Archer Review 1a

You are working in the emergency department when a 23-year-old woman comes in after being bitten by multiple fire ants. You examine her and notice that there are many fluid-filled bites on her legs and ankles. She is complaining of numbness in her face and you notice swelling around her lips. She complains of shortness of breath and her respiratory rate is 28 breaths per minute. You hear wheezing when you auscultate her lungs. Her heart rate is 110/minute and her blood pressure is 82/40 mmHg. You have the following orders for this patient: Administer epinephrine Ensure a patent airway Administer an antihistamine Place on a cardiac monitor to analyze the heart rhythm As you work to prioritize these tasks, you know that the best sequence for doing them is:

Ensure a patent airway Administer epinephrine Administer an antihistamine Place on a cardiac monitor to analyze the heart rhythm Explanation Correct ordered sequence: The nurse should recognize that this patient is in anaphylaxis, which is a life-threatening allergic reaction to ant bites. Although all of these tasks should be done for this patient, the one with the highest priority is to ensure that the woman has a patent airway. If an advanced airway is required, the nurse should call for assistance to complete this task. In most patients, positioning the patient and providing supplemental oxygen will be sufficient. This should be followed very quickly by the administration of epinephrine IM or SC. Epinephrine is the drug of choice for anaphylaxis since it helps to increase blood pressure and inhibits the release of mediators, causing the reaction. Next, the nurse should administer an antihistamine such as diphenhydramine. This should never replace the administration of epinephrine because the onset of action of antihistamines is slower than epinephrine. Often, clinicians will administer both diphenhydramine and ranitidine since one is an H1 blocker, and the other is an H2 blocker. Finally, it is essential to connect the patient to a cardiac monitor since anaphylaxis can lead to cardiac arrhythmias. If other team members are present, this can often be accomplished simultaneously with the other tasks, but connecting the patient to a cardiac monitor is a lower priority than the other actions. NCSBN Client Need Topic: Management of Care, Sub-Topic: Establishing Priorities, Critical Care

While working in the pediatric emergency department, you receive a 2-year-old patient from EMS who has ingested an unknown amount of a household chemical. You will be the nurse caring for this patient. Place the following interventions in order from highest priority to lowest priority. Identify the specific type of poison Administer the antidote if available Assess the client Ensure no further exposure to poison

Explanation Assess the client is the first action. Poisoning is a frequent cause of admission to pediatric emergency departments. The priority of nursing action will always be to assess the client. Follow the "ABCs" (airway, breathing, and circulation) and intervene as appropriate. If the child does not have an airway, establish one. If they are not breathing, manually ventilate them. If circulation is inadequate, provide fluid boluses or vasopressors for support as prescribed by the health care provider. The next priority nursing action is to ensure there is no further exposure to the poison. Is the chemical present near their mouth? Is the poison on their skin? Ensure that it is completely removed before proceeding. Next, the nurse needs to take action to identify the specific type of poison. This could mean asking the parents or whoever witnessed what happened, or looking at the chemical bottle themselves if the parents or EMS brought it along. The last priority action is to administer the antidote if available. If an antidote is available, correctly administer this medication to the client to prevent ongoing tissue damage from the poison that was ingested. Learning Objective Prioritize the order of emergency Department care based on assessment of the affected pediatric client. Additional Info The nurse should be able to recognize that the most significant risk to the victim of an accidental poisoning is airway compromise and respiratory failure. The nurse should response by assessing their client and ensuring there is no further poison risk to the client or staff caring for the client who ingested the poison. The nurse should further respond by placing an IV line and ensuring patency of the established IV and ensure that there is emergency resuscitation equipment readily available. The nurse should contact poison control in collaboration with the healthcare provider to receive guidance for possible antidotes that may be administered along with further guidelines on patient management.

A nurse educator is talking to her students about health care reform. She mentions the Patient Protection and Affordable Care Act (PPACA). The students show an understanding of the PPACA when they say which statement? A. "There will be an increase in the wages of all health care practitioners. " [3%] B. "Acute care hospitals will hire more nurses." [11%] C. "More nurses will be deployed in the community." [31%] D. "Patients will no longer pay for their healthcare costs." [55%]

Explanation C is correct. In the past, health care focused on the management of acute illness; currently, the emphasis is geared toward promoting health and preventing disease. Based on this health care reform, more nurses are expected to function in community-based settings. A is incorrect. The Patient Protection and Affordable Care Act (PPACA) does not affect the wages of nurses and other health care professionals. B is incorrect. PPACA does not affect the staffing and hiring protocols of acute care hospitals. D is incorrect. PPACA does not affect the charges of healthcare institutions on their beneficiaries.

What is the priority nursing assessment for a 76-year-old patient with pneumonia? A. Airway patency [80%] B. Percussion sounds [1%] C. Breath sounds [13%] D. Respiratory rate [6%]

Explanation Choice A is correct. Impaired mobility in older adults creates a risk for airway collapse, reduced air exchange, hypoxia, hypercapnia, and acidosis. Reduced gag and cough reflexes can place older people at risk for aspiration of secretions and, potentially, aspiration pneumonia. There is a possibility of postoperative respiratory complications because of impaired cough reflex, weaker muscles, and decreased inspiratory capacity. Older adults are at increased risk of respiratory complications due to stress. The nurse should pay attention to maintaining adequate ventilation, keeping lung volumes high, clearing secretions, and positioning to prevent aspiration. Choices B, C, and D are incorrect. The airway always assumes priority in an assessment. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Thorax and Lung Assessment

The pediatric nurse is reading the chart for a newly admitted child suffering from intussusception. The nurse knows that this disorder is characterized by: A. The telescoping of one area of the intestines into another [85%] B. The absence of alveoli in one segment of the lobe [2%] C. A twisted colon [10%] D. The prolapse of the rectum [3%]

Explanation Choice A is correct. Intussusception generally occurs as a result of a blockage in the intestines, which results in the telescoping of one portion of the bowel into another part of the colon. This disorder occurs more frequently in children, often males. Choice B is incorrect. Intussusception is the telescoping of the intestine and does not have to do with alveoli. Choice C is incorrect. Twisted bowel is simply a twist or loop in the gut and is not known as intussusception. Choice D is incorrect. Rectal prolapse occurs from chronic constipation and weakened anal sphincter. NCSBN client need Topic: Physiologic integrity, Adaptations in Body Systems

A client at 32 gestational weeks reports the sudden onset of painless, bright red vaginal bleeding. The assessment showed a normal fetal heart rate and a non-tender uterus. The nurse understands that this client is at the highest risk of developing A. placenta previa. [83%] B. threatened abortion. [2%] C. placental abruption. [14%] D. uterine souffle. [1%]

Explanation Choice A is correct. Placenta previa may occur as early as 20 gestational weeks. The manifestations of painless, bright red vaginal bleeding coincide with this condition. Commonly, the presentation of placenta previa is a finding on routine ultrasound examination at approximately 16 to 20 weeks. Choices B, C, and D are incorrect. A threatened abortion may only occur before 20 gestational weeks. Thus, this condition is excluded. Placental abruption is highly serious and manifests with painful vaginal bleeding that causes the uterus to be firm and tender. Uterine souffle is a soft, blowing sound. This sound may be auscultated over the uterus. This is the sound of blood circulating through the dilated uterine vessels, and it corresponds to the maternal pulse. Additional Info Placenta previa is an implantation of the placenta in the lower uterus. As a result, the placenta is closer to the internal cervical os than to the presenting part (usually the head) of the fetus. The classic sign of placenta previa is the sudden onset of painless uterine bleeding in the last half of pregnancy. Many cases of placenta previa are diagnosed by ultrasound examination before any bleeding occurs.

Which of the following scores for distance visions indicates the patient with the poorest vision? A. 20/100 [37%] B. 200/20 [50%] C. 18/20 [9%] D. 24/20 [4%]

Explanation Choice A is correct. The average refractive index is 20/20. Visual acuity for distance vision is documented in reference to what a person with normal vision can see standing 6 m (20 feet) in front of the test (which is the numerator of the acuity fraction). The numerator is compared to what a person with normal visual acuity could read on that particular line (which is the denominator in the acuity fraction). Someone with a 20/20 vision can read at 20 ft. What a person with normal vision can read at 20 ft. Choices B, C, and D are incorrect. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Visual Acuity

A patient is being evaluated in the clinic for pancreatitis. Besides an elevated white blood cell count and serum lipase levels, which assessment finding indicates a positive finding for pancreatitis? A. The discoloration of the abdomen and periumbilical area [68%] B. Overactive bowel sounds [11%] C. Low bilirubin levels [18%] D. Bluish discoloration of the soles of the feet [2%]

Explanation Choice A is correct. The discoloration of the abdomen and periumbilical area is known as Cullen's sign and indicates pancreatitis when it occurs in conjunction with other symptoms. Other findings include elevated white blood cell count, bilirubin, and urinary amylase levels. Choice B is incorrect. In pancreatitis, bowel sounds are generally diminished or absent. Choice C is incorrect. Bilirubin levels are generally elevated in instances of pancreatitis. Choice D is incorrect. Bluish discoloration of the feet is not associated with pancreatitis. However, bluish discoloration of the flanks is known as Turner's sign and is used as an indicator of pancreatitis. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse is caring for a client who has pulmonary tuberculosis (TB). Which infection control measure should the nurse implement? A. Restrict visitors who are pregnant. [33%] B. Remove any portable fans in the room. [46%] C. Wear a dosimeter badge during patient care. [3%] D. Place the patient further away from the nursing station. [18%]

Explanation Choice B is correct. Fans should be removed from a room for a client with droplet or airborne precautions. Fans may propel the transmission of a pathogen. A client with pulmonary tuberculosis should be isolated using airborne precautions. Choices A, C, and D are incorrect. Restricting visitors who are pregnant is not an infection control measure necessary for pulmonary tuberculosis. It would also be inappropriate to wear a dosimeter badge or place the patient further away from the nursing station. Radiation exposure is not a risk associated with TB; thus, a dosimeter badge is unnecessary. Additional Info For a client with suspected or active pulmonary tuberculosis, the following infection control measures should be taken - Initiate and maintain airborne precautions. Keep the door closed to promote negative pressure. An appropriate respirator must be worn during direct care. Strict adherence to hand hygiene. If the client needs to leave the room, they should wear a surgical mask.

A 30-year-old male client in the medical ward was admitted for a hiatal hernia and is being discharged today. The nurse talks to him regarding methods to prevent and reduce pain associated with his condition. Which of the following statements from the client indicate that teaching is successful? A. "I need to wear loose-fitting clothes." [76%] B. "After a meal, I must lie down to avoid dumping syndrome." [20%] C. "I need to eat three large meals a day." [2%] D. "I can go to my favorite Indian restaurant anytime of the week." [1%]

Explanation Choice A is correct. The nurse should teach the client measures that reduce gastric acid reflux in the patient. The nurse should instruct the patient to wear loose-fitting clothes to prevent pressure in the stomach that might cause reflux. Choice B is incorrect. The client should not lay down after a meal. Instead, the client should remain in an upright position for 2 hours after eating. Dumping syndrome in a hiatal hernia does not exist. Choice C is incorrect. The nurse should instruct the client to have frequent small feedings rather than three large meals to avoid gastric reflux. Choice D is incorrect. Spicy food and caffeine trigger acid reflux and should be avoided. Indian food is full of spices, therefore clients should avoid eating spicy food.

The nurse is precepting a newly hired nurse administer an intramuscular injection to an adult. Which action by the newly hired nurse requires follow-up? A. Prepares to administer the medication in the dorsogluteal. [79%] B. Prepares to insert the needle at a 90-degree angle. [9%] C. Uses isopropyl alcohol to clean the area prior to injection. [10%] D. Washes their hands before and after the procedure. [2%]

Explanation Choice A is correct. This action requires follow-up as the dorsogluteal site is not recommended. The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels. Choices B, C, and D are incorrect. These are correct actions and do not require follow-up. Intramuscular injections should be given at a 90-degree angle. Prior to injecting the medication, the nurse should appropriately clean the skin with isopropyl alcohol. Standard precautions are utilized for an injection which requires the use of thorough hand hygiene. Additional Info For adults, potential intramuscular sites include the ventrogluteal, vastus lateralis, and deltoid. The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels. A normal, well-developed adult patient tolerates 3 mL of medication into a larger muscle without severe muscle discomfort. Larger volumes of medication (4-5 mL) are unlikely to be absorbed properly. Children, older adults, and patients who are thin tolerate only 2 mL of an IM injection. Do not give more than 1 mL to small children and older infants, and do not give more than 0.5 mL to smaller infants

The manager at a home health nursing agency is making assignments for her RNs. Which client should be assigned to the most experienced RN? A. A client recovering from Guillain-Barre syndrome complaining of constant fatigue. [34%] B. A client with stage 3 and stage 4 pressure ulcers on the sacral area. [44%] C. A 2-week post-operative laryngectomy client due to laryngeal cancer. [17%] D. A client being discharged from home health services in the coming week. [4%]

Explanation Choice B is correct. A client with stage 3 and 4 pressure ulcers would require extensive wound care and experienced nurses who can properly care for the pressure ulcers. Choice A is incorrect. A client with Guillain-Barre syndrome that complains of fatigue is appropriately expected to have this symptom; this would not require the most experienced nurse. Choice C is incorrect. A client recovering from a laryngectomy would not require extensive teaching nor nursing care; this client would not need the most experienced nurse. Choice D is incorrect. A client being discharged from home health has been given discharge instructions starting from the time they are admitted; once they are ready for discharge, they would have received enough teaching from the nurse and other allied health team members; they would not require the most experienced nurse.

A nurse assesses an infant with a heart rate of 50, cyanotic, and apneic. The nurse should initially A. start chest compressions. [28%] B. call an infant code blue. [39%] C. deliver rescue breaths. [26%] D. obtain intravenous access. [6%]

Explanation Choice B is correct. According to the Basic Life Support (BLS) algorithm, for an infant with a heart rate below 60, showing signs of poor perfusion and apneic, the initial action would be to call a code blue (infant). Once this is completed, the nurse should start CPR at a rate of thirty compressions to two rescue breaths. Choices A, C, and D are incorrect. Chest compressions will need to be initiated following the signaling of a code blue. An infant's heart rate of less than 60 is grossly inadequate to sustain perfusion. Two rescue breaths will then need to be delivered after thirty chest compressions. Peripheral intravenous access will need to be obtained, but this is not the priority for an infant experiencing cardiac arrest. Additional Info For an infant requiring basic life support, it is important to keep the following points in mind - Chest compressions may be delivered using the two-finger technique or the two-thumb encircling hands technique. The chest should be depressed 1.5 inches and allowed to recoil. The chest compression rate should be approximately 100 to 120 per minute. An AED should be obtained as soon as possible to increase the odds of survival from ventricular dysthymias. The airway should be opened with the head tilt-chin lift maneuver unless a cervical spinal cord injury is suspected; if it is suspected, utilize the jaw thrust maneuver. If a pulse is present and rescue breaths are required, one breath should be given via a bag valve mask at a rate of one breath every two to three seconds.

A nurse is assigned to care for several clients with eating disorders. How would the nurse differentiate bulimic clients from anorexic clients, based on physical appearance? A. By observing their teeth [43%] B. By body size and weight [45%] C. Mallory-Weiss tears [3%] D. It is impossible to distinguish the clients based on physical exam only [9%]

Explanation Choice B is correct. Both bulimic and anorexic clients have the propensity to impose weight loss rituals, but bulimic clients tend to eat much more, as they have binge episodes, and are expected to be near-normal weight. Choices A, C, and D are incorrect. Not all bulimic clients have enamel-loss on their teeth, especially if the disorder has developed only recently. Mallory-Weiss tears are small tears in the esophageal mucosa brought about by forceful vomiting but aren't always present in bulimic clients.

A 10-month-old infant was admitted for dehydration after days of severe diarrhea. His mother voiced out her concern about his development. Which developmental milestone is expected of the infant at this point? A. Able to say three words other than "mama" and "dada" [10%] B. Can sit without support [85%] C. Able to build a tower of two cubes [4%] D. Can walk well [1%]

Explanation Choice B is correct. Children between the ages of 5 and 7 months must have attained the ability to sit without support. Choices A, C, and D are incorrect. The ability to say three words other than "mama" and "dada" is reached between the ages of 11 and 18 months. The ability to build a tower of two cubes is attained between the ages of 13 and 21 months. The ability to walk well is reached between the ages of 11 and 15 months.

An 81-year-old adult arrives in the emergency department complaining of shortness of breath and bilateral leg swelling. Following an EKG order, what is the first drug the nurse should expect the doctor to order? A. Mannitol [7%] B. Furosemide [78%] C. Hydrochlorothiazide [7%] D. Spironolactone [7%]

Explanation Choice B is correct. Due to the shortness of breath, leg swelling, and patient's age, the nurse can suspect that this patient is suffering from congestive heart failure (CHF). The drug of choice in managing fluid overload in CHF is a loop-acting diuretic, i.e. furosemide, also known as Lasix. Furosemide acts on the ascending limb of Henle's loop and blocks the sodium-potassium-chloride cotransporter; thus, inhibiting sodium and chloride reabsorption. Decreased NaCl reabsorption will result in hypotonicity in the nephron's interstitial space, leading to significant free water excretion. Furosemide is also used in managing non-cardiac peripheral edema, fluid retention, and ascites. Choice A is incorrect. Mannitol is a diuretic used for the reduction in increased intracranial pressure. This is because mannitol is an osmotic diuretic that does not cross the blood-brain barrier. A gradient is developed between plasma and brain cells, causing a shift from the extracellular space into the blood vessels. Choice C is incorrect. Hydrochlorothiazide is a thiazide diuretic. These diuretics also inhibit the sodium/chloride cotransporter, but their site of action is in the "distal convoluted tubule" of the nephron. Thiazide diuretics are used in treating hypertension. The amount of NaCl reabsorption in the distal tubule is small. Therefore, blocking this site alone does not cause large enough diuresis. Hence, thiazides are not the drug of choice in heart failure. In CHF, loop diuretics are most effective because their site of action is on Henle's loop, where 25% of NaCl reabsorption occurs. Hence, these agents promote the most effective diuresis in CHF. Choice D is incorrect. Spironolactone is a potassium-sparing diuretic. Spironolactone helps treat high blood pressure, edema, ascites, and conditions with high hormone aldosterone levels (Conn's syndrome, primary hyperaldosteronism). NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Subtopic: Cardiovascular

The nurse is caring for a client who is receiving clozapine. Which of the following findings would warrant immediate follow-up? A. Total cholesterol 206 mg/dL [2%] B. WBC 3,000 mm3 [73%] C. Weight gain 1 kilogram [5%] D. Blood glucose 255 mg/dL [20%]

Explanation Choice B is correct. Follow-up laboratory work is essential for a client taking clozapine. The medication may adversely cause neutropenia. The client will be instructed to obtain this necessary laboratory work to ensure they are not experiencing agranulocytosis, which enhances the risk of infection. This WBC count is quite low and requires follow-up. Choices A, C, and D are incorrect. Clozapine may cause considerable weight gain, hyperglycemia, and hyperlipidemia. These findings are concerning but are not a priority over leukopenia. Additional information: Clozapine is an atypical antipsychotic reserved for those who have not responded to other agents. This medication is used to treat schizophrenia as well as mood disorders that may cause significant aggression or violence. This medication carries serious effects, including agranulocytosis, myocarditis, sialorrhea, and weight gain. The client will require frequent laboratory work to monitor their neutrophil count. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Adverse Effects/Contraindications/Side Effects/Interactions

The nurse is caring for a client admitted to the acute care facility. The nurse takes a phone call from the client's neighbor who wants to know where the client is located. The nurse should A. inform the individual that this information cannot be released. [42%] B. provide the caller with the client's current location. [39%] C. not acknowledge the presence of this individual. [4%] D. inquire with the caller as to the reasoning for the information. [14%]

Explanation Choice B is correct. HIPAA allows directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated. The client may also decide against having this information shared in the directory. If that is the case, the nurse should not acknowledge that an individual by this name is currently in the facility. The item provided does not state that the client has decided against being in the directory. Directory information can be released to any caller unless the client requests not to. For more information regarding this HIPAA provision, refer to the HHS website. Choices A, C, and D are incorrect. Directory information may be released and stating that it cannot be divulged would be inappropriate. Unless the client has asked to be removed from the directory, the nurse is permitted to a state where the client is located, the health condition in general terms, and their religious affiliation. Not acknowledging the presence of this client would only be appropriate if the client wanted to be removed from the hospital directory. The nurse would simply state, "I do not have a client by that name." The nurse does not need to inquire about the reasoning for the caller's inquiry - that would be inappropriate. Additional Info HIPAA allows directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated. The client must be informed about the information to be included in the directory and to whom the information may be released, and must have the opportunity to restrict the information or to whom it is disclosed, or opt-out of being included in the directory. The client may be informed and make their preferences known, orally or in writing. Reference: HHS

The nurse in the ER is caring for an Asian-American with an acute asthma attack. When assessing the client, the nurse understands that which of the following information holds the least priority? A. History of present illness [7%] B. Psychosocial assessment [80%] C. Neurological status [11%] D. Vital signs and oxygen saturation [2%]

Explanation Choice B is correct. In Asian American culture, asking personal questions during the initial meeting is uncomfortable and indiscreet. The nurse can put off this assessment until the patient is already relaxed and comfortable. Choice A is incorrect. Assessing for the history of present illness is necessary, providing information that will help direct client care. Choice C is incorrect. Following the hierarchy of needs, the physiological concerns of the patient should be prioritized over other aspects. Neurological status should be assessed as soon as possible. Choice D is incorrect. Following the hierarchy of needs, the physiological concerns of the patient should be prioritized over other aspects. Oxygen saturation and vital signs should be assessed with a high priority.

While you are tending to a one-day-old newborn, the mother tells you that the baby has not had a bowel movement yet. Which of the following terms refers to the first stool passed by a newborn infant? A. Melena [1%] B. Meconium [98%] C. Diarrhea [0%] D. Hematemesis [0%]

Explanation Choice B is correct. Meconium is defined as the first stool passed by a newborn infant. It is typically a dark black/green sticky stool. In about 99% of healthy full-term infants, meconium is passed within 24 hours of birth. In the absence of any pathology, 100% of full-term infants should pass meconium by 48 hours of delivery. In pre-term infants, there may be a delay in passing the first stool beyond 48 hours. Occasionally, the fetus can pass meconium into the surrounding amniotic fluid while still inside the uterus and may end up aspirating it. Any event that triggers fetal stress may cause the fetus to pass meconium while inside the womb. Decreased fetal oxygenation due to placental or umbilical cord pathology may trigger the fetus to pass meconium. Therefore, meconium-stained amniotic fluid is regarded as a sign of fetal distress. Sometimes, meconium is not passed within 24 hours of birth in a full-term infant. Such presentation may signal conditions that cause intestinal obstruction, including meconium ileus, cystic fibrosis, and Hirschprung's disease. Choice A is incorrect. Melena is a term that refers to dark, sticky feces that contains old, digested blood. It indicates an upper GI bleed. Choice C is incorrect. Diarrhea is a loose, watery stool. Choice D is incorrect. Hematemesis is bloody vomiting. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care; Pediatrics - Gastrointestinal

The nurse is caring for a patient with Meniere's disease. Which of the following nursing interventions is of the highest priority when caring for this patient? A. Discussing treatment options [1%] B. Initiating fall risk measures [90%] C. Keeping the patient calm during an episode [6%] D. Providing teaching on potential causes [2%]

Explanation Choice B is correct. Since Meniere's disease causes vertigo or the feeling that one is spinning, the patient is at an increased risk for falls. To keep this patient safe, the nurse must initiate fall risk measures. Choice A is incorrect. Discussing treatment options, while necessary, is not the highest priority when caring for patients with Meniere's disease. Promoting patient safety by preventing falls is a priority. Choice C is incorrect. While an episode of vertigo can be frightening in a patient, keeping the patient calm is not the highest priority when caring for patients with Meniere's disease. Promoting patient safety by preventing falls is a priority. Choice D is incorrect. Providing teaching on causes of episodes is always an essential part of patient care; however, keeping the patient with Meniere's disease safe should be the priority. NCSBN client need Topic: Physiological Integrity, Physiological Adaptation

The nurse is caring for a patient who is receiving prescribed lamotrigine. Which of the following findings is highly concerning? A. Abnormal dreams [9%] B. Skin blistering [43%] C. Dyspepsia [18%] D. Xerostomia [29%]

Explanation Choice B is correct. Skin blistering associated with lamotrigine therapy is a critical finding to report. This is a feature of Steven-Johnson syndrome (SJS). Lamotrigine has been implicated as causing this adverse finding. Choices A, C, and D are incorrect. Lamotrigine may cause alteration in the mood either intentionally or unintentionally. The indication for this medication is for epilepsy or bipolar disorder. Abnormal dreams are a common effect associated with this medication but are not highly concerning compared to skin blistering, which is consistent with SJS. Dyspepsia (painful digestion) and xerostomia (dry mouth) are not priority effects that should be reported as they are not life-threatening. Additional information: Lamotrigine is a mood stabilizer and antiepileptic. This medication may adversely cause SJS, which is manifested by tender skin lesions that appear as blisters. These skin eruptions may also involve the eyes and mouth. Prompt treatment is necessary because of the risk of sepsis that may consequently occur because of the erosion of the skin. These lesions often spread fast, underlining the necessity of prompt treatment. If this should occur, the offending agent should be withdrawn.

The nurse is caring for a client who has narcolepsy. Which of the following would indicate the client is achieving the treatment goals? A. Increased focus and attention. [20%] B. Decreased daytime sleeping. [62%] C. Increased daytime energy. [14%] D. Decreased social avoidance. [3%]

Explanation Choice B is correct. The cardinal feature of narcolepsy is daytime sleepiness, in which they may have sleep attacks that cause an individual to rapidly doze off with little warning. If a client is meeting the treatment goals, they would report decreased daytime sleeping, which would lead to increased productivity. Choices A, C, and D are incorrect. Increased focus and attention would be a treatment goal for a client with attention deficit hyperactivity disorder (ADHD). While increased daytime energy would be beneficial for an individual with narcolepsy, if the client is meeting the treatment goals, then the core feature (daytime sleepiness) would be ameliorated. Decreased social avoidance would be a treatment goal for certain personality disorders. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Knowledge/comprehension Additional Info Narcolepsy is a syndrome in which a client has significant daytime sleepiness that often lessens after a nap. A client with narcolepsy may also have cataplexy, a brief emotionally triggered muscle weakness after laughter, excitement, etc. The client will then experience muscle paralysis in the face or neck. The episode typically resolves within minutes of its onset.

The nurse is taking care of a client two days post lobectomy. He is complaining of difficulty breathing. He is restless, lethargic, and has bilateral crackles. What is the nurse's most appropriate initial intervention? A. Check the client's oxygen saturation. [52%] B. Notify the rapid response team (RRT). [33%] C. Place the client in Trendelenburg position. [8%] D. Check the client's surgical dressing. [6%]

Explanation Choice B is correct. The client is in obvious respiratory distress. The nurse needs help with initiating life-saving procedures such as endotracheal intubation. The nurse need not call a "Code Blue" since the client is still breathing. However, a Rapid Response Team (RRT) can be called for help. The RRT is a team of healthcare professionals who respond to client emergencies even when they are still breathing and/or have a pulse. Since the client is in obvious respiratory distress, no additional assessment is needed prior to calling the RRT. Choice A is incorrect. The client is in obvious respiratory distress, even without the oxygen saturation reading. The nurse should initiate a nursing intervention to help the client. RRT needs to be contacted right away. Please note, "When in distress do not assess!" Choice C is incorrect. The Trendelenburg position is appropriate for clients in shock, but it is inappropriate for clients in respiratory distress. Choice D is incorrect. The client is already in respiratory distress. Checking the dressing of the client is inappropriate and causes an unnecessary delay of priority interventions.

Due to the influx of patients at a local hospital due to a cholera outbreak, the charge nurse was asked by the nurse manager which patients can be transferred to their rehabilitation ward to free up some space in the medical ward. Which client does this apply to? A. A client with diabetic foot. [45%] B. A client with right hemiparesis due to a TIA four days ago. [43%] C. A post-myocardial infarction patient with PVCs. [6%] D. A client with pneumonia and a respiratory rate of 25. [6%]

Explanation Choice B is correct. The client with hemiparesis is the most stable of all these patients. The client will also benefit the most from the rehabilitation ward. Choice A is incorrect. This patient is still unstable and will need the care provided in the acute care setting. Choice C is incorrect. A client that suffered an MI and is having PVCs is at high risk for developing cardiac arrest. This patient is still unstable and will need the care provided in the acute care setting. Choice D is incorrect. The patient needs to be monitored in case he gets into respiratory arrest. This patient is still unstable and will need the care provided in the acute care setting.

While working in the PICU, you are checking the drip rates of your vasoactive infusions. Your patient is ordered to have epinephrine running at 0.03 mcg/kg/min. Their weight is 10 kg. The concentration of the epinephrine bag is 20 mcg to 1 mL. What rate should the pump be set to? A. 0.99 mL/hr [3%] B. 0.9 mL/hr [73%] C. 0.09 mL/hr [15%] D. 9 mL/hr [9%]

Explanation Choice B is correct. The formula for calculating the rate of vasoactive infusion is dose x weight x minutes, then divided by the concentration of the drug. In this case, the epinephrine is ordered at 0.03 mcg/kg/min. So the calculation is 0.03 mcg x 10 kg x 60 minutes = 18 mcg/hr. Then divide by the concentration to get the final rate: (18mcg/hr)/20mcg/1mL = 0.9mL/hr. This is the rate the pump should be set to. Choice A is incorrect. This rate is too fast and will deliver too much epinephrine to your patient. Choice C is incorrect. This rate is too slow and will not deliver enough epinephrine to your patient. Choice D is incorrect. This rate is too fast and will deliver too much epinephrine to your patient. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Medication Administration

You are ready to administer a unit of packed red blood cells to your client. Which of the following nursing interventions is a high priority for you once the transfusion has begun? A. Directly monitor the client and their responses to the transfusion continuously for at least 30 minutes after the transfusion began. [20%] B. Directly monitor the client and their responses to the transfusion continuously for at least 15 minutes after the transfusion began. [78%] C. Start the infusion by adjusting the rate of the infusion to less than 30 mL per minute. [1%] D. Start the infusion by adjusting the rate of the infusion to less than 20 mL per minute. [1%]

Explanation Choice B is correct. The nurse must directly monitor the client and their responses to the transfusion continuously for at least 15 minutes after the bleeding began. This is because transfusion reactions are most likely to manifest within 15 minutes after the transfusion starts. Choice A is incorrect. Although you would directly monitor the client and their responses to the transfusion continuously for some time, this duration is typically less than 30 minutes after the bleeding began. Choice C is incorrect. You would start the infusion by adjusting the rate of the injection to a volume that is less than 30 mL per minute; rates of 30 mL per minute can lead to a more severe reaction than a much lower rate would. Choice D is incorrect. You would start the infusion by adjusting the rate of the injection to a volume that is less than 20 mL per minute; rates of 20 mL per minute can lead to a more severe reaction than a much lower rate would.

The nurse is preparing a client for a thoracentesis. All of the following are appropriate actions by the nurse, except: A. Arrange for obtaining informed consent. [14%] B. Place the client in semi-fowler's position. [72%] C. Instruct the client to hold still when the needle is inserted. [9%] D. Monitor for tachypnea, dyspnea, and cyanosis. [4%]

Explanation Choice B is correct. This is an inappropriate action by the nurse, therefore the correct answer to the question. The client should be placed upright, leaning over the tray table. Choice A is incorrect. This is an appropriate action by the nurse, and informed consent is needed for a Thoracentesis. The nurse should arrange for the physician to come by to explain the procedure and obtain informed consent. Choice C is incorrect. This is an appropriate action by the nurse. The insertion of the needle is painful, and any sudden movement by the client may force the hand through the pleural space and injure the visceral pleura and lung parenchyma. Choice D is incorrect. This is an appropriate action by the nurse. Changes in respiratory rate and character may indicate pneumothorax, which is a common complication to Thoracentesis.

You ask your 32-year-old female client about her hobbies. The client tells you that they thoroughly enjoy reading, making pottery, hiking, and rock climbing in the mountains. Which of these interests would you primarily focus on and encourage? A. Making pottery because this avocation is relaxing and not hazardous. [17%] B. Hiking because this avocation is a good and low-impact exercise. [45%] C. Reading because this avocation is relaxing and not hazardous. [34%] D. Rock climbing because this avocation is a good and low-impact exercise. [3%]

Explanation Choice B is correct. You would primarily focus on and encourage hiking because hiking is not only a hobby and interest for the client, but it is an excellent form of exercise that is low impact and relatively safe in comparison to other hazardous hobbies like rock climbing. Choice A is incorrect. Making pottery is not the activity or hobby that you would focus on and encourage because pottery is a sedentary and solitary activity; not one that provides enjoyable outdoor exercise and social interactions with others. However, it can be relaxing and with minimal hazards. Choice C is incorrect. Reading is not the activity or hobby that you would focus on and encourage because it is a sedentary and solitary activity; not one that provides any exercise and social interactions with others, although it can be relaxing. Choice D is incorrect. Rock climbing is not the activity or hobby you would focus on and encourage because rocking climbing is exceptionally hazardous, although it is an excellent and high-impact exercise.

The right brake on your client's wheelchair is not holding as strong as the left brake. What is your priority action? A. Ask the client if this just happened today. [3%] B. Immediately remove it from use. [73%] C. Try to tighten the brake up with a simple tool. [5%] D. Call the physical therapist for another device. [18%]

Explanation Choice B is correct. Your priority action is to immediately remove the wheelchair from use as soon as you notice that the right brake on your client's wheelchair is not holding as strong as the left brake. Before any piece of medical equipment, including all assistive devices, is used the piece of equipment must be inspected; when there is any irregularity, as the right brake on your client's wheelchair not holding as strong as the left brake, it is not your role or responsibility to attempt to fix it because you are not competent to do so; therefore, you must immediately remove it from use and then notify the appropriate person or department and advise them that the piece of medical equipment needs a safety check and repair. Choice A is incorrect. Asking the client if this just happened today is irrelevant and unnecessary because it is not necessary to know when it occurred. Choice C is incorrect. You would not try to tighten the brake up with a simple tool because, not only is this not your role and responsibility, you are not equipped to do this. Choice D is incorrect. You would not call the physical therapist for another device as your priority action; however, after you have completed your priority action, you may call the physical therapist for a wheelchair.

Your client is on complete bed rest for 10 days. Which of the following is the highest priority nursing diagnosis for this client? A. At risk for social isolation related to complete bed rest. [1%] B. At risk for decreased muscular strength related to complete bed rest. [10%] C. At risk for increased respiratory secretion accumulation related to complete bed rest. [45%] D. At risk for impaired skin integrity related to complete bed rest. [44%]

Explanation Choice C is correct. "At risk for increased respiratory secretion accumulation related to complete bed rest" is the highest priority nursing diagnosis for a client who is on complete bed rest for ten days. The accumulation of respiratory secretions in the airway can lead to life-threatening complications. According to the ABCs of the airway, breathing, and cardiovascular status, Maslow's Hierarchy of Needs, and the MAA-U-AR method of priority setting method, all establish the highest priorities as A: Airway, B: Breathing, and C: Circulation in that decreasing order of preference. Choice A is incorrect. "At risk for social isolation related to complete bed rest" is not the highest priority nursing diagnosis for a client who is on complete bed rest for ten days. Choice B is incorrect. "At risk for decreased muscular strength related to complete bed rest" is not the highest priority nursing diagnosis for a client who is on complete bed rest for ten days. Choice D is incorrect. "At risk for impaired skin integrity related to complete bed rest" is not the highest priority nursing diagnosis for a client who is on complete bed rest for ten days.

A primigravida patient at 38 weeks arrives at the hospital reporting a sudden gush of clear fluid from her vagina. The nurse suspects the patient has a premature rupture of the membranes. Which test shall the nurse perform to confirm her suspicion? A. An internal vaginal examination [11%] B. Ultrasound [8%] C. Nitrazine paper test [79%] D. A Gram stain [2%]

Explanation Choice C is correct. A Nitrazine test tape determines the acidity and alkalinity of a substance. Amniotic fluid is alkaline and will turn the nitrazine test strip blue. The presence of amniotic fluid outside of the membranes would indicate a rupture. Choice A is incorrect. An internal vaginal examination is done when the client is in labor to determine cervical dilatation and effacement. Once membranes are suspected to have ruptured, it is already contraindicated. Choice B is incorrect. An ultrasound cannot determine if there has been a premature rupture of the membranes. Choice D is incorrect. Gram staining is done to detect the presence of infections.

A Pap smear is recommended to screen for which of the following conditions? A. Ovarian cancer [4%] B. Endometrial cancer [2%] C. Cervical cancer [92%] D. Vaginal cancer [1%]

Explanation Choice C is correct. A Pap smear is an excellent screening tool to detect precancerous or cancerous cells of the cervix. There is a long lag time between the appearance of precancerous cells and the development of invasive cervical cancer. Therefore, early detection of precancerous lesions by PAP smear and addressing them promptly with localized treatments help prevent cervical cancer. Choice A is incorrect. Tests and procedures used to diagnose ovarian cancer include a pelvic exam. During a pelvic exam, the provider performs a bimanual exam while simultaneously pressing on the abdomen to palpate pelvic organs. Imaging and blood tests may also be ordered, but they are not accurate for "screening" purposes. Choice B is incorrect. An endometrial biopsy is done to determine endometrial cancer. Choice D is incorrect. A vaginal biopsy determines the presence of cancerous vaginal tissue cells.

The RN is caring for a patient with suspected meningitis. Which action would the nurse recognize as the highest priority immediately following a lumbar puncture procedure? A. Test for gag reflex return [7%] B. Elevate the head of the bed to 30 degrees [24%] C. Encourage oral fluid intake [32%] D. Assess patient for Brudzinski sign [37%]

Explanation Choice C is correct. A lumbar puncture (or spinal tap) procedure is used to obtain cerebrospinal fluid (CSF) to diagnose meningitis and identify the cause. The nurse would encourage oral fluid intake following this procedure to replace CSF volume and reduce the risk of spinal headaches. Choice A is incorrect. A lumbar puncture procedure would involve local anesthetic at the site of the lower spine but would not involve sedation that would affect the gag reflex. Choice B is incorrect. The patient should be positioned lying flat for several hours following the lumbar puncture procedure to reduce the risk of spinal fluid leakage and spinal headache. Choice D is incorrect. A positive Brudzinski sign indicates meningeal irritation and may be used to screen for meningitis, but would not be appropriate to perform after the lumbar puncture procedure. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential

A nurse in the nursery is assessing a newborn in the unit. Which finding would necessitate further investigation? A. A soft spot just above the newborn's head [2%] B. Greasy, white substances that resemble cheese on the baby's neck, back, and thighs [4%] C. A single crease on the palm [67%] D. Acrocyanosis [27%]

Explanation Choice C is correct. A single crease on the palm is also called a Simian crease and would indicate that the child has Down's syndrome. The nurse should further assess this finding to confirm Down's syndrome in the child. Choice A is incorrect. The soft spot on the newborn's head is the anterior fontanel. They allow the bony plates of the baby's skull to flex so the baby's head can get through the birth canal. They do not close until 9-18 months. Choice B is incorrect. This is the vernix caseosa, which is a greasy, cheese-like substance on the newborn that occurs naturally to provide insulation on the newborn. Choice D is incorrect. Acrocyanosis is cyanosis of the newborn's extremities. This is a regular occurrence during the first hours of the newborn's life.

The nurse is educating a patient who is taking phenytoin. To make sure phenytoin does not fail, which over-the-counter (OTC) medication should the nurse advise the patient not to take at the same time? A. Acetaminophen [12%] B. Ibuprofen [27%] C. Calcium carbonate [41%] D. Ranitidine [20%]

Explanation Choice C is correct. Calcium carbonate (Tums) should not be taken at the same time as Phenytoin because taking them together can decrease the effects of phenytoin. Antacids containing calcium carbonate reduce the bioavailability of phenytoin by reducing both the rate of absorption and the amount of intake. Phenytoin is an anticonvulsant and not getting it at a therapeutic dose may result in the client having a recurrent seizure. Clients should be cautioned against the concomitant use of antacids/tums and phenytoin. If the client needs calcium carbonate, he should be instructed to separate the times of intake of calcium carbonate and phenytoin by at least two to three hours. Choice A is incorrect. Acetaminophen and phenytoin can be taken together without any concern for therapeutic failure. Choice B is incorrect. Ibuprofen and phenytoin can be taken together and do not cause the therapeutic failure of phenytoin. Choice D is incorrect. Ranitidine and phenytoin can be taken together and do not cause the therapeutic failure of phenytoin. Ranitidine may, however, increase the effects of Phenytoin, so the patient should be monitored for any phenytoin-related adverse effects.

While assessing a newborn infant in the nursery, you observe bounding +3 radial pulses and faint +1 pedal pulses. You also notice that the feet are cold and pale, while the hands are warm and pink. Which cardiac defect do you suspect this infant has? A. Tetralogy of Fallot (TOF) [30%] B. Hypoplastic left heart syndrome [8%] C. Coarctation of the aorta (COA) [48%] D. Transposition of the great arteries [14%]

Explanation Choice C is correct. Coarctation of the aorta is a narrowing of the aorta near the ductus arteriosus. Because of this narrowing, there is increased blood flow to the upper extremities and decreased blood flow to the lower extremities. That is what causes the symptoms described in the question: bounding upper pulses, faint lower pulses, and overall better perfusion to the upper extremities. Choice A is incorrect. In tetralogy of Fallot, there is a combination of four defects - an overriding aorta, pulmonary stenosis, hypertrophy of the right ventricle, and a VSD. At birth, the nurse would appreciate a murmur and mild to severe cyanosis depending on the case. The described symptoms do not fit tetralogy of Fallot. Choice B is incorrect. In hypoplastic left heart syndrome, there is underdevelopment of the left side of the heart. The nurse would note cyanosis and murmur at birth, but the described symptoms do not fit hypoplastic left heart syndrome. Choice D is incorrect. In transposition of the great arteries, the pulmonary artery leaves the left ventricle and the aorta leaves the right ventricle. These infants are severely cyanotic at birth and need surgery early in life, but the described symptoms do not fit the transposition of the great arteries. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Cardiovascular

While working on a pediatric floor, you have a patient diagnosed with pertussis. Which image below indicates the correct precautions the nurse needs to place the patient on?

Explanation Choice C is correct. Droplet precautions are necessary for the patient with pertussis. This means that the client needs a private room, or a room shared only with another client with pertussis. Staff should and visitors must wear a mask when entering the room. A mask must be placed on the client if they need to leave the room. Choices A, B, and D are incorrect. These types of precautions are not applicable to patients with pertussis. NCSBN Client Need Topic: Health Promotion and Maintenance Subtopic: Health Promotion/Disease Prevention

The nurse caring for a client with lung cancer who is scheduled for a wedge resection the following day. What part of the lung will be removed? A. One lobe of the lung [16%] B. An entire lung [1%] C. A small, localized slice near the superficial surface of the lung [69%] D. One portion of the lung with all bronchioles and alveoli [14%]

Explanation Choice C is correct. During a wedge resection, a small, localized portion of the lung will be removed. This section will be near the surface of the lung. Choices A, B, and D are incorrect. The removal of an entire lung or lobe is considered a lobectomy. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The patient with appendicitis is experiencing discomfort before her appendectomy. The nurse should avoid which of the following non-pharmaceutical therapies to relieve this discomfort? A. Applying ice packs to the abdomen [12%] B. Practicing breathing exercises with the patient [9%] C. Using a heating pad [76%] D. Encouraging rest [3%]

Explanation Choice C is correct. Heat should not be applied to the abdomen of patients experiencing pain from appendicitis. Heat will cause vasodilation and increased blood flow to the appendix which may lead to rupture. A ruptured appendix puts the client at risk for a life-threatening condition known as peritonitis. Choice A is incorrect. Applying ice packs to a patient's abdomen experiencing discomfort related to appendicitis is an appropriate non-pharmaceutical intervention. Choice B is incorrect. Using breathing techniques to work through appendicitis pain is an appropriate non-pharmaceutical intervention. Choice D is incorrect. Encouraging plenty of rest is an excellent way to prevent and manage pain from appendicitis. NCSBN client need Topic: Physiological Adaptation, Basic Care and Comfort

The nurse manager encountered several problems in the unit. She calls a staff meeting and presents several solutions to the staff during the meeting to ask for input. Upon hearing the staff's opinions, the nurse manager implements several options presented. Which management style does the manager represent? A. Autocratic [6%] B. Democratic [54%] C. Participative [36%] D. Laissez-faire [4%]

Explanation Choice C is correct. In a participative style of management, problems are identified by the manager and presented to the staff with several solutions. Staff members are encouraged to provide input however, the manager makes the final decision. Choice A is incorrect. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit. Choice B is incorrect. In a democratic style of management, staff members are encouraged to participate in the decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in this management style. Choice D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of management. The manager abdicates responsibility and decision-making whenever possible in this type of management.

Select the medication that is accurately paired with one of its contraindications. A. Isotretinoin: Contraindicated among clients with diabetes. [8%] B. Aspirin: Contraindicated among clients during the first trimester of pregnancy. [49%] C. Oral contraceptives: Contraindicated among clients taking troglitazone. [25%] D. Cisapride: Contraindicated among clients taking warfarin. [18%]

Explanation Choice C is correct. Oral contraceptives are contraindicated among clients taking troglitazone. It has been found that troglitazone (Rezulin, Noscal, and Resulin) reduces the concentration of oral contraceptives by about 30%, thus placing the client at risk for an unwanted pregnancy. Choice A is incorrect. Isotretinoin is not contraindicated among clients with diabetes; this acne medication is contraindicated during pregnancy. Choice B is incorrect. Aspirin is not contraindicated among clients during the first trimester of pregnancy; it is, however, contraindicated among clients during the third trimester of pregnancy Choice D is incorrect. Cisapride is not contraindicated among clients taking warfarin; however, it is contraindicated among clients taking an antimicrobial medication such as clarithromycin, erythromycin, and ketoconazole as well as other medications such as indinavir and nefazodone. Cisapride, in combination with these medications and others, can lead to severe life-threatening adverse effects.

A client diagnosed with an anxiety disorder is at a local mental health clinic. Due to the number of people coming and going through the clinic, the client suddenly suffers an acute anxiety attack. The nurse in the clinic would initiate which nursing intervention initially? A. Give one tablet of alprazolam immediately. [6%] B. Talk to the client and explore his feelings. [24%] C. Accompany the client to a vacant room and let him rest. [62%] D. Take the client's vital signs. [9%]

Explanation Choice C is correct. The most appropriate initial intervention is for the nurse to remove him from the stressful situation and let him rest. This will help decrease the anxiety of the client. Choice A is incorrect. Giving the client medication does not remove the stressor from the client. It will also take approximately 30 minutes to take effect. Choice B is incorrect. The nurse cannot talk to the client at this time as the client is still anxious and cannot collect himself. This is not the most appropriate initial action for the nurse to take. Choice D is incorrect. The nurse should remove the client from the stressful situation first, then take his vital signs.

Which of the following findings during an adolescent health screening requires further teaching? A. The patient reports that she is experiencing growing pains. [22%] B. The client started her menstrual cycle 2 years ago. [3%] C. The patient reports she is taking birth control pills [32%] D. The client recently lost 6 pounds [43%]

Explanation Choice C is correct. The adolescent who is taking birth control pills should be offered additional education regarding the prevention of the spread of STDs, as birth control pills do not protect against them. Choices A, B, and D are incorrect. These answers are not abnormal findings during an adolescent health screening. Adolescents are usually self-directed in meeting their health needs. Due to maturation changes, they need teaching and guidance in several health care areas. Promoting health and wellness includes screening for tobacco, alcohol, and drug use, screening for sexual practices, screening for mental health status, and checking blood work as recommended by the primary care provider. Protective Measures Immunizations as recommended, such as adult tetanus-diphtheria vaccine, MMR, pneumococcal, human papillomavirus (HPV), and hepatitis B vaccine Screening for tuberculosis Periodic vision and hearing screenings Regular dental assessments Obtaining and providing accurate information about sexual issues Assessing mental health status Adolescent Safety Adolescents taking responsibility for using motor vehicles safely (e.g. completing a driver's education course, wearing a seat belt and helmet) Making sure that proper precautions are taken during all athletic activities (e.g. medical supervision, proper equipment) Parents keeping lines of communication open and being alert to signs of substance abuse and emotional disturbances in the adolescent Nutrition and Exercise Importance of healthy snacks and appropriate patterns of food intake and exercise Factors that may lead to nutritional problems (e.g. obesity, anorexia nervosa, bulimia) Engaging in regular vigorous exercise, at least three times a week for 1 hour each time Social Interactions Encouraging and facilitating adolescent success in school Helping adolescents to establish relationships that promote discussion of feelings, concerns, and fears Parents helping teenage peer group activities that promote appropriate moral and spiritual values Parents acting as role models for relevant social interactions Parents providing a comfortable home environment for appropriate adolescent peer group activities Expecting adolescents to participate in and contribute to family activities Developmental Assessment Guidelines of the adolescent In these three developmental areas, does the adolescent do the following? Physical Development Exhibit physical growth (weight, height) within the normal range for age and sex Demonstrate male or female sexual development consistent with standards Manifest vital signs within the normal range for age and sex Exhibit vision and hearing abilities within the normal range Psychosocial Development Interact well with parents, teachers, peers, siblings, and persons in authority Like self Think and plan for the future, such as college or a career Choose a lifestyle and interests that fit your own identity Determine your own beliefs and values Begin to establish a sense of identity in the family Seek help from appropriate persons about problems Development in Activities of Daily Living Demonstrate knowledge of physical development, menstruation, reproduction, and birth control Exhibit healthy lifestyle practices in nutrition, exercise, recreation, sleep patterns, and personal habits Demonstrate concern for personal cleanliness and appearance NCSBN Client Need Topic: Health Promotion and Maintenance, Adolescence (12-18 Years)/Health Assessment and Promotion

The nurse is caring for a G4P3 client in active labor that has undergone three caesarean sections. The client suddenly screams out in pain and immediately quiets down. Examination reveals tenderness over the previous caesarean scar and cessation of uterine contractions. Which of the following should the nurse perform first? A. Prepare the client for delivery [5%] B. Notify the primary healthcare provider ( PHCP) [29%] C. Increase the rate of her IV fluids [12%] D. Assess the client's contraction pattern [53%]

Explanation Choice C is correct. The client's presentation is consistent with a ruptured uterus ( sudden onset of severe pain and cessation of previously present uterine contractions). A uterine rupture is an emergency and must prompt immediate action. Immediate delivery and treatment of maternal hemorrhage are the two most critical interventions. Uterine structures are hyper vascular during pregnancy and a rupture puts the client at a significant risk of severe hemorrhage. Hypotension and hemorrhagic shock may follow. The nurse should anticipate these complications. The nurse should increase the rate of IV fluids to counteract the hypovolemia due to blood loss. If large volume blood loss is noticed, blood transfusion should be immediately arranged. Choice A is incorrect. The client has ruptured her uterus. There is already no chance for the client to deliver her baby spontaneously because of a ruptured uterus. Choice B is incorrect. The nurse should initiate measures to stabilize the client first before calling the primary healthcare provider. Increasing the IV fluid rate in an emergency is an independent nursing action. Waiting for the provider's order will delay the basic resuscitation measure and jeopardizes client's safety. Choice D is incorrect. Due to the rupture of the client's uterus, the contraction pattern can no longer be assessed. Additionally, total cessation of contractions noted on the client's exam may indicate a total uterine rupture. Learning Objective Understand the signs and symptoms of uterine rupture. Recognize that a uterine rupture requires prompt interventions - immediate delivery and treatment of maternal hemorrhage must be performed simultaneously.

A young couple is at a well-baby clinic for their regular check-up. The couple asks about introducing solid foods to their child. The nurse replies that the earliest time they can add solid food to their child is at: A. 1 month [0%] B. 2 months [1%] C. 3 months [8%] D. 4 months [91%]

Explanation Choice D is correct. The child's sucking reflex disappears at 4-6 months. The GI system and immune system are also already mature at this time. Solid food can now be introduced to the child. Choice A is incorrect. The child's sucking reflex is still intact, and the GI system at this age is still immature. The immune system of the child is also naive. The parents cannot yet introduce solid food. Choice B is incorrect. The child's sucking reflex is still intact, and the GI system at this age is still immature. The immune system of the child is also naive. The parents cannot yet introduce solid food. Choice C is incorrect. The child's sucking reflex is still intact, and the GI system at this age is still immature. The immune system of the child is also naive. The parents cannot yet introduce solid food.

As the charge nurse on 3 East, you have assigned a nursing assistant to transfer a client from the bed to the chair using a mechanical lift. This is something that is within the scope of practice and in the job description for nursing assistants. When the nursing assistant sees the written assignment, the nursing assistant says, "I don't know how to use our mechanical lift." How should you respond to this nursing assistant? A. "It is your responsibility to be able to use it. You have been taught about its proper and safe use; this is part of your job description." [1%] B. "I have looked at your competency checklist and you were deemed competent to use mechanical lifts during your orientation." [2%] C. "Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift." [95%] D. "Oh, that is okay. I will assign the transfer of this client using a mechanical lift to another nursing assistant." [1%]

Explanation Choice C is correct. The nurse should respond to the nursing assistant by saying, "Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift." This statement allows the nurse to reeducate the nursing assistant about the use of a mechanical lift and determine the nursing assistant's ability and competency to use it. Choice A is incorrect. The nurse would not respond with a statement such as, "It is your responsibility to be able to use it. You have been taught about its proper and safe use; this is part of your job description." This statement does not address the underlying learning need of the nursing assistant. Choice B is incorrect. The nurse would not respond with a statement such as, "I have looked at your competency checklist, and you were deemed competent to use mechanical lifts during your orientation." This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift. Choice D is incorrect. The nurse would not respond with a statement such as, "Oh, that is okay; I will assign the transfer of this client using a mechanical lift to another nursing assistant." This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift.

A woman in her 37th-week of gestation is wary about complications and labor signs. She asks the nurse, how would she know if it was time to go to the labor and delivery unit? The best response is: A. "When the mucus plug is out." [12%] B. "When you feel a heaviness in your bladder." [8%] C. "When you see a large gush of fluid coming out of your vagina." [79%] D. "When you feel nauseated and vomit altogether." [1%]

Explanation Choice C is correct. The rupture of membranes causes the amniotic fluid to be expelled in large amounts. If the fetus has not engaged, the umbilical cord may prolapse along with the fluid; this poses a danger to both the fetus and the mother. The mother should then promptly arrive to the labor and delivery unit. Choice A is incorrect. The mucus plug may be passed several weeks before the onset of actual labor. Choice B is incorrect. The mother may experience bladder pressure and frequency when the fetus settles into the pelvis and this may occur a few weeks before labor. Choice D is incorrect. Prodromal signs of labor include nausea and vomiting but are not indicative of actual labor.

The nurse is the guest speaker in a seminar at a local elementary school. She is talking about accident prevention for school-aged children. Which statement by the attendees indicates an understanding of the topic? A. "School-aged children become settled and less adventurous compared to pre-schoolers." [6%] B. "School-aged children are less susceptible to home hazards than pre-schoolers." [12%] C. "School-aged children understand the dangers when you explain it to them." [71%] D. "School-aged kids are less controlled by their parents compared to toddlers." [11%]

Explanation Choice C is correct. The school-aged kids' cognitive levels are now developed to enable understanding of and adherence to rules. They are now susceptible to instruction. Choice A is incorrect. School-aged kids have greater freedom. They become more adventurous and daring. Choice B is incorrect. School-aged kids are still prone to dangers in the home because of their increased motor abilities and independence. They should be made aware of hazards such as firearms, alcohol, and medications. Choice D is incorrect. School-aged kids are now able to exercise control. They are a lot easier to control compare to pre-schoolers.

The nurse in the surgical ward is taking care of a patient that had just undergone an elbow arthroplasty. All of the following should be included in the patient's care plan, except? A. Elevate the arms of the patient to above his shoulders for 4-5 days. [52%] B. Check the client's operative hand strength frequently. [6%] C. Check the client's radial and ulnar pulses as well as capillary refill. [4%] D. Tell the client that he can do exercises after 2 weeks. [37%]

Explanation Choice D is correct. The client is instructed not to lift more than 5 pounds for months. Telling him that he can exercise after two weeks is inaccurate and should not be included in his care plan. Choice A is incorrect. The client should elevate his arms above his shoulders to facilitate lymphatic drainage and decrease swelling. Choice B is incorrect. Checking the strength of his hand frequently assesses the client for ulnar nerve entrapment. The nurse should also assess the client's thumb and index finger's ability to pinch. Choice C is incorrect. The nurse should assess radial and ulnar pulses as well as capillary refill to check for the client's tissue perfusion.

Which of the following are appropriate nursing interventions to prevent aspiration after a child has vomited? Select all that apply. A. Position the child on their side. [39%] B. Suction the mouth to remove vomitus. [34%] C. Offer the child a sip of water to clear the mouth. [10%] D. Assess the character and amount of vomitus. [16%]

Explanation Choices A and B are correct. Positioning the child on their side will prevent aspiration and maintain a patent airway (Choice A). Suctioning the mouth will remove any further vomitus keeping the mouth clean and preventing aspiration (Choice B). Choice C is incorrect. It is not safe to offer the child a sip of water at this time as they may aspirate on thin liquids. The child first needs to be assessed and the problem identified before it is decided that they are safe for oral intake. Chocie D is incorrect. Although it is an appropriate nursing intervention to assess the character and amount of emesis, this does not do anything to prevent aspiration after the child has vomited. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Reduction of risk potential, Gastrointestinal disorders

After giving medication to the wrong patient, the nurse reports that the client responded to the client's name that she said. What is the appropriate documentation for this event? A. Note the client's orientation. [6%] B. Note on the medication records what drug was given. [6%] C. If the client did not experience harm, there is no need for documentation. [0%] D. Fill out an incident report. [87%]

Explanation Choice D is correct. An incident report should always be filled out following any medication error. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP, 2013) estimates that 98,000 people die annually from medical errors that occur in hospitals. The NCC MERP defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems; including prescribing, order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, and monitoring. Medication administration errors result from the system and individual factors. Individual factors include fatigue and stress. Many studies report medication errors to occur related to the system factor of interruptions and distractions during medication administration. Research has demonstrated that disruptions create an excellent risk for and severity of errors in medication administration. Choice A is incorrect. The patient's status, including orientation, should be assessed. However, an incident report must be filled out following any medication administration error. Choice B is incorrect. The medication administration, in this case, should be documented on an incident report. A copy of the report will be attached to the medication record (depending on agency guidelines). Choice C is incorrect. ALL errors should be reported to a supervisor and documented on an incident report. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Documentation

The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema? A. Assess for skin tenting over the sternum [5%] B. Weigh patient at same time daily [52%] C. Obtain baseline BNP level [4%] D. Record calf circumference daily [39%]

Explanation Choice D is correct. Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema. Choice A is incorrect. Checking for tenting is a technique to assess skin turgor for dehydration, not to monitor peripheral/dependent edema. Additionally, assessing for the turgor does not provide an accurate measure of dehydration in older patients due to loss of skin elasticity with age. Choice B is incorrect. Weighing the patient daily would be an appropriate method of monitoring for alternations in overall fluid status, but does not specifically address peripheral edema. Choice C is incorrect. BNP (B-type natriuretic peptide) reflects left ventricular presence/severity of heart failure. This value may be abnormal due to cor pulmonale, but would not specifically reflect the patient's level of edema. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential

The patient is receiving instructions from the clinic nurse regarding dietary modifications to help in the treatment of her cystitis. The nurse is giving her a list of foods to avoid because they irritate her bladder. All of the following are foods that she needs to avoid, except: A. Coffee [2%] B. Spaghetti [25%] C. Alcohol [5%] D. Cranberry juice [68%]

Explanation Choice D is correct. Cranberry juice is used to acidify the urine of the patient with cystitis and should be included in her dietary regimen. Choice A is incorrect. Coffee/caffeine is an irritant to the bladder and should be avoided by patients with cystitis. Choice B is incorrect. Spaghetti sauce contains tomatoes which are an irritant to the bladder and should be avoided by patients with cystitis. Choice C is incorrect. Alcohol is an irritant to the bladder and should be avoided by patients with cystitis.

The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below. A. Pulmonary embolism [28%] B. Hypovolemic shock [7%] C. Disseminated intravascular coagulation (DIC) [5%] D. Pulmonary edema [60%]

Explanation Choice D is correct. The client's history of congestive heart failure significantly increases the risk for pulmonary edema. The vital signs show respiratory distress (tachypnea, hypoxia, and tachycardia), which supports the complication of pulmonary edema. Choices A, B, and C are incorrect. These conditions are not as likely to occur in an individual with CHF. While CHF places a client at higher risk for venous thromboembolism, it is reasonable for the nurse to first suspect the most common complication, which is pulmonary edema. DIC is quite rare and is highly unlikely. Hypovolemic shock is not plausible because the client with CHF typically has a problem with fluid volume excess, not a deficit. Additional Info Pulmonary edema is a medical emergency requiring prompt recognition and aggressive management through oxygenation, nitrates, and intravenous diuretics. Manifestations of pulmonary edema include crackles, dyspnea at rest, orthopnea, frequent coughing, hypoxia, tachypnea, anxiety, and a feeling of impending doom.

The nurse is caring for a client who has acute pancreatitis. Based on the 11:15 AM vital signs, the nurse should prioritize which action? See the image below. A. Obtain a 12-lead electrocardiogram [12%] B. Assess the client for pain [16%] C. Apply oxygen via nasal cannula [8%] D. Infuse 500 ml 0.9% sodium chloride bolus [63%]

Explanation Choice D is correct. The client's vital signs indicate hypovolemic shock. The tachycardia and hypotension that started at 11:00 AM have worsened, and the nurse should initiate prescribed intravenous fluids to restore circulating volume. Choices A, B, and C are incorrect. It is not necessary to obtain a 12-lead electrocardiogram for this client as the tachycardia is associated with hypotension suggesting hypovolemic shock. Assessing the client for pain is not the immediate priority as pain may cause tachycardia, but not hypotension. Oxygen via nasal cannula is not indicated, considering the client's oxygen saturation of 96%. Additional Info Acute pancreatitis may cause hypovolemic shock, and the client should be resuscitated with isotonic intravenous fluids once a diagnosis is made to prevent this complication. Pancreatitis may be triggered by cholelithiasis or alcoholism. This disorder commonly causes a client to experience intense epigastric pain, nausea/vomiting, and sometimes jaundice.

You are called to assist in caring for the client depicted below. Which of the following diagnoses would you suspect when you see the client? A. Chronic obstructive pulmonary disease (COPD) [14%] B. An airway obstruction from the accumulation of respiratory secretions [4%] C. Hypoxia related to a cardiovascular or pulmonary disorder [11%] D. Central sleep apnea related to muscular dystrophy [72%]

Explanation Choice D is correct. The device shown in the exhibit is a continuous positive airway pressure (CPAP) device. You would suspect central sleep apnea when you see a client as in the exhibit provided. Central sleep apnea is treated with a CPAP device and often results from muscular dystrophy with a compromised brain stem. The brain stem houses the respiratory control mechanisms for the body. By providing continuous pressure (CPAP) keeps airways open and promotes better ventilation. Sleep apnea is classified into two types: central and obstructive. CPAP is also used for the treatment of obstructive sleep apnea. Choice A is incorrect. The CPAP device is not used to treat chronic obstructive pulmonary disease (COPD), and it does not deliver oxygen. A BiPAP (Bi-level positive airway pressure) machine is often used in providing ventilation to clients with chronic obstructive pulmonary disease (COPD) exacerbations. Both CPAP and BiPAP are considered methods to deliver non-invasive positive pressure ventilation (NPPV). Choice B is incorrect. The CPAP device is not used to treat airway obstruction from the accumulation of respiratory secretion. It does not deliver oxygen or suctioning. Choice C is incorrect. The CPAP device is not used to treat hypoxia related to a cardiovascular or pulmonary disorder. In some cases of respiratory distress due to congestive heart failure (CHF) exacerbations, a BiPAP may be used. By increasing intrathoracic pressure, a BiPAP results in decreased preload and decreased afterload. It may prevent intubation by decreasing respiratory effort and improving gas exchange.

During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP) working with her. Which of the following is the nurse's primary responsibility? A. Document the completion of the task. [4%] B. Make a list of tasks not yet completed to pass on to the next shift. [1%] C. Observe the UAP for the duration of the task. [3%] D. Follow-up with the UAP to ensure completion of the task and evaluate the outcome. [91%]

Explanation Choice D is correct. The nurse should follow up with the UAP to ensure the completion of the task and evaluate the outcome. The ultimate responsibility for any job will always remain with the person who delegated it. Therefore, after delegating a task, the nurse's primary responsibility will be to follow up with the UAP. Choice A is incorrect. The nurse's primary responsibility after delegating a task will be to follow up with the UAP. The nurse cannot document the completion of the job until the follow-up has been performed. Choice B is incorrect. It is unnecessary to make a list of tasks not yet completed to pass on to the next shift. The nurse's primary responsibility after delegating a job will be to follow up with the UAP. Choice C is incorrect. If delegating correctly, the nurse must delegate a task within the scope of practice of the UAP; therefore would not need to observe the UAP for the duration of the job. The nurse's primary responsibility after delegating a task will be to follow up with the UAP. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Infection control and safety; Prioritization, delegation, and leadership

There is a massive airline crash near your acute care facility. As the victims of this massive external disaster arrive at your facility, your new graduate nurse asks you what the black-colored triage tags on the incoming victims indicate. How should you respond to this new nurse? A. The victims are the lowest priority for care. [11%] B. The victims have life-threatening injuries and are in need of immediate care. [3%] C. The victims are always dead. [22%] D. The victims are in a severe medical crisis, and they have little chance of survival. [63%]

Explanation Choice D is correct. You should tell the new graduate nurse that the black-colored triage tags on the incoming victims mean that the victims are in a severe medical crisis, and they have little chance of survival. In mass casualty scenarios, an advanced triage system is implemented and involves a color-coding scheme using red, yellow, green, white, and black tags. Remember the "DIME" acronym: Delayed; Immediate, Minor, Expectant. Red tags- IMMEDIATE - highest priority treatment/transfer. These patients cannot survive without immediate treatment but have a high chance of post-treatment survival. E.g. Tension pneumothorax, cardiac tamponade, massive hemorrhage. Yellow tags- DELAYED - medium priority. No immediate danger of death, stable but will still need hospital care. Under normal circumstances, these patients will be treated immediately, but in mass casualty scenarios, they are medium priority. E.g. isolated humerus or femur fracture. Green Tags- MINOR - lowest priority - those with minor injuries, ambulating ("walking" wounded). E.g. abrasions sprain. These are attended to after high and medium-priority patients are addressed. Black Tags- EXPECTANT - keep comfortable, pain medications only until death. These are patients with injuries so extensive that they will not be able to survive with the best available care or those dead already. E.g. Massive head injury with fixed pupil, third-degree burns involving 95% body surface. Walking away from those with black tags can be emotionally and ethically challenging. About "expectant" victims, WHO states, "It is unethical for a physician to persist, at all costs, at maintaining the life of a patient beyond hope, thereby wasting to no avail scarce resources needed elsewhere." Choice A is incorrect. You should not tell the student nurse that black-colored tags on the incoming victims mean that the victims are the lowest priority for care. Green indicates that the victims are the lowest priority for care. Black has no preference for ongoing care, and only comfort care needs to be provided. Choice B is incorrect. You should not tell the new graduate nurse that the black-colored triage tags on the incoming victims mean that the victims with these black tags have life-threatening injuries and need immediate care. The red color tag indicates that the victims have fatal injuries and need urgent attention. Choice C is incorrect. You should not tell the new graduate nurse that the black-colored triage tags on the incoming victims always means that the victims are dead because it could also represent critically injured but unsalvageable victims.

The nurse is reviewing laboratory data for a male client scheduled for surgery. Which laboratory data requires follow-up with the primary healthcare physician (PHCP)? Select all that apply. A. Calcium 7.9 mg/dL [41%] B. Potassium 3.3 mEq/L [44%] C. Sodium 143 mEq/L [4%] D. BUN 17 mg/dL [6%] E. Creatinine 0.9 mg/dL [5%]

Explanation Choices A and B are correct. A Calcium of 7.9 mg/dL is critically low (normal 9.0 - 10.5 mg/dL) and requires the nurse to follow up with the PHCP. A potassium level of 3.3 mEq/dl is low (normal 3.5 - 5.0 mEq/dL), and the PHCP should also be notified of this finding. Choices C, D, and E are incorrect. The laboratory values for the sodium (normal 135-145 mEq/dL), BUN (normal 10-20 mg/dL), and creatinine (0.6-1.2 mg/dL for males) are all within normal limits and do not require notification to the PHCP. NCLEX Category: Reduction of Risk Potential Related Content: Lab Values Question Type: Analysis Additional Info When preparing a client for surgery, the nursing responsibilities include: Ensuring that all pre-procedure paperwork is completed, including consent and corresponding checklists. Maintaining the client on "by mouth (NPO)" status, if appropriate. Appropriate attire and hygiene, including preprocedural bath with specified soap, clean gown, and anti-embolism stockings or sequential compression devices (SCDs). Recent laboratory data including CBC, CMP, UA, clotting factors (PTT, PT/INR), and HCG if the client is a female.

Select the complication of intravenous therapy that is accurately paired with one of its preventive measures. Select all that apply. A. Catheter embolus: Never reinserting the stylet into the catheter [27%] B. Hematoma: Start the infusion prior to releasing the tourniquet [7%] C. Infiltration: Insuring that the catheter is securely stabilized [32%] D. Site ecchymosis: Changing the intravenous site every 48 hours [14%] E. Fluid overload: Insuring that the client's arm is not swollen [20%]

Explanation Choices A and C are correct. Catheter embolus can be prevented by never reinserting the stylet into the catheter during insertion. Infiltration can be restricted by ensuring that the catheter is securely stabilized. Choice B is incorrect. Hematomas are a complication of intravenous therapy that can be prevented by a variety of interventions, which do not include starting the infusion before releasing the tourniquet. Hematomas can be avoided by releasing the tourniquet before initiating the intravenous flow. Other preventive measures include maintaining pressure over the intravenous insertion site when the intravenous therapy is discontinued and minimizing the duration of time that a tourniquet is in place during the intravenous therapy initiation process. Choice D is incorrect. Site ecchymosis is a complication of intravenous therapy that can be prevented by starting the infusion before releasing the tourniquet. Hematomas can be restricted by releasing the tourniquet before initiating the intravenous flow. Other preventive measures include maintaining pressure over the intravenous insertion site when the intravenous therapy is discontinued and minimizing the duration of time that a tourniquet is in place during the intravenous therapy initiation process. Site ecchymosis is not prevented by changing the intravenous site every 48 hours. Choice E is incorrect. Fluid overload is a complication of intravenous therapy that can be prevented by monitoring the rate of administration, checking the client's vital signs, monitoring the client's intake and output, assessing the client for the signs and symptoms of fluid overload, and ensuring that the client (particularly a confused client) cannot reach and manipulate the intravenous flow rate. Observing the client's arm for swelling is not a way to prevent fluid overload.

The nurse is planning care for a client with a borderline personality disorder. The nurse recognizes that the client will likely demonstrate which defense mechanism? Select all that apply. A. Splitting [26%] B. Sublimination [16%] C. Altruism [10%] D. Projection [30%] E. Conversion [18%]

Explanation Choices A and D are correct. Severe impairments in functioning characterize borderline personality disorder. Its major features are patterns of marked instability, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Splitting is a hallmark manifestation of this disorder in which an inability to view both positive and negative aspects of others as part of a whole, results in viewing someone as either a wonderful person or a horrible person. Projection is also a cardinal defense mechanism for this disorder in which an individual unconsciously rejects emotionally unacceptable features and attributes them to others. Choices B, C, and E are incorrect. Sublimination and altruism are generally constructive defense mechanisms and not employed by a client with BPD. Conversion is characterized by the unconscious transformation of anxiety into a physical symptom with no organic cause. Additional Info Borderline personality disorder is about five times more common in first-degree biological relatives with the same disorder compared with the general population. This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation. A key intervention for a client with BPD is to assess for suicidality. Parasuicide is common with this personality disorder; however, it is essential to keep this client safe. Defense mechanisms commonly seen in this personality disorder include splitting, projective identification, and denial.

While providing education to a group of expected mothers regarding the prevention of postpartum thrombophlebitis, you know they understand your teaching when they make which of the following statements? Select all that apply. A. "After we give birth, we are at an increased risk of clots for 6 to 8 weeks." [21%] B. "We shouldn't go on car rides longer than 4 hours for a few weeks after we give birth." [20%] C. "After delivery, we should get up and walk as soon as we are able to prevent clots from forming." [32%] D. "Trying not to cross our legs will help prevent clots from forming." [27%]

Explanation Choices A, B, C, and D are all correct. A is correct. Mothers are at an increased risk for clots for about 6 to 8 weeks after delivery. This is due to a natural increase in clotting factors in the body at this time. When there are increased clotting factors, clots form more readily. Therefore mothers are at risk for developing postpartum thrombophlebitis. B is correct. You should advise mothers not to go on car rides longer than 4 hours for a few weeks after they give birth. This is due to the increased amount of clotting factors present after birth, which puts them at higher risks for clots. Sitting still in a car for longer than 4 hours could be dangerous due to the likelihood of developing a clot. C is correct. This is excellent advice to share with expecting mothers. One of the essential ways to prevent postpartum thrombophlebitis is early ambulation. By encouraging them to get up and walk as soon as they are able, the likelihood of them developing clots will decrease. D is correct. One way to help prevent clots after delivery is by discouraging mothers from crossing their legs. When our legs are crossed for a prolonged period, increased pressure and immobility can lead to clot development. These mothers should be encouraged to ambulate as soon as they are able. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Maternal and Newborn Health; Postpartum

Which of the following clients require droplet precautions in addition to standard precautions as a priority? Select all that apply. A. A patient diagnosed with rubella [26%] B. A patient diagnosed with diphtheria [26%] C. A patient diagnosed with varicella [8%] D. A patient diagnosed with tuberculosis [9%] E. A patient diagnosed with MRSA [7%] F. An infant diagnosed with adenovirus [23%]

Explanation Choices A, B, and F are correct. Rubella, diphtheria, and adenovirus infections are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Choices C and D are incorrect. Airborne precautions are used for patients who have infections spread through the air with small particles, for example, tuberculosis, varicella, and measles. Choice E is incorrect. Contact precautions are used for infected or colonized patients by multidrug-resistant organisms (MDRO), such as MRSA. NCSBN Client Need Topic: Safe and Effective Care Environment; Subtopic: Safety and Infection Control

While working in the ICU, you are caring for a client receiving Total Parenteral Nutrition (TPN). Which of the following complications should the nurse monitor while this client receives TPN? Select all that apply. A. Pneumothorax [13%] B. Infection [40%] C. Air embolism [38%] D. Tamponade [9%]

Explanation Choices A, B, and C are correct. Pneumothorax is a possible complication of TPN administration. This is usually caused by incorrect catheter placement and is a medical emergency that requires the nurse to notify the health care provider immediately. Infection is a possible complication of TPN administration due to poor aseptic technique, contamination of the catheter, or contamination of the TPN solution itself. To prevent disease, the nurse should use careful aseptic technique when dealing with the catheter, monitor the patient's temperature, and frequently assess the IV site for signs of infection. Air embolism is a possible complication of TPN administration if the catheter system is opened or disconnected, allowing air to enter the IV tubing instead of the TPN solution. It is a nursing responsibility to ensure air never enters the catheter system by clamping all connections and ensuring the pipe is connected correctly. Choice D is incorrect. Tamponade is not a complication of TPN administration. Tamponade occurs when there is bleeding into the pericardial sac and an abrupt increase in the central venous pressure with a decrease in the systemic blood pressure. No complications of TPN administration would cause tamponade. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies Subtopic: Parenteral/Intravenous Therapies

Which of the following is correct when practicing the surgical aseptic technique? Select all that apply. A. Open sterile supplies or instruments away from your body to make sure contamination does not occur. [33%] B. If anything on the sterile field is contaminated, dispose of everything and start over. [32%] C. Only touch the outer 1 inch or less of the edge of the sterile feild. [18%] D. Apply both sterile gloves by touching their insides when applying. [16%]

Explanation Choices A, B, and C are correct. The surgical aseptic technique uses the "sterile to sterile" rule. Surgical asepsis is implemented using a sterile technique to remove all the pathogenic microorganisms. If anything is contaminated, it should be remedied immediately. Contaminated objects should be kept away from the sterile field. The nurse should avoid touching the sterile field as much as possible but is permitted to touch the outer one-inch edge of the field if necessary. Therefore, all of these options, A, B, and C, reflect proper sterile aseptic techniques. Choice D is incorrect. Only the first glove should be touched on the inside while applying. When applying sterile gloves, follow the procedure below: Apply the glove to the dominant hand first. Using the non-dominant hand, pick up the glove for the dominant hand by touching only the "inside" of the glove's cuff and then apply it to the dominant hand. Do not touch the outside of the first glove; touch only the inside part that will be next to your skin. With your sterile gloved hand, slip under the cuff of the other glove by grabbing the outside (not inside). With the gloved hand still under the cuff, slide the glove onto the non-dominant hand. Grabbing the outside of the second glove using a sterile gloved hand ensures your ungloved hand does not contaminate the outside of the sterile gloved hand when putting it on.

The nurse is educating a diabetic client regarding foot care. Which of the following statements by the client indicates that he understood the nurse's instructions? Select all that apply. A. "I need to check my feet daily for sores, blisters, dry skin, and cuts." [32%] B. "I need to wash my feet daily and keep them dry." [29%] C. "If I get sores or blisters on my feet, I should not pop them." [30%] D. "I need to apply cream to my heels and between my toes daily." [8%]

Explanation Choices A, B, and C are correct. These statements indicate that the client correctly understood the instructions. Due to the deficit in nerve sensation, some diabetic patients may not feel the ache of a blister or the sting of a cut on their feet. Vascular changes in diabetic patients may cause decreased perfusion of the tissues in the feet. If a wound of any type occurs, it may be slower to heal. Therefore, prevention is the best tool to protect a diabetic patient. It is important that the nurse teach diabetic foot care and ensure that the client has a clear understanding of the risks associated with poor foot care. The patient should be taught to check his feet daily for any signs of blisters, sores, or dryness, which can cause cracking (Choice A). The patient should keep the feet dry and this will prevent chafing from moisture (Choice B). A blister or sore should never be opened. If opened it may create a non-healing open wound because the healing time for a diabetic patient is often delayed (Choice C). Choice D is incorrect. Thin creams or lotions can be applied on the tops and bottoms of feet to keep the feet soft and prevent cracking. However, creams should not be applied between the toes because it promotes moisture, which can lead to chafing, blisters, and open wounds. Moisture between toes may also predispose to fungal infections. Instead, the skin between the toes should be kept dry by sprinkling talcum powder or cornstarch between the toes. NCSBN Client Need Topic: Health Promotions and Maintenance, Subtopic: Diabetic Foot Care

The nurse is evaluating a patient taking levothyroxine sodium for hypothyroidism. Which of the following findings indicate that the patient is experiencing side effects of this medication? Select all that apply. A. Slight heat intolerance [22%] B. Weight loss [19%] C. Bradycardia [11%] D. Constipation [13%] E. Insomnia [24%] F. Weight gain [12%]

Explanation Choices A, B, and E are correct. Levothyroxine sodium is taken to treat hypothyroidism. Side effects of levothyroxine sodium include some heat intolerance, weight loss, and insomnia. Choices C, D, and F are incorrect. Bradycardia, constipation, and weight gain are associated with hypothyroidism and should not be apparent while the patient takes levothyroxine sodium. NCSBN client need Topic: Physiological integrity, Pharmacological and Parenteral Therapies

The nurse is assessing a patient with pheochromocytoma. Which of the following would be an expected finding? Select all that apply. A. Hyperglycemia [19%] B. Hypertension [30%] C. Ataxia [9%] D. Oliguria [12%] E. Headache [30%]

Explanation Choices A, B, and E are correct. Manifestations of pheochromocytoma include hyperglycemia, hypertension, and headache. Other features associated with this condition include weight loss, anxiety, and palpitations. Choices C and D are incorrect. Ataxia, or uncoordinated movements, is not a feature of pheochromocytoma. Oliguria, or low urine output, is also not a feature of this condition. This would be a feature consistent with the syndrome of inappropriate antidiuretic hormone (SIADH). Additional information: Pheochromocytoma is a condition caused by a tumor that sits on the adrenal medulla. This causes a surge in catecholamine discharge resulting in headaches, palpitations, marked hypertension, and hyperglycemia. Treatment includes antihypertensives and removal of the tumor.

The RN is the only RN in the assisted care facility on a busy evening shift. Of the following tasks, the ones that can be safely delegated to an experienced LPN/LVN include: Select all that apply. A. Completing an admission assessment on a new patient [0%] B. Administering PO medications to patients on the unit [34%] C. Removal of a urinary catheter [33%] D. Completing a dressing change [32%]

Explanation Choices B, C, and D are correct. In general, LPN/LVN training allows those nurses to do those tasks that have the most predictable outcomes. That includes administering oral meds, removal of urinary catheters, dressing changes, and other similar jobs. The RN must understand the limits prescribed by the state's nurse practice act since some states allow more freedom than others. Choice A is incorrect. The LPN/LVN role does NOT include assessment, initial patient education, or any activity that requires critical nursing decision-making. NCSBN Client Need Topic: Management of Care, Sub-topic: Assignment and Delegatio

You are the nurse in the emergency department who is caring for a patient who was just admitted with nausea, vomiting, and epigastric pain. You note a blood pressure of 98/60 mmHg and a heart rate of 108 beats per minute during your assessment. You note a pulsating mass in his abdomen. You know that which of the following interventions are indicated? Select all that apply. A. Palpate the mass to determine the size [5%] B. Insert an intravenous solution of Lactated Ringers [25%] C. Prepare for an abdominal ultrasound [35%] D. Closely monitor the patient's vital signs [36%]

Explanation Choices B, C, and D are correct. You should recognize that this patient most likely has an abdominal aortic aneurysm (AAA). Given this possible diagnosis, you should insert an IV and draw lab work, including a type and crossmatch. You should anticipate that an abdominal ultrasound will be done to confirm the diagnosis. Recognizing that the patient's vital signs are abnormal and that bleeding is a likely issue, the team must closely monitor his vital signs. Choice A is incorrect. The nurse should NOT palpate the mass since this action may result in the rupture of the aneurysm. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Complications from Surgical Procedures; Critical Care; Cardiovascular

Which of the following opportunistic illnesses are a sign that a patient with HIV now has AIDS? Select all that apply. A. Stomach ulcers [9%] B. Symptomatic tuberculosis [29%] C. Toxoplasmosis of the brain [25%] D. Osteoporosis [4%] E. Pneumocystis carinii pneumonia [33%]

Explanation Choices B, C, and E are correct. Generally, tuberculosis (TB) does not affect those with healthy CD4 levels. Symptomatic TB is a sign of AIDS. An infection with Toxoplasmosis of the brain indicates a serious infection directly related to the condition. Affecting the lung, pneumocystis carinii pneumonia is typical of patients with AIDS and a serious sign of low CD4 counts. Choice A is incorrect. While some people with HIV or AIDS may have stomach ulcers, they are not indicative of an AIDS diagnosis. Choice D is incorrect. Osteoporosis, a condition where a reduction in bone strength increases a person's risk of bone breakage. This is not a sign of AIDS. NCSBN client need Topic: Physiological Integrity, Illness Management

Which of the following antepartum test results indicate a need to further follow up? Select all that apply. A. Contraction stress test - negative [19%] B. Nonstress test - reactive [15%] C. Contraction stress test - positive [31%] D. Nonstress test - nonreactive [36%]

Explanation Choices C and D are correct. A positive contraction stress test means the baby had decelerations in response to contractions and therefore, may not tolerate labor. Therefore, follow-up is needed (Choice C). A nonreactive nonstress test means that the baby did not have two or more 15 by 15 accelerations during the 20 minute test period and is not responding appropriately to movement. Follow-up would be needed for this test result, most likely with a contraction stress test (Choice D). Choice A is incorrect. In a contraction stress test, the result we want is negative. This means that the baby did not have decelerations in response to contractions. Follow up would not be needed for this test result. Choice B is incorrect. In a non-stress test, the result we want is reactive. This means that the baby had two or more 15 by 15 accelerations during the 20 minute test period and is responding appropriately to movement. Follow up would not be needed for this test result. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn

The nurse is assessing a client who gave birth to twins at 31 weeks of gestation and to a stillborn infant at 23 weeks of gestation. One year later, she had a spontaneous abortion at 12 weeks of gestation. She is currently pregnant at 25 weeks of gestation. It would be correct for the nurse to document this client's GTPAL as A. G4-T0-P2-A1-L2 [59%] B. G4-T0-P1-A2-L2 [23%] C. G4-T0-P1-A2-L3 [4%] D. G4-T1-P1-A1-L2 [14%]

Explanation G = 4, T = 0 (no pregnancies went to term), P = 2 (the twins count as 1 and the stillborn infant counts as 1 pregnancy ending in preterm birth), A = 1 (the 12 weeks spontaneous abortion), L = 2 (the two living children) Additional Info A method for calculating gravida and para is to separate pregnancies and their outcome using the acronym GTPAL: G = gravida, T = term, P = preterm, A = abortions, and L = living children. G = pregnancies or gravida, T = term pregnancies delivered, P = preterm pregnancies delivered, A = abortions (spontaneous and induced), and L = living children Term pregnancies are any pregnancy 37 weeks or greater; preterm is any pregnancy 20-36 weeks; abortions are any abortions spontaneous or induced prior to 20 weeks.

While assessing your patient in active labor, you evaluate the fetal monitor and note late decelerations and significantly decreased variability. The patient is on a Pitocin infusion. Upon observing this nonreassuring fetal heart rate, the nurse should take the following actions in what order? Identify the cause Stop the Pitocin infusion Change the mother's position Administer oxygen Prepare for delivery if unresolved.

Identify the cause Stop the Pitocin infusion Change the mother's position Administer oxygen Prepare for delivery if unresolved. Explanation The first action the nurse should take is to identify the cause of the nonreassuring fetal heart rate. Is the patient lying on her back? Is the Pitocin drip inappropriately titrated? There are many causes of nonreassuring fetal heart rates, and sometimes a simple intervention can fix the problem. After the nurse tries to identify the cause, she should stop the Pitocin infusion. Remove the potential cause or contributing factor first. Even if the fetal heart rate seems to be improving, the Pitocin infusion should be stopped to prevent any further decelerations or decreased variability. Next, the nurse should change the mother's position and lay the mother in the left lateral position. If she is on her back, the fetus could be putting pressure on her descending aorta, or the fetus could be compressing the umbilical cord, and a simple change of position will resolve this. Next, the nurse should begin administering oxygen to the mother via a simple face mask at 8-10 L/min. This will optimize oxygenation to the fetus. Lastly, if still unresolved, the nurse needs to prepare for an emergency delivery. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Medical Emergencies