mynclex set 10- 36

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply. 1. Administered 9:00 AM medication at 9:30 AM 2. Developed worsening cellulitis after missing antibiotics for 1 day 3. Has a seizure and a history of epilepsy 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan OmittedCorrect answer 2,4,5 60%Answered correctly

Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 4 is a fall, although the mechanism probably results in a lesser chance of serious injury. The risk fall assessment should be adjusted. Option 5 is an avoidable delay in application of a test, which will affect timely diagnosis. The nurse should advocate for a more timely completion of the test. Option 2 is a failure to provide appropriate treatment and has a direct correlation for worsening cellulitis. (Option 1) Failure to complete an ideal nursing care plan is not an adverse event. Hospitals have policies that allow medications to be given within a range (usually 30-60 minutes) of the due time. It could be an issue if the treatment was significantly out of the time range or omitted completely. (Option 3) The client's seizure is most likely related to an underlying condition rather than a medical management error. Educational objective:Adverse events cause injury that is related to medical management, not the client's underlying condition. Identified areas are diagnostic, treatment, preventive or failure of communication, and equipment or other systems. Adverse events include falls, unreasonable delay in diagnostic tests, and failure to provide a prescribed treatment.

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first? 1. Administer 0.25 mg hydromorphone IV push for pain (25%) 2. Draw blood for complete blood count and electrolyte levels (20%) 3. Initiate IV access and infuse normal saline 100 mL/hr (50%) 4. Obtain urine specimen for urinalysis (4%) OmittedCorrect answer 3 50%Answered correctly

Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3). (Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO status in case of emergency surgery. However, circulation takes priority over pain medication. (Options 2 and 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining laboratory specimens. Educational objective:Nurses caring for clients with appendicitis should prioritize client care according to the ABCs (ie, airway, breathing, circulation). Initiating IV crystalloids (eg, normal saline) is a priority action that prevents circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status. Additional Information Physiological Adaptation NCSBN Client Need

T/he nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? 1. The parent cannot stay at the hospital due to potential job loss from absence (5%) 2. The parent is in the process of a divorce and will soon be a single parent (3%) 3. The parent is witnessed stealing food and drinks from the cafeteria (13%) 4. The parent leaves the client's younger sibling to care for the client's newborn sibling (77%) OmittedCorrect answer 4 77%Answered correctly

Child neglect occurs when a caregiver purposely withholds or does not adequately provide necessary resources to fulfill the basic needs of a child (eg, adequate nutrition, security, hygiene). Supervisory neglect, leaving children without adequate guardianship to ensure safety, is one form of child neglect (Option 4). Children age <12 lack formal operational reasoning and cannot anticipate safety risks or respond appropriately to emergencies, and should therefore not be left to supervise other children. It is a priority for the nurse to intervene, as this is an unsafe situation for the young children. The nurse, or social services, should report the situation to an appropriate government child protective service and/or law enforcement. (Option 1) Potential job loss indicates that the parent may be overwhelmed. The nurse should alert a social worker about the situation at a later time to discuss potential assistance. (Option 2) Transitioning to the role of a single parent can present mental and financial stressors, possibly requiring assistance from a social worker. However, this does not require immediate intervention. (Option 3) A parent stealing food may warrant calling the police or security, but the children's safety is a priority requiring immediate action. Educational objective:Supervisory neglect (eg, leaving a young child to supervise other children) is a type of child neglect and represents an immediate risk to the safety of younger children. The nurse should ensure that the children are safe and report the child neglect incident to social services, the appropriate child protective service, and/or law enforcement.

A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? 1. Amlodipine (12%) 2. Codeine (63%) 3. Ipratropium (13%) 4. Methylprednisolone (11%) OmittedCorrect answer 2 63%Answered correctly

Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD). (Option 1) Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). (Option 3) Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm. (Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD. Educational objective:Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory (15%) 2. Improvement in spontaneous activity (65%) 3. Reduction in number of visual hallucinations (10%) 4. Reduction of dizziness with standing (8%) OmittedCorrect answer 2 65%Answered correctly

Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably. (Option 1) Carbidopa-levodopa does not improve memory. Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory. (Options 3 and 4) Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions, agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care providers usually start the medications at low doses and gradually increase them to prevent these effects. Educational objective:The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement).

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? 1. C-reactive protein (CRP) (46%) 2. Prothrombin time (PT) (29%) 3. Serum LDL cholesterol (3%) 4. Tuberculin skin test (TST) (20%) OmittedCorrect answer 4 20%Answered correctly

TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur (Option 4). (Option 1) CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy. (Options 2 and 3) LDL cholesterol and PT are unrelated to the administration of these medications. Educational objective:Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB.

/A newborn diagnosed with trisomy 18 (Edwards syndrome) is on ventilator support. The client's parents have repeatedly asked when their child will be able to breathe without the ventilator. Which action by the nurse is appropriate? 1. Facilitate a meeting between the health care providers, palliative care team, and parents to discuss care plan (81%) 2. Notify the parents of the newborn's genetic test results and provide information to read about trisomy 18 (8%) 3. Provide the parents with information about various options for curative medical treatment for their child (5%) 4. Share with the parents that many newborns with trisomy 18 live long enough to go home with their families (4%) OmittedCorrect answer 1 81%Answered correctly

Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday. Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as well as make decisions about interventions and the potential need for end-of-life care (Option 1). (Option 2) The nurse should not notify parents of genetic test results; this is the responsibility of the HCP. Information regarding the newborn's condition may be provided after the HCP notifies the parents of test results. (Option 3) There is no cure for a newborn with trisomy 18 because it is a chromosomal abnormality. (Option 4) The nurse should be sensitive toward the parents and provide accurate information. Telling the parents that their newborn might live long enough to go home is inappropriate because it gives them false hope, as this possibility occurs in only a small number of newborns with trisomy 18. Educational objective:Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality. Many of those affected will die in the first week of life and most do not make it to the first birthday. The nurse should request a collaborative meeting between the health care providers and the palliative care team to help the parents understand their infant's condition and make decisions. Additional Information Management of Care NCSBN Client Need Copyright © UWorld. All rights reserved.

/The nurse assessing a 2-year-old should expect the child to be able to perform which actions? Select all that apply. 1. Build a tower with blocks 2. Draw a square 3. Hop on one foot 4. Say own name 5. Walk without help OmittedCorrect answer 1,4,5 58%Answered correctly

Nurses play an important role in identifying appropriate growth and development in all clients. Children who do not meet key developmental milestones for their age should be reported to the health care provider (HCP) to determine the need for further testing. Developmental milestones that a 2-year-old toddler should meet include: Motor skills: Walks alone, builds block towers, draws lines, kicks a ball Language: Knows 300+ words, uses 2- to 3-word phrases, states name Cognitive/social skills: Engages in parallel play, imitates others, exerts independence (Option 2) Normally, a child will develop the ability to draw or copy a square later during the preschool years (age 3-5). (Option 3) A 2-year-old client will not yet demonstrate the balance required for this activity. The ability to hop and stand on one foot for 5-10 seconds develops during the preschool years (age 3-6). Educational objective:Developmental assessment findings in 2-year-old clients include the ability to build block towers, say their own name, and walk without assistance. The nurse should notify the HCP if a child is not meeting age-appropriate developmental milestones so the child can be referred for further testing. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply. 1. Client with a malignancy prescribed filgrastim has neutropenia 2. Client with acute osteomyelitis prescribed vancomycin has leukocytosis 3. Client with acute pancreatitis prescribed hydromorphone has an elevated lipase level 4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level OmittedCorrect answer 4,5 20%Answered correctly

Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg, lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia (Option 4). Aminoglycosides (eg, gentamicin, tobramycin, amikacin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level (>1.3 mg/dL [115 µmol/L]) to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity. An adjustment in the dose and dosing interval may be required (Option 5). (Option 1) Neutropenia (decreased neutrophil count) increases a client's susceptibility to infection. Filgrastim (Neupogen) is used to increase the neutrophil count in clients with certain malignancies and in those undergoing chemotherapy. Neutropenia is expected in this client and is not the most important result to report. (Option 2) Acute osteomyelitis, an infection of the bone, is characterized by local and systemic manifestations of infection (eg, leukocytosis - white blood cell count >11,000/mm3 [11.0 x 109/L], increased erythrocyte sedimentation rate, fever) and involves long-term antibiotic therapy. This is expected and is not the most important result to report. (Option 3) Acute pancreatitis is an acute inflammation of the pancreas, characterized by abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced by the pancreas. The pain is treated with opioids (eg, hydromorphone, fentanyl). Morphine can also be used; worsening pancreatitis due to an increase in sphincter of Oddi pressure has not been proven in studies. Elevated lipase level is expected and is not the most important result to report. Educational objective:ACE inhibitors (eg, lisinopril, ramipril) and angiotensin II receptor blockers ("sartans") can cause hyperkalemia (potassium >5.0 mEq/L [5.0 mmol/L]). Aminoglycosides (eg, tobramycin, gentamicin, amikacin) can cause nephrotoxicity.

/A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1. ECG (22%) 2. IV morphine 2 mg (5%) 3. Normal saline bolus (50%) 4. Urine sample (21%) OmittedCorrect answer 3 50%Answered correctly

Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability. The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body. Common signs of rhabdomyolysis are dark, oftentimes bloody urine, oliguria, and fatigue. (Option 1) With muscle injury, intracellular potassium is released into the circulation, potentially causing dangerous arrythmias. Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium levels decrease rapidly. In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the injured muscles. Therefore, aggressive fluid resucitation is a high priority. The general rule is that treatment/prevention of an underlying expected problem is a priority over testing to identify the problem. (Option 2) Pain and symptom management should be a high priority but should not take precedence over preserving the client's kidney function. (Option 4) Although obtaining a urine specimen to assess the characteristics is important, laboratory testing would not take priority over treatment to preserve kidney function. Educational objective:Rhabdomyolysis is a medical emergency caused by muscle injury that releases myoglobin into the bloodstream. The nurse's priority when treating the client is to preserve kidney function by administering large volumes of IV fluid.

/The nurse is performing a cardiac assessment. Where does the nurse expect to feel the client's point of maximal impulse (PMI)? IncorrectCorrect answer Refer to Hotspot 59%Answered correctly

The PMI is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular line, the heart may be enlarged. Educational objective:During cardiac assessment, the nurse should palpate the PMI medial to the midclavicular line at the 4th or 5th intercostal space. Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement. Additional Information Health Promotion and Maintenance NCSBN Client Need

/Which of the following drug administrations should be reported as a practice error? Select all that apply. 1. Cephalexin administered; client has history of anaphylaxis from penicillin 2. Hydromorphone 2 mg administered; client reports pruritus 3. Immunization for 3-month-old administered in ventrogluteal site 4. Oral niacin (nicotinic acid) administered; client has facial flushing 5. Warfarin administered; client at 12 weeks gestation OmittedCorrect answer 1,3,5 31%Answered correctly

Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception (Option 5). For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option 3). History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option 1). (Option 2) Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. (Option 4) Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues. Educational objective:Do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have a cross-sensitivity response. Narcotic-induced pruritus is not a true allergy.

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? 1. Collect a urine specimen and send to the lab (3%) 2. Deflate the balloon on the urinary catheter (74%) 3. Remove the catheter by gently pulling from the urethra (2%) 4. Use a sterile 4x4 pad to absorb the blood around the meatus (18%) OmittedCorrect answer 2 74%Answered correctly

Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. Steps for removing an indwelling catheter include the following: Perform hand hygiene Ensure privacy and explain the procedure to the client Apply clean gloves Place a waterproof pad underneath the client Remove any adhesive tape or device anchoring the catheter Follow specific manufacturer instructions for balloon deflation Loosen the syringe plunger and connect the empty syringe hub into the inflation port Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client. If any resistance is met, stop the removal procedure and consult with the urologist for removal Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy Remove gloves and perform hand hygiene (Option 1) A urine specimen can be collected after the balloon is deflated or after the catheter is removed if needed. (Option 4) The meatus should be cleaned after balloon deflation. Educational objective:When the urinary catheter balloon occludes the urethra, it should be deflated immediately to prevent further injury or complication. After balloon deflation, gently and slowly remove the catheter. If there is resistance, notify the urologist.

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. 1. Apply a heating pad and encourage range-of-motion exercises 2. Assess the temperature and movement of the fingers 3. Elevate the arm on pillows above the level of the heart 4. Notify the health care provider 5. Reassure the client, document findings, and reassess in 1 hour OmittedCorrect answer 2,4 25%Answered correctly

Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal to the injury. It results from either decreased compartment size (restrictive dressings, splints, or casts) or increased pressure within the compartment (bleeding, inflammation, and edema). Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings include diminished/absent pulses, pallor, coolness, swelling, decreased movement, and cyanosis. Failure to treat this condition can lead to loss of limb function, paralysis, and tissue necrosis. The nurse should assess neurovascular status and report to the health care provider immediately (Options 2 and 4). Removal of tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure. (Option 1) Heat should not be applied to a client experiencing altered sensation, as it may burn the client. Active range of motion will not resolve compartment syndrome and delays needed care. (Option 3) Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also reduce perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart. (Option 5) Documenting findings is important. However, reassurance and reassessment 1 hour later without immediate intervention delays needed care. Educational objective:Compartment syndrome is caused by decreased blood flow to the tissue distal to the injury and can cause ischemic necrosis. Acute compartment syndrome following surgery or casting is potentially limb-threatening and requires emergency evaluation by a health care provider. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply. 1. Family history of skin cancer 2. High number of moles 3. History of severe adolescent acne 4. Immunosuppressant medication use 5. Outdoor occupation OmittedCorrect answer 1,2,4,5 31%Answered correctly

Skin cancers are most often linked to damage of skin cells' DNA by overexposure to ultraviolet radiation (eg, sunlight, tanning beds). The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas grow rapidly and are highly metastatic, making them the deadliest form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Risk factors for skin cancer include: Family or personal history of skin cancer (Option 1) Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) Aging Atypical or high number of moles because some skin cancers develop from pre-existing moles (Option 2) Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations (Option 4) Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns) (Option 5) Clients should be taught to avoid overexposure to sunlight, perform monthly skin checks with the ABCDE assessment, and immediately report any abnormal findings to their health care provider. Early detection and treatment significantly improve outcomes. (Option 3) Acne is not a known risk factor for skin cancer. Educational objective:Risk factors for skin cancer include family or personal history of skin cancer, Celtic ancestry traits (eg, light skin, blue eyes), aging, atypical or high number of moles, immunosuppression, and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation).

//SEE EX The nurse has just administered a dose of 0.5 mg atropine to a client with a heart rate of 48/min and blood pressure of 90/62 mmHg. Which rhythm strip would indicate that the medication achieved the desired outcome? 1. (11%) 2. (83%) 3. (3%) 4. (2%) OmittedCorrect answer 2 83%Answered correctly

Atropine is given to the client experiencing symptomatic bradycardia. In symptomatic bradycardia, the heart rate is <60/min and is inadequate for the client's condition, causing symptoms such as hypotension, chest pain, or syncope. Atropine acts to increase the heart rate by inhibiting the action of the vagus nerve (parasympatholytic effect). A normal sinus rhythm and reversal of clinical symptoms indicate that the medication has had the desired effect. (Option 1) A continuation of sinus bradycardia would not indicate that the atropine had been effective. (Option 3) Sinus tachycardia would be an undesirable effect of atropine as the heart rate would be >100/min. (Option 4) The client with first-degree atrioventricular block may have a normal heart rate, but the atrioventricular conduction time is prolonged. Educational objective:Atropine is given to the client with symptomatic bradycardia. The desired outcome would be an increase in heart rate, evidence of normal sinus rhythm on the cardiac monitor, and reversal of any clinical symptoms associated with the bradycardia. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? 1. "Genetic counseling is recommended. You will receive a referral before you leave." (49%) 2. "Huntington disease inheritance requires both biological parents to carry the gene." (42%) 3. "There are other ways to grow your family. You should consider adoption." (0%) 4. "This disease occurs spontaneously and is not likely to affect your children." (7%) OmittedCorrect answer 1 49%Answered correctly

Huntington disease (HD) is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like movement) is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis. HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counseling (Option 1). (Option 2) Autosomal dominant traits require only one copy of the affected gene (from one carrier parent) to manifest (eg, cause disease). (Option 3) Although adoption may be considered, the nurse's opinion is not appropriate or therapeutic for the client. After genetic testing and further education from a genetic counselor, the client can make an informed decision about starting a family. (Option 4) HD is hereditary, not spontaneous. The offspring of a client with the HD gene have at least a 50% chance of inheritance. Educational objective:Huntington disease is an incurable autosomal dominant disease that causes progressive nerve degeneration, which impairs movement, swallowing, speech, and cognitive abilities. Death typically occurs within 20 years. Clients who have a parent with this disease should receive genetic counseling, especially when planning to start a family. Additional Information Health Promotion and Maintenance NCSBN Client Need

The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? 1. Client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours (4%) 2. Client with an indwelling urinary catheter who is 1-day postoperative prostatectomy reports severe bladder spasms (7%) 3. Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria (3%) 4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea (85%) OmittedCorrect answer 4 85%Answered correctly

Autonomic dysreflexia (hyperreflexia) can occur in any individual with a spinal cord injury at or above T6. The condition causes an exaggerated sympathetic nervous system response resulting in uncontrolled hypertension. Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset of throbbing headache, nausea, and blurred vision; hypertension and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention (eg, bladder catheterization) to remove the precipitating trigger. (Option 1) Oliguria (<0.5 mL/kg/hr or <280 mL in 8 hours for an adult of average weight [154 lb or 70 kg]) is an expected finding in a client with kidney injury scheduled for hemodialysis; this client assessment is not the priority. (Option 2) Bladder spasms are an expected finding in a client with an indwelling urinary catheter following a prostatectomy. The nurse can administer prescribed analgesic and antispasmodic drugs (eg, Belladonna-opium suppositories, oxybutynin) to alleviate discomfort. However, this client assessment is not the priority. (Option 3) Laser lithotripsy breaks down a large stone into small fragments to ease stone elimination. The ureteral stent maintains ureter patency by preventing obstruction caused by edema or stone fragments. Burning on urination and hematuria are common expected side effects associated with this procedure. This client assessment is not the priority. Educational objective:A client with a spinal cord injury at or above T6 is at risk for autonomic dysreflexia, a medical emergency that can lead to hypertensive emergency (eg, stroke, myocardial infarction) and death. Common triggers include bladder or rectum distention and pressure ulcers.

The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication? 1. Aspirin 81 mg PO once a day (30%) 2. Furosemide 40 mg PO once a day (25%) 3. Glyburide 10 mg PO once a day (29%) 4. Levothyroxine 50 mcg PO once a day (14%) OmittedCorrect answer 3 29%Answered correctly

Beers Criteria lists medications that may be inappropriate for the geriatric population due to risks outweighing benefits. The nurse collaborates with the health care provider to minimize polypharmacy and reduce adverse effects (eg, falls, confusion). Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) (Option 3). (Option 1) Aspirin is used to prevent platelet aggregation in clients with a history of stroke or myocardial infarction. Aspirin and other nonsteroidal anti-inflammatory medications (eg, ibuprofen) have an increased risk of gastrointestinal bleeding. Therefore, aspirin is used cautiously in the older adult population, and doses should not exceed 325 mg/day. (Option 2) Furosemide is a loop diuretic used to treat fluid overload in heart failure, making it an important part of symptom management. This drug may cause dehydration if the client is not ingesting food and fluids well; otherwise, it should be continued. (Option 4) Levothyroxine is required to maintain thyroid hormone levels in clients with hypothyroidism. Major side effects typically occur only with improper dosing (eg, elevated levels). Educational objective:The Beers Criteria can be used to identify potentially inappropriate drugs that contribute to adverse events (eg, falls, confusion) and drug toxicity in older adults. Sulfonylureas (eg, glyburide) should be avoided due to potential delayed elimination causing risk for prolonged hypoglycemia.

/A client diagnosed with vaginal candidiasis is instructed on self-care management techniques and proper administration of the prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? 1. "Each time I use the bathroom, I will wipe myself from the front to the back." (2%) 2. "I should choose loose-fitting cotton underwear instead of nylon undergarments." (6%) 3. "I will refrain from having sex until my partner is also tested and treated for the infection." (67%) 4. "Prior to going to bed at night, I will apply miconazole cream using the vaginal applicator." (23%) OmittedCorrect answer 3 67%Answered correctly

Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions. Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period (Option 4). Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days (Option 3). However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated. Other teaching points for this client should include: Ensuring proper hygiene of the perineum - cleansing from anterior to posterior (front to back) to prevent accidental introduction of fecal organisms (Option 1) Wearing loosely fitted cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and reduce moisture (Option 2) Refraining from douching, which can introduce organisms higher up into the vaginal canal and cervix Educational objective:Miconazole cream is commonly prescribed to treat vaginal candidiasis. Miconazole is best applied at bedtime so that it will remain in the vagina longer. Clients being treated for vaginal candidiasis should wear loose-fitting cotton underwear and refrain from sexual intercourse for the duration of treatment.

//A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. 1. Assess abdominal distension every 4 hours 2. Check gastric residual every 12 hours 3. Keep head of the bed at ≥30 degrees 4. Maintain endotracheal cuff pressure 5. Use caution when administering sedatives OmittedCorrect answer 1,3,4,5 13%Answered correctly

Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option 1) Assess feeding tube placement at regular intervals Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 3) Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 4) Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option 5) Avoid bolus tube feedings for clients at high risk for aspiration (Option 2) Gastric residual should be checked no less than every 4 hours in intubated clients. Educational objective:Precautions to prevent aspiration in the client receiving continuous tube feedings include assessing for gastric intolerance (ie, residual, distension) every 4 hours, keeping the head of the bed at ≥30 degrees, using sedation cautiously, and regular assessment of tube placement. If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and suction appropriately. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse is assessing a 4-year-old boy in a pediatric clinic. Which behaviors by the client would concern the nurse for possible Duchenne muscular dystrophy? Select all that apply. 1. Frequently trips and falls at home 2. Has painful knees and elbows in the morning 3. Places hands on the thighs to push up to stand 4. Suddenly rigidly extends the arms and legs 5. Walks on tiptoes and has disproportionately large calves OmittedCorrect answer 1,3,5 32%Answered correctly

Duchenne muscular dystrophy is an X-linked recessive (carried by females and affecting males) disorder that causes the progressive replacement of dystrophin, a protein needed for muscle stabilization, with connective tissue. The proximal lower extremities and pelvis are affected first. In response to proximal muscle weakness, the calf muscles hypertrophy (pseudohypertrophy) initially and are later replaced by fat and connective tissue. Children with Duchenne muscular dystrophy raise themselves to a standing position using the classic Gower sign/maneuver (placing hands on the thighs to push up to stand) and walk on tiptoes (Options 3 and 5). Parents may also report frequent tripping and falling (Option 1). (Option 2) Joint pain that is worse in the morning is a symptom of juvenile idiopathic arthritis. Children with this type of arthritis also experience symptoms of joint swelling and stiffness, high fever, and skin rash. (Option 4) Rigid extension of the arms and legs is seen in the tonic phase of a tonic-clonic seizure. During this time, muscles become stiff, the jaw becomes clenched, and pupils can be fixed and dilated. Educational objective:Duchenne muscular dystrophy is an X-linked recessive disorder characterized by progressive replacement of muscle tissue with connective tissue. Classic signs include Gower sign/maneuver (placing hands on the thighs to push up to stand), enlarged calves, walking on tiptoes, and frequent tripping/falling. Additional Information Physiological Adaptation NCSBN Client Need

//SEE EX //The clinic nurse is reviewing the laboratory results of a 35-year-old client who reports fatigue for the last month. Based on the laboratory results, which additional clinical manifestations would the nurse expect? Click on the exhibit button for additional information. Select all that apply. 1. Bradycardia 2. Cold intolerance 3. Constipation 4. Hair loss 5. Warm, moist skin 6. Weight loss OmittedCorrect answer 1,2,3,4 36%Answered correctly

Primary hypothyroidism is an endocrine disorder identified by low circulating thyroid hormone (ie, triiodothyronine [T3], thyroxine [T4]) and high thyroid-stimulating hormone (TSH) levels. Primary hypothyroidism occurs when TSH is unable to stimulate the thyroid to produce thyroid hormones, often after trauma or autoimmune-related tissue damage (eg, Hashimoto thyroiditis). Therefore, TSH levels remain elevated as primary counterregulatory hormone (ie, T3, T4) levels remain low. Thyroid hormones act in multiple body sites to stimulate and increase metabolic functions (eg, body temperature, cellular energy, oxygen consumption, neuron conduction). Therefore, clients with hypothyroidism exhibit clinical manifestations of low metabolic state, including: Bradycardia and hypotension (Option 1) Hypothermia and cold intolerance (Option 2) Constipation (Option 3) Fragile, dry skin and hair loss (Option 4) Forgetfulness, slurred speech, and confusion (Options 5 and 6) Clients with hypothyroidism often gain weight and develop dry, fragile skin because of decreased metabolic activity. Weight loss and warm, moist skin are characteristic of an increased metabolic rate, as found in clients with hyperthyroidism. Educational objective:Primary hypothyroidism is a condition identified by low thyroid hormone and elevated thyroid-stimulating hormone levels, which result in decreased metabolic function throughout the body. Clinical manifestations include weight gain, constipation, dry skin, hair loss, cold intolerance, bradycardia, and confusion. Additional Information Physiological Adaptation NCSBN Client Need

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately? 1. Drinks 6 cans of beers on the weekend (1%) 2. Gets up 4 times during the night to void (9%) 3. Smokes 1 pack of cigarettes daily (33%) 4. Uses sildenafil occasionally (55%) OmittedCorrect answer 4 55%Answered correctly

Sildenafil (Viagra) is a phosphodiesterase inhibitor used to treat erectile dysfunction. The use of sildenafil is most important for the nurse to report to the HCP. This must be communicated immediately as concurrent use of nitrate drugs (commonly prescribed to treat unstable angina) is contraindicated as it can cause life-threatening hypotension. Before any nitrate drugs can be administered, further action is necessary to determine when sildenafil was taken last (ie, half-life is about 4 hours). (Option 1) Clients do not always report the amount of alcohol they consume accurately. The nurse should monitor all clients for alcohol withdrawal syndrome as it is quite common in hospitalized clients. (Option 2) Getting up 4 times during the night to void can be associated with medication, an enlarged prostate gland, or drinking fluids at bedtime. Further action may be needed to determine the cause of the nocturia, but this is not the most significant information to report to the HCP. (Option 3) Smoking 1 pack of cigarettes daily needs to be addressed as tobacco causes vasoconstriction and decreased oxygen supply to the body tissues. Further action is needed regarding smoking cessation education. However, the client's tobacco history is not the most important information to report to the HCP. Educational objective:Nitrate drugs are prescribed to treat angina. The concurrent use sildenafil (Viagra) and nitrates is contraindicated as it can cause life-threatening hypotension. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take? 1. Assess the client's vital signs (10%) 2. Check the client's blood glucose (67%) 3. Report the findings to the health care provider (1%) 4. Slow down the rate of infusion (20%) OmittedCorrect answer 2 67%Answered correctly

A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: Excessive dextrose infusion A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones High infusion rate Administration of medications such as steroids Infection Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin. (Option 1) Checking vital signs will not confirm that the client is experiencing hyperglycemia. (Option 3) The nurse first needs to assess. The health care provider will need to be contacted if a change in TPN treatment is indicated. (Option 4) Slowing down the rate of infusion is an intervention to resolve hyperglycemia; the nurse needs to first confirm that the client's symptoms are related to high blood glucose. Educational objective:Hyperglycemia is a complication of TPN. Based on the client's reported symptoms related to hyperglycemia, the nurse needs to assess the client's blood sugar before implementing an intervention.

The nurse receives a report on 4 clients. Which client should the nurse assess first? 1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless (6%) 2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% (61%) 3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused (25%) 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place (7%) OmittedCorrect answer 2 61%Answered correctly

A fat embolism is life-threatening; therefore, the client with the femur fracture is the priority. There is a risk for the formation of fat emboli following certain fractures, typically those of the long bones and pelvis. Globules of fat leave the bone and travel through the bloodstream to the lungs, skin, and brain where they cause damage by occluding small vessels. Altered mental status will result from blocked blood vessels in the brain. An embolism to the lung would result in respiratory distress. A hallmark sign of fat emboli is the presence of petechiae (pin-sized red/purple spots) that result from small-vessel clotting and appear across the chest, in the axillae, and in the soft palate. (Option 1) This hospitalized heroin user is likely experiencing heroin withdrawal, which manifests with vomiting, abdominal cramping, and diarrhea; restlessness and diaphoresis; frequent yawning; rhinorrhea and lacrimation; and myalgias and arthralgias. This client needs treatment, but this condition is not life-threatening. (Option 3) Moderate hyponatremia (normal sodium 135-145 mEq/L [135-145 mmol/L]) can cause altered mental status and can lead to seizures if it becomes severe. This client needs treatment and should be the second priority after the client with fat embolism. (Option 4) Infections can cause altered mental status, especially in elderly clients. As the infection resolves, mental status improves. Educational objective:Clients with pelvic or long-bone fractures are at risk for the development of life-threatening fat embolism syndrome. Respiratory distress, mental status changes, and petechiae (on chest, axillae, and soft palate) are the classic manifestations.

/The nurse is caring for a client with an ileal conduit. While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey. What is the nurse's best action? 1. Administer an antibacterial agent and assess for further signs of infection (2%) 2. Document the findings and continue to monitor for changes (3%) 3. Measure the stoma and apply a larger pouching device (4%) 4. Report the findings to the health care provider (HCP) immediately (90%) OmittedCorrect answer 4 90%Answered correctly

An ileal conduit is a surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary diversion. The client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine. A healthy stoma should be pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or any shade of blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This finding is considered a medical emergency (Option 4). (Option 1) Infection is a potential complication; signs and symptoms of infection may include fever, elevated white blood cell count, odor, and delayed healing. A bluish grey color indicates impaired perfusion, not infection. (Option 2) Although the nurse will document the findings and monitor for changes, lack of perfusion to the stoma is an emergency that must be reported immediately. (Option 3) Applying an appropriate-size pouching system (approximately 0.1 in [0.25 cm] larger than the stoma) prevents decreased perfusion and skin irritation. Using a larger drainage bag, especially at night, prevents urine backflow through the stoma and reduces the risk for infection. These are important concepts of stoma care but are not the priority at this time. Educational objective:Stoma care involves frequent nursing assessment for signs of potential complications such as impaired perfusion, infection, and wound dehiscence. The stoma should be pink to brick-red and moist. Suspected impaired perfusion is considered a surgical emergency and should be reported immediately.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? 1. Get the client out of bed and away from the radiation source (6%) 2. Manually reinsert the implant and notify the health care provider (1%) 3. Use long-handled forceps to secure the implant in a lead container (86%) 4. Wrap the implant in the linens and place it in a biohazard bag (5%) OmittedCorrect answer 3 86%Answered correctly

An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside. Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant in case of dislodgment. If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure (Option 3). The nurse should also notify the health care provider (radiation oncologist). (Option 1) Containing the source quickly is a priority as the implant continues to emit radiation that could be dangerous to the staff coming to evaluate the client and clean the room. (Option 2) The nurse should not handle dislodged radiation implants without the use of forceps. Furthermore, device reinsertion should be performed only by the health care provider. (Option 4) Wrapping the implant in linens and placing it within a biohazard bag does not reduce radiation exposure. Educational objective:If an internal radiation implant has dislodged, the nurse should use long-handled forceps to place it in a lead-lined container to contain radiation exposure.

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? 1. Administer PRN analgesic medication (2%) 2. Administer PRN antihypertensive medication (17%) 3. Lower the head of the bed (17%) 4. Palpate the client's bladder (62%) OmittedCorrect answer 4 62%Answered correctly

Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke (Option 4). Noxious stimuli may include: Bladder distention (eg, obstructed urinary catheter, neurogenic bladder) Fecal impaction Tight clothing (eg, shoelaces, waistbands) (Options 1 and 2) Hypertension, headache, and nausea due to uncontrolled sympathetic activity will resolve once the cause is identified and removed. (Option 3) Lowering the head of the bed would increase blood pressure. The head of the bed should be raised to lower the blood pressure. Educational objective:Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli (eg, bladder distention, tight clothing) in clients with spinal cord injuries above T6. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. The nurse must immediately identify and remove noxious stimuli to prevent a stroke and resolve symptoms. Additional Information Reduction of Risk Potential NCSBN Client Need

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) (10%) 2. B-type natriuretic peptide (BNP) (54%) 3. Cardiac enzymes (CK-MB) (28%) 4. Chest x-ray (6%) OmittedCorrect answer 2 54%Answered correctly

BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test. Educational objective:Elevation of BNP to >100 pg/mL is seen in heart failure. It aids in the assessment of the severity of heart failure and helps distinguish cardiac from respiratory causes of dyspnea. Additional Information Reduction of Risk Potential NCSBN Client Need

/////A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia (76%) 2. Fetal tachycardia with moderate variability (20%) 3. Increased anxiety and discomfort with contractions (1%) 4. Painful, strong contractions every 3-4 minutes (2%) OmittedCorrect answer 1 76%Answered correctly

Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. (Option 2) Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation. (Option 3) Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. (Option 4) The nurse should be hypervigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern. Educational objective:Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

/The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? 1. Complete hourly pain assessments using a numeric pain scale (38%) 2. Document that the client appears to be experiencing minimal pain (1%) 3. Monitor for nonverbal signs of ineffective coping with labor (57%) 4. Recognize that the client's stoicism is ineffective coping with labor (2%) OmittedCorrect answer 3 57%Answered correctly

Developing cultural competence (ie, understanding, attitudes, and abilities acquired to meet the needs of culturally diverse clients) helps the nurse provide culturally sensitive labor support and pain management. Clients from Japanese culture may value silence and nonverbal communication over overt forms of communication. It may be considered culturally appropriate to be stoic (ie, showing admirable patience) during labor, and pain may be accepted as a part of the process. Therefore, the client may not desire pharmacologic pain management. In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping (Option 3). Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief. (Option 1) Pain assessments using a numeric pain scale do not adequately assess coping during labor. Furthermore, the appropriate frequency of pain assessments varies and may be influenced by labor progress and the client's preferred pain-relief method. (Options 2 and 4) Stoicism and lack of outward expressions of pain do not indicate that the client is not experiencing pain, nor should they be misidentified as ineffective coping. Educational objective:A client's cultural background may affect expression of pain during labor. In Japanese culture, silence and nonverbal communication may be valued over overt forms of communication. The nurse should assess the client's coping and monitor for nonverbal cues of ineffective coping (eg, writhing, screaming, panicking).

/The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially? 1. Food poisoning (9%) 2. Influenza (11%) 3. Myocardial infarction (62%) 4. Stroke (16%) OmittedCorrect answer 3 62%Answered correctly

Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. (Option 1) Taking a careful history and evaluating for any sick contacts would be helpful in identifying food poisoning, but a more important initial step is to assess for a heart attack. (Option 2) A viral infection is a possibility, but fever and myalgia are usually present during an episode of influenza. (Option 4) Early intervention in stroke is also critical, and a neurologic assessment would take place after the acute coronary syndrome algorithm, especially with negative electrocardiography and serum heart enzyme levels. Educational objective:Myocardial infarctions in women, the elderly, and diabetics may have gastrointestinal distress as the main symptom; this needs to be evaluated with the institutional protocol for acute coronary syndrome. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply. 1. Child is the youngest of four children in the home 2. One parent is incarcerated for spousal abuse 3. One parent was diagnosed with anorexia nervosa prior to having children 4. One parent works a full-time job outside the home 5. Parents are concerned about not having enough money to buy food OmittedCorrect answer 2,3,5 42%Answered correctly

Failure to thrive (FTT) describes a client with poor growth due to inadequate caloric intake, inadequate food absorption, or excess caloric expenditure. In children, a weight that is <80% of ideal weight for height, weight that is below the 3rd to 5th percentile on growth charts, or persistent decrease in growth over time on growth charts support the diagnosis of FTT. Causes of FTT are typically multifactorial but may be related to certain medical conditions (eg, low birth weight, prematurity, congenital anomalies) or influenced by psychosocial risk factors, including: Domestic violence in the home and/or history of child neglect or abuse (Option 2) Caregiver or child with negative attitudes toward food (eg, fear of obesity, anorexia, food restriction) (Option 3) Poverty or food insecurity (which is the greatest risk factor) (Option 5) Disordered feeding behaviors (eg, unstructured mealtimes) (Option 1) Children are not at risk for FTT based on birth order or number of siblings. (Option 4) Children with a parent who works outside the home do not have an increased risk for FTT. Educational objective:Failure to thrive (FTT) describes a client with poor growth due to inadequate caloric intake, inadequate food absorption, or excess caloric expenditure. In children, psychosocial risk factors for FTT include lack of structured mealtimes, domestic violence, negative attitudes toward food, and poverty.

//A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first? 1. Administer 2 mg morphine IV (2%) 2. Assess fingerstick blood glucose (58%) 3. Draw blood for basic metabolic panel (2%) 4. Obtain a 12-lead electrocardiogram (37%) OmittedCorrect answer 4 37%Answered correctly

Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction (MI), such as diaphoresis, nausea, fatigue, or dyspnea, but may not always experience chest discomfort. Pain may be absent or atypical or may radiate to unusual locations (eg, jaw, back). Some clients may report pain as "indigestion" (epigastric burning or gas). The nurse should obtain a 12-lead electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or infarction (Option 4). ST-segment elevation MI is life-threatening and requires rapid coronary intervention. (Option 1) Morphine is administered to relieve pain and anxiety. A 12-lead ECG must be obtained to verify that the symptoms are cardiac in nature before giving medications. (Option 2) In clients with diabetes, diaphoresis may indicate hypoglycemia, but other symptoms, such as epigastric pain, in this client make MI more likely. (Option 3) Nausea and generalized weakness may result from some electrolyte imbalances, and the nurse should send blood for routine studies (eg, basic metabolic panel, complete blood count). However, a 12-lead ECG will give more immediate assessment information, allowing for quicker intervention if MI is present. Educational objective:Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction. The nurse should obtain a 12-lead electrocardiogram immediately for any client with atypical symptoms before assessing for other causes.

The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the best priority response by the nurse? 1. "Do you have any friends in the building?" (0%) 2. "Have you had any thoughts of hurting yourself?" (69%) 3. "Tell me more about how you're feeling." (24%) 4. "You're not thinking of killing yourself, are you?" (5%) OmittedCorrect answer 2 69%Answered correctly

Giving away possessions and making statements such as, "There is no reason for me to go on," are indications of suicidal ideation. The most important nursing action is to perform a suicide risk assessment to determine interventions to ensure the client's safety. Determining if the client has had thoughts of self harm is a priority. The nurse can ask the client direct questions such as, "Do you feel like hurting yourself?" or "Are you thinking about killing yourself?" or "Do you want to die?" During the assessment, it is important for the nurse to create a sense of trust and compassion and engage the client in a nonjudgmental manner. Additional questions that are part of a suicide risk assessment include the following: Have you thought about how you would kill yourself? Do you have a plan to kill yourself? If you were to kill yourself, how would you do it? If the client has a suicide plan, the nurse needs to ask about the details. The risk of a client completing suicide increases when the client has planned for a specific time and place, has chosen a highly lethal method (eg, firearm, hanging), and has chosen circumstances in which there would be little or no chance of interruption. (Option 1) It is important to assess the client's social support system, but it is not the priority assessment. (Option 3) This is not the priority assessment; it is more important to determine if the client is thinking about suicide or has a plan. (Option 4) This is a leading question and implies what the answer should be. Educational objective:A suicide risk assessment is the priority nursing action for a client who expresses thoughts about "not wanting to go on" or "wishing for death" or engages in potential suicidal indicators such as giving away possessions. Asking the client directly about thoughts of hurting or killing oneself is a therapeutic approach and an essential component of the risk assessment.

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply. 1. Gloves when contact with body fluids is anticipated 2. Gloves when starting an intravenous line 3. Gown, gloves, face shield, and goggles for every client encounter 4. Hand hygiene before and after providing client care 5. N95 respiratory mask and face shield OmittedCorrect answer 1,2,4 91%Answered correctly

Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloves when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse anticipates splashing of body fluids on clothing. A face shield and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line. (Option 3) This would be an acceptable level of protective equipment if the client undergoes a non-sterile procedure with significant splash risk, such as vaginal delivery. (Option 5) Face shields are used when splashing on the face or in the eyes is anticipated. A N95 respirator mask is used when caring for a client with airborne isolation precautions. Educational objective:The Centers for Disease Control and Prevention recommend the use of standard precautions for preventing transmission of HIV. Additional Information Safety and Infection Control NCSBN Client Need

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply. 1. "I use a soft-bristle toothbrush and mild mouth rinse." 2. "I enjoy walking and wear nonskid footwear for safety." 3. "I use a safety razor and gentle shaving cream." 4. "Sometimes I get constipated, so I have been taking docusate." 5. "When I have a headache, I take over-the-counter ibuprofen." OmittedCorrect answer 3,5 49%Answered correctly

Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count <150,000/mm3 (150 x 109/L) and are at increased risk of bleeding. Key teaching to reduce the client's risk of bleeding includes: Use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes. These prevent periodontal disease and gingival bleeding (Option 1). Avoid activities that may cause trauma (eg, high-intensity sports). Appropriate exercise includes low-impact activity (eg, walking) while wearing nonskid footwear to help prevent falls (Option 2). Take prescribed stool softeners and laxatives as needed. These medications prevent hard stools and straining, which can cause anorectal fissuring, bleeding, and hemorrhoids (Option 4). (Option 3) Clients with ITP should use electric razors instead of safety or straight razors. Electric razors have a more complete guard, reducing the risk of accidentally nicking the skin. (Option 5) Clients with ITP should avoid nonsteroidal anti-inflammatory drugs (eg, aspirin, ibuprofen, ketorolac), which further impair platelet function. Acetaminophen and opiates are better options for pain management. Educational objective:Clients with immune thrombocytopenic purpura (ITP) have low platelet counts and an increased risk of bleeding. Appropriate care for clients with ITP includes safe exercise; using stool softeners, electric razors, and soft-bristle toothbrushes; and avoiding nonsteroidal anti-inflammatory drugs.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. 1. A client who fell and hit the head but refuses to go to the emergency department 2. A client who is due for a maintenance dose of cyanocobalamin 3. A client who needs pre-filled insulin syringes 4. A client who was discharged from the hospital yesterday after heart failure treatment 5. A client with a stage 3 pressure injury in need of a dressing change OmittedCorrect answer 1,3,5 36%Answered correctly

In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed. (Option 2) Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client. (Option 4) This client can be provided with telephonic care management; the nurse can perform medication reconciliation over the phone and provide instructions regarding care. Educational objective:During a weather-related emergency, home care visits are classified as: High priority - unstable clients who need care and are at risk for hospitalization if not seen. Moderate priority - clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients. Low priority - clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? 1. "I should not donate blood while taking this medication." (12%) 2. "I will stop taking my tetracycline prior to taking this medication." (37%) 3. "I will take vitamin A supplements." (29%) 4. "I will use condoms and birth control pills." (19%) OmittedCorrect answer 3 29%Answered correctly

Isotretinoin is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception (Option 4). Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication (Option 3). (Option 1) Blood donation is also prohibited during the duration of treatment and up to a month after treatment ends due to the possibility of inadvertent transfusion to a pregnant woman. (Option 2) Isotretinoin should not be taken with tetracycline because the latter also increases the risk for intracranial hypertension. Educational objective:Isotretinoin is a vitamin A derivative prescribed to treat severe and/or cystic acne. Side effects include birth defects, skin changes (eg, dry skin, skin fragility, cutaneous atrophy), and risk for increased intracranial pressure. Clients need to be instructed to avoid tetracycline, excess sun and tanning, and vitamin A supplements. Women of child-bearing age should use 2 forms of contraception to prevent pregnancy.

//The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? 1. "I have been seeing small flashes of light." (7%) 2. "I have trouble threading my sewing needle. I have to hold it far away to see it." (9%) 3. "I notice that my peripheral vision is becoming worse." (19%) 4. "I see a blurry spot in the middle of the page when I read." (63%) OmittedCorrect answer 4 63%Answered correctly

Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact (Option 4). Macular degeneration has two different etiologies. "Dry" macular degeneration involves ischemia and atrophy of the macula that results from blockage of the retinal microvasculature. "Wet" macular degeneration involves the abnormal growth of new blood vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of macular degeneration may be slowed with smoking cessation, intake of specific supplements (eg, carotenoids, vitamins C and E), laser therapy, and injection of antineoplastic medications. Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term poor intake of carotenoid-containing fruits and vegetables. (Option 1) Seeing small flashes of light is associated with retinal detachment. (Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age and therefore unable to adjust to near and far vision. (Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma. Educational objective:Macular degeneration is a progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving rise to distortion (blurred or wavy visual disturbances) or loss in the center of the visual field. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching? 1. "I need to enroll in a smoking cessation program." (3%) 2. "I need to restrict the amount of potassium in my diet." (72%) 3. "I will lie down and avoid walking unassisted during acute attacks." (12%) 4. "I will limit the amount of caffeine and alcohol that I consume." (12%) OmittedCorrect answer 2 72%Answered correctly

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and feelings of fullness or pressure in the ear. The disorder typically affects only one ear and can lead to permanent hearing loss. Attacks of Meniere disease can result in a total loss of proprioception, and clients often report feeling "pulled to the ground" (drop attacks), making client safety a priority. Vertigo can be severe and is associated with nausea, vomiting, and feelings of anxiety. Self-care for Meniere disease may include: Consuming a low-sodium diet to decrease the potential for fluid excess within the inner ear. Intake of potassium and other electrolytes does not need to be restricted (Option 2). Limiting or avoiding aggravating substances (eg, nicotine, caffeine, alcohol) and stimuli (eg, flickering lights, watching television) (Options 1 and 4) Adhering to prescribed therapies for relief of symptoms (eg, antiemetics, antihistamines, sedatives, and mild diuretics) Avoiding sudden changes in the position of the head (eg, bending over) during vertigo spells Participating in vestibular rehabilitation therapy Implementing safety measures during attacks (eg, assistance with walking, bed rest) (Option 3) Educational objective:Meniere disease results from excess fluid accumulation in the inner ear. Attacks involve severe vertigo, nausea, and hearing loss. Clients with Meniere disease should be taught to adhere to a low-sodium diet; eliminate tobacco products; limit caffeine and alcohol; and limit or avoid exacerbating factors (eg, flickering lights).

/An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? 1. Administer IV antibiotics (21%) 2. Infuse bolus of IV normal saline (67%) 3. Prepare to assist with lumbar puncture (8%) 4. Transport client for head CT scan (2%) OmittedCorrect answer 2 67%Answered correctly

Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4). Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy. Educational objective:For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.

A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? Select all that apply. 1. Excess blinking of eyes 2. Dry mouth 3. Dull headache 4. Lip smacking 5. Puffing of cheeks OmittedCorrect answer 1,4,5 30%Answered correctly

Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: Protruding and twisting of the tongue Lip smacking Puffing of cheeks Chewing movements Frowning or blinking of eyes Twisting fingers Twisted or rotated neck (torticollis) (Options 2 and 3) Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care provider. Educational objective:Both antipsychotic medication and metoclopramide use can be associated with significant extrapyramidal side effects (eg, tardive dyskinesia). The nurse should teach the client the importance of immediately communicating these to the health care provider.

A client is admitted to the ambulatory care unit for an endoscopic procedure. The gastroenterologist administers midazolam 1 mg intravenously for sedation and titrates the dosage upward to 3.5 mg. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? 1. Benztropine (10%) 2. Flumazenil (36%) 3. Naloxone (46%) 4. Phentolamine (7%) OmittedCorrect answer 2 36%Answered correctly

Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines. (Option 1) Benztropine (Cogentin) is used in the treatment of extrapyramidal side effects associated with antipsychotic medications or metoclopramide. (Option 3) Naloxone (Narcan) is the antidote drug to reverse the effects of opioids. (Option 4) Phentolamine (Regitine) is the antidote drug used to treat a norepinephrine (Levophed) extravasation. Educational objective:Flumazenil is a drug used to reverse the sedative effects of benzodiazepines such as midazolam.

/The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action? 1. Blood-tinged stain on the inner aspect of the cast (13%) 2. Capillary refill of 2 seconds on the affected extremity (4%) 3. Mild swelling of toes on the right foot (16%) 4. Pain of 9/10 an hour after a dose of morphine (65%) OmittedCorrect answer 4 65%Answered correctly

Neurovascular integrity should always be tested first after cast application by performing circulation, motor, and sensory checks. The client should have no numbness or tingling. If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify the health care provider (HCP). Permanent damage to the circulatory and nervous systems (compartment syndrome) can occur if this is not addressed immediately (Option 4). Pallor, pulselessness, and paralysis are late signs of compartment syndrome. (Option 1) Blood stains on a cast after an open orthopedic surgical procedure are not unusual. The nurse should circle the stains and mark the date and time on the cast so further bleeding can be easily visualized. However, rapid enlargement of a stain needs to be reported to the HCP. (Option 2) The skin on the affected extremity should be pink and warm. When blanched, it should return to normal color in <3 seconds. (Option 3) Mild swelling/edema of the toes can occur from cast pressure and can be reduced with leg elevation using pillows. Increasing swelling should be reported to the HCP. Most clients report severe pain when the cause is compartment syndrome, which is a priority. Educational objective:Compartment syndrome is a limb-threatening emergency that can occur after fracture reduction. Neurovascular checks should always be performed first. The client should not have numbness or tingling. If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify the health care provider.

/The obstetric nurse is reviewing phone messages. Which client should the nurse call first? 1. Client at 18 weeks gestation taking ceftriaxone and reporting mild diarrhea (10%) 2. Client at 22 weeks gestation with twins who is taking acetaminophen twice a day (23%) 3. Client at 28 weeks gestation taking metronidazole and reporting dark-colored urine (27%) 4. Client at 32 weeks gestation taking ibuprofen for moderate back pain (38%) OmittedCorrect answer 4 38%Answered correctly

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin, naproxen) inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or to reduce fever. NSAIDs are pregnancy category C in the first and second trimesters and pregnancy category D in the third trimester. NSAIDs must be avoided during the third trimester due to the risk of causing premature closure of the ductus arteriosus in the fetus (Option 4). During the first and second trimesters, NSAIDs should be taken only if benefits outweigh risks and under the supervision of a health care provider (HCP). (Option 1) Beta lactam antibiotics (eg, amoxicillin, ceftriaxone [Rocephin]) are pregnancy category B. Diarrhea is a common side effect of beta lactams. Although diarrhea should be reported to the HCP, as it could indicate pseudomembranous (Clostridium difficile) colitis or lead to dehydration if prolonged, this client is not the priority. (Option 2) Acetaminophen (pregnancy category B) is a common pain reliever and/or fever reducer used during pregnancy. Acetaminophen intake should not exceed 4 g per day, including any over-the-counter or prescription combination medications that contain acetaminophen. (Option 3) Metronidazole (Flagyl) is an anti-infective and pregnancy category B. Dark-colored urine is an expected side effect of metronidazole and not cause for concern. Educational objective:Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in the third trimester due to risk of premature closure of the fetal ductus arteriosus. NSAIDs should be taken only under the direction and supervision of a health care provider during the first and second trimesters. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports "numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take? 1. Ask if the client wants pain medication for the "numbness and tingling" (1%) 2. Ask the client if the "numbness and tingling" were present before surgery (57%) 3. Continue assessment by observing the surgical dressing (18%) 4. Notify the health care provider (HCP) immediately (22%) OmittedCorrect answer 2 57%Answered correctly

Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of bilateral peripheral neuropathy include the following: Diabetic neuropathy - most common; distribution is usually sock-and-glove pattern Autoimmune neuropathy - Guillain-Barré syndrome Toxic neuropathy - alcohol use Establishing that the sensations the client is experiencing were present before surgery indicates whether this is a complication of surgery. Because the sensation is bilateral and the surgery was on the right knee, the "numbness and tingling" are probably baseline diabetic neuropathy. This should be confirmed by gathering more information from the client (Option 2). (Option 1) Diabetic neuropathy is not usually treated with traditional post-surgical medications such as opioids. Medications for diabetic neuropathy are usually given on a fixed, timed schedule and include duloxetine, pregabalin, amitriptyline, and gabapentin. If the client uses an as-needed medication, it is important to ask for more information before administering it. The client should be asked whether the pain is baseline and what medication is taken. (Option 3) The nurse should question any abnormal finding, whether expected or unexpected. Questioning the client further would allow the nurse to gather more information and confirm that the client's "numbness and tingling" do not indicate a more serious situation. (Option 4) It is not necessary to notify the HCP immediately. Bilateral pedal pulses and normal capillary refill indicate sufficient blood flow to the extremities. Educational objective:The nurse should assess for causes of pain and rule out serious complications as part of a pain assessment. Sensations of "numbness and tingling" indicate diabetic neuropathy but should be confirmed as baseline for the client before continuing the assessment.

A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse? 1. 25-year-old client who reports a fish-like vaginal odor for the past month (14%) 2. 30-year-old client with an intrauterine device who reports heavy bleeding with menses (22%) 3. 40-year-old client with endometriosis who reports persistent pain during intercourse (5%) 4. 60-year-old client who reports bloating and pelvic pressure for the past 2 months (57%) OmittedCorrect answer 4 57%Answered correctly

Ovarian cancer results in more deaths than any other gynecologic cancer. Symptoms are often subtle and may include abdominal bloating; pelvic pain or pressure; abdominal girth increase; early satiety; abdominal, back, or leg pain; urinary urgency/frequency; and gastrointestinal disturbances (Option 4). Due to the lack of routine screening and reports of vague symptoms, ovarian cancer may not be diagnosed until an advanced stage. (Option 1) A fish-like vaginal odor is often caused by bacterial vaginosis, an overgrowth of vaginal bacterial flora. This condition is not usually serious and is treated with oral or vaginal antibiotics (eg, metronidazole). (Option 2) Heavy menstrual bleeding is a common disadvantage of having an intrauterine device. If the client cannot tolerate heavy bleeding or if excessive bleeding results in anemia, another form of birth control should be considered. (Option 3) Reports of painful intercourse are not unusual in clients with endometriosis. Disease management and pain control should be discussed. Educational objective:Symptoms of ovarian cancer are often subtle, and the condition is often not discovered until an advanced stage due to a lack of routine screening guidelines. Clients may present with bloating, early satiety, urinary symptoms (pressure on the bladder), and pelvic pressure.

A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention? 1. Lochia that soaks a perineal pad every 2 hours (18%) 2. Persistent headache with blurred vision (72%) 3. Red, painful nipple on one breast (0%) 4. Strong-smelling vaginal discharge (9%) OmittedCorrect answer 2 72%Answered correctly

Persistent headache and blurred vision could indicate postpartum preeclampsia. The majority of clients with preeclampsia develop symptoms before birth; however, a small percentage do not develop the complication until several days after birth. This potentially serious condition can rapidly worsen, leading to seizures and death if left untreated. Additional signs and symptoms may include high blood pressure, proteinuria, and edema (Option 2). (Option 1) In the immediate postpartum period, lochia should be assessed frequently to monitor for postpartum hemorrhage. Soaking a perineal pad in ≤1 hour would indicate excessive bleeding that requires urgent intervention. (Option 3) Red or painful nipples in a breastfeeding client may be the result of incorrect latch and/or improper breastfeeding technique. The nurse should observe the client while breastfeeding, identify any problems with the newborn's latch, and obtain additional assessment from a lactation consultant, if appropriate. (Option 4) Strong- or foul-smelling vaginal discharge may represent an infection (eg, endometritis). This assessment finding indicates the need for further evaluation but is not immediately life-threatening. Educational objective:Preeclampsia can develop in the postpartum period several days after birth. Clients in the postpartum period with signs and symptoms of preeclampsia (eg, edema, persistent headache, vision changes, elevated blood pressure) should be evaluated and treated immediately. Additional Information Physiological Adaptation NCSBN Client Need

The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client? 1. Apply tocodynamometer and evaluate current contraction pattern (33%) 2. Ask the client about the family's desire for speaking with a chaplain (10%) 3. Draw coagulation tests, fibrinogen, and complete blood count with platelets (38%) 4. Initiate oxytocin prescription to begin induction of labor (17%) OmittedCorrect answer 3 38%Answered correctly

Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for disseminated intravascular coagulation (DIC). Thromboplastin from the retained dead fetus activates the clotting cascade, followed by consumption of clotting factors and platelets that leads quickly to life-threatening external and internal bleeding. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (eg, petechiae, ecchymosis), and organ damage from blood clotting (eg, respiratory distress, renal failure). Baseline laboratory tests (eg, coagulation studies, platelets, fibrinogen) and physical assessment for signs of DIC are a priority for at-risk clients because clotting and bleeding are often sudden and life-threatening (Option 3). (Option 1) The nurse applies a tocodynamometer ("toco") to monitor for contractions that may begin prior to oxytocin administration, but this is not a priority over laboratory assessment for DIC. (Option 2) The nurse offers chaplain services and emotional support to clients and families experiencing pregnancy loss, but this is not the priority action. (Option 4) A hemodynamically stable client with fetal demise should have labor induced as quickly as possible to prevent DIC, but this does not take priority over initial laboratory assessment. Educational objective:Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for developing disseminated intravascular coagulation (DIC). DIC can progress quickly; therefore, the nurse should prioritize assessment for any signs of DIC (eg, abnormal laboratory tests [coagulation studies, fibrinogen, platelets], signs of bleeding) before performing other interventions.

A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as: 1. Psychogenic dystonia (46%) 2. Psychogenic gait (2%) 3. Psychomotor retardation (25%) 4. Somatization (24%) OmittedCorrect answer 3 25%Answered correctly

Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior). Specific clinical findings of psychomotor retardation include the following: Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait Lack of facial expression Downcast gaze Speech impairment - reduced voice volume, slurring of speech, delayed verbal responses, short responses Social interaction - reduced or non-interaction Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement. (Option 1) Psychogenic dystonia is a psychogenic movement disorder characterized by involuntary muscle contractions that cause slow, repetitive movements such as twisting and abnormal postures. (Option 2) Psychogenic gait is a psychogenic movement disorder characterized by unusual standing postures and walking. The client may experience knee buckling and falling or may veer from side to side as if staggering. (Option 4) Somatization is a term to describe physical symptoms that cannot be explained by a medical condition or disease. Educational objective:Psychomotor retardation is a clinical finding in some clients diagnosed with major depressive disorder. The key features include decreased movement, inability or decreased ability to talk, and impaired cognitive function. Additional Information Psychosocial Integrity NCSBN Client Need

/A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority? 1. Administer prescribed IV fluids (2%) 2. Apply supplemental oxygen via nonrebreather mask (16%) 3. Assist the health care provider to prepare for chest tube insertion (12%) 4. Cover the wound with petroleum gauze taped on three sides (68%) OmittedCorrect answer 4 68%Answered correctly

The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure (ICP), which indicate shunt malfunction. Vomiting may be a sign of increased ICP and would require that the HCP be contacted. (Option 1) Fever may indicate shunt infection, but a temperature of 99 F (37 C) remains within acceptable parameters. Contacting the HCP is not indicated. (Option 2) Memory lapse or changes in mental status may indicate increased ICP. The inability to remember one meal would not indicate a change of mental status. (Option 4) A VP shunt is tunneled under the scalp and can be palpated. Educational objective:Increased ICP may occur with VP shunt malfunctions. The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status. Early intervention by the HCP will decrease the risk of damage to the brain tissue. Additional Information Physiological Adaptation NCSBN Client Need Copyright © UWorld. All rights reserved. Highlight Add To Flash Card

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? 1. Assess vital capacity and tidal volume once per shift and PRN (23%) 2. Perform passive range of motion exercises on affected joints every 4 hours (8%) 3. Provide time during each shift for the client to express feelings (8%) 4. Turn the client every 2 hours throughout the day and night (60%) OmittedCorrect answer 1 23%Answered correctly

Quadriplegia (tetraplegia) occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values (if prescribed). (Options 2, 3, and 4) This client will need passive range of motion exercises on affected joints to prevent contractures. Turning the client will be necessary to prevent skin breakdown over bony prominences. The client will need to express feelings and work through the grief process related to loss of function. Bladder and bowel training programs will be necessary. All of these interventions are important for this client but are not the priority over maintenance of adequate oxygenation. Educational objective:The priority assessment in a client newly diagnosed with quadriplegia (tetraplegia) is airway management and oxygenation.

A critically ill client receiving vasopressor therapy for hypotension requires continuous blood pressure monitoring via an arterial catheter. The nurse sets up the pressure monitoring system and correctly places the transducer at the phlebostatic axis. Where on the chest does the nurse mark this reference point? Correct 46%Answered correctly

The phlebostatic axis is an external anatomical point on the chest at the level of the atria of the heart (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest). It is used as a reference point for correct placement of the zeroing point of the transducer when measuring continual arterial blood pressure (BP), central venous pressure (CVP) using a central line, and/or cardiopulmonary pressures via a pulmonary artery (Swan-Ganz) catheter. The nurse places the transducer and marks the chest at the phlebostatic axis, which helps to assure accuracy of measurement. After it is placed, the zero reference stopcock of the transducer is "leveled," or aligned with the level of the atrium, using a ruler or carpenter's level. If the zeroing stopcock is placed below this level, falsely high readings occur; if it is too high, falsely low readings are obtained. The phlebostatic axis is also used as a reference point for the upper arm when measuring BP indirectly using a noninvasive BP device or the auscultatory method with sphygmomanometer and stethoscope. If the upper arm is above or below this level, the BP reading will be inaccurate. Educational objective:The phlebostatic axis (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest) is an external reference point on the thorax used to determine proper placement of the pressure monitoring system transducer when measuring direct BP, CVP, and/or cardiopulmonary pressures invasively. It is also used as a reference point for the upper arm when measuring BP indirectly.

//The nurse is reinforcing education with the parents of a 2-year-old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? Select all that apply. 1. "Diets consisting of legumes as the only protein source are sufficient for growth." 2. "It is important to feed your child fortified breads and cereals to help with iron intake." 3. "Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake." 4. "Try to pair foods high in iron with foods high in vitamin C to aid iron absorption." 5. "Your child may require calcium and vitamin D supplementation due to lack of dairy intake." OmittedCorrect answer 2,4,5 42%Answered correctly

Skin cancers are most often linked to damage of skin cells' DNA by overexposure to ultraviolet radiation (eg, sunlight, tanning beds). The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas grow rapidly and are highly metastatic, making them the deadliest form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Risk factors for skin cancer include: Family or personal history of skin cancer (Option 1) Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) Aging Atypical or high number of moles because some skin cancers develop from pre-existing moles (Option 2) Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations (Option 4) Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns) (Option 5) Clients should be taught to avoid overexposure to sunlight, perform monthly skin checks with the ABCDE assessment, and immediately report any abnormal findings to their health care provider. Early detection and treatment significantly improve outcomes. (Option 3) Acne is not a known risk factor for skin cancer. Educational objective:Risk factors for skin cancer include family or personal history of skin cancer, Celtic ancestry traits (eg, light skin, blue eyes), aging, atypical or high number of moles, immunosuppression, and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation). Additional Information Health Promotion and Maintenance NCSBN Client Need

1The nurse is caring for a pediatric client with end-stage leukemia who is on comfort care and is unresponsive. The child's parent asks, "How can you tell if my child is in pain?" Which of these would the nurse describe as signs of discomfort? Select all that apply. 1. Blank facial expression 2. Facial grimacing 3. Groaning 4. Knees bent up near chest 5. Lying still OmittedCorrect answer 2,3,4 84%Answered correctly

The FLACC scale (face, legs, activity, cry, and consolability) can be used to assess pain in the child who is nonverbal. This includes assessment for: Facial grimacing Leg movement, tension, or bending up toward the chest Activity, including squirming, arching, jerking Crying or moaning Difficulty consoling or comforting the child The nurse will provide teaching on signs that should prompt the parent to administer as-needed pain medication to the child. (Option 1) A child who is comfortable will usually have a neutral facial expression. A child in pain is likely to exhibit grimacing, frowning, or clenching of the jaw, based on the FLACC face assessment. (Option 5) A child who is comfortable will be lying quietly. A child who is squirming and moving is more likely to be in pain, based on the FLACC activity assessment. Educational objective:It is difficult to assess for pain in the nonverbal client, particularly if the person is unresponsive at the end of life. The FLACC scale is an accurate method of assessing pain in the nonverbal child. This tool should be used to teach parents how to promote comfort for their nonverbal child. Additional Information Basic Care and Comfort NCSBN Client Need

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Alert the x-ray department about maintaining airborne isolation precautions 2. Explain to the client why the client must wear a mask during transport to another department 3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment 4. Remind visitors to wear a respirator mask and keep the door closed while in the client's room 5. Talk with the family about the reasons for airborne isolation precautions in the client OmittedCorrect answer 3,4 47%Answered correctly

The RN can delegate the following tasks to the experienced UAP: Post signs for airborne isolation precautions on the client's door and stock necessary equipment: The UAP has the knowledge and skill to implement isolation precautions when caring for clients on contact, droplet, or airborne transmission-based precautions (Option 3). Remind visitors to wear a respirator mask and keep the door closed while in the client's room: The UAP can reinforce the procedures and principles of infection control regarding airborne isolation precautions (eg, respirator masks, negative airflow room). However, the nurse should provide the initial instructions and is responsible for visitor compliance (Option 4). (Option 1) The RN is responsible for calling the x-ray or other departments to communicate pertinent information about the client, including the need to maintain airborne isolation precautions before and while transporting the client for diagnostic tests. (Option 2) The RN is responsible for explaining to the client that wearing a mask during transport to another department prevents transmission of airborne microorganisms from the client to others. This is client teaching and must be done by the RN. The UAP can implement the task of applying the mask before transport. (Option 5) The RN is responsible for talking with the family about the reasons the client is on airborne isolation precautions and teaching them about preventing the spread of the disease by wearing protective equipment upon entering the client's room. Educational objective:Experienced UAP can post signs on the client's door that display airborne isolation precautions, stock necessary equipment, and remind visitors to wear a respirator mask when entering the client's room. The RN is responsible for appropriate communication with other departments and providing instruction to clients and their families.

//A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? 1. pH 7.26, PaCO2 56 mm Hg (7.5 kPa), HCO3 23 mEq/L (23 mmol/L) (30%) 2. pH 7.30, PaCO2 30 mm Hg (4.0 kPa), HCO3 15 mEq/L (15 mmol/L) (55%) 3. pH 7.40, PaCO2 40 mm Hg (5.3 kPa), HCO3 24 mEq/L (24 mmol/L) (2%) 4. pH 7.58, PaCO2 48 mm Hg (6.4 kPa), HCO3 44 mEq/L (44 mmol/L) (11%) OmittedCorrect answer 2 55%Answered correctly

The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA) is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaCO2 30 mm Hg [4.0 kPa], HCO3 15 mEq/L [15 mmol/L]). DKA is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L]) resulting in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1 diabetes cannot produce. Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis (low pH and low HCO3). As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate for the ketoacidosis, which has nearly normalized the pH. (Option 1) This is an example of respiratory acidosis (low pH and increased CO2 levels). It is commonly seen in conditions that cause CO2 retention (eg, chronic obstructive pulmonary disease, obesity hypoventilation syndrome, respiratory depression due to narcotics). (Option 3) This is an example of normal ABG results. (Option 4) This is an example of metabolic alkalosis (high pH and elevated HCO3), which typically presents with prolonged vomiting and aggressive diuresis. Educational objective:The arterial blood gas result most consistent with the diagnosis of diabetic ketoacidosis is metabolic acidosis or partially compensated metabolic acidosis (pH ≤7.30 and HCO3 ≤18 mEq/L [18 mmol/L]). Respiratory compensation may raise pH to near-normal values, but the PCO2 will be dramatically lower than normal (PCO2 ≤30 mm Hg [4.0 kPa]). Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear (18%) 2. 4-year-old post adenotonsillectomy who is now reporting ear pain (53%) 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics (3%) 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice today (24%) OmittedCorrect answer 4 24%Answered correctly

The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding (eg, frequent swallowing or throat clearing). The child may also experience increased pain. The nurse should instruct this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery. (Option 1) Tympanostomy tubes or grommets are pressure-equalizing tubes placed in the tympanic membrane to facilitate drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be notified. (Option 2) Clients often report ear pain (otalgia) following adenotonsillectomy due to irritation of the 9th cranial nerve (glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding. (Option 3) The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of beginning antibiotic treatment. This client is able to return to activities and does not require an immediate call back. Educational objective:The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs.

A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living? 1. "Be aware of the client's shoulder weakness and provide support as needed." (10%) 2. "Ensure that the client sits upright and tucks the chin when swallowing food." (37%) 3. "Explain all procedures in step-by-step detail before performing them." (27%) 4. "Make sure the items needed by the client are within reach." (24%) OmittedCorrect answer 4 24%Answered correctly

The client has an impairment of cranial nerve (CN) VIII, the vestibulocochlear (or auditory) nerve. Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. Therefore, when instructing the unlicensed assistive personnel (UAP) about helping the client with activities of daily living, the nurse emphasizes the need to keep items at the bedside within the client's reach (Option 4). (Option 1) Weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Impairment of CN VIII does not affect shoulder strength. (Option 2) Dysphagia may occur with impairment of CN IX (glossopharyngeal) and CN X (vagus), not CN VIII. Instructing the client to tuck the chin while eating is a technique for those who have difficulty swallowing. (Option 3) Impairment of visual acuity occurs with disorders affecting CN II (optic). Because impairment of CN VIII does not affect visual acuity, providing a detailed, step-by-step explanation of procedures may be helpful but is not the most appropriate instruction to give the UAP. Educational objective:Impairment of cranial nerve (CN) VIII, the vestibulocochlear or auditory nerve, may cause dizziness, vertigo, loss of hearing, and motion sickness. To assist the client with impairment of CN VIII, needed items should be placed nearby to decrease the risk of the client getting out of bed and falling. Additional Information Reduction of Risk Potential NCSBN Client Need

Laboratory results White blood cells 1,100/mm3 (1.1 x 109/L) Absolute neutrophil count 400/mm3 (0.4 x 109/L) Hemoglobin 8.2 g/dL (82 g/L) Platelets 78,000/mm3 (78 x 109/L) The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Click on the exhibit button for additional information. 1. Administer erythropoietin injection (8%) 2. Minimize venipunctures and avoid intramuscular injections (16%) 3. Place sequential compression devices (SCDs) to the legs (0%) 4. Provide a private room and neutropenic precautions (74%) OmittedCorrect answer 4 74%Answered correctly

The client's laboratory results show severe neutropenia, with a reduced white blood cell count (normal 4,000-11,000/mm3 [4.0-11.0×109/L]) and reduced absolute neutrophil count (normal 2200-7700/mm3 [2.2-7.7 ×109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: A private room Strict handwashing Avoiding exposure to people who are sick Avoiding all fresh fruits, vegetables, and flowers Ensuring that all equipment used with the client has been disinfected (Option 1) The client's laboratory results show moderate anemia. Blood transfusion and/or erythropoietin injections are important but not a priority. Infections in immunocompromised clients are life threatening. (Option 2) The client's platelet count of 78,000/mm3 (78 ×109/L) is decreased but not dangerously low; therefore, it is not the highest priority intervention. Avoiding intramuscular injections and minimizing venipunctures is most important when the platelet count is below 50,000/mm3 (50 ×109/L), as these can cause prolonged bleeding. (Option 3) This client would need SCDs for prevention of deep vein thrombosis to the legs as anticoagulants may not be used due to the risk of bleeding from low borderline platelet count. However, this is not a priority over infection prevention. Educational objective:Neutropenic precautions should be used to prevent infection in clients who have low white blood cell and absolute neutrophil counts and are receiving chemotherapy. Infections in these clients are life threatening.

//The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline (49%) 2. 2 days postcoronary bypass graft surgery with a white blood cell count of 18,000/mm3 (18.0 × 109/L) (16%) 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion (19%) 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema (14%) OmittedCorrect answer 1 49%Answered correctly

The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival. (Option 2) An elevated white blood cell count (>11,000/mm3 [11.0 x 109/L]) could be caused by an underlying infection or the stress of the surgery. This needs to be assessed as soon as possible, but it does not take priority over the possible limb loss with graft occlusion. (Option 3) A decreased ejection fraction (normal 55%-70%) results in decreased cardiac output and inability to meet oxygen demand, leading to shortness of breath and activity intolerance. The nurse should assess lung sounds. However, this is an expected finding, so the nurse does not need to assess this client first. (Option 4) Subcutaneous emphysema is air in the tissue surrounding the chest tube insertion site and can occur in a client with a pneumothorax. The nurse should assess lung sounds and palpate to determine the degree of emphysema. However, this is an expected finding, so the nurse does not need to assess this client first. Educational objective:A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity in a client who is postoperative abdominal aortic aneurysm repair can indicate the presence of an arterial or graft occlusion and poses the greatest threat to survival. Additional Information Management of Care NCSBN Client Need

/A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy. The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit. Which statement by the unlicensed assistive personnel would require immediate action by the nurse? 1. "I changed the client's perineal pad 3 times in the last 2 hours." (65%) 2. "I have been encouraging the client to exercise the legs while in bed." (7%) 3. "I thought you should know the client voided 500 mL of straw-colored urine." (7%) 4. "I just took the client's vital signs, which are blood pressure 108/60 mm Hg, pulse 58, and respirations 12." (19%) OmittedCorrect answer 1 65%Answered correctly

The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates more than one perineal pad in an hour. The nurse should further assess the client and report these findings and excessive vaginal bleeding to the health care provider (HCP). (Option 2) The client should be encouraged to perform leg exercises while in bed to promote circulation and prevent deep vein thrombosis (DVT). (Option 3) The client's voiding of 500 mL of straw-colored urine is a normal finding. (Option 4) The client received metoprolol, a beta-adrenergic blocker, which slows the heart rate. If the heart rate is below 60 (or prescribed rate) prior to medication administration, the nurse should withhold further metoprolol and contact the HCP. The vital signs do not require immediate action by the nurse. Educational objective:A client recovering from a vaginal hysterectomy should be monitored for excessive vaginal bleeding, urinary retention, backache, decreased urinary output, and the development of signs and symptoms of complications such as DVT.

The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching? 1. "I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading." (42%) 2. "I will move the indicator to the desired reading on the numbered scale before using the device." (11%) 3. "I will record my personal best reading, which is the average of 3 consecutive peak flow readings." (38%) 4. "I will remember to use the device after taking my fluticasone metered-dose inhaler (MDI)." (7%) OmittedCorrect answer 1 42%Answered correctly

The peak flow meter is a hand-held device used to measure peak expiratory flow rate (PEFR) and is most helpful for clients with moderate to severe asthma. Exhaling as quickly and forcibly as possible through the mouthpiece of the device evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath. Use of the device permits self-management and provides information to guide and evaluate treatment. (Option 2) The client moves the indicator on the numbered scale to 0 or to the lowest number on the scale before using the device. (Option 3) The personal best reading is the highest peak flow reading the client can attain, usually over a 2-week period, when asthma is in good control. (Option 4) The peak flow meter is used after a short-acting bronchodilator rescue MDI to evaluate response, not after a corticosteroid MDI. Educational objective:The peak flow meter is used to measure PEFR and is most helpful for clients with moderate to severe asthma. A reading is obtained by exhaling as quickly and forcibly as possible through the mouthpiece of the device.

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply. 1. Calcium supplements 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises OmittedCorrect answer 1,4,5 60%Answered correctly

The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture. Teaching to increase bone mineral density and prevent bone loss (resorption) includes: Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast]) Calcium and Vitamin D supplementation (Options 1 & 4) Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30 minutes, as increasing mechanical stress on bone increases bone density (Option 5) Interventions to prevent falls and resulting hip fracture include: Maintain bed in low and locked position Ensure that call light and personal belongings are within reach Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed Keep environment well-lit and free of clutter (Option 2) A client should not be placed on bed rest solely for the prevention of falls. Immobilization actually increases fracture risk due to bone resorption, a condition called disuse osteoporosis. The nurse should encourage and assist with mobility and weight-bearing exercises to prevent muscle atrophy and bone resorption. (Option 3) The client may actually incur more injury from a fall if trying to climb over side rails to get out of bed. The nurse should utilize bed alarms if the client is prone to getting out of bed without assistance. Educational objective:An osteoporosis-related fall is the most common cause of hip fracture in the elderly. Interventions to reduce the risk of fall and hip fracture include bisphosphonate medication, calcium and vitamin D supplements, mobility and weight-bearing exercise, smoking cessation, and avoiding excessive use of alcohol.

//The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are torn and show signs of wear (65%) 2. The client has a 30-degree bend at the elbow when walking (8%) 3. The crutches and injured foot are moved simultaneously in a 3-point gait (16%) 4. There is a 3 finger-width space noted between the axilla and axillary pad (9%) OmittedCorrect answer 1 65%Answered correctly

The proper fit and use of crutches are important in preventing injury. They include: Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). (Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Educational objective:Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation continues.

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3 (0.45 ×109/L). What information contained in the admission history of this client will need to be addressed during discharge education? 1. Eats steamed vegetables daily (12%) 2. Enjoys eating grilled shrimp weekly (6%) 3. Gardens as hobby (74%) 4. Takes a bath daily and applies moisturizer (7%) OmittedCorrect answer 3 74%Answered correctly

This client has a very low absolute neutrophil count (normal: 2200-7700 cells/mm3 [2.2-7.7 ×109/L]); having <500 cells/mm3 (0.5 ×109/L) indicates severe neutropenia and increases the risk of infection. All risks for infection should be minimized in a client with neutropenia. Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask. (Option 1) The client with neutropenia is allowed to consume cooked vegetables. However, raw or unwashed vegetables should be avoided due to possible contamination with pathogens as this can increase the risk of infection. A healthy diet containing vegetables is encouraged to increase consumption of necessary nutrients. (Option 2) Protein is a necessary component in the diet of a client receiving chemotherapy. Protein aids in the healing process of the body. As long as the meat or seafood is fully cooked, it is safe for the client with neutropenia to consume. Raw or undercooked meat/seafood is to be avoided due to possible exposure to pathogens. (Option 4) Clients with neutropenia are encouraged to bathe daily to remove pathogens that could cause infection. Moisturizer should be applied to prevent dry skin. If the skin becomes dry or cracked, pathogens could use these openings as portals of entry; this can lead to infection in the host. Educational objective:A low absolute neutrophil count increases a client's risk for infection. Gardening (soil) and contact with fresh flowers and plants should be avoided due to potential exposure to pathogens. The client's room should not have standing water.

The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what? 1. React anxiously to altered daily routines (22%) 2. Realize that death eventually affects everyone (6%) 3. Think about the religious or spiritual aspects of death (2%) 4. Understand that death is permanent but be curious about it (69%) OmittedCorrect answer 4 69%Answered correctly

Understanding a child's perception of illness and death can empower caregivers (eg, parents) to support the child during the loss of a loved one. A child's developmental stage as well as the caregiver's view of death and relationship with the child will influence coping during bereavement. The nurse should educate the parent of an 8-year-old client about how to assist with coping based on the knowledge that school-aged children (age 6-12 years) most likely have both a curiosity and fear about the implications of death (eg, process of dying, funeral services) and understand that death is permanent (Option 4). Therefore, it is important for the parents to be honest during discussions about death, talk about the lost loved one, and provide anticipatory guidance to reduce fears. (Option 1) Infants (age 1-12 months) and toddlers (age 12-36 months) mostly react to separation from caregivers, both temporary and permanent, because it affects daily routines. (Option 2) A child will most likely be aware that death affects everyone and also perceive it as evil by age 10-12 years. (Option 3) Adolescents are most likely to think about the religious and spiritual aspects of death, although this may occur earlier for some children. Educational objective:The nurse should understand how children perceive illness and death within each age group to provide guidance for caregivers. School-aged clients most likely understand the concrete finality of death and are curious and fearful about its implications (eg, process of dying, funeral services). Additional Information Health Promotion and Maintenance NCSBN Client Need

//The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. 1. Don gown, gloves, and N95 respirator when entering the client's room 2. Ensure that pregnant staff members are not assigned to care for this client 3. Place single-use, disposable thermometer and stethoscope in the room 4. Place the client in a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted OmittedCorrect answer 1,2,3,4,5 20%Answered correctly

Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment) (Options 1 and 3). Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued (Option 5). Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway (Option 4). Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities (Option 2). Educational objective:Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted. Additional Information Safety and Infection Control NCSBN Client Need

/The charge nurse on a telemetry unit is training a new registered nurse (RN). The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? 1. A client in atrial fibrillation with an International Normalized Ratio of 4.0 who has a warfarin dose due (38%) 2. A client who had coronary artery bypass surgery 2 days ago, has a temperature of 99 F (37.2 C), and has a dose of vancomycin due (4%) 3. A client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due (51%) 4. A client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids (5%) OmittedCorrect answer 3 51%Answered correctly

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP). (Option 1) The client with atrial fibrillation (AF) should be seen after the MI client. Vital signs are stable, but the International Normalized Ratio (INR) should be lower (therapeutic range of 2.0-3.0 for AF). The nurse should assess for signs of bleeding and notify the HCP; the scheduled dose of warfarin should likely be held. (Option 2) A temperature of 99 F (37.2 C) is not uncommon in the days immediately following surgery. The nurse should assess surgical incisions and respiratory status and give the scheduled antibiotic. (Option 4) After NPO status is discontinued, the client should be offered fluids. This task can be delegated to unlicensed assistive personnel and is not the priority. Educational objective:Ventricular bigeminy in a client following a myocardial infarction indicates risk for developing ventricular tachycardia or ventricular fibrillation, both potentially life-threatening dysrhythmias. The nurse should assess the client's vital signs, electrolytes, and apical-radial pulse, and notify the health care provider. Additional Information Management of Care NCSBN Client Need

A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent? 1. Administer prescribed PRN lorazepam and apply soft wrist restraints (8%) 2. Explain all activities of care clearly and calmly while facing the client (66%) 3. Place the client in the room that is closest to the nurses' station (12%) 4. Request security personnel to be present to protect clients and staff (12%) OmittedCorrect answer 2 66%Answered correctly

Violence in the health care setting poses a safety risk to clients, staff, and visitors. It also decreases the quality of care that a violent client receives due to avoidant and fearful behaviors by staff. Risk factors for violence include altered level of consciousness, substance abuse, emotional stress, and behavioral/psychiatric disorders. Nursing interventions that help prevent violence include using clear, thorough communication (Option 2); encouraging active participation in care; promoting a low-stimulation environment; and providing comfort through pharmacological and nonpharmacological methods. The nurse should demonstrate undivided attention to the client (eg, facing the client, unhurried body language, calm tone). (Option 1) Chemical (eg, lorazepam) and physical restraints should be used only as last resorts to keep clients and others safe. It is not appropriate to use restraints to prevent escalation to violence. (Option 3) Placing the client near the nurses' station may increase anxiety due to the noise and activity in that area. The client should be closely monitored, but this is not an effective intervention for preventing violence. (Option 4) The presence of security personnel does not prevent violence and may cause increased client anxiety. The nurse should consider other interventions (eg, effective communication) to prevent violence. Educational objective:Violence is a safety concern for all in the health care setting. Nurses must identify those at risk for violent behavior and use clear, thorough communication to prevent violence. The nurse should provide undivided attention to the client while explaining all activities of care in a calm tone.

/A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Discard aspirated gastric residual in a biohazard container 2. Flush the nasogastric tube before and after administering the feeding 3. Place the client in the semi-Fowler position 4. Start the feeding after obtaining a gastric residual volume of 75 mL 5. Start the feeding when the gastric residual has pH of 6 OmittedCorrect answer 2,3,4 27%Answered correctly

When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees (semi-Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk (Option 3). Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic tests). Feeding tubes should be flushed before and after feedings to keep the tube patent (Option 2). Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV (eg, >500 mL) to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well (Option 4). Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance (eg, abdominal distension, nausea/vomiting), which may indicate that feedings should be held or reduced in volume. (Option 1) Aspirated GRV should be returned to the stomach. If acidic gastric juices are repeatedly discarded, there is risk for hypokalemia and metabolic alkalosis. (Option 5) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. Newly inserted nasogastric tubes also require x-ray confirmation before feedings are initiated. Educational objective:When administering bolus enteral feedings, the nurse should place the client in semi-Fowler position, check gastric residual volumes (GRVs) as prescribed, verify acidic pH ≤5, return aspirated GRV to the stomach, and flush the tube before and after feedings.

/The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? Select all that apply. 1. Attach wrist restraint straps to the upper side rails 2. Position the client supine to keep restraint straps taut 3. Release restraints at regular intervals and assess behavior 4. Use a square knot to tie restraint straps to the bed 5. Use gauze to pad bony prominences under restraints OmittedCorrect answer 3,5 22%Answered correctly

When caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (eg, every 2 hours): Provide skin care and range-of-motion exercises; ensure basic needs are met (eg, fluids, nutrition, elimination). Assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints, if necessary, to protect skin (Option 5). Determine the need for continued restraint by releasing restraints briefly and assessing the client's reaction; regularly assessing the need for restraints promotes discontinuation as soon as possible (Option 3). (Option 1) Restraint straps should be attached to areas that move with the bed frame (ie, elevates with the frame and head of the bed). Areas that do not move with (eg, base) or move independently of (eg, side rails) the frame should never be used, as injury may occur when they are raised or lowered (eg, pulling, entrapment). (Option 2) Supine positioning increases aspiration risk as the client may be unable to self-reposition if vomiting occurs. Side-lying or semi-Fowler position promotes drainage of emesis or oral secretions. (Option 4) Restraint straps should be tied in a quick-release knot, in case of emergency, and never in a square knot, which is difficult to release quickly. Educational objective:Nurses caring for restrained clients must ensure that basic needs are met, assess skin integrity and neurovascular status of restrained extremities, and determine the need for continued use. Supine position is avoided to decrease aspiration risk. Quick-release knots are used to attach restraints to parts of the bed frame that move with bed position changes. Additional Information Safety and Infection Control NCSBN Client Need