Archer Review 5

The pregnant client measures normal with their fundal height is at her navel. The health care provider would be correct in placing them at ___________ weeks pregnant. A. 12 [9%] B. 16 [13%] C. 20 [63%] D. 24 [15%]

Explanation Choice C is correct. At around 20 weeks; fundal height will land at the client's navel. Choice A is incorrect. At 12 weeks, the prenatal client's fundus will lay at about the pubic symphysis. Choice B is incorrect. At 16 weeks, the fundus will lay about midway between the pubic symphysis and the navel. Choice D is incorrect. At 24 weeks, the fundus will be between the xiphoid process and the navel. NCSBN client need Topic: Health Promotion and Maintenance, Ante / Intra / Post Partum

Which of the following is the correct interpretation for the following arterial blood gas? pH: 7.47 PCO2: 55 HCO3: 36 A. Metabolic acidosis [4%] B. Respiratory acidosis [5%] C. Metabolic alkalosis [67%] D. Respiratory alkalosis [24%]

Explanation Choice C is correct. This ABG shows metabolic alkalosis. The pH is higher than 7.45, which is alkalotic. The PCO2 is more elevated than 45, which is acidotic (this is compensating for the metabolic alkalosis). Lastly, HCO3 is greater than 26, which is alkalotic. The HCO3 shows alkalosis like the pH, so we know this is metabolic alkalosis. Choices A, B, and D are incorrect. These are not the correct acid-base disorder for this patient. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Laboratory Values

The nurse is taking care of a client with multiple fractures in his leg. A plaster cast was applied. In positioning the casted leg, the nurse should: A. Keep the leg in a level position. [24%] B. Elevate the leg for 3 hours and put it flat for 1 hour. [17%] C. Keep the leg straight for 3 hours and elevate it for 1 hour. [10%] D. Elevate the leg on pillows continuously for 24 to 48 hours. [50%]

Explanation Choice D is correct. The leg should be elevated consistently for 24 - 48 hours to promote venous drainage and minimize swelling. Choice A is incorrect. Keeping the leg in a leveled position on the bed predisposes it to swell due to lymphatic congestion. Choices B and C are incorrect. The nurse should keep the leg elevated all the time to promote venous drainage and decrease swelling.

The nurse is caring for a client with acute respiratory failure in the Intensive Care Unit (ICU). The nurse should expect which arterial blood gas (ABG) results? A. pH: 7.29; PCO2: 56; PaO2: 83; HCO3: 22 [76%] B. pH: 7.38; PCO2: 40; PaO2: 92; HCO3: 25 [3%] C. pH: 7.49; PCO2: 30; PaO2: 96; HCO3: 28 [9%] D. pH: 7.40; PCO2: 65; PaO2: 85; HCO3: 34 [12%]

Explanation Choice A is correct. A client in respiratory distress should be expected to exhibit acidosis, hypoxemia, and hypercapnia (respiratory acidosis) on ABG. Choice B is incorrect. This is indicative of a normal arterial blood gas result. Choice C is incorrect. This arterial blood gas result shows respiratory alkalosis. Respiratory alkalosis commonly occurs in hyperventilation wherein more carbon dioxide is eliminated. Choice D is incorrect. This is an example of compensated respiratory acidosis.

The nurse is caring for a client who has been prescribed olanzapine. Which of the following assessment findings would warrant immediate notification to the primary healthcare physician (PHCP)? A. Muscle rigidity [79%] B. Weight gain [5%] C. Hyperglycemia [12%] D. Fatigue [4%]

Explanation Choice A is correct. Olanzapine is an atypical antipsychotic drug. Adverse reactions of olanzapine include neuroleptic malignant syndrome, which is manifested by tachycardia, delirium, fever, and muscle rigidity. Thus, muscle rigidity should be reported to the provider immediately. Choices B, C, and D are incorrect. Weight gain, hyperglycemia, and fatigue are all side-effects of this drug class but do not require immediate notification to the provider.

The nurse is participating in a committee reviewing strategies to reduce falls in the older adult. Which of the following recommendations by the nurse would be appropriate to make? A. Increase the number of bedside commodes in the nursing units [64%] B. Provide more hand sanitizer stations in high traffic areas [1%] C. Standardize administration times of diuretics to the evening hours [6%] D. Implement a bedside handoff reporting process for nursing staff [29%]

Explanation Choice A is correct. Utilizing more bedside commodes for older adults may reduce falls because it shortens the distance a client needs to travel to the bathroom. Bedside commodes are especially effective for those receiving medications such as diuretics and undergoing bowel prep. Thus, a bedside commode is an effective intervention to reduce falls for the older adult. Choices B, C, and D are incorrect. Increasing the number of hand sanitizer stations would not reduce falls as this is an effective intervention for reducing infections. Standardizing administration times of antihypertensive and diuretics would be helpful, but the times should not be standardized to the evening hours. Diuretics should be administered early in the day to prevent nocturia. Handoff reporting for nursing staff at the bedside is an effective tool to increase client satisfaction and communication but not a mechanism to reduce falls. Since handoff reporting happens at a predictable interval and is infrequent, this would not be the most effective intervention to recommend to mitigate falls. Learning Objective NCLEX Category: Safety and Infection Control Related Content: Accident/Error/Injury Preventionn Question type: Application Additional Info Universal fall precautions involve • Monitor the client's activities and behavior as often as possible, preferably every 30 to 60 minutes. • Teach the client and family about the fall prevention program to become safety partners. • Remind the client to call for help before getting out of bed or a chair. • Help the client get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs before transferring client's. • Teach clients to use the grab bars when walking in the hall without assistive devices or when using the bathroom. • Provide or remind the client to use a walker or cane for ambulating if needed; teach him or her how to use these devices. • Remind the client to wear eyeglasses or hearing aid if needed.

The nurse is teaching a patient who is scheduled for a colonoscopy. Which of the following information should the nurse include? A. "The day before the procedure you may have a regular diet." [4%] B. "You will not have anything to eat or drink by mouth for 4 to 6 hours prior to the test." [63%] C. "You may notice chalky white stools immediately after the procedure." [22%] D. "Your abdomen will be painful and distended after the test." [11%]

Explanation Choice B is correct. A colonoscopy is a test used to study the lining of the large intestine. Four to six hours before the procedure. the nurse is correct to instruct the client to not intake anything by mouth (NPO). Choice A is incorrect. The day before the process, the nurse should tell the client to have a clear liquid diet. Choice C is incorrect. Chalky white stools after the procedure are expected with a barium enema - not a colonoscopy. Choice D is incorrect. Abdominal pain and distention are unlikely as this would be worrisome for a perforation.

The nurse is assessing a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory tests require careful monitoring? A. Potassium [29%] B. Sodium [66%] C. Glucose [4%] D. Magnesium [1%]

Explanation Choice B is correct. Dilutional hyponatremia may occur from SIADH from the excess water caused by the antidiuretic hormone. The hyponatremia may be so severe that it may cause neuromuscular weakness and seizure activity. Choices A, C, and D are incorrect. SIADH causing dilutional hyponatremia does not impact the patient's potassium, glucose, or magnesium. Additional information: SIADH may be caused by pulmonary tuberculosis and certain lung malignancies. Clinical features of SIADH include hyponatremia because of excessive water. This, in turn, leads to oliguria and increased urine concentration. The vital signs for this patient will reflect hypertension and, at worst, fluid volume overload.

A nurse receives a client who has just returned from a circular skin punch biopsy to confirm a diagnosis of skin cancer. The nurse should immediately observe the site for: A. Dehiscence [8%] B. Infection [11%] C. Bleeding [72%] D. Swelling [9%]

Explanation Choice C is correct. A punch biopsy is usually done using a circular blade ranging in size from 1 mm to 8 mm. The priority concern immediately after the procedure is to monitor the site for bleeding. Choices A, B, and D are incorrect. Dehiscence is likely to happen in more extensive wounds of the abdomen or thorax. Infection may occur at a later time, but not immediately after the procedure is done. Swelling is a normal reaction with any event that breaks the skin.

The client is scheduled for exercise electrocardiography and the nurse is helping her prepare for the test. All of the following are appropriate statements by the nurse, except? A. "Please wear loose, comfortable clothing." [1%] B. "You can drink an energy drink 20 minutes before the test to get some extra energy for the test." [93%] C. "We will check your blood pressure and heart's electrical activity before, during, and after the stress test." [3%] D. "You should not do anything strenuous before the test." [2%]

Explanation Choice B is correct. This statement by the nurse is incorrect and therefore the right answer to the question. The client should not eat or drink anything that contains caffeine, which can alter the client's ECG. Energy drinks contain high amounts of caffeine and should not be taken by the client. Choice A is incorrect. The client is instructed to wear loose, comfortable clothing with non-slip supportive footwear. Choice C is incorrect. The client's blood pressure and ECG, along with her other baseline vital signs, are taken before, during, and after the test to determine any changes in the patient's status. Choice D is incorrect. The client should be instructed to rest 12 hours before the test and not do any strenuous activities.

The nurse is caring for a patient with myasthenia gravis who is recovering from a total thymectomy. Which would be the highest priority to have at this patient's bedside? A. Crash cart [29%] B. Bag-valve mask [45%] C. Incentive spirometer [9%] D. Atropine sulfate [16%]

Explanation Choice B is correct. This patient should have a bag-valve-mask setup (Ambu) and suction equipment at the bedside. Recent total thymectomy procedure puts this patient at risk for myasthenic crisis (an exacerbation of myasthenia gravis symptoms due to insufficient cholinergic medications) and risk for impaired gas exchange (due to potential hemothorax/pneumothorax). A myasthenic crisis results in muscle weakness and increases the risk of respiratory issues. Noninvasive mechanical ventilation should be used to support respiratory status and improve gas exchange in the event of respiratory distress until other interventions are available. Choice A is incorrect. It would not be necessary to keep a crash cart at the bedside for this patient but it should be readily available on the unit in case of an emergency. Choice C is incorrect. Myasthenia gravis causes muscle weakness in the face and mouth, so it may be difficult for this patient to form a seal around the mouthpiece of an incentive spirometer. In addition, diaphragm and intercostal muscles may be weakened, which makes it difficult to deep breathe or cough. If the patient is able to use an incentive spirometer it would be appropriate to have it at the bedside, but would not be the highest priority, as it would only help to prevent atelectasis after surgery, not improve potential acute respiratory distress. Choice D is incorrect. The Tensilon test is used to differentiate cholinergic crisis vs myasthenic crisis and may cause cardiac dysrhythmias or cardiac arrest. Atropine, the antidote for Tensilon, should be available if the patient is undergoing this test, but would not be important following a thymectomy.

Which of the following descriptions best defines general adaptation syndrome? A. Activation of brain signals followed by avoidance in response to a perceived threat [15%] B. The arousal of the hippocampus after being triggered by a specific memory [5%] C. The body's response to stress over both short and long-term periods [73%] D. The development of depression over time as a result of a negative situation [7%]

Explanation Choice C is correct. General adaptation syndrome (GAS) is a stress response in which the body modifies its reaction to stress. Initially, the body alters its response in reaction to short-term stressful events. Over time, general adaptation syndrome develops as the body adapts to long-term or chronic levels of stress. General adaptation syndrome is the name for the group of nonspecific responses that all people share in the face of stressors. GAS has three stages: (1) the initial alarm stage, (2) resistance (adaptation), and (3) the final stage of either recovery or exhaustion. Choices A and B are incorrect. Generalized adaptation syndrome is not in response to a perceived threat or triggered by a memory. Choice D is incorrect. Generalized adaptation syndrome is not related to the development of depression. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation

The nurse is caring for a patient who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings would be essential for the nurse to follow-up? A. Incisional pain level of "6" on a 1-10 scale. [6%] B. An oral temperature of 99.5 degrees Fahrenheit. [16%] C. A heart rate of 112 beats-per-minute (BPM). [55%] D. Hypoactive bowel sounds in all four quadrants. [23%]

Explanation Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, which is one of the earliest manifestations of shock, and the nurse needs to assess the client further. Choice B is incorrect. A low-grade temperature is an expected finding following surgery because of the inflammation. Choices A and D are incorrect. Incisional pain and hypoactive bowel sounds are all expected findings in the immediate post-operative period.

The RN provides discharge instructions to a patient with a diagnosis of paroxysmal atrial fibrillation and a history of macular degeneration. Which instruction would be most important to promote this patient's safety within the home? A. Instruct the caregiver to place items in the patient's central point of vision. [41%] B. Avoid eating green, leafy vegetables while on warfarin therapy. [19%] C. Keep a large-print list of emergency contact numbers posted on the refrigerator. [31%] D. Use an electronic blood pressure cuff to monitor and record blood pressure daily. [8%]

Explanation Choice C is correct. Of the options listed, keeping a large print list of emergency numbers would be most important to promote the patient's safety in the home. Macular degeneration is a progressive visual problem that affects central vision and can make it difficult to visualize text. Patients should be encouraged to use large print resources, ensure adequate lighting, and use magnifying tools to maximize their remaining vision. Choice A is incorrect. Macular degeneration affects central vision, not peripheral. Placement of items in the central line of view would be appropriate for a visual problem that affects peripheral vision, such as glaucoma. Choice B is incorrect. Green leafy vegetables can interfere with the coagulation and effectiveness of warfarin. Although the nurse would expect this patient to be on anticoagulant therapy due to atrial fibrillation, the question does not specify warfarin is ordered, so this teaching may not be appropriate for this patient. Additionally, a diet rich in fruits and dark green leafy vegetables is recommended for slowing the progression of macular degeneration. Choice D is incorrect. The question does not mention this patient has any issues with blood pressure. Although it would not be harmful to monitor blood pressure, this would not be the best action to promote the patient's safety at home based on the given information.

You are preparing to start an IV on a patient recently admitted to your unit. You begin the IV using an 18 gauge intravenous catheter. The physician's order reads, "Give 500 mL of normal saline IV over the next four hours." The flow rate you will set is: A. 50 mL per hour [2%] B. 100 mL per hour [2%] C. 125 mL per hour [95%] D. 250 mL per hour [1%]

Explanation Choice C is correct. This question requires that the nurse understand the total volume ordered, the time for administration of the fluid, and the calculation for figuring the rate of fluid administration. The formula for this calculation is: Volume ordered/Total time for infusion = Flow rate in mL/hr. In this example, you would substitute the correct values into the equation. Therefore, 500 mL/4 hours = 125 mL/hr. Choices A, B, and D are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Dosage Calculation, Medication Administration

A nurse is taking care of a client with acute peritonitis. The nurse's focus of care is the client's nutritional needs. To meet this, the nurse should do which of the following? A. Administer feedings via NGT [18%] B. Administer gastric enteral feedings [8%] C. Feed the client orally [15%] D. Administer parenteral feedings [60%]

Explanation Choice D is correct. In clients with peritonitis, it is recommended to give the GI tract time to rest and recover. Food is not administered through the GI tract. Clients with peritonitis are typically fed parenterally via TPN or peripheral parenteral nutrition. Choices A, B, and C are incorrect.

The patient is diagnosed with atrial fibrillation. What assessment data would require immediate intervention by the RN? A. Irregular QRS complexes on telemetry reading [27%] B. Rapid, irregular pulse [20%] C. The patient reports palpitations [8%] D. The patient reports lightheadedness [44%]

Explanation Choice D is correct. Lightheadedness/dizziness may be a sign that the patient's rhythm has changed. The nurse should assess the patient and the rhythm as well as report any changes to the physician. Choice A is incorrect. Irregular QRS complexes are expected in atrial fibrillation. Choice B is incorrect. Irregular and rapid pulse readings are expected in atrial fibrillation. Choice C is incorrect. A patient may be able to feel palpitations when in atrial fibrillation. NCSBN Client Need Topic: Cardiovascular, Subtopic: Establishing priorities, diagnostic tests, the potential for alterations in body systems, changes/abnormalities in vital signs

The nurse is providing discharge instructions to a client with a skin abscess that has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following instructions should the nurse include? A. Avoid using alcohol hand-based sanitizers. [11%] B. Use disposable dishes and utensils for all meals. [23%] C. Wear a surgical mask when you are out in public. [7%] D. Keep the wound covered with a dry bandage. [58%]

Explanation Choice D is correct. MRSA transmission requires contact with a colonized individual or contaminated surface. The nurse should advocate for appropriate infection control by advising the client to cover the wound with a dry bandage. This will help decrease the pathogen from being deposited onto surfaces. Choices A, B, and C are incorrect. Alcohol-based sanitizers are effective in the prevention of MRSA infections. This would not be the correct choice for pathogens such as C. diff. Disposable dishes and utensils are unnecessary for MRSA infections as hot water and detergents kill the pathogen. The client transmits this pathogen by contact means, not droplets; thus, a mask is unnecessary. NCLEX Category: Physiological adaptation Activity Statement: Illness management Question type: Application Additional Info According to the Centers for Disease Control, the transmission of MRSA can be disrupted in the home through: Meticulous hand hygiene with soap and water or alcohol-based hand sanitizers. Disinfect surfaces with a cleaning agent such as 70% isopropyl alcohol. Not sharing contaminated towels, razors, or linens with others. Keeping the wound covered and disposing of used bandages in the trash.

The nurse is taking care of a 9-year-old boy undergoing testing for acute myeloid leukemia (AML). She is assisting with the client's positioning for a lumbar puncture. Which of the following positions is appropriate? A. Prone [6%] B. Trendelenburg [2%] C. Supine [2%] D. Side lying [90%]

Explanation Choice D is correct. Side-lying (lateral recumbent) is the most appropriate position for a lumbar puncture (LP). The client's legs are flexed at the knee and pulled towards the chest, while the upper thorax is curved forward in an almost fetal position. A pillow may be placed under the client's head and/or between the legs. This position will allow the health care provider to identify the lumbar vertebrae and insert the needle into the subarachnoid space at the L3-4 or L4-5 interspace. The lateral recumbent position is preferred over the upright position because it allows for accurate measurement of the cerebrospinal fluid (CSF) opening pressure. An upright or sitting position may be used for the LP when the client's lateral position is not feasible. Choice A is incorrect. Placing the patient in the prone position for a bedside lumbar puncture is not appropriate. The prone position is generally preferred for LPs performed under fluoroscopic guidance with the patient lying face down. Prone positioning is also used to increase ventilation and perfusion to the lungs in acute respiratory distress syndrome (ARDS) and in some infants with congenital anomalies such as tracheoesophageal fistula (TEF) that are at risk for aspiration. Choice B is incorrect. Placing the patient in a Trendelenburg position for a lumbar puncture is not appropriate. Trendelenburg refers to a position where the patient is placed supine and then reclined so that the feet are 15-30 degrees above the head. Trendelenburg is used in preterm labor or placing a central venous catheter in the internal jugular or subclavian vein. Choice C is incorrect. The supine position is not appropriate for a lumbar puncture. With a patient lying on the back, the health care provider would not be able to access the intrathecal space to perform the LP. However, the client is instructed to lie supine following the LP since headache is a common complaint after the LP. Post-LP headache occurs due to CSF pressure changes and sitting up soon after the LP can worsen the headache. Therefore, the client is advised to lie flat for 6-12 hours after the LP. NCSBN Client Need:Topic: Physiological Integrity; Subtopic: Basic care, comfort

While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case? Select all that apply. A. Intrauterine growth restriction (IUGR) [27%] B. Hemolytic disease of the newborn [20%] C. Hydrocephaly [19%] D. Large for gestational age infant (LGA) [3%] E. Stillbirth [31%]

Explanation Choices A, C, and E are correct. Women infected with rubella are at an increased risk of having a miscarriage or a stillbirth. Their infants are more likely to suffer from intrauterine growth restriction and hydrocephaly. Choice B is incorrect. Hemolytic disease of the newborn is an alloimmune condition that occurs when the mother is Rh-negative and is pregnant with an Rh-positive baby. Choice D is incorrect. Women infected with rubella while pregnant are not at an increased risk for delivering an infant who is large for gestational age.

Which of the following are appropriate foods items to treat hypoglycemia? Select all that apply. A. 2 cups of orange juice [29%] B. 1 small box of raisins [21%] C. 1 candy bar [32%] D. ½ cup of milk [18%]

Explanation Choices B and C are correct. These are appropriate food items to treat hypoglycemia since these amounts have enough glucose to appropriately correct hypoglycemia. Choice A is incorrect. While orange juice is commonly used to treat hypoglycemia, only half of a cup should be offered at a time. Two cups are too much and could cause rebound hyperglycemia. Choice D is incorrect. While milk is an appropriate choice to treat hypoglycemia, half a cup does not have enough glucose in it to raise the blood sugar adequately. Instead, 1 cup of milk should be offered. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Reduction of risk potential, endocrine

Which of the following are management functions that nurses fulfill? Select all that apply. A. Being a visionary [10%] B. Directing [27%] C. Coordinating [31%] D. Organizing [31%]

Explanation Choices B, C, and D are correct. The four management functions that nurses fulfill are directing, coordinating, organizing, and planning. Serving as a visionary is a function of leadership and not management. Choice A is incorrect. Being a visionary is part of the leadership role and not one of the functions that nurses fulfill as a manager.

Your client has been diagnosed with acute renal failure. Which one of the following lab results should be reported immediately? A. Blood urea nitrogen 50 mg/dL [18%] B. Serum potassium 6 mEq/L [79%] C. Venous blood pH 7.30 [1%] D. Hemoglobin of 10.3 mg/dL [1%]

Explanation Choice B is correct. Although all of these findings are abnormal, elevated potassium is a life-threatening finding and must be reported immediately. Acute renal failure can cause a significant imbalance in lab values. Although all of the lab results listed are abnormal, the elevated potassium level is a life-threatening finding. Choice A is incorrect. The average BUN level should be 7 to 20 mg/dL. Choice C is incorrect. Venous blood pH should be 7.31 to 7.41. Choice D is incorrect. Normal hemoglobin levels differ based on age, sex, and general health. The normal range for hemoglobin is: For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

The nurse is caring for a client who has sickle cell disease (SCD). Which prescription from the primary healthcare provider (PHCP) should the nurse anticipate? A. Hydroxyurea [39%] B. Methotrexate [35%] C. Nortriptyline [12%] D. Verapamil [13%]

Explanation Choice A is correct. Hydroxyurea is an effective treatment for SCD. This medication increases fetal hemoglobin and decreases hemoglobin S. Choices B, C, and D are incorrect. Methotrexate is a medication indicated to treat autoimmune conditions such as rheumatoid arthritis. Nortriptyline is a tricyclic antidepressant (TCA) with significant anticholinergic properties and would be detrimental to the management of SCD. Verapamil is a calcium channel blocker and is utilized in the management of hypertension and other vascular disorders. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected actions/outcomes Question type: Knowledge/comprehension Additional Info Hydroxyurea is an efficacious medication used in the management of sickle cell disease (SCD). This medication has been shown to decrease vaso-occlusive events and therefore reduce hospitalization. Adversely, this medication increases the risk of leukemia, myelosuppression, alopecia, and other malignancies.

The nurse is caring for assigned clients. The nurse should recognize that the client at greatest risk for compartment syndrome is the client who has which of the following? A. A left tibial fracture that was recently placed in a cast [83%] B. Swelling in the ankles and is wearing compression stockings [7%] C. Chronic osteomyelitis of the right femur [4%] D. Skin traction following a left hip fracture [7%]

Explanation Choice A is correct. A client who recently had a fracture and cast is at high risk of compartment syndrome. The recent fracture causes swelling, which can be enclosed by the cast. Orthopedic fractures are a significant risk factor for compartment syndrome. Choices B, C, and D are incorrect. Swelling in the ankles and compression hose is not a significant risk factor compared to an orthopedic injury. A client with chronic osteomyelitis is not at risk, even though this involves a long bone (femur). A client in traction for a hip fracture is at risk for skin breakdown and a thromboembolism - not compartment syndrome. Additional Info Signs and symptoms of compartment syndrome include pain that is unrelieved by an opioid and aggravated by passive exercise. One of the earliest manifestations of compartment syndrome is paresthesia. Other manifestations include - - Pallor - Pulselessness - Paralysis Tibial fractures and recent casting and splinting are significant risk factors for compartment syndrome. The nurse should immediately loosen any restrictive dressings if compartment syndrome is suspected.

Which of the following nursing actions reflects effective time management? A. The nurse asks the patient what is their priority to accomplish each day [28%] B. The nurse includes a "nice to do" for every "need to do" task on the list [16%] C. The nurse "front loads" the schedule with "must-do" priorities [54%] D. The nurse avoids helping other nurses if scheduling does not permit it [2%]

Explanation Choice A is correct. To manage time; the nurse should establish goals and priorities for each day and include the patient in prioritizing tasks. Choice B is incorrect. "Need to do" should be differentiated from "nice to do" tasks. Choices C and D are incorrect. The nurse should establish a timeline and allocate priorities to hours in the workday. This will allow the nurse to recognize any falling behind and correct the problem before the day is lost. Additionally, using teamwork appropriately will enhance the work schedule. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care - Prioritizing Care

You are caring for an elderly woman who is a practicing Orthodox Judaism. Which meal would you most likely offer this client? A. Cottage cheese and fruit [84%] B. Beef lasagna [8%] C. A hamburger and milk [3%] D. Pork cutlet parmigiana [5%]

Explanation Choice A is correct. You would offer this client a meal consisting of cottage cheese and fruit because Orthodox Jewish people are not permitted to have dairy products and meat in one meal. Choice B is incorrect. You would not offer this client a meal consisting of beef lasagna because Orthodox Jewish people are not permitted to have dairy products and meat in one meal; beef lasagna has both meat and cheese. Choice C is incorrect. You would not offer this client a meal consisting of a hamburger and milk because Orthodox Jewish people are not permitted to have dairy products and meat in one meal. Choice D is incorrect. You would not offer this client a meal consisting of pork parmigiana because Orthodox Jewish people are not permitted to have dairy products and meat in one meal; pork parmigiana has both meat and cheese in addition to the fact that Orthodox Jewish people do not eat pork or pork products.

A newly registered nurse is assigned to the pediatric intensive care unit. She is about to suction an 8-month-old infant with a tracheostomy. She asks the senior nurse about the correct suction settings. What would be the senior nurse's most appropriate response? A. 100-120 mmHg [7%] B. 80-100 mmHg [31%] C. 60-80 mmHg [38%] D. 20-40 mmHg [25%]

Explanation Choice B is correct. 80-100 mmHg is the most appropriate suction setting for an infant. Choice A is incorrect. 100-120 mmHg suction setting is more suited for children older than 3 years old. Choice C is incorrect. 60-80 mmHg suction setting is for neonates. Choice D is incorrect. 20-40 mmHg suction setting is too low for a tracheostomy.

You are caring for a client who has severe burns on her right arm and is in extreme pain, despite receiving a potent analgesic. You decide to rub the client's uninjured left arm to relieve pain in the right. This approach is known as which of the following? A. Massage [8%] B. Contralateral stimulation [85%] C. TENS [4%] D. Acupressure [2%]

Explanation Choice B is correct. Contralateral stimulation involves stimulating the skin in an area opposite to the painful site. The stimulation may be in the form of scratching, rubbing, or applying heat or cold. This intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast. Choice A is incorrect. By providing cutaneous stimulation and relaxing the muscles, massage helps to reduce pain. Massage can be used as a type of contralateral stimulation. Choice C is incorrect. A transcutaneous electrical nerve stimulator (TENS) is an externally worn battery-powered device consisting of electrode pads, connecting wire, and a stimulator. The pads are directly applied to the painful area. Due to the burns, the TENS unit is not an appropriate answer. Choice D is incorrect. Similar to the ancient art of acupuncture, acupressure stimulates specific sites in the body. However, instead of needles, fingertips provide a firm, gentle pressure over the various pressure points. It is not recommended for a patient with burns. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care & Comfort

Which of the following wounds has serosanguineous exudate?

Explanation Choice B is correct. This is the photo that shows serosanguinous exudate. Choice A is incorrect. This exudate is serous. Choice C is incorrect. This exudate is sanguineous. Choice D is incorrect. This exudate is purulent.

The nurse is administering blood to a 72-year-old female who reports that she has never had a blood transfusion before. Which action is contraindicated? A. The nurse flushes the tubing with saline before and after administering a scheduled medication via IV push. [4%] B. The nurse obtains a new bag of Lactated Ringers to hang with the blood. [64%] C. The nurse stays at the patient's bedside for the initial 30 minutes of the transfusion. [6%] D. The nurse asks the UAP to take the patient's vitals before the transfusion begins and then again after 30 minutes. [26%]

Explanation Choice B is correct. Only 0.9% normal saline, an isotonic solution, should be administered with blood. Other fluids such as Dextrose or Lactated Ringer's solutions are contraindicated for blood transfusions due to a higher risk of causing clotting and red blood cell hemolysis. Choice A is incorrect. If medications are required during a transfusion, it is best to administer via a separate IV site. However, if no other site is available, medications can be given in the same tubing as the transfusion. The blood transfusion must be stopped, the line must be completely cleared with 0.9% normal saline before and after the medication is administered, and then the transfusion can be resumed. Choice C is incorrect. The nurse must stay with the patient for the first 15 minutes of a transfusion. If no reaction occurs during the initial 15 minutes, the nurse would not be required to stay for additional time. This action would not be the best use of the nurse's time, but would not be contraindicated. Choice D is incorrect. The UAP (unlicensed assistive personnel) could take the patient's vitals before the infusion. The nurse is responsible for assessing and recording vitals during the first 15 minutes of the transfusion in case the patient experiences any adverse reactions. If the patient is stable after the first 15 minutes of the bleeding, the UAP could take the vitals at 30 minutes. NCSBN Client Need Topic: Blood and blood products, the potential for complications of treatments, hemodynamics, Subtopic: Skills/procedures

The nurse is talking to new parents about their toddler. The mother is concerned that the child is getting independent and she wants to tend to the toddler all the time. The nurse's most appropriate response would be: A. "Your child will develop mistrust." [14%] B. "Your child will develop shame." [53%] C. "Your child will feel guilt." [10%] D. "Your child will feel inferior." [23%]

Explanation Choice B is correct. Toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Autonomy vs. shame and doubt is the second stage of Erikson's psychosocial development and occurs during the toddler age. It is important to allow the toddler to develop autonomy. Choice A is incorrect. Infants develop mistrust when their needs are not consistently gratified. Choice C is incorrect. Preschoolers develop guilt when their initial needs are not met. Choice D is incorrect. School-aged kids develop a sense of inferiority when their industry needs are not met.

Select the disorder which is accurately paired with its preferred corrective action. A. Pediculus capitis: The application of a depilatory [6%] B. Scabies: The application of lindane [21%] C. Tick: Removing it with a tweezer [68%] D. Hirsutism: The application of permethrin [5%]

Explanation Choice C is correct. A tick must be removed with a tweezer by pulling it out gently using a straight horizontal movement rather than twisting or turning it so that the tick's entire body is pulled out intact. Twisting or turning is contraindicated since the tick's mouthparts may break off and remain in the skin. Tick paralysis can occur due to neurotoxins present in the tick's saliva that enter the bloodstream while the tick is feeding. Symptoms can occur within 2-7 days, present with lower extremity weakness, and if the tick is not removed, it progresses to respiratory muscle weakness and death. Tick paralysis progresses only in the presence of the tick. Once the tick is removed, symptoms resolve rapidly. Because the toxin is present within the tick's salivary glands, utmost care must be taken to remove the entire tick intact. Otherwise, the tick paralysis symptoms may persist. Pathogenic ticks can transmit parasites responsible for causing Lyme disease; Rocky Mountain Spotted fever, Tularemia, Babesiosis, and Ehrlichiosis. Unlike tick paralysis, these diseases are caused by the continued proliferation of parasites in the hosts even long after the tick is removed. Choice A is incorrect. A depilatory is a chemical used to remove hair from the skin and is used for cosmetic purposes. The application of a depilatory is not used to treat pediculus capitis or head lice; instead, permethrin is used to treat head lice. Choice B is incorrect. The application of lindane is not preferred for the treatment of scabies. Lindane (Kwell) was widely used to treat scabies in the past. However, the U.S. Food and Drug Administration (FDA) has cautioned against lindane's use because of neurotoxicity concerns. Lindane is now only used as a second-line agent only if other agents have failed. Scabies, an infestation of mites, is treated with the thorough washing of the client's skin, clothing, and bed linens, followed by applying a scabicide lotion such as topical permethrin. Choice D is incorrect. The application of permethrin is indicated for treating pediculus capitis or head lice and not for hirsutism. Hirsutism, which is unwanted hair in unusual places, such as facial hair on females, is removed with a tweezer or a depilatory to remove the unwanted hair.

What is the leading cause of cognitive impairment in old age? A. Stroke [9%] B. Malnutrition [10%] C. Alzheimer's disease [77%] D. Loss of cardiac reserve [4%]

Explanation Choice C is correct. Alzheimer's disease is the most common degenerative neurological illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks. Choices A, B, and D are incorrect. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation - Cognitive Changes in Aging

The nurse is observing infection control practices in the nursing unit. Which of the following findings require follow-up? A client with: Select all that apply. A. H. pylori placed on standard precautions. [21%] B. rotavirus provided a disposable blood pressure cuff. [12%] C. rubella and their door is kept closed. [23%] D. influenza ambulating in the hall with a surgical mask. [10%] E. Legionnaires' disease placed on contact precautions. [34%]

Explanation Choice C is correct. The door should be closed in airborne isolation precautions, not droplet precautions. A client with rubella should be placed on droplet precautions. Droplet and contact precautions do not require that the door be kept closed. Therefore, this statement is incorrect and requires follow-up. The PPE required for rubella includes a surgical mask. Choice E is correct. Legionnaires' disease is not transmitted person-to-person but rather through infected water or soil. This bacterium requires standard precautions; therefore, contact precautions are inappropriate and require follow-up. Choices A, B, and D are incorrect. H. pylori infections are transmitted predominantly by contaminated water. H. pylori can spread within the families through close contact among family members. While an intrafamilial transmission is possible through contact with infected family members, there is no data to support using special isolation precautions while caring for a client diagnosed with H.Pylori. According to the Centers for Disease Control ( CDC), standard precautions are sufficient for H.Pylori ( Choice A). Rotavirus requires contact precautions. Sanitization of the surfaces is necessary to prevent transmission from contact with the contaminated surfaces. A disposable blood pressure cuff is appropriate for a client with rotavirus as infected surfaces may transmit this pathogen ( Choice B). Influenza requires droplet precautions. It is appropriate for a client with influenza to ambulate with a surgical mask as it may spread through infected droplets ( Choice D). Learning Objective Recognize the CDC-recommended transmission-based precautions used in infection prevention. Additional Info The CDC maintains an up-to-date list of the recommended precautions for different infections and conditions. This list can be referenced at https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html#L.

According to the American Nurse Association Code of Ethics, "liability with the performance of duties in a specific role" is: A. Accountability [59%] B. Authority [1%] C. Responsibility [35%] D. Delegation [5%]

Explanation Choice C is correct. Responsibility involves liability with the performance of duties in a specific role. Essentially, this means that when an LPN/LVN accepts an assignment, they also take responsibility for performing the task correctly. Accountability refers to the review of actions to determine if they were performed successfully. This means that the RN verifies that the LPN/LVN accepts responsibility for the task that is delegated to them. Authority in the delegation process means that the RN can legally transfer responsibility to another competent individual on the team. The RN also has the authority to complete assessments, plan/evaluate nursing care, and exercise nursing judgment in the course of care. Choices A, B, and D are incorrect. Accountability, authority, and trust are all aspects of the delegation process. NCSBN Client Need Topic: Management of Care, Sub-topic: Assignment and Delegation

Which of the following represents appropriate nursing documentation of a patient with a normal mood? A. Sad and tearful during conversation [3%] B. Grandiose or strongly confident [2%] C. Pleasant or appropriate to the situation [94%] D. Tearful but mildly humble and meek [1%]

Explanation Choice C is correct. The mood is a sustained emotion. Nurses should assess the intensity, depth, and duration of an altered climate. Patients may describe feeling happy, excited, sad, tearful, depressed, angry, anxious, or fearful. When assessing a patient's climate, it is essential to listen to verbal cues but also observe for nonverbal cues. For example, if the patient states, "I am happy," but she seems nervous or is crying, the nurse should document the objective data, as well. Choices A, B, and D are all incorrect. These answer choices reflect abnormal moods, which are described as sad, tearful, depressed, angry, anxious, grandiose, and fearful. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Mood and Behavior

While orienting to the PICU as a new nurse, your preceptor asks you regarding the position that would be appropriate for your patient with acute respiratory distress syndrome (ARDS). Which of the following is/ are the most beneficial position (s)? Select all that apply. A. Supine [12%] B. Left side up [34%] C. Prone [22%] D. Right side up [29%] E. Trendelenburg [3%]

Explanation Choice C is correct. Widespread inflammation in the lungs may result in acute respiratory distress syndrome (ARDS). ARDS patients are at very high risk for decreased oxygenation, mismatched lung perfusion, and infection related to ineffective drainage from the lungs. Prone positioning ( placing the clients on their abdomen) supports both drainage and oxygenation for the ARDS patient. Generally, it is used for ARDS patients that are mechanically intubated and are on the ventilator. Although challenging to achieve in some clients, this is the most appropriate choice for an ARDS patient. Choices A, B, D, and E are incorrect. These positional changes do not confer an additional advantage in the ARDS compared to the prone position. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Basic Care and Comfort Learning Objective Recognize that where possible, the prone position is the most preferred position to help oxygenation in intubated clients with the ARDS. Additional Info Prone position in intubated clients may be challenging to achieve because the endotracheal tube, other devices, and drains may dislodge with changes in position. The prone position also places pressure on the shoulders, and face, predisposing these sites to pressure ulcers. However, prone positioning has several benefits in ARDS, and the benefits outweigh the risks. All clients placed prone must be monitored for worsening respiratory symptoms or other risks. In ARDS, prone positioning is helpful because of the following reasons: In ARDS, there is extensive inflammation, causing alveolar collapse. Gas exchange is compromised in the collapsed segments of the lung. In the supine position, mediastinal structures ( heart) and abdominal organs place pressure on the lungs, exacerbating the collapse of these lung segments. When the client is prone, the lung compression is less, improving gas exchange and oxygenation. In ARDS, there is a mismatch between ventilation ( airflow) and perfusion ( blood flow to alveoli). Prone positioning improves gas exchange by redistributing blood flow and airflow more evenly among the lung segments. In ARDS, there are significant pulmonary secretions due to inflammation. Facing prone (mouth and nose facing down) promotes the drainage of secretions better.

You are working as a school nurse in a local high school. One of the students frequently presents to your office with a fever, runny nose, nausea, vomiting, and dilated pupils. What do you suspect is most likely happening with this high school student? A. Inhalant abuse [36%] B. Barbiturate abuse [18%] C. Oxycodone abuse [28%] D. Viral infection [18%]

Explanation Choice C is correct. You most likely suspect that this high school student is abusing an opioid drug such as oxycodone. Fever, runny nose, excessive yawning, nausea, vomiting, and dilated pupils are some of the signs associated with opiate withdrawal. Based on the presentation, it appears like the student is abusing opioids potentially after school and now showing early withdrawal signs. Withdrawal symptoms may present just after 8 to 12 hours in clients with a history of chronic opioid abuse. Symptoms of Opioid Withdrawal: Early symptoms and signs of opioid withdrawal include diaphoresis, nausea, yawning, lacrimation, tremor, rhinorrhea, agitation, dilated pupils, and increased pulse rate at greater than 90. These early withdrawal symptoms start 8-12 hours after the last dose. Late signs of opioid withdrawal are more severe and include nausea with vomiting, abdominal cramps, diarrhea, chills, insomnia, dilated pupils, tachycardia, tachypnea, and hypertension. Opioid overdose may present with symptoms opposite to those of withdrawal. These include slurred speech, respiratory depression, hypotension, drowsiness, and constricted pupils. However, a client with an opioid overdose is likely to present to the emergency department rather than attending school. The nurse should be aware of the effects of various drugs on the pupil size because it may help determine the substance being abused. Opioid overdose is the only condition that is associated with pupillary constriction (pinpoint pupils). The substance-abuse conditions that are associated with pupillary dilation include: Use of CNS stimulants: Marijuana (Cannabis); Amphetamines (MDMA, Ecstasy), Cocaine, Mescaline, SSRIs (Selective Serotonin Reuptake Inhibitors), Hallucinogens (mescaline, LSD, psilocybin) Withdrawal of opioids (i.e. Heroin withdrawal) Choice A is incorrect. An inhalant abuse should be suspected in a client who is demonstrating slurred speech, uncoordinated movements, and stupor. Such symptoms can also be seen with opioid overdose. Pupil size tends to be normal in an inhalant overdose or withdrawal. Choice B is incorrect. Withdrawal from barbiturate abuse or other CNS depressant abuse should be suspected if the client is presenting with withdrawal symptoms of nausea, vomiting, insomnia, hyperreflexia, anxiety, tremors, seizures, hallucinations, and psychomotor agitation. Pulse and respiratory rate may increase. Fever may be seen in barbiturate withdrawal. Symptoms of barbiturate withdrawal develop 24-36 hours after the last dose. However, dilated pupils are not a manifestation of barbiturate withdrawal and serve as a differentiator from opioid withdrawal. Barbiturate overdose also does not affect pupil size. If the pupils are dilated in a barbiturate overdose patient, that is from secondary anoxia rather than the drug itself. Choice D is incorrect. Although fever is a distractor, this presentation is not consistent with an infection because of the frequent occurrence over the last one month and the presence of dilated pupils.

The nurse is providing health education on a client with dumping syndrome. Which teaching point about drinking fluids is accurate? A. The client should drink fluids immediately before meals [3%] B. The client must only drink fluids with meals [5%] C. The client must drink fluids before and during meals [9%] D. The client should drink fluids at least a half an hour after meals [83%]

Explanation Choice D is correct. Fluids should be taken at least 30 minutes to 1 hour after meals to avoid dumping syndrome. Choices A, B, and C are incorrect. Fluids consumed at the same time as food increase the speed of gastric emptying, subsequently increase the likelihood of dumping syndrome.

The nurse is caring for a patient diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which of the following medications? A. Topiramate [17%] B. Risperidone [18%] C. Prazosin [9%] D. Baclofen [56%]

Explanation Choice D is correct. Multiple Sclerosis (MS) may produce symptoms such as muscle spasticity, optic neuritis, fatigue, heat intolerance, and symptoms that seem to intensify on occasion (relapses). Muscle spasticity is best controlled with muscle relaxers such as baclofen. Choices A, B, and C are incorrect. Topiramate is an anticonvulsant drug indicated in the treatment of epilepsy as well as psychiatric conditions such as bipolar disorder. Risperidone is indicated for psychotic disorders such as schizophrenia. Prazosin is an antihypertensive that may be used for high blood pressure. This medication also may be indicated for psychiatric illnesses such as PTSD. Additional information: MS symptoms are often vague and non-specific. These symptoms often include fatigue, optic neuritis, muscle spasms, heat intolerance, and difficulty with coordinating movements. Symptoms may exacerbate and remit. Treatment includes symptomatic care and interferon therapy.

A 40-year-old patient who is blind and deaf has been admitted to the medical floor. What is the nurse's primary responsibility for this patient? A. Make others aware of the patient's deficits [3%] B. Communicate with the nursing supervisor any patient safety concerns [6%] C. Continuously update the patient on the social environment [8%] D. Provide a secure environment for the patient [83%]

Explanation Choice D is correct. The nurse's primary responsibility is patient safety. For this deaf and blind patient, it is critical to provide secure environment. According to Maslow's hierarchy of needs, physiological needs and thereafter, safety needs should be prioritized in that order. Visual impairment has been associated with falls that often result in fractures, and dislocations. A patient with visual impairment may experience disorientation as a consequence of being in a strange hospital environment. Certain important interventions the nurse can undertake in providing a secure environment for a deaf-blind client include: escorting the patient around the new environment as and when required. This will help meet the need for safety, promote some orientation and instill a feeling of security in the patient. orienting patient to layout of room, restrooms, location and operation of call button, telephone, television, and environmental controls. Such orientation helps prevent accidents. The nurse must also provide adequate supervision when patient needs to visit the toilet. Other measures include placing the bedside locker on the side most appropriate for the individual patient, and placing the the call within easy reach. orienting patient to treatment room and supplies. orienting patient to lounges, recreation rooms, and nursing station in relationship to patient's room. communicating evacuation/rescue plans; orientation to fire alarm pull boxes, fire extinguisher, and emergency exits training in self-care and use of medical equipment. assisting with feeding, toileting, bathing, or dressing (only if required). Choices A, B, and C are incorrect. The nurse should make other care team members aware of patient's visual and hearing deficits using a sign placed above the bed, in report, and on medical record. Communication with the supervisor regarding safety concerns, and updating the patient on social environment are all necessary, however, patient safety needs (providing a secure environment) takes the utmost priority. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Visually and Hearing Impaired Clients

You have been asked to lead a health promotion course for the community about cancer. Which of the following symptoms should you include in your education about early signs and symptoms of cancer? Select all that apply. A. Incontinence [30%] B. Weight gain [9%] C. Trouble swallowing [39%] D. Insomnia [21%]

Explanation Choices A and C are correct. Any changes in the bowel and bladder habits for a patient are concerning for cancer and clients should be taught to report this to the healthcare provider immediately (Choice A). Any difficulties swallowing are potential early signs of cancer that should be reported (Choice C). Choice B is incorrect. Weight loss, not gain, is concerning for cancer. Choice D is incorrect. Fatigue, not insomnia, is the most common symptom of cancer. For clients experiencing unexplained fatigue, their healthcare provider should be notified. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Oncology

The nurse is caring for a 3-year-old newly diagnosed with acute lymphoblastic leukemia (ALL). While talking to the family, which of the following educational points does the nurse know to reinforce based on the child's diagnosis? Select all that apply. A. Bleeding precautions [39%] B. Contact precautions [13%] C. Neutropenic precautions [45%] D. Sternal precautions [3%]

Explanation Choices A and C are correct. Bleeding precautions are an essential educational point for a patient with ALL. Due to the excess of blast cells, their platelet count will drop. With decreased platelets, it will take the patient longer than usual to clot, leading to an increased bleeding risk (Choice A). Neutropenic precautions are essential to discuss with the family of a child with ALL. Since the child has a low absolute neutrophil count and a high blast percentage, their ability to fight infections will be severely impaired. This means that special precautions need to be in place to protect the child from disease. These neutropenic precautions include no fresh flowers or plants in the room; all visitors should wash their hands before entering the room and wear a mask, no sick visitors, and keep the door closed (Choice C) Choice B is incorrect. Contact precautions are not necessary for a patient with ALL. Contact precautions would be used for a disease that is spread from person to person via contact with the infectious agent, such as MRSA. ALL is not a contagious disease that can be transmitted from person to person, so contact precautions are unnecessary. Choice D is incorrect. Sternal precautions are unnecessary for the patient with ALL. Sternal precautions are put in place after an incision is made on the sternum during cardiothoracic surgery. It is to prevent excessive pulling and tension on these sutures while the sternum heals. The patient with ALL does not need sternal precautions. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Infection control and safety; Pediatrics - Oncology

Which of the following anatomical characteristics are descriptive of the congenital heart defect tetralogy of Fallot? Select all that apply. A. There is a hole between the two ventricles called a ventricular septal defect. [28%] B. There is an overriding aorta. [26%] C. The pulmonary arteries are stenosed. [22%] D. There is right ventricular hypertrophy. [25%]

Explanation Choices A, B, C, and D are all correct. A is correct. Tetralogy of Fallot is a congenital heart defect composed of four different errors, a ventricular septal defect (VSD) being one of them. The VSD is a hole between the right and left ventricles, which allows the oxygenated and deoxygenated blood to mix in which is essentially one ventricle. B is correct. Tetralogy of Fallot is a congenital heart defect composed of four different defects, an overriding aorta being one of them. This means that the aorta is positioned over the VSD instead of over the left ventricle where it should be. C is correct. Tetralogy of Fallot is a congenital heart defect composed of four different defects, pulmonary stenosis being one of them. The pulmonary arteries are narrowed and hardened, making it difficult for the right ventricle to pump blood to the lungs. D is correct. Tetralogy of Fallot is a congenital heart defect composed of four different defects, right ventricular hypertrophy being one of them. This portion of the error is actually due to another part: the pulmonary stenosis. Since these vessels are narrowed and hardened, it is difficult for the right ventricle to pump blood through them and out to the lungs. This puts extra work on the heart and after some time the muscle of the right ventricle gets more substantial or hypertrophied due to the extra work. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Cardiovascular

Which of the following symptoms may be an indicator of preeclampsia? Select all that apply. A. Hyperreflexia [22%] B. Headache [41%] C. Uncontrolled vomiting [15%] D. Epigastric pain [21%]

Explanation Choices A, B, and D are correct. Hyperreflexia, headache, and epigastric pain are typical symptoms of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure used to be normal. If left untreated, preeclampsia can lead to serious, sometimes fatal, complications for both mother and baby. The most effective treatment is delivery of the baby. Even after delivering the baby, recovery may not be immediate. Rarely, preeclampsia develops after delivery of a baby, a condition known as postpartum preeclampsia. Choice C is incorrect. Uncontrolled vomiting is the defining characteristic of hyperemesis gravidarum. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Pregnant Women

The nurse counsels a client about a newly inserted copper intrauterine device (IUD) for contraception. It would require follow-up if the client states which of the following? Select all that apply. A. "This device may raise my risk for breast cancer." [25%] B. "I may continue to have bleeding and cramping." [13%] C. "I should perform weight-bearing exercises." [16%] D. "I will need my device replaced after 15 years." [25%] E. "This device may raise my risk for a stroke." [21%]

Explanation Choices A, C, D, and E are correct. The copper intrauterine device is non-hormonal; therefore, it does not raise the risk of breast cancer. Unlike depot medroxyprogesterone, the IUD does not cause bone demineralization, so weight-bearing exercises are not a relevant teaching point for this type of contraception (where they would be for depot medroxyprogesterone). An increase in cardiovascular disease is not associated with the copper IUD as it is non-hormonal. The IUD is to be replaced every ten years (US FDA approved duration) - not fifteen. Choice B is incorrect. The most common adverse effect of the copper IUD is increased bleeding and cramping within the first six months after application. This may cause the client to discontinue the device. Additional Info The copper IUD is an effective contraceptive method that does not involve the use of hormones. This is an attractive feature because it does not raise the risk of cancers, thromboembolism, or cardiovascular disease. The IUD has a high degree of client satisfaction and is one of the most effective methods of contraception. The client should be educated that menstrual cycles with the copper IUD may be heavier and cause more cramping. This device may also be utilized for emergency contraception.

The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply. A. pulmonary tuberculosis with multiple prescriptions. [12%] B. ischemic stroke who has left-sided hemiplegia. [22%] C. hyperthyroidism and is scheduled for a thyroidectomy. [7%] D. stage one Alzheimer's disease who lives with family. [11%] E. fractured tibia and fibula and is homeless. [28%] F. end-stage-renal disease who refuses dialysis. [20%]

Explanation Choices B and E are correct. A client with an ischemic stroke with hemiplegia will require interdisciplinary care such as occupational and physical therapy. Further, the client may require subacute rehabilitation provided by nursing. A client with a fractured tibia and fibula will require physical therapy along with consultation with social services to assist the patient with housing. Choices A, C, D, and F are incorrect. A client with pulmonary tuberculosis requiring multiple prescriptions will require nursing care to reinforce teaching on the therapies. Additionally, a client scheduled for surgery will require nursing care until discharge. Further, a client with stage one Alzheimer's disease can still live independently even with this patient going to reside with family. Finally, a client refusing care will require counseling from nursing and not any other specialty. Additional Info Clients requiring interdisciplinary conferences are individuals who have complex medical needs requiring multiple services such as social services, therapy, or case management.

In caring for a client who underwent surgical repair of a detached retina of the right eye, which nursing action should the nurse include in the care plan? Select all that apply. A. The client should be placed in the prone position [2%] B. Always approach the client from the left side [22%] C. Instruct client to perform deep breathing and coughing exercises [3%] D. Instruct client to avoid bending down [25%] E. Orient client to his environment [24%] F. Prevent constipation by administering a stool softener [24%]

Explanation Choices B, D, E, and F are correct. The nurse should always approach the client from the unaffected side—in this case, the left side (Choice B), to avoid startling the client. The client should always be oriented to his environment to prevent unwarranted injury (Choice E). Activities that increase intraocular pressure, such as bending down (Choice D), should be avoided. Constipation and straining during defecation may increase intraocular pressure. Stool softeners (Choice F) are administered to avoid constipation. Choices A and C are incorrect. Post-operatively, activities that increase intraocular pressure should be avoided. Increased intraocular pressure can lead to postoperative vision loss and recurrent retinal detachment. The intraocular pressure increases significantly within 10 minutes after the patient is placed in the prone position (Choice A) and continues to increase while the patient remains prone. Therefore, the client should lie down on his back (supine) or on the unaffected side to reduce intraocular pressure in the affected eye. Additionally, bending down, deep breathing (Choice C), hard coughing, sneezing, and other activities that may increase intraocular pressure are discouraged.

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client's care? A. Implement contact precautions when handling the client. [85%] B. Educate the client and family members on ways to prevent transmission of VRE. [1%] C. Monitor the results of the laboratory culture and sensitivity test. [3%] D. Collaborate with other departments when the client is transported for an ordered test. [10%]

Explanation Choice A is correct. All hospital personnel who care for the client are responsible for the proper implementation of contact precautions. Choices B, C, and D are incorrect. These are all actions that should be carried out by a nurse. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care

The nurse preceptor observes a newly hired nurse care for a client with a myxedema coma. It would require follow up by the nurse preceptor if the newly hired nurse is observed A. applying a cooling blanket to the client. [59%] B. requesting a prescription for hydrocortisone. [21%] C. removing the water pitcher from the bedside. [13%] D. placing an oral endotracheal tube at the bedside. [7%]

Explanation Choice A is correct. One of the clinical features of a myxedema coma is hypothermia. Passive warming of the client is an effective treatment measure for this emergency. Cooling the client would require follow-up as this would worsen the hypothermia. Choices B, C, and D are incorrect. Immediate treatments for myxedema are hydrocortisone and levothyroxine. A corticosteroid is necessary to administer until adrenal insufficiency is excluded. The corticosteroid is also helpful in correcting the hyponatremia that is a feature of this condition. The client with a myxedema coma has a decreased mental status and is at risk for aspiration. The water pitcher should be removed from the bedside as IV fluids are given to restore the circulating volume. Advanced airway equipment such as an oral endotracheal tube should be available as severe hypoventilation may manifest with this condition. Additional Info Myxedema coma is a severe form of hypothyroidism that causes an array of clinical manifestations, including - Decreased mental status Bradycardia Hyponatremia Hypoglycemia Hypotension Hypothermia Treatment is aimed at giving the client intravenous levothyroxine, corticosteroids, intravenous fluids with dextrose, rewarming, and mechanical ventilation, if necessary.

A patient is scheduled for an IV pyelogram. He asks the nurse what he needs to do to prepare for the test. The correct response is: A. "You need to have a full bladder for the test to be successful." [27%] B. "You need to alert the technician if you feel any burning after the dye is injected." [31%] C. "You will receive a bowel preparation before the test can be performed." [29%] D. "You must lie on your back for four hours after the test is performed." [13%]

Explanation Choice C is correct. Bowel prep is necessary to make sure the x-rays are bright and bowel contents do not obstruct viewing of urinary structures. An IV pyelogram is an x-ray that is used to view the urinary structures. Choice A is incorrect. A full bladder is unnecessary for the test to be successful. Choice B is incorrect. Although the technician should be alerted if any uncomfortable sensations occur, allergies should be checked before the test is administered. Choice D is incorrect. It is not necessary to lie down after the test is performed. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

A 9-year-old child diagnosed with leukemia is scheduled for a bone marrow aspiration tomorrow. Regarding his informed consent, which initial nursing action is most appropriate? A. Obtain assent from the child. [21%] B. Ask his parents to sign the consent. [41%] C. Ask the physician to sign the consent. [1%] D. Witness the informed consent. [38%]

Explanation Choice A is correct. The child needs to have some control and input in the decision-making process regarding his care. Assent means the child has been fully informed about the procedure and concurs with those giving the informed consent. Choice B is incorrect. A minor is a person under 18 years of age, not married and has not been married, or has not had the disabilities of minority removed by the court via emancipation. Since the child is under 18, the parents must sign the informed consent form. However, the initial action should be to obtain a child's assent. Both the parents and the nurse must first obtain permission from the child. Choice C is incorrect. The physician cannot sign informed consent for the minor child. Legally, informed consent for a minor can be signed by the biological mother/father; adoptive mother/father, a parent who is appointed managing conservator (even for invasive procedures), and a parent who is appointed possessory conservator (as long as not for invasive procedures). In the absence of the above people to sign the consent, then a grandparent, adult sister/adult brother, or an educational institution who has possession of the minor child can sign the informed consent. Choice D is incorrect. The nurse can witness the signing of the informed consent for the procedure. However, it is not the priority action for the situation.

The nurse is teaching a client about prescribed metronidazole. Which of the following statements, if made by the client, would indicate effective teaching? A. "I should not drink alcohol while I'm taking metronidazole." [81%] B. "It is okay for me to be in the sun while I'm taking this medicine." [2%] C. "I should take the medicine until my stomach stops hurting, then stop." [3%] D. "I should take the medicine on an empty stomach." [14%]

Explanation Choice A is correct. The client should be advised not to take metronidazole with alcohol since mixing the two can cause abdominal pain, nausea, vomiting, and dizziness. The client should wait for three days after the prescription is complete before drinking any alcohol. Choices B, C, and D are incorrect. Metronidazole can cause photosensitivity (increased sensitivity to sunlight). The client should be advised to stay out of the sun during treatment. Since metronidazole is an antibiotic, the client should understand that the entire prescription should be taken as directed. Taking the medication with food or a full glass of milk is advisable to avoid an upset stomach. Other side effects of metronidazole include a metallic taste in the mouth, decreased appetite, diarrhea or constipation, and a darkening of the color of the urine. Additional Info Metronidazole is an effective antibiotic for targeting anaerobic pathogens. This medication is commonly utilized for gastrointestinal and sexually transmitted infections. A darkening urine, avoidance of alcohol, and metallic-like taste are all essential teaching points.

Which of the following statements correctly outlines the proper flow of blood through the heart? A. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation [57%] B. Superior and Inferior vena cavas → Right atrium → Mitral valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Tricuspid valve → Left ventricle → Aortic valve → Aorta → Systemic circulation [15%] C. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary veins→ Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation [21%] D. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Aortic valve → Pulmonary veins→ Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Pulmonary valve → Aorta → Systemic circulation

Explanation Choice A is correct. This is the proper flow of blood through a healthy heart with normal anatomy. The superior and inferior vena cavas are the large veins that bring back deoxygenated blood from the body to the right atrium of the heart. The blood enters the right atrium, passes through the tricuspid valve into the right ventricle, and is then pumped into the lungs through the pulmonary artery. Here, in the pulmonary circulation, the deoxygenated blood drops off its carbon dioxide and waste products and picks up fresh oxygen to deliver to the body. It is now oxygenated. The blood returns to the left atrium through the pulmonary veins and passes through the mitral valve to enter the left ventricle and is then pumped out to the body through the aorta. Oxygenated blood is now in the systemic circulation, where it can deliver oxygen to all the tissues of the body. Choice B is incorrect. In this sequence, the mitral and tricuspid valve locations are switched. Remember, the mitral valve is between the left atrium and ventricle, whereas the tricuspid valve is between the right atrium and ventricle. Choice C is incorrect. In this sequence, the pulmonary artery is switched with the pulmonary vein. The pulmonary artery carries deoxygenated blood away from the heart and to the lungs. It is the only artery in the body that carries deoxygenated blood. The pulmonary vein brings oxygenated blood back from the lungs to the left atrium. Choice D is incorrect. In this sequence, the pulmonary and aortic valves are switched. This should be easy to remember, as the pipes are named after which vessel they open into. The pulmonary valve is located at the opening of the pulmonary artery, whereas the aortic valve is located at the opening of the aorta. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk of the potential reduction; Cardiac

Many documents fall under the category of an advanced directive. One of the most common legal papers is called 'Durable Power of Attorney for Health Care' and works to: A. Review a person's personal preferences for medical care in the future. [3%] B. Authorize another person to make medical decisions for a person if they become unable to on their own. [78%] C. Assign a legal authority in making medical decisions while honoring the spoken word of the family. [7%] D. Define what care should be administered or withheld by health care professionals, no matter which medical facility the patient finds themselves in.

Explanation Choice B is correct. A 'Durable Power of Attorney for Health Care' works to authorize a person to make medical decisions for the patient should the patient be unable to make a choice themselves as a result of a decrease in mental capacity or level of consciousness. Choice A is incorrect. When a patient and their health care team review their personal preferences for future medical decisions, they are creating a 'living will'. Choice C is incorrect. If a legal authority is assigned to make medical decisions, as is the case with 'Durable Power of Attorney', this person has the full authority to choose or decline treatment. If the family's opinion conflicts with this assigned person's choices, the health care staff must honor the person with legal authority over the family members. Choice D is incorrect. This choice defines a guideline that is known as 'Physician Orders for Life-Sustaining Treatment' and describes what care will take place no matter what health care facility the patient finds themselves in. NCSBN client need Topic: Management of Care, Advanced Directives

A client is admitted with a possible diagnosis of Guillain-Barré syndrome. Which important question should the nurse include when taking this client's history? A. "Have you experienced frequent bruising?" [4%] B. "Did you have a recent bout of upper respiratory tract infection?" [67%] C. "Have you been overseas during the past 4 months?" [6%] D. "Does anybody in your family have Guillain-Barré syndrome?" [23%]

Explanation Choice B is correct. Approximately 60-70% of clients diagnosed with Guillain-Barré syndrome experience upper respiratory tract infection 1-4 weeks before symptoms set in. This syndrome is idiopathic, but it may be a cell-mediated immune response that attacks the peripheral nerves as a response to a viral infection. Its significant pathologic effect is the segmental demyelination of the peripheral nerves, subsequently destroying the myelin sheath of the nerve. Choices A, C, and D are incorrect. It is not a hereditary disorder, does not affect the body's ability for clotting, and is not related to exposure during foreign travel.

The nurse is taking vital signs on a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action? A. Notify the healthcare provider [4%] B. Document and continue to monitor [66%] C. Place the mother on her left side [27%] D. Administer 100% FiO2 via face mask [2%]

Explanation Choice B is correct. Since the nurse has noted a reassuring sign of the fetal heart rate, it is appropriate for her to document the finding and continue to monitor the mother. If the nurse had noticed a non-reassuring sign, other interventions would be necessary. Choice A is incorrect. The nurse has observed an acceleration in the fetal heart rate, which is an increase in fetal heart rate by 15 bpm above the baseline. An acceleration lasts about 10-15 seconds and then the heart rate returns to baseline. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip. The nurse does not need to report this to the healthcare provider. Choice C is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require repositioning of the mother to the left side. Repositioning the mother to the left-lateral position will be needed if a non-reassuring sign (e.g. fetal bradycardia, late decelerations) is noted. Choice D is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require administration of 100% FiO2 via face mask. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Problems with Labor and Delivery

A 23-year-old college student seeks medical help at the infirmary complaining of severe fatigue. She reports exertional dyspnea, and her skin appears pale. Aplastic anemia is suspected. Laboratory values reflect anemia, and the client is advised for a bone marrow biopsy. The client refuses to sign the consent and states, "Come on, just get the doctor to give me a transfusion and let me go. Spring break begins this weekend, and I'm leaving for Florida." The nurse's most significant concern at this time would be: A. The possibility that the client may contract an infection from being exposed to large crowds during spring break. [26%] B. The client does not understand the full impact of her condition. [57%] C. The client may need a transfusion before leaving for spring break. [2%] D. The causative agent needs to be identified and the treatment should be started. [15%]

Explanation Choice B is correct. The most significant concern at this point is the fact that the client does not fully grasp the gravity of her condition. She must be educated and be allowed to verbalize her feelings about her situation. Choices A, C, and D are incorrect. The possibility of an infection is a concern but not the most pertinent issue at this point. A transfusion is only a temporary measure because the causative agent has not been identified. For treatment to commence, a bone marrow biopsy needs to be done first, but before that, the client's feelings regarding her condition need to be addressed for care to continue.

The med-surge nurse receives a report on a patient who is legally blind. Which action by the nurse would be most likely to reduce this patient's anxiety? A. Assign the patient to a private room. [2%] B. Orient the patient to their room. [84%] C. Request for a sitter to be assigned. [9%] D. Instruct the UAP to check on the patient frequently. [4%]

Explanation Choice B is correct. The nurse should meet the patient upon arrival to the unit and should describe the layout of the room using a focal point and directions. The nurse should include information about calling for help when needed. These measures will reduce the patient's anxiety as well as promote the patient's independence and safety. Choice A is incorrect. A patient would not require a private room due to visual impairment. These rooms should be reserved for patients with impaired immunity or transmittable diseases. Being placed in a private room would not necessarily directly mitigate the patient's anxiety. Choice C is incorrect. A patient's visual impairment would not be a reason to assign a sitter automatically. If the nurse assesses the patient to be a safety risk, the nurse may consider interventions such as requesting a sitter or moving the patient to a room close to the nurse's station. Still, these would not relate to reducing the patient's anxiety. Choice D is incorrect. Without having first assessed the patient's level of impairment/functional status, the nurse would not know if more frequent monitoring would be appropriate. It is not suitable for the nurse to delegate this action until the patient has been assessed. NCSBN Client Need Topic: Visual/auditory, Subtopic: sensory/perceptual alterations, stress management, therapeutic communication, therapeutic environment

Which photo below indicates the appropriate location to auscultate an apical pulse in an infant?

Explanation Choice B is correct. This image highlights the 4th intercostal space to the left of the sternum at the midclavicular line. This is the area where you would auscultate the apical pulse of an infant. Choice A is incorrect. This image highlights the 5th intercostal space to the left of the sternum at the midclavicular line. This is the area where you would auscultate the apical pulse of an adult, but it is different for an infant. Choice C is incorrect. This image highlights the 5th intercostal space to the right of the sternum at the midclavicular line. You would not auscultate this area for the apical pulse in anyone, as the apex of the heart is to the left of the sternum, not the right. Choice D is incorrect. This image highlights the 4th intercostal space to the right of the sternum at the midclavicular line. You would not auscultate this area for the apical pulse in anyone, as the apex of the heart is to the left of the sternum, not the right. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care, Cardiology

Which statement about dentition is accurate? A. Caucasians tend to have less tooth decay than African Americans. [11%] B. Tooth size can normally vary among some different ethnicities. [75%] C. African Americans lose more teeth than Caucasians. [8%] D. Neonatal teeth are more present at birth among African Americans than others. [5%]

Explanation Choice B is correct. Tooth size can usually vary among some different ethnicities. For example, Caucasians have the smallest tooth size and then, in ascending order of increasing tooth size, are African Americans, people with an Asian ethnicity, and then North American Native Americans with the largest tooth size. Choice A and C are incorrect. African Americans tend to have less tooth decay/tooth loss than Caucasians. This difference is most likely related to the fact that African Americans have more dense tooth enamel to protect the teeth against corrosion than Caucasians do. Choice D is incorrect. Neonatal teeth are not more prevalent at birth among African Americans than others. The presence of teeth at birth is more prevalent among members of some Canadian Eskimos and some native Alaskan Americans.

A 16-year-old was rushed to the emergency department after falling off his motorcycle earlier in the day. He sustained a closed head injury but is still conscious. The physician in the ED orders a set of medications for the client. Which medication should the nurse question? A. Ranitidine 50 mg IV [20%] B. Docusate sodium 50 mg PO [21%] C. Morphine sulfate 10 mg IM [39%] D. Promethazine 25 mg IM [19%]

Explanation Choice C is correct. Morphine sulfate is a narcotic analgesic. Narcotic analgesics should not be given to patients with a head injury as it masks signs of increased intracranial pressure. Choice A is incorrect. Ranitidine is an H2 receptor antagonist; it reduces gastric acid production, preventing gastric ulcers. Choice B is incorrect. Docusate sodium is a stool softener. It is beneficial for clients on bed rest to have a stool softener to prevent constipation related to immobility. Choice D is incorrect. Promethazine is an H1 receptor blocker, used as an antiemetic.

The nurse is providing patient care working in a unit that uses the total patient care model for delivering nursing care. The nurse recognizes which of the following as an aspect of this nursing care delivery model? A. The RN assumes responsibility for a caseload of patients. [5%] B. The RN supervises team members providing direct patient care. [13%] C. The RN provides care for the same patients during their hospital stay. [9%] D. The RN is responsible for all aspects of care during a shift of care. [74%]

Explanation Choice D is correct. Characteristics of the total patient care model include: the RN being responsible for all aspects of care during a shift of care, care can be delegated, and the RN works directly with the patient, family, and health care team members. Choices A and C are incorrect. The RN having responsibility for a caseload of patients and providing care for the same patients during their hospital stay are characteristics related to the primary nursing model. Choice B is incorrect. In team nursing, team members provide patient care under the supervision of the RN team leader. Bloom's Taxonomy: Analyzing

The nurse is caring for a client with heart failure. The patient is ordered a nitroglycerin patch to be attached. Which of the following nursing actions regarding the administration of a nitroglycerin patch is most relevant? A. Use a bare hand when putting the patch on the patient. [4%] B. Place the patch on the same spot every day. [5%] C. Place the client in the supine position with his feet elevated on a pillow. [5%] D. Instruct the client to rise slowly. [86%]

Explanation Choice D is correct. Patients under nitroglycerin therapy are at risk for postural hypotension. The client should rise slowly to avoid a sudden drop in blood pressure when standing up. Choice A is incorrect. The nurse should wear gloves when administering a nitroglycerin patch to avoid skin contact with the medication. Choice B is incorrect. The patch should be rotated to ensure optimum absorption through the skin. Choice C is incorrect. The purpose of nitroglycerin in heart failure is to dilate the venous circulation and trap the blood in the veins, decreasing the preload. Placing the client in the supine position and elevating his feet increases venous return, thus increasing preload. This defeats the purpose of nitroglycerin.

Although you were informed that your assigned patient has no special skincare needs, upon your assessment, you observe reddened areas over bony prominences. What action is appropriate? A. Correct the initial assessment form [1%] B. Redo the assessment and document current findings [16%] C. Conduct and document an emergency assessment [1%] D. Perform and document a focused assessment of skin integrity [81%]

Explanation Choice D is correct. Performing and documenting a focused assessment on skin integrity is appropriate since this is a newly identified problem. Choices A and B are incorrect. The initial assessment stands as-is and cannot be redone or correct. Choice C is incorrect. This is not a life-threatening event. Therefore, there is no need for an emergency assessment. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Assessing Skin Integrity

Which of the following is a neurological complication that may occur when a vest restraint is too tight around a patient's body? A. Skin breakdown [11%] B. Strangulation [23%] C. Changes in skin pallor [10%] D. Numbness [56%]

Explanation Choice D is correct. The neurological complication can occur when a vest restraint is too tight around the client's body causing numbness and tingling that, unless corrected, can lead to neurological damage. Choices A, B, and C are incorrect. Skin breakdown, strangulation, and changes in skin pallor can occur when the restraint is too tight. These complications are usually related to the integumentary, respiratory, and circulatory systems, rather than neurological system complications. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

A client with a fractured left ankle was instructed to avoid any weight-bearing on the left foot. The nurse has taught him to use crutches when ambulating properly. Which action by the client should indicate to the nurse that the health teaching was effective? A. The client places the crutch on his left side, then the left crutch and the right foot advance at the same time. [13%] B. The client advances the right crutch, then the left foot, then the left crutch, and then the right foot. [18%] C. The client advances both crutches together; then both his legs are lifted and swung past the crutches, followed by the feet landing at a point in front of the crutches. [25%] D. The client advances both crutches and the left foot together, followed by the right foot. [44%]

Explanation Choice D is correct. This client is exhibiting a three-point gait. The three-point gait is used for partial weight-bearing or no-weight bearing on the affected leg. A three-point gait is used when one leg is affected. In the three-point gait, both crutches and the affected lower leg are moved forward simultaneously. Then the unaffected lower extremity is pushed forward while most of the bodyweight is put on the crutches. This is the correct gait for the client with an ankle fracture who was recommended no weight-bearing on foot. It is used for lower limb fractures or amputation. Choice A is incorrect. This client is demonstrating a two-point gait. This gait is used for partial weight-bearing and bilateral lower extremity prosthesis. The two-point pace is a progression from the four-point stride and allows faster ambulation. Weight is placed on both lower extremities and both crutches. The patient advances left foot and right crutch together and then advances right foot and left crutch together. This gait is not recommended for the client. Choice B is incorrect. This client is demonstrating a four-point gait. This method is recommended for partial weight-bearing. In a four-point gait, the crutch-foot sequence follows the pattern: Right crutch -> Left Foot -> Left Crutch -> Right foot. The four-point pace can be used only by patients who can move each leg separately and bear a considerable amount of weight on each of them. This is not recommended for the client. Choice C is incorrect. This is swing-through gait. Patients with paralyzed legs and hips utilize swing gaits (swing-through and swing-to; e.g. spinal cord injury). In a swing-through stride, both crutches are taken forward; then, both lower limbs are lifted and swung past the crutches so that the crutches are left behind the point where the feet land on the floor. This is not suitable for patients with painful lower limbs and is not recommended for this client.

When educating an adolescent diagnosed with bacterial conjunctivitis about how to prevent the spread of their infection, which of the following points should you include? Select all that apply. A. Do not share towels or washcloths with family members. [38%] B. Stay home from school until they have taken antibiotics for 48 hours. [19%] C. Apply a warm compress to lessen any irritation. [15%] D. Throw out the contact lenses and get new ones. [27%]

Explanation Choices A and D are correct. To prevent the spread of bacterial conjunctivitis, it is essential not to share towels or washcloths with anyone while infected (Choice A). This is appropriate advice for preventing reinfection of bacterial conjunctivitis. If a patient wears the same contact lenses, they will likely spread the disease for a second time and become infected again. They should also be instructed to discard their eye makeup to prevent reinfection (Choice D). Choice B is incorrect. It is okay to go back to school after 24 hours of antibiotics, not 48 hours. Choice C is incorrect. Applying a compress will help improve comfort for the patient with bacterial conjunctivitis, but has nothing to do with preventing the spread of the infection. Furthermore, utilizing a warm compress would cause further irritation with bacterial conjunctivitis; instead, a cold compress should be used. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Integumentar

The nurse is providing care to a client with an endotracheal tube that requires suctioning. While suctioning, the client's heart rate and respiratory rate increase. Which priority actions are appropriate for the nurse to take. Select all that apply. A. Check oxygen saturation. [39%] B. Call a rapid response. [5%] C. Increase suction pressure. [1%] D. Stop suctioning. [38%] E. Notify the physician. [17%]

Explanation Choices A and D are correct. Tracheal suctioning is often needed to clear the secretions and maintain an open airway. It is important for the RN to understand the complications of tracheal suctioning. If the nurse notices a change in vital signs (tachycardia, tachypnea) while suctioning a patient, the nurse should stop the suctioning and check the oxygen saturation immediately. When the client becomes tachycardic and tachypneic while suctioning, it is a sign of distress which indicates that the client is not tolerating the suctioning. Hence, suctioning needs to be immediately discontinued to prevent further distress and the cause of the distress should be explored. Hypoxemia is an important cause of tachycardia and cardiac arrhythmias during suctioning. If hypoxemia is noted, 100% oxygen should be administered quickly. Other things to monitor for would be bradycardia, changes in the heart rhythm (arrhythmias), desaturations, or cyanosis. Choice B is incorrect. There is no information in the question that indicates that a rapid response needs to be called. By discontinuing the suctioning and further exploring the cause of distress, the nurse has taken the appropriate actions. If the client's condition were to continue to deteriorate after the suctioning was discontinued, then a rapid response may need to be called. Choice C is incorrect. It is not appropriate for the nurse to increase suction pressure. The client's vital signs have changed indicating that he/she is not tolerating the suctioning. If the nurse continues to suction or increases pressure further, the client may further deteriorate. Choice E is incorrect. In this scenario, notifying the physician is not the immediate nursing action. Independent nursing interventions (the actions in Choices A and D) should be implemented first. By discontinuing the suctioning and further exploring the cause of distress, the nurse has taken the appropriate action. If the client's condition were to continue to deteriorate after the suctioning was discontinued, then the physician needs to be notified.

A client is experiencing spiritual distress after receiving a diagnosis of advanced brain cancer. Which of the following would be appropriate interventions? Select all that apply. A. Ask the patient how he/she is feeling. [25%] B. Provide food compatible with the person's religious needs. [19%] C. Help the patient identify feelings of guilt. [13%] D. Offer to massage the client's shoulders. [9%] E. Offer encouragement based on assumptions about the patient's beliefs. [11%] F. Assess the patient's needs for reconciliation. [23%]

Explanation Choices A, B, C, D, and F are correct. It is essential to offer the client an opportunity to express his/her feelings. The best way to do this is to simply ask how they are feeling or what they think about a particular situation (Choice A). Providing foods that are compatible with the client's religious beliefs adds to the feeling of self. In some cases, it may be acceptable to encourage family members to bring food from home (Choice B). Help the patient identify feelings of guilt. You might ask the following after a patient has voiced a concern: "How do you feel about that?" or "You seem to feel sad about saying/doing that" (Choice C). Maximize the patient's comfort. This is one of the most important spiritual activities a nurse can perform. A patient cannot think about religious issues when plagued with physical pain or discomfort (Choice D). Assess the patient's needs for reconciliation. This may include reconciliation with self, others, and God (Choice F). Choice E is incorrect. The nurse should not make assumptions about the patient's and family's beliefs. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Death & Dying

The nurse cares for a newly admitted client with a full-thickness burn of over 25% of the total body surface area. The nurse should take which of the following actions? Select all that apply. A. Keep the patient on NPO status [21%] B. Obtain a 12-lead electrocardiogram [24%] C. Prepare to infuse hypertonic saline [18%] D. Irrigate the burns with chlorhexidine [8%] E. Obtain an arterial blood gas (ABG) [29%]

Explanation Choices A, B, and E are correct. The nurse should acutely assess and maintain airway patency for a client admitted with a significant burn. Further, the nurse should keep the client on NPO status because of the risk of oral mucosa irritation and gastrointestinal dysfunction. A twelve-lead echocardiogram is necessary because the potassium shifts extracellular, leading to hyperkalemia acutely. This may lead to cardiac dysrhythmias. Finally, the nurse should obtain an arterial blood gas to determine the client's arterial oxygen status. Choices C and D are incorrect. Rapid intravenous access needs to be obtained. If this is not available, the provider should insert a central line for fluid resuscitation. The client will initially be prescribed isotonic intravenous fluids such as Lactated Ringers. Hypertonic saline is indicated for increased intracranial pressure. Full-thickness burns should be irrigated with sterile saline and not disinfectants such as chlorhexidine. The burn should then be covered with a sterile, non-adherent dressing. Additional Info A client with a significant thermal burn requires immediate intervention. The nurse should assess the client's airway, breathing, and circulation. Following a thermal burn, the immediate threat to a client is the risk of carbon monoxide poisoning and smoke inhalation. For major thermal burns, the nurse should anticipate using the rule of nines to estimate the area affected and the Parkland formula to guide prescribed isotonic fluid resuscitation. The Parkland formula is 4 mL x the client's weight in kilograms x total body surface area burned. This will provide the total amount of isotonic fluid needed in the first twenty-four hours.

The nurse is caring for a client who has a factitious disorder. The client reports chest pain. Which of the following actions should the nurse take? Select all that apply. A. Provide reassurance that this is part of the disorder [6%] B. Notify the primary healthcare physician (PHCP) [25%] C. Obtain a 12-lead Electrocardiogram [32%] D. Disregard the symptom as it may be unreliable [1%] E. Assess vital signs [35%]

Explanation Choices B, C, and E are correct. Chest pain is a worrisome manifestation as it may be a clinical finding associated with myocardial infarction, pulmonary embolism, or other pathology. Despite the client having factitious disorder, which is characterized by the client feigning their symptoms, the nurse should intervene by notifying the PHCP, obtaining a 12-lead Electrocardiogram, and assessing vital signs. This is the standard of care for any client reporting an acute change such as angina. Choices A and D are incorrect. Factitious disorder is characterized by the client feigning their symptoms. Despite this characterization, the nurse must consider the validity of the client report and act accordingly. Reassuring the client and disregarding the report would be inappropriate because the nurse must consider physical needs first. Additional Info Factitious disorder is characterized by an individual feigning their symptoms. The individual falsifies medical or psychiatric symptoms. This disorder may be imposed on themselves or others (by proxy). Nursing care for a client with this disorder includes - Develop a therapeutic rapport with the patient. Avoid confrontation or power struggles. Focus on the patient's disorder - not symptoms. Investigate any new physical symptoms appropriately without them dominating the conversation.

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply. A. Goggles [10%] B. Gown [28%] C. Gloves [32%] D. Shoe covers [3%] E. N95 respirator [14%] F. Surgical face mask [12%]

Explanation Choices B, C, and E are correct. Since herpes zoster is spread through airborne means and by direct contact with the lesions, contact and airborne precautions should be followed in case of "disseminated" herpes zoster. This means the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia. VZV can be reactive later in a person's life and create a painful, maculopapular rash called herpes zoster. Active herpes zoster lesions are infectious, through direct contact with vesicular fluid, until they dry and crust over. People with active herpes zoster lesions should cover their injuries and avoid contact with susceptible people in their household and occupational settings until their wounds are dry and crusted. Choices A and D are incorrect. Goggles and shoe covers are not needed for airborne or contact precautions. Choice F is incorrect. A surgical face mask filters only large particles and will not protect against herpes zoster. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control

The nurse is caring for a patient with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply. A. Presbyopia [4%] B. Tinnitus [32%] C. Vertigo [32%] D. Dyskinesia [7%] E. Hearing loss [25%]

Explanation Choices B, C, and E are correct. The cardinal features of Meniere's disease include sensorineural hearing loss, vertigo, and tinnitus. These features relapse and remit and can be debilitating. Choices A and D are incorrect. Presbyopia is age-related farsightedness that is not a feature of Meniere's disease. Dyskinesia is difficult motor movements which is not a finding with this condition. Additional information: Meniere's disease is a condition that is caused by excessive endolymphatic fluid in the inner ear. This relapsing and remitting disease may bring bouts of tinnitus, vertigo, and hearing loss. Treatment includes diuretics, antiemetics, antihistamines, and a diet low in sodium.