Archer Review 2a

Which of the following nursing diagnoses is the most appropriate for an immobilized client on complete bed rest who has a blood calcium level of 9.9 mg/dL and a urinary pH of 9.9? A. Impaired urinary function related to an alkaline urinary pH [42%] B. Demineralization related to immobilization and complete bed rest [21%] C. At risk for impaired urinary function related to immobilization [29%] D. At risk for hypocalcemia related to bone demineralization [8%]

Explanation Choice A is correct. "Impaired urinary function related to an alkaline urinary pH" is the most appropriate nursing diagnosis for an immobilized client on complete bed rest. A urinary pH of 9.9 is not normal and it is outside of the normal parameters; the normal urinary pH ranges from 4.5 to 8; a pH less than 4.5 is considered abnormally acidic; a pH of more than 8 is considered abnormally alkaline. Abnormal alkalinity, which is a hazard of immobility, places the client at risk for the formation of renal calculi and urinary impairments. Choice B is incorrect. "Demineralization related to immobilization and complete bed rest" is not an appropriate nursing diagnosis for this immobilized client on complete bed rest because there is no information in this question that indicates that this client has bone demineralization with a blood calcium level within normal limits which can range from 8.5 to 10.5 mg/dL. Bone demineralization and hypercalcemia are commonly occurring complications of immobilization and non-weight bearing activity. Choice C is incorrect. "At risk for impaired urinary function related to immobilization" is not an appropriate nursing diagnosis for this immobilized client on complete bed rest because this client's urinary pH is outside of normal limits and this indicates the need for an actual rather than an "at-risk" nursing diagnosis. Choice D is incorrect. "At risk for hypocalcemia related to bone demineralization" is not an appropriate nursing diagnosis for this immobilized client on complete bed rest because this client is at risk for hypercalcemia secondary to bone demineralization and not hypocalcemia.

The nurse is obtaining consent for surgery from a client. What should be the initial action of the nurse while obtaining consent? A. Determine if the client has sufficient knowledge about the procedure. [71%] B. Witness the signature of the client. [24%] C. Tell the client that obtaining a signature is routine prior to surgery. [3%] D. Explain the risks involved in the surgery. [2%]

Explanation Choice A is correct. "Informed" consent means that the client must understand the procedure, the alternative options, and the risks and consequences involved. The nurse should make sure that the client has sufficient knowledge about the procedure before asking him to sign a consent. While it is crucial for the client to know the risks of the procedure before signing the consent, those risks should be explained to the client by the doctor, not the nurse. Choice B is incorrect. The nurse should first assess the client's understanding of the surgery/procedure before signing as a witness. Choice C is incorrect. Procuring the client's signature for consent is routine before the surgery. However, just telling this to the client does not satisfy the client's right to informed consent. Choice D is incorrect. Explaining the procedural risks involved is not the nurse's responsibility and should be done by the doctor.

While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention? A. "The pain doesn't feel as bad now. I think it was just a stomach ache." [77%] B. "Would you mind getting me an ice pack?" [5%] C. "I know I'm not supposed to eat anything right now, but I'm hungry." [11%] D. "I wonder if I can play in the basketball game on Monday." [7%]

Explanation Choice A is correct. A patient who is suspected of having appendicitis who suddenly feels better has likely experienced a rupture of the appendix. This situation warrants immediate attention, as surgery will be necessary. Choices B, C, and D are incorrect. The patient may want an ice pack because he feels like it will ease his pain. Stating that he feels hungry is not an example of non-compliance, nor is it an emergency. Wondering if he can play basketball is not a reason for concern. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Appendicitis

The nurse is caring for a patient receiving bupropion. Which of the following findings would indicate a therapeutic response? A. A decrease in depressive symptoms [55%] B. A decrease in manic symptoms [13%] C. A decrease in delusions [7%] D. A decrease in alcohol cravings [24%]

Explanation Choice A is correct. Bupropion is an antidepressant medication that may be used for patients with major depressive disorder (MDD). Choices B, C, and D are incorrect. Bupropion is a medication indicated for major depressive disorder. A patient with bipolar mania should not receive bupropion because of the medication's activating effects. Bupropion is not an antipsychotic medication and would not decrease delusional symptoms. Finally, bupropion is not indicated for alcohol abuse disorder. Rather, it is commonly utilized for those wishing to abstain from smoking. Additional information: Bupropion is a medication indicated for MDD. This medication increases norepinephrine and dopamine; therefore, it activates a patient. This medication is often advantageous because compared to the serotonergic agents (such as citalopram), this medication does not cause sexual side effects such as decreased drive. This medication may make anxiety worse and oftentimes is not utilized for anxiety disorders.

Which of the following is considered the gold standard for determining fluid balance? A. Daily weights [53%] B. Strict intake and output measurements [35%] C. Urine osmolarity testing [5%] D. Basal metabolic panel results [7%]

Explanation Choice A is correct. Daily weights are considered the gold standard for monitoring fluid balance. Monitoring for changes in normal pressure is the most direct and useful way to compare changes in fluid status and evaluate needed interventions. Choice B is incorrect. This is not the gold standard for determining fluid balance. Choice C is incorrect. This is not the gold standard for determining fluid balance. Choice D is incorrect. This is not the gold standard for determining fluid balance. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Renal

The nurse is caring for a client who has been prescribed depot medroxyprogesterone acetate. Which of the following statements, if made by the client, requires follow-up? A. "I will need another injection in 8 weeks." [35%] B. "I may gain weight while on this medication." [7%] C. "I can expect increased vaginal bleeding." [41%] D. "I should increase my weight-bearing exercises." [17%]

Explanation Choice A is correct. Depot medroxyprogesterone acetate is an injection that provides contraception for 13 weeks. The client should return for another injection at 13-week intervals - not 8 weeks. Choices B, C, and D are incorrect. Weight gain, acne, increased vaginal bleeding, and decreased bone density are common effects associated with this contraception. Additional Info Depot medroxyprogesterone acetate is an effective contraceptive that is given intramuscularly or subcutaneously every 13 weeks. While a client takes depot medroxyprogesterone acetate, calcium and vitamin D supplementation are recommended, coupled with weight-bearing exercises. Women who have a high risk for cardiovascular disease and a stroke should not take depot medroxyprogesterone acetate.

The nurse is educating a new nurse working on the pediatric unit about the causes of bacterial tonsillitis in children. Which of the following is the most common cause of bacterial tonsillitis? A. Group A beta hemolytic streptococcus [40%] B. Streptococcus pneumoniae [11%] C. Group B Streptococcus [47%] D. Neisseria meningitidis [2%]

Explanation Choice A is correct. Group A beta hemolytic streptococcus is the most common cause of bacterial tonsillitis. Choice B is incorrect. Streptococcus pneumoniae is a gram-positive bacterium that causes pneumonia; this bacterium does not cause tonsillitis. Choice C is incorrect. Group B Streptococcus is a type of bacteria sometimes found in a pregnant woman's vagina or rectum; this bacterium does not cause tonsillitis. Choice D is incorrect. Neisseria meningitidis is a gram-negative bacterium that causes meningococcal diseases such as meningitis; this bacterium does not cause tonsillitis. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Infection control and safety, Pediatric - HEEN

The patient recovering from cardiac surgery is wondering when he can resume sexual activity. The nurse would be most correct in stating that sexual intercourse may be returned at which point in time? A. After exercise tolerance is assessed [70%] B. One week after surgery [3%] C. When the patient can comfortably jog two miles [21%] D. Three months after surgery [7%]

Explanation Choice A is correct. Patients who have undergone cardiac surgery should have their exercise tolerance evaluated by a physician before resuming sexual activity. Many physicians agree that a patient may return to sexual activity if they can climb two flights of stairs without symptoms. Choice B is incorrect. All patients recover differently. Therefore a time frame is not the best way to evaluate readiness for sexual activity. Choice C is incorrect. Jogging two miles may be strenuous even for patients who have not undergone cardiac surgery. This is not the best way to judge readiness for sexual activity. Choice D is incorrect. All patients recover differently. Therefore a time frame is not the best way to evaluate readiness for sexual activity. NCSBN client need Topic: Physiological Integrity, physiological adaptation

The NICU nurse is caring for an infant with heart failure and watching for interventions that necessitate administering oxygen. Of the following procedures, which will the nurse most likely need oxygen to be available? A. Administering vaccinations [43%] B. During the infant's naps [23%] C. While the infant nurses [27%] D. After the parents have held the baby [7%]

Explanation Choice A is correct. The nurse would be most accurate if they applied oxygen to the infant receiving vaccinations. Since injections are often painful, most babies cry while receiving them. Crying uses much of an infant's energy, increasing its demand for oxygen. Choices B, C, and D are incorrect. Since napping, nursing, and being held are generally calming moments for an infant, there will likely not be an increased need for oxygen. NCSBN client need Topic: Physiological Integrity, reduction of risk potential

The nurse is reviewing electrocardiogram tracings for various clients. Which tracing requires immediate follow-up?

Explanation Choice A is correct. This electrocardiogram (ECG) shows a third-degree heart block, otherwise known as a complete heart block. This rhythm is fatal without intervention. If you notice this, you must notify the physician immediately so appropriate interventions can be implemented. A complete heart block may lead to fatal symptomatic bradycardia with a heart rate of less than 40/min, hypotension, seizures, cerebral ischemia, or cardiac arrest, and sudden cardiac death. It is considered a fatal rhythm, and hence, this patient is a top priority. In a 3rd degree or complete heart block, there is no atrioventricular conduction, so no impulses from the supraventricular nodes (sinus impulses) are conducted to the ventricles whatsoever. This results in erratic heart rates where the sinus node and the atrioventricular nodes are beating independently. This leads to a junctional rhythm where there is no correlation between P-waves and QRS complexes. The atrial rhythm will be regular (P to P interval regular). Ventricular rhythm is steady (R-to-R range is consistent). However, the P-R interval will be variable. These are the typical characteristics of a 3rd degree AV block. Choices B, C, and D are incorrect. This ECG shows sinus bradycardia. There are is a regular P-R interval and the proper relationship between P waves and QRS complexes. But the heart rate is lower. The price of impulses arising from the sinoatrial (SA) node is more economical than expected. The average adult heart rate, resulting from the SA node, is usually 60 to 100 beats per minute. Sinus bradycardia is defined as a sinus rhythm with a rate below 60 beats per minute. While sinus bradycardia can sometimes be concerning, it is not a fatal rhythm that requires immediate attention in the absence of symptoms. This may even be an average heart rate for the patient, depending on their baseline. Athletes who are very well conditioned tend to have low baseline heart rates, such as a heart rate in the 40s. Therefore, it is so important to know what is normal for your patient. This ECG shows supraventricular tachycardia or SVT. While this is a concerning rhythm that will need attention, it is not your priority given that you have a patient with third-degree heart block that could suffer sudden cardiac death. SVT is often tolerated by patients for long periods and can be challenging to break. The typical treatment is adenosine or cardioversion to convert the patient back into a normal sinus rhythm. This ECG shows normal sinus rhythm or NSR. This is the baseline rhythm that we expect to see in all patients, so this patient would not be your priority. You would need to see all the other patients on your above list first, as they all have irregular rhythms. Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences. Additional Info To understand a complete heart block, you must first understand a normal EKG. The image shown below indicates a normal EKG where there is a clear relationship between a "P" wave and a "QRS" complex. The P-R interval is regular. The "P" wave indicates SA (sinoatrial node) node firing, whereas QRS indicates ventricular contraction. The P-R interval is the time interval from sinus node firing to the time it reaches the ventricle and results in shrinkage. "T" wave indicates ventricular repolarization and marks the beginning of ventricular relaxation.

The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up? A. Spills sterile water onto the sterile field. [55%] B. Holds their hands above their elbows during handwashing. [34%] C. Has sterile gauze placed into the sterile field [3%] D. Keeps the sterile field above their waist. [8%]

Explanation Choice A is correct. When a sterile surface comes in contact with a liquid, the sterile object or field becomes contaminated. The nurse should intervene because microorganisms travel to the sterile object if moisture leaks through the protective covering of a sterile package. Choices B, C, and D are incorrect. These observations all adhere to surgical asepsis. Fluid flows in the direction of gravity. A sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the surface of the object. Thus, it is appropriate for handwashing to occur with their hands over their elbows. Sterile gauze may be placed on the sterile field as long as the opening of the package is not torn and the object touches the border of the sterile field. The sterile field should be above the waist. Additional Info Surgical asepsis prevents contamination of an open wound, serves to isolate an operative or procedural area from an unsterile environment, and maintains a sterile field for surgery or procedural intervention. Surgical asepsis differs from medical asepsis in that surgical asepsis aims to completely kill microorganisms, whereas medical asepsis prevents the microorganisms from spreading.

A client with Alzheimer's disease is being cared for by the nurse. Which nursing problem for the client would be the nurse's primary concern? A. Inability to do activities of daily living. [17%] B. Increased risk for injury. [79%] C. Potential for constipation. [1%] D. Ineffective family coping. [2%]

Explanation Choice A is incorrect. Alzheimer's patients have difficulty completing activities of daily living. However, the nurse should prioritize client safety over other problems. Choice B is correct. Safety should be the highest priority for the client. Clients with Alzheimer's disease are unaware of their surroundings and tend to wander. The nurse should implement safety measures. Choice C is incorrect. Older clients have an increased risk for constipation; however, their safety should take priority for other concerns. Choice D is incorrect. It is understandable for the family to be troubled regarding their loved one's condition. However, the nurse should always prioritize the client's safety over other problems.

The nurse is providing discharge instructions to a client who has chronic diabetes insipidus (DI). Which of the following client statements would indicate a correct understanding of the discharge instructions? A. "I will need to drink no more than 800 ml per day." [5%] B. "I will need to weigh myself at the same time every day." [39%] C. "I should increase salty snacks in my diet." [8%] D. "I need to log my fluid intake and urine output." [48%]

Explanation Choice B is correct. A client with chronic diabetes insipidus (DI) is instructed to weigh themselves daily. This weight should be taken with the same scale and obtained after the first-morning void. Choices A, C, and D are incorrect. Fluid restrictions would be appropriate for clients with the syndrome of inappropriate antidiuretic hormone (SIADH). This would not be appropriate for DI as the client will need to consume more fluids to replace those that are lost. Salty snacks are not encouraged because this may hasten the hypernatremia associated with this disease. Logging intake and output are not useful because this provides a crude way of assessing fluid status. Additional Info DI is a condition that may be central or nephrogenic. The nurse must teach the client about the treatment plan, which will involve the replacement of antidiuretic hormone via vasopressin or desmopressin. The client is at risk for fluid volume deficit because the client may experience polyuria. This may manifest as tachycardia, hypotension, thready pulse, and hypernatremia because the urine output is pale and mostly comprised of water.

Which ergonomically designed work tool can prevent repetitive stress syndrome? A. A back support belt [31%] B. A special computer mouse [29%] C. A special chair for sitting [29%] D. Weighted pens and pencils [10%]

Explanation Choice B is correct. A special ergonomically designed work tool that can prevent repetitive stress syndrome (for example, carpal tunnel syndrome) is a special computer mouse. Choice A is incorrect. A back support belt is a protective device that may help to avoid a back injury and not repetitive stress syndrome. Choice C is incorrect. A special chair for sitting in the correct posture prevents muscle fatigue and maintains the body in the correct alignment with lumbar support, but it does not prevent repetitive stress syndrome. Choice D is incorrect. Weighted pens and pencils may be used by clients with poor fine motor coordination, but they do not prevent repetitive stress syndrome.

The nurse receives a call from her mother who tells her that her father is having sudden and severe chest pain but is refusing to go to the hospital. What should be the nurse's initial action? A. Tell her mother to call 911. [37%] B. Ask her mother to let her father chew an aspirin. [44%] C. Ask what her father ate recently. [8%] D. Ask her mother if she can talk to her father. [11%]

Explanation Choice B is correct. An acute myocardial infarction (MI) should always be suspected while considering a differential diagnosis of new-onset chest pain in an elderly man. Often, the pathophysiology of acute myocardial infarction or unstable angina involves thrombus (clot) formation and propagation. The patient should be given an aspirin to chew on first to decrease platelet aggregation and prevent the thrombus from getting any bigger. The patient is obviously in distress and intervention should be initiated. The benefits of early aspirin administration outweigh the risks. Several clinical trials have strongly suggested that the early administration of aspirin can significantly reduce the size of the myocardial infarction and improve survival. Studies have shown that aspirin administration within one hour of emergency room presentation by a patient with an acute MI or unstable angina is associated with a substantial reduction in 30-day mortality when compared to those given aspirin an hour after the presentation. Therefore, the nurse should certainly advise her mother to give her father an aspirin. Also, the patient should be instructed to chew aspirin rather than swallowing it at once. Chewed aspirin works faster compared to swallowing it at once. Generally, if a patient experiences a new onset of chest pain, the recommended sequence of action is to call 911 or local emergency first and then take an aspirin. Often, it is the 911 operator who first evaluates the patient's symptoms and advises the patient to take an aspirin. Once dispatched, the paramedics can give oxygen and medications and move the patient fast to the ER. If the patient is indeed having a heart attack, early intervention with thrombolytics or angioplasty can limit the damage. Therefore, calling 911 is crucial. In this case, the patient's wife has already called her daughter who is a nurse. The wife also mentioned that the patient is unwilling to go to the hospital. Being a nurse, it would be an appropriate and responsible action for the daughter to advise her mother to give the aspirin right away. Following that, the daughter can talk to her father to alleviate his anxiety, convince him to call 911, and go to the hospital. Choice A is incorrect. Had the mother not already reached out to her daughter who is a nurse, the recommended course of action would be to call 911 and then give her husband an aspirin. However, the mother has reached out to a nurse. In the role of a nurse, it is appropriate for the daughter to advise her mother to give her father aspirin right away and then call 911. Choice C is incorrect. Obtaining more history will certainly help to narrow down the differential diagnoses of new-onset chest pain. Asking what her father ate could give the nurse additional information about the potential cause of the chest pain; if it is related to a gastrointestinal or cardiac etiology. However, the patient is in distress and the first intervention should be to give an aspirin. The benefits of early aspirin administration outweigh the risks. Choice D is incorrect. The nurse can talk to her father to alleviate his anxiety and get more history while her mother is getting the aspirin. The priority action should be to give aspirin to her father.

A 74-year-old female client is on her 3rd postoperative day and has an indwelling urinary catheter attached. While the nurse was making the morning rounds, she complains, "Oh dear, I feel like peeing again!" The most appropriate response for the nurse is: A. "It's just bladder spasms. Nothing to worry about." [3%] B. "Let me take a look at that urine bag and make sure it's draining properly." [78%] C. "You should do Kegel exercises regularly to stop this urge to void." [4%] D. "Is this the first time this has happened?" [15%]

Explanation Choice B is correct. Bladder spasms may cause the urge to void, but the most appropriate initial action is for the nurse to check the patency of the urinary catheter, as the most frequent reason for an urge to void while an indwelling catheter is in place is blocked tubing. Choices A, C, and D are incorrect. Performing Kegel exercises while an indwelling catheter is in place will not help prevent voiding urges and could cause irritation to the urethral sphincter. While it is good for the nurse to probe whether the client has experienced this problem before, the best initial action would be to check the patency of the catheter.

The nurse is assessing a patient's neurological status and notes 4+ deep tendon reflexes (DTR). Which of the following conditions would not be a possible cause of hyperactive DTRs? A. Hypocalcemia [28%] B. Muscular dystrophy [35%] C. Upper motor neuron lesion [13%] D. Hyperthyroidism [23%]

Explanation Choice B is correct. Hyperactive deep tendon reflexes (DTRs) would not be expected in a patient with muscular dystrophy. Muscular dystrophy DTRs are typically decreased or absent. Choice A is incorrect. Hypocalcemia (low calcium level) is a potential cause of hyperactive DTRs. Choice C is incorrect. The presence of an upper motor neuron (UMN) lesion is a potential cause of hyperactive DTRs. Choice D is incorrect. Hyperthyroidism is a potential cause of hyperactive DTRs. NCSBN Client Need Topic: Skills/procedures, Subtopic: potential for complications from health alterations, system-specific assessments

An older man on the cardiac floor has EKG changes, including tall T waves and extensive QRS complexes. This is new to him since his last EKG two months ago. What electrolyte imbalance does the nurse suspect this patient is suffering from? A. Hypomagnesemia [4%] B. Hyperkalemia [84%] C. Hypokalemia [9%] D. Hypercalcemia [4%]

Explanation Choice B is correct. Hyperkalemia, potassium greater than 5.0, can cause EKG changes and eventually, cardiac arrest if it gets high enough. High potassium causes peaked T waves and widened QRS complexes. Choice A is incorrect. Low magnesium can cause a prolonged QTc but does not create tall T waves and extensive QRS complexes. Choice C is incorrect. Tall T waves and extensive QRS complexes are due to hyperkalemia. Hypokalemia can cause T wave depression and ST-segment depression. Choice D is incorrect. Hypercalcemia can cause a shortened QTc but does not create tall T waves and extensive QRS complexes. NCSBN Client Need Topic: Physiological Adaptations, Sub-topic: Fluid and Electrolyte Imbalances, Fluid, Electrolyte, and Acid-Base Imbalances

A client complains of persistent fever and urinary urgency. He was asked to provide a urine specimen for culture and sensitivity analysis. The nurse ensures that the client collects the specimen properly by informing the client that he should collect the specimen from: A. The first stream of urine from the bladder [4%] B. The midstream urine from the bladder [93%] C. The final stream of urine from the bladder [1%] D. The full volume of urine from the bladder [2%]

Explanation Choice B is correct. It is recommended to collect urine specimens from the midstream as it is less likely to be contaminated with microorganisms from the external genitalia. Choices A, C, and D are incorrect. Both the first stream and final stream pose the risk of contamination from the external genitalia. It is not necessary to collect the entire urine specimen for a urine culture and sensitivity analysis.

The nurse is caring for a client with Multiple Sclerosis (MS) undergoing plasmapheresis. The nurse understands that plasmapheresis controls symptoms of MS by removing which of the following elements from the blood? A. Catecholamines [24%] B. Antibodies [25%] C. Plasma proteins [46%] D. Lymphocytes [4%]

Explanation Choice B is correct. Multiple sclerosis (MS) is a disease wherein antibodies attack the myelin sheath of the neurons causing MS symptoms. In plasmapheresis, these antibodies are removed from the client's plasma, removing the cause of myelin sheath demyelination. Choices A, C, and D are incorrect. Plasmapheresis does not remove catecholamines, plasma proteins, or lymphocytes.

A patient being treated for hypertension is assessed by the nurse and found to have poor gait and impaired balance. What would the nurse's appropriate action be? A. Do nothing as this has nothing to do with why the patient was hospitalized. [0%] B. Speak with the attending physician about his concerns and request a referral to physical therapy. [70%] C. Speak with the attending physician about his concerns and request a referral for the patient to go to the hospital gym. [1%] D. Add this issue to the nursing care plan and have daily gait/balance training as an intervention. [28%]

Explanation Choice B is correct. Nurses need to be aware of the patient's needs even if they do not pertain to the reason for hospitalization and treatment. Observation is a crucial nursing skill. The nurse should always be alert for any changes in a patient's condition, regardless of the initial diagnosis. Being aware of the patient's status will equip the nurse to be a better advocate for patients and to request referrals when concerns or issues arise during care. Choice A is incorrect. Any changes in a patient's status should be reported, even if it has nothing to do with the reason for admission. Choice C is incorrect. A referral to go to the hospital gym is not necessary. Physical Therapy can assist the client with balance and gait issues. Choice D is incorrect. The nursing care plan should include safety measures related to gait/balance impairment. However, gait training will be provided by physical therapy. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Planning and Evaluation of Patient Outcomes

The nurse is attaching a 24 hour Holter monitor to a client with a history of dysrhythmias. What should the nurse instruct the client to do while he is on the Holter monitor? A. Stop taking all of his medications. [2%] B. Record his activities all throughout the day. [68%] C. Check and record his blood pressure frequently. [9%] D. Do not use the microwave. [22%]

Explanation Choice B is correct. The client's activities in the day should be recorded so that they can be compared with the occurrence of dysrhythmias. Choice A is incorrect. Discontinuing medications is not necessary when undergoing 24 hour Holter monitoring. Choice C is incorrect. Taking frequent blood pressure measurements during a 24 hour Holter monitoring is not necessary. Choice D is incorrect. Avoiding the microwave is not necessary as it does not have any effect on the results of the Holter monitor.

A nurse is reviewing the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 of 30 mm Hg, and HCO3-of 22 mEq/L. What of the following do these results indicate? A. Metabolic acidosis, compensated [8%] B. Respiratory alkalosis, compensated [76%] C. Metabolic alkalosis, uncompensated [10%] D. Respiratory acidosis, uncompensated [6%]

Explanation Choice B is correct. The normal pH ranges between 7.35-7.45. A respiratory condition would show an inverse relationship between the PCO2 and the pH, as seen in this case. In a metabolic state, the HCO3- would be directly proportional to the pH (i.e. if bicarbonate is elevated, the pH is elevated; and vice versa). Because the pH is at 7.45, which is within the normal range, this is an indication that compensation has occurred. Choices A, C, and D are incorrect. These do not match the ABG labs for the client in this case.

The nurse is assessing a client with a chest tube for crepitus. Which assessment technique is most appropriate for the nurse to perform? A. Press down on the client's abdomen, releasing, and assessing for pain. [3%] B. Palpate the skin around the chest tube and observe for a crackling sensation. [69%] C. Auscultating the bowel sounds in each quadrant. [11%] D. Inspect the client's chest for an even rise and fall. [18%]

Explanation Choice B is correct. The nurse may assess for crepitus by palpating the skin around the chest tube and observing for a crackling sensation. Crepitus is defined as infiltration of air in the subcutaneous layer of the skin, also known as subcutaneous emphysema. It is caused by air leaking into the subcutaneous space. Choice A is incorrect. When the nurse presses down on a client's abdomen and then releases it, the nurse is assessing for rebound tenderness. This occurs when pain is present upon letting go of the client's abdomen, not pressing inward; this is a sign of peritonitis. Choice C is incorrect. Auscultating the bowel sounds in each quadrant is not an appropriate way to assess for crepitus. Choice D is incorrect. Inspecting the client's chest for even rise and fall will not allow the nurse to monitor for crepitus; rather this will help the nurse to assess for a symmetrical chest and unlabored breathing. NCSBN Client Need: Topic: Reduction of Risk Potential, Subtopic: System Specific Assessments, Respiratory

The nurse is evaluating the lab test results of one of her prenatal clients. She is eight weeks along and has a hematocrit level of 36% and hemoglobin of 11.7 gm/dL. These numbers are down from her pre-pregnancy H and H levels. The priority action of the nurse would be to: A. Call the client and request that she have her levels redrawn. [3%] B. Record these normal findings and confirm that the client is on a prenatal vitamin during her next visit. [76%] C. Report this abnormal finding to the doctor immediately. [20%] D. Notify the lab that these results are not normal and need to be re-assessed. [2%]

Explanation Choice B is correct. These results are typical and should be recorded as such. A drop from pre-pregnancy values is an expected phenomenon if they remain within or close to the normal range. Most women see a decrease in their hemoglobin and hematocrit levels during pregnancy. This phenomenon is known as physiological anemia and occurs as a result of increased plasma volume in the maternal bloodstream. It is essential to confirm that the client is taking prenatal vitamins. Demand for iron increases during pregnancy. Folic acid supplementation is necessary to prevent fetal neural tube defects. Prenatal vitamins will serve to address those needs. Normal hemoglobin in a pregnant client is > 11 g/dL. Normal hematocrit in a pregnant client is > 33%. Choices A, C, and D are incorrect. This mother will not need emergent care, and thus the doctor does not need to be notified regarding this expected drop from pre-pregnancy values. No lab values will need to be redrawn at this time. NCSBN Client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

You are orienting a new nurse on your unit. The nurse is in the process of setting up portable suction in a client's room. After receiving the portable suction machine from the engineering department, the nurse tells you that it is not working. She then calls the engineering department and they pick the machine up for repairs. Ten minutes later, the engineering department calls you and tells you that this piece of equipment was working properly. You would suspect that: A. Someone is being dishonest with you. [1%] B. The new nurse didn't understand how to set up the equipment. [87%] C. The equipment is still not working. [1%] D. There is an electrical shortage in the plug. [10%]

Explanation Choice B is correct. You would suspect that the new nurse didn't know the setup of this portable suction equipment so you would address this learning need with education and training about the proper setup of the mobile suction equipment. Choice A is incorrect. You would not suspect that someone is dishonest with you. Something else is most likely occurring. Choice C is incorrect. You would not suspect that the equipment is still not working because there is no evidence for that. Choice D is incorrect. You would not suspect that there is an electrical shortage in the plug because there is no evidence for this.

A client has undergone repeated tests for 4th generation HIV test and has been confirmed to be HIV infected. The viral load is detectable but the client is asymptomatic. Which of these statements about the client's ability to transmit the virus is accurate? A. The client is not infectious because the virus is dormant [4%] B. The client is only infectious if he/she manifests symptoms [3%] C. The client is considered infectious at this time [77%] D. Specific tests should be done to determine whether the client is infectious or not [17%]

Explanation Choice C is correct. A fourth generation HIV Enzyme Linked Immunosorbent Assay (ELISA) test detects both the HIV antibody and antigen ( IgM and IgG antibody and p24 antigen). In a chronic HIV infection, the sensitivity and specificity of a fourth generation HIV test is close to 100%. Even in an acute/ early HIV infection, a fourth generation test is able to identify HIV infection in 80% cases ( unlike the antibody tests). The client is confirmed to have HIV based on these tests. Additionally, the HIV viral load ( RNA test) is detectable. The patient, therefore, is considered infectious unless treated to undetectable viral load. Choices A, B, and D are incorrect. The client has a positive HIV antibody + antigen test and a detectable HIV viral load. No further testing is needed to determine infectiousness ( Choice D). It is possible to render the client noninfectious by achieving undetectable viral load with an adequate anti-retroviral therapy. Being asymptomatic ( Choice B), and having a dormant infection (Choice A) do not render the client noninfectious as long as the viral load is detectable. The client should be counseled regarding his/ her ability to transmit the virus, safe sex practices, and treatment options.

The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following? A. Apraxia [7%] B. Agraphia [14%] C. Agnosia [40%] D. Aphasia [39%]

Explanation Choice C is correct. Agnosia is a clinical feature associated with dementia. Agnosia is the inability to identify familiar objects or people, even a spouse. Choices A, B, and D are incorrect. Apraxia is a clinical feature of dementia, and apraxia is the inability to perform familiar and purposeful tasks. An example of this is when a client is instructed to brush their hair or tie their shoes, they cannot perform the task. Agraphia is a term describing when a client has difficulty writing. This is often seen in early Alzheimer's disease. Aphasia is the difficulty finding the correct word, then is reduced to a few words, and finally is reduced to babbling or mutism. NCLEX Category: Physiological Adaptation Related Content: Alterations in Body Systems Question type: Knowledge/comprehension

The school nurse is performing the corneal light reflex test on a child suspected of having strabismus. Which finding does the nurse identify as a sign of this condition? A. Symmetrical pin-point light on each pupil [7%] B. Red reflex in both eyes [9%] C. Asymmetrical pin-point lights on the pupils [74%] D. Sun setting sign [10%]

Explanation Choice C is correct. Asymmetrical pin-point lights on the pupils are a sign of strabismus. If the nurse suspects that the child has strabismus and conducts a corneal light reflex test, this may confirm her suspicions. This child should have a full eye exam performed to confirm the diagnosis and receive proper treatment. Choice A is incorrect. A symmetrical pin-point light on each pupil is the normal finding in a corneal light reflex test. This is not a sign of strabismus, rather it is a normal finding. Choice B is incorrect. The red reflex is a normal sign in healthy eyes. It occurs when light passes through the pupil and is reflected back off the retina to a viewing aperture, creating a reddish-orange glow. Choice D is incorrect. Sun setting sign is an indication of increased intracranial pressure that presents when the eyes appear driven downward. The sclera is seen between the upper eyelid and the iris, while part of the lower pupil may be covered by the lower eyelid. The nurse does not assess for this sign with a corneal light reflex and it is not a sign of strabismus.

After discovering an unconscious 7-year-old, the LPN discovers that the child is not breathing and does not have a pulse. There is no immediate access to a call button. What should the nurse do first? A. Give 2 minutes of CPR at a compression-ventilation ratio of 15:2. [20%] B. Look for help and an AED, then give 1 minute of CPR at a compression-ventilation ratio of 15:2. [10%] C. Give 2 minutes of CPR at a compression-ventilation ratio of 30:2. [50%] D. Look for help and an AED, then give 2 minutes of CPR at a compression-ventilation ratio of 30:2. [21%]

Explanation Choice C is correct. Current American Heart Association (AHA) guidelines recommend that if you find an unconscious infant or child (to puberty) and are alone, you should give 2 minutes of CPR at a compression-ventilation ratio of 30:2, then look for help and AED. A compression-ventilation rate of 15:2 is used in 2-person CPR. For infants and children, the guidelines reaffirm the C-A-B (compressions, airway, breathing) sequence and that compressions and ventilation are needed for pediatric cardiac arrest. Compressions should be done at a rate of 100 to 120 compressions per minute at a depth of about 1.5 inches for infants, about 2 inches for children, and at least 2 inches but no greater than 2.4 inches for adolescents. If rescuers are unwilling or unable to deliver breaths, they should perform compression-only CPR. Choices A, B, and D are incorrect. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Responding to Emergencies

The nurse is talking to a client who is scheduled to undergo a pelvic exam the following week. The nurse would include which instruction to the client? A. The client will undergo local anesthesia during the procedure. [5%] B. She should relax by clenching her fists or squeezing her eyes during insertion of the speculum. [10%] C. She should avoid douching 24 hours before the examination. [80%] D. She should open her mouth wide when the speculum is inserted. [5%]

Explanation Choice C is correct. Douching within 24 hours of the pelvic exam kills the flora as well as other cells in the cervix and surrounding areas leading to inaccurate results. Choice A is incorrect. Local anesthesia is not used during a pelvic examination. Choice B is incorrect. The client should avoid clenching her fists and squeezing her eyes to facilitate relaxation. Choice D is incorrect. When the speculum is inserted, the client is encouraged to breathe slowly and deeply, exhaling with her mouth open and lips in an "O" shape. This facilitates the relaxation of the vaginal wall.

What ethical principle below is accurately paired with a way that ethical principle is applied to nursing practice? A. Beneficence: Doing no harm during the course of nursing care. [21%] B. Justice: The obligation to be fair; equally dividing time and other resources among a group of clients. [35%] C. Veracity: Fully answering the client's questions without any withholding of information. [38%] D. Fidelity: Upholding the American Nurses Association's Code of Ethics. [6%]

Explanation Choice C is correct. Fully answering the client's questions without withholding any information is an example of the application of veracity into nursing practice. Veracity is being completely truthful with patients; nurses must not withhold the true information from clients even when it may lead to patient distress. Ethical concepts and principles are useful in patient care discussions because they provide a common language for healthcare professionals to identify the issues. Even if people disagree about which action is right in a situation, they can agree on which principles to apply. The agreement can provide common ground for a compromise or other resolution of the problem. There are 6 major ethical principles in healthcare. Choice A is incorrect. Beneficence is doing good and the right thing for the patient. Nonmaleficence is doing no harm. Choice B is incorrect. While the terms equity and equality may sound similar, implementing one versus the other results in different outcomes for clients in need. Equal distribution means each client is given the same amount of time and resources. Equitable distribution refers to the allocation of exact resources based on the needs of each client to reach an equal outcome. Justice is fairness. Nurses must be fair when they distribute care and resources equitably, which is not always equally among a group of patients. For example, a critically ill patient may require more resources than a less critical patient. This amounts to a fair decision-making process, leading to positive outcomes for both individuals. Choice D is incorrect. Fidelity is the duty to keep promises; faithfulness. Learning objective: Understand the six major ethical principles in nursing practice: autonomy, non-maleficence, beneficence, justice, veracity, and fidelity. NCSBN Client Need: Topic: Management of care; Sub-topic: Ethical concepts and principles

The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following? A. Penicillin [9%] B. Cat dander [2%] C. Latex [76%] D. Peanuts [13%]

Explanation Choice C is correct. Individuals with allergies to bananas are at an increased risk of developing an allergy to latex. Tropical fruit allergies may also indicate an increased risk. Working in a profession with increased exposure to latex, such as a hairdresser or house cleaner, also places a person at an increased risk for developing this allergy. Choices A, B, and D are incorrect. Having an allergy to bananas does not increase a person's risk of developing an allergy to penicillin, cat dander, or peanuts. NCSBN client need Topic: Health Promotion and Maintenance, health promotion

The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services? A. A client newly diagnosed with skin cancer that lives with family. [4%] B. A client recovering from a stroke and is discharged to inpatient rehab. [9%] C. A client who is homeless and has a substance use disorder. [77%] D. A client leaving against medical advice for the treatment of cellulitis. [10%]

Explanation Choice C is correct. Individuals with difficulty obtaining and sustaining housing have high rates of treatment non-adherence. Lack of adequate housing poses a serious threat to treatment adherence because of the lack of privacy, storage of medications, and a sense of detachment from the community. This client should be referred for outpatient services because they are homeless and have a substance use disorder. Both are issues that may be mitigated with community services. Choices A, B, and D are incorrect. Cancer support groups are essential for a client coping with the illness. This would be an appropriate referral, but not the greatest need of a referral considering the client lives with family, which can be viewed as a support system. A client recovering from a stroke requires many interdisciplinary resources and would not need a referral for community services because they are going to inpatient rehab. A client leaving AMA would not require a referral; the serious cellulitis diagnosis is acute and will resolve with antibiotics. Additional Info An RN may initiate referrals. The nurse should identify clients with the most significant need for community services. Examples of clients needing community services include: Homelessness Complex conditions (HIV, cancer) Insufficient support systems Financial instability

While caring for a young client brought to the emergency department for a fractured leg, the healthcare team assesses several other limb fractures in various stages of healing. The healthcare teams suspect __________. A. Neglect [4%] B. Psychological abuse [1%] C. Physical abuse [95%] D. That he is a clumsy child [1%]

Explanation Choice C is correct. Physical abuse is any intentional act causing injury or trauma to another person. In the child, multiple fractures in various stages of healing are very suspicious for abuse. This points to repeated injuries over a period of time and needs to be thoroughly investigated. Choice A is incorrect. Neglect is to fail to care for properly. This could be manifested by poor hygiene, ill-fitting clothes, or malnourishment, but would not be what the nurse suspects upon seeing fractures in various stages of healing. Choice B is incorrect. There is nothing in the stem of the question that points to psychological abuse. Currently, the team is only aware of multiple fractures in various stages of healing, pointing to physical abuse. Choice D is incorrect. The team does not simply suspect that this boy is a clumsy child. The multiple fractures in various stages of healing are very suspicious of abuse. This points to repeated injuries over a period of time and needs to be thoroughly investigated. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Pediatrics - Musculoskeletal/Abuse

The nurse is about to prepare the morning medications for clients on the ward. Which medication should the nurse prepare and administer first? A. Prednisolone (Deltsone), a glucocorticoid, to a client with inflammatory bowel disease. [9%] B. Rivastigmine (Exelon), an anticholinesterase inhibitor, to a client with dementia. [6%] C. Sucralfate (Carafate), a mucosal barrier agent, for a client with a duodenal ulcer. [32%] D. Enoxaparin (Clexane), an anticoagulant, to a client on bed rest after surgery. [53%]

Explanation Choice C is correct. Sucralfate is a mucosal barrier agent that must be given 30 minutes before the client's meal. This medication must be given first to achieve its effect. Choice A is incorrect. This medication can be given 30 minutes before and after the scheduled time. This medication does not have to be the first medication given. Choice B is incorrect. Exelon can be given within a 30 minute time frame of the scheduled time. This medication does not have to be given first. Choice D is incorrect. Clexane can be given within a 30 minute time frame of the scheduled time. This medication does not need to be administered first.

What is shown in the picture below? A. An implanted defibrillator [18%] B. A central venous catheter [10%] C. A cardiac pacemaker [70%] D. A chest drainage tube [2%]

Explanation Choice C is correct. The picture above shows a cardiac pacemaker with two leads. There are several types of cardiac pacemakers, including a biventricular pacemaker, a single chamber pacemaker, and a dual-chamber pacemaker. Choice A is incorrect. This is not a picture of an implanted defibrillator; below is a picture of an implanted defibrillator. Choice B is incorrect. This is not a picture of a central venous catheter; below is a picture of a central venous catheter. Choice D is incorrect. This is not a picture of a chest drainage tube; below is a picture of a chest drainage tube.

The nurse is caring for a patient with a medical diagnosis of scleroderma who reports fingertips tingling and turning white in response to cold or stress. The nurse would recognize these symptoms as which problem? A. Sjögren's Syndrome [8%] B. Sclerodactyly [8%] C. Raynaud's phenomenon [81%] D. Telangiectasia [2%]

Explanation Choice C is correct. This patient's symptoms are consistent with Raynaud's phenomenon. This condition is characterized by sudden or intermittent vasospasms in the fingertips and toes in response to cold temperatures or stress, resulting in decreased blood flow and blanching of the skin in these areas. This phase is typically followed by a blue phase, when hemoglobin releases oxygen into these tissues, and a red phase, when the areas are rewarmed. Sensations of tingling and numbness are common during these episodes. Choice A is incorrect. Sjögren's syndrome describes a condition of dry eyes and dry mouth that is experienced by approximately 20% of patients with scleroderma. Choice B is incorrect. Sclerodactyly describes the tightening of the skin of fingers and toes. Choice D is incorrect. Telangiectasia describes the presence of red spots on the hands, forearms, palms, face, and lips due to capillary dilation.

A client admitted due to emergent hypertension is about to be discharged. The nurse is giving instructions about dietary modifications. Which food choice by the client would indicate an accurate understanding of a low fat, low cholesterol diet? A. Macaroni and cheese [2%] B. Fish and chips [5%] C. Turkey breast salad [93%] D. Pepperoni pizza [1%]

Explanation Choice C is correct. Turkey breast contains 2.2 grams of saturated fats, 2.1 grams of polyunsaturated fats, and 2.6 grams of monounsaturated fats per 100 grams. It is also a high protein source `with 29 grams per 100 grams. Choice A is incorrect. Macaroni and cheese contain 8 grams of cholesterol and 5 grams of fat per 100-gram servings. Choice B is incorrect. Fish and chips contain an average of 11.1 grams of fat per 100-gram serving. Choice D is incorrect. Pepperoni pizza contains 10 grams of fat per 100-gram serving. It is also high in saturated fat.

A patient presents with weight loss and diarrhea with frothy, fatty, foul-smelling, yellow-gray stools. Which of the following malabsorption issues would not be a possible cause? A. Pancreatitis [24%] B. Celiac disease [29%] C. Lactose intolerance [24%] D. Tropical sprue [24%]

Explanation Choice C is correct. Weight loss and diarrhea are general signs and symptoms of most malabsorption disorders and are not specific enough symptoms to differentiate these disorders. Therefore, the critical symptom is the frothy, fatty, foul yellow-gray stools (steatorrhea). Steatorrhea may occur in all of the other answer choices listed but is not seen in lactose intolerance. Choice A is incorrect. Steatorrhea is caused by the presence of undigested, unabsorbed fat. Steatorrhea, infection, and diabetes are signs that pancreatic damage is worsening. Choice B is incorrect. The most common signs/symptoms of celiac disease are diarrhea, flatulence, abdominal distention, and malnutrition symptoms such as weight loss and steatorrhea. Choice D is incorrect. Tropical sprue refers to bacterial proliferation that is common in tropical regions and causes chronic/progressive damage to jejunal and ileal tissues. Steatorrhea may occur as a result of the damage to these tissues and malabsorption. NCSBN Client Need Topic: Adult health - Gastrointestinal, Subtopic: Elimination, nutrition, and oral hydration

When assessing a patient with nausea, vomiting, and diarrhea, which of the following focused assessment techniques should the nurse use? A. Evaluate for dehydration, assess skin turgor, auscultate lungs [52%] B. Auscultate lungs, auscultate heart, auscultate abdomen [3%] C. Auscultate abdomen, palpate the abdomen, evaluate for dehydration [43%] D. Palpate the abdomen, percuss the abdomen, auscultate heart [1%]

Explanation Choice C is correct. With the presence of nausea, vomiting, and diarrhea, the concern arises about fluid volume deficit and the potential for dehydration, which would be noted with poor skin turgor. The abdomen should be auscultated to evaluate for suspected hyperactive sounds due to the increased peristalsis. Choices A and B are incorrect. The lungs are not grouped with the symptoms presented. Choice D is incorrect. Auscultating the heart is an option to determine heart rate, but an increased heart rate can be evaluated when vital signs are collected. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Objective Data Collection

The nurse is caring for a client who repeatedly attempts to get up from their wheelchair unassisted and has fallen twice. The primary healthcare provider (PHCP) prescribes restraints. Which type of restraint does the nurse anticipate? A. Soft wrist restraints [22%] B. Mitten restraints [3%] C. Seclusion [1%] D. Waist belt restraint [74%]

Explanation Choice D is correct If restraints are necessary for this client, the most appropriate restraint would be a waist belt restraint. This restrains the client's ability to stand up, which is the device's intent. Choices A, B, and C are incorrect. Soft wrist restraints would not be appropriate for this clinical situation. This type of restraint would be appropriate for clients who pull at tubes or devices. Soft wrist restraints may also be suitable for a client who is agitated and has hit themselves or others. Mitten restraints may be indicated for a client who pulls at tubing or devices. Seclusion is a form of restraint and would be contraindicated in this case as seclusion is used for individuals who are violent. Clients who are at risk of falling should not be placed in seclusion. Additional Info Belt restraints may be warranted for confused or impulsive clients who are continually trying to get out of bed or a chair after repeated redirection when it's unsafe for them to get up unassisted. Belt restraints should be applied over clothing and secured over the client's waist. The restraint should be anchored to an immovable part of the bed or the chair.

The cardiac nurse is evaluating cardiac markers to determine whether or not their patient's heart has suffered from muscle damage. The nurse is aware if damage has occurred, CK-MB levels will be their highest after how many hours? A. 3 to 6 [36%] B. 1 to 2 [12%] C. 48 to 72 [34%] D. 18 [17%]

Explanation Choice D is correct. CK-MB, or creatine kinase myocardial muscle, levels measure muscle cell death and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels first begin elevating about 3 to 6 hours after a cellular injury or myocardial infarction and stay elevated for about 48 to 72 hours. Choice A is incorrect. While CK-MB levels begin to rise about 3 to 6 hours after myocardial cellular death, they do not peak until 18 hours. Choice B is incorrect. CK-MB enzyme levels will not have risen yet by 1 to 2 hours. Standards do not begin to rise until 3 to 6 hours and hit their peak around 18 hours. Choice C is incorrect. At 48 to 72 hours, CK-MB enzyme levels will likely return to normal. NCSBN client need Topic: Physiological adaptation, reduction of risk potential

A client with prostate cancer is undergoing brachytherapy. The client's wife is visiting him and asks if she can spend more time with her husband. The most appropriate response for the nurse should be: A. The hospital does not allow you to stay for more than the allotted visiting hours. [11%] B. You do not need to stay for longer than you should. [2%] C. Your husband will get better sleep if you go home. [1%] D. You can only stay up to half an hour to protect yourself from the radiation. [86%]

Explanation Choice D is correct. Clients undergoing brachytherapy have radium implants. They should have limited close contact with a family of up to only 30 minutes to 2 hours a day. The visitors should limit their exposure time to radium, have adequate distance between them, and use a lead shield against the radium. Choice A, B, and C are incorrect. These responses are apathetic and inappropriate. The client may get better sleep without the visitors ( Choice C), but this response does not address the radiation-related dangers to the visitor. Learning Objective Understand that the clients on brachytherapy have radiation implants which pose risks to the visitors and healthcare personnel. Vistors and healthcare staff should limit their exposure to the client as long as these implants are in place. Additional Info Brachytherapy is an internal radiation therapy where a radiation source ( small radioactive implant) is placed close to cancer. This way, cancer receives a very high dose of radiation, but only low levels reach adjacent tissues thus, limiting side effects. Brachytherapy is commonly used to treat prostate, uterus, cervix, and vaginal cancers. It is essential to have safety measures in place during brachytherapy to protect the visitors and healthcare staff. Patients may be admitted to the hospital for a few days in a single room during brachytherapy. Once the level of radioactivity goes down to a safe level, the patients can go home. Following discharge, the clients should avoid contact with children and pregnant women for quite some time. The following are nursing specific instructions in caring for the clients receiving radioactive source implants: The patient should be in a single room with access to the bathroom. Post specific "stay times" on the room door and do not spend any more time in the room than needed to care for the patient. No pregnant visitors No visitors under the age of 18 years Visitors should remain at least 6 feet from the patient. The time can vary from 30 minutes to 2 hours per visitor per day. Housekeeping should not enter the room unless escorted by the nurse, and only essential cleaning must be performed.

Analyze the following ABG: pH 7.62, CO2 19, HCO3 24 A. Compensated metabolic acidosis [2%] B. Uncompensated metabolic acidosis [4%] C. Compensated respiratory acidosis [5%] D. Uncompensated respiratory alkalosis [89%]

Explanation Choice D is correct. First, determine if the ABG is compensated or uncompensated. Since the pH is not between 7.35 and 7.45, it is uncompensated. Next, decide whether it is acidosis or alkalosis. The pH is higher than 7.45, so it is an alkalosis. Lastly, determine if it is respiratory or metabolic. Evaluate the CO2 and HCO3 to see which is out of range. The HCO3 is normal, and the CO2 is low, so this is a respiratory problem. Putting it all together, this case is an uncompensated respiratory alkalosis. This patient is breathing off too much CO2, which is an acid. Because they are losing too much acid, they are becoming alkalotic, hence their pH of 7.62. The kidneys have not yet begun compensating by decreasing the amount of HCO3 they are producing, therefore the HCO3 value is still normal. Choices A, B, and C are incorrect. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation

A client with sickle cell anemia is talking to the nurse asking for advice regarding his vacation. Which recommendation should the nurse give? A. Trek up the mountains and camp overnight [5%] B. Go on a snow-skiing trip [5%] C. Take a plane ride for some sight-seeing [20%] D. A long drive for a picnic on the beach [69%]

Explanation Choice D is correct. High altitudes and cold temperatures cause sickling and therefore, should be avoided. A picnic on the beach does not expose the client to cold nor high temperatures and, therefore, is suitable for the client. Choice A is incorrect. The nurse should recommend to the client to avoid activities that cause sickling episodes. A trek on the mountains and camping means that the client will go to a high altitude and be exposed to the cold at night. High altitudes and cold temperatures cause sickling and therefore, should be avoided. Choice B is incorrect. Cold temperatures cause sickling; therefore, a ski trip should be avoided. Choice C is incorrect. Taking a plane ride exposes the client to high altitudes, which can cause sickling. This should be avoided.

The nurse is caring for a 5-year-old client whose family is of Orthodox Jewish faith. The mother requests that the client remains kosher while in the hospital. Which of the following actions while assisting the child with lunch would best respect the mother's request? A. Finding metal utensils instead of plastic [16%] B. Placing the food on plastic plates instead of paper [5%] C. Helping the child unwrap the plastic utensils from their packaging [6%] D. Allowing the child and his mother to unwrap the eating utensils [73%]

Explanation Choice D is correct. It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested. Choice A is incorrect. It is not appropriate for the nurse to replace the utensils that come with the tray with metal utensils. Kosher meals will arrive on the unit on paper plates with sealed plastic utensils which the nurse should not open. Choice B is incorrect. It is not appropriate for the nurse to transfer the food to another dish. The nurse should deliver the tray to the client on the paper plate that it arrives on. Choice C is incorrect. It is not appropriate to help the child unwrap the plastic utensils from their packaging. The nurse should deliver the paper plate and sealed plastic utensils directly to the client and the mother. The mother can assist in the unwrapping, but the nurse should not do it for the client unless otherwise instructed. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Culture & Spirituality

The nurse is taking care of a client that is suffering from orthostatic hypotension. The client's health care provider is contemplating prescribing an alpha-adrenergic agonist. Which alpha-adrenergic agonist is most likely to be administered? A. Clonidine [32%] B. Phenylephrine [23%] C. Ephedrine [22%] D. Midodrine [22%]

Explanation Choice D is correct. Midodrine is an oral drug that is used to treat orthostatic hypotension in patients who do not respond to traditional therapy. It causes peripheral vasoconstriction and an increase in vascular tone and blood pressure. Choice A is incorrect. Clonidine is an alpha 2 receptor agonist that is used to treat essential hypertension. Choice B is incorrect. Phenylephrine is a potent vasoconstrictor that is used in many cold and allergy products. Choice C is incorrect. Ephedrine is an adrenergic agonist that is used for the chronic management of asthma and allergic rhinitis.

Which of the following client needs would be the highest priority and the one that is also supported by an appropriate rationale? A. The need to develop trust versus mistrust because this is the most basic of all needs. [5%] B. The need to be free of fear and anxiety because these feelings impede coping. [5%] C. The need for adequate cardiovascular functioning because, without this, life cannot be sustained. [6%] D. The need for a patent airway because, without this, life cannot be sustained. [84%]

Explanation Choice D is correct. The "need for a patent airway because, without this, life cannot be sustained" would be the correct answer. Maslow's Hierarchy of Needs is used to set priorities from the most basic physical needs to the most advanced self-actualization needs. Of all the most basic physical needs, the greatest of all from highest to lowest priority are: "A, B, and C = airway to breathing to cardiovascular functioning". Maslow's Hierarchy of Needs is shown below. Choice A is incorrect. Although the need to develop trust versus mistrust is the first developmental milestone for the infant, it is not the most basic of all requirements. Physical needs rather than trust are priorities because physical needs are higher priority needs than psychological needs. Choice B is incorrect. The need to be free of fear and anxiety is a psychological need, and, according to Maslow's Hierarchy of Needs, physical needs are a higher priority than psychological needs. Choice C is incorrect. The need for adequate cardiovascular functioning is not the highest priority. Of all the most basic physical needs, the greatest of all from highest to lowest priority are: "A, B, and C = airway to breathing to cardiovascular functioning".

An 8-year-old child was brought to the physician's office with complaints of swelling and pain in the knees. His mother informs the nurse that "The swelling came out of nowhere, and it just keeps getting worse." The impression is Lyme disease. Which questions should be included during the interview of both mother and child when taking initial history? A. "Have you noted any flank pain and a decrease in the volume of urine?" [6%] B. "Has there been a fever of over 103 degrees F over the last 2-3 weeks?" [31%] C. "Did you notice rashes on the palms and soles?" [26%] D. "Do you have headaches, malaise, or sore throat?" [36%]

Explanation Choice D is correct. The classic symptoms of Lyme disease include flu-like symptoms such as headache, body malaise, and unexplained fatigue. Other symptoms are a stiff neck, anorexia, lymphadenopathy, conjunctivitis, sore throat, splenomegaly, abdominal pain, and cough. Choices A, B, and C are incorrect. The rash that is associated with Lyme disease is erythema migrans or the "bulls-eye" rash. The rashes do not appear on the palms and soles. Urinary tract infections are not commonly associated with Lyme Disease, nor is a fever of 103 degrees F.

The nurse walks into the room and finds her client complaining of severe shortness of breath and chest pain. She suspects a pulmonary embolism. After notifying the rapid response team, the nurse's priority action is which of the following? A. Obtain vital signs and place the client in left-sided, Trendelenburg position. [42%] B. Administer heparin. [4%] C. Check lung sounds. [9%] D. Elevate the head of the bed. [46%]

Explanation Choice D is correct. The first action following the notification of the rapid response team when a pulmonary embolism is suspected is "elevating the head of the bed" to about 30 degrees. This is a quick action that does not require a doctor's order. A pulmonary embolism causes ventilation and perfusion mismatch. In a position with the head of the bed elevated, gravity pulls the diaphragm downward, allowing for lung expansion and improved ventilation. Please note that an embolus may refer to a blood clot (pulmonary embolism, arterial thromboembolism), air bubble (air embolism), or a piece of fatty deposit (fat embolism) that can be carried into the bloodstream to lodge in a vessel and cause an embolism. Many students make a knee-jerk selection of Trendelenburg's position the moment they see the word embolism in the question. Please note that the Trendelenburg's position or left lateral position is used in patients with "air" embolism. This is because air is a gas and it will float in the upper part of the right ventricle/right atrium when patients are placed in such a position. Pulmonary embolism (PE) is a blood clot. Often, it travels from the lower extremities to the lungs. You do not want to keep a patient with acute PE in Trendelenburg's position because that may facilitate further embolism in an acute thromboembolism scenario. Choice A is incorrect. The patient is short of breath and is clearly in distress. Vital signs should be taken after the patient's head of the bed is elevated and oxygen has been initiated. Choice B is incorrect. While this patient may receive heparin, a doctor's order will be needed to initiate heparin. Choice C is incorrect. The patient is in distress. The rapid response team needs to be notified and the head end of the bed needs to be elevated prior to proceeding with further assessment. The nurse may assess lung sounds after the head of the bed is elevated and oxygen has been initiated. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action? A. File an incident report [0%] B. Assist the child back to bed [2%] C. Call for help [9%] D. Assess the child for any injuries [88%]

Explanation Choice D is correct. The priority nursing action is to assess the client. The nurse should assess the child for any injury and/or loss of consciousness. Following the assessment, the nurse can determine a further course of action. Choice C is incorrect. While it is likely that the nurse will need to call for help, this is not the priority nursing action. The nurse should first assess the fallen child. Choice A is incorrect. Following any fall event, the nurse must file an incident report. Incident reports help evaluate the cause of falls and help take steps to prevent future unwanted incidents. However, the patient is the utmost priority, and the nurse must assess the patient first before proceeding to other actions. Choice B is incorrect. Before assisting the child back to the bed, the nurse must complete her assessment. This includes assessing for an injury (fractured bones, etc). If the child is injured, the nurse should take appropriate actions to move them safely. Inappropriate handling of an injured limb (example: hip fracture) may inflict further distress to the child and/or aggravate the injury. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Infection control and safety

The nurse is caring for a client with tracing on the electrocardiogram shown in the exhibit provided. The nurse should perform which priority action? See the exhibit. A. Initiate a code blue. [38%] B. Establish intravenous access. [3%] C. Notify the primary healthcare physician (PHCP). [13%] D. Assess the client's airway, breathing, and circulation. [45%]

Explanation Choice D is correct. The tracing indicated that the client is experiencing ventricular fibrillation (Vfib). This is a fatal rhythm. However, the priority action of the nurse is to immediately establish the validity of this fatal arrhythmia tracing by assessing the client's airway, breathing, and circulation. Ventricular fibrillation is characterized by a complete lack of coordinated contraction, resulting in chaotic electrical activity on the rhythm strip. Due to rapid ventricular contractions, the ventricular filling decreases markedly, leading to a significant decrease in cardiac output. Consequently, a pulse is absent. Clinically, at the time of the event, the patient should be pulseless, unconscious, and unresponsive. Please note that the same question may be presented differently with assessment findings disclosed within the question (e.g. information such as the patient is unresponsive and pulse is absent within the question stem), the answer would then be choice A (proceed with CPR and defibrillation because the assessment has already been completed). Choices A, B, and C are incorrect. None of these options can be implemented until the validity of the rhythm is established. The nurse should clinically validate the rhythm before proceeding to call a code blue. Once the client's vitals validate this fatal rhythm, cardiopulmonary resuscitation (CPR), according to Advanced Cardiac Life Support (ACLS) guidelines, should be initiated immediately and the physician must be notified.

The nurse is teaching a client scheduled for a vaginal and cervical colposcopy with biopsy. Which of the following information should the nurse include? A. You should not eat or drink eight hours prior to this test. [16%] B. You will need to have someone drive you home after this test. [21%] C. A metallic taste is common once you get the contrast dye. [10%] D. Vaginal intercourse may be painful after the procedure. [52%]

Explanation Choice D is correct. Vaginal intercourse following a vaginal colposcopy with a biopsy is not advised 48-hours after the procedure. Intercourse may be painful and increase post-procedure bleeding. Choices A, B, and C are incorrect. The client does not need to be NPO (nothing by mouth) prior to this procedure. This procedure also does not involve contrast dye or require that the client not drive after the procedure considering sedation is not utilized. NCLEX Category: Reduction of Risk Potential Activity Statement: Diagnostic Procedures Question type: Analysis Additional Info A colposcopy is a diagnostic procedure that may be utilized to detect an array of gynecological conditions, including herpes simplex virus, human papillomavirus, cervical cancer, and any other abnormal tissue in the vagina, cervix, and vulva. This outpatient procedure requires the client to provide consent, and the client should be instructed that after the procedure, a small amount of bleeding is normal if biopsies were obtained.

You have been asked by a new graduate nurse why peaks and trough levels of medications are measured. How should you respond to this new graduate nurse's question? A. "Monitoring medication peaks and troughs are important to ensure that the medication is not causing a sensitivity reaction." [2%] B. "Measuring medication peaks and troughs are necessary to ensure that the medication is not causing an adverse effect." [9%] C. "We can ensure that the medication is administered at the most effective intervals by measuring peaks and troughs." [13%] D. "Medication peaks and troughs are essential to monitor and ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect."

Explanation Choice D is correct. You should state that medication peaks and troughs are essential to ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect. Peak and trough levels are most often performed for the clients receiving antimicrobial medication(s). Choice A is incorrect. Peaks and troughs of medications are not indicated to monitor a sensitive reaction to the medication. Choice B is incorrect. Peaks and troughs of medications are not indicated to monitor if an adverse reaction to the medication is occurring. Choice C is incorrect. The main reason for measuring peaks and troughs of medications is to ensure therapeutic drug levels. Although this may affect the dosing schedule, the primary reason for measuring these labs is not to determine the dosing schedule. Learning Objective Verbalize the rationale behind the need for peak and trough lab monitoring. Additional Info Peak and trough are used to describe drug concentrations. Both peak and trough levels are typically measured from blood samples. The peak level is when the drug has reached the highest level in the blood. This must be monitored, as drug toxicity may occur if the peak blood level elevates above a therapeutic level. The trough level is the lowest blood level of a drug. The time the peak level is taken depends on the medication's route of administration, while the trough level is taken just prior to administration of the next dose. If the trough level is too low, the drug may not be at a therapeutic level capable of generating a response. Therapeutic drug monitoring is utilized to verify therapeutic effects and minimize drug toxicity. A clinical pharmacist often carries out this monitoring.

You are working in the newborn nursery taking care of a 2-day old infant with fetal alcohol spectrum disorder and preparing the family for discharge. Which of the following educational points are essential to include? Select all that apply. A. Regular therapy appointments will need to be scheduled. [36%] B. An individualized education plan should be formulated with the child's school when he is preparing for kindergarten. [19%] C. With proper therapy, the condition will improve. [25%] D. A regular infant diet should be followed. [20%]

Explanation Choices A and B are correct. Therapy will be incredibly important for this infant after discharge. Physical therapy, occupational therapy, and speech therapy should all be incorporated with this infant's care plan. They will keep track of milestones and help aid in the development, motor skills, and cognitive abilities of the infant. Parents should be educated about the importance of these therapies so that they take them seriously and keep up with their appointments (Choice A). This child will require special education when starting school. The parents should be educated about this need so that they are realistic about their culture and prepared for the future needs of the child. Individualized education plans will be accommodated through the school system; the therapists and health care providers of the child can help inform them (Choice B). Choice C is incorrect. Fetal alcohol spectrum disorder is a lifetime disability. There is no cure. Even with proper occupational therapy, physical therapy, and speech therapy, there are expected delays in the life of this infant. He or she will likely have difficulties with poor judgment, cognition, impulse control, memory, and learning for the rest of their life. Emphasizing the chronicity of this disease may help the mother refrain from consuming alcohol during any future pregnancies and will ensure she is educated about the needs her child will face in the future. Choice D is incorrect. Infants with fetal alcohol spectrum disorder face challenges, including weak growth. They are often of short stature, low weight, and have smaller heads than average. Because of this, their nutritional needs will be unique. A nutritionist should be consulted to work with the family before discharge and teach them about the proper formulas/diet plan for their infant to maximize growth. NCSBN Client Need: Topic: Health Promotion and Maintenance; Subtopic: Newborn

When interpreting results from a direct Coombs test, you know that a positive result indicates which of the following? Select all that apply. A. Maternal antibodies are present on the infant's red blood cells. [28%] B. Antibodies are present in the maternal serum. [28%] C. The infant is at risk for erythroblastosis fetalis. [26%] D. The mother is at risk for Rh immunization. [19%]

Explanation Choices A and C are correct. A direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant's red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis (Choice C). Choice B is incorrect. The direct Coombs test does not measure antibodies in the maternal serum. Instead, the indirect Coombs test does this. Choice D is incorrect. The indirect Coombs test will check to see if the mother is at risk for Rh immunization. NCSBN Client Need: Topic: Safe and Effective Care Environment Subtopic: Safety and Infection Control

The LPN is assigned to take care of a patient with hemophilia. When she reviews the lab values, she would expect to find which of the following? Select all that apply. A. Normal PT level [12%] B. Abnormal PTT level [44%] C. Normal thrombin time [11%] D. Abnormal INR [33%]

Explanation Choices A, B, and C are correct. A is correct. Patients with hemophilia will have an average PT level, between 11 and 13.5. The Prothrombin time test measures the time necessary to generate fibrin after activation of factor VII. This evaluates the extrinsic pathway: Factors V, X, prothrombin, and fibrinogen. Since patients with hemophilia have deficiencies in factors XIII, IX, or XI depending on their sub-type, this test result will be reasonable. B is correct. Patients with hemophilia will have an abnormal PTT level. The partial thromboplastin time measures the integrity of the intrinsic clotting cascade, evaluating factors XII, XI, VIII, and IX. Since these are the factors in which a deficiency leads to a type of hemophilia, this level will be abnormal in patients with hemophilia. It is prolonged from the regular 25 to 35 seconds, meaning that it takes the blood longer than usual to clot. C is correct. Patients with hemophilia will have a standard thrombin time. Thrombin time assesses how long it takes fibrin to form from fibrinogen in plasma. This is not part of the clotting cascade that patients with hemophilia have a deficiency in, so there is no abnormality. Their value will be reasonable, between 12 and 14 seconds. Choice D is incorrect. The INR, otherwise known as the international normalized ratio, is a value calculated from the PT or prothrombin time. It is often used to monitor patients who are taking warfarin. Patients with hemophilia will have a normal INR because they have a regular PT. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Coordinated Care; Pediatrics - Hematology

Which of the following medications should the nurse monitor for the side effect of constipation? Select all that apply. A. Levetiracetam [20%] B. Oxycodone [43%] C. Poly-vi-sol [13%] D. Magnesium sulfate [24%]

Explanation Choices A, B, and C are correct. Levetiracetam (Choice A) is an antiepileptic medication and one of the side effects of antiepileptics is constipation. Oxycodone (Choice B) is an opioid medication used for severe pain. Opioids commonly cause constipation and the nurse should be aware of these side effects when administering them. Poly-vi-sol (Choice C) is an over-the-counter multivitamin with iron, and one of the most common side effects of iron supplements is constipation. Choice D is incorrect. Magnesium sulfate is used in various conditions, including premature labor, status asthmaticus, and hypomagnesemia. Magnesium has a variety of side effects, but none of them include constipation. Instead, high doses of magnesium from supplements can cause nausea, abdominal cramping, and diarrhea. Magnesium toxicity may cause arrhythmias, poor reflexes, confusion, weakness, and flushing. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological therapies; Pediatrics - Gastrointestinal

You are taking care of an infant newly diagnosed with hydrocephalus. Which of the following assessment findings do you expect? Select all that apply. A. Increased head circumference [38%] B. Macewen's sign [22%] C. Sunken anterior fontanelle [10%] D. Setting sun eyes [30%]

Explanation Choices A, B, and D are correct. A is correct. The increased head circumference is due to an increasing amount of CSF in the cranial vault due to impaired absorption within the subarachnoid space. This is often the first and most noticeable sign of hydrocephalus. B is correct. Macewen's sign is an indication of hydrocephalus. This sign is positive when the nurse percusses the skull bones and hears a 'cracked-pot' sound. This sound is due to thin, widely separated skull bones present with hydrocephalus. D is correct. Setting sun eyes is an assessment finding found in children with hydrocephalus that has progressed so far it is causing increased ICP. The child looks as if they are always looking down with more prominent sclera in the top part of their eyes. Choice C is incorrect. A sunken anterior fontanelle would indicate dehydration or low fluid volume status. In hydrocephalus, there is increased fluid volume in the head, not decreased. The nurse would see a tense, bulging fontanelle. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Neurology

Which of the following are potential complications of cleft lip and cleft palate in the infant? Select all that apply. A. Ear infections [23%] B. Feeding difficulties [39%] C. Weight gain [2%] D. Speech delay [36%]

Explanation Choices A, B, and D are correct. Choice A is correct. When a child has a cleft lip and cleft palate, the tissue and bone inside their mouth are not appropriately fused, which means there is a space between their upper lip and their palate. Ear infections will be a frequent complication for these patients due to the dysfunction of the eustachian tube, which connects the middle ear and the throat. Choice B is correct. Feeding issues are a common complication of cleft lip and cleft palate because it is harder for these infants to eat with the abnormality in their palate. The space in the roof of the mouth makes it very hard to suck and make a good seal around the bottle or nipple. Choice D is correct. Speech delays and language delays are both common complications of cleft lip and cleft palate. The roof of the mouth and lip have spaces, which decrease muscle function and lead to delayed or abnormal speech. Eventually, many of these patients will require consultation with a speech-language pathologist. Choice C is incorrect. Weight gain is not a common complication of cleft lip and cleft palate. With these abnormalities, it is much more difficult for the infant to eat and they commonly experience feeding issues— leading to weight loss or failure to thrive, not weight gain. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Risk potential reduction

The nurse is caring for a client who has developed Malignant Hyperthermia. Which of the following actions should the nurse take? Select all that apply. A. Apply a cooling blanket [32%] B. Insert indwelling urinary catheter [11%] C. Monitor hourly blood glucose [13%] D. Obtain blood cultures [19%] E. Administer prescribed Dantrolene [25%]

Explanation Choices A, B, and E are correct. Malignant hyperthermia is a medical emergency and requires the nurse to intervene by applying a cooling blanket and ice to the axilla and groin. The nurse should also monitor the client's urinary output by inserting an indwelling catheter. Hydrating the client is essential because the client risks developing rhabdomyolysis and preventing kidney damage; aggressive hydration is implemented, and its efficacy can be monitored using an indwelling catheter. The nurse should be prepared to administer Dantrolene as this skeletal muscle relaxant is an effective treatment. Choices C and D are incorrect. Monitoring a client's hourly glucose is an appropriate intervention for diabetic ketoacidosis (DKA). This intervention is not applicable for malignant hyperthermia. Obtaining blood cultures is not indicated because this autonomic reaction is not pathogenic. Obtaining blood cultures will be indicated if the client has bacteremia. Additional Info Malignant hyperthermia is a rare but potentially fatal adverse reaction to inhaled anesthesia or intravenous succinylcholine. This condition may be genetic. The client will manifest tachycardia, muscle rigidity, fever, and rhabdomyolysis. Thus, the nurse must monitor the client for acute kidney injury and metabolic acidosis. Dantrolene is a muscle relaxant that should be used to treat this emergency.

The nurse is caring for an assigned client. Which prescription requires clarification based on the laboratory data? See the exhibit. Select all that apply. A. Vancomycin 1-gram IVPB Daily [27%] B. Furosemide 40 mg PO Daily [22%] C. 500 ml of 0.9% Saline IV Bolus x 1 [14%] D. Diltiazem XR 120 mg PO Daily [13%] E. Ketorolac 15 mg IV Q 8 hours [23%]

Explanation Choices A, B, and E are correct. The prescribed vancomycin, furosemide, and ketorolac are all medications that should be clarified with the PHCP based on the BUN and creatinine being elevated. These elevations represent renal insufficiency. All three of these medications are nephrotoxic. Vancomycin is an antibiotic indicated for MRSA infections. Furosemide is used for cardiovascular disorders such as congestive heart failure, and ketorolac is a non-steroidal anti-inflammatory (NSAID) indicated for mild to moderate pain. Choices C and D are incorrect. 500 ml of 0.9% saline bolus would be helpful for this client, considering the labs showing nephrotoxicity. Diltiazem XR is okay to give to a client based on these laboratory findings. Additional Info Elevations of the creatinine (normal: 0.6-1.2 mg/dL for males, 0.5-1.1 mg/dL for females) usually are caused by an offending agent such as an NSAID (ketorolac), antibiotic (vancomycin), or sulfa-based drugs. The elevation of the BUN (normal 10-20 mg/dL) may be caused by dehydration. In this case, it would be detrimental to give the client the furosemide considering existing signs of dehydration and renal insufficiency.

The nurse is caring for a client receiving a continuous infusion of norepinephrine. The nurse should plan to monitor which of the following for the client? Select all that apply. A. Blood pressure [32%] B. Intracranial pressure [12%] C. Intravenous site [22%] D. Urine output [23%] E. Blood glucose [11%]

Explanation Choices A, C, D, and E are correct. An infusion of norepinephrine is indicated if the client is in shock. This medication helps restore vascular tone and is useful in treating life-threatening hypotension. This medication is a vesicant, and the preferred delivery is through a central line. If this is not possible, a large-bore intravenous catheter should be utilized. The patency of this catheter should be assessed frequently to prevent damaging extravasation. Blood pressure needs to be monitored continuously while this medication is administered to assess the desired response of increased vascular tone. This medication causes vasoconstriction, which decreases renal blood flow, thereby decreasing urine output. Norepinephrine causes an increase in blood glucose. Choice B is incorrect. Norepinephrine is a medication used in the management of shock. The nurse must monitor the client's blood pressure, intravenous site, urine output, and blood glucose. One of the monitoring parameters not indicated is intracranial pressure (ICP) - this would be more applicable if the medication was mannitol. Additional Info Vasopressors are highly preferred to be administered via a central line. This is because these medications are vesicants and may cause serious extravasation if the peripheral IV is not patent. The nurse should ensure that the client has appropriate hemodynamic monitoring while receiving vasopressors such as continuous cardiac and blood pressure monitoring.

A patient has completed a living will stating that he does not want intubation, mechanical ventilation, or artificial nutrition/hydration should he become unable to communicate his preferences related to medical care. However, the patient's adult children have expressed their opposition to the patient's wishes. Which are appropriate nursing actions? Select all that apply. A. Notify the patient's physician, the nursing supervisor, and the risk manager. [28%] B. Explain to the patient's family that the living will cannot be changed at this point. [16%] C. Encourage the family to discuss their feelings to try to resolve this issue. [30%] D. Request a consult with the facility ethics committee if needed. [24%] E. Advise the patient to just go along with the wishes of his adult children. [1%]

Explanation Choices A, C, and D are correct. Should such a conflict be observed, the nurse should notify the patient's physician, the nursing supervisor, and the risk manager. It is also important to encourage the family to discuss the issue among themselves and with the above individuals, to resolve the conflict. A consult with the ethics committee may also be indicated. Choice B is incorrect. The patient may revoke or change an advance directive at any time, either orally or in writing. Choice E is incorrect. By law, the patient has a right to autonomy and self-determination, including the right to choose and refuse treatment. Bloom's Taxonomy - Analyzing

Which of the following fall under the right time of the 8 rights of medication administration? Select all that apply. A. Have a second nurse independently calculate the medication dosage. [10%] B. Double-check the last time that the medication was administered. [41%] C. Verify the frequency with which the medication is ordered. [40%] D. Document the pertinent vital signs. [10%]

Explanation Choices B and C are correct. B is correct. Double-checking the last time that the medication was administered is a part of the right time step in the 8 rights of medication administration. This is important because the nurse needs to verify that she is giving the dose at the correct time and that it is not being administered too frequently based upon the previous administration. C is correct. Verifying the frequency with which the medication is ordered is a part of the right time step in the 8 rights of medication administration. The nurse needs to verify that the frequency with which the medication is being ordered will be safe not just for this dose, but for the cumulative dosage if the medication is being administered more than once. For example, with acetaminophen, one dose of 1,000 mg may be appropriate, but administering this dosage every 4 hours would result in a daily intake of 6,000 mg of acetaminophen, far above the maximum of 4,000 mg. This is why the right frequency is a part of the right time step in the 8 rights of medication administration. Choice A is incorrect. Having a second nurse independently calculate the medication dosage is an important part of verifying the right dose. This check ensures that two nurses both calculate the dosages and come up with the same answer, decreasing the chance of an error in calculation. However, this is not a part of the right time check. Choice D is incorrect. Documenting the pertinent vital signs is part of the right documentation step to the 8 rights of medication administration, not the right time. The nurse must always document pertinent vital signs when administering medication. For example, if giving an antihypertensive, blood pressure should be documented. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Fundamentals - Medication Administration

You are taking care of a 45-year-old female who is being treated with electroconvulsive treatment (ECT) for severe depression. After her treatment today, which of the following nursing interventions are appropriate? Select all that apply. A. Position her supine with the head of the bed at 30 degrees [27%] B. Reorient the patient frequently [34%] C. Remain with the patient at all times [23%] D. Promote bedrest for 12-24 hours [16%]

Explanation Choices B and C are correct. It will be a very important nursing intervention to frequently reorient the patient who has just received electroconvulsive therapy (ECT). This is because temporary memory loss is associated with this procedure, so they will likely be very confused and disoriented. Due to this disorientation, they will likely be scared; to make them feel safe and secure the nurse will need to frequently reorient them to their place and situation (Choice B). It will be a very important nursing intervention to remain with the patient who has just received electroconvulsive therapy. A side effect of electroconvulsive therapy is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them at all times to keep them safe (Choice C). Choice A is incorrect. Supine with the head of the bed at 30 degrees is not the best position for a patient who has just had electroconvulsive therapy. This patient is at risk for aspiration, so the appropriate positioning is on her side. This will prevent anything from entering her airway and causing an aspiration event. Supine with the head of the bed at 30 degrees would be the appropriate positioning for a patient post-op from neurosurgery or at risk for increased ICP. Choice D is incorrect. It is not necessary or appropriate to promote bedrest for 12-24 hours in the patient who has just received electroconvulsive therapy. After they are awake and re-oriented, it is best to promote activity and get them back to their normal routine. Staying active is an important part of treating depression, so bed rest is not appropriate for this patient. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing

Which of the following statements about calcium are true? Select all that apply. A. Calcium increases vitamin D levels. [28%] B. 50-70% of serum calcium is ionized in the serum. [30%] C. Albumin and calcium levels can be directly correlated. [18%] D. Calcium that is bonded to protein can pass through capillary walls. [23%]

Explanation Choices B and C are correct. These are true statements. 50-70% of serum calcium is ionized in the serum (Choice B). Due to the protein-binding ability of calcium and albumin, calcium levels can be directly correlated (Choice C). Choice A is incorrect. This statement is false. Vitamin D increases serum calcium, not the other way around. Choice D is incorrect. This statement is false. Calcium that is bonded to protein cannot pass through capillary walls because the molecule is not small enough to move from the extracellular fluid to the intracellular space. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Renal

Fear and anxiety are quite similar. However, there are differences. Select the statements below that are accurate in terms of differentiating fear from anxiety. Select all that apply. A. Fear is related to the present danger, whereas anxiety is related to future danger. [22%] B. Anxiety is secondary to a psychological stressor, whereas fear is secondary to a physical or psychological stressor. [25%] C. Fear is secondary to an identifiable source, whereas anxiety is secondary to an unidentifiable source. [25%] D. Anxiety is diffuse and vague, whereas fear is more specific and definable. [28%]

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

The nurse is caring for a pregnant client who is experiencing late decelerations. Which of the following actions should the nurse take? Select all that apply. A. Initiate intravenous magnesium sulfate [5%] B. Reposition the patient on her side [33%] C. Administer oxygen via face mask [32%] D. Discontinue oxytocin infusion [26%] E. Prepare for an amnioinfusion [3%]

Explanation Choices B, C, and D are correct. Late decelerations are a non-reassuring fetal heart pattern that requires immediate intervention. The nurse should place the client in a left lateral position, administer oxygen via face mask, and discontinue oxytocin. Repositioning the client will relieve the vena cava compression. Oxygen will correct any maternal hypoxia, and oxytocin should be stopped because uterine contractions decrease uteroplacental blood flow. Choices A and E are incorrect. Magnesium sulfate is indicated for clients with preeclampsia or eclampsia. It has no use for late decelerations. Amnioinfusion of an isotonic solution is utilized for variable decelerations - not late decelerations. Additional Info Late decelerations are primarily caused by uteroplacental insufficiency, and the client should be repositioned into a left lateral position. If the left lateral position is ineffective, then the nurse may consider using the right lateral position. The nurse should also consider prescribed intravenous (IV) fluids to restore maternal blood volume.

The charge nurse is reviewing staff assignments for one Registered Nurse (RN) and one Licensed Practical/Vocational Nurse (LPN/VN) on the nursing unit. Which patient assignment requires modification to ensure that the patient and diagnosis are proportional to skill level? See the exhibit. Select all that apply. A. Room 1 [12%] B. Room 2 [8%] C. Room 3 [36%] D. Room 4 [6%] E. Room 5 [9%] F. Room 6 [28%]

Explanation Choices C and F are correct. The patient with angina and ST-segment changes should be assigned to the RN because of this patient's clinical unpredictability. Angina accompanied by ST-segment changes is a worrisome sign for myocardial infarction. A 59-year-old requiring chronic wound care and the insertion of an indwelling catheter is more appropriate for the LPN to ensure an evenly divided patient assignment. These are skills (wound care and indwelling catheter insertion) within the scope of an LPN. Choices A, B, D, and E are incorrect. Antibiotic administration is within the scope of an LPN, and the LPN may be assigned predictable patient diagnoses such as cystitis. A patient who is three days post-operative following a laparoscopic procedure is low acuity and therefore may be assigned to the LPN. This contrasts with a patient three-hour post-operative following a thyroidectomy which should be assigned to the RN. This patient has the risk of developing laryngeal edema. Insulin titration is not within the scope of an LPN, and the RN is responsible for titrating medications based on patient assessment. 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 primary healthcare provider (PHCP) prescribes three liters of 0.9% saline to infuse over 24-hours. How many mL per hour will be administered to the client? Fill in the blank. 125 mL/hour

Explanation First, convert the prescribed liters to milliliters to determine the total volume ordered 3 liters x 1000 mL = 3000 mL Next, divide the prescribed total volume by the infusion time 3000 mL / 24 hrs = 125 mL/hr Additional Info 0.9% saline is an isotonic solution used for simple dehydration and blood transfusions.

The primary healthcare provider (PHCP) prescribes 1.5 grams of vancomycin to be infused over 90 minutes. The pharmacy supplies the medication in a bag labeled 1500 mg of Vancomycin in 250 mL of 0.9% saline. How many mL/hour should the nurse administer this medication? Round your answer to the nearest whole number. Fill in the blank. 167 mL/hr

Explanation To solve this problem, the nurse will use the formula of volume / time (hours) First, convert the 90 minutes to hours 90 minutes / 60 minutes = 1.5 hr Next, divide the volume by the hour(s) 250 mL / 1.5 hr = 166.67 mL/hr Finally, round the answer to the nearest whole number 166.67 mL/hr =167 mL/hr Additional Info Vancomycin is a glycopeptide antibiotic effective in the treatment of MRSA infections. The nurse should assess the client closely for red man syndrome, which will cause the client to feel flushed and develop a diffuse rash over their torso. The treatment for this syndrome is slowing the rate of the infusion.

The nurse is tending to a newly admitted client with alcohol withdrawal. Place the following components of alcohol withdrawal in the order the nurse would expect to see them occur. Mild tremors Hyperthermia Hallucinations Delirium tremens

Mild tremors Hyperthermia Hallucinations Delirium tremens Explanation The correct sequence of symptoms/signs of alcohol withdrawal is mild tremors, hyperthermia, hallucinations, and delirium tremens. Alcohol withdrawal symptoms typically evolve in 4 phases as follows: The first phase (early withdrawal): Mild tremors are seen at the beginning of alcohol withdrawal. This typically starts about 4-12 hours after the patient has stopped drinking and will be accompanied by other symptoms such as nausea, insomnia, and headaches. At this point, the patient is still alert and oriented. The second phase (moderate withdrawal): Hyperthermia will follow the mild tremors. Patients at this point will start to be somewhat confused and hyperactive. Remember, "Everything increases" (temperature, activity, blood pressure, respiratory rate, heart rate): hyperthermia, hyperactivity, diaphoresis, hypertension, tachypnea, and tachycardia. The third phase: Hallucinations (alcoholic hallucinosis) will begin after hyperthermia and hyperactivity. This is considered a sign of severe/late-stage withdrawal. Hallucinations and illusions can be auditory or visual. They often precede progression to delirium tremens and seizures. It is crucial to recognize this stage. They begin 12-24 hours after the last drink and can last for 1 to 2 days. Usually, these patients are not disoriented, have a fairly clear mental state, and typically report seeing bugs or animals in the room ("pink elephants"). Vital signs tend to be healthy. Since the patient is still oriented, these can be very scary for the patient. The nurse needs to stay with the patient at this phase of the withdrawal, notify the physician, and implement seizure precautions. The fourth phase: Progression to delirium tremens (DTs) is the last stage in alcohol withdrawal syndrome. Typically, DTs occur 3-5 days after the last drink. This is the most dangerous phase and is considered a medical emergency. These patients have an altered mental status and sympathetic overdrive (sweating, fever, hypertension), which can progress to cardiovascular collapse. They continue to experience hallucinations and illusions and can have tonic-clonic seizures. It is important to note that the hallucinations in DTs are different from those in the 3rd stage. They may be referred to as "immersion" hallucinations where patients are immersed in another time and place and are interacting with that environment.

The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child? A. Peripheral nerve block [11%] B. Spinal anesthesia [2%] C. General Anesthesia [33%] D. Local Anesthesia [54%]

The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child? A. Peripheral nerve block [11%] B. Spinal anesthesia [2%] C. General Anesthesia [33%] D. Local Anesthesia [54%]