NCLEX

The nurse is educating a client scheduled for pulmonary function tests. It would indicate effective teaching if the client makes which statement? A. "I should not use my bronchodilator four to six hours before these tests." B. "I should not eat or drink six to eight hours prior to these tests." C. "I will need someone to drive me home after I wake up from the anesthesia." D. "My gag reflex will have to return before I resume eating and drinking."

A. "I should not use my bronchodilator four to six hours before these tests." Choice A is correct. Bronchodilator medications are withheld four to six hours prior to the testing. The purpose of holding this medication is to prevent skewing of the results. Choices B, C, and D are incorrect. These statements are incorrect and require follow-up. PFTs do not require a client to be NPO and are non-invasive, so anesthesia is not utilized. PFTs may be performed at the bedside. Pulmonary function tests (PFTs) do not require any sedation or invasive machinery and may be done at the bedside. The purpose is to assess lung function and breathing problems. These tests measure lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and ventilation distribution. The results are interpreted by comparing the patient's data with expected findings for age, gender, race, height, weight, and smoking status. Before the testing, the client is instructed to withhold any bronchodilators four to six hours prior, abstain from smoking, and refrain from wearing tight or restrictive clothing.

The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to: A. Prevent client injuries B. Comply with regulations C. Determine the cause D. Correct mistakes

A. Prevent client injuries Choice A is correct. The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to prevent client injuries. Choice B is incorrect. Although regulations mandate the reporting of incidents, accidents, medical errors, and sentinel events, compliance is not the primary and ultimate purpose. Choice C is incorrect. Though determining the cause of incidents, accidents, medical errors, and sentinel events is an outcome of this reporting, this is not the primary and ultimate purpose. Choice D is incorrect. While correcting mistakes and faulty processes are outcomes of this reporting, this is not the primary and ultimate purpose.

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.

A. mechanical ventilation and the low-pressure alarm sounds. 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.

Fear and anxiety are quite similar. However, there are differences. Select the statements below that are accurate in terms of differentiating fear from anxiety. Select all that apply. Fear is related to the present danger, whereas anxiety is related to future danger. Anxiety is secondary to a psychological stressor, whereas fear is secondary to a physical or psychological stressor. Fear is secondary to an identifiable source, whereas anxiety is secondary to an unidentifiable source. Anxiety is diffuse and vague, whereas fear is more specific and definable.

Anxiety is secondary to a psychological stressor, whereas fear is secondary to a physical or psychological stressor. Fear is secondary to an identifiable source, whereas anxiety is secondary to an unidentifiable source. Anxiety is diffuse and vague, whereas fear is more specific and definable. Choices B, C, and D are correct. Anxiety is secondary to a psychological stressor, whereas fear is secondary to either a physical or psychological stressor (Choice B). Anxiety is secondary to an unidentifiable source, whereas fear is secondary to an identifiable source (Choice C). Anxiety is diffuse and vague, whereas fear is more specific and definable (Choice D). Choice A is incorrect. Fear can be related to past, present, or future threats or stressors.

A registered nurse (RN) and a licensed practical nurse (LPN) work together in a psychiatric ward. Which of the following clients may the RN assign to the LPN? A. A client taking amitriptyline who is currently grinding their jaw and grimacing B. A client with dementia who is currently confused and disoriented C. A client with bipolar disorder with a lithium level of 2.0 mEq/L D. A client with a history of chronic alcoholism currently experiencing delirium tremens

B. A client with dementia who is currently confused and disoriented Choice B is correct. Confusion and disorientation in a dementia client are common findings. Dementia is a slow, progressive deterioration of mental functioning that impairs the client's cognition (i.e., memory, thinking, judgment, ability to learn, etc.). Symptoms of dementia often include memory loss, difficulty expressing language and performing activities, personality changes, general disorientation, confusion, and disruptive or inappropriate behavior. In the absence of any new or acute changes in the mental status of this specific client, the licensed practical nurse (LPN) is fully qualified to care for this client and is, therefore, the appropriate client for the registered nurse (RN) to designate to the LPN for care. Choice A is incorrect. Based on this client's symptoms, this client is not an appropriate client for the registered nurse (RN) to assign to the licensed practical nurse (LPN). Amitriptyline, a tricyclic antidepressant, has been associated with various movement disorders, including dystonia and dyskinesias. Based on the exhibited symptoms, the RN should be concerned that the client may be experiencing a dystonic reaction (potentially from the client's medication) which would require immediate intervention(s). Although this client likely requires transfer to a higher level of care to receive the appropriate medical care, at this time, this client should be cared for by a qualified registered nurse with psychiatric experience. Choice C is incorrect. Lithium, a mood stabilizer, is used primarily to treat bipolar disorder. A therapeutic lithium level ranges between 0.6 to 1.2 mEq/L, with levels of 1.5 mEq/L or greater considered toxic. This client's lithium level of 2.0 mEq/L indicates the client is experiencing severe lithium toxicity, therefore necessitating the client receive care over and beyond that which a licensed practical nurse (LPN) can provide. Based on this client's lab result, following an immediate discussion with the client's health care provider (HCP), the RN should initiate steps to transfer the client to a higher level of care to receive the appropriate medical care. Choice D is incorrect. Delirium tremens (DTs) is a form of severe alcohol withdrawal typically accompanied by profound confusion, autonomic hyperactivity, and/or cardiovascular collapse. When caring for a client with DTs, initial minor withdrawal symptoms are often characterized by anxiety, insomnia, palpitations, headache, and/or gastrointestinal symptoms, usually occurring as early as six hours after the client's last alcohol intake. As the hours and days progress, DTs are often associated with a number of complications, including hallucinations, respiratory depression, seizures, arrhythmias, and/or aspiration pneumonitis. Based on the unpredictable and unstable outcomes demonstrated by clients experiencing DTs, this client requires a level of care above which the licensed practical nurse (LPN) is capable of providing and is therefore inappropriate for the registered nurse (RN) to assign to the LPN. Additionally, the RN should immediately assess this client, speak with the client's health care provider (HCP) and arrange for the client to be transferred to a higher level of care to receive the appropriate medical care.

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

B. Care is appropriately routed to an individual or discipline 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.

The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding? Correct A. Ketonuria B. Hematuria C. Polyuria D. Glycosuria

B. Hematuria Choice B is correct. Clinical features of acute glomerulonephritis (AGN) include proteinuria, hematuria, periorbital edema, weight gain, high blood pressure, and decreased glomerular filtration rate (GFR). Choices A, C, and D are incorrect. Individuals with glomerulonephritis would have oliguria and not polyuria. This is explained because of the massive inflammation occurring in the glomerulus. Glycosuria and ketonuria are not features of this disease; instead, these may be expected in a client with uncontrolled blood glucose.

The nurse is performing a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are Correct A. Heberden's nodes B. Janeway lesions C. Tophi D. Bouchard's nodes

B. Janeway lesions Choice B is correct. Janeway lesions are common with infective endocarditis (IE). The cause of these findings are the cause of the lesions are septic microemboli from the valvular lesion. These macules are not painful and are typically located on the palms, soles, and plantar surfaces of the toes. Choices A, C, and D are incorrect. Heberden's and Bouchard's nodes are associated with arthritis. Heberden nodes are bony nodules at the distal interphalangeal [DIP] joints. Bouchard's nodes are bony nodules at the proximal interphalangeal [PIP] joints. Tophi are dermal and subcutaneous deposits of urate crystals associated with gout.

The nurse is educating a client about their newly prescribed soft diet. It would be appropriate for the nurse to suggest which food item? A. Chunky peanut butter B. Raw carrot sticks C. Applesauce D. Beef jerky

C. Applesauce Choice C is correct. A soft diet is commonly used for individuals with problems with swallowing, chewing, or trauma to the jaw. Applesauce has a smooth texture acceptable for a client prescribed a soft diet. Choices A, B, and D are incorrect. Nuts, seeds, raw vegetables, and fruits should be avoided in a soft diet. These food items do not qualify as soft foods.

The nurse reviews clinical data for a client 24 hours postpartum following a vaginal delivery. Which of the following findings would require follow-up by the nurse? A. White blood cell count 14,000 mm3 B. BUN 18 mg/dL C. Capillary blood glucose 258 mg/dL D. Urinary output 60 mL/hr

C. Capillary blood glucose 258 mg/dL Choice C is correct. This blood glucose is greater than 250 mg/dL and is clinical hyperglycemia. Regardless if the client has a history of diabetes mellitus, this CBG requires follow-up because it is the only abnormal clinical data. Choices A, B, and D are incorrect. Leukocytosis is a common and benign postpartum finding. The white blood cell count may be as high as 30,000/mm3 during labor and usually returns to normal limits by six days postpartum. A BUN of 18 mg/dL is within normal limits (10-20 mg/dL is normal). Urinary output of 60 mL/hr is fine as postpartum diuresis commonly occurs. A urinary output of up to 3000 mL/day may occur, especially on days 2 through 5 postpartum. While this client does have hyperglycemia, this finding would be expected in the absence of hyperglycemia.

The patient presents to the emergency department with back pain and numbness in the extremities after experiencing a fall. The nurse assesses muscle flaccidity and hypotension. What is the nurse's highest priority regarding this patient? A. Assess for external bleeding B. Prepare the patient for intubation C. Stabilize the cervical spine D. Insert an 18g IV for fluid replacement

C. Stabilize the cervical spine Choice C is correct. The highest priority action would be to stabilize the patient's cervical spine to prevent further damage and to preserve airway patency. Choice A is incorrect. The nurse should assess the patient for bleeding and other injuries due to the trauma, but it would not be the highest priority/first action. Choice B is incorrect. The patient may require intubation if the airway is not patent. Still, the nurse would first need to stabilize the spine and assess the airway before knowing whether intubation is appropriate. Choice D is incorrect. Inserting a large-gauge IV catheter would be an appropriate action for this patient, but not the highest priority. Fluid replacement would not be a more immediate need than the airway.

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.

C. asking the client to say "ninety-nine" while palpating the intercoastal spaces beginning at the lung apex. 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.

The nurse is performing a breast exam on her 65-year-old patient. Which quadrant location would be most likely to find a malignant lump? A. I (UPPER OUTER) B. II (UPPER INNER) C. III (LOWER OUTER) D. IV (LOWER INNER)

Choice B is correct. Quadrant (II) is the outer, upper quadrant of the breast, where malignant masses are most often found. The breast tissue is thicker in the exterior, upper quadrant and will sometimes extend into the tissue surrounding the armpits. The nurse should pay close attention to palpation of this region of the breast. About 50% of breast cancer is detected in the upper outer quadrant (UOQ). UPPER QUAD NEAR THE ARMPIT!!

The nurse is working in the emergency department caring for a client with diabetic ketoacidosis (DKA). Which of the following arterial blood gas (ABG) results would be expected? A. pH = 7.50; PaO2 = 90 mm Hg; PaCO2 = 37 mm Hg; HCO3- = 31 mEq/L B. pH = 7.31; PaO2 = 90 mm Hg; PaCO2 = 56 mm Hg; HCO3- = 23 mEq/L C. pH = 7.51; PaO2 = 94 mm Hg; PaCO2 = 31 mm Hg; HCO3- = 24 mEq/L D. pH = 7.31; PaO2 = 90 mm Hg; PaCO2 = 37 mm Hg; HCO3- = 15 mEq/L

D. pH = 7.31; PaO2 = 90 mm Hg; PaCO2 = 37 mm Hg; HCO3- = 15 mEq/L Choice D is correct. The ABG depicts metabolic acidosis, which is an expected finding with DKA. Metabolic acidosis develops with DKA because fats are used as fuel because of the absence of insulin. This causes ketones to be produced, creating a state of acidosis. Choices A, B, and C are incorrect. These ABGs do not depict metabolic acidosis, a consistent finding with DKA. Choice A depicts metabolic alkalosis, choice B depicts respiratory acidosis, and choice c depicts respiratory alkalosis.

The nurse is caring for a client prescribed amphotericin b for a systemic fungal infection. The nurse should anticipate a prescription for which medication before the infusion? Select all that apply. Diphenhydramine Acetaminophen 0.9% saline bolus Regular insulin Sodium bicarbonate

Diphenhydramine Acetaminophen 0.9% saline bolus Choices A, B, and C are correct. Amphotericin B is a potent antifungal medication. This medication is commonly prescribed for cryptococcal meningitis or histoplasmosis. The infusion can make the client feel quite ill, and preventative treatments such as acetaminophen, 0.9% saline bolus, and diphenhydramine are often used. Symptoms the client experiences during the infusion include nausea, rigors, fever, and chills. Thus, premedication is necessary. Amphotericin B is nephrotoxic, and the client should increase their fluid intake. Choices D and E are incorrect. Amphotericin does not raise blood glucose, and regular insulin is not indicated. Sodium bicarbonate is not necessary during therapy.

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

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

Diagnosis- varicella The primary healthcare provider diagnoses the client with varicella. The nurse understands that this virus is primarily spread through aerosolized droplets contaminated water surfaces of objects To primarily prevent the transmission of varicella, the nurse should advocate for immunization a prescription for valacyclovir screening those in the household

aerosolized droplets immunization High concentrations of the varicella-zoster virus are found in the nasopharynx. The virus is primarily transmitted through aerosolized droplets. Varicella is not spread through contaminated water, nor are surfaces of objects an effective vector for transmission. Primary prevention stems from education and immunization. To advocate for the primary prevention of varicella, the nurse should encourage immunization. Screening is a secondary prevention measure. Valacyclovir is an antiviral that is used once varicella has been diagnosed. Treatment aimed at preventing complications is a tertiary level of prevention.

The nurse provides discharge education ➢ Click to specify the information the nurse should include in the discharge teaching? Select all that apply Your child may return to school once all the lesions have crusted. Warm baths with baking soda or oats may help with the itching. Contact the school to report your child's infection. Watch for signs of skin infection including swelling, drainage, and pain. To treat the fever, you may alternate between acetaminophen and aspirin.

Warm baths with baking soda or oats may help with the itching. Contact the school to report your child's infection. Watch for signs of skin infection including swelling, drainage, and pain.

The nurse determines that if the client's itching is not controlled, which complication may develop? Cellulitis Pneumonia Encephalitis Desquamation

cellulitis The most common complication of varicella infections is secondary bacterial skin infections such as cellulitis. This is caused when bacteria enter from a break in the skin. Pneumonia and encephalitis are common complications of varicella, but they are not triggered by incessant itching. These complications are common for immunocompromised individuals and arise from the migration of the virus. Desquamation is the peeling of the skin. This is a normal process that occurs once the lesion has crusted over. This is not a complication, yet, an expected finding towards the end of the infection.

The nurse understands that the acetaminophen is prescribed to treat the client's pruritus pyrexia skin lesions Additionally, the diphenhydramine has been prescribed to decreased symptoms of pruritus decrease the pyrexia prevent viral replication

pryrexia decreased symptoms of pruritus Pyrexia is a common feature of varicella infections. The pyrexia (fever) can be mitigated with acetaminophen. Diphenhydramine is an antihistamine and can be used to mitigate symptoms of pruritus. This medication is intended to decrease the symptoms of pruritus (itching) and promote comfort.

The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 8:30 AM to compare them with the current vital signs at 10:30 AM. What action should the nurse take? See the image below. A. Assess the surgical wound B. Collect blood cultures C. Administer oxygen at 2 L/minute D. Encourage by-mouth (PO) fluids

A. Assess the surgical wound Choice A is correct. The client's 10:30 AM vital signs show signs of shock. Considering this client is in the immediate postoperative period, the nurse should assess the surgical wound for signs of hemorrhage. The nurse should reinforce the dressing if this is the source of the bleeding. The nurse should notify the primary healthcare physician (PHCP) of the client's change in condition. Choices B, C, and D are incorrect. Collecting blood cultures is unnecessary as the likely hood of this being a surgical site infection or sepsis is low. This is because the client is immediately postoperative, and infections typically begin in the extended postoperative period. Oxygen administration is not indicated, as oxygen saturation of 95% is optimal. The nurse should not encourage by-mouth fluids - rather, obtain a prescription for intravenous fluids.

The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)? A. Muscle rigidity of the neck B. Hyperactive bowel sounds C. Frequent diarrhea D. Abdominal distention

A. Muscle rigidity of the neck Choice A is correct. Metoclopramide is a dopamine antagonist in treating gastroparesis, nausea, and vomiting. Dopamine antagonists may induce dystonia which is depicted in this option. This finding is highly concerning. Choices B, C, and D are incorrect. Metoclopramide increases gastric motility and may therapeutically treat gastroparesis. Hyperactive bowel sounds and frequent diarrhea may occur because of increased gastric motility. However, these findings are not concerning because they are expected with this medication. Abdominal distention is a characteristic of gastroparesis and would not be reported to the PHCP. Gastroparesis is a finding associated with various conditions, including diabetes mellitus. This disorder causes the client to have abdominal fullness, nausea, vomiting, and weight loss. Treatment is aimed at increasing gastrointestinal motility by using agents such as metoclopramide or erythromycin. Dystonic reactions adversely occurring with metoclopramide may be treated with diphenhydramine or benztropine.

The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take? A. Notify the rapid response team (RRT). B. Obtain a prescription for a chest radiograph. C. Increase nasal cannula oxygen to seven liters a minute. D. Auscultate the lung fields for adventitious sounds.

A. Notify the rapid response team (RRT). Choice A is correct. This client demonstrates signs of acute respiratory distress syndrome (ARDS), a complication of pneumonia (hypoxemia). The client's inability to oxygen is highly concerning and is a classic manifestation of ARDS. An RRT should be immediately called to assist with appropriate interventions, including intubation by a qualified provider. Choices B, C, and D are incorrect. Assessment is not the priority because the provided information on the ABG and the SpO2 is worrisome and requires immediate intervention. A chest radiograph may be obtained to determine the presence of ARDS; however, this is not an initial intervention nor auscultating the lung fields. It would be inappropriate for the nurse to increase the nasal cannula oxygen to higher than six liters a minute because six is the maximum for this delivery device. The nurse should immediately consider applying a non-rebreather which will considerably maximize the amount of oxygen delivered to the client (it can deliver a FiO2 greater than 90%).

A patient with cholecystitis is reporting acute pain. Where should the nurse expect to find the location of this pain? Correct A. Right upper quadrant, radiating to the right shoulder B. Right upper quadrant, radiating to the left shoulder C. Right lower quadrant, radiating to the pelvic bones D. Right lower quadrant, radiating to the umbilicus

A. Right upper quadrant, radiating to the right shoulder Choice A is correct. Cholecystitis is known to be painful in the right upper quadrant and refers to the right shoulder and scapula. A referred pain is a pain that is felt away from the originating site. Visceral pain can be referred to a corresponding somatic structure and is mediated by similar segmental innervation of the originating visceral organ and the referred somatic site. Choice B is incorrect. Right upper quadrant pain never radiates to the left shoulder. A left upper quadrant pain may radiate to the left shoulder and such a referred pain may be noticed with splenic injury. Choice C is incorrect. A right lower quadrant pain radiates to the pelvic bones. A right lower quadrant pain radiating to pelvic bones may be noticed with ovarian torsion. Choice D is incorrect. A right lower quadrant pain radiating to the umbilicus may be seen with acute appendicitis, not cholecystitis.

The charge nurse reviews medical records for clients ready for discharge from the nursing unit. Which client should be recommended for disease management services? A client with A. congestive heart failure (CHF), who has been admitted three times in the past two months. B. epilepsy who had one seizure after switching prescribed antiepileptics. C. diabetes mellitus, with an increase in hemoglobin A1C from 6.7% to 6.9%. D. schizophrenia being switched from daily dosing to long-acting injectable antipsychotic.

A. congestive heart failure (CHF), who has been admitted three times in the past two months. Choice A is correct. This client requires a disease management referral because the client has been admitted multiple times to the hospital. Disease management is a coordinated set of interventions that aim to maximize the client's functionality while minimizing disease-related complications. The cost associated with hospitalizations and the risk of complications during hospitalizations make this client an ideal candidate for disease management services. Choices B, C, and D are incorrect. A client having a seizure while switching anti-epileptics is quite common. The reasoning is that when one therapeutic level declines, it takes time for the other to increase. An isolated seizure does not necessitate a disease management referral. The client with diabetes had an increase in their hemoglobin A1C. However, it is still below the desired goal of 7%. The nurse should trend the A1C and continue to advocate for more frequent blood glucose monitoring and adherence to prescribed medications. A client with schizophrenia being switched to a long-acting injectable is an excellent strategy to maximize adherence and minimize exacerbations (psychosis). These long-acting injectables are given in a single shot, and the client will return in a few weeks for another injection.

The nurse creates a plan of care for the client ➢ Click to specify if each intervention is indicated or not indicated Apply hydrogen peroxide solution to the affected area Educate the client on appropriate hand hygiene Education on baths with baking soda for itching Administration of prescribed acetaminophen Collection of blood cultures

Apply hydrogen peroxide solution to the affected area - not indicated Educate the client on appropriate hand hygiene- indicated Education on baths with baking soda for itching- indicated Administration of prescribed acetaminophen- indicated Collection of blood cultures- not indicated Interventions that are indicated include appropriate hand hygiene. Frequent hand sanitation will decrease the likelihood of cellulitis if the skin is broken by itching. Educating on comfort measures such as baths with baking soda or oats is indicated to soothe itching. Acetaminophen would be helpful if the client has a fever. Hydrogen peroxide does not hasten healing and may irritate the lesions. This would not be indicated. Varicella is a virus and would not reflect if blood cultures were obtained.

A registered nurse (RN) is working with a licensed practical nurse (LPN) in a psychiatric ward. On a busy day, the RN understands that delegating tasks to the LPN is necessary. Which job would the RN delegate to the LPN? A. Escorting a client with a serum lithium level of 2.2 mEq/L to the emergency department. B. Accompanying a bulimic client for an hour after lunch. C. Conducting art therapy for a group of clients in the day room. D. Chaperoning a client who is talking to their parent on the phone.

B. Accompanying a bulimic client for an hour after lunch. Choice B is correct. Clients with bulimia require a trained health care provider (HCP) to remain with them to prevent the client from purging in the immediate aftermath of a meal. Having the licensed practical nurse (LPN) remain with the client for one hour after lunch precludes the client from inducing vomiting. Additionally, choosing to use the LPN instead of a UAP will allow the LPN to use therapeutic communication techniques if needed with the client. Choice A is incorrect. A therapeutic lithium level ranges between 0.6-1.2 mEq/L. Lithium toxicity occurs when lithium levels reach 1.5 mEq/L or higher. Based on the client's current serum lithium level of 2.2 mEq/L, this client is likely experiencing lithium toxicity. Based on this information, the client is deemed unstable; therefore, the registered nurse must accompany this client to the emergency department, as this task cannot be delegated to a licensed practical nurse. Choice C is incorrect. A licensed practical nurse (LPN) is not trained in conducting art therapy for a group of psychiatric clients. The registered nurse with specialized psychiatric training in this area should be the individual conducting this activity. Choice D is incorrect. The licensed practical nurse (LPN) should not be tasked with listening to the client's phone conversation, as the client should be provided privacy while communicating with their parent.

The nurse is caring for a client on a medical floor. The nurse would recognize that which diagnosis increases the client's risk of developing hyperkalemia? A. Cushing's syndrome B. Acute renal failure C. Cystic fibrosis D. Bulimia nervosa

B. Acute renal failure Choice B is correct. Typically, healthy kidneys excrete 80-90% of the body's potassium. When there is injury or damage to the kidneys, such as with acute renal failure, potassium excretion is impaired. Metabolic acidosis can also occur because of the decreased ability to filter acids and reabsorb bicarbonate. Hence, as hydrogen ions enter the cells, potassium is pushed out of the cells and into the extracellular fluid. If the acute renal failure is related to trauma, the damaged cells release additional potassium into the extracellular fluid. These processes all increase the body's potassium, so the client would be at risk of developing high potassium levels (hyperkalemia). Choice A is incorrect. Cushing syndrome puts a client at risk for hypokalemia, not hyperkalemia. These clients experience decreased potassium levels due to increased urinary losses of potassium and excess cortisol production, which interferes with the sodium/potassium pump action. Choice C is incorrect. Cystic fibrosis is an endocrine disease that impacts the function of multiple organs. It puts clients at risk of low potassium levels (hypokalemia) due to renal potassium wasting, increased sweating, and metabolic acidosis. Choice D is incorrect. Bulimia nervosa is an eating disorder characterized by periods of binge eating, followed by inappropriate, extreme weight control methods. Repeated vomiting, diuretic use, and/or laxative use all deplete the body's potassium stores, so this client would be at risk for hypokalemia, not hyperkalemia.

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

B. Care is appropriately routed to an individual or discipline 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.

The nurse is caring for a child in the emergency department (ED) who sustained a bite by a rabid animal. The nurse should take which initial action? A. Assess the wound's length and width B. Cleanse the wound with soap and water C. Obtain a prescription for an antibiotic D. Report the bite to animal control

B. Cleanse the wound with soap and water Choice B is correct. Cleansing the wound inflicted by a rabid animal with soap and water is essential to prevent a rabies infection. Aggressive wound cleaning minimizes the exposure to this infection which can be fatal without the appropriate cleaning and post-exposure prophylaxis. Choices A, C, and D are incorrect. These actions are appropriate to take following an injury caused by a rabid animal; however, to minimize the likelihood of a client getting rabies, they should have aggressive wound cleansing as soon as possible.

A 32-year-old man comes into the emergency department after being hit by a baseball bat in his chest. The nurse would suspect a pneumothorax because of which sign? A. Decreased respiratory rate B. Diminished breath sounds C. Presence of a barrel chest D. A sucking sound at the injury site

B. Diminished breath sounds Choice B is correct. A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema. Choice A is incorrect. The client who has a pneumothorax would display tachypnea (an increase in respiratory rate), not a decrease in respiratory rate. Choice C is incorrect. A barrel chest would indicate emphysema, a form of COPD. Patients with pneumothorax do not exhibit a barrel chest. Choice D is incorrect. The client's injuries are from a blunt object; therefore, the resulting pneumothorax would be a closed one. A sucking sound at the site of injury would denote an open chest injury.

You are assigned to supervise a client care unit. Over the last several months, the nurses in the unit have told you that the unit dose dispensing of medications by the pharmacy has not been accurate at all times. Fortunately, there have been no medication errors as a result of these inaccuracies. Which of the following actions should be prioritized? A. Praise the staff for catching these inaccuracies B. Investigate and explore these near misses C. Investigate and explore these medical errors D. Report these inaccuracies to the State Department of Health

B. Investigate and explore these near misses Choice B is correct. As the supervising nurse on your client care unit, you should investigate and explore the near misses similar to how you deal with sentinel events. Near misses, such as these inaccuracies, should be reported per hospital policy to be studied and examined to circumvent future errors. Choice A is incorrect. Although you should praise the staff for catching these inaccuracies before a medication error occurred, this is not the priority action. Choice C is incorrect. Although unit-dose dispensing was inaccurate, it did not result in a medication error. These near misses are not actual medical errors. Near misses are also referred to as close calls and should be investigated and explored. A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. Such an adverse event could include side effects to medications/vaccines, medical procedures, or errors during the execution of care. They may or may not be from negligence. Choice D is incorrect. Since a near miss is not a medical error, it does not have to be reported to the State Department of Health.

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with sandbag B. Palpate pedal pulses C. Assess for signs of claudication D. Apply warm compress to incision sites

B. Palpate pedal pulses Choice B is correct. The most significant complications this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain. Choice A is incorrect. These symptoms are expected following this type of surgery. Manual pressure would be appropriate if the patient was actively bleeding. Choice C is incorrect. Intermittent claudication is a cramp-like pain in the leg or buttock during activity due to poor blood supply. This is a sign of arterial disease, but not of postoperative complication, and would not be a priority for this patient. Choice D is incorrect. The RN should perform a focused assessment to rule out potential complications before implementing any interventions. Applying a warm compress may be helpful for reducing the patient's pain, but will also result in vasodilation which may increase swelling.

The nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving an infusion of regular insulin. Which of the following clinical data should be reported to the primary healthcare provider (PHCP) immediately? Correct A. Glucose 297 mg/dL B. Potassium 3.2 mEq/L C. BUN 24 mg/dL D. Hemoglobin A1C 8.9%

B. Potassium 3.2 mEq/L Choice B is correct. Regular insulin can cause hypokalemia. While a client receives treatment for diabetic ketoacidosis (DKA) with regular insulin, the nurse should continually monitor potassium and glucose as the insulin will lower both. Choices A, C, and D are incorrect. Hyperglycemia is an expected finding with DKA. Thus, following up with the PHCP regarding high blood sugar is unnecessary. Dehydration is also expected with DKA, so the elevated BUN does not require follow-up. An A1C level of 8.9% is concerning yet poses no immediate risk to the client as this is a cumulative estimate of the diabetes management over the past 90-120 days. This lab value indicates poor glycemic control.

The clinic nurse is preparing to administer vaccinations intramuscularly to a 3-year-old toddler. What is the nurse's first intervention? A. Instruct the mother to immobilize the child's leg. B. Talk to the child about the procedure. C. Swab the area with alcohol. D. Inject the medication in the thigh.

B. Talk to the child about the procedure. Choice B is correct. The nurse must always explain the procedure to the child in words that he/she can understand. Choice A is incorrect. The child's leg should be immobilized, but this is not the first intervention for the nurse. Choice C is incorrect. Swabbing the area with alcohol cleanses the site, but this is not the first intervention to be done by the nurse. Choice D is incorrect. The vaccination should be injected in the thigh, but the nurse should first explain the procedure to the child.

The image below depicts which post-operative surgical complication? A. Wound Evisceration B. Wound Dehiscence C. Diabetic Ulcer D. Tertiary Healing

B. Wound Dehiscence Choice B is correct. This image shows wound dehiscence. Wound dehiscence is a partial or total separation of previously approximated wound edges due to a failure of proper wound healing, sometimes described as "splitting open of the wound." The abdominal muscle layer is intact in wound dehiscence, preventing the internal organs from protruding out. Typically, this occurs five to eight days following surgery when healing is still in the early phases. The causes of wound dehiscence correlate with the causes of poor wound healing, including ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity. Additional studies have correlated increased findings of dehiscence occurring more often in patients with diabetes, obesity, immune deficiency, malnutrition, or those who utilize steroids. Choice A is incorrect. Although somewhat similar, wound evisceration is a surgical complication that occurs when an incisional site spontaneously opens, allowing internal abdominal viscera to protrude through the opening. Unlike wound dehiscence, evisceration is the total separation of all wound layers ( including the muscle) and protrusion of internal organs through the open wound. Evisceration is a surgical emergency, and the HCP (i.e., surgeon) must be contacted immediately, as the client must be returned to the surgical suite. Therefore, Choice A is incorrect, as the image contained within this question does not depict wound evisceration. Choice C is incorrect. Although non-compliant diabetic patients have a much higher risk of delayed healing, nothing in this question or the accompanying image suggests this wound was caused by a non-compliant diabetic patient or that the wound itself is even a diabetic ulcer. While diabetes mellitus may have been a contributing factor, Choice C is incorrect. Choice D is incorrect. Tertiary healing (third intention) is delayed primary wound healing after four to six days. This occurs when the process of secondary intention is intentionally interrupted, and the wound is mechanically closed. This usually occurs after granulation tissue has formed. Based on the information provided, there is no evidence that this wound has undergone tertiary healing.

Which of the following is the nurse's priority nursing action for the infant experiencing a tetralogy of Fallot (tet) spell? A. Administer propranolol B. Administer sodium bicarbonate C. Calm the infant D. Notify the healthcare provider

C. Calm the infant Choice C is correct. Immediately calming the infant is the nursing priority during a tet spell. While the infant is crying, their pulmonary vascular resistance is increasing leading to decreased oxygenated blood and more cyanosis. By calming them down you will immediately be decreasing their pulmonary vascular resistance so that blood can flow to the lungs and provide oxygen to the body. This is the first action that the nurse should take. Choice A is incorrect. While propranolol may be used in children with tetralogy of Fallot, it will not be the priority nursing action for the infant experiencing a tet spell. It will be given much later if necessary. Choice B is incorrect. Sodium bicarbonate may be needed at some point during a tet spell if it is not resolving, but would not be indicated as soon as it starts and would not be the priority nursing action. Choice D is incorrect. While the nurse will need to notify the healthcare provider of the spell and may need additional assistance, this still isn't the priority action. There is another action listed that will immediately help the infant and should be the priority.

The nurse is caring for a client suspected of having an endocrine disorder. Based on the client's laboratory data, the client is at the highest risk for which condition? See the image below. sodium- 130 meq/l hematocrit- 33% urine specific gravity- 1.040 A. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) B. Diabetes Insipidus (DI) C. Cushing's syndrome/disease D. Adrenal insufficiency

Choice A is correct. Based on the client's laboratory data showing hyponatremia, hemodilution, and increased urine specific gravity (concentration), SIADH is highly likely. SIADH causes increased water retention thus leading to hemodilution and dilutional hyponatremia. The low urine output is also a feature (oliguria) and if urine is produced, it has a high specific gravity. The normal serum sodium is 135-145 mEq/L; The normal hematocrit is 42-52% for males and 37-47% for females; The normal USG is 1.005 - 1.030 Choices B, C, and D are incorrect. Diabetes insipidus causes polyuria that has a low specific gravity because the urine is comprised mostly of water. DI also features high sodium and hematocrit because all of the water is being excreted in the urine. Cushing's disease/syndrome causes hypernatremia because of the effect of aldosterone. This could lead to fluid retention, thereby decreasing the hematocrit. Adrenal insufficiency may cause hyponatremia, but it would not cause a decrease in hematocrit because the client is so dehydrated that hemoconcentration would occur.

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

Choice C is correct. This tracing shows atrial fibrillation. Atrial fibrillation is an irregularly irregular arrhythmia that produces an irregular pulse. This pulse irregularity is often a clinical indicator that a client requires a cardiac evaluation. Choices A, B, and D are incorrect. JVD is not a clinical feature consistent with atrial fibrillation. JVD would coincide with conditions such as right-sided heart failure or pulmonary hypertension. A systolic murmur is not a feature specific to atrial fibrillation. A widened pulse pressure is a clinical feature associated with increased intracranial pressure (late sign).

The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching? A. "Before use, I should put the sliding marker at the top of the numbered scale." B. "I should have my child sit at a 45-degree angle while performing this procedure." C. "My child should inhale as quickly as they can through the mouthpiece." D. "I should record the highest of the three readings."

D. "I should record the highest of the three readings." Choice D is correct. The child's highest reading out of three times should be recorded (not the average). It is important that between each measurement, a 30-second rest is taken by the child. Choices A, B, and C are incorrect. The peak flow meter is a great tool for the client to determine the control of their asthma. Prior to the child measuring their peak flow, the device should be reset by sliding the marker (or arrow) on the meter by placing it at the bottom of the numbered scale. The child should not be sitting for this measurement; rather, they should be standing upright to allow for maximum chest expansion. The peak flow meter measures expiratory volume, so the child should be instructed to blow as hard and quickly as possible.

The health care provider (HCP) places an order to administer gentamicin intravenously to a client with acute diverticulitis. It is important the nurse knows that intravenous gentamicin is administered: A. Over one minute via IV push B. Over two minutes via IV push C. As an IV infusion over 15-20 minutes D. As an IV infusion over 30 minutes to two hours

D. As an IV infusion over 30 minutes to two hours Choice D is correct. Gentamicin is a weight-based medication requiring the client's pretreatment body weight to calculate the correct dosage. For this reason (and to clarify the above order), it would be reasonable for the nurse to contact the health care provider (HCP) to clarify the above order prior to administration. Regarding the administration of gentamicin, the medication may be given intramuscularly or by intravenous infusion. An additional form of gentamicin is available in eyedrop form. When administering a single dose of intravenous gentamicin, the medication is diluted in 50 to 200 mL of normal saline solution or 5% dextrose in water and intravenously infused over a period of 30 minutes to two hours. Choice A is incorrect. Gentamicin is not recommended to be administered via intravenous push. Choice B is incorrect. Gentamicin is not recommended to be administered via intravenous push. Choice C is incorrect. Gentamicin is not recommended to be administered via intravenous bolus.

Minimizing and challenging the client's report of pain and pain intensity is: A. Often necessary if the client has a history of substance abuse. B. Often necessary if the client has a history of drug seeking behavior. C. Contrary to and in violation of the Nightingale oath. D. Contrary to and in violation of the American Nurses Association's standard of care.

D. Contrary to and in violation of the American Nurses Association's standard of care. Choice D is correct. Minimizing and challenging the client's report of pain/pain intensity is in violation of the American Nurses Association's standards of care about pain/pain management. Specifically, the American Nurses Association's Standards of Professional Performance for Pain Management Nursing. For example, nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be true and accurate. Choice A is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not often necessary if the client has a history of substance abuse; this expression and reporting of pain must be considered valid and accurate. Nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be accurate. Choice B is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not often necessary if the client has a history of drug-seeking behavior; this expression and reporting of pain must be considered valid and accurate. Nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be accurate. Choice C is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not in violation of the Nightingale oath. There is no mention of pain management in the Nightingale oath.

A nurse is assigned to care for a client who recently underwent a thyroidectomy. The nurse notes that the client has developed peripheral numbness and tingling, muscle twitching, and spasms. Based on this information, the nurse should anticipate administering: A. Thyroid supplements B. Barbiturates C. Antispasmodics D. Intravenous calcium gluconate

D. Intravenous calcium gluconate Choice D is correct. This client is displaying classic signs and symptoms of hypocalcemia (i.e., paresthesia and tetany). If left untreated, symptoms may progress to seizures, encephalopathy, and heart failure. More convincingly, the client's recent thyroidectomy supports a presumptive diagnosis of hypocalcemia. Although the thyroid gland in and of itself does not regulate calcium levels within the body, four parathyroid glands (responsible for releasing parathyroid hormone (PTH) to control calcium levels in your blood) are located within the thyroid. Hypoparathyroidism often results after the accidental removal of or damage to one or more parathyroid glands during thyroidectomy. The nurse should anticipate administering intravenous calcium gluconate to this client. Choice A is incorrect. Thyroid supplements are typically given post-thyroidectomy but are not directly related to this problem. Choice B is incorrect. Antispasmodics will not treat the cause of the problem. Choice C is incorrect. Barbiturates are not indicated in this situation and will not address the issue at the core of the problem.

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

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

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. Reporting a decreased appetite. Engaging in daily exercise. Increasing social ties. Drinking alcohol with friends. Not attending therapy sessions.

Engaging in daily exercise. Increasing social ties. 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. MDD is a significant medical condition that is a burden on both the individual and the healthcare system. The acronym of SIGECAPS can recall the symptomology of MDD. · S sleep disturbances · I interest decreased · G guilt or feeling of worthlessness · E energy is decreased · C concentration is impaired · A appetite disturbances · P psychomotor retardation or agitation · S suicidal ideations

The nurse is caring for a seven-year-old client brought to the clinic by her parents 7-year-old female arrives with her parents with reports of a rash on her back and chest that started two days ago. The parents state that she has been itching the area incessantly and that she reports a burning pain in the area. The parents say that her appetite has decreased, and she had a temperature of 100° F (37.8° C) the day prior. The client has no medical history or hospitalizations. Her parents state it is unknown that she has been around anyone who has been sick because she does attend school and an after-school program regularly. On exam, she has erythemic papules and vesicles on her back and torso. She states they 'burn and itch' and denies any other symptoms. Her skin is hot and appears dry. All other physical exam findings were unremarkable. The nurse reviews the history and physical and vital signs ➢ Which findings are most significant? Select all that apply Temperature Papules and vesicles Reports of burning and itching Blood pressure Location of the lesions

Temperature Papules and vesicles Location of the lesions The clinical findings that are the most significant include the client's temperature, which indicates a fever. The presence of papules and vesicles that burn and itch is a common characteristic of varicella. Additionally, the location of the lesions as varicella characteristically has a centripetal outbreak starting at the trunk and working outward. The client's blood pressure is within normal limits.