NCLEX REVIEW 3

Which of the following signs and symptoms are expected for your patient experiencing placental abruption? Select all that apply.

A. Dark red bleeding (Pain) B. Hypotension C. Rigid abdomen

When interpreting results from a direct Coombs test, you know that a positive result indicates which of the following?

A. Maternal antibodies are present on the infant's red blood cells B. The infant is at risk for erythroblastosis fetails

The nurse is caring for several clients in a long-term care facility. Which interventions should the nurse implement to reduce the risk of injury from falls? Select all that apply.

A. Secure the call button to the side of the bed B. Keep the bed in the lowest position C. Place fall risk bands on clients at risk of falling

Rationalization

Apparent logical reasons are given to justify behavior that is motivated by unconscious instinctual impulses 현실 회피를 위한 정당성을 만든느 것 '정신승리'

Denial

Ignoring or refusing to acknowledge unacceptable realities Example: Planning a vacation in a year after receiving terminal diagnosis

The nurse is in charge of a male client scheduled for a liver biopsy at 8 AM. In preparing this client for the procedure, the nurse should do which of the following?

Inform him that his vital signs will be monitored closely after this procedure. Explain: The client will be monitored closely for bleeding and shock after the procedure. It is appropriate to monitor vital signs.

A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions. After you get the client situated in a labor, delivery, and recovery room, you notice the client's health care provider (HCP) enter the room to evaluate the client. Following the evaluation, the HCP exits the room, and shortly thereafter, you enter. During your discussion, the client states the HCP "went to order oxytocin." In anticipation of that order, you understand this client's oxytocin will be administered via which route of administration?

Intravenous administration via piggyback using an infusion pump Explain: Oxytocin should always be administered intravenously as a piggyback infusion.

The nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following would indicate the client is achieving the treatment goals?

Mean arterial pressure (MAP) 71 mmHg Explain: For a client with DKA, hypovolemia and hyperglycemia are the primary problems. Hyperglycemia contributes to acidosis and hypovolemia. A normal MAP would indicate effective tissue perfusion and, thus, would be a favorable finding indicating that the hypovolemia has resolved. Normal MAP is between 70 and 100 mm Hg.

Your 78-year-old client has been receiving antibiotics for ten days and tells you that he is having frequent watery stools. Which action will you take first?

Place the client on contact precautions Explain: The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be to place him on contact precautions in order to prevent the spread of C. difficile to other clients.

Displacement

Redirecting feelings to a safer, substitute object 선택적으로 감정 풀이를 하는 행위 '종로에서 뺨 맞고 한강에서 눈 흘긴다' 가스라이팅의 대표적인 사례 Example: When placed to sit in time- out, a child kicks and knocks over the chair

Regression

Reverting to behaviors from an earlier stage of development in response to extreme stress 심각한 스트레스나 위험에 처했을 때 회피 수단으로 발달 단계를 역행한느 것 Example: A teenager experiences episodes of wetting the bed after being bullied

Risperidone

Second-generation antipsychotic used in delirium, schizophrenia, and some childhood disorders.

Sjögren's syndrome

describes a condition of dry eyes and dry mouth that is experienced by approximately 20% of patients with scleroderma.

Telangiectasia

describes the presence of red spots on the hands, forearms, palms, face, and lips due to capillary dilation.

Sclerodactyly

describes the tightening of the skin of fingers and toes.

Acyclovir

given to slow the growth of the herpes virus

D2.5W

hypotonic solution.

D5NS

is a hypertonic solution

D51/4NS

is an isotonic solution

0.33% NS

is hypotonic solution

The nurse is developing a plan of care for a client who had bariatric surgery. Which of the following should the nurse include?

pneumatic compression device Explain: Following bariatric surgery, the client faces various complications, including hemorrhage, wound disruption, pneumonia, and infection. Venous thromboembolism is a significant complication and may be mitigated using pneumatic compression devices as well as chemical prophylaxis.

The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client

recovering from cardiac catheterization that has developed atrial fibrillation. Explain: Following a cardiac catheterization, the nurse should assess the client closely for any arrhythmias, including atrial fibrillation. This is a significant finding as the client will have an increased risk of thrombosis, which may migrate and cause a cerebrovascular accident (CVA).

Haloperidol and fluphenazine

typical antipsychotics indicated in the treatment of schizophrenia (choices A, B). These medications do not modulate serotonin; therefore, they have no use in anxiety disorders.

The nurse is assessing a client with Guillain Barré syndrome. Which of the following would be an expected finding?

Paresthesia Explain: Guillain Barré is a polyneuropathy manifested by paralysis, paresthesia, autonomic disturbances, and depressed or absent reflexes. The paresthesia is typically found in the peripheral extremities and may persist for quite some time, even after the return of motor function.

If a female patient weighed 7 lbs at birth, the nurse would expect her weight at her 2-year-old well-child visit to be:

35 lbs Explain: First 3 month - 175-210g per week 5 month- double 6th month onwards - 400g per month 1yr- three times 2yr- four times 3yr- five times

You are caring for a client who is complaining of phantom limb pain after a below-the-knee amputation. What type of pain is this client most likely experiencing?

Peripheral neuropathic pain

Select an appropriate nursing diagnosis for your client who is affected with hyperalgesia.

A risk for abnormal and irreversible pain related to hyperalgesia

Which of the following are potential complications of cleft lip and cleft palate in the infant?

A. Ear infections B. Feeding difficulties C. Speech delay

Which of the following medications are used in the treatment of panic disorders?

A. Amitriptyline B. Diazepam C. Phenelzine

Pressure ulcer prevention

A. Applies zinc oxide to the client's perineal skin B. Uses a pillow to float the client's heels No donut pillow

The nurse is reviewing dietary teaching with a client who has hypercalcemia. Which foods should the nurse recommend that the client avoid?

A. Broccoli B. 2% milk C. Seafood High in Calcium

The nurse is caring for a client diagnosed with atrial fibrillation. The nurse should anticipate a prescription for which of the following medications?

A. Diltiazem B. Warfarin

The nurse is performing a physical assessment on a child admitted with erythema infectiosum (Fifth disease). Which of the following would be an expected finding? Select all that apply.

A. Erythema on face B. Headache Explain: Erythema infectiosum (Fifth disease) characteristically causes a child to develop erythema on the face (slapped face appearance). It also causes the appearance of maculopapular red spots distributed on the upper and lower extremities. Finally, the client will have mild flu-like symptoms such as a fever, headache, and malaise.

The nurse is caring for a client who is receiving prescribed olanzapine. Which findings would indicate that the client has an undesired effect of this medication?

A. Hyperglycemia B. Weight gain C. Hyperlipidemia Explain: Olanzapine is a second-generation antipsychotic (SGA). SGAs such as olanzapine and clozapine have a high risk of causing a client to develop metabolic

You have been asked to lead a health promotion course for the community about cancer. Which of the following symptoms should you include in your education about early signs and symptoms of cancer?

A. Incontinence B. Trouble swallowing

The nurse cares for a newly admitted client with a full-thickness burn of over 25% of the total body surface area. The nurse should take which of the following actions? Select all that apply.

A. Keep the patient on NPO status B. Obtain 12-lead electrocardiogram C. Obtain an arterial blood gas (ABG)

The nurse is planning a staff development conference about the causes of labor dystocia. It would be correct for the nurse to identify which of the following may cause a delayed progression during labor? Select all that apply.

A. Magnesium sulfate infusion B. Uterine overdistention C. Hypoglycemia D. Epidural analgesia

Innervation of chest with

T1-T8

A mental health clinic is being constructed in a local community. A nurse manager is hired to facilitate the unit's nursing policies. Which of the following is the best resource for these policies?

Nurse Practice Act Explain: The Nurse Practice Act describes the scope of nursing practice. It directs the philosophy and standards of nursing. The formulation of policies and procedures should be based on this document.

Analyze the following ABG: pH 7.36, CO2 69, HCO3 37

Compensated respiratory acidosis Explain: First, determine if the ABG is compensated or uncompensated. Because the pH is between 7.35 and 7.45, it is compensated. You know this because the pH is normal, but the CO2 and HCO3 are not. Next, determine if it is acidosis or alkalosis. The pH is closer to 7.35, which anything less than would be acidotic, so it is an acidosis. Lastly, determine if it is respiratory or metabolic. To do this match, which value, CO2 or HCO3, coincides with the pH. CO2 is acidic, and HCO3 is basic. In this example, we have an acidosis, so the CO2 is what corresponds, making this a respiratory issue. Putting it all together, this case would be compensated respiratory acidosis. This patient is retaining CO2, which is causing them to become acidotic. In response, the kidneys are increasing the production of bicarbonate to bring the pH back into a healthy range. They have been able to compensate for respiratory acidosis.

The nurse is caring for a client who sustained an ischemic cerebrovascular accident (CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg. The nurse should take which action?

Continue to monitor Explain: Permissive hypertension during an ischemic stroke allows the blood pressure to go up to 185/110 mm Hg. This enables perfusion around the stroke to distal tissue. Thus, the nurse will continue to monitor because the blood pressure of 168/101 mmHg does not meet the threshold to notify the PCP. A blood pressure of 150/100 mm Hg is needed to maintain cerebral perfusion after an acute ischemic stroke.

The nurse is caring for a hospitalized infant due to dehydration and failure to thrive. The nurse notes that her mother is a drug user. With this knowledge, the nurse would expect the child to develop:

Mistrust Explain: An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in this case of the infant with a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment.

A 55-year-old client with osteoarthritis develops coagulopathy due to long-term NSAID use. The nurse caring for the client understands that the client's coagulopathy is mainly the result of:

Decreased platelet adhesiveness Explain: Platelets play vital roles in hemostasis and thrombosis and can be inhibited by nonsteroidal anti‐inflammatory drugs (NSAIDs). NSAIDs reduce platelet adhesiveness, therefore impairing coagulation.

A male client with chronic renal failure has questions regarding the effects of his kidney disease on his sexual activity. Which of the following is a sexual complication of chronic renal failure?

Decreased testosterone Explain: Chronic renal failure causes decreased testosterone levels. Low testosterone results in reduced sex drive

Which of the following psychological symptoms, occurring at the end of life, is accurately paired with an appropriate intervention that you would incorporate into your client's plan of care?

Hallucination: Dopamine antagonist

Legs

L3

Two nurses are taking an apical-radial pulse and note a difference in the pulse rate of 8 bpm. The nurse would document this difference as to which of the following?

Pulse deficit Explain: Counting of the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical-radial pulse rate. A difference between the apical and radial pulse rates is called the pulse deficit, which indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated. When taking a pulse, the rate, rhythm, and strength or amplitude of the pulse are noted. The average pulse in an adult is between 60 and 100 beats per minute. The rhythm is checked for possible irregularities, which may be an indication of the general condition of the heart and the circulatory system.

At an eating disorder treatment center, a nurse is caring for a client with anorexia nervosa who has recently arrived at the facility. Which intervention should the nurse apply following the client's meals?

Restrict the client from using the restroom for 90 minutes after each meal

You are the registered nurse in a multi-ethnic community health department clinic. In this role, you are asked to identify clients with genetic risk factors related to ethnicity to screen them for some commonly occurring diseases. You would identify a client who is of:

Saudi Arabian ethnicity for sickle cell anemia

The nurse is caring for a client who sustained a fractured tibia and fibula and has a cast applied to the extremity. Which of the following findings would indicate the client has developed compartment syndrome?

Severe pain that is unrelieved by an opioid analgesic

You are taking care of a 10-year-old with a gastro-jejunostomy (GJ) tube. Which electrolyte deficit is this patient at risk for?

Sodium Explain: There is a large amount of extracellular fluid in the peritoneal cavity, which contains a high amount of sodium. If this fluid is lost through the GJ tube, there will be a sodium deficit

The nurse is caring for a client with the below laboratory result. Which early vital sign change would the nurse expect to support this finding? See the image below. Hgb- 5.6g/dL Hematocrit- 16.8%

Tachycardia Explain: The hemoglobin and hematocrit are critically low in this client. When critically low hemoglobin is evident, the nurse will likely see the client demonstrate tachycardia as a compensatory mechanism for the low blood volume. Tachycardia is the most reliable and earliest sign of hypovolemic shock.

Which of the following suspected diagnoses requires immediate referral for a 21-year-old patient with complaints of scrotal pain?

Testicular torsion Explain: Testicular torsion requires immediate surgical intervention to prevent strangulation of the testicle.

Which legislative initiative is the most closely related to information technology utilized in healthcare organizations?

The Confidentiality and information security rule Explain: The Confidentiality and Information Security rule under the Health Insurance Portability and Accountability Act (HIPAA) is the legislative initiative that is the most closely and specifically related to information technology that is utilized in healthcare organizations. This rule specifically addresses the need for data security and protection.

Which of the following is an expected outcome for a pediatric client who is transitioning from being a toddler to a pre-school child?

The child will develop new coping strategies to adapt to a maturational crisis

The client in the delivery room has just delivered her third child. The physician ordered methylergonovine (Methergine) for the client and it was promptly administered. Which manifestation would indicate to the nurse that the medication is having its intended effect?

The nurse palpates a firm uterus on the client Explain: Methylergonovine promotes vasoconstriction and uterine contraction. A firm and contracted uterus is a sign that the medication is having its desired effect.

The nurse has provided medication instruction to a client who has been prescribed metformin. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching?

This medication may cause me to have bloating or loose stools Explain: The most common side-effect associated with Metformin is gastrointestinal upset. This side-effect typically occurs at the start of the therapy and subsides over time. To minimize these effects, the client should take this medication with meals, or they may be prescribed the extended-release form.

Analyze the following ABG: pH 7.19, CO2 36, HCO3 12

Uncompensated metabolic acidosis Explain: First, determine if the ABG is compensated or uncompensated. Since the pH is not between 7.35 and 7.45, it is uncompensated. Next, decide whether it is acidosis or alkalosis. The pH is less than 7.35, so it is an acidosis. Lastly, determine if it is respiratory or metabolic. Evaluate the CO2 and HCO3 to see which is out of range. The CO2 is average, and the HCO3 is low, so this is a metabolic problem. Putting it all together, you have an uncompensated metabolic acidosis.

Repression

Unconscious suppression of unwanted thoughts or information from consciousness Example: After being mugged, a person is unable to recall the experience

The nurse works on a medical/surgical unit and cares for a patient receiving digoxin and furosemide. Which of the following, if reported by the patient, must be assessed immediately?

Vomiting and halos around lights Explain: Furosemide causes the patient to lose potassium. Digoxin, if taken when the patient has a low potassium level, can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights.

Reaction-formation

a person unconsciously replaces an unwanted or anxiety-provoking impulse with its opposite, often expressed in an exaggerated or showy way. 실제 자신의 느낌과는 반대의 행위를 하는 거승로 미운 놈 떡 하나 더 준다 같은 것

Methylphenidate

treatment of ADHD, and its stimulating effects may even worsen anxiety

Ribavirin

used to treat hepatitis C

Parkinson's disease TX

A. levodopa-carbidopa B. ropinirole C. diazepam D. pramipexole

The nurse is providing discharge teaching to a patient receiving sulfamethoxazole. Which of the following instructions should be given during this teaching?

Drink plenty of fluids Explain: Sulfamethoxazole (SMX) is used to treat urinary tract infections and should be taken with plenty of water. Each dose should be taken with a full glass of water.

The nurse has instructed a client who is being discharged with crutches about using stairs. Which statement by the client would indicate a correct understanding of the teaching?

I should hold the handrail for support with one hand Explain: This statement is correct and indicates an understanding of using crutches. The client should place both crutches on the side away from the handrail and then hold the handrail for support with one hand. The client should lead with their affected leg and crutch as they descend the stairs. When a client is ascending stairs, the client leads with the stronger leg. When the client is descending the stairs, the client should lead with the affected leg. The client must always have a rubber tip on the crutch to ensure appropriate traction.

The nurse is caring for a patient with a T5 spinal cord injury. Which assessment information would indicate to the nurse that the patient is experiencing autonomic dysreflexia?

Headache Explain: Autonomic dysreflexia is a severe, uncompensated cardiovascular reaction that occurs in response to visceral stimulation after spinal shock has resolved. Patients with spinal cord injuries at T6 or above are at risk of developing autonomic dysreflexia. A sudden, throbbing headache is one of the most important warning symptoms that a patient is experiencing this life-threatening condition.

The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with

Heart failure receiving diuretics Explain: Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate client to room with would be an individual receiving intravenous diuretics for heart failure as this client does not have any transmissible pathogens.

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?

Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor Explain: For a client who is ambulating, the nurse should always be slightly behind the client and positioned on the affected (weaker) side. If a client starts to fall, the nurse should hold the gait belt, try to extend one leg, let the client slide against the leg, and gently lower the client to the floor, protecting the head. The nurse can help prevent client injury by maintaining a wide base of support.

The nurse is caring for a neonate experiencing cold stress. The nurse should also assess the neonate for

Hypoglycemia Explain: When a neonate develops hypoglycemia, norepinephrine is released, causing tachycardia which causes an increase in glucose metabolism. This increase in glucose metabolism depletes the neonate's reserve of glucose. If a neonate is experiencing cold stress, the nurse should warm the neonate by applying warm clothes, removing the neonate from any drafts, and ensuring the neonate is dry. The nurse should assess the neonate for hypoglycemia via heel stick once the neonate's temperature stabilizes.

Your client asks you which foods he can eat so that he gets the recommended daily allowance of vitamins. Select the vitamins that are accurately paired with major food sources.

Folate (B9): Citrus and milk VK: Liver and leafy green vegetables VD: Fish and fortified milk Pantothenic acid (B5): Grains and legumes Niacin (B3): meats, liver, fish, legumes, peanuts, coffee, and tea Riboflavin (B2): leafy green vegetables and milk

The nurse is caring for a 3-year-old boy that is admitted for pneumonia. The nurse notices that the boy is always irritable and anxious. Which action by the nurse is most appropriate?

Give the child some molding clay Explain: Children release their anxiety by pounding, hitting, running, punching, or shouting. Giving the child some molding clay allows the child to pound and hit the clay flat, helping him relieve his anxiety.

You are caring for a toddler who is experiencing pain as the result of a tonsillectomy. Which independent nursing intervention would you implement in terms of this pain?

Give the toddler a "magic" blanket to take the pain away. Explain: Toddlers are magical and mystical thinkers so this "magic" blanket may be an effective pain management technique for children of this age.

The nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below. Sinus Tachycardia

Graves' disease This tracing reflects sinus tachycardia (ST). ST can be caused by an array of conditions such as dehydration, hypo- and hyperglycemia, stress, anxiety, and thyroid conditions such as hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism, and this increased metabolic and sympathetic activity would cause tachycardia.

The 6-year-old immigrant child has been diagnosed with Hepatitis A. He was brought from Mexico by his grandparents a few days ago. You would expect that treatment for this child will include:

Supportive care Explain: Removing the source of the infection and providing a healthy diet will often help resolve the infection. A hepatitis A vaccine is available that should be given to all children and high-risk adults. This vaccine should be given in two doses.

The prenatal client is 7 months pregnant and wants to start an exercise program. The nurse should suggest which of the following exercises to the patient?

Swimming Explain: Swimming is the best exercise at this point in the mother's pregnancy. Swimming is low impact and requires no balance, which can be troublesome with the weight a woman carries in her third trimester.

Innervation of the abdomen corresponds to

T9 to T12 injury

Identification

an individual, in varying degree, makes himself or herself like someone else; he identifies with another person. 오이디푸스 콤플렉스나 엘렉트라 콤플렉스, 오마주 등을 들 수 있으나 '손민수한다'

At the time of birth, the nurse should accomplish the following tasks:

1. Assess muscle tone and presence of respiratory effort 2. Clear secretions as needed 3. Assess the newborn's heart rate 4. Provide positive pressure ventilation

The nurse administers a combination of regular insulin and NPH insulin subcutaneously to a client at 0800. At which time should the nurse assess the client for hypoglycemia?

1000 Explain: Regular insulin is short-acting and will peak two to four hours after subcutaneous administration. Assessing the client at 1000 would be when the regular insulin would peak and thus, be the likely time for the client to exhibit hypoglycemia symptoms. The second peak will occur four to twelve hours after administering NPH insulin or around noon.

Which of the following clients is at the highest risk for complications related to folate deficiency?

25-year-old woman who is attempting to get pregnant Explain: Evidence shows that adequate intake of folate before conception and in the first trimester of pregnancy reduces the incidence of neural tube defects. The U.S. Public Health Service recommends that all women of childbearing age and capable of pregnancy consume 400 ugs of synthetic folic acid daily from either foods or supplements

The nurse is caring for a client diagnosed with Generalized Anxiety Disorder (GAD). The nurse should anticipate a prescription for which medication?

Buspirone Buspirone is a serotonergic agent that is efficacious in the treatment of anxiety. It is approved by Food and Drug Agency (FDA) for generalized anxiety disorder (GAD). While buspirone is primarily used to treat generalized anxiety disorder, it also treats depression, social phobia, and ataxia. Buspirone takes time to work (approximately two to four weeks), and the clients should be counseled that they may not appreciate a symptom improvement during that period.

Innervation of the arm correlates with

C5 to T1

Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient?

A. Circumferential burns on the feet B. Same thickness of skin damage throughout the burn Explain: Circumferential burns on the feet would lead you to suspect non-accidental trauma in a 1-year-old. As a mandatory reporter, you are required to report these suspicions. Circumferential burns are full-thickness burns affecting the entire circumference of an area. They are very dangerous and can cause serious complications. A burn that has the same thickness of skin damage throughout the burn is suspicious for non-accidental trauma. In an accident where something such as boiling water was spilled, the water will cool as it moves and leaves different levels of tissue damage in different areas. Likewise, if the child splashes in a bathtub with water that is too hot, areas will be affected differently. If the burn has the same thickness of skin damage throughout, it is suspicious for being non-accidental.

The nurse knows that her patient with acute myeloid leukemia (AML) is neutropenic. When reviewing their CBC results in the morning, which of the following does she expect?

A. Decreased neutrophil count B. Increased blast percentage C. Decreased platelet count Explain: The patient with AML will have an increased percentage of blast cells. Blast cells are immature neutrophils. The patient with AML will have a decreased platelet count. This is because of the proliferation of blast cells and suppression of other standard and healthy cells in her bone marrow.

Select the normal physiological changes associated with the aging process that can adversely affect the excretion and elimination of medications in the human body.

A. Diminished glomerular filtration B. Low functioning nephrons

Which of the following anatomical characteristics are descriptive of the congenital heart defect tetralogy of Fallot?

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

The nurse is teaching a client about methotrexate (MTX). Which of the following statements should the nurse include?

A. This medication may cause you to bruise more easily. B. You will need to take folic acid with this medication C. Avoid large crowds and wash your hands frequently Explain: Methotrexate (MTX) is indicated for a variety of autoimmune conditions. This medication carries serious adverse effects such as pancytopenia (low red blood cells, white blood cells, and platelets). Thus, the client may bruise more easily and be at a higher risk of infection, so avoiding crowded areas and practicing good hand hygiene is essential. MTX antagonizes folic acid, and while a client is taking MTX, folic acid supplementation is typically prescribed.

Which of the following falls under the right dose of the 8 rights of medication administration?

A. Using a drug reference to verify that the dose ordered is appropriate B. Having a second nurse independently calculate the medication dosage

Sublimation

Channeling negative emotions or socially unacceptable impulses into socially acceptable behavior 전치의 긍적적인 영향으로 볼 수 있는 사례 (예술 등에 몰두한다) Example: Deep cleaning the entire house after a breakup

The nurse is teaching parents of a child diagnosed with varicella. Which of the following information should the nurse include? Select all that apply.

A. Your child may return to school once the lesions have crusted. B. Acetaminophen may be used for fever C. Warm baths with baking soda may help with the itching D. Do not use any aspirin or ibuprofen during the illness. Explain: Varicella is a highly contagious virus that may be spread by aerosolized droplets, contact with lesions, and contaminated surfaces. A child may return to school once all the lesions have crusted over. Fever is a common manifestation associated with varicella, and acetaminophen may be taken as prescribed to decrease the fever. Symptomatic care for a child with varicella includes warm baths with products such as baking soda or uncooked oatmeal added to relieve itching. Calamine lotion may also be applied to soothe the skin. Ibuprofen and aspirin should not be taken during the course of the illness because they may cause life-threatening skin infections.

A woman in her 30th week of gestation was brought into the emergency department for falling down a flight of stairs. On evaluation, the physician notes a rigid, board-like abdomen. FHR is 167 bpm; with otherwise, stable vital signs. Which obstetric emergency must be anticipated considering a possible abdominal trauma?

Abruptio placentae Explain: External trauma can lead to abruptio placentae, the complete or partial separation of the placenta from the uterine wall. A sign that concealed hemorrhage has occurred is the rapid increase in uterine size along with rigidity.

As part of your psychosocial assessment of a 46-year-old female client, you would most likely assess which of the following in the client?

Affect Explain: You would most likely assess the client's affect and mood as part of your psychosocial assessment of a 46-year-old female client. The effect is an indicator of the client's psychological disposition. For example, a flat affect indicates the abnormal absence of emotion.

Which of the following healthcare providers are responsible for documenting care provided to a patient?

All staff members should document all of the care that they have provided Explain: All staff members, including unlicensed assistive staff like nursing assistants, document and sign all of the care that they have personally provided. For example, the nursing assistants will document the vital signs that they have taken; the licensed practical nurses will document all of the treatments and medications that they have given to the patient, and the registered nurse will document nursing diagnoses and assessments that they have completed.

While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor?

An upper respiratory infection about a month ago Explain: Upper respiratory infections or stomach infections correlate with the development of Guillain-Barre syndrome. Guillain-Barre syndrome is a disorder that involves the peripheral and cranial nerves causing ascending paralysis.

Doxycycline

Antibiotic ➢ Doxycycline absorption may decrease when the client takes it with calcium. ➢ The client should be instructed not to take this medication with calcium-rich foods, dairy products, or antacids containing calcium. The client should take this medication on an empty stomach. ➢ Doxycycline may cause superinfections such as C. diff. Foul-smelling diarrhea that may be accompanied by abdominal cramping should be reported. ➢ Doxycycline can also cause skin reactions, including photosensitivity. The client should be instructed to wear protective clothing, hats, and sunscreen outdoors.

Projection

Attributing one's own feelings, thoughts, behaviors, or motives to others 받아들일 수 없는 현실이나 환경을 외부의 탓으로 돌리는 것. 잘되면 내 탓, 못되면 남 탓 Example: A partner who had an affair is convinced their partner is cheating

A 4-year-old boy is recovering from abdominal surgery at the pediatric unit. As the nurse caring for the child, which of the following activities do you recommend that he prioritize?

Blowing bubbles Explain: if the child is under the age of five or is unable to use the incentive spirometer for another reason, they should blow bubbles for two to three minutes every hour. Blowing bubbles will serve as an alternative to incentive spirometry in these children.

A 35-year-old patient presents to the emergency department complaining of fever, chills, and headaches for the past two days. There is a pink, macular rash on the palms, wrists, and soles of the feet. Which statement by the patient would indicate to the nurse a potential medical emergency?

I went hiking 2 weeks ago Explain: The patient is experiencing symptoms of Rocky Mountain Spotted Fever (RMSF): fever, chills, headache, and a macular rash that appears on the palms of hands, wrists, soles of feet, and ankles within ten days of exposure. RMSF occurs due to Rickettsia rickettsii bacteria that can be transmitted to humans via the Ixodes tick (deer tick). The patient has been hiking, which puts them at risk for coming into contact with ticks. RMSF is hard to diagnose in the early stages and without treatment can be fatal.

The nurse preceptor is observing a newly hired nurse care for a client with a tracheostomy. Which of the following actions by the newly hired nurse would require follow-up by the observing nurse preceptor?

Inflates the tracheostomy's cuff with 5 mL of air to suctioning Explain: These observations are inappropriate and require follow-up. Inflating the cuff of the tracheostomy is not something that is done before suctioning. The purpose of the cuff is to keep the tracheostomy in place. Overinflation can result in significant damage; thus, monitoring the cuff pressure should be done with a manometer. Normal pressure should range between 14-20 mmHg.

What is the priority intervention when caring for an infant diagnosed with transposition of the great arteries?

Initiate alprostadil infusion Explain: Alprostadil will keep the ductus arteriosus from fetal circulation patent, allowing the shunting of blood from left to right so that some oxygenated blood can exit the transposed aorta and be distributed to the body. Without alprostadil administration, the ductus arteriosus will begin to close, and if the infant does not have an ASD or VSD they will become profoundly hypoxic due to the lack of oxygenated blood in the systemic circulation.

Which of the following statements best describes the cardiovascular system?

It is a double-pump circulating blood out to the lungs and the body Explain: The heart is a double pump with four chambers, four valves, and a conduction system with a pacemaker originating in the atrium.

Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate client to room with would be an individual receiving intravenous diuretics for heart failure as this client does not have any transmissible pathogens.

Measure the NG tube length from the bridge of the nose to the earlobe to the halfway point between the umbilicus and the xiphoid process. Explain: For infants ( less than one year of age), the nurse should measure the distance from the bridge of the nose to the earlobe to a point halfway between the xiphoid process and the umbilicus. This measurement ensures that the tube is long enough to enter the stomach. However, for children older than one year, the NG tube measurement should be from the bridge of the nose to the earlobe to the xiphoid process.

You are admitting a new client. During your collection of data for the health history, you ask the client about the medications, including over-the-counter medications, herbs, supplements, and vitamins that they are taking at home. You are performing the:

Medication reconciliation process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)?

Muscle rigidity of the neck Explain: Metoclopramide is a dopamine antagonist in treating gastroparesis, nausea, and vomiting. Dopamine antagonists may induce dystonia which is depicted in this option. This finding is highly concerning.

The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first?

Place the client on droplet precautions Explain: Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. Protecting the other clients and staff from disease transmission is essential for the nurse. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing a surgical mask in the client's presence.

The nurse is caring for a patient with a medical diagnosis of scleroderma who reports fingertips tingling and turning white in response to cold or stress. The nurse would recognize these symptoms as which problem?

Raynaud's phenomenon Explain: This patient's symptoms are consistent with Raynaud's phenomenon. This condition is characterized by sudden or intermittent vasospasms in the fingertips and toes in response to cold temperatures or stress, resulting in decreased blood flow and blanching of the skin in these areas. This phase is typically followed by a blue phase, when hemoglobin releases oxygen into these tissues, and a red phase, when the areas are rewarmed. Sensations of tingling and numbness are common during these episodes.

The charge nurse is assigning tasks to a unlicensed assistive personnel (UAP). Which task would be appropriate to delegate?

Record how much drainage is in the suction cannister Explain: Recording intake and output is a skill within the scope of a UAP. This task may be appropriately delegated to a UAP to complete. UAPs cannot perform any task that requires sterility. Collecting urine from an indwelling catheter requires clamping the tubing and collecting the urine using a sterile syringe and a sterile container. UAPs may assist with clean catch urine specimen collections, but not collection from an indwelling catheter.

The nurse is caring for a client who reports excessive flatulence and abdominal cramping. The nurse anticipates a prescription for

Simethicone

Single crease on the palm

Simian crease- indicate that the child has Down's syndrome.

Which activity would best promote the achievement of school-age child development?

Simon says Explain: The most appropriate action for school-age children is Simon says, as it promotes cooperation with some competition, refines communication skills, and is a group activity.

Chemotherapy induces vomiting by:

Stimulating neuroreceptors in the medulla Explain: Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to the expulsion of gastric contents.