. Reviewing the client's platelet count is inappropriate as it is irrelevant to the refusal. This action should have been completed before obtaining the medication.

While reviewing the side effects of adjuvant analgesic medications, the nurse understands which of the following drugs is accurately paired with its most serious adverse side effect? A. Acetaminophen: Gastrointestinal tract bleeding B. Ibuprofen: Hepatic failure C. Clonidine: Renal failure D. Aspirin: Anaphylaxis

Choice D is correct. The most severe adverse effect of aspirin is an anaphylactic shock, which is life-threatening. Other side effects of aspirin include gastrointestinal ulcerations and hemolytic anemia. Choice A is incorrect. Acetaminophen is often used as adjuvant medication in treating pain. The most severe adverse effects of acetaminophen are hepatic failure, hepatotoxicity, and kidney damage. Gastrointestinal bleeding is not a side effect of acetaminophen. Choice B is incorrect. Ibuprofen is an NSAID (Non-Steroidal Anti-inflammatory Drug). NSAIDs can damage the gastrointestinal mucosa by inhibiting prostaglandins. Gastric and duodenal ulcers with bleeding are often seen with chronic NSAID use. Therefore, the most severe adverse effect of Ibuprofen is gastrointestinal tract bleeding and not hepatic failure. Choice C is incorrect. Clonidine is a centrally acting non-opioid analgesic drug. In addition to its use in treating refractory hypertension, it is also used as an adjuvant pain medication. The most serious adverse effect of clonidine is rebound hypertension which can be severe in some cases. Severe rebound hypertension can occur due to the sudden discontinuation of clonidine. When it occurs, rebound hypertension can be treated by restarting clonidine or with alpha-blockers such as phentolamine. Other less severe but common side effects of clonidine include dry mouth, sedation, constipation, and headache. Renal failure is not a usual side effect of clonidine.

While reviewing the side effects of adjuvant analgesic medications, the nurse understands which of the following drugs is accurately paired with its most serious adverse side effect? A. Acetaminophen: Gastrointestinal tract bleeding B. Ibuprofen: Hepatic failure C. Clonidine: Renal failure D. Aspirin: Anaphylaxis

Choice D is correct. The most severe adverse effect of aspirin is an anaphylactic shock, which is life-threatening. Other side effects of aspirin include gastrointestinal ulcerations and hemolytic anemia. Choice A is incorrect. Acetaminophen is often used as adjuvant medication in treating pain. The most severe adverse effects of acetaminophen are hepatic failure, hepatotoxicity, and kidney damage. Gastrointestinal bleeding is not a side effect of acetaminophen. Choice B is incorrect. Ibuprofen is an NSAID (Non-Steroidal Anti-inflammatory Drug). NSAIDs can damage the gastrointestinal mucosa by inhibiting prostaglandins. Gastric and duodenal ulcers with bleeding are often seen with chronic NSAID use. Therefore, the most severe adverse effect of Ibuprofen is gastrointestinal tract bleeding and not hepatic failure. Choice C is incorrect. Clonidine is a centrally acting non-opioid analgesic drug. In addition to its use in treating refractory hypertension, it is also used as an adjuvant pain medication. The most serious adverse effect of clonidine is rebound hypertension which can be severe in some cases. Severe rebound hypertension can occur due to the sudden discontinuation of clonidine. When it occurs, rebound hypertension can be treated by restarting clonidine or with alpha-blockers such as phentolamine. Other less severe but common side effects of clonidine include dry mouth, sedation, constipation, and headache. Renal failure is not a usual side effect of clonidine.

The nurse is caring for assigned clients. Which client should be evacuated first during a fire? A client with A. below-the-knee amputation receiving patient-controlled analgesia. B. acute respiratory distress syndrome receiving mechanical ventilation. C. advanced dementia receiving enteral feedings and intravenous fluids. D. acute glomerulonephritis with an indwelling urinary catheter.

Choice D is correct. When evacuating clients from a fire, the nurse should evacuate the client closest to the fire. Once that has been completed, the nurse should evacuate the most ambulatory client. The client with acute glomerulonephritis only has one device, and the nurse can quickly change the system to a leg bag or instruct the client to keep the bag below their bladder. Choices A, B, and C are incorrect. The client with a below-the-knee amputation will require significant resources to mobilize. Further, the client's PCA device must be secured before evacuation. The client receiving mechanical ventilation will require manual ventilation and oxygen. Thus, requiring a significant number of resources. Finally, the client with dementia receiving enteral feedings and IV fluids must have their devices clamped and locked before evacuation. This client also is unlikely to comprehend evacuation instructions effectively and should be supervised.

The nurse conducts a review course on older adults and medication elimination/excretion. It would be appropriate for the nurse to note which factor may impact drug elimination? Select all that apply. A. Diminished glomerular filtration B. Decreased enzyme functioning C. Decreased peristalsis D. Lower pH of the gastric secretions E. Increased acidity of the gastric secretions F. Low functioning nephrons

Choices A and F are correct. As people age, several physiological changes occur. Many of these changes impact the pharmacokinetics and pharmacodynamics of medications. The regular physiological changes associated with the aging process that can adversely affect the excretion and elimination of drugs in the human body are the aging population's low-functioning nephrons and diminished glomerular filtration. These changes can lead to the accumulation of medications in the body because they are not properly eliminated. Choices B, C, D, and E are incorrect. Decreased hepatic enzyme functioning slows down the metabolism of medications, but not the excretion and elimination of medications in the human body. Decreased peristalsis slows down the absorption of medications, but not the excretion and elimination of drugs in the human body. Increased pH of the gastric secretions, rather than lower pH, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body. Increased alkalinity, not acidity, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body.

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

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

The nurse reviews the function of a prescribed beta-blocker in the cardiovascular system. It would be appropriate for the nurse to state that beta-blockers Select all that apply. A. block catecholamines from binding to the beta receptors. B. reduce myocardial oxygen demand. C. increase cardiac contractility. D. increase cardiac output. E. prevent sodium and water resorption by inhibiting aldosterone secretion.

Choices A and B are correct. Beta-blockers decrease blood pressure by causing vasodilation of the vessels. They block catecholamines from the beta receptor sites found in the heart and lungs. Beta-blockers decrease the heart's workload through vasodilation and lowering the heart rate. This relaxation of the vasculature and reduction in heart rate will reduce the myocardial oxygen demand. This is why beta blockers (low doses) may be prescribed during an acute myocardial infarction and afterward. Choices C, D, and E are incorrect. Beta-blockers decrease contractility and cardiac output. They block those beta-cell receptor sites for catecholamines such as epinephrine and norepinephrine. The catecholamines work to increase contractility, but the beta-blockers block them. As the catecholamine receptor sites are blocked, the contractility of the heart decreases. This leads to a reduction in stroke volume and, ultimately, cardiac output. Beta-blockers do not prevent sodium and water resorption by inhibiting aldosterone secretion; this is the action of an angiotension converting enzyme inhibiting drug such as enalapril.

The nurse is assessing a client with venous thromboembolism in the lower extremity. Which of the following assessment findings would be expected? Select all that apply A. Pain B. Swelling C. Paralysis D. Pulse deficit E. Dependent rubor

Choices A and B are correct. Pain and swelling of the affected extremity are classic manifestations of venous thromboembolism. Other manifestations include warmth to the affected extremity and erythema. Choices C, D, and E are incorrect. Paralysis is a late manifestation associated with compartment syndrome not found in a VTE. A pulse deficit is a medical term describing the difference between the apical and peripheral pulse rates. This is a feature of an arrhythmia, not VTE. Dependent rubor is a classic manifestation associated with peripheral arterial disease.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that airborne precautions are used for which condition? Select all that apply. A. Pulmonary tuberculosis B. Pertussis C. Rubeola D. Hepatitis A E. Rubella

Choices A and C are correct. Conditions requiring airborne precautions include pulmonary tuberculosis and rubeola. Choices B and E are incorrect. Pertussis and rubella are diseases requiring droplet precautions. Choice D is incorrect. Hepatitis A is managed with standard precautions.

The nurse is caring for a client receiving a continuous infusion of heparin for a pulmonary embolism. The nurse reviews the client's laboratory data and should take which action? See the image below. Select all that apply. - POSITIVE FOR HEPARIN INDUCED THROMBOCYTOPENIA A. Discontinue the heparin infusion B. Obtain an immediate activated partial thromboplastin time (aPTT) C. Assess the client's intravenous site for bleeding D. Prepare to administer a unit of packed red blood cells E. Notify the primary healthcare provider (PHCP)

Choices A and E are correct. Discontinuing the heparin infusion is essential because this is a life-threatening complication. Heparin-induced thrombocytopenia (HIT) is a hypercoagulable condition and promotes clotting. Continuing heparin in a client with HIT and acute pulmonary embolism may cause an extension of thrombus and even death. The physician must be notified; however, the heparin infusion must be held while awaiting the physician's orders. Choices B, C, and D are incorrect. Obtaining an immediate aPTT would be unhelpful because the issue is an autoantibody reaction with the heparin. This reaction would show in the client's platelets. Assessing the client for bleeding would be highly unlikely as thrombosis is likely to occur with this complication. Preparing a unit of packed red blood cells would not be an effective treatment as the client is not bleeding, and the immediate treatment is to cease the client's exposure to heparin.

The nurse is providing handoff report to the oncoming nurse. Which information should be included? Select all that apply. A. As needed (PRN) medications that were administered B. Normal assessment findings for the shift C. Normal laboratory results D. Scheduled medications that were administered E. Abnormal vital signs

Choices A and E are correct. Medications administered as needed should be included in the nursing handoff and abnormal vital signs. Nursing handoffs should accurately and quickly review the client's condition during the past shift. As needed, medications are administered for a change in the client's condition, and abnormal vital signs will require follow-up. Choices B, C, and D are incorrect. Normal assessment findings for the shift are not a necessary component of the nursing handoff. Reviewing all normal assessment findings would not only take too long but is not necessary information. Any changes in assessment findings, abnormal findings, and current problems should be included as they will likely require follow-up. The client's scheduled medications are not a necessary component of the nursing handoff. This information may be obtained from the medication administration record (MAR) by the oncoming nurse.

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

Choices A, B, C, D and E are correct. All of these actions are appropriate and expected in this situation. Also, the team should assess both of the mothers for any infectious process. Additionally, the nurse should educate both sets of parents that the risk of transmission of the disease is small. The mother may have concerns about exposure to hepatitis B and C; however, these infections cannot be spread from a woman to an infant through breastmilk. Probably the most critical intervention is to put processes in place to prevent mix-ups of milk from happening again. The healthcare facility should review the incident (Choice E) and take steps to prevent similar errors from occurring in the future, such as staff education, process improvements, or implementing technology to reduce medication errors.

A nurse is providing education on home safety to a group of new parents. Which of the following educational points should the nurse include? Select all that apply. A. Parents should never leave a baby unattended in the bath, even for a moment. B. Cover the electrical outlets by the time your infant is 7 months old. C. Baby's toys should be larger than the baby's mouth to prevent choking. D. Parents should always use a rear-facing car seat in the back seat of the car. E. Teach parents to always place the baby on their back for sleeping

Choices A, B, C, D, and E are correct. A is correct. Parents should never leave the baby unattended on a high surface, like a changing table or bed. Baby gates should be used to block stairways. B is correct. Parents should baby-proof the house to prevent accidents as the baby starts to crawl and explore. This includes securing furniture to the wall, covering electrical outlets, and installing locks on cabinets. C is correct. Parents should keep small objects, plastic bags, and balloons out of the baby's reach. Baby's toys should be larger than the baby's mouth to prevent choking. D is correct. Parents should always use a rear-facing car seat in the car's back seat. Ensuring the car seat is correctly installed and the baby is adequately secured is essential. E is correct. Teach safe sleep practices. Teach parents to always place the baby on their back for sleeping, not on the stomach or side, to reduce the risk of Sudden Infant Death Syndrome (SIDS). The baby should sleep in a crib or bassinet with a firm mattress and a fitted sheet, without pillows, blankets, or soft toys.

The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply. A. Fever B. Night sweats C. Osler nodes D. Cardiac murmur E. Syncope F. Weight loss

Choices A, B, C, D, and F are correct. Infective endocarditis (IE) is a serious condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other physical manifestations that may be assessed with IE include a cardiac murmur, Janeway lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of feet). Choice E is incorrect. Syncope is not a clinical feature of IE. This would be associated if the client was to have a vasovagal reaction.

A 30-year-old man comes into the clinic after being bitten by a wild skunk approximately 12 hours ago. The nurse knows that treatment for this client is likely to include: Select all that apply. A. Rabies immune globulin and vaccine B. Wound cleansing with povidone-iodine or saline solution and debridement C. Treatment with an appropriate antibiotic D. Suturing of the wound E. Debridement of wound edges F. Tetanus vaccine prophylactically

Choices A, B, C, E and F are correct. Wild skunks have a high incidence of rabies and should be considered rabid. The patient should receive rabies immune globulin and vaccine. The CDC recommends the irrigation of the wound with povidone-iodine since that solution is virucidal and may help prevent infection. In the clinical judgment of the provider, saline can be safely substituted for povidone-iodine. Debridement of the wound edges may also help to prevent disease by cutting away tissue, clots, and other material in the wound. Any bite wound should be considered potentially infected, so an appropriate antibiotic and tetanus prophylaxis will be administered. Choice D is incorrect. The primary suturing of the injury is NOT recommended in this case. The bite is older than 8 hours and from an animal that has a high infection risk. Suturing the wound will close any potential infectious agents into the injury leading to an increased risk for infection.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing type II diabetes mellitus? A. Gestational diabetes B. Metabolic syndrome C. Chronic corticosteroid use D. Gastric bypass surgery E. Obesity

Choices A, B, C, and E are correct. Type two diabetes mellitus is the most common type of diabetes worldwide. Risk factors for diabetes mellitus include gestational diabetes, metabolic syndrome, chronic corticosteroid use, and obesity. Individuals with gestational diabetes should be tested for diabetes mellitus, type II, within one year following their pregnancy. Choice D is incorrect. Gastric bypass surgery would help ameliorate the signs and symptoms of diabetes mellitus (DM). This surgery would not cause DM. This surgery has been associated with B12 deficiency anemia.

The nurse educates a client regarding prescribed albuterol via metered dose inhaler (MDI). Which of the following expected side effects would be included in client teaching? Select all that apply. A. Tachycardia B. Hypotension C. Tremors D. Dry mouth E. Hyperglycemia F. Bradycardia

Choices A, C, D, and E are correct. Albuterol is a short-acting bronchodilator indicated in treating asthma and other chronic respiratory illnesses. Side effects associated with this medication include hyperglycemia, tremors, hypokalemia, and nervousness. Albuterol can stimulate the beta-2 receptors in the salivary glands, which can cause a decrease in the production of saliva. Choices B and D are incorrect. Albuterol is a beta-2 agonist and is a central nervous stimulant. Hypotension would not be expected because the medication causes the adrenal medulla to discharge excessive catecholamines; these catecholamines cause an elevation in the blood pressure, pulse, and blood glucose. An expected side effect of albuterol is tachycardia.

The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen. Which of the following instructions should the nurse include? Select all that apply. A. Keep a pulse oximetry device readily available. B. Pad the tubing in areas that put pressure on the skin. C. Have a sign on your door indicating the presence of oxygen. D. Use the oven and not the stovetop to cook. E. You may apply petroleum jelly to your nares to prevent drying.

Choices A, B, and C are correct. A pulse oximetry device should be provided to the client, and they should be encouraged to log their oxygen saturations as directed. If the client experiences dyspnea or tachypnea, the client should be instructed to seek medical attention for a level less than 95% (unless otherwise directed). Padding the tubing around pressure ears (back of the ears) is recommended to avoid injury. A sign posted on the door should be visible to alert visitors of the oxygen and extinguish and open flames. Choices D and E are incorrect. Stovetop and oven cooking is highly discouraged as the presence of oxygen may accelerate any fire that may ignite. Rather, if cooking is to be done using heat or flames, another individual should do the cooking, and the oxygen should be greater than six feet away from the flame source. Petroleum jelly should not lubricate the nares as it may be aspirated. Water-soluble jelly is recommended.

The nurse is caring for a client with advanced cirrhosis of the liver. Which of the following medications would the nurse clarify with the primary healthcare provider (PHCP) prescribe? Select all that apply. A. Isoniazid B. Valproic Acid C. Amiodarone D. Lithium E. Thiamine

Choices A, B, and C are correct. Isoniazid, valproic acid, and amiodarone are extensively metabolized by the liver and have been implicated in causing hepatotoxicity. Thus, the nurse should clarify these medications with the PHCP if the client has an existing hepatic injury, such as advanced cirrhosis. Choices D and E are incorrect. Lithium is a salt and is not metabolized by the liver. This medication would not aggravate the client's existing liver cirrhosis and would be safe. Lithium raises the concern for nephrotoxicity. Thiamine is a water-soluble vitamin and is not implicated in worsening hepatic injury.

While ambulating a patient who has an infusion running through their peripherally inserted central catheter (PICC) in the right arm, they suddenly complain of dyspnea and chest pain. You immediately sit them down in the closest chair and assess them. Their BP is 72/38 mmHg and their heart rate is 186. What is the priority nursing action? Select all that apply. A. Clamp the catheter B. Notify the health care provider C. Lay the patient flat D. Administer oxygen

Choices A, B, and D are correct. The nurse suspects that the patient has an air embolism related to their PICC line. This is a potential complication of central venous catheters and the nurse is expected to monitor for it. Signs and symptoms include tachycardia, hypotension, chest pain, dyspnea, tachypnea, and hypoxia. Since the nurse suspects an air embolism, she should clamp the catheter immediately to prevent any further air entry. This is a medical emergency, and the health care provider should be notified promptly. Hypoxia is a symptom of an air embolism; therefore the patient should immediately begin receiving oxygen to prevent tissue ischemia and further complications. Choice C is incorrect. Laying the client supine could cause air embolism to exit the right atrium of the heart and travel to the brain or lungs, causing complications such as a stroke or pulmonary embolism (PE). The patient should be positioned on their left side with their head lower than their feet. This will trap the embolism in the right atrium of the heart and prevent further complications.

The nurse is reviewing dietary teaching with a client who has hypercalcemia. Which foods should the nurse recommend that the client avoid? Select all that apply. A. Broccoli B. 2% milk C. Whole wheat pasta D. Bananas E. Seafood

Choices A, B, and E are correct. Choices A and B. Hypercalcemia can occur in various conditions such as primary hyperparathyroidism, malignancies, milk-alkali syndrome, medications, vitamin D toxicity, and sarcoidosis. Symptomatic hypercalcemia can lead to constipation, psychosis, polyuria, and dehydration. Clients with hypercalcemia should take some dietary precautions to reduce calcium intake. Broccoli is rich in calcium and should therefore be avoided in clients with hypercalcemia. Milk is rich in calcium and should therefore be avoided in clients with hypercalcemia. Choice E. Vitamin D is one substance that, along with parathyroid hormones, regulates a person's calcium levels. Several kinds of seafood are rich in Vitamin D and should be avoided if hypercalcemia is a concern. Choices C and D are incorrect. Whole wheat pasta is not a calcium-rich food. Bananas are particularly high in potassium, not calcium. The nurse does not need to instruct the client with hypercalcemia to avoid whole wheat pasta or bananas.

he nurse is preparing to reinforce the results of a reactive nonstress test (NST). It would be correct for the nurse to interpret this finding as Select all that apply. A. two increases in the fetal heart rate of 15 beats per minute. B. two decreases in the fetal heart rate of 15 beats per minute. C. two increases in the fetal heart rate for 15 seconds. D. two decreases in the fetal heart rate for 15 seconds. E. no decelerations,

Choices A, C and E are correct. For a nonstress test to be reactive, there must be two accelerations. Acceleration is defined as an increase in fetal heart rate by 15 beats per minute for at least 15 seconds with movement (Choice A). For a nonstress test to be reactive, there must be two accelerations. Acceleration is defined as an increase in fetal heart rate by 15 beats per minute for at least 15 seconds with movement (Choice C). There should be no significant decelerations of the fetal heart rate during the monitoring period (Choice E) Choice B is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a nonreassuring sign. Slowdowns would lead to a nonreactive nonstress test. Choice D is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a nonreassuring sign. Slowdowns would lead to a nonreactive nonstress test.

During a routine prenatal visit in the second trimester, the nurse informs the client about the quad screen test. The nurse explains that this test evaluates the risk of carrying a baby with certain genetic abnormalities. Which of the following conditions can be detected by the quad screen test? Select all that apply. A. Down syndrome B. Tay-Sachs disease C. Spina bifida D. Cystic fibrosis E. Abdominal wall defects

Choices A, C and E are correct. The quad screen, or quadruple marker test, is done in the second trimester of pregnancy and includes measuring levels of AFP, HCG, estriol, and inhibin A. The clinician uses this test to evaluate the chance of carrying a baby with Down syndrome (Choice A) and spina bifida (Choice C). Gastroschisis or omphalocele are birth defects that affect the abdominal wall (Choice E) These conditions can also be diagnosed when an ultrasound during the first trimester is not done or is not conclusive. As DNA screening improves, that diagnostic method might be used instead of the quad screen. Choices B and D are incorrect. The screen does not test for Tay-Sachs disease or cystic fibrosis.

A newly admitted client is in septic shock. This client has a high risk for injury related to a known clotting disorder. Which of the following are appropriate interventions that should be added to the nursing care plan for this client? Select all that apply. A. Administer packed RBCs, if ordered. B. Place a piece of gauze over a venipuncture site and dress with paper tape C. Obtain an order for a stool softener. D. Encourage the client to rinse his mouth with mouthwash and use an oral sponge to brush the teeth. E. Implement measures to prevent falls and injury

Choices A, C, D, and E are correct. Sepsis claims more than 200,000 lives annually in the United States. Clients often present with fever, shaking chills, and rapid heartbeat. Severely ill clients may also have drowsiness, rapid breathing, sweating, decreased urine output, and low blood pressure. Packed red blood cell (pRBC) transfusion has been incorporated into the recommended treatment bundle of sepsis since 2004. Packed red blood cells are used to treat illness and anemia as well as to improve oxygen delivery to tissues. Packed red blood cell transfusion may be indicated in the following circumstances: In clients with evidence of hemorrhagic shock or proof of acute illness and hemodynamic instability or inadequate oxygen delivery. Since the client in this question also has a clotting disorder, interventions to prevent bleeding are observed. These measures include avoiding constipation by offering stool softeners and preventing the use of sharp or hard objects to provide care. For example, a mouth sponge may be used for oral care, rather than a regular toothbrush. The bristles of the toothbrush may cause too much damage to the clients gingival tissue and cause further bleeding issues. Clients with septic shock are at high risk for falls and injury due to weakness and confusion (Choice E. The nursing care plan should include measures to prevent falls such as bed rails, non-slip footwear, and close monitoring by the nursing staff. Choice B is incorrect. Firm, direct pressure should be applied to venipuncture sites for 30 minutes before the final dressing because of the clotting abnormality. Simply placing a piece of gauze over the venipuncture site will not ensure hemostasis. This client is at high risk for bleeding due to their history of a clotting disorder in addition to the concern of developing DIC while septic.

The nurse is caring for a client with atrial fibrillation who takes prescribed warfarin. Which alternative therapies should the nurse advise this patient to avoid? Select all that apply. A. Ginger root B. Aloe vera C. Garlic D. Ginko biloba E. Saw palmetto

Choices A, C, D, and E are correct. The client taking prescribed warfarin should avoid alternative therapies that may potentiate the anticoagulant effects and increase bleeding risk. Alternative therapies such as Ginkgo Biloba, ginger root, garlic, and saw palmetto increase the bleeding risk in a client taking warfarin. The client should be advised against taking these medications. Choice B is incorrect. Aloe vera is used in alternative/complementary medicine purported to relieve constipation. Aloe may cause electrolyte imbalances and decreased blood glucose levels but is not known to increase bleeding risk.

The nurse is teaching parents of a child diagnosed with varicella. Which of the following information should the nurse include? Select all that apply. A. Your child may return to school once the lesions have crusted. B. Your child should take the entire course of antibiotics. C. Acetaminophen may be used for fever. D. Baths with baking soda may help with the itching. E. Do not use any aspirin or ibuprofen during the illness.

Choices A, C, D, and E are correct. Varicella is a highly contagious virus that may be spread by aerosolized droplets, contact with lesions, and contaminated surfaces. A child may return to school once all the lesions have crusted over. Fever is a common manifestation associated with varicella, and acetaminophen may be taken as prescribed to decrease the fever. Symptomatic care for a child with varicella includes cool baths with products such as baking soda or uncooked oatmeal added to relieve itching. Calamine lotion may also be applied to soothe the skin. Ibuprofen and aspirin should not be taken during the course of the illness because they may cause life-threatening skin infections. Choice B is incorrect. Varicella is a viral infection; antibiotics would be unnecessary in treating this infection.

The pediatric nurse knows that which of the following are true regarding aortic regurgitation in a pediatric client with complex congenital heart disease? Select all that apply. A. Aortic regurgitation increases preload in the left ventricle. B. Aortic regurgitation leads to a systolic murmur. C. Aortic regurgitation causes decreased cardiac output. D. Aortic regurgitation increases left ventricle end diastolic pressure. E. Aortic regurgitation leads to systemic edema

Choices A, C, and D are correct. With aortic regurgitation, during diastole, there is a backward flow of blood from the aorta into the left ventricle. The blood should be moving forward into the systemic circulation, but when the heart relaxes, there is a small amount of 'regurgitation,' and the blood trickles back to where it came from. With this increased amount of blood flowing back into the left ventricle, there is increased preload in the left ventricle (A is correct), a decrease in cardiac output (C is correct), and an increased left ventricular end-diastolic pressure (D is correct). Choice B is incorrect. Aortic regurgitation does not cause a systolic murmur but rather a diastolic murmur. The blood backflows across the aortic valve when the heart relaxes during diastole, causing a diastolic murmur. Choice E is incorrect. Aortic regurgitation would more likely lead to blood backing up in the pulmonary system, rather than the systemic system. This would be more likely with tricuspid regurgitation and right-sided heart failure.

The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply. A. Lymphadenopathy B. Vaginal discharge C. Paresthesia D. Dysmenorrhea E. Malaise

Choices A, C, and E are correct. The initial outbreak of herpes simplex is often the worst (as it pertains to symptoms). Clients typically experience prodromal symptoms such as headaches, a low-grade fever, malaise, paresthesia, and itching at the site of the outbreak. Then the client will experience the eruption of the painful vesicles. Choices B and D are incorrect. Vaginal discharge suggests another infection and is not associated with herpes simplex infections. HSV does not impact the regularity of the client's menstrual cycle.

The nurse is assessing assigned clients. Which client has a risk for urinary retention? Select all that apply. A. A 78-year-old man diagnosed with an enlarged prostate. B. An 83-year-old woman on bed rest. C. A 75-year-old woman with vaginal prolapse. D. An 89-year-old man with dementia. E. A 73-year-old woman on antihistamines to treat allergies. F. A 90-year-old man with difficulty walking to the restroom.

Choices A, C, and E are correct. Urinary retention occurs when urine is produced normally but is not entirely emptied from the bladder. Retention can occur because of mechanical obstruction of the bladder outlet (enlarged prostate in a man or vaginal prolapse in a woman). Antihistaminic medications (such as diphenhydramine) tend to have anticholinergic side effects. Urinary retention can occur from the use of drugs with anticholinergic side effects. The bladder muscle's (detrusor smooth muscle) primary function is to "contract" and fully empty the bladder. Detrusor smooth muscle has muscarinic (cholinergic) receptors that facilitate this contraction. Anticholinergic agents impair this function and predispose to urinary retention. Excessive urinary retention eventually results in "overflow" incontinence. Choices B, D, and F are incorrect. All these answer options (immobility, dementia, walking difficulty) may place the clients at risk for urinary incontinence, not urinary retention.

The nurse cares for a client with major depressive disorder (MDD). Which of the following would indicate that the client is achieving the treatment goals? Select all that apply. A. Reporting a decreased appetite. B. Engaging in daily exercise. C. Increasing social ties. D. Drinking alcohol with friends. E. Not attending therapy sessions.

Choices B and C are correct. A client engaging in daily exercise and increasing their social ties are significant strides in meeting the treatment goals. A client engaging in exercise decrease their neurological inflammation and exposes themselves to light, which is quite helpful in treating MDD. Loneliness is a significant risk factor for depression and by a client increasing their social ties, they are engaging with others and strengthening their ability for self-expression. Choices A, D, and E are incorrect. Changes in appetite (less or more) are symptoms consistent with MDD. Thus, this would not indicate a client meeting the treatment goals. Drinking alcohol is a maladaptive coping mechanism regardless of other individuals. Alcohol causes disinhibition and may lead to a client harming themselves. Therapy is a highly effective adjunct in the treatment of MDD. Thus, a client must attend prescribed sessions as part of the treatment plan.

The nurse is teaching parents about fire safety in the home. Which of the following recommendations should the nurse make? Select all that apply. A. Use smoke detectors instead of carbon monoxide detectors B. Teach your child what the smoke detector sounds like and what to do when one is heard C. Teach children how to light a candle in the event of power failure D. Practice escaping from your home at least twice a year E. Ensure that electrical wiring is under rugs, not above them F. If a house fire occurs, call emergency services before evacuating

Choices B and D are correct. Teaching children about signs of fire is key. One of the critical aspects is teaching children about what the smoke (or carbon monoxide) detector sounds like so recognition is appropriately instilled. Practice drills should be performed twice a year in the event of a fire. These practice drills will help children escape and find a predetermined area in the neighborhood where the family will meet after escaping the house from a fire. The smoke detector batteries should be replaced twice a year. Choices A, C, E, and F are incorrect. A combination of smoke and carbon monoxide detectors should be utilized in the home. One smoke detector should be installed on every level of the house and outside each sleeping area. Children should not be taught how to use matches or lighters. If a power failure occurs, flashlights should be used - not candles. Electrical wiring should not be threaded under rugs because of a fire risk. Instead, the wiring should be secured to the wall perimeter. Rescuing (and evacuating) family members is the priority when a fire occurs. Once individuals have been rescued and evacuated, emergency services should be called for assistance.

The nurse is caring for a client with a major thermal burn. Which initial laboratory abnormalities does the nurse anticipate in response to the burn? Select all that apply. A. Hemodilution B. Hyperkalemia C. Metabolic Acidosis D. Hyperglycemia E. Hemoconcentration

Choices B, C, D, and E are correct. Following a major burn, significant fluid and electrolyte changes occur from cellular damage, which causes potassium to leak into the extracellular space. Thus, life-threatening hyperkalemia may occur. Metabolic acidosis is likely because of the impairment the burn causes to the kidney's ability to recycle bicarbonate. The discharge of catecholamines causes glucose release from the liver, raising the blood glucose. Finally, the loss of fluid causes hemoconcentration, illustrated by elevated hematocrit. Choice A is incorrect. Initially, the client with a major thermal burn will have hemoconcentration from all of the fluid loss. Hemodilution may occur later in the process from the fluid shift.

The nurse is assessing a client with schizophrenia. Which of the following would be an expected finding? Select all that apply. A. Apraxia B. Anhedonia C. Avolition D. Delusions E. Bradykinesia

Choices B, C, and D are correct. Clinical features of schizophrenia include positive and negative symptoms. Anhedonia, avolition, and delusions are all associated with this psychiatric disorder. Choices A and E are incorrect. Apraxia is defined as being unable to complete a purposeful movement. This is a feature associated with several neurological conditions, such as Alzheimer's disease, but is not a feature of schizophrenia. Echopraxia is common with schizophrenia, this is a positive symptom in which the individual mimics the movements of another individual. Bradykinesia is a feature associated with Parkinson's disease, which is slow motor movements.

The nurse is caring for a client prescribed lithium. Which laboratory tests would be necessary for the nurse to monitor? Select all that apply. A. Troponin B. Creatinine C. Thyroid-stimulating hormone D. Sodium E. Potassium

Choices B, C, and D are correct. Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity). Choice A is incorrect. Troponin is a cardiac marker and not relevant to lithium therapy. Potassium levels would not influence lithium the way sodium does. Thus, sodium is the essential electrolyte to monitor.

The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a pressure ulcer. Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply. A. Applies zinc oxide to the client's perineal skin. B. Provides a donut pillow while the client is sitting in the chair. C. Maintain the head of the client's bed at 90 degrees. D. Encourages the client to consume foods rich in carbohydrates. E. Uses a pillow to float the client's heels.

Choices B, C, and D are correct. If the newly hired nurse provides a donut pillow while the client is sitting in the chair, this will require follow-up because this pillow creates pressure and damages capillary beds. Maintaining the client's position at 90 degrees would require follow-up because this contributes to the client sliding, therefore creating shearing. It is recommended that they be kept at 30 degrees (if not medically contraindicated). A diet rich in carbohydrates is unhelpful to a client at risk for a pressure ulcer. A diet dense in protein is recommended to maintain skin integrity and mitigate any edema. Choices A and E are incorrect. Applying zinc oxide to the client's skin is recommended. This product is a common ingredient in topical creams because it repels moisture. Floating the client's heels is essential as it helps with offloading pressure. This can be done using a device comprised of foam or a pillow.

The nurse is caring for a client with hyperkalemia. Which of the following treatments would the nurse recognize as appropriate options for treating this electrolyte imbalance? Select all that apply. a) Spironolactone b) Sodium polystyrene c) Regular insulin d) Hemodialysis e) Magnesium sulfate

Choices B, C, and D are correct. Sodium polystyrene is a medication that causes potassium to be excreted in the feces. This lowers the amount of potassium in circulation and is an appropriate treatment for hyperkalemia. Regular insulin is a standard and effective treatment for hyperkalemia. The standard dose is ten units given by intravenous push. Hemodialysis is an appropriate treatment for hyperkalemia. Hemodialysis can remove potassium from the blood. Choice A is incorrect. Spironolactone is a potassium-sparing diuretic. Therefore it increases the potassium that is reabsorbed and put back in circulation. This would increase serum potassium. Magnesium sulfate would have no relevance to treating either hypo or hyperkalemia. However, during a potassium disturbance, it is common for clinicians to assess the magnesium level to determine if that level is altered.

The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply. A. Presbyopia B. Tinnitus C. Vertigo D. Dyskinesia E. Hearing loss

Choices B, C, and E are correct. The cardinal features of Meniere's disease include sensorineural hearing loss, vertigo, and tinnitus. These features relapse and remit and can be debilitating. Choices A and D are incorrect. Presbyopia is age-related farsightedness that is not a feature of Meniere's disease. Dyskinesia is difficult motor movements which is not a finding with this condition.

Which of the following are expected changes during different trimesters of a healthy pregnancy? A 25-year-old female client who is 10 weeks gestation reports mild fatigue. As a nurse, you reassure her that this is normal, but you also want to educate her about the regular changes that occur during pregnancy. Select all that apply. A. Thyroid gland decreases in size B. Maternal blood volume increases C. Intestinal mobility increases D. Diastolic blood pressure decreases E. Digestive changes

Choices B, D, and E are correct. To provide adequate nutrition and gas exchange for the developing fetus, a woman's body undergoes several changes during pregnancy, including cardiovascular, hematologic, metabolic, renal, and respiratory changes. In a healthy pregnancy, maternal blood volume may increase by as much as 40 to 50% by week 32 of the pregnancy. Despite this increase in red blood cell production, the mother may develop dilutional physiological anemia. Mild to moderate fatigue may be experienced. During the second trimester, the nurse might note a decrease in diastolic blood pressure. Cardiac output may decrease as the mother changes positions. Hormonal changes during pregnancy can slow down digestion (Choice E), which can cause constipation, heartburn, or other digestive issues. Choice A and C are incorrect. The thyroid and pituitary glands typically increase in size during pregnancy, not decrease (Choice A) . Reflecting the increased metabolic needs during pregnancy, TSH (thyroid-stimulating hormone) increases, and therefore, thyroid volume increases. Intestinal mobility decreases (Choice C) as progesterone levels increase to allow for increased absorption of nutrients. The nurse should be aware that this change may also increase the risk of constipation.

The nurse assists a client with diverticulosis select appropriate foods on a menu. Which food choice, if made by the client, would require further teaching? Select all that apply. A. Bran cereal B. Fresh peaches C. White toast D. Scrambled eggs E. Cabbage soup

Choices C and D are correct. Diverticulosis requires the client to adhere to a high-fiber diet. White toast and eggs are low in fiber and would require follow-up by the nurse. Wheat bread would be a better choice. Choices A, B, and E are incorrect. These food items are rich in fiber and do not require follow-up. Bran cereal, fresh fruit, and cabbage are appropriate choices.

The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions? Select all that apply. A. Rubeola B. Psoriasis C. Pediculosis D. Rubella E. Scabies F. Clostridium difficle

Choices C, E, and F are correct. Conditions requiring contact precautions include RSV, pediculosis, Clostridium difficle, and scabies. Pediculosis refers to infestation with head lice. Clostridium difficle is a spore-forming bacteria that causes diarrhea. Rubeola (measles) is primarily spread by aerosolized droplets. Rubeola is extremely contagious and may be spread four days before the rash appears. Choices A, B, and D are incorrect. Rubella (German measles) is isolated using droplet precautions. Psoriasis is an autoimmune condition that does not require isolation.

The nurse is reviewing their client's laboratory findings and notes that one of her client's serum calcium level was 7.2 mg/dL. They know that of each of the following clients, which ones are most likely to have this result? Select all that apply! A. Client w/ breast cancer & bone metastases B. Client w/ obesity C. Client w/ Vit D toxicity D. Client w/ hypoparathyroidism E. Client w/ chronic renal failure

D & E