Archer Review 1t

The nurse is triaging a child with bilateral lower extremity chemical burns. The nurse suspects that the child may have been abused. The nurse should take which initial action? A. Cover the affected area with sterile dressing [13%] B. Irrigate the affected area with saline [46%] C. Report the suspected abuse [38%] D. Document the findings [2%]

Explanation Choice B is correct. A common mnemonic to remember is "the solution to pollution is dilution." When a client has a chemical burn, the highest priority is to copiously irrigate it (dilute it) with saline or water. Prompt irrigation of the area exposed to caustic substances ( acid, alkali) dilutes the chemical, attempts to neutralize the pH change in the skin, and decreases the extent of the dermal injury. Additionally, dilution lessens the risk of the caregiver getting burned by the chemical. Choices A, C, and D are incorrect. All of these actions are appropriate, but the nurse should not prioritize these actions over caring for the client's immediate physical needs ( applying Maslow's hierarchy while answering priority questions, one should address the physical needs first). Before suspected abuse should be reported ( Choice C), the nurse should stabilize the client. Irrigation to decrease further damage to the client's integument is the highest priority with any chemical burn. Learning Objective Prioritize immediate irrigation to lessen the risk of further damage to the client with a chemical injury. Additional Info In the case of chemical injuries, decontamination is the focus of urgent treatment. Contaminated clothing is removed, and chemicals in powder form are brushed off. Then the burn is irrigated with copious amounts of water.

The nurse is reviewing a new prescription for amphotericin b. The nurse understands that this medication treats A. autoimmune infections. [14%] B. fungal infections. [49%] C. viral infections. [6%] D. bacterial infections. [30%]

Explanation Choice B is correct. Amphotericin B is a powerful antifungal indicated in treating systemic fungal infections. This medication requires pre-medication with isotonic saline, diphenhydramine, and acetaminophen to help decrease the symptoms of fever, chills, and rigors associated with the infusion. Choices A, C, and D are incorrect. Amphotericin B is an antifungal that targets various fungal species, including Candida Albicans. Additional Info Nursing care for a client receiving amphotericin b includes: Anticipating that the client will be premedicated with isotonic saline, diphenhydramine, ondansetron, and acetaminophen. A corticosteroid may be used in lieu of diphenhydramine. During the therapy, the client may experience fever, chills, rash, rigors, and nausea. Thus, this is why premedication may be necessary. Monitoring the client's creatinine and potassium. This medication is known to decrease serum potassium. Potassium supplementation is likely. Amphotericin b is nephrotoxic, and the creatinine should be closely monitored.

The nurse is assessing a client experiencing psychosis. The client states, "I am convinced my wife and brother-in-law want to kill me." The nurse interprets this statement as a A. delusion of reference. [16%] B. delusion of persecution. [72%] C. delusion of grandeur. [9%] D. delusion of erotomania. [3%]

Explanation Choice B is correct. Delusion of persecution is when an individual is falsely convinced someone is out to get them or intends to cause them harm. This is a serious delusion because the client may react with violence. Choices A, C, and D are incorrect. A delusion of reference is when an individual is convinced that something they are observing is explicitly meant for them. For example, a client is watching a television newscast about a wanted individual and is convinced that the individual is them. Delusion of erotomania occurs when an individual is convinced that someone is in love with them. Delusion of grandeur is when an individual has a self-inflated view of themselves. Additional Info Key interventions for a client experiencing a delusion include - Build trust by being open, honest, genuine, and reliable. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner. Ask the client to describe their beliefs. Do not use avoidance. Inquire about the delusion and its content. Never debate the delusional content. Validate if part of the delusion is real. Example - "Yes, there was a package at the nurses' station, but it did not contain a recording device."

A client with a left-sided pneumothorax had a chest tube inserted 3 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. What should be the nurse's first action? A. Auscultate the client's chest wall. [16%] B. Assess the tubing for any kinks. [76%] C. Instruct the client to take deep breaths. [3%] D. Ask the client to turn from side to side. [4%]

Explanation Choice B is correct. If there is no fluctuation in the water seal chamber, the nurse should first check the integrity of the chest tubes from the client's chest wall down to the Pleurovac for dependent loops or kinks. Choice A is incorrect. The nurse should assess for breath sounds but should determine why there is no fluctuation in the water-seal chamber first. Re-expansion of the lungs after 3 hours is too early to occur. Choice C is incorrect. The nurse should check the tubing for kinks or dependent loops first; afterward, the nurse can tell the client to deep breathe and cough to push out blockages through the pipe. Choice D is incorrect. Turning the client does not aid in troubleshooting the problem for the client.

The nurse is caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider? A. Trazodone [16%] B. Modafinil [47%] C. Diazepam [26%] D. Fluoxetine [11%]

Explanation Choice B is correct. Narcolepsy is a disorder characterized when a client unexpectedly falls asleep in the middle of normal daily activities. Agents to keep the client awake during the day are the treatment goal. A common medication used is modafinil. Modafinil is a central nervous stimulant dosed during daylight hours to keep the client alert. Choices A, C, and D are incorrect. The treatment goal for narcolepsy is for the client to stay awake during the day. Trazodone and diazepam are central nervous system depressants and would cause sleepiness. Fluoxetine is not indicated in the treatment of narcolepsy as this medication modulates serotonin and is helpful for anxiety and depressive disorders. Additional Info Narcolepsy is a condition characterized by the client experiencing 'sleep attacks,' which may cause serious injury if one should occur while the client is driving, etc. The client with narcolepsy may also have Cataplexy, a sudden skeletal muscle weakness. The condition is often associated with strong emotions (e.g., joy, anger), and commonly the knees buckle, and the individual falls to the floor while still awake.

The nurse is caring for a client who sustained an ischemic cerebrovascular accident (CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg. The nurse should take which action? A. Place the client supine [11%] B. Continue to monitor [21%] C. Obtain orthostatic blood pressure [9%] D. Request a prescription for an antihypertensive [59%]

Explanation Choice B is correct. Permissive hypertension during an ischemic stroke allows the blood pressure to go up to 185/110 mm Hg. This enables perfusion around the stroke to distal tissue. A blood pressure of 150/100 mm Hg is needed to maintain cerebral perfusion after an acute ischemic stroke; pressures above this reading may lead to an extension of the stroke. Choice A, C, and D are incorrect. Placing the client supine during a stroke is contraindicated because of its increase in the intracranial pressure. Orthostatic blood pressure is not indicated and is usually performed if hypovolemia could cause hypotension, not hypertension. An antihypertensive is not necessary based on this blood pressure. Additional Info Labetalol is a common antihypertensive used when a client has an ischemic stroke and has a blood pressure greater than 185/110 mm Hg.

When an elderly home health client suddenly develops delirium, what is the first thing the home health nurse should assess for? A. Drug intoxication [84%] B. Increased hearing loss [8%] C. Cancer metastases [1%] D. Congestive heart failure [6%]

Explanation Choice A is correct. Drug intoxication, from prescription or OTC medications, is more common in the elderly, due to slower metabolism and absorption. Combinations of digoxin, diuretics, analgesics, and anticholinergics should be examined. Delirium is an acute and reversible syndrome. It is characterized by changes in memory, judgment, language, mathematical calculation, abstract reasoning, and problem-solving ability. The most common causes of delirium are infection, medications, and dehydration. Some symptoms of delirium include: Hallucinations Restlessness, agitation, or combative behavior Calling out, moaning, or making other sounds Being quiet and withdrawn — especially in older adults Slowed movement or lethargy Disturbed sleep habits Reversal of night-day sleep-wake cycle Choices B, C, and D are incorrect. Although the other options can lead to delirium, the onset is gradual, not sudden. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Health Assessment and Promotion

The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity? A. Constricted pupils [56%] B. Hypertension [8%] C. Coarse Tremors [31%] D. Diarrhea [5%]

Explanation Choice A is correct. Fentanyl is an opioid. A clinical feature of opioid toxicity includes central nervous system depression that manifests as lethargy leading to somnolence. Further, the client will have pupillary constriction, bradypnea, and decreased gastrointestinal motility. Since this client is receiving mechanical ventilation, respiratory depression would not be a reliable finding. Choices B, C, and D are incorrect. Manifestations of opioid toxicity would consist of hypotension, not hypertension, because of the effects of histamine. Tremors and diarrhea are not a finding consistent with opioid toxicity. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Adverse Reactions Question type: Knowledge/comprehension Additional Info Opioids such as fentanyl, morphine, hydromorphone, and oxycodone may produce life-threatening manifestations if taken in excess. Opioid use disorder is a treatable illness through medication-assisted treatment and psychotherapy. Treatment of acute opioid toxicity includes stopping the offending agent and the administration of naloxone.

The med-surge nurse is caring for a patient who is receiving enteral feedings. What is the most effective method to verify initial tube placement is correct? A. Obtain chest and abdominal x-rays. [82%] B. Aspirate the contents to assess pH range. [11%] C. Mark tubing at the exit site and record the length of tubing that protrudes. [1%] D. Insert 20-30 mL of air into the tube while auscultating the epigastrium. [5%]

Explanation Choice A is correct. Getting chest and abdominal x-rays are the gold standard to verify that the enteral tube placement is correct. Choice B is incorrect. Testing pH may help to identify a problem but is not the most specific or reliable way to confirm placement. Respiratory and small intestine secretions have a pH greater than 6. Gastric pH ranges from 1-5 in fasting patients, or up to 6 if on gastric acid-reducing medications. Choice C is incorrect. This may be done, but does not verify or confirm that the initial placement is correct. Choice D is incorrect. This method is subjective and is not considered a reliable way to confirm tube placement. NCSBN Client Need Topic: Skills/procedures, Subtopic: nutrition and oral hydration, diagnostic tests, system-specific assessments

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate follow-up? A. Disorientation [83%] B. High urine specific gravity [6%] C. Oliguria [7%] D. Excessive thirst [4%]

Explanation Choice A is correct. Hyponatremia is a classic clinical feature associated with syndrome of inappropriate anti-diuretic hormone (SIADH). The hyponatremia may become severe and cause the client to have altered mental status (AMS). This AMS is concerning because this signals that the serum sodium is quite low and warrants immediate intervention. Choices B, C, and D are incorrect. Expected findings associated with SIADH include increased urine-specific gravity, oliguria, and excessive thirst. These are expected findings, so they would not require immediate follow-up. Additional information: AMS is a clinical feature of severe hyponatremia (sodium less than 125 mEq/L). This finding warrants immediate follow-up because the risk for seizures and further neurological decline at this level is quite high. The nurse should initiate seizure precautions and notify the primary healthcare provider (PHCP) of this finding. SIADH may be induced by selective serotonin reuptake inhibitors, mood stabilizers (carbamazepine), and antidiabetics such as chlorpropamide. Other causes include malignancy and traumatic brain injuries. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Alterations in Body Systems

The nurse is reviewing isolation precautions for patient room assignments on the nursing unit. Which patient room assignment requires follow-up? See the exhibit. A. Room 1 [44%] B. Room 2 [14%] C. Room 3 [20%] D. Room 4 [21%]

Explanation Choice A is correct. Lyme disease is not transmitted human-to-human. This client should be placed on standard precautions as contact precautions are inappropriate. This client requires follow-up as the contact precautions are inappropriate. Choices B, C, and D are incorrect. Varicella requires a client to be placed on airborne and contact precautions until the lesions are dry and have crusted. Mumps requires droplet precautions. HIV does not require isolation precautions. Additional Info Standard precautions require the nurse to wash their hands and use additional personal protective equipment (PPE) as appropriate. Contact precautions require the nurse to wear gloves and a fluid resistance gown while in the room. Droplet precautions warrant the nurse to wear a surgical mask. Airborne precautions require the nurse to wear an N95 respirator during client care.

The nurse is caring for a client who is prescribed enoxaparin. Which of the following findings in the medical history would require follow-up with the primary healthcare physician (PHCP)? A. Recent spinal surgery [44%] B. Diabetes mellitus [6%] C. Osteoarthritis [6%] D. Venous thromboembolism [44%]

Explanation Choice A is correct. Recent spinal surgery requires follow-up with the prescription of enoxaparin. This medication may cause a hematoma, which may consequently cause severe neurological impairment. Choices B, C, and D are incorrect. Diabetes mellitus and osteoarthritis are not contraindications for enoxaparin. Further, enoxaparin is utilized in the management of venous thromboembolism. Additional Info Enoxaparin is a low molecular weight-based heparin that does not require monitoring the partial thromboplastin time (PTT). The nurse still needs to monitor the client for bleeding as well as heparin-induced thrombocytopenia (HIT). HIT would manifest as a reduction of platelets and may seriously cause thrombosis elsewhere. Contraindications to administering enoxaparin include recent spinal surgery, epidural, peptic ulcer disease, thrombocytopenia, and uncontrolled hypertension.

The nurse is caring for a client who is diagnosed with acute appendicitis. After several hours of pain, the client suddenly states a relief in his pain. What is the initial action of the nurse? A. Notify the physician [93%] B. Document the finding [5%] C. Insert an IV cannula [2%] D. Administer a laxative [0%]

Explanation Choice A is correct. The nurse should notify the physician immediately to assess the client and prepare for surgery since this could signify a rupture of the appendix; any delay could cause peritonitis. Choice B is incorrect. The nurse needs to document the finding, but only after necessary interventions are initiated. Choice C is incorrect. The nurse can insert an IV cannula during preparations for surgery. However, the initial action of the nurse is to notify the physician. Choice D is incorrect. The nurse should never administer a laxative, an enema, or apply heat to the abdomen since any of these can cause perforation of the bowels.

The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL. Which action should the nurse take next? A. Evaluate the client for non-adherence. [25%] B. Instruct the client to skip the next scheduled dose. [1%] C. Assess the client for VPA toxicity. [51%] D. Document the result as within normal limits. [22%]

Explanation Choice A is correct. The therapeutic VPA level is 50-125 mcg/mL. A VPA level of 40 mcg/mL is considered sub-therapeutic and requires follow-up as the client is at risk of seizure. Choices B, C, and D are incorrect. Skipping the next dose of VPA, assessing for toxicity, and documenting the result as therapeutic/within normal limits would be inappropriate as a level of 40 falls outside of the therapeutic range. Additional Info VPA is indicated in preventing seizures, treatment for bipolar disorder, and migraine headache prevention. The most common adverse effects of VPA include nausea, vomiting, blood dyscrasias, hair loss, and metabolic syndrome. The liver enzymes should be monitored while a client takes VPA as hepatic injury may occur.

What is the most important factor to consider when assessing a home health patient on the risk of falls? A. Correct illumination of the environment [93%] B. Amount of regular exercise [2%] C. The resting pulse rate [3%] D. Status of salt intake [2%]

Explanation Choice A is correct. To prevent falls; the environment should be well lit. Night lights should be used if necessary. Other factors in assessing include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate. While home health nurses cannot expect to change a family's living space and lifestyle, they can express their concern and react appropriately when a situation suggests that an injury is imminent. Nurses must document information they provide and the family's response to the instruction and make ongoing assessments about the family's use of safety precautions. Walkways and stairways (inside and outside) should also be inspected. Note any uneven sidewalks or paths, broken or loose steps, absence of handrails, or placement on only one side of stairs, insecure bars, congested hallways, or other traffic areas, and adequacy of lighting at night. Some important things for the home health nurse to assess, educate the patient about, and document include: Floors: Note uneven and highly polished or slippery floors and any unanchored rugs or mats. Furniture: Note the hazardous placement of furniture with sharp corners. Note chairs or stools that are too low to get into and out of or that provide inadequate support. Bathroom(s): Note presence of grab bars around tubs and toilets, nonslip surfaces in bathtubs and shower stalls, handheld showerhead, adequacy of night lighting, need for a raised toilet seat or bath chair in tub or shower, ease of access to shelves, and water temperature regulated at a maximum of 49 °C (120 °F). Choice B is incorrect. The amount of regular exercise is not the most critical factor to assess. It is only indirectly related. Choice C is incorrect. The resting pulse rate is not related to preventing falls. Choice D is incorrect. The salt intake is not directly related to preventing falls. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control, Selected Dimensions of Home Health Nursing

Select the therapeutic communication technique that is accurately paired with an example of it. A. Reflecting: "I really believe that you should not be thinking in this self-destructive and self-deprecating manner." [3%] B. Seeking clarification: "I am sorry. Could you restate that thought so I can be clear about what you are saying?" [81%] C. Offering of self: "I am here to talk with you about your fears because you have refused to talk about these before." [13%] D. Probing: "It is now time for you to start telling me about your substance abuse problem without further delay." [2%]

Explanation Choice B is correct. "I am sorry. Could you restate that thought so I can be clear about what you are saying?" is an example of seeking clarification, which is a therapeutic communication technique. Seeking clarification aims to ensure that the receiver of the message is precise and clear about the meaning of the sender's word. Choice A is incorrect. "I believe that you should not be thinking in this self-destructive and self-deprecating manner" is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should allow the client to ventilate these feelings and then attempt to work with the client to resolve these feelings. Choice C is incorrect. "I am here to talk with you about your fears because you have refused to talk about these before" is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should offer help and allow the client to vent their fears and concerns in an environment of openness, trust, caring, and compassion. Choice D is incorrect. "It is now time for you to start telling me about your substance abuse problem without further delay" is not at all a therapeutic communication technique. It is highly authoritative, judgmental, and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should not probe the client but, instead, allow the client to ventilate about their substance abuse problem in an environment of openness, trust, caring, and compassion.

The nurse is completing an assessment on a 6-year-old client with asthma. Which of the following assessment findings is of most concern to the nurse? A. Expiratory wheezing [21%] B. Silent chest [64%] C. Cough [1%] D. Head bobbing [15%]

Explanation Choice B is correct. Silent chest is the assessment finding of most concern. This refers to the inability to auscultate any lung sounds. There is complete obstruction of the patient's airway and therefore the inability to move air. When complete obstruction occurs, this is a medical emergency. This assessment finding is of most concern because the client has lost their airway. Choice A is incorrect. Expiratory wheezing is an expected finding when a client is having an asthma exacerbation. This occurs when there is inflammation in the airways and air trapping, making it hard for the client to fully exhale all of the air in their lungs. The wheezing is audible as they attempt to exhale. Although it is a significant finding, it is not the finding of most concern in this question, because the client still has a patent airway. Choice C is incorrect. A cough is an expected finding when a client is having an asthma exacerbation. This finding is not of most concern. Choice D is incorrect. Head bobbing is an indication of increased work of breathing in the pediatric client experiencing an asthma exacerbation. It occurs when the child's head moves forward each time they take a breath. This finding is significant and an indication that further support is needed, but it is not the priority. This is categorized under "B" for breathing, while there is another assessment finding falling under the "A" for airway which is the priority. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological adaptation, Pediatric - Respiratory

The nurse is giving discharge instructions to the patient regarding his antihypertensive medication, amlodipine. Which statement by the client would necessitate further teaching from the nurse? A. "I need to inform my doctor if I want to stop my medication." [4%] B. "I'll just eat more whenever I feel nauseous." [38%] C. "I must take my medication an hour before my meal." [7%] D. "I don't need to worry about dizziness because it will just pass after a few days." [51%]

Explanation Choice B is correct. The client is instructed to eat small frequent meals when nausea develops, not eat more substantial meals. Choice A is incorrect. This statement does not need further teaching. The client must inform the prescribing physician whenever the client wants any changes to his medication. Choice C is incorrect. Taking the medication an hour before meals or 2 hours after meals ensures optimum absorption of the drug. Choice D is incorrect. The initial side effect of amlodipine is dizziness. The client is advised that the dizziness will go away after a few days of treatment. However, if dizziness persists for more than a week, the client needs to contact his health care provider.

Your client is expressing feelings of dread and impending danger. As you allow the client to freely express these feelings, you attempt to determine the cause of these feelings but are unable to identify the source. What is the most likely nursing diagnosis for this client? A. Fear related to an unidentifiable source [37%] B. Anxiety related to an unidentifiable source [51%] C. Ineffective coping related to a source that is not based on reality [10%] D. Maladaptive coping related to a source that is based on reality [2%]

Explanation Choice B is correct. The most likely nursing diagnosis for this client is "anxiety related to an unidentifiable source". Unlike fear, anxiety can result from an unidentifiable source as well as one that is identifiable. Fear is related to an identifiable source. Choice A is incorrect. Fear is related to an identifiable source and not an unidentifiable source. Choice C is incorrect. The nursing diagnosis of "ineffective coping related to a source that is not based on reality" is not accurate because this client's feelings may or may not be based on reality. Choice D is incorrect. The nursing diagnosis of "maladaptive coping related to a source that is based on reality" is not accurate because this client's feelings may or may not be based on reality.

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with sandbag [5%] B. Palpate pedal pulses [64%] C. Assess for signs of claudication [27%] D. Apply warm compress to incision sites [4%]

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

The sense of hearing is assessed using which standardized test? A. Taylor test [4%] B. Rinne test [94%] C. Babinski test [1%] D. APGAR test [1%]

Explanation Choice B is correct. The sense of hearing is assessed using the Rinne test, Weber test, and a tuning fork. Choice A is incorrect. A Taylor hammer, not a Taylor test, is used to check reflexes like the biceps and triceps reflexes. Choice C is incorrect. The Babinski sign occurs when the foot goes into dorsiflexion and the great toe curls up; this sign is an abnormal response to this stimulation and can indicate the presence of neurological lesions. Choice D is incorrect. The APGAR test is used to assess the neonate immediately after birth in terms of the infant's appearance, grimace, reflexes, skin color, and respiratory rate/effort. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: sensation, Perception & Cognition

The nurse is caring for an infant with the below tracing on the electrocardiogram (ECG). The nurse should plan to take which initial action? See the image below. A. Instruct the infant to beardown. [17%] B. Prepare a bag filled with ice and water. [25%] C. Assess the infant's axillary temperature. [25%] D. Obtain the infant's carotid pulse. [32%]

Explanation Choice B is correct. This tracing reflects SVT, which is concerning because of the very high rate. The rate may be as high as 100 to 280 beats/min in adults. Characteristically, SVT does not have P-waves as they are buried in the T-waves. Preparing a bag filled with ice and water is essential because this may be applied to the face above the nose and mouth for 15 to 30 seconds. If that is not effective, another vagal maneuver would be pressing the infant's knees to the chest for 15-30 seconds. Choices A, C, and D are incorrect. Instructing an infant to beardown would be futile because the infant does not have the cognitive ability to follow this instruction. This is the instruction that could be provided to a child or adult. Assessing the infant's axillary temperature would not have clinical significance because of the necessity to break the SVT. While SVT may be caused by severe febrile illness, the infant's rhythm must be corrected. The pulse on an infant should be obtained via the brachial artery. Additional Info During SVT, P waves may not be visible, because the P waves are embedded in the preceding T wave. A client with SVT may be asymptomatic. If the client is symptomatic, they may exhibit manifestations such as palpitations, dizziness, dyspnea, and nervousness. Treatment includes vagal maneuvers. Vagal maneuvers include having the beardown, blowing through a straw, having the primary healthcare provider (PHCP) perform a carotid massage, and, if the client is an infant, applying a bag filled with ice and water to the face above the nose and mouth for 15 to 30 seconds. If that is not effective, another vagal maneuver would be pressing the infant's knees to the chest for 15-30 seconds. If these measures are ineffective, the nurse should prepare to administer the prescribed adenosine by rapid intravenous push (IVP) that is followed by a flush of 0.9% saline. When adenosine is administered, the emergency (code) cart should be nearby, and the nurse should always have additional personnel in the room.

The nurse is caring for a client with herpes simplex virus who is experiencing an outbreak. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe? A. Metronidazole [3%] B. Valacyclovir [94%] C. Imiquimod [1%] D. Fluconazole [2%]

Explanation Choice B is correct. Valacyclovir is an antiviral and is effective in the management (and prevention) of outbreaks associated with herpes simplex virus (HSV). A client will either take this during an outbreak or daily to prevent an outbreak (called suppressive therapy). It is highly recommended that the client start this medication at the earliest sign of an outbreak which is the prodromal symptoms of headache, fever, malaise, itching, and burning in the affected area. Choices A, C, and D are incorrect. Metronidazole is an antibiotic and ineffective for HSV. Metronidazole is effective for some sexually transmitted infections and anaerobic bacteria. Imiquimod is indicated in the treatment of genital warts and certain skin cancers. Fluconazole is an antifungal agent indicated in a variety of fungal infections. Additional Info Herpes simplex virus (HSV) is both sexually and non-sexually transmitted. The client often experiences the worst symptoms during the initial outbreak, which include headache, malaise, fever, and localized lymphadenopathy. Following these prodromal symptoms, painful skin eruptions occur, putting the client at higher risk of transmitting the infection. The client should be educated that even when an outbreak is not present, they risk infecting others with the virus. Medications to manage outbreaks are best taken early and include valacyclovir.

As you are taking the "staff only" elevator, you encounter a nurse who is now caring for a client, Mr. B, whom you provided care for the week before. You ask the nurse how Mr. B is doing, and the nurse tells you how significantly his condition has deteriorated over the past week. You have now: A. Asked an appropriate question since you are in a private, staff-only elevator. [68%] B. Violated Mr. B's right to healthcare information privacy. [23%] C. Demonstrated your compassion for Mr. B. [4%] D. Asked an appropriate question since you anticipate Mr. B will return to you as a client shortly. [4%]

Explanation Choice B is correct. You have violated Mr. B's right to healthcare information privacy under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, under the Privacy Rule contained within HIPAA, healthcare providers may exchange information with other healthcare workers who are actively involved in patient care. Given the information provided in the question, you are no longer actively involved in Mr. B's patient care, therefore making the provision of any information to you a HIPAA violation. Even if you were involved in Mr. B's care, to comply with HIPAA, any information provided to you would need to be the bare minimum necessary to perform the task which you needed to perform. Additionally, despite being a "staff only" elevator, conversations involving confidential client information should never be held in public locations, including "staff only" elevators. Choice A is incorrect. You have asked an inappropriate question in an inappropriate location. The location is also inappropriate, as there is no information provided within the question stating whether there are or are not other hospital staff members on the elevator. Other hospital staff may enter or exit the elevator at any time during your discussion. Additionally, the question is inappropriate under HIPAA, as you are no longer providing any type of care for Mr. B. Choice C is incorrect. Although you may have asked this question because you consider yourself a compassionate nurse, you have violated the confidentiality of Mr. B's private healthcare information under HIPAA, as you are no longer actively involved in Mr. B's care. Being a compassionate nurse does not exempt you from the following federal law set forth under HIPAA. Choice D is incorrect. Although you may anticipate the return of Mr. B to your care in the future, he is not actively your client at this time. Unless you are actively involved in Mr. B's care at the time information is received, any receipt of Mr. B's healthcare information in this scenario would be considered unnecessary and inappropriate (i.e., a violation) under HIPAA. Learning Objective Recognize that the question asked violated the client's right to healthcare information privacy. Additional Info The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, was enacted into federal law to ensure that patient medical data remains private and secure. The Minimum Necessary Standard is a key protection of a portion of HIPAA known as the Privacy Rule which states that health information should not be disclosed when it is not needed to satisfy a particular purpose or perform a function. This rule also applies to other healthcare providers who may be exchanging information with other healthcare workers who are actively involved in patient care (i.e., "need to know" basis).

The nurse is assessing a child with glomerulonephritis. Which assessment finding requires follow-up by the nurse? A. Periorbital edema [29%] B. Decreased urine output [17%] C. Headache [28%] D. Hematuria [26%]

Explanation Choice C is correct. A complication of glomerulonephritis is encephalopathy caused by severe hypertension associated with the disease process. A client's report of a headache should clue the nurse into checking the client's blood pressure. The client should be monitored for this potential complication, which can be avoided by closely monitoring the client's blood pressure. Choices A, B, and D are incorrect. These manifestations are associated (and expected) with glomerulonephritis and do not require follow-up. Additional Info AGN is a serious condition secondary to many infectious processes such as streptococcal infections, mononucleosis, and hepatitis. Nursing care aims to prevent the most common complications, including fluid volume overload and hepatic encephalopathy. The client may have dietary restrictions such as fluid, sodium, and potassium. The nurse should monitor the client's intake and output, weight, and blood pressure.

The nurse is working in the NICU for the morning shift. While assessing four neonates less than 6-hours old, which neonate warrants additional attention from the nurse? A. A neonate with a molded head and overriding sutures. [3%] B. A neonate with cyanotic hands and feet that has not passed meconium. [19%] C. A neonate that is spitting up excessive mucus, with a temperature of 36.1 °C (97°F), and is dusky in appearance. [55%] D. A neonate with abdominal respirations and intermittent tremors of the extremities. [23%]

Explanation Choice C is correct. A neonate is expected to be pinkish in appearance. Saliva should be minimal and the normal temperature for a newborn is from 36.5 °C to 37 °C. These signs need to be evaluated by the nurse to determine whether the baby needs further assessment. Choice A is incorrect. Molding and overriding sutures in a neonate are normal and may persist for a few days. Choice B is incorrect. Acrocyanosis in the newborn may be present for 2 to 6 hours. Meconium is expected to be passed within 24 hours after delivery. Choice D is incorrect. Tremors in the neonate are common. There is no need to worry about this sign.

The nurse is assessing a client who has a pneumothorax. Which of the following assessment findings should the nurse expect? A. Blood-tinged sputum [5%] B. Increased anterior-posterior diameter [5%] C. Reduced breath sounds on the affected side [74%] D. Auscultation of a loud, rough, grating sound [15%]

Explanation Choice C is correct. A pneumothorax has clinical features such as reduced breath sounds on the affected sides, tachypnea, dyspnea, and pleuritic chest pain. Some clients may be asymptomatic, depending on the size of the pneumothorax. Choices A, B, and D are incorrect. A pneumothorax does not have features such as blood-tinged sputum, increased AP diameter (this is a feature in COPD), or auscultation of a loud, rough, grating sound. Additional Info Pneumothorax may be caused by trauma to the chest wall secondary to a traumatic injury. Pneumothorax may also adversely develop during the placement of a subclavian or intrajugular central line. The priority treatment for clients unstable with pneumothorax is the placement of a chest tube.

The nurse is performing an assessment on a client. The client tells the nurse, "You people are part of the government plotting to destroy me." The nurse should respond with which appropriate statement? A. "Would you like me to come back later for your assessment?" [3%] B. "I believe you and think we should explore why you feel this way." [8%] C. "Tell me more about someone trying to destroy you." [72%] D. "Let us talk about your current medication and how it can help with those thoughts." [16%]

Explanation Choice C is correct. Exploring the content of the client's delusion is important because this assessment will determine if the delusion has any logic (unlikely) and will help foster a therapeutic relationship with the client. Helping the client come to the realization that the delusion is just that; a delusion can be a challenge. This challenge is often mitigated when a therapeutic rapport is established. Choices A, B, and D are incorrect. Diverting the assessment shows avoidance and is a missed opportunity in intervening in a delusion that may cause a client to react with violence. Avoidance is never therapeutic. Stating that you believe the client is not appropriate. While it is important to explore the client's thought content, validating that someone is after the client, etc., further reinforces the delusion. The nurse should only validate the delusion if it is real. Discussing the treatment plan, while important, does not explore the content of the delusion, which is important. Additional Info Key interventions for a client experiencing a delusion include - Build trust by being open, honest, genuine, and reliable. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner. Ask the client to describe their beliefs. Do not use avoidance. Inquire about the delusion and its content. Never debate the delusional content. Validate if part of the delusion is real. Example - "Yes, there was a package at the nurses' station, but it did not contain a recording device."

The nurse is caring for a client prescribed amphotericin b. Which laboratory data is necessary for the nurse to monitor during treatment? A. Triglycerides [18%] B. Hemoglobin A1C [11%] C. Potassium [59%] D. High-density lipoprotein (HDL) [10%]

Explanation Choice C is correct. Hypokalemia is a common adverse reaction associated with amphotericin b therapy. Hypokalemia associated with this medication is caused by the kidneys leaking the potassium via the collecting ducts. Potassium supplementation may be necessary during the amphotericin b therapy. Choices A, B, and D are incorrect. Significant lipid levels and hemoglobin A1C alteration is not associated with amphotericin b. Additional Info Nursing care for a client receiving amphotericin b includes: Anticipating that the client will be premedicated with isotonic saline, diphenhydramine, ondansetron, and acetaminophen. A corticosteroid may be used in lieu of diphenhydramine. During the therapy, the client may experience fever, chills, rash, rigors, and nausea. Thus, this is why premedication may be necessary. Monitoring the client's creatinine and potassium. This medication is known to decrease serum potassium. Potassium supplementation is likely. Amphotericin b is nephrotoxic, and the creatinine should be closely monitored.

Which of the following interventions is helpful in reducing the effects of GERD? A. Lie down after eating. [9%] B. Wear a girdle. [1%] C. Elevate the head of the bed on 4-6 inch blocks. [86%] D. Increase fluid intake just before bedtime. [4%]

Explanation Choice C is correct. Patients should be encouraged to elevate the head of the bed to allow food to move out of the stomach before lying flat. GERD occurs when stomach acid slips into the esophagus. Any position that hinders or slows the movement of food from the stomach should be avoided. Choice A is incorrect. Lying down after eating causes the movement of food out of the stomach to slow, which could aggravate symptoms. Choice B is incorrect. The compression of the stomach reduces its volume and those who wear girdles or waist trainers find that overeating gives them indigestion and heartburn. Choice D is incorrect. When a patient lies in bed shortly after eating or drinking, gravity is not as quickly keeping digestive juices in the stomach. Eating or drinking more than three to four hours before bed reduces the risk of nighttime heartburn. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse is caring for a 2-year-old client who is intubated and mechanically ventilated. Two hours into the shift, the hospital receives a tornado warning. What is the priority action the nurse should take? A. Clock out, her shift is over, and she is not responsible. [0%] B. Remove the child from the ventilator and carry her to a tornado shelter. [4%] C. Move the patient as close to the interior of the room as possible. [68%] D. Close all of the doors. [28%]

Explanation Choice C is correct. The priority action for the nurse is always to "best protect her patient." During a tornado warning, the appropriate nursing action is to move patients away from windows and as close to the room's interior as they can safely be moved. This action best protects them in the event of a tornado. Choice A is incorrect. It is not appropriate to clock out because her shift is over. The nurse is always responsible for her patients' safety, so clocking out does not best protect her patient. Choice B is incorrect. It is inappropriate to remove the child from the ventilator because it could result in serious harm and even death if the child is dependent on mechanical ventilation. Choice D is incorrect. Closing all of the doors will not protect the patient during a tornado. This is an appropriate action in some fire events depending on the fire's location, but never for a tornado. NCSBN Client Need Topic: Effective, safe care environment; Subtopic: Infection control and safety

Which of the following sacred symbols is most similar to rosary beads that are a sacred symbol for Catholics? A. A sari for a female Hindu believer [18%] B. A sari for a female Buddhist believer [16%] C. A mala for a practicing Muslim [31%] D. A mala for a practicing Hindu [35%]

Explanation Choice D is correct. A mala for a practicing Hindu is the most like rosary beads that are a sacred symbol for Catholics. Like rosary beads, a mala is a holy object that is carried by members of the Hindu religion. Many of the world's religions have sacred objects. Choice A is incorrect. A sari for a female Hindu believer is a piece of clothing that is worn and not carried as rosary beads, a sacred object that is carried by Catholics. Choice B is incorrect. A sari for a female of Indian culture, rather than a Buddhist, is a piece of clothing that is worn and not carried as rosary beads, a sacred object that is carried by Catholics. Choice C is incorrect. Although Muslims use sacred beads, Islamic prayer beads are called Misbaha or Tasbih, not Mala. Buddhists and Hindus use the "Japa Mala".

The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include? A. Sterile gloves should be used to perform urinary catheter care. [40%] B. Urinary specimens may be collected from a catheter bag. [9%] C. You may irrigate a catheter with warm water for poor outflow. [7%] D. Daily use of soap and water should be used around the urinary meatus. [44%]

Explanation Choice D is correct. Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus. Choices A, B, and C are incorrect. It is not necessary to utilize sterile gloves for catheter care as this is a waste of resources. Urinary specimens should not be collected from the catheter bag as this sample will be contaminated. If irrigating a urinary catheter is required, normal saline should be used as it is sterile. Water should not be used as it is not sterile and will cause cystitis. Additional Info When managing a client with an indwelling urinary catheter, the nurse should - Evaluate the reasoning for the indwelling catheter. The insertion of an indwelling catheter is invasive, so other measures such as external devices should be considered. Minimize the amount of time that a client has the device. Urinary catheters are directly implicated in catheter-associated urinary tract infections (CAUTIs). Perform meticulous hand hygiene before the insertion of the device. Aseptic technique during the insertion of the device is imperative. Ensure system patency by decreasing kinks and loops in the tubing. The catheter should always be below the bladder and catheters with anti-reflux valves are highly preferred.

Select the age group that is accurately paired with an expected outcome that would indicate effective coping with their age-related stressor. A. Infants: will develop autonomy. [11%] B. Toddlers: will compete in the school environment. [8%] C. Adolescents: will begin to manage their home. [12%] D. Middle-aged adults: will cope with the challenges of the "sandwich generation". [69%]

Explanation Choice D is correct. During the middle-aged adult years, there is a lot of coping with challenges associated with work, raising adolescent children, and caring for their adult aging parents. Caring for one's children and caring for aging parents places middle-aged adults in the "sandwich generation". Choice A is incorrect. Infants have to cope with and develop trust, but not autonomy. Choice B is incorrect. Toddlers have to cope with and develop autonomy, but not compete in the school environment. Choice C is incorrect. Adolescents have to cope with the changes associated with puberty and the development of interpersonal relationships, but not managing the home.

The nurse is teaching a client about storing their prescribed insulin. Which statement, if made by the client, would indicate a correct understanding of the teaching? A. Opened vials of insulin may be kept in the freezer." [6%] B. "My opened vial of insulin is good for 45 days." [13%] C. "If I travel, I can keep a vial of insulin in my car." [3%] D. "Unopened vials of insulin may be stored in the refrigerator." [78%]

Explanation Choice D is correct. Extra vials (unopened) of insulin may be stored in the refrigerator. Insulin should never be frozen or administered cold. Choices A, B, and C are incorrect. Insulin should never be stored in the freezer. Insulin may be kept on ice but should not be allowed to freeze. Insulin should be discarded 28-days after it has been opened. Keeping a vial of insulin in the car is not recommended. Car temperatures vary greatly and will damage the effects of insulin. Additional Info When counseling a client about insulin storage, the nurse should emphasize the following points: Refrigerate insulin that is not in use to maintain potency Prevent exposure to sunlight, and inhibit bacterial growth Insulin in use may be kept at room temperature for up to 28 days To prevent loss of drug potency, avoid exposing insulin to temperatures below 36°F (2.2°C) or above 86°F (30°C) Avoid excessive shaking, and protect insulin from direct heat and light Insulin should not be allowed to freeze Do not inject insulin that is cold

A nurse is preparing the plan of care for a client with stage 2 ovarian cancer who is a Jehovah's witness. The client has been told that surgery is necessary. Taking into consideration the client's religious preferences in developing the plan of care, the nurse documents which of the following? A. Religious sacraments and traditions are unimportant [0%] B. Medication administration is not allowed for this group [0%] C. Surgery is strictly prohibited in this religious group [1%] D. Blood transfusion or the administration of blood and blood products is forbidden for this group [98%]

Explanation Choice D is correct. For Jehovah's witnesses, surgery is allowed, but the administration of blood and blood products is forbidden. Choices A, B, and D are incorrect. Sacraments are part of the Roman Catholic belief, not Jehovah's witnesses. Administration of medication is acceptable for Jehovah's witnesses, except if the medication is derived from blood products. NCSBN Client need: Topic: Psychosocial integrity; Sub-topic: Religious and Spiritual influences on health

The nurse is planning a staff development conference about hospice services. Which of the following information should the nurse include? A. Hospice services are useful for symptom management of acute diseases. [3%] B. Treatment is limited to pain management and symptom control. [12%] C. The goal is to implement curative therapies and treatments. [3%] D. Services may be offered in settings such as the home and inpatient. [81%]

Explanation Choice D is correct. Hospice is a service that provides comfort and dignity for clients with six or fewer months left to live. This service is flexible in that it may be rendered both inpatient and outpatient. Hospice services may be provided to individuals incarcerated or in long-term care. It also can be provided in specialized facilities. The portability of this service is one of its many benefits. Choices A, B, and C are incorrect. Hospice services are not utilized for acute diseases. A key difference between hospice and palliative care is that hospice is prescribed for individuals with a prognosis of six months or less with a terminal illness. The goal of these services is not curative; rather, it provides care that eases suffering and promotes maximum comfort. Services are broad and may include respite care for caregivers, pain management, specialized medical devices, medication management, and physical therapy. Additional Information: Hospice service differs from palliative care in that hospice is prescribed for those with an illness with a prognosis of six months or less. Palliative care may be ongoing, and the goal of this type of care is symptom management for chronic illnesses. Common illnesses that receive palliative care include congestive heart failure and dementia. Once these illnesses have become end-stage, a hospice referral may be considered depending on the prognosis (if it is six months or less). NCLEX Category: Management of Care Related Content: Continuity of care Question type: Knowledge/comprehension

The nurse manager on the unit is heard talking to his staff, saying, "As long as patients don't die on your shift, it's okay. Just do what you wish." The nurses also notice very infrequent staff meetings, and unit policies have not been updated for years. The nursing director takes note of this style of leadership and recognizes this as: A. Autocratic [9%] B. Democratic [5%] C. Participative [2%] D. Laissez-faire [84%]

Explanation Choice D is correct. 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. 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 C is incorrect. 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.

The nurse observes a newly hired nurse caring for a client prescribed a unit of packed red blood cells. It would require immediate intervention if the nurse observes the newly hired nurse A. verifies the physician's order for a blood transfusion and ensures that it is complete. [7%] B. verifies the client's name, blood compatibility, and expiration date with another nurse. [4%] C. instructs the unlicensed assistive personnel (UAP) to obtain baseline vital signs. [73%] D. remains with the client for the first 15-30 minutes to observe for a febrile reaction. [17%]

Explanation Choice D is correct. Observing a client at the initiation of the blood transfusion is to quickly assess a potentially fatal hemolytic / ABO incompatibility reaction - not a febrile reaction. This reaction manifests as back or chest pain, apprehension, and dyspnea. A febrile reaction would not manifest as quickly as a hemolytic reaction. Therefore, this action requires follow-up. Choices A, B, and C are incorrect. These actions are appropriate and do not require follow-up by the nurse. It is appropriate for the newly-hired nurse to thoroughly verify the physician's order, the compatibility of the blood product, consent for the transfusion, and the universal identifiers of the client's name and date of birth. A second nurse must verify the blood product with the nurse to assure client safety. It is appropriate for a UAP to obtain baseline vital signs as this task may be delegated. Additional Info The nurse should remain with the client during the first fifteen to thirty minutes of a transfusion to observe for a hemolytic reaction. A hemolytic blood transfusion may be fatal if not caught promptly. The primary cause of this reaction is the misidentification of the client and the blood product. Manifestations of a hemolytic reaction include low-back pain, chest pain, tachycardia, hypotension, and a feeling of impending doom. If a hemolytic reaction is assessed, the nurse should immediately discontinue the transfusion and save the tubing and unit of blood for further analysis. Immediate client care involves spiking a new bag of isotonic saline (with new tubing) and keeping the intravenous catheter patent.

The nurse reviews a client's medical history and identifies a diagnosis of presbycusis. The nurse should integrate which intervention in the care plan? A. Have educational materials in large print [26%] B. Provide an eye patch to the affected eye [18%] C. Request food be seasoned with herbs [0%] D. Move closer to the better-hearing ear [54%]

Explanation Choice D is correct. Presbycusis is a type of sensorineural hearing loss associated with aging. Sensorineural hearing loss is often permanent. Interventions for a client with this type of hearing loss include speaking in the ear less affected, speak clearly and slowly, avoid shouting, and ensure that the environment is well lit while conversing. Choices A, B, and C are incorrect. Presbycusis is a type of sensorineural hearing loss, and interventions such as scanning the room, having large print for reading materials, and seasoning food are not relevant to this condition. Scanning the room would be an intervention appropriate for visual field loss. Additional Info Hearing loss is divided into sensorineural or conductive. Conductive hearing loss is caused by obstruction. Causes of this type of hearing loss include cerumen, foreign body, water, edema, infection, or tumor. This type of hearing loss may be reversible. Impairments of the nerve fibers cause sensorineural hearing loss. Causes of this type of hearing loss include prolonged exposure to noise, ototoxic substances (aminoglycosides), diabetes mellitus, and presbycusis (age-related hearing loss). This type of hearing loss is often not reversible.

The nurse is talking to the patient's son who was just diagnosed with coronary heart disease. He asks about the risk factors that can be modified to decrease the chances of acquiring this medical condition. The nurse educates him by saying that the following are modifiable risk factors for coronary heart disease: A. Gender, cholesterol levels, and obesity [6%] B. Age and elevated blood pressure [1%] C. Stress, age, and gender [1%] D. Smoking, obesity, and physical activity [92%]

Explanation Choice D is correct. Smoking, obesity, and physical activity are all modifiable risk factors of coronary heart disease. Choice A is incorrect. Gender is a non-modifiable risk factor, whereas cholesterol levels and obesity are modifiable risk factors. Choice B is incorrect. Age is a non-modifiable risk factor, whereas blood pressure is a modifiable risk factor. Choice C is incorrect. Stress is a contributing risk factor, whereas age and gender are non-modifiable risk factors.

The school nurse is responding to a child who has suffered a penetrating eye injury on the playground, upon inspection. The nurse notes that a small wood chip is piercing the eye. What is this nurse's primary intervention? A. Remove the wood chip immediately [3%] B. Have the student lie flat [10%] C. Attempt to rinse the wood chip from the eye [9%] D. Cover the eyes with a cup and tape it in place [77%]

Explanation Choice D is correct. The nurse's first action should be to cover the eye with a cup and tape it in place so that the patient cannot further damage their eye by rubbing or touching the object. After this has been performed, the nurse should immediately contact the patient's primary health care provider. Choice A is incorrect. The nurse should never remove a penetrating object as it may be holding eye structures in place. The student's health care provider should perform this procedure. Choice B is incorrect. The nurse should advise the student to avoid lying flat or bending over as these changes may move the object, leading to further injury. Choice C is incorrect. The nurse should not attempt to rinse out this object as it may cause further damage. NCSBN client need Topic: Physiological Integrity, Physiological Adaptation

The volunteer in the medical ward recognizes one of the clients as her neighbor and asks the nurse about the client's condition. What should the nurse tell the volunteer? A. Ask the volunteer about how she knows the patient. [3%] B. Inform the volunteer of the client's condition in simple terms. [2%] C. Ask permission from the client to talk to the volunteer. [39%] D. Educate the volunteer that client information is on a need-to-know basis. [56%]

Explanation Choice D is correct. The volunteer should be reminded of the HIPAA and confidentiality rules that govern any information concerning clients in a healthcare setting. Choice A is incorrect. The volunteer is neighbors with the client but this does not warrant her the right to discuss the client's condition with the nurse. Choice B is incorrect. The nurse cannot release any information to anyone without the permission of the client. This is a violation of the Health Insurance Portability and Accountability Act (HIPAA). Choice C is incorrect. The nurse should not discuss the client with the volunteer.

The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse? A. Inserts the needle, bevel up at a 15-degree angle [6%] B. Instructs the client that the test will be read in 48-72 hours [6%] C. Selects a site 3 to 4 finger widths below the antecubital space [9%] D. Administers the test using a 20-gauge needle, 2 inches long [79%]

Explanation Choice D is correct. When administering a PPD, the nurse should administer the test intradermal at an angle of 15-degrees. The appropriate gauge and length of the needle should be 25- to 27-gauge, ½- to 5⁄8-inch. Choices A, B, and C are incorrect. These observations do not require follow-up because these observations are appropriate. It is appropriate for the nurse to administer this test at an angle of 15-degrees with the bevel up. PPD testing is read within 48-72 hours and is administered 3 to 4 finger widths below the antecubital space. Additional Info A positive PPD intradermal skin test result does not necessarily mean the client has active tuberculosis (TB). A positive result indicates the client has been exposed to TB and only confirms the presence of antibodies. A client who tests positive for this test would need additional testing to confirm or rule out tuberculosis. A sputum culture will need to be performed to determine if a client has active pulmonary tuberculosis. A positive PPD for an individual who is immunocompetent is an induration of 10-15 mm. A positive PPD for an individual who is immunocompromised is 5 mm.

The nursing supervisor is preparing to complete performance appraisals on subordinate staff members. In order to minimize bias when conducting the evaluations, the nurse supervisor should A. compare the performance of the nurse with another nurse. [2%] B. focus on a positive experience and rate all areas based on that measure. [19%] C. review the employee's previous evaluations before completing the new evaluation. [18%] D. gather feedback from peers regarding skills, performance, attitude, and competencies. [60%]

Explanation Choice D is correct. When conducting performance reviews, it is essential to avoid evaluator bias. Two methods that are becoming popular to minimize evaluator bias and get a full picture of the nurses' performance are using peer review or 360 feedback. Choices A, B, and C are incorrect. Comparing performance with another nurse would create bias. An employee should be evaluated based on their sole performance. Focusing only on an employee's positive attributes would bias the evaluator in their rating of the employee. Reviewing the employee's previous evaluations would create an evaluator bias as the performance evaluation should occur on the employee's current performance. Additional Info A peer review may involve observations or a skills test. The format involves feedback from peers regarding skills, performance, attitude, and competencies. The benefits of this format are that it can give the manager a more well-rounded view of the employee's strengths and challenges. Bias may occur; this is why the evaluator needs to get input for multiple peers. 360-degree feedback This appraisal involves multiple individuals who interact with the employee, specifically, the supervisor, peers, patients, families, staff from other departments, and outside vendors.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that airborne precautions are used for which condition? Select all that apply. A. Pulmonary tuberculosis [42%] B. Pertussis [13%] C. Rubeola [27%] D. Hepatitis A [1%] E. Rubella [16%]

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

The nurse has provided medication instructions to a client who has been prescribed venlafaxine. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? Select all that apply. A. "I may not notice an improvement in my mood right away." [31%] B. "This medication may lower my blood pressure." [18%] C. "If I have thoughts of harming myself, I should call 911." [34%] D. "I will need to have weekly laboratory tests." [15%] E. "I may continue taking St. John's Wort." [3%]

Explanation Choices A and C are correct. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI). This medication is used to treat depression and anxiety. Like most serotonergic drugs, the client may not experience an effect for two to four weeks. If no effect is achieved by six weeks, the prescriber may change the medication. Venlafaxine may increase thoughts of suicidal ideation, and the client should be educated to seek help if these thoughts should occur. Choices B, D, and E are incorrect. Venlafaxine is a medication that modulates serotonin and norepinephrine. The norepinephrine may cause a client to have an increase in their blood pressure, not a decrease. Weekly laboratory testing is not indicated for this medication as weekly laboratory testing is required for clients prescribed clozapine. St. John's Wort should not be combined with a serotonergic because of this risk of serotonin toxicity. Additional Info Venlafaxine is a common SNRI. This medication may be used for depressive and anxiety disorders. The benefit of venlafaxine is that it may be activating and assist a client who may have decreased energy. Like all antidepressant medications, it will take two to four weeks for a client to experience a response. Antidepressant medications may produce an array of adverse reactions, including suicidal ideations. Thus, education must be provided to seek help if this should occur.

This nurse is caring for a client who is receiving prescribed ketorolac. Which of the following findings would indicate a therapeutic response? Select all that apply. A. Decreased pain [36%] B. Increased urinary output [8%] C. Decreased blood pressure [19%] D. Decreased temperature [20%] E. Increased muscle coordination [16%]

Explanation Choices A and D are correct. Ketorolac is a medication used to treat pain and pyrexia. A client exhibiting a decrease in pain and having a decrease in temperature would be a therapeutic response. Choices B, C, and E are incorrect. Ketorolac does not therapeutically lower blood pressure, increase urinary output, or increase muscle coordination. Medications that could be used to lower blood pressure would be agents such as lisinopril, atenolol, etc. Agents used to increase urinary output would be diuretics such as furosemide. The improvement in muscle coordination may be achieved by medications such as levodopa-carbidopa. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Expected Actions/Outcomes Question Type: Application Additional Info Ketorolac is an anti-inflammatory drug that may be administered parenterally (IM/IV). This medication is efficacious for pain or pyrexia. This medication is nephrotoxic; therefore, monitoring renal function (BUN and creatinine) is essential while this medication is being taken.

The nurse is caring for a client with newly prescribed amphotericin b for a systemic fungal infection. The nurse should anticipate a prescription for which medication before the infusion? Select all that apply. A. Diphenhydramine [30%] B. Acetaminophen [21%] C. 0.9% saline bolus [34%] D. Regular insulin [4%] E. Sodium bicarbonate [9%]

Explanation Choices A, B, and C are correct. Amphotericin B is a potent antifungal medication. The infusion can make the client feel quite ill, and preventative treatments such as acetaminophen, 0.9% saline bolus, and diphenhydramine are often used. Symptoms the client experiences during the infusion include nausea, rigors, fever, and chills. Thus, premedication is necessary. Amphotericin B is nephrotoxic, and the client should increase their fluid intake. Choices D and E are incorrect. Amphotericin does not raise blood glucose, and regular insulin is not indicated. Sodium bicarbonate is not necessary during the course of the therapy. Additional Info Nursing care for a client receiving amphotericin b includes: Anticipating that the client will be premedicated with isotonic saline, diphenhydramine, ondansetron, and acetaminophen. A corticosteroid may be used in lieu of diphenhydramine. During the therapy, the client may experience fever, chills, rash, rigors, and nausea. Thus, this is why premedication may be necessary. Monitoring the client's creatinine and potassium. This medication is known to decrease serum potassium. Potassium supplementation is likely. Amphotericin b is nephrotoxic, and the creatinine should be closely monitored.

The nurse is teaching a group of students about Rho(D) Immune Globulin. It would be correct if the student states that this medication is indicated when Select all that apply. A. delivering an Rh-positive infant. [43%] B. aborting an Rh-positive fetus. [32%] C. undergoing chorionic villus sampling. [19%] D. having a transvaginal ultrasound. [3%] E. non-stress testing (NST). [3%]

Explanation Choices A, B, and C are correct. Rho(D) Immune Globulin should be administered to Rh-negative women who have been exposed to Rh-positive blood. Such exposures may be linked to Delivering an Rh-positive infant Chorionic villus sampling Aborting an Rh-positive fetus Receiving accidental transfusion of Rh-positive blood Amniocentesis Intraabdominal trauma while carrying an Rh-positive fetus. Choices D and E are incorrect. Transvaginal ultrasound has no risk of mixing maternal and fetal blood, which is not an indication to administer Rho(D) Immune Globulin. Rho(D) Immune Globulin is not indicated for noninvasive antepartum testing such as an NST. Additional Info Rh immune globulin (RhoGAM) prevents the production of anti-Rho(D) antibodies in Rh-negative women who have been exposed to Rh-positive blood by suppressing the immune reaction of the Rh-negative woman to the antigen in Rh-positive blood; preventing antibody response and thereby preventing hemolytic disease of the newborn in future Rh-positive pregnancies. Type and antibody screening of the mother's blood and cord blood type of the newborn should be performed to determine the need for the medication. The mother must be Rh-negative and negative for Rh antibodies. The newborn must be Rh-positive. If the fetal blood type after the termination of pregnancy is uncertain, the medication should be administered. The newborn might have a weakly positive antibody test if the woman received Rho(D) immune globulin during pregnancy. The drug is administered to the mother, not the infant. The deltoid muscle is recommended for intramuscular administration. The medication may be given intravenously if prescribed.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing testicular cancer? Select all that apply. A. Cryptorchidism [25%] B. Human immunodeficiency virus (HIV) [17%] C. Vasectomy [7%] D. Family history [35%] E. Herpes simplex virus (HSV) [15%]

Explanation Choices A, B, and D are correct. Risk factors for testicular cancer include cryptorchidism, human immunodeficiency virus (HIV), and family history. Cryptorchidism ( Choice A) refers to undescended testicle where the testicle fails to descend to its normal position in the scrotum. Undescended testicles are associated with decreased fertility, testicular torsion, inguinal hernias, and increased risk of testicular germ cell tumors. HIV-positive ( Choice B) men have an increased risk of developing testicular cancer, according to a study. Family history ( Choice D) of testicular cancer is another risk factor, with an 8-10 times increased risk if the man has a sibling with testicular cancer. Choices C and E are incorrect. A vasectomy is not a risk factor for testicular cancer. This procedure is done to interrupt each vas deferens to induce male sterility. Herpes Simplex Virus (HSV) is a virus that may be transmitted sexually but does not raise the risk for testicular cancer, unlike HIV. Additional information: Testicular cancer, if caught early, has a high cure rate. This cancer most likely occurs between ages 15-34. Risk factors for testicular cancer include Caucasian males, ages 15-34, HIV infection, cryptorchidism, and family history. Testicular cancer may manifest as a dull ache in the scrotum or abdomen, solid mass on a testicle, scrotal swelling, or heaviness. If a primary healthcare provider suspects testicular cancer, a scrotal ultrasound is the preferred imaging.

The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. A. Diabetes mellitus [11%] B. Menieres disease [28%] C. Excessive cerumen [16%] D. Exposure to loud noise [29%] E. Excessive fluid [15%]

Explanation Choices A, B, and D are correct. These are all risk factors for sensorineural hearing loss. Diabetes may cause an insult to vasculature supplying the cochlea. Thus, causing hearing loss. Meniere's disease is a condition that features vertigo, hearing loss, and tinnitus. Exposure to loud noise is a significant risk factor because of the insult it causes to the nerve fibers. Choices C and E are incorrect. Obstruction in the ear is a cause of conductive hearing loss, which may be reversed. Additional Info Hearing loss is divided into sensorineural or conductive. Conductive hearing loss is caused by obstruction. Causes of this type of hearing loss include cerumen, foreign body, water, edema, infection, or tumor. This type of hearing loss may be reversible. Impairments of the nerve fibers cause sensorineural hearing loss. Causes of this type of hearing loss include prolonged exposure to noise, ototoxic substances (aminoglycosides), diabetes mellitus, and presbycusis (age-related hearing loss). This type of hearing loss is often not reversible.

The nurse is developing a plan of care for a client who has epilepsy and is undergoing an electroencephalogram. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Provide padding to the side rails [30%] B. Verify suction is at bedside and working properly. [32%] C. Keep bite block at bedside in case of seizure. [6%] D. Ensure nasal cannula is available and working at the bedside. [24%] E. Establish peripheral vascular access [9%]

Explanation Choices A, B, and E are correct. Ensuring the side rails are raised and padded will provide a safe environment for the client in case of a seizure. It is imperative to have suction ready at the bedside should the client vomit during a seizure. Timely clearing of the airway will prevent aspiration, maintain a patent airway, and keep your patient safe. Suctioning the client should only occur once the seizure has terminated as it is contraindicated to put objects in the client's mouth. Ensuring that peripheral vascular access is essential because if the client has a seizure, parenteral benzodiazepines (diazepam/lorazepam) are necessary. Choice C is incorrect. It is not appropriate to put a bite block or any other object into a client's mouth that is seizing. This could result in injury to yourself or the client. Nursing priorities during a seizure are ensuring the client is safe and has a patent airway. Choice D is incorrect. While it is essential to have oxygen available in the room, a nasal cannula is inappropriate for this client. There should be a face mask or Ambu bag readily available that is of appropriate size and is connected to 10 L of 100% oxygen. Additional Information - For the client with epilepsy, the nurse should maintain seizure precautions during the EEG. Seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available. If the patient does not have IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure.

The nurse is teaching a client about methotrexate (MTX). Which of the following statements should the nurse include? Select all that apply. A. "This medication may cause you to bruise more easily." [24%] B. "You will need to take folic acid with this medication." [17%] C. "You must remain upright for thirty minutes after taking a dose." [15%] D. "You should avoid receiving inactivated vaccinations." [12%] E. "Avoid large crowds and wash your hands frequently." [31%]

Explanation Choices A, B, and E are correct. Methotrexate (MTX) is indicated for a variety of autoimmune conditions. This medication carries serious adverse effects such as pancytopenia (low red blood cells, white blood cells, and platelets). Thus, the client may bruise more easily and be at a higher risk of infection, so avoiding crowded areas and practicing good hand hygiene is essential. MTX antagonizes folic acid, and while a client is taking MTX, folic acid supplementation is typically prescribed. Choices C and D are incorrect. Remaining upright after taking this medication is not indicated. This would be an appropriate instruction to reduce the risk of reflux for a client taking bisphosphonate medication. Methotrexate reduces inflammation by suppressing the body's immune response, so the client should be instructed to avoid live vaccines such as MMR, varicella, and herpes zoster (shingles). Inactivated vaccines such as pneumococcal and influenza would be appropriate to encourage. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Question Type: Knowledge/Comprehension Additional Info Methotrexate is a folate antagonist used in the treatment of conditions such as rheumatoid arthritis, psoriasis, and some cancers. Common drugs interactions that can occur with methotrexate include: Protein-bound drugs and weak organic acids such as salicylates, sulfonamides, phenytoin Penicillins, NSAIDs Live virus vaccines Theophylline Hepatotoxic drugs

What characteristics best describe physical changes occurring in the aging adult? Select all that apply. A. Fatty tissue is redistributed [20%] B. The skin is drier and wrinkles appear [36%] C. Cardiac output increases [4%] D. Muscle mass increases [2%] E. Hormone production increases [2%] F. Visual and hearing acuity diminishes [35%]

Explanation Choices A, B, and F are correct. Physical changes occurring with aging include fatty tissue redistribution, the skin is drier with the appearance of wrinkles, and also the visual and hearing acuity diminishes. Choice C is incorrect. Cardiac output decreases with age. Choice D is incorrect. Muscle mass decreases with age. Choice E is incorrect. Hormone production decreases, causing menopause and andropause. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Age-Related Changes

The nurse is caring for a client who presents with a blood glucose level of 45 mg/dL. Which of the following findings are expected? Select all that apply. A. Blurred vision [22%] B. Increased urinary output [2%] C. Cool and clammy skin [27%] D. Palpitations [19%] E. Orthostatic hypotension [17%] F. Paresthesias [13%]

Explanation Choices A, C, D, and F are correct. Blurred vision (Choice A), cool and clammy skin (Choice C), palpitations (Choice D), and paresthesias (Choice F) are expected findings with hypoglycemia. Hypoglycemia is a blood sugar less than 70 mg/dL. Symptoms of hypoglycemia can be divided into two broad categories: Neurogenic (autonomic): Adrenergic vs cholinergic symptoms: include those from the release of catecholamines such as tremors, palpitations (Choice D), anxiety (catecholamine-mediated, adrenergic), sweating, hunger, and paresthesias (Choice F) (acetylcholine-mediated, cholinergic). Neuroglycopenic: Neuroglycopenia refers to a deficiency of glucose in the brain and neurons secondary to hypoglycemia. Symptoms of moderate neuroglycopenia include blurred vision (Choice A), slurred speech, drowsiness, dizziness, and extreme fatigue. Severe neuroglycopenia can cause delirium, confusion, and eventually, seizure and coma. Choice B is incorrect. Increased urinary output is a manifestation of osmotic diuresis from hyperglycemia, not hypoglycemia. Choice E is incorrect. Orthostatic hypotension is an expected finding due to dehydration from osmotic diuresis related to hyperglycemia, not hypoglycemia.

The nurse is discussing risk factors for breast cancer at a local community college. Which of the following should the nurse include in the presentation? Select all that apply. A. Nulliparity [21%] B. Multiparity [10%] C. Early menarche [25%] D. Overweight or obesity [24%] E. Multiple sexual partners [6%] F. Human papillomavirus [12%]

Explanation Choices A, C, and D are correct. Risk factors for breast cancer include: Female Age: For a woman living in the United States, the lifetime risk of 1 in 8 Race: White women are more likely to develop breast cancer, but Black women are more likely to die because they tend to develop breast cancer at an age younger than 40 and are more aggressive. Asian, Hispanic, and Native American women have a lower risk of developing and dying from breast cancer. Early menarche (<12 years), late menopause (>55 years) Nulliparity or first pregnancy after 30 years Personal history of breast cancer Genetic risk factors Family history in first-degree relatives (mother, sister, daughter) Family history of other cancer Mutations in the BRCA1 and BRCA2 genes Mutations in other genes: CHEK-2 gene, ATM (ataxia-telangiectasia mutated) gene, PTEN gene Previous irradiation of the chest area as a child or a young woman as a treatment for another cancer (such as Hodgkin's disease or non-Hodgkin's lymphoma) Previous abnormal breast biopsy results Atypical hyperplasia increases the risk four to five times. Fibrocystic changes without proliferative changes do not change breast cancer risk. Long-term hormone replacement therapy with estrogen and progesterone Excessive alcohol consumption Overweight or obesity Physical inactivity Choices B, E, and F are incorrect. These are not risk factors for breast cancer. Multiparty is a protective factor for breast cancer. HPV and multiplied sexual partners are risk factors for cervical cancer. Additional Info Strong primary prevention measures the nurse can advocate for to prevent breast cancer include motivating the client to maintain a normal body mass index, exercise regularly, smoking cessation, and moderation of alcohol intake. Secondary prevention includes mammography. Most women have an average risk for breast cancer and should begin yearly mammograms at age 45.

The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply. A. Lymphadenopathy [20%] B. Vaginal discharge [26%] C. Paresthesia [11%] D. Dysmenorrhea [13%] E. Malaise [29%]

Explanation Choices A, C, and E are correct. The initial outbreak of herpes simplex is often the worst (as it pertains to symptoms). Clients typically experience prodromal symptoms such as headaches, a low-grade fever, malaise, paresthesia, and itching at the site of the outbreak. Then the client will experience the eruption of the painful vesicles. Choices B and D are incorrect. Vaginal discharge suggests another infection and is not associated with herpes simplex infections. HSV does not impact the regularity of the client's menstrual cycle. Additional Info Herpes simplex virus (HSV) is both sexually and non-sexually transmitted. The client often experiences the worst symptoms during the initial outbreak, which include headache, malaise, fever, and localized lymphadenopathy. Following these prodromal symptoms, painful skin eruptions occur, putting the client at higher risk of transmitting the infection. The client should be educated that even when an outbreak is not present, they risk infecting others with the virus. Medications to manage outbreaks are best taken early and include valacyclovir.

Which of the following patients should the nurse screen for possible urinary retention? Select all that apply. A. A 78-year-old man diagnosed with an enlarged prostate. [25%] B. An 83-year-old woman on bed rest. [12%] C. A 75-year-old woman with vaginal prolapse. [16%] D. An 89-year-old man with dementia. [8%] E. A 73-year-old woman on antihistamines to treat allergies. [9%] F. A 90-year-old man with difficulty walking to the restroom. [12%] G. An 80-year-old African American man with benign prostatic hyperplasia taking prazosin. [18%]

Explanation Choices A, C, and E are correct. Urinary retention occurs when urine is produced normally but is not entirely emptied from the bladder. Retention can occur because of mechanical obstruction of the bladder outlet (enlarged prostate in a man or vaginal prolapse in a woman) or from the use of medications with anticholinergic side effects. The bladder muscle's (detrusor smooth muscle) primary function is to "contract" and fully empty the bladder. Detrusor smooth muscle has muscarinic (cholinergic) receptors that facilitate this contraction. Anticholinergic agents impair this function. Therefore, urinary retention has been treated with the use of drugs that have anticholinergic activity. Calcium channel blockers can also lead to urinary retention by directly impairing the contractility of the detrusor muscle. Excessive urinary retention eventually results in "overflow" incontinence. Choices B, D, F, and G are incorrect. All these answer options (immobility, dementia, walking difficulty, alpha-adrenergic blockers) may place the patients at risk for urinary incontinence, not urinary retention. Patients with benign prostatic hypertrophy are often placed on alpha-adrenergic agonists like prazosin, doxazosin, or terazosin to facilitate bladder emptying (Choice G). However, one predominant side effect of these drugs is urinary incontinence, not retention. A study found that alpha-blockers increased the risk of urinary incontinence in older African American men by fivefold. In the normal setting, stimulation of alpha-adrenergic receptors causes bladder outlet resistance. Blocking these alpha-adrenergic receptors with medications (prazosin) leads to decreased bladder outlet resistance and incontinence. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic Care and Comfort

The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the RN? Select all that apply. A. A patient newly diagnosed with type II diabetes mellitus. [26%] B. A patient requiring sterile dressing changes to an infected wound. [8%] C. A patient who requires enteral feedings and tracheostomy care. [7%] D. A patient with an acute kidney injury (AKI) with a potassium 5.6 mEq/l. [27%] E. A patient who is two days post-operative following a mastectomy. [5%] F. A patient receiving intravenous nitroglycerin for acute coronary syndrome. [27%]

Explanation Choices A, D, and F are correct. When making patient assignments, the RN should be assigned to the unstable patient, has the least predictable outcome, and may require frequent assessment or teaching. A patient newly diagnosed with type II diabetes mellitus will require a large amount of teaching. A patient with an AKI and hyperkalemic is at risk for cardiac instability. Finally, a patient experiencing acute coronary syndrome receiving IV nitroglycerin will need frequent assessment because of the unpredictable nature of the condition. Choices B, C, and E are incorrect. The LPN should assume care for patients who are stable and have predictable outcomes. The patient requiring sterile dressing changes is within the LPN's scope as well as providing enteral feedings and tracheostomy care. A patient two days post-operative is stable. Additional information: When making patient assignments, the nurse should always assign the most unstable patient to the RN. This also involves patients requiring initial assessments or discharge teaching. The LPN may reinforce teaching, data collection, and care for patients with low acuity illnesses.

The nurse is caring for a client who has major depressive disorder (MDD). Which of the following would indicate that the client is achieving the treatment goals? Select all that apply. A. Reporting a decreased appetite. [4%] B. Engaging in daily exercise. [45%] C. Increasing social ties. [45%] D. Drinking alcohol with friends. [4%] E. Not attending therapy sessions. [1%]

Explanation Choices B and C are correct. A client engaging in daily exercise and increasing their social ties are significant strides in meeting the treatment goals. A client engaging in exercise decreases their neurological inflammation and exposes themselves to light, which is quite helpful in the treatment of MDD. Loneliness is a significant risk factor for depression and by a client increasing their social ties, they are engaging with others and strengthening their ability for self-expression. Choices A, D, and E are incorrect. Changes in appetite (less or more) are symptoms consistent with MDD. Thus, this would not indicate a client meeting the treatment goals. Drinking alcohol is a maladaptive coping mechanism regardless of other individuals. Alcohol causes disinhibition and may lead to a client harming themselves. Therapy is a highly effective adjunct in the treatment of MDD. Thus, a client must attend prescribed sessions as part of the treatment plan. Additional information: MDD is a significant medical condition that is a burden on both the individual and the healthcare system. The acronym of SIGECAPS can recall the symptomology of MDD. · S sleep disturbances · I interest decreased · G guilt or feeling of worthlessness · E energy is decreased · C concentration is impaired · A appetite disturbances · P psychomotor retardation or agitation · S suicidal ideations Establishing a therapeutic rapport with the client is essential. The nurse should encourage gentle socialization, exercise (or exposure to natural light), education on sleep hygiene measures, and adherence to prescribed treatments. NCSBN Client Need: Topic: Psychosocial integrity; Subtopic: Mental Health Concepts

Which of the following are features characteristic of fetal alcohol spectrum disorder? Select all that apply. A. Macrocephaly [19%] B. Attention deficit disorder [28%] C. Encephalopathy [31%] D. Enlarged philtrum [21%]

Explanation Choices B and C are correct. Attention deficit disorder, or ADD, is a common finding when dealing with a fetal alcohol spectrum disorder. Many central nervous system disturbances are observed in these patients, including encephalopathy, hypersensitivity, seizures, learning disabilities, difficulty remembering things, impulsivity, and ADD or ADHD (Choice B). Encephalopathy is a common finding when dealing with a fetal alcohol spectrum disorder. There are many central nervous system disturbances that are observed in these patients, including encephalopathy, hypersensitivity, seizures, learning disabilities, difficulty remembering things, impulsivity, and ADD or ADHD (Choice C). Choice A is incorrect. Microcephaly, not macrocephaly, is the expected finding in fetal alcohol spectrum disorder. Macrocephaly is a larger than average head. There are many causes, including hydrocephalus, brain bleeds, and tumors. Fetal alcohol spectrum disorder causes microcephaly or a smaller than normal head. Choice D is incorrect. An absent philtrum is a finding of fetal alcohol spectrum disorder, not an enlarged philtrum. The philtrum is the vertical indentation in the middle area of the upper lip; it is also known as the medial cleft. In children with a fetal alcohol spectrum disorder, this is commonly absent, leaving the area between the lips and the nose completely smooth. NCSBN Client Need: Topic: Health Promotion and Maintenance; Subtopic: Newborn

Which of the following educational points are appropriate for your patient being discharged with oral potassium supplements? Select all that apply. A. Take on an empty stomach. [15%] B. Commonly causes GI upset. [44%] C. Should only be taken at night. [5%] D. Mix well. [35%]

Explanation Choices B and D are correct. The most common side effect of oral potassium is GI upset. You should explain this to your patient and instruct them to take their supplement with food (Choice B). You should teach your patient to mix potassium supplements well before administering them (Choice D). Choice A is incorrect. Oral potassium should never be taken on an empty stomach because it causes GI upset. Always instruct your patient to take oral potassium supplements with food. Choice C is incorrect. This is not true. Potassium supplements can be administered at any time. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Electrolytes

A nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client Select all that apply. A. stating that they took their prescribed carbamazepine with a sip of water. [9%] B. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL. [27%] C. reporting that they shaved their abdomen for their scheduled appendectomy. [9%] D. reporting difficulty with their last surgery, stating they got 'a really high fever'. [27%] E. reporting burning upon urination and increased urinary frequency. [28%]

Explanation Choices B, C, D, and E are correct. These clients require follow-up. Preoperative (and postoperative) hyperglycemia is detrimental to optimal outcomes. This client has a glucose of 266 mg/dL, which is hyperglycemia. This client should also have the prescribed infusion of D5W questioned. Clipping hair at the operative site is the best practice because it reduces the risk of surgical site infection. If shaving has to be done, it is completed immediately before the incision to reduce the chance of postoperative infection. The client stated that they got a high fever after their previous surgery requires follow-up. This could be a concern for malignant hyperthermia. Although rare, this genetic disorder can be life-threatening when the client is exposed to certain anesthesia. The client reporting burning upon urination preoperative requires follow-up as preoperative infections may cause cancelation of surgery as they complicate healing. Choice A is incorrect. This client does not require follow-up. Carbamazepine is an anticonvulsant and is commonly permitted to be taken with a sip of water to prevent seizure activity. Additional Info When performing a preoperative surgical assessment, the nurse assesses the client's physical status and reviews elements such as Adherence to nothing by mouth (NPO) status Preoperative laboratory and diagnostic data Basic understanding of the procedure Discharge planning Postoperative education

The nurse is providing education for a diabetic client who is given a terbinafine prescription for onychomycosis. Which statements by the client demonstrate a good understanding regarding the treatment with terbinafine? Select all that apply. A. "Following a successful course of treatment, my chance of getting cured is 90%." [8%] B. "I will have to take terbinafine for 3 to 6 months." [17%] C. "I will need liver function tests before starting terbinafine." [24%] D. "I will take this on an empty stomach to help improve its absorption." [9%] E. "It may cause taste or vision changes, so I will report vision changes to my doctor." [22%] F. "Dark urine, pale stools, and persistent nausea may indicate a serious side effect." [20%]

Explanation Choices B, C, E, and F are correct. Onychomycosis, also known as Tinea unguium, is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque, and crumbling. Dermatophytes cause 90% of these toenail infections. The remaining 10% are caused by non-dermatophytes (Saprophytes) and yeast (Candida). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). By inhibiting squalene epoxidase, terbinafine blocks the synthesis of ergosterol (Ergosterol is a crucial component of the fungal cell membranes). The nurse should be aware of the interactions and common side effects of terbinafine because it is one of the commonly prescribed antifungal drugs. Client education points include: Even after prolonged treatment, failure and recurrence rate is high (20 to 50% failure). The cure rate with terbinafine is close to 50% (Choice A is incorrect). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails (1 month). Educate the client regarding the prolonged duration of treatment and instruct them to be compliant (Choice B is correct). Educate the client regarding essential side effects and when to contact the healthcare provider. Common side effects include headache, gastrointestinal side effects (abdominal pain, nausea, dyspepsia, diarrhea), rash, and taste changes. To minimize gastrointestinal side effects, terbinafine should be taken with food. Taking it on an empty stomach may exacerbate gastrointestinal side effects (Choice D is incorrect). Vision changes may also occur. These may represent changes in the retina and must be reported immediately to the provider (Choice E is correct). Rarely, terbinafine can cause severe liver toxicity. This can happen in even those without pre-existing liver disease. Yellow-colored urine, pale stools, jaundice, and persistent nausea may indicate acute liver damage (Choice F is correct). Baseline liver function tests (LFTs) must be checked before the initiation of terbinafine (Choice C is correct). In the past, LFTs have been monitored every 4 to 6 weeks while on terbinafine, but new guidelines do not require routine monitoring of LFTs. NCSBN Client Need Topic: Pharmacological and parenteral therapies; Sub-topic: Adverse Effects/Contraindications/Side Effects/Interactions

The primary healthcare provider (PHCP) prescribes amoxicillin 80 mg/kg/day to be given in two divided doses. The infant weighs 19.2 lbs. The label of the medication reads 250 mg/mL of amoxicillin. How many mL of amoxicillin should the nurse administer for one dose? Fill in the blank. Round your answer to the nearest tenth. mL

Explanation This is a multistep problem. First, convert the weight to kilograms (kg) 19.2 lbs / 2.2 = 8.72 kg Next, determine the daily prescribed dosage 80 mg x 8.72 kg = 697.6 mg Further, this medication is ordered in two divided doses, so divide the daily dose by 2 697.6 mg / 2 = 348.8 mg Finally, divide the prescribed dose by the amount on hand 348.8 mg / 250 mg = 1.39 mL Complete the problem by rounding the final answer to the nearest tenth 1.39 mL = 1.4 mL

You are assigned to take care of a client who just underwent a cholecystectomy. Which of the following would decrease the risk of developing atelectasis in this client? Select all that apply. A. Deep inspiration. [26%] B. Supine position with the head end of the bed elevated. [21%] C. Change position every 2 hours. [29%] D. Encourage the patient to cough at least 10 times/hr. [24%]

Explanation Choices A, B, C, and D are correct. Atelectasis is defined as the total or partial collapse of the alveoli. This is a common complication in the immediate postoperative period, especially after abdominal surgeries. If atelectasis is not addressed, it may progress to pneumonia. Since alveoli are responsible for gas exchange, alveolar collapse can lead to impaired gas exchange/impaired oxygenation. Post-operatively, the client may not be able to take deep breaths due to pain from the movement of abdominal muscles. This impaired expansion of the alveoli leads to the accumulation of secretions/mucus plug, decreased surfactant, as well as the obstruction of airway and collapse of alveoli. Additional factors that predispose to this may include hypoventilation, sedation, and reduced mobility. When such factors are identified, the nurse should encourage the client to adopt interventions to mitigate those factors and prevent atelectasis. Such interventions include: Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry. An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expansion of the alveoli. Keeping the client in the supine position with the head end of the bed elevated (Choice B) or semi-recumbent area (head of the bed raised 30 to 45 degrees). This allows for maximum thoracic expansion by lowering the abdominal pressure on the diaphragm. Encouraging the client to change position at least every 2 hours (Choice C). This increases mobility and allows full chest expansion and increases perfusion to both lungs. Encouraging the client to cough at least ten times per hour (Choice D) when awake. This helps promote alveolar expansion. The above interventions are aimed at preventing atelectasis. However, the nurse should be aware of detecting atelectasis if it did end up happening. Physical exam findings assist in the diagnosis and include fever and decreased breath sounds on the side of atelectasis. In the case of complete atelectasis/collapse, the trachea/mediastinum may be shifted to the same side due to the pull by a collapsed lung. Atelectasis in the postoperative period is referred to as "resorption atelectasis" but the nurse should also be aware of other types in different client scenarios. Once the nurse detects atelectasis, treatment interventions from a nurse's perspective include: Use of incentive spirometry (IS) - IS mimics the natural process of sighing or yawning. It encourages the patient to take slow and deep breaths. The result of this process is decreased pleural pressure, increased lung expansion, and improved gas exchange. Regular repetition of IS can prevent or even reverse atelectasis. Supportive devices to assist with deep coughing. Chest physiotherapy includes tapping on the chest to loosen mucus Mobilizing the patient early, i.e. encouraging sitting up in bed, sitting over the edge of the bed, standing, or assisted ambulation. Postural drainage - to achieve this, the body is positioned with the head lower than the chest to promote gravitational drainage of the mucus from the bottom of the lungs. (Note this position is for treatment of atelectasis and is different from the semi-recumbent area used to prevent atelectasis) Bronchoscopy may be ordered in certain cases by the physician to remove the mucus plug if the patient is not showing improvement despite the above non-invasive measures.

Which of the following interventions is a priority for patient safety during care? Select all that apply. A. Proceed with surgeries immediately with no time-out. [2%] B. Use two patient identifiers such as name and date of birth. [37%] C. Provide documentation, medical terminology, and SBAR for verbal communication. [23%] D. Use alarms safely, especially to prevent harm to patients who are at risk for falls. [38%]

Explanation Choices B, C, and D are correct. Each of these answer choices reflects safety priorities that should be included in the care of every patient. In the past, hospitals were considered the safest place for sick patients to be. Unfortunately, that assumption is no longer valid as more reports and studies identify the risks, errors, and potential complications that hospitalized patients are exposed to. The Joint Commission has updated the National Patient Safety Goals for hospital care to improve patient safety. To address the risk in health care delivery in hospitals, some of the updated goals include that nurses must: Improve the accuracy of patient identification by using at least two patient identifiers when providing care. Improve the effectiveness of communication among caregivers by using written documentation, approved medical terminology, and SBAR (situation, background, assessment, recommendation) for verbal communication. Improve the safety of using medications by labeling all drugs and adopting practices to reduce the likelihood of patient harm associated with the use of anticoagulation therapy and reduce the adverse patient outcomes associated with medication discrepancies. Reduce the risk of harm associated with clinical alarm systems by using alarms safely, mainly to prevent the risk of falls. Reduce the risk of healthcare-associated infections by implementing CDC or WHO goals to improve hand cleaning, prevention of diseases from central lines, post-surgical infections, and identify clients at risk for developing hospital-acquired infections. Choice A is incorrect. All surgeries must have a "time-out" period to avoid wrong-site surgeries and other complications. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Safety Interventions for Hospitalized Patients

The nurse is caring for a primigravida patient with the following clinical data. The nurse should take which of the following actions based on the result? See the exhibit. A. Inform the patient of the normal finding. [79%] B. Prepare the patient for a contraction stress test. [14%] C. Arrange for a repeat test. [4%] D. Inquire if the patient ate prior to the test. [3%]

Explanation Choice A is correct. A reactive NST is an expected finding and indicates fetal well-being. Choices B, C, and D are incorrect. A reactive nonstress test is a normal finding, and the patient will not need a contraction stress test (CST). A CST is only utilized if the NST is abnormal. A normal finding will not require repeat testing. A patient may or may not eat before the test. Dietary restrictions are not necessary prior to an NST. Additional information: A nonstress test is performed in the third trimester if the patient has indications such as a high-risk pregnancy that may result in a stillbirth or complications such as fetal hypoxia. A reactive finding indicates fetal well-being, specifically, that the fetal heart rate increased by 15 beats-per-minute lasting for 15 seconds. A nonreactive NST is non-reassuring and indicates decrease variability with an absence in a fetal heart rate acceleration.

You are taking care of an 80-year-old patient who is post-op day one from abdominal surgery. Upon assessment, you notice bowel protruding through her incision and quickly determine that evisceration has occurred. Place the following actions in order of priority: Call for help and stay with the patient. Cover the wound with a sterile normal saline dressing. Prepare the patient for immediate surgery. Take vital signs and monitor for signs of shock. Document the incident.

Call for help and stay with the patient. Cover the wound with a sterile normal saline dressing. Take vital signs and monitor for signs of shock. Prepare the patient for immediate surgery. Document the incident. Explanation The priority of nursing action is to call for help but stay with the patient. The nurse should tell the person who responds to notify the surgeon immediately. This is a surgical emergency, therefore the surgeon must be notified STAT. After help has been called, the nurse needs to cover the wound with a sterile 0.9% sodium chloride dressing. This helps prevent infection and keep the protruding organ moist and hydrated before surgery. The nurse should instruct the patient not to strain or cough, and keep the client in low Fowler's position (no more than 20 degrees of bed elevation) with his/her knees flexed. This position relaxes abdominal muscles and reduces abdominal muscle tension. After this, the next nursing action is to check the patient's vital signs and monitor for shock while waiting for the health care providers. If signs of shock such as tachycardia and hypotension are noted, this is a medical emergency, and the health care provider/rapid response team needs to be called to the bedside immediately. After taking vital signs, the nurse should begin preparing the patient for immediate surgery. Lastly, after the patient has been taken to surgery, the nurse needs to document the incident.

Which of these strategies would the nurse suggest to parents to add to their activities to promote tactile stimulation for an 11-month-old? A. Give the infant finger foods of different textures [35%] B. Provide soft squeeze toys of various textures [52%] C. Allow the infant to play nude on a soft, furry rug [4%] D. Comb the infant's hair with a soft brush [8%]

Explanation Choice A is correct. At this age; finger foods are being introduced into the infant's diet. Providing a variety of foods with different textures provides a natural way to promote tactile stimulation. Choices B, C, and D are incorrect. Although all of the remaining answers will provide tactile stimulation, the question asks what should be "added" to the infant's activities. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Health Promotion of the Infant

The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle? A. Autonomy [81%] B. Justice [3%] C. Paternalism [3%] D. Veracity [12%]

Explanation Choice A is correct. By a client providing their consent, this is respecting their decision and, thus, their autonomy. This ethical principle exemplifies the patient's self-determination and ability to make their own choices without interference or coercion. Choices B, C, and D are incorrect. Justice refers to the equality and the nurse to provide care to individuals regardless of cost or other factors. Paternalism refers to taking a course of action (or treatment) guided by someone else in the client's best interest. Veracity refers to telling the truth and not being deceptive. Additional Info The nurse serves as a witness to the informed consent, and during this process, the nurse should ensure that the client is who they say they are and that they meet the legal age for consent. Finally, the nurse should verify the client's general understanding of the procedure.

You are working in the pediatric cardiac ICU and are caring for a 2-year-old who is two weeks post-op from a bidirectional Glenn procedure. You are getting ready to discharge the patient home today and are preparing discharge instructions for the family. Which of the following are important points to include? Select all that apply. A. Avoid any play for at least 6 weeks post operatively. [20%] B. Do not go into crowded places for 2 weeks post operatively. [38%] C. Avoid sunlight directly on the incision site. [24%] D. Do not get any immunizations for 2 months following surgery. [18%]

Explanation Choices B, C, and D are correct. Avoiding crowds post-operatively will help minimize the chance of infection. It is essential to avoid direct sunlight on the incision site to optimize healing and minimize scarring. Getting immunizations in the immediate post-operative phase when the patient's immune system is still compromised can be dangerous. After the 2-months have passed, all vaccines should continue on a regular schedule. Choice A is incorrect. It is not appropriate to ask a 2-year-old to avoid any play for six weeks. Instead, the nurse should instruct the parents on selecting appropriate play activities and avoiding those where the child could fall. For example, coloring would be a better choice than biking. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Alterations in Body Systems

You are a nurse working in a medical unit with a trained aide. You have admitted a new patient and have received the following orders. Place the answer choices in the correct sequential order based on the prioritization for performing these tasks. Insulin 2 units Humulin subcutaneous now. CBC, electrolytes, urinalysis, and 2 sets of blood cultures. Amoxicillin 250 mg by mouth first dose now and then every 6 hours. Vital signs every 4 hours.

Insulin 2 units Humulin subcutaneous now. CBC, electrolytes, urinalysis, and 2 sets of blood cultures. Amoxicillin 250 mg by mouth first dose now and then every 6 hours. Vital signs every 4 hours. Explanation Correct ordered sequence: Insulin - 2 units Humulin subcutaneous now CBC, Electrolytes, urinalysis, and 2 sets of blood cultures Amoxicillin 250 mg by mouth first dose now and then every 6 hours Vital signs every 4 hours While prioritizing the orders from the physician, the nurse should look for the orders that specify urgency - such as "STAT" or "as soon as possible" or "now." A "now" prescription for insulin should be done as soon as possible after the patient arrives on the floor. The nurse should understand that insulin lowers the patient's blood sugar and can help to prevent sequelae associated with high blood sugar. Since the patient is being initiated on antibiotics, it appears there is a suspicion of infection. In patients with suspected infection, glycemic control is helpful in achieving good outcomes. Collecting the labs is the second task that should be completed since blood cultures have been ordered. Blood cultures must always be collected BEFORE the administration of an antibiotic so that the antibiotic does not interfere with the results. Obtaining cultures after antibiotics may give false-negative results. As soon as the blood cultures are drawn, the nurse should administer the amoxicillin since it is ordered for "now" and then every 6 hours. In almost any infection including sepsis, guidelines allow a 1 to 2 hour window from the time of patient arrival before which antibiotics can be administered. Blood cultures must be obtained before antibiotics. Finally, vital signs are the lowest priority for the nurse since this is a task that can be delegated to the aide following an initial assessment. It can be executed after the above orders are completed. NCSBN Client Need Topic: Management of Care; Sub-Topic: Establishing Priorities

While working on a pediatric floor, your 2-year old patient begins experiencing epistaxis. Place the appropriate priority nursing actions in the correct sequence: Keep the child calm and quiet Help the child to sit up and lean forward Apply pressure to the nose for at least 10 minutes If still bleeding, Insert cotton into each nostril Apply ice to the bridge of the nose

Keep the child calm and quiet Help the child to sit up and lean forward Apply pressure to the nose for at least 10 minutes If still bleeding, Insert cotton into each nostril Apply ice to the bridge of the nose Explanation The priority nursing action to take is to keep the child calm and quiet. If the child becomes distressed and is crying, it will exacerbate the bleed. Next, the nurse needs to sit the child up and lean them forward. Many parents think they should pinch the child's nose and tilt their head backward, but this will not aid in stopping the bleed and can be an aspiration risk. Do not let the parent tilt the child's head back. Next, begin applying pressure to the nose, and check to see if the bleeding continues after 10 minutes. If the nose is still bleeding, the next action would be to insert absorbent cotton into each nostril. If the nose continues to bleed after that, the following priority action is to apply ice to the bridge of the nose to aid in vasoconstriction thus stopping the bleed. NCSBN Client Need Topic: Reduction of Potential Risk Subtopic: Potential for Alterations in Body Systems