Archer Review 14b

The nurse is assessing a client with possible bipolar I disorder. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which laboratory testing? A. Thyroid Stimulating Hormone (TSH) [35%] B. Complete Metabolic Panel (CMP) [51%] C. Glycated Hemoglobin A1C (HbA1c) [3%] D. C-Reactive Protein (CRP) [11%]

Explanation Choice A is correct. A TSH is the standard of care prior to diagnosing a mood disorder such as bipolar disorder or major depressive disorder. While this test does not confirm the presence of a mood disorder, it excludes alterations of the thyroid, which could alternatively explain the client's symptoms. Choices B, C, and D are incorrect. A CMP would not necessarily explain mood symptoms. Most certainly, alterations in electrolytes may influence mood, but not to the extent of an actual disorder as it would be transient. An HbA1c would be useful to determine if the client has diabetes mellitus as well as how they are managing their glucose levels. CRP would be an inflammatory marker and is not specific to a psychiatric disorder. NCLEX Category: Psychosocial Integrity Activity Statement: Mental Health Concepts Question type: Analysis

The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using A. soft wrist restraints. [72%] B. mitten restraints. [8%] C. elbow restraints. [9%] D. waist belt restraint. [11%]

Explanation Choice A is correct For the client being physically violent towards staff, the nurse may, as prescribed, chemically restrain the client or physically restrain the client. The appropriate option for this client is to either seclude the individual or use soft wrist restraints. Choices B, C, and D are incorrect. Mitten restraints would be appropriate if the client attempted to disconnect medical tubing or devices. This could be plausible if tethered to the frame, but mittens are more restrictive than necessary. Elbow restraints make removing a medical device near the face or neck difficult. It does not impede the removal of abdominal or urinary medical devices. Waist belt restraints would still allow the client to hit staff. This type of restraint is best utilized for confused or impulsive clients who are continually trying to get out of bed or a chair after repeated redirection. Additional Info Soft wrist restraints are best utilized for clients becoming increasingly agitated, cannot be redirected with distraction, and keep trying to remove needed medical devices. This type of restraint may also be applied to the ankles. Elbow restraints make it difficult for a client to remove a medical device near the face or neck. It does not impede the removal of abdominal or urinary medical devices. Waist belt restraints are utilized for confused or impulsive clients who are continually trying to get out of bed or a chair after repeated redirection. Mitten restraints are only considered a restraint if they are tethered to an immovable object and the client cannot remove it from their hand. This restraint is appropriate if the client attempts to disconnect medical tubing or devices.

A client admitted for a pneumothorax three days ago accidentally pulled out his chest tube. Which action should be the nurse's initial intervention? A. Arrange for a chest x-ray. [1%] B. Reinsert the tube herself. [1%] C. Notify the physician. [9%] D. Place a vaseline gauze over the incision site.

Explanation Choice D is correct. The nurse should cover the incision site with an occlusive dressing whenever a chest tube is pulled out. This action places a seal over the site. The nurse should then notify the physician regarding the incident. Choice A is incorrect. A chest x-ray might be ordered by the physician to check for lung expansion. However, this is not the initial action for the nurse. Choice B is incorrect. The nurse is not allowed to insert a chest tube into the client. Choice C is incorrect. The nurse must place an occlusive dressing first before notifying the physician.

Which of the following are bypasses in fetal circulation? Select all that apply. A. Ductus arteriosus [41%] B. Foramen ovale [31%] C. Ductus pulmonic [16%] D. Foramen aortic [12%]

Explanation Choices A and B are correct. The ductus arteriosus is a bypass in fetal circulation. It connects the pulmonary artery to the aorta (Choice A). The foramen ovale is a bypass in fetal circulation. It is an opening between the right and left atriums of the heart (Choice B). Choice C is incorrect. There is no ductus pulmonic; this is not a bypass in fetal circulation. Choice D is incorrect. There is no foramen aortic; this is not a bypass in fetal circulation. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk of the potential reduction, Newborn

Which of the following signs does the nurse know to expect for her 1-year-old patient in heart failure? Select all that apply. A. Diaphoresis [31%] B. Weight loss [17%] C. Insomnia [12%] D. Poor feeding [39%]

Explanation Choices A and D are correct. Diaphoresis, or increased sweating (Choice A), is an expected clinical manifestation of heart failure. As the heart works harder and harder to maintain cardiac output, the body starts to tire and this is manifested in signs such as diaphoresis. Diaphoresis is possibly related to a catecholamine surge and can mainly occur during feeding when the infant/child attempts to eat while in respiratory distress. Poor nutrition (Choice D) is another expected clinical manifestation of heart failure in infants and children. As the left side of the heart begins to fail, there is fluid backing up in the lungs (pulmonary edema). This causes dyspnea and makes eating increasingly tricky for patients. Choice B is incorrect. Weight gain, rather than loss, is an expected clinical manifestation of heart failure. Weight gain is secondary to fluid retention. In heart failure (especially with right heart failure), the heart struggles to move fluid forward in the body and therefore liquid begins to back up, causing venous congestion and weight gain. Venous congestion in right-sided heart failure manifest with liver enlargement (hepatomegaly), ascites, pleural effusion, peripheral edema, and jugular venous distension. Venous congestion in left-sided heart failure manifests with tachypnea, intercostal retractions, nasal flaring or grunting, rales, and pulmonary edema. Primary mechanisms of fluid retention in heart failure include reduced renal perfusion and, thereby, activation of the renin-angiotensin-aldosterone system. Increased aldosterone production leads to sodium and water retention. Congestion in patients with chronic heart failure usually develops over weeks or even months. In the case of exacerbations of congestive heart failure (CHF), patients may present 'acutely' having gained several liters of excess fluid and hence several pounds of excess weight. Therefore, management in these acute CHF exacerbation patients involves removing that excess fluid (acutely retained fluid) and transitioning them back to a diagnosis of chronic heart failure. In managing clients with acute CHF exacerbation, daily weight monitoring is a crucial measure to monitor outcomes and achieve desired weight loss (removal of excess fluid). Loop diuretics are the principal agents to attain that target. Choice C is incorrect. Insomnia is not an expected clinical manifestation of heart failure in children. These patients are often very fatigued but do not typically experience insomnia. Although paroxysmal nocturnal dyspnea and orthopnea in left heart failure may cause some sleep disturbances, insomnia is not a commonly reported direct symptom of heart failure. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological adaptation.

Ergonomic principles are most closely associated with: A. Normal bodily alignment [71%] B. The control of infection [6%] C. Preventing congenital abnormalities [5%] D. Preventing hospital-acquired infections [17%]

Explanation Choice A is correct. Ergonomic principles are most closely associated with normal bodily alignment. Ergonomics is defined as a body of knowledge and laws related to human anatomy, physiology, and proper physical alignment. Ergonomics and the ergonomic design of workplace items aim to protect the safety, comfort, and efficiency of work processes. Choice B is incorrect. Standard precautions and transmission-based precaution principles are closely associated with the control of infection, not ergonomic principles. Choice C is incorrect. Ergonomic principles have nothing to do with the prevention of congenital abnormalities. However, proper prenatal care standards and policies do. Choice D is incorrect. Standard precautions and transmission-based precaution principles are closely associated with preventing hospital-acquired infections, not ergonomic principles.

You have been asked to present a class about priority setting to a group of new graduate nurses. Whose theory should you include in this class? A. Maslow's theory [89%] B. Piaget's theory [3%] C. Orem's theory [5%] D. Skinner's theory [2%]

Explanation Choice A is correct. You should include Maslow's Hierarchy of Needs theory in this class about priority setting. Maslow's approach is the most popular and most frequently used theory to determine priorities from the most basic physical needs to the most advanced self-actualization needs. The argument is often presented as a five-level pyramid. When answering NCLEX questions, it is important to note that basic/lower-level needs are of "HIGHEST" priority. Choice B is incorrect. Piaget's theory addresses the cognitive development of infants and children along the life span and would not be included in a class about priority setting. Choice C is incorrect. Orem's theory addresses the self-care needs of clients and would not be included in a class about priority setting. Choice D is incorrect. Skinner's theory addresses operant conditioning and would not be included in a class about priority setting.

The nurse is planning a staff development conference about restraints. Which of the following information should the nurse include? Select all that apply. A. Mittens are not restraints if untethered and the client is physically able to remove the mitt. [16%] B. Elbow restraints may allow a client to remove abdominal or urinary medical devices. [17%] C. Soft wrist restraints should be removed one at a time if a client is violent. [23%] D. Belt restraints may be prescribed on an as-needed basis. [15%] E. Belt restraints should be applied over a client's clothing garments. [29%]

Explanation Choices A, B, C, and E are correct These statements are true and should be included in the conference. Mittens are not considered restraints if they are untethered, and the client may be able to remove the mitt. Elbow restraints make it difficult to remove a medical device near the face or neck. It does not impede the removal of abdominal or urinary medical devices. Belt restraints should be applied over a client's clothing and secured to the bedframe. Significant impairment to a client's skin may result if the belt is directly applied over the skin. Choice D is incorrect. Physical restraints, no matter the type, cannot be utilized on an as needed (PRN) basis. Physical restraint usage should be appropriately justified based on the client's behavior at that time of the demonstration. This information should not be included because it is incorrect. Additional Info Restraints should be used as a last resort if alternative methods are not effective. A nurse should never threaten a client with restraints. This is considered assault. The nurse may place a client who is violent in restraints without an order from the primary healthcare provider (PHCP). If this was to occur, the nurse has one hour to inform the provider and obtain an order. Restraints are never as needed (PRN). They should be discontinued at the earliest possible time. When restraining a client, the reason for the restraint must be explained to the client and the behavior the client needs to demonstrate for the restraints to be discontinued. The nurse should observe the client at frequent intervals to offer nutrition & toileting, assess their behavioral status, obtain vital signs, and provide range of motion. These intervals are determined by the facility and the type of restraint—the more restrictive the restraint and the younger the client, the more frequent assessment. Restraints must be able to quickly be removed via a quick release buckle (knots are no longer recommended). The nurses' documentation must be comprehensive, describing the reasoning for the restraints, alternatives utilized, the education provided to the client, the type of restraint utilized, how it was secured, and the ongoing behavior necessary to continue the restraint. The nurse should also document the intervals at which the restraints were released.

You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you complete the following actions? Remove gloves Take off goggles Take off the gown Remove the N95 respirator Perform hand hygiene

Remove gloves Take off goggles Take off the gown Remove the N95 respirator Perform hand hygiene Explanation Doffing refers to the process of removing the Personal Protective Equipment (PPE). The CDC has provided guidelines for doffing sequence. The correct order of the doffing sequence is: Remove gloves Take off goggles or face shield Take off gown Remove the N95 respirator Perform hand hygiene Following an appropriate doffing sequence will prevent contact of the contaminated gloves and gowns with areas (such as your hair) that cannot be easily cleaned after client contact. This will help stop the transmission of microorganisms to health care professionals and other clients. Alternatively, "donning" refers to the process of putting on the Personal Protective Equipment (PPE): Put on the gown Put on mask or respirator Put on goggles or a face shield Put on gloves NCSBN Client Need Topic: Safe and Effective Care Management; Subtopic: Safety and Infection Control

What would the nurse emphasize as an increased risk for an older adult patient? A. Blepharitis and chalazion [1%] B. Myopia and strabismus [4%] C. Exophthalmos and presbyopia [3%] D. Glaucoma and cataracts [91%]

Explanation Choice D is correct. Glaucoma, cataracts, and macular degeneration are all more common in the elderly. Choice A is incorrect. Blepharitis is inflammation of the margin of the eyelid. A chalazion is a cyst in the eyelid. Choice B is incorrect. Myopia is nearsightedness. Strabismus is when a person cannot align both eyes simultaneously under normal conditions (cross-eyes). Choice C is incorrect. Exophthalmos is an anterior protrusion of the eyeball out of the socket. Presbyopia is believed to be caused by the loss of elasticity of the crystalline lens. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Age Considerations

The nurse is discussing infection control with a group of nursing students. It would be correct to state that the contact precautions with alcohol-based hand hygiene measures should be sufficient for which of the following conditions? Select all that apply. A. Respiratory Syncytial Virus (RSV) [19%] B. Mumps [12%] C. Rubella [11%] D. Varicella [11%] E. Scabies [30%] F. Clostridium difficile [16%]

Explanation Choices A and E are correct. Conditions requiring the usual contact precautions include Respiratory Syncytial Virus (RSV) and Scabies. RSV is spread through contact with surfaces and contact with infectious droplets. Droplet precautions are not necessary for RSV. The CDC recommends standard and contact precautions for RSV. Other conditions requiring the usual contact precautions include: Mucocutaneous Herpes Simplex Virus (HSV) Methicillin-Resistant Staphylococcus Aureus (MRSA) Pediculosis Contact precautions protect against organisms that spread through contact with the patient or the patient's environment. Personal Protective Equipment (PPE) required for contact precautions include gloves and a gown. In contact precautions, the nurse/visitor must perform hand hygiene before entering the patient's room and after leaving the room. One can clean hands either with an alcohol-based hand sanitizer or soap and water. However, in diarrheal illnesses such as Clostridium difficile or norovirus, one must follow contact precautions but with an additional requirement. It requires visitors to perform hand hygiene by cleaning hands with soap and water after leaving the patient room. These special contact precautions are referred to as contact enteric precautions, and the isolation sign on the patient room must clearly state this requirement. Alcohol-based disinfectants do not kill Clostridium spores or norovirus. Therefore, soap and water are mandatory to clean hands upon leaving the patient's room. Choices B and C are incorrect. Mumps and Rubella require droplet precautions. Rubella (German measles) and Rubeola (Measles) sound similar, but they are two different diseases. Rubeola (Measles) spreads by airborne route and needs airborne isolation, whereas Rubella needs droplet isolation. Choice D is incorrect. Varicella-Zoster Virus (VZV) causes Chickenpox and Shingles. Varicella (Chickenpox) needs both contact and airborne isolation precautions, not just contact precautions. Both contact and airborne precautions are used in Varicella and "disseminated" Herpes Zoster (shingles) until all the lesions dry and crust over. In contrast, standard precautions alone are sufficient for "localized" Herpes Zoster in immunocompetent patients if the lesions can be contained/covered. Choice F is incorrect. Clostridium difficile is a bacteria that causes diarrhea and is highly contagious. It spreads by contact and fecal-oral route. Contact precautions are certainly used to prevent the spread of Clostridium difficile. However, an additional requirement of cleaning hands with soap and water upon leaving the patient's room is mandatory. To standardize infection control practices and to specify this additional hand hygiene requirement, many hospitals have adopted special signage, "contact enteric precautions". Please note the difference in the signage of contact precautions vs. contact-enteric precautions below:

The nurse is caring for a female client who is incontinent of urine. The MD orders an indwelling Foley catheter to be placed. Place the following actions in the correct order for the nurse to appropriately insert the Foley catheter: Perform hand hygiene, identify the patient, explain the procedure to the patient, and prepare the insertion kit using sterile gloves. Cleanse the meatus from front to back on the right side, then left side, and down the center. Spread the labia and hold them open. Insert the catheter and inflate the balloon. Secure the catheter to the patient, then initial the securement device with the date and time.

Perform hand hygiene, identify the patient, explain the procedure to the patient, and prepare the insertion kit using sterile gloves. Spread the labia and hold them open. Cleanse the meatus from front to back on the right side, then left side, and down the center. Insert the catheter and inflate the balloon. Secure the catheter to the patient, then initial the securement device with the date and time. Explanation Correct ordered sequence: B, C, A, D, E First: the nurse should perform hand hygiene, identify the client using 2 patient identifiers, explain the procedure to the client, and prepare the insertion tray using sterile gloves. Second: The nurse uses her nondominant hand (now dirty) to spread the labia and hold them open. Third: the nurse uses her dominant hand (sterile) to cleanse the meatus from front to back on the right side, then left side, then down the center. Fourth: the nurse will insert the catheter, wait for a urine return, and inflate the balloon. Lastly, fifth: the nurse will secure the catheter to the leg and place their initials, date, and time on the securement device. NCSBN Client Need: Topic: Reduction of Risk Potential; Subtopic: Potential for Complications of Diagnostic tests/Treatments/Procedures, Genitourinary

The nurse has established a support group for individuals with major depressive disorder (MDD). The nurse recognizes that this support group is A. tertiary prevention. [67%] B. primary prevention. [9%] C. secondary prevention. [18%] D. essential prevention. [5%]

Explanation Choice A is correct. Establishing a support group for individuals with a disease or disorder to maximize their functioning is tertiary prevention. Choices B, C, and D are incorrect. The crux of secondary prevention is to screen and detect diseases and disorders. Primary prevention is true prevention that involves vaccination and education. Additional Info Primary prevention is true prevention. Its goal is to reduce the incidence of disease. Primary prevention includes health education programs, nutritional programs, and physical fitness activities. It includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities Secondary prevention focuses on preventing the spread of disease, illness, or infection once it occurs. Activities are directed at diagnosis and prompt intervention, thereby reducing its severity. Examples include identifying people who have a new case of a disease or following people who have been exposed to a disease but do not have it yet. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Activities are directed at rehabilitation rather than diagnosis and treatment.

After administering an insulin injection to a patient on a sliding scale, the nurse realizes that a high dose was erroneously given. Which of the following would be the best response by the charge nurse to prevent future errors? A. Discuss events preceding the error with the nurse [62%] B. Complete an incident report and place it in the patient's chart [16%] C. Inform the patient, family, and physician of error [6%] D. Monitor the patient for adverse effects

Explanation Choice A is correct. Events preceding the error should be discussed with the nurse. This is the only response that focuses on preventing future errors. It would be most important to determine factors that contributed to the error, such as rushing, lack of knowledge/education, improper staffing caseload/patient acuity, or communication issues. Choice B is incorrect. Incident reports are legal, confidential documents and are not placed in the chart. They should be reported based on facility policy. Choice C is incorrect. It would be appropriate for the nurse to notify the patient, family, and physician per facility policy, but this action does not prevent future errors. Choice D is incorrect. The nurse should closely monitor for any adverse effects of the patient receiving the wrong dose, but this action does not prevent future errors. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential

Which of the following maternal deficiencies may result in neural tube defects in a fetus? A. Folic acid [91%] B. Vitamin B12 [5%] C. Vitamin E [0%] D. Iron [3%]

Explanation Choice A is correct. Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the machine to close. Neural tube defects are one of the most common congenital disabilities, occurring in approximately one in 1,000 live births in the United States. A neural tube defect is an opening in the spinal cord or brain that occurs very early in human development. The first spinal cord of the embryo begins as a flat region, which rolls into a tube (the neural tube) 28 days after the baby is conceived. When the neural tube does not close completely, a neural tube defect develops. Neural tube defects develop before most women know they are even pregnant. Neural tube defects are congenital disabilities of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman even knows that she is pregnant. The two most common neural tube defects are spina bifida and anencephaly. Neural tube defects are considered a complex disorder because they are caused by a combination of multiple genes and multiple environmental factors. Known environmental factors include folic acid deficiency, maternal insulin-dependent diabetes, and maternal use of certain anticonvulsant (antiseizure) medications. While only a few environmental factors have been characterized, many different studies provide evidence that NTDs have a genetic component in their development. Studies of twins with NTDs have shown both identical twins have NTDs more than both fraternal twins. Studies of families show that the chance of having a second family member born with an NTD after one child is born with an NTD is increased. For example, the general population's chance of having an NTD is approximately 0.1% (1 in 1000). However, once the couple has one child with an NTD, their chance of having a second child with an NTD is increased to approximately 2-5%. Further studies have shown evidence for a genetic pattern of inheritance for NTDs. NTDs are a feature (or symptom) of known genetic syndromes, such as trisomy 13, trisomy 18, specific chromosome rearrangements, and Meckel-Gruber syndrome. Choices B, C, and D are incorrect. None of these are associated with neural tube defects. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological Adaptation, Antepartum

Which of the following is the earliest indication of change in a child's neurological status? A. Level of consciousness [72%] B. Glasgow Coma Scale [10%] C. ICP measurement [6%] D. Pupil assessment [11%]

Explanation Choice A is correct. However, a simple observation, the level of consciousness, is widely recognized as the most sensitive indicator to a change, either improvement or deterioration, in a child's neurological status. Any changes, such as increased irritability or lethargy, should be reported to the team. Choice B is incorrect. The Glasgow Coma Scale evaluates eye-opening, motor response, and verbal response. It is an indicator of neurological status but is not the earliest indication of change. Choice C is incorrect. Direct ICP measurements are possible through a catheter inserted directly into the epidural space, but changes in ICP will manifest later than changes in a child's level of consciousness. Choice D is incorrect. A pupil assessment is an essential component of a neurological exam, but changes in the pupils would be a very late sign of an issue. The level of consciousness, on the other hand, will be a very early indication of change. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Neurologic

The patient taking lithium for bipolar disorder is experiencing vomiting, diarrhea, and blurred vision. Their lithium level is 2.5 mEq/L. The nurse suspects which finding is occurring? A. Lithium toxicity [96%] B. An allergic reaction to the medication [1%] C. A normal reaction to lithium [2%] D. This lithium level is too low [1%]

Explanation Choice A is correct. The average lithium level is 0.6 mEq to 1.2 mEq/L. Any level over 1.5 mEq/L indicates a toxic serum lithium level. Vomiting, diarrhea, blurred vision, abdominal pain, tremors, and tinnitus are symptoms of lithium toxicity. Choice B is incorrect. These symptoms do not describe an allergic reaction to lithium. Choice C is incorrect. Vomiting, diarrhea, and blurred vision are not normal findings in a patient taking lithium. Choice D is incorrect. Evidence suggests that the lithium level is too high, at 2.5 mEq/L, not too low. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral Therapies

The nurse supervises a newly hired nurse caring for an infant immediately following a cleft lip repair. Which of the following actions by the newly hired nurse requires follow-up? A. Repositions the infant prone. [83%] B. Obtains an axillary temperature. [2%] C. Cleans the suture line with saline. [8%] D. Places suction equipment at the bedside. [6%]

Explanation Choice A is correct. This action requires follow-up because placing the client prone will irritate the suture line, cause the client discomfort, and may raise the risk for aspiration. Choices B, C, and D are incorrect. These actions are appropriate and do not require follow-up. Obtaining an axillary temperature is appropriate because the nurse should not place any rigid utensils in the infant's mouth. After all, this may disrupt the suture line and cause pain. Cleaning the suture line with saline after feedings is appropriate to prevent infection. Suction equipment should be kept at the bedside in case of aspiration. The nurse should observe for signs of aspiration, which includes excessive swallowing. Additional Info Following a cleft lip repair, some surgeons allow the infant to return to breastfeeding or bottle-feeding, whereas others require syringe-feeding once the child is awake and alert. The nurse should provide pain management which may include acetaminophen. The nurse should ensure that no rigid objects are inserted into the mouth that may disrupt the suture line. Finally, the infant should not be positioned prone and positioned to prevent airway obstruction.

An emergency room nurse is assigned to triage. Four people check-in at the same time. Which patient should receive immediate priority care? A. A 29-year-old female two-day post-cesarean section that complains of a headache and leg swelling. [83%] B. A 15-year-old female with LLQ pain for three days. [5%] C. A 55-year-old male with dull RUQ pain & history of pancreatitis. [9%] D. A 2-year-old female child with pain upon urination. [3%]

Explanation Choice A is correct. This patient is at risk for pre-eclampsia which is a severe condition that can lead to seizures, stroke, and other complications if not promptly treated. Pregnant women are at risk for preeclampsia anytime through pregnancy as well as 6-10 weeks post-partum. Post-partum pre-eclampsia usually develops in 48 hours post-partum but the risk can extend up to 6 to 10 weeks. Symptoms include headache, blurred vision, proteinuria, swelling in the hands/face, and high blood pressure. If treatment is started, this condition can be controlled. Choices B, C, and D are incorrect. These patients are less of a priority compared to the patient described in choice A. The patient in choice B had pain for 3 days, which is likely not an immediate threat. The other answer choices do not mention any altered sensorium, high fever, or sepsis findings. NCSBN client needs Topic: Management of care; Sub-topic: Establishing Priorities.

You are caring for a client at the end of life who is terminally ill, confused, and no longer able to give informed consent. The doctor has spoken to the spouse about the need for a feeding tube because the client is malnourished and is failing to thrive. The spouse, who is the client's healthcare surrogate, states that she wants the tube feedings to begin as soon as possible so that the spouse will "not die of starvation"; however, the client's advance directive, which was written five years ago, states that the client does not want a feeding tube or any other life-saving measures. What should you say to the client's spouse about the feeding tube? A. "I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive." [92%] B. "I agree that starvation is a bad way to die. I will contact the doctor and let the doctor know that you have agreed to place the feeding tube." [5%] C. "You cannot make that decision for your husband even though the doctor will probably give your husband the feeding tube." [1%] D. "Feeding tubes are not recommended for clients at the end of life who are affected with malnutrition and are failing to thrive."

Explanation Choice A is correct. You would respond to the client's spouse with, "I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive." An advance directive supersedes the wishes of the healthcare surrogate. Choice B is incorrect. You would not respond to the client's spouse with, "I agree that starvation is a bad way to die. I will contact the doctor and let the doctor know that you have agreed to place the feeding tube." The client should not get the feeding tube because they have chosen to NOT have one in their advance directive. Choice C is incorrect. You would not respond to the client's spouse with, "You cannot make that decision for your husband even though the doctor will probably give your husband the feeding tube" because this statement does not recognize or address the client's spouse's feelings or beliefs in a therapeutic manner. Choice D is incorrect. You would not respond to the client's spouse with, "Feeding tubes are not recommended for clients at the end of life who are affected with malnutrition and are failing to thrive" because this statement is not only false, it does not follow the client's wishes as stated in their advance directive.

The nurse is caring for a client with an ectopic pregnancy. Which findings does the nurse expect? Select all that apply. A. Pelvic pain [30%] B. Fever [12%] C. Vaginal bleeding [25%] D. Positive pregnancy test [27%] E. Dysuria [5%]

Explanation Choice A, C, and D are correct. An ectopic pregnancy is a gynecological emergency. If not treated, a rupture may occur that leads to intraperitoneal bleeding. Classic manifestations of an ectopic pregnancy include: Presumptive pregnancy signs (nausea, breast tenderness) Vaginal bleeding Increased human chorionic gonadotropin (hCG) levels causing a positive pregnancy test Unilateral abdominal pain that may be confined to the pelvic area Choices B and E are incorrect. An ectopic pregnancy (EP) is not an infectious process like appendicitis. So fever is not an expected finding. Finally, dysuria would be a manifestation associated with cystitis. Again, an EP is not infectious and would not cause dysuria. Additional Info An ectopic pregnancy (EP) is an extrauterine pregnancy. Almost all ectopic pregnancies occur in the fallopian tube, but other possible sites include cervical, interstitial, hysterotomy (cesarean) scar, ovarian, or abdominal. Manifestations of an EP include unilateral abdominal (pelvic) pain, vaginal bleeding, and a positive pregnancy test. Rapid management is needed because life-threatening intraabdominal bleeding may occur. For EP's that have not ruptured and the woman is stable, methotrexate may be used. If that is not the case, surgical management will be necessary.

A client who completes an informed consent is asserting and using their basic right to: A. Beneficence [13%] B. Nonmaleficence [5%] C. Self-determination [60%] D. Have choices [22%]

Explanation Choice C is correct. A client who completes an informed consent is asserting and using their fundamental right to self-determination. Self-determination is defined as the intrinsic right of all people, including healthcare consumers, to make their own autonomous decisions about accepting or rejecting care or treatments, as is done with informed consent. Choice A is incorrect. Beneficence is an ethical principle that states that we should "do good" for the client. It is not the basis of informed consent. Choice B is incorrect. Nonmaleficence is an ethical principle that states that we should do "no harm" to the client. It is not the basis of informed consent. Choice D is incorrect. Although the client makes choices with informed consent, making choices is not the basis of informed consent; making choices among alternatives of treatments is suppor

The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question? A. Levothyroxine for a client with a myxedema coma [19%] B. Hydrochlorothiazide for a client with hyperparathyroidism [59%] C. Hydrocortisone for a client with adrenal insufficiency [11%] D. Regular insulin for a client with diabetic ketoacidosis [11%]

Explanation Choice B is correct. Hyperparathyroidism causes hypercalcemia, and the treatment for hyperparathyroidism is a combination of 0.9% saline infusion followed by furosemide. Hydrochlorothiazide is a thiazide diuretic and causes the retention of calcium. This would be detrimental for a client experiencing hypercalcemia. This prescribed medication requires follow-up with the prescriber. Choices A, C, and D are incorrect. Levothyroxine is the essential treatment for myxedema, a severe form of hypothyroidism. Hydrocortisone is a priority treatment for adrenal insufficiency as the hallmark of this disease is an insufficient amount of mineralocorticoids and glucocorticoids. DKA is an endocrine emergency and requires aggressive fluid resuscitation and intravenous regular insulin. Additional Info Hyperparathyroidism is a disorder in which parathyroid secretion of parathyroid hormone is increased, resulting in hypercalcemia (excessive serum calcium levels) and hypophosphatemia (inadequate serum phosphorus levels). Diuretic and hydration therapies help reduce serum calcium levels. Furosemide, a diuretic that increases kidney excretion of calcium, is used along with IV saline in large volumes to promote calcium excretion.

A nurse is caring for a client taking sildenafil. While reviewing the client's other medications, which medication requires follow-up? A. Furosemide [25%] B. Isosorbide [45%] C. Atorvastatin [15%] D. Losartan [15%]

Explanation Choice B is correct. Isosorbide is a nitrate medication and should not be taken concurrently with phosphodiesterase inhibitors such as sildenafil. The combination of the two may result in profound hypotension. Choices A is incorrect. Furosemide is a loop diuretic and has no adverse interaction with sildenafil. Furosemide is indicated for congestive heart failure, edema, and decreased urine output. Choice C is incorrect. Atorvastatin is indicated for hyperlipidemia and has no interaction with sildenafil. Choice D is incorrect. Losartan is an ARB and is indicated for congestive heart failure or hypertension. It has no adverse interaction with sildenafil. Additional Info Phosphodiesterase inhibitors such as sildenafil, tadalafil, and vardenafil are indicated to treat erectile dysfunction and pulmonary hypertension. The client should not take these medications concurrently with isosorbide, a nitrate, because of the serious hypotension that may develop.

Which of the following statements are true about special populations and the administration of analgesics? A. Oncology clients with moderate pain typically need a strong opioid. [29%] B. Oncology clients do not have a dosage limitation in terms of analgesics. [22%] C. The elderly should be assessed for pain with behavioral cues rather than self-reports. [30%] D. The elderly should be assessed for pain with physical cues rather than self-reports. [18%]

Explanation Choice B is correct. Oncology clients do not have a dosage limitation in terms of analgesics until effective pain management is accomplished. At times, very high dosages of analgesic medications are essential to relieve pain. However, on some occasions, the medication dosage may have to be titrated downward when the side effects of the drug outweigh its benefits in terms of pain relief. Choice A is incorrect. Oncology clients with moderate pain do not typically need a potent opioid. According to the World Health Organization (WHO), clients with moderate pain usually benefit therapeutically with a mild opioid or a nonopioid analgesic, with or without the combination of a co-analgesic/adjuvant medication. However, the use of a potent opioid is not prohibited for oncology clients with moderate pain when it is needed to manage the client's pain. Choice C is incorrect. The elderly should not be assessed for pain with behavioral cues rather than self-reports of pain except when they are cognitively impaired or nonverbal clients that cannot self-report pain. When this occurs, the nurse must be knowledgeable about the fact that nonverbal, behavioral indications of illness, such as facial expressions, are not as useful as self-reports of pain. Still, they are more effective than physiological indicators of pain, such as guarding the painful site and changes in the vital signs. Choice D is incorrect. The elderly should not be assessed for pain with physical cues rather than self-reports except when they are cognitively impaired or nonverbal clients that cannot self-report pain. When this occurs, the nurse must be knowledgeable about the fact that nonverbal, behavioral indications of pain, such as facial expressions, are not as useful as self-reports of pain. Still, they are more effective than physiological indicators of illness, such as guarding the painful site and changes in the vital signs.

While monitoring the administration of intravenous heparin to a patient. The nurse asks the physician to order which medication in case of an emergency? A. Potassium chloride [1%] B. Protamine sulfate [82%] C. Vitamin K [16%] D. Naloxone [1%]

Explanation Choice B is correct. Protamine sulfate is the antidote to heparin therapy. Protamine sulfate should be readily available in case the patient experiences heavy bleeding or hemorrhage. Choice A is incorrect. Potassium chloride is given to patients experiencing a serum potassium deficit. Choice C is incorrect. Vitamin K is the antidote to warfarin sodium. Choice D is incorrect. Naloxone is the antidote to opiate medications. NCSBN client need Topic: Physiological integrity, pharmacological and parenteral therapy

While working in the newborn nursery, you are called to L&D and asked to assign the APGAR score after birth. When you evaluate the infant at 1 minute of life, you find the following: cyanotic trunk and extremities, HR is 30 bpm, slight withdrawal when you pinch her foot, floppy muscles, and RR is 10 and irregular. What APGAR score do you assign? A. 1 [11%] B. 3 [46%] C. 5 [35%] D. 7 [8%]

Explanation Choice B is correct. The APGAR score is 3. The infant gets 0 points for blue skin color all over, 1 point for an HR below 100 bpm, 1 point for a minimal response to stimulation, 0 points for absent muscle tone, and 1 point for a slow and irregular respiratory rate. This APGAR score indicates severe distress; therefore, the baby needs immediate action. Choices A, C, and D are incorrect. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn

The PACU nurse is caring for a patient who is presenting with agitation following knee replacement surgery. What action should the nurse take first? A. Notify the anesthesiologist of the adverse reaction. [7%] B. Assess the patient's respiratory function. [85%] C. Obtain an order for additional sedation to keep the patient safe during agitation. [4%] D. Administer a benzodiazepine antagonist. [3%]

Explanation Choice B is correct. The most common cause of postoperative agitation in the PACU is hypoxemia. The nurse should first check this patient's airway and breathing, then address other possible causes of agitated behavior. Choice A is incorrect. The nurse should first assess the patient before notifying the physician of a possible adverse reaction. Choice C is incorrect. Additional sedation may be necessary for patient and staff safety due to a patient's agitated state, but assessment should be performed before administering any medication. Choice D is incorrect. A benzodiazepine antagonist may be appropriate for this patient if the sedation is too strong or the patient is not waking up when expected, but would not be the first action. This patient is agitated, so it can be inferred that the patient is awake/arousable, not profoundly sedated. NCSBN Client Need Topic: Prioritization, Subtopic: Establishing priorities, the potential for complications from surgical procedures and health alterations

You have been caring for a severely depressed client in the community. When you see this client today, the client is far less depressed than they were in the past. What priority should the nurse consider in terms of this client's current psychological state? A. The client has resolved the depression. [1%] B. The client may have planned their suicide plan. [82%] C. The antidepressant medications are effective. [10%] D. Their cognitive behavioral therapy is effective. [7%]

Explanation Choice B is correct. The priority that the nurse should consider in terms of this client's current psychological state is the possibility that this severely depressed client has planned their suicide; this may occur when a severely depressed client becomes far less depressed than they were in the past. Although this client may be effectively treated with antidepressant medications and cognitive behavioral therapy, the priority concern is associated with a heightened risk of suicide. Choice A is incorrect. Although the client may have resolved their depression, there is a chance that this patient may be experiencing less depression because something else severe may be occurring. Choice C is incorrect. Although this client may be effectively treated with antidepressant medications, something else very serious may be occurring. Choice D is incorrect. Although this client may be effectively treated with their cognitive behavioral therapy, something else very serious may be occurring.

While in the OB/Gyn clinic, your client tells you that this is her 4th pregnancy. She had an abortion in her first pregnancy at 22 weeks. Her second pregnancy was twins, born at 25 weeks, and they passed away in the NICU shortly after their delivery. Her third pregnancy was a boy born at 32 weeks, healthy. She is currently 30 weeks pregnant. Which of the following describes your patient? A. G2T4P0A0L2 [2%] B. G4T0P3A0L1 [25%] C. G4T0P4A0L1 [10%] D. G4T0P3A1L1

Explanation Choice B is correct. This describes your patient: she has been pregnant four times (G4), had 0 term births (T0), three preterm births (P3), 0 abortions (the fetus that was aborted after 20 weeks, spontaneously or electively, is counted as premature birth, and P will increase but A and L will not) and has one living child (L1). The GTPAL acronym is commonly used to describe pregnancy outcomes: The G stands for gravidity, the number of times that the patient has been pregnant, this includes current pregnancies. So in this case, it is 4. The T stands for term births or the number of births occurring at 37 weeks gestation or later. In this case, the patient has had no births at term, so for T, we have a 0. The P stands for preterm births or the number of births occurring before 37 weeks. For this case, the patient had twins at 25 weeks, so she gets P1 for twins, a baby boy at 32 weeks, and had an abortion after 20 weeks. Hence, she gets a total of 3 preterm births or 3 for "P." Note: Multiple births (twins, triplets, and higher multiples) count as one pregnancy (gravidity - G1) and as one birth (P1 or T1 based on whether twins/triplets are pre-term or term). The A stands for abortions or miscarriages. The "abortions" number refers to the total number of spontaneous or induced abortions and miscarriages, including ectopic pregnancies, before 20 weeks. If a fetus is aborted after 20 weeks, spontaneously or electively, it is counted as premature birth, and P will increase, but A and L will not. If the abortion occurred before 20 weeks, count it under 'A' and 'G.' If the abortion happened after 20 weeks, count it under 'P' and 'G.' For this patient, she had one abortion. It happened after 20 weeks, so it gets counted under the G and P sections but not under "A." Lastly, L stands for the current number of living children. She tells us her twins passed away in the NICU, and her baby boy from her third pregnancy lives at home, so she gets a 1 for 'L.' Choice A is incorrect. This answer choice is for a patient that has been pregnant two times, had four term births, no preterm births, no abortions, and has two living children. Choice C is incorrect. This answer choice is for a patient that has been pregnant four times, had 0 term births, four preterm births,0 abortions, and has one living child. Choice D is incorrect. This answer choice is for a patient that has been pregnant four times, had no term births, three preterm births, one abortion (likely occurred before 20 weeks as it is not counted here under P), and has one living child. NCSBN Client Need: Topic: Health Promotion and Maintenance; Subtopic: Antepartum

A prenatal client is worried about her fetus' activity, so she performs a "kick count". She informs the nurse that while laying down, she felt ten kicks in one hour. The nurse should tell this client that: A. She'll need to come into the clinic and have a non-stress test performed. [15%] B. Ten kicks in an hour is a reassuring finding. [73%] C. She is dehydrated and should drink more water before re-trying the kick count. [3%] D. She should get up and walk for ten minutes and then re-try the test. [9%]

Explanation Choice B is correct. This is a reassuring finding. Ten kicks noticed during a 1 - 2 hour period are considered normal. Choices A, C, and D are incorrect. These interventions are not necessary. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

You are caring for a patient with blood clots in his lungs. He is receiving urokinase for treating pulmonary embolism. The urokinase has been infusing for the last 10 hours. As you assess the patient, you note that his blood pressure is 102/64, heart rate is 108, and his respiratory rate is 16 breaths per minute. The patient asks to use the bedpan. When he is finished, you notice that he has passed a medium-sized bloody stool. Your best intervention is to: A. Closely monitor the patient [10%] B. Stop the urokinase and call the physician [79%] C. Administer Vitamin K intramuscularly [3%] D. Slow the administration of urokinase [8%]

Explanation Choice B is correct. You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders. Choices A, C, and D are incorrect. Slowing the intravenous infusion of urokinase will not help to control the bleeding. The nurse should anticipate the administration of Amicar, which is used to treat bleeding associated with the use of fibrinolytic. Vitamin K will not do anything to reverse the fibrinolytic. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Adverse Effects/Contraindications/Side Effects/Interactions, Respiratory

A senior RN is supervising a newly registered nurse in the emergency department. Which situation would require the senior RN to intervene? A. The new RN elevates the foot of a 13-year-old with a fractured tibia. [29%] B. The new RN calls Child Protective services for the child she suspects is being sexually abused. [7%] C. The new RN checks the tonsils of a drooling 3-year-old with a sore throat. [61%] D. The new RN gives a nebulization treatment to an 8-year-old with asthma.

Explanation Choice C is correct. A child with a sore throat that is drooling may be manifesting epiglottitis. Drooling may indicate that the child is going into respiratory distress and warrants timely intervention by the healthcare team. The senior RN should step in and guide the new RN in what to do. Choice A is incorrect. Elevating the foot to relieve swelling and edema in a fractured foot is an accurate nursing action. Choice B is incorrect. For any suspected child abuse, the nurse is obligated by law to report the case to Child Protective Services (CPS). Choice D is incorrect. Giving a nebulization treatment to a child having an asthma attack relaxes the bronchial walls of the child and improves respiratory status.

A patient in the emergency department presents with dyspnea, chest tightness, night sweats, and blood-tinged sputum. What is the best action for the nurse to take? A. Get the patient in a negative air pressure room and alert the attending of active tuberculosis. [4%] B. Arrange for a chest x-ray and private room then wait for results. [9%] C. Implement airborne precautions, arrange for a chest x-ray of the patient and place the patient in a negative air pressure private room. [86%] D. Review admission criteria, cohort patient with a patient positive for the flu, and then draw blood for a full workup.

Explanation Choice C is correct. All of the symptoms that the patient has presented with are indicative of tuberculosis and should be treated as such until confirmed or disproven by tests. These actions help to prevent the spread of this airborne disease. Choice A is incorrect. Although the patient should be put in a negative air pressure room, the nurse should not declare an active tuberculosis diagnosis without a proper test to confirm. Choice B is incorrect. The patient should be in a negative air pressure private room. Choice D is incorrect. The patient has presented with symptoms of tuberculosis, therefore TB precautions should be implemented. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Respiratory Precautions

The nurse receives a prescription for donepezil. The nurse understands that this medication is used to treat A. Guillain Barré syndrome [12%] B. Parkinson's disease [19%] C. Alzheimer's disease [55%] D. Meniere's disease [13%]

Explanation Choice C is correct. Alzheimer's disease is the most common form of dementia. Treatment options are limited but may include donepezil which is approved to treat mild, moderate, or severe Alzheimer's disease. This medication is an acetylcholinesterase Inhibitor. Choices A, B, and D are incorrect. Donepezil has a narrow label and off-label use for Alzheimer's disease. This medication is not used in ADHD, Parkinson's disease, or Meniere's disease. Additional Info Donepezil is an acetylcholinesterase Inhibitor and may be administered orally or transdermally. The most common adverse effect of this medication is diarrhea, anorexia, and insomnia. If this medication should be discontinued, it should be tapered. If it is abruptly withdrawn, psychiatric symptoms such as hallucinations and rapid cognitive decline may be experienced by the client.

A 28-year old male arrives at the emergency department for midsternal chest pain, shortness of breath, and nausea that began suddenly 20 minutes ago. He has no medical history and reports he uses cocaine every once in a while. What cardiac rhythm will the nurse suspect to see? A. Normal sinus rhythm [2%] B. Bradycardia [15%] C. ST-elevation [69%] D. 3rd degree heart block [14%]

Explanation Choice C is correct. Cocaine increases the effects of the sympathetic nervous system and exaggerates or causes cardiovascular disease. The nurse may see cardiac dysrhythmias, such as ventricular tachycardia or ventricular fibrillation, and can see myocardial infarction as well. Choice A is incorrect. The nurse may see a normal sinus rhythm, but because of the symptoms of chest pain, shortness of breath, nausea, and use of cocaine, the nurse will most likely see an ST-elevated myocardial infarction (STEMI), which is an indication of a heart attack. Choice B is incorrect. Cocaine increases the effects of the sympathetic nervous system, which will increase heart rate, respirations, diaphoresis, and raise blood pressure. Bradycardia is not likely to be seen. Choice D is incorrect. The patient may already have a 3rd-degree heart block coincidentally, but a STEMI is most likely to be seen in this patient. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: System-specific Assessments, Cardiovascular System

The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). Which medication should the nurse question? A. Venlafaxine [26%] B. Esomeprazole [22%] C. Topiramate [37%] D. Lurasidone [15%]

Explanation Choice C is correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder. If a client is taking the anticonvulsant topiramate, this will increase the seizure threshold and may attenuate the efficacy of ECT. Choices A, B, and D are incorrect. Antidepressant medications (such as venlafaxine) and antipsychotics (such as lurasidone) may be given concurrently with ECT. These medications may enhance the efficacy of the treatment. Proton pump inhibitors (such as esomeprazole) are typically given the day of treatment to prevent gastric reflux and aspiration. Additional information: Electroconvulsive therapy (ECT) is an effective treatment for an array of conditions, including major depressive disorder, psychosis, and post-partum disorders. A stigma is attached to ECT that it is somehow cruel. This stigma is false as ECT is a highly effective treatment when medications are ineffective. Nursing care for ECT includes witnessing informed consent, ensuring that the client is NPO prior to the procedure, and preprocedural laboratory work including a 12-lead electrocardiogram (ECG) has been completed. Certain medications should be withheld prior to ECT, including anticonvulsants and benzodiazepines. NCSBN Client Need: Topic: Reduction of Risk Potential; Subtopic: Therapeutic Procedures

The patient just arrived from the operating room after the hypophysectomy surgery was performed. In order to reduce the possibility of surgical complications, which position is the best option for this patient? A. Trendelenburg [7%] B. Side-lying [13%] C. Semi-fowler's to Fowler's [70%] D. Reverse Trendelenburg

Explanation Choice C is correct. Hypophysectomy is generally performed via the transsphenoidal route to remove tumors from the pituitary gland. Semi-Fowler's to Fowler's position is the most appropriate position as it facilitates drainage and prevents swelling to the head and neck or an increase in intracranial pressure. Choice A is incorrect. Trendelenburg would be a precarious position in this patient, increasing intracranial pressure and creating swelling. Choice B is incorrect. Side-lying does not promote draining, which will be needed in this patient's care. Choice D is incorrect. Reverse Trendelenburg is too drastic of a position for this patient. NCSBN client need Topic: Reduction of Risk Potential: Surgical Complications and Health Alterations

The nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD). What should be the nurse's priority nursing diagnosis for the client? A. Activity intolerance [3%] B. Ineffective coping [1%] C. Impaired gas exchange [96%] D. Self-care deficit [0%]

Explanation Choice C is correct. Impaired gas exchange is a priority problem for the client with COPD. The nurse should implement measures that ensure adequate oxygen and carbon dioxide exchange in the client. Choice A is incorrect. There is activity intolerance in a client with COPD; however, it does not take priority over gas exchange, which is impaired in the client due to pathologic changes in his lungs. Choice B is incorrect. Ineffective coping is a problem for the client, but it is a psychosocial problem. Physiological issues should always take priority over psychosocial issues. Choice D is incorrect. A self-care deficit should not be a priority over the gas exchange. Additional Info

The nurse is taking vital signs on her patient with a diagnosis of acute lymphoblastic leukemia (ALL). His temperature is 38.7 degrees C. What is the nurse's priority? A. Place cool washcloths on the patient's head. [27%] B. Continue with her assessment. [15%] C. Obtain intravenous access on the patient. [31%] D. Assess the patient's perfusion. [27%]

Explanation Choice C is correct. It is the priority action to establish intravenous access for this patient. This patient has a diagnosis of ALL, so the nurse knows that he is immunocompromised. He is very susceptible to infections and with a fever of 38.7 degrees C, she has a high index of suspicion for disease. Broad-spectrum IV antibiotics will need to be started right away. Therefore it is the priority of the nurse to start an IV. Choice A is incorrect. Placing cold washcloths on the patient's head is not the priority; there is a better answer. This would only need to be done if the patient was at risk for seizures due to incredibly high body temperature. The temperature of 38.7 degrees C does not warrant cooling measures and the nurse has another immediate priority given the patient's immunosuppression along with her suspicion of an infection. Choice B is incorrect. It is inappropriate for the nurse to simply continue with her assessment since she suspects an infection in her patient who is immunocompromised. Another answer has an immediate priority that the nurse must do. Choice D is incorrect. Assessing the patient's perfusion has nothing to do with the nurse's suspicion of an infection. She should immediately establish IV access for the administration of antibiotics. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Infection control and safety; Pediatrics - Oncology

Which of the following actions is most effective at reducing the incidence of health-care-associated infections? A. Screen all newly admitted clients for colonization or infection with MRSA. [9%] B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms. [3%] C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. [82%] D. Require nursing staff to wear gowns to change wound dressings for all clients. [6%]

Explanation Choice C is correct. Since the hands of healthcare workers are the most common means of transmission for infection from one client to another, the most effective method of preventing the spread of disease is to make supplies for hand hygiene readily available for staff to use. Reducing the risk of healthcare-associated infections is the responsibility of every healthcare worker. Following standard precautions for all patients is the easiest and most effective way of preventing the spread of disease. Choice A is incorrect. Although some hospitals have started screening newly admitted clients for MRSA, there is no evidence that this decreases the spread of infection. Choice B is incorrect. Because the administration of antibiotics to individuals who are colonized by bacteria may promote the development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection. Choice D is incorrect. Wearing a gown to care for clients who are not on contact precautions is unnecessary. NCSBN Client Need Topic: Safe and Effective Care Management, Subtopic: Safety and Infection Control

An 82-year-old man with history of falls is being discharged today, after hip replacement surgery. Which person would be best to assign to care for him? A. A licensed practical nurse with experience on a medical unit. [3%] B. A licensed practical nurse that has experience with surgical patients. [35%] C. A licensed practical nurse with experience in long-term care. [31%] D. A licensed practical nurse with experience in ambulatory care.

Explanation Choice C is correct. The elderly who have had a hip replacement is more prone to falls and recurrent hip fractures/ dislocations. Several factors such as impaired vision, medications, environmental hazards, and poor bone health contribute to the fall risk. The client has a history of falls. Post-hip replacement surgery, he will benefit from long term care placement given his risk of post-operative falls. Treatment goals include pain control, physical therapy, maintaining a healthy diet with calcium- and vitamin-D-rich foods, and strengthening exercises. When making patient assignments, it is essential to match the staff member's area of expertise to the patient's needs. Please note that an LPN is being assigned to take care of this stable patient post-discharge. The question is not asking about handling discharge teaching or discharge planning - these do not fall under the LPN's scope of practice. Choices A, B, and D are incorrect. In this case, the LPN with experience in geriatric or long-term care is the best choice. This nurse will better understand this specific client's needs than the nurses with medical/surgical care or ambulatory care experience. Bloom's Taxonomy: Analyzing

The maternal health nurse is taking the history and physical for a pregnant woman in her second trimester. She has several mysterious bruises on her arms and appears isolative. The nurse would provide vigilant surveillance for which common occurrence in pregnancy? A. Chronic depression [3%] B. Physiological anemia [9%] C. Domestic violence [88%] D. Acute insomnia [0%]

Explanation Choice C is correct. The incidence of domestic violence intensifies while a woman is pregnant. Signs of domestic violence while pregnant include the late onset of prenatal care, unexplained bruising, and depression. Other symptoms include problems adhering to prenatal care, missed appointments, and drug or alcohol abuse. Choice A is incorrect. Depression may occur during pregnancy; however, unexplained bruising is not an anticipated finding in a depressed patient. Choice B is incorrect. While the occurrence of physiological anemia rises during pregnancy, it is not associated with a late onset of prenatal care. Choice D is incorrect. Insomnia does sometimes occur during pregnancy but is unrelated to the unexplained bruising or late onset of prenatal care. NCSBN client need Topic: Psychosocial Integrity. Abuse/Neglect

While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action? A. Continue preparing for the procedure in the room. [12%] B. Notify the chaplain. [1%] C. Leave the room quietly and come back after 15 minutes to change the client's dressing. [78%] D. Ask the son if he wants the nurse to join in prayer.

Explanation Choice C is correct. The nurse should respect the client and her son in their moment of prayer and should not impose on them. The nurse's best action is to leave the room and come back when they are finished praying. Choices A, B, and D are incorrect. It is inappropriate for the nurse to continue preparing for the procedure (Choice A). The nurse should respect the client and her son's need for privacy during the prayer. The most appropriate action of the nurse is to leave the room momentarily. Unless requested by the client, the nurse should not inform the chaplain (Choice B) or any other person. Asking the son if she can be allowed to join the prayer (Choice D) is inappropriate. The nurse should respect their right to privacy and should not impose on the client.

The nurse is preparing a client for a bronchoscopy the following day. All of the following are appropriate interventions, except: A. Educate the client that he will be experiencing a sore throat after the procedure. [5%] B. Tell the client that he will be lying on his back for 30 to 45 minutes. [8%] C. He can eat right away after the procedure is done. [81%] D. He must not eat or drink anything 6 hours prior to the test. [7%]

Explanation Choice C is correct. This is an incorrect statement and therefore the correct answer to this question. The client should be kept NPO (nothing by mouth) until the cough and gag reflex return. When the cough and gag reflex return, the patient is given ice chips and small sips of water and is then slowly progressed into a regular diet. Choice A is incorrect. This is a correct statement. The patient is expected to feel a sore throat after the procedure due to some trauma in the pharynx and larynx. Choice B is incorrect. This is a correct statement. The whole procedure lasts 30 - 45 minutes. During which, he will be lying supine with his neck hyperextended. Choice D is incorrect. This is a correct statement. The client is kept NPO 6 hours before the procedure to decrease the risk of aspiration.

The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client A. position the cane on their weaker side. [19%] B. advances their weaker leg first, then the cane. [14%] C. measures the height of the cane from their wrist crease. [49%] D. advances the cane 12-16 inches with each step. [18%]

Explanation Choice C is correct. This observation is correct and reflects effective teaching. The nurse should instruct the client that the height of the cane should be measured with the client facing forward, wearing their shoes, and either from their wrist crease or greater trochanter. Choices A, B, and D are incorrect. These observations are incorrect and require further teaching. The cane should be positioned on the client's unaffected (stronger) side. The cane is always advanced first, then the affected (weaker) leg. To prevent the client from falling, the cane should be advanced 6-10 inches. Additional Info When a client ambulates with a cane, the nurse should ensure that a gait belt is applied before getting out of bed. The nurse is positioned on the client's affected (weaker) side, slightly behind the client. Measure the height of the cane from the wrist crease or greater trochanter The cane should be held on the unaffected (stronger) side The elbow should be flexed 15-30 degrees The cane should be advanced first, 6-10 inches Advance the affected (weaker) leg to the cane Finally, advance the stronger leg just past the cane A rubber tip should always be applied to a cane to ensure appropriate traction with the ground.

Which of these would be most relevant to include in discharge teaching for a patient with a platelet count of 40,000 per mcL (40 x 10^9/L)? A. Be sure to take your aspirin with meals daily [4%] B. You may continue to shave with a straight edge razor [2%] C. Use a soft toothbrush and floss gently [87%] D. You should take a multivitamin daily [7%]

Explanation Choice C is correct. This patient has thrombocytopenia and should be on bleeding precautions. Using a soft toothbrush and flossing gently can prevent the gum tissue from bleeding. Platelets (thrombocytes) are important for blood clotting. The normal range for platelets is 150,000-400,000 per microliter (or 150-400 x 10^9/L). Thrombocytopenia is a condition where platelets are lower than the normal reference range (less than 150,000 platelets per microliter). Low platelets increase the risk of bleeding and may lead to symptoms including petechiae, purpuric rash, prolonged bleeding after minor cuts, spontaneous bleeding, and menorrhagia. Several factors can cause thrombocytopenia. It can be inherited or acquired. Acquired causes are most common and can be grouped as follows: Diminished production: caused by viral infections, liver disease, vitamin deficiencies, aplastic anemia, or drug-induced. These factors suppress bone marrow platelet production. Increased destruction: caused by drugs, heparin use, idiopathic, pregnancy, disseminated intravascular coagulation (DIC), thrombotic thrombocytopenic purpura (TTP), or immune-mediated destruction (ITP). Sequestration: caused by an enlarged spleen, neonatal, and gestational (pregnancy). Here, platelets are sequestrated from the circulation, i.e. thrombocytopenia from splenomegaly causing platelet sequestration. Choice A is incorrect. Aspirin can interfere with clotting and should be discontinued. Choice B is incorrect. An electric razor should be used for shaving to avoid cuts. Choice D is incorrect. Unless a nutritional etiology has been identified, multivitamins have no role in thrombocytopenia treatment. If a vitamin B12 deficiency is identified as the etiology, B12 supplements can correct thrombocytopenia. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic Care and Comfort

The nurse is providing patient teaching regarding phenazopyridine, a medication used to treat pain resulting from a urinary tract infection. Which priority teaching should the nurse provide to this patient? A. Discontinue this medication if urinary discoloration occurs [5%] B. Take this medication on an empty stomach [6%] C. Only take the medication before bed [3%] D. Urine may have a reddish or orange coloration after taking this medication [86%]

Explanation Choice D is correct. After taking this medication, the urine may become discolored. This is an expected finding and the patient should be advised to refrain from becoming alarmed. Choice A is incorrect. A reddish-orange discoloration of the urine is an expected finding when taking phenazopyridine. Patients should not discontinue this medication when this change in the urine occurs. Choice B is incorrect. This medication should be taken with food to prevent stomach discomfort. Choice C is incorrect. This medication can be taken at any time during the day, not only before bedtime. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral Therapies

A fiberglass cast has just been applied on a client's left arm due to a humerus fracture. Three hours later, the client complains of numbness in his fingers, and says his fingers "have become pale." What is the nurse's most appropriate action? A. Reassure the client that this is just a normal occurrence after having a cast. [1%] B. Ask the client to clench his fist frequently. [4%] C. Remove the cast immediately. [18%] D. Notify the physician. [78%]

Explanation Choice D is correct. Compartment syndrome occurs when pressure increases within one or more compartments, leading to decreased blood flow, tissue ischemia, and neurovascular damage. The nurse should immediately notify the physician of these findings so that the cast may be loosened or a fasciotomy can be performed. Choice A is incorrect. Paresthesia and pallor are not normal after a cast has been applied. This indicates the presence of a compartment syndrome. Choice B is incorrect. Isometric exercises help in preventing muscle atrophy in casted limbs. It does not, however, help in compartment syndrome. Choice C is incorrect. A cast can only be removed with a physician's order, especially if it is within 24 hours of a client's fracture. By eliminating the cast without the physician, the nurse may do more harm than good.

You are working in the emergency department when a 23-year-old woman comes in after being bitten by multiple fire ants. You examine her and notice that there are many fluid-filled bites on her legs and ankles. She is complaining of numbness in her face and you notice swelling around her lips. She complains of shortness of breath and her respiratory rate is 28 breaths per minute. You hear wheezing when you auscultate her lungs. Her heart rate is 110/minute and her blood pressure is 82/40 mmHg. A trained emergency department technician is working with you. The task that you can safely and legally delegate to this technician is: A. Administer epinephrine [23%] B. Administer an antihistamine [4%] C. Start an IV of normal saline [7%] D. Place the patient on a cardiac monitor to analyze the heart rhythm [66%]

Explanation Choice D is correct. Placing the patient on a cardiac monitor is a task that you can safely and legally delegate to an unlicensed, trained team member. The question stipulates that the technician is trained, so it is safe to assume that they can do this task. Starting an intravenous line and giving medications are tasks that cannot be delegated to an unlicensed person. The nurse needs to understand the limits of unauthorized personnel as defined by facility policy, state regulations, and the scope of practice of the team member. Each state has different ranges of training for all healthcare providers, so the nurse must understand the state regulations before delegating a task. When in doubt about the appropriate delegation of a job, the nurse should never assign the duty. Any time the nurse delegates a responsibility, it is critical that the nurse follow up to ensure that the task was completed accurately. The nurse should also be aware of the five rights of delegation: right assignment, right circumstance, right person, proper direction/communication, and correct supervision. NCSBN Client Need Topic: Management of Care, Sub-Topic: Assignment, Delegation, and Supervision, Assignment/Delegation

The nurse is caring for a client newly diagnosed with type I diabetes mellitus. It would be essential to educate the client to A. check their hemoglobin A1C level every three months. [5%] B. rotate injection sites for insulin administration. [17%] C. examine their feet with a mirror daily. [5%] D. recognize the symptoms of hypoglycemia. [72%]

Explanation Choice D is correct. Recognizing the signs and symptoms of hypoglycemia is essential since hypoglycemia can be lethal. Signs and symptoms of hypoglycemia include palpitations, tachycardia, cool and clammy skin, lethargy, and coma. Choices A, B, and C are incorrect. Checking a hemoglobin A1C level every three months, rotating injection sites, and examining the feet in a mirror are key teaching points for a client newly diagnosed with diabetes. However, hypoglycemia may be lethal, and the client must recognize these symptoms. Additional Info Hypoglycemia may be caused by - Inappropriate dosing of insulin or antidiabetics such as glipizide Insulin and mealtime mismanagement (example - rapid-acting insulin given when the patient is NPO or given too early prior to a meal) Inappropriate dosing of insulin Exercise or the consumption of alcohol Treatments for hypoglycemia include 15 grams of quick-acting carbohydrates and rechecking the blood glucose within 15 minutes. If the patient is lethargic, do not feed the client and consider prescribed treatments such as dextrose 50% or glucagon.

A client is brought to the emergency department after a severe car accident. They need immediate surgery if their life is to be preserved. However, they are unconscious and unable to consent to the operation. Which of the following is the best action? A. Ask a friend who was with the client to sign the consent form. [2%] B. Attempt calling a family member to obtain consent. [5%] C. Call the on-staff nursing supervisor and request a court order for the surgery. [3%] D. Immediately transport the client to the operating department without obtaining consent. [89%]

Explanation Choice D is correct. When delaying treatment to a client would result in severe injury or death, consent is not needed. The only other circumstance where treatment of adults does not require approval is if the client declines treatment. Choice A is incorrect. Asking the friend would delay lifesaving treatment. Note that the subject of the question states that immediate treatment is necessary. Choice B is incorrect. Attempting to contact a family member may be impossible in this situation and will likely delay treatment. Choice C is incorrect. A court order is not needed to perform lifesaving procedures on unconscious clients. NCSBN client need Topic: Management of Care: Informed Consent

The nurse is caring for a patient newly diagnosed with heart failure. Which of the following medications would the nurse anticipate to be prescribed? Select all that apply. A. Furosemide [36%] B. Lisinopril [31%] C. Diltiazem [21%] D. Naproxen [4%] E. Prednisone [8%]

Explanation Choices A and B are correct. Heart failure management includes medications such as diuretics, ACE inhibitors, and low-dose beta-blockers. Furosemide (loop diuretic) would be an appropriate choice along with lisinopril (ACE inhibitor). Choices C, D, and E are incorrect. Diltiazem is a calcium channel blocker and would be contraindicated in the treatment of heart failure. These agents decrease cardiac contractility, which would be detrimental. Naproxen is an NSAID and would cause fluid retention and should not be used in the management of an individual with heart failure. Prednisone would be detrimental during heart failure because a corticosteroid leads to fluid retention. Additional information: Heart failure requires extensive patient education that focuses on the prescribed medications, low salt diet restrictions, and the encouragement of aerobic exercise. The patient should be reminded to weigh themselves daily. ACE inhibitors are central in the management of heart failure because they inhibit the heart from getting larger and the patient retaining fluid.

The nurse is caring for a client receiving a continuous infusion of regular insulin. The nurse should plan to monitor which clinical data? Select all that apply. A. Hourly blood glucose [33%] B. Potassium [31%] C. BUN and creatinine [16%] D. Gastric pH [4%] E. Fasting blood glucose [17%]

Explanation Choices A and B are correct. Hourly glucose and potassium are essential labs to be monitored while a client receives a continuous infusion of regular insulin. Potassium levels need to be monitored while a client is receiving regular insulin because it pushes potassium back into the cell, and this shift causes hypokalemia. Hourly glucose is essential to monitor as it may cause a client to develop life-threatening hypoglycemia. Choices C, D, and E are incorrect. BUN and creatinine, gastric pH, and fasting blood glucose are three labs not essential to a client receiving a continuous infusion of regular insulin. Hourly capillary blood glucose is necessary as regular insulin peaks within fifteen minutes when it is administered intravenously. Fasting blood glucose would be useful in screening a client with possible diabetes and is not done while a client is receiving a continuous infusion of insulin. Additional Info Regular insulin infusions are typically prescribed for clients experiencing diabetic ketoacidosis (DKA). The nurse must monitor the client for hypoglycemia and hypokalemia, as both can be fatal. The client typically gets hourly blood glucose assessments along with q 4-6-hour basic metabolic panels (BMP) to evaluate their potassium level.

Which of the following statements are true regarding beta blockers' mechanism of action? Select all that apply. A. Decrease blood pressure [39%] B. Decrease workload of the heart [38%] C. Increase contractility [8%] D. Increase cardiac output [14%]

Explanation Choices A and B are correct. The vasodilation properties of a beta-blocker mean that they decrease blood pressure. This is because the beta-blockers are blocking the receptor sites for your catecholamine, so they cannot do their job and cause vasoconstriction (Choice A). Beta-blockers decrease the workload of the heart. This is because of the vasodilation, subsequent decrease in blood pressure, and then fall in afterload. Remember, afterload is the pressure against which the left ventricle must pump. With decreased blood pressure, we reduce afterload. With reduced afterload, the left ventricle does not have to work as hard to pump blood to the body. Therefore, beta-blockers decrease the workload of the heart (Choice B). Beta-blockers block the beta cells of the body. Beta cells are receptor sites for catecholamines, such as epinephrine and norepinephrine. When we block the receptor sites for the catecholamines, they cannot do their job. Catecholamines function to increase everything - increase blood pressure, increase pulse, increase contractility, and cause vasoconstriction. This is because they are fight-or-flight hormones. They get the body excited and ready to go. So, when beta-blockers block them, everything decreases. Your body vasodilates, the heart slows down, and the blood pressure decreases. Choice C is incorrect. Beta-blockers decrease contractility, not increase; this is because they are blocking those beta cell receptor sites for catecholamines such as epinephrine and norepinephrine. The catecholamines work to increase contractility, but they are blocked by the beta-blockers. So, beta-blockers decrease contractility. Choice D is incorrect. Beta-blockers decrease cardiac output, not increase; this is because of the decreased contractility. While the catecholamine receptor sites are blocked, they are unable to cause increased contractility and the contractility of the heart decreases. With decreased contractility comes a decreased stroke volume. Since CO = HR x SV, a reduced stroke volume means a reduced cardiac output. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Cardiac

While preparing to discharge a 2-year-old newly diagnosed with hypothyroidism, you include which of the following educational points in your discharge teaching? Select all that apply. A. Take the thyroid medication at the same time each day. [45%] B. Take the thyroid medication 30 minutes after breakfast. [14%] C. Avoid taking the thyroid medication in the evening. [39%] D. No follow-up labs are necessary. [1%]

Explanation Choices A and C are correct. When discharging a pediatric patient who is newly diagnosed with hypothyroidism, it is essential to educate the parents about how to administer thyroid medication. Taking thyroid medication in the evening can cause insomnia. It should be taken at the same time each day, on an empty stomach, 30 minutes before breakfast. Choices B and D are incorrect. Taking the drug after breakfast interferes with its absorption. Follow-up labs to check TSH and T4 levels are necessary. NCSBN Client Need: Topic: Health Promotion and Maintenance, Child Health, Subtopic: Endocrine

Which of the following clinical manifestations would alert the nurse to the possibility of Kawasaki's disease in an 8-year-old patient? Select all that apply. A. Strawberry tongue [42%] B. Fruity breath [7%] C. Drooling [15%] D. Bright red, swollen lips [36%]

Explanation Choices A and D are correct. Kawasaki's disease is a swelling in the walls of the arteries throughout the body. Due to this inflammation, a strawberry tongue is a common identifying symptom. Other signs and symptoms include a high fever that persists for five or more days, a rash on the torso and groin, bloodshot eyes, bright red, swollen lips, as well as red palms and soles of the feet. Choice B is incorrect. Fruity breath is not a sign of Kawasaki's disease. Fruity breath is characteristic of a child presenting with DKA. Choice C is incorrect. Drooling is not a sign of Kawasaki's disease. Drooling is characteristic of a child presenting with epiglottitis. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatrics

Select the pharmacological terms that are accurately paired with their definition/description. Select all that apply. A. Adverse effects: highly serious, sometimes life-threatening, and rare side effects of a particular medication. [24%] B. Therapeutic index: The relationship of the therapeutic, desired effect of a drug to its onset, peak, trough, and duration. [21%] C. Peak plasma level: The steady and maintained level of the medication in the body with several doses of the medication. [5%] D. The plateau of a medication: The highest possible concentration of a medication that is achieved with a dose of a medication. [10%] E. Potentiating effect: The ability of a medication to produce its desired effect by the addition of one or more kappa receptor medications. [14%] F. First pass effect: The inactivation of a medication as it is inactivated by the metabolic role of the liver. [10%] G. Inhibiting effect: The ability of a medication to reduce its side effects with the addition of one or more agonist medications. [15%]

Explanation Choices A and F are correct. Adverse effects are highly severe, sometimes life-threatening, and rare side effects of a particular medication. Medications are most often discontinued when a client is adversely affected. A first-pass effect is the inactivation of a medication as it is inactivated by the metabolic role of the liver; this sometimes occurs with oral medications. Choice B is incorrect. The therapeutic index is not the relationship of the therapeutic, desired effect of a drug to its onset, peak, trough, and duration; instead, the therapeutic index is the narrow margin of the medication dosage between its optimal effect and drug toxicity. Choice C is incorrect. The peak plasma level is not the steady and maintained level of the medication in the body with several doses of the drug; instead, this process is the plateau of a medication. Choice D is incorrect. The plateau of a medication is not the highest possible concentration of a drug that is achieved with a dose of drugs; instead, this process is the peak plasma level. Choice E is incorrect. The potentiating effect is not the ability of a medication to produce its desired result by the addition of a nonsteroidal anti-inflammatory medication; medications are potentiated when the addition of a drug to another one increases the effect(s) of one or both of the medications. Choice G is incorrect. An Inhibiting effect of a medication is not the ability of a drug to reduce its side effects with the addition of one or more agonist medications. An inhibiting effect is when a drug binds to a receptor and decreases its activity.

The nurse is teaching a client who is pregnant about how to increase the fiber in her diet. It would be appropriate for the nurse to recommend which foods? Select all that apply. A. Bran muffin [20%] B. Kidney beans [20%] C. Brown rice [23%] D. Whole wheat pasta [22%] E. Corn [14%] F. French fries [0%]

Explanation Choices A, B, C, D, and E are correct. Fiber-dense foods are an excellent choice for individuals who are (and are not) pregnant. They sustain satiety and prevent spikes in blood glucose. Bran, vegetables, whole wheat, beans, and lentils are fiber-rich and would be appropriate to recommend to the client. Choice F is incorrect. French fries have very low nutritional value. They are rich in oil and sodium and often lead to fluid retention because of the high sodium level. Additional Info Common sources of dietary fiber include: Fruits and vegetables (with skins, when possible): Apples, strawberries, pears, carrots, corn, potatoes with skins, and broccoli Whole grains and whole grain products: Whole wheat bread, bran muffins, bran cereals, oatmeal, brown rice, and whole-wheat pasta Legumes: Peas, lentils, kidney beans, lima beans, baked beans, and nuts

The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply. A. Nausea and vomiting [28%] B. Constipation [25%] C. Pruritus [16%] D. Urinary retention [21%] E. Nystagmus [9%

Explanation Choices A, B, C, and D are correct. Fentanyl is an opioid analgesic used in the management of acute and chronic pain. Common effects associated with this drug include nausea and vomiting, constipation, pruritus, and urinary retention. Choice E is incorrect. Nystagmus is not associated with fentanyl. Ophthalmic effects associated with fentanyl include blurred vision and miosis. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Question Type: Knowledge/Comprehension Additional Info Fentanyl is an opioid medication that may be given in a variety of routes, including intravenous, intramuscular, transdermal, intranasal, and buccal. Prior to the administration of an opioid, the nurse should assess the client's pain level, blood pressure, and respiration. The fentanyl patch should be applied no greater than 72 hours.

The nurse is caring for an assigned client. Which prescription requires clarification with the primary healthcare provider (PHCP) based on the laboratory data? See the exhibit. Select all that apply. A. Furosemide 40 mg PO Daily [36%] B. Metformin 1-gram PO Daily [18%] C. Ibuprofen 800 mg PO Daily PRN Pain [18%] D. Citalopram 20 mg PO Daily [10%] E. Lisinopril 20 mg PO Daily [18%]

Explanation Choices A, B, C, and E are correct. Furosemide, Metformin, Ibuprofen, and Lisinopril are all medications that may lead to nephrotoxicity. The laboratory data showed hypokalemia and an increase in creatinine which should prompt the nurse to clarify the prescriptions with the PHCP. Choice D is incorrect. Citalopram is an antidepressant that does not cause nephrotoxicity. This medication should be okay to administer to the client based on the laboratory data. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Question Type: Analysis Additional Info Elevations of the creatinine (normal: 0.6-1.2 mg/dL for males, 0.5-1.1 mg/dL for females) usually are caused by an offending agent such as an NSAID (ibuprofen), antibiotic (vancomycin), ACE inhibitors (lisinopril), and sulfa-based drugs. In this case, the client had elevated creatinine and low potassium, which support the clarification of the furosemide.

The nurse prepares to administer a cycled tube feeding to a client through the nasogastric tube. Before initiating the feed, which actions would be appropriate for the nurse to take? Select all that apply. A. Flush the nasogastric tube with sterile water or potable tap water. [19%] B. Verify placement of the nasogastric tube. [33%] C. Elevate the head of the bed. [33%] D. Ask the client to remain in bed during the tube feeding. [15%]

Explanation Choices A, B, and C are correct. A is correct. Before beginning a cycled tube feeding, the nurse should flush the nasogastric tube with sterile water. If the patient is not immunocompromised or critically ill, potable tap water is also appropriate for flushing the feeding tube. Sterile saline can be used in patients with hyponatremia. Flushing the enteral tube before feeding helps to confirm that the tube is patent and ensures that the formula freely flows into the client's gastrointestinal tract during the feeding. B is correct. It is essential to always verify the placement of the nasogastric tube before putting anything in it. If the tube has moved and the tip of it is no longer in the stomach, the feeding could be aspirated, causing serious problems such as pneumonia. The gold standard to verify tube placement is visualization on an x-ray. After the placement has been initially verified, the nurse may mark where the tube is located at the nare of the client so that the nursing staff can check that the tube has not moved and remains in the stomach prior to each feeding. C is correct. It is appropriate to elevate the head of the bed before any tube feeding. This allows gravity to help the tube feeding flow into the stomach and prevent reflux. For clients receiving a bolus feeding, a high-Fowler's position is preferred, and for clients receiving a cycled or continuous feeding, a semi-Fowler's position is preferred. Choice D is incorrect. The nurse doesn't need to instruct the client to remain in bed for the duration of their tube feeding. However, some clients may prefer to stay in bed, or they may like to get up to the chair, sit up, get up to ambulate to the restroom, etc.

You are learning about latex allergies from a senior nurse. Which of the following is not true regarding latex allergies? Select all that apply. A. They always result in anaphylactic reactions and shock. [31%] B. They cannot be caused by equipment such as a stethoscope. [26%] C. They can be reduced by using moisturizing oils after hand-washing. [30%] D. They are more common in nurses and frequently in hospitalized patients. [14%]

Explanation Choices A, B, and C are correct. Latex allergies do not always result in anaphylactic reaction/shock. Most of the reactions are like contact/irritant dermatitis. Latex allergies can be caused by equipment such as a stethoscope. Moisturizing the hands after washing does NOT help decrease latex allergies. On the contrary, this practice may increase the likelihood of latex allergies. One should avoid oil-based hand creams and moisturizing lotions, which may deteriorate the gloves and accelerate the release of latex allergens. It is recommended to wash hands with a pH-balanced soap and let them dry between glove use. Such practice helps remove latex proteins and prevents skin irritations. Latex allergies usually result from repeated exposure to proteins in natural rubber latex through skin contact or inhalation. Latex can be present in many commonly used medical equipment like blood pressure cuffs, stethoscopes, intravenous tubing, syringes, gloves, and surgical masks. Reactions usually begin within minutes of exposure to latex, but they can occur hours later and produce various symptoms. Less commonly, severe symptoms such as anaphylaxis can occur. Choice D is incorrect. The question is asking to select "not true" statements regarding latex allergy. The report, "Latex allergies are more common in nurses and frequently in hospitalized patients," is a true statement and is, therefore, not the answer to this question. Nurses and other health care workers are more likely to have latex allergies than the general population (Choice D). The U.S. Department of Labor, Occupational Safety and Health Administration (2014) reports that there is 8-12% of latex allergies are among healthcare workers vs. 1% of the general population.

The nurse performs a physical assessment on a client. Which of the following would the nurse recognize as a technique of inspection? Select all that apply. A. Ecchymosis to sacral area. [32%] B. Foul odor noted to urine. [27%] C. Jugular veins distended. [32%] D. Abdomen is tympanic. [7%] E. Bowel sounds hyperactive. [2%]

Explanation Choices A, B, and C are correct. Assessing that the client has bruising over the sacral area is achieved by visually inspecting the skin. Noting the presence of a foul odor is an example of inspection that uses the sense of smell. The nurse would inspect the client's neck to note visible jugular vein distension. Choices D and E are incorrect. Assessment of tympany in the abdomen is obtained through percussion and is typically observed over areas of air-filled organs such as the intestines. Assessment of the bowel sounds is obtained through auscultation with a stethoscope. NCLEX Category: Health Promotion and Maintenance Related Content: Techniques of Physical Assessment Question Type: Application Additional Info Inspection is the first step in a physical assessment and describes the process of obtaining purposeful observations about a client using the senses of vision, hearing, and smell. Auscultation involves listening to areas of the client's body (such as lungs, heart, and bowel sounds) with a stethoscope. Palpation and percussion are methods that use the sensation of touch and are performed by using the hands or fingers to tap or feel areas of the client's body. Palpation gives information about aspects such as the skin temperature, turgor, moisture level, tenderness, and the presence of any edema. Percussion provides information about whether an area is filled with air, an organ, bone, or other solid masses.

You are educating a patient newly diagnosed with hypertension about sodium and its role in blood pressure. Which of the following statements about sodium are true? Select all that apply. A. Sodium cannot be completely eliminated from the diet. [26%] B. There is no sodium in fresh fruits and vegetables. [7%] C. Canned vegetables should be avoided. [33%] D. The body needs some sodium as it plays an important role in water balance. [33%]

Explanation Choices A, C, and D are correct. A is correct. It is not possible to eliminate sodium from the diet, nor would it be recommended. Sodium is a principal cation and it plays a role in driving the sodium-potassium pump as well as regulating water balance, so wholly eliminating sodium is not a good idea. C is correct. Canned vegetables do use a large amount of sodium to preserve flavor, so you should advise your patient with hypertension to avoid them. D is correct. The body indeed needs some sodium as it plays a vital role in water balance, so this is an appropriate teaching point for your patient. Choice B is incorrect. There is a small amount of sodium in fresh fruits and vegetables, but these are still good diet choices for a patient newly diagnosed with hypertension. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Renal

The nurse is giving a teaching on decreasing CAD risk. Which information regarding nutritional recommendations should be included? Select all that apply. A. Increase complex carbohydrates in the diet. [12%] B. Decrease caloric intake to achieve a BMI of 25-29.9. [13%] C. Reduce sodium intake. [37%] D. Reduce saturated fat intake. [38%]

Explanation Choices A, C, and D are correct. Dietary recommendations for reducing CAD risk include increasing dietary complex carbohydrates and vegetable proteins, reducing sodium intake, reducing caloric intake to achieve/maintain ideal body weight, and limiting dietary cholesterol as well as total and saturated (animal) fats. Choice B is incorrect. The BMI range of 25-29.9 is considered overweight. The target BMI range is 18.5-24.9. NCSBN Client Need Topic: Adult health - Nutrition, Subtopic: Nutrition and oral hydration, illness management

The nurse conducts safety rounds within the nursing unit. Which observation requires follow-up? Select all that apply. A. The client's armband was affixed to the bedside table. [30%] B. The client's telephone number and name were used as identifiers. [21%] C. Multiple blood specimen tubes are labeled before specimen collection. [16%] D. A room number is used as an identifier during medication administration. [30%] E. Verifies client's name, date of birth, consent, site, and procedure during a time out process. [2%]

Explanation Choices A, C, and D are correct. These observations require follow-up because they are unsafe. The client's armband should not be the sole source of client identification but rather collateral information. It should be attached to the client, not a bedside table or bed. Specimen tubes should never be prelabeled. Specimen collection requires appropriate labeling and client verification when obtaining the specimen. A room number cannot be used as a reliable client identifier. Choices B and E are incorrect. These observations reflect appropriate practice and do not require follow-up. A client's telephone number is an acceptable identifier when combined with their name. A time-out procedure should involve the client and participants of the procedure. Elements include the client's name, date of birth, consent, site, and procedure during a time-out process. Additional Info Two reliable client identifiers should be verified for client activities. Acceptable client identifiers include Name Date of Birth An assigned identification number (e.g., medical record number, etc). Telephone number or another person-specific identifier Electronic identification technology coding, such as bar coding or RFID includes two or more person-specific identifiers The nurse should not use identifiers such as the client's room number.

You are administering hydralazine to your patient with a blood pressure of 162/112 mmHg. Which of the following actions do you expect to occur with the administration of this medication? Select all that apply. A. Decreased cardiac output [23%] B. Vasodilation [36%] C. Decreased afterload [30%] D. Increased contractility [10%]

Explanation Choices B and C are correct. Administration of hydralazine will cause vasodilation; it is very effective at lowering blood pressure. By dilating the vessels of the body, the fluid in the vessels have more room and therefore the pressure they are exerting on the vessel walls decreases. Think of it like a garden hose - to decrease the pressure in the hose you can either make the hose bigger or put less water in the hose. Hydralazine makes the "hose" or blood vessels bigger by causing vasodilation (Choice B). When the patient vasodilates and their blood pressure drops, the afterload decreases; this is because the heart has less pressure to pump against (Choice C). Choice A is incorrect. Hydralazine is a blood pressure medication that causes vasodilation throughout the body. Vasodilation decreases blood pressure in hypertensive patients. This will actually increase a patient's cardiac output, not decrease. This is because when the patient vasodilates and their blood pressure drops, the afterload decreases (the heart has less pressure to pump against). With decreased afterload, the stroke volume is able to increase. Since CO = HR x SV, when there is an increased SV, there is an increased CO. Choice D is incorrect. Hydralazine will not cause increased contractility in the heart. Hydralazine is a blood pressure medication that causes vasodilation throughout the body. Medications that cause increased contractility in the heart are called inotropes and they include medications such as dopamine, dobutamine, and milrinone. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Cardiac

Which of the following interventions does the nurse expect when caring for a toddler who has a diagnosis of phenylketonuria? Select all that apply. A. Initiation of a keto diet [10%] B. IV iron dextran treatments [18%] C. Elimination of dairy, meat, and eggs from the diet [39%] D. Strict avoidance of aspartame [32%]

Explanation Choices C and D are correct. Elimination of dairy, meat, and eggs from the diet is an essential intervention for toddlers with PKU. In phenylketonuria (PKU), there is impaired metabolism of a critical amino acid named phenylalanine. When patients eat foods that contain this amino acid, they cannot break it down, and levels of this amino acid can then become toxic to the patient. Dairy, meat, and eggs are high in protein and therefore have a large amount of the amino acid phenylalanine. Thus, eliminating these items from the diet is essential for children with PKU (Choice C). Strict avoidance of aspartame is an essential intervention for toddlers with PKU. The artificial sweetener aspartame has a large amount of the amino acid phenylalanine. Therefore, eliminating it from the diet is essential for children with PKU (Choice D). Choice A is incorrect. A ketogenic diet is a high-fat, adequate-protein, low-carbohydrate diet used to treat hard-to-control epilepsy in children. In this diet, since the body has so few carbs to use for energy, it burns fat, which produces ketones. This diet is not used in children with PKU. Choice B is incorrect. Iron dextran is used to treat iron deficiencies and iron deficiency anemia. It is essential for oxygen transport within the body and affects the oxygen-carrying capacity. Administration of IV iron dextran would not be useful in a child with PKU. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Problems with Labor and Delivery

The nurse is observing infection control practices on the nursing unit. Which of the following findings requires follow-up? Select all that apply. A. A client with H. pylori placed on standard precautions. [21%] B. Disposable blood pressure cuff used on a client with rotavirus. [11%] C. A client's room door kept closed who has rubella. [23%] D. A client with influenza ambulating in the hall with a surgical mask. [10%] E. Contact precautions for a client with Legionnaires' disease. [35%

Explanation Choices C and E are correct. A client with rubella should be placed on droplet precautions. Droplet precautions do not require that the door be kept closed. The PPE required for rubella includes a surgical mask. Legionnaires' disease is not transmitted person-to-person but rather through infected water or soil. This bacterium requires standard precautions. Choices A, B, and D are incorrect. These observations are correct and do not require follow-up. H. pylori infections are not transmitted from person to person, and thus, standard precautions are appropriate. A disposable blood pressure cuff is appropriate for a client with rotavirus as infected surfaces may transmit this pathogen. It is appropriate for a patient with influenza to ambulate with a surgical mask as this may be spread through infected droplets. Additional Info The minimum personal protective equipment (PPE) required for contact is gloves and a surgical mask. For droplet precautions, it is a surgical mask. Finally, airborne precautions require the client's room door to be kept closed, with negative pressure, and an N95 respirator to be worn.

Place the following stages of Piaget's Stages of Cognitive Development into the appropriate order: Sensorimotor Preoperational Concrete operational Formal operational

Explanation The correct ordered sequence is: Sensorimotor Preoperational Concrete operational Formal operational The first stage of Piaget's Stages of Cognitive Development is the sensorimotor stage. This stage occurs between 0 and 2-years-old. During this stage, the child learns to coordinate their senses with motor responses. They are curious about the world and use their minds to explore. They start to form language and use it for demands. They also develop object permanence. The second stage of Piaget's stages is the preoperational stage. This stage occurs between 2 and 7-years-old. In this stage, the child is a symbolic thinker. They can use language with proper grammar to express their thoughts. Their imagination and intuition are developing rapidly. They are not yet able to think complex abstract thoughts. The third stage is the concrete operational stage. This stage occurs from 7 to 11-years-old. In this stage, concepts are attached to specific situations. The ideas of time, space, and quantity begin to develop. The fourth and last stage in Piaget's stages of cognitive development is the formal operational stage. This stage begins at age 11 and continues into adulthood. In this stage, children can use theoretical, hypothetical, and counterfactual thinking. They can reason and use abstract logic. Planning for future events and using strategy start to become possible. They can learn concepts in one area and apply them to another area. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Development

Place the following elements of evaluation in their correct sequence: Interpreting and summarizing findings Collecting data to determine whether evaluative criteria and standards are met Documenting one's judgment Terminating, continuing, or modifying the plan of care Identifying evaluative criteria and standards

Explanation The correct ordered sequence is: 5, 2, 1, 3, 4. The five classic elements of evaluation are: Identifying evaluative criteria and standards (what you are looking for when you evaluate) Collecting data to determine whether these criteria and standards are met Interpreting and summarizing findings Documenting your judgment Terminating, continuing, or modifying the plan In the 5th step of the nursing process, evaluating, the nurse measures how well the patient has achieved the outcomes specified in the plan of care. When evaluating patient outcome achievement, the nurse identifies factors that contribute to the patient's ability to achieve expected results and, when necessary, modifies the plan of care. The purpose of the evaluation is to allow the patient's achievement of expected outcomes to direct future nurse-patient interactions. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care - Components of Evaluation

Place the following steps for starting a peripheral intravenous line in the correct sequential order? Place the tourniquet 1 to 2 inches above the selected vein site. Inspect and palpate the extremity for a suitable vein. Prep the selected area with an antiseptic wipe. Allow the area to air dry. Pull the skin taut above the selected vein. Insert the intravenous catheter at a 15 to 30 degree angle. Advance the catheter until a flash of blood is seen. Stabilize the intravenous catheter. Place a sterile dressing over the IV site.

Explanation The correct sequence of steps to start a peripheral intravenous line are as follows: Inspect and palpate the extremity for a suitable vein. Place the tourniquet 1 to 2 inches above the selected vein site. Prep the selected area with an antiseptic wipe. Allow the area to air dry. Pull the skin taut above the selected vein. Insert the intravenous catheter at a 15 to 30-degree angle. Advance the catheter until a flash of blood is seen. Stabilize the intravenous catheter. Place a sterile dressing over the IV site. NCSBN Client Need: Topic: Reduction of Risk Potential; Sub-Topic: Insert, maintain, or remove a peripheral intravenous line.

The nurse is assessing a client who is five months pregnant and has a son born at 40 weeks of gestation and a daughter born at 33 weeks of gestation. It would be correct for the nurse to document this client's GTPAL as A. G4-T1-P1-A0-L2 [1%] B. G3-T1-P1-A0-L2 [83%] C. G3-T1-P1-A0-L3 [4%] D. G3-T2-P0-A0-L2 [11%]

Explanation This client is currently pregnant and has had two other pregnancies prior to the current one. This would make her a gravida three (G3). She has delivered one child at 40 weeks of gestation, which is one term birth (T1). She delivered one child at 33 weeks (P1). She has had two live births (L2). Additional Info A method for calculating gravida and para is to separate pregnancies and their outcome using the acronym GTPAL: G = gravida, T = term, P = preterm, A = abortions, and L = living children. G = pregnancies or gravida, T = term pregnancies delivered, P = preterm pregnancies delivered, A = abortions (spontaneous and induced), and L = living children Term pregnancies are any pregnancy 37 weeks or greater; preterm is any pregnancy 20-36 weeks; abortions are any abortions spontaneous or induced prior to 20 weeks.

Before administering a nasogastric feeding to a preterm infant, the nurse prepares to aspirate the residual fluid from the stomach. Please place the following nursing actions in sequential order. Position the patient with the head slightly elevated Aspirate gastric contents Measure the aspirate Return the aspirate and subtract the amount of the aspirate from the feeding Begin the prescribed nasogastric feeding

osition the patient with the head slightly elevated Aspirate gastric contents Measure the aspirate Return the aspirate and subtract the amount of the aspirate from the feeding Begin the prescribed nasogastric feeding Explanation The correct sequence is: Position the infant with his or her head slightly elevated to reduce the risk of aspiration. This should be done before the feeding is resumed. If the infant is on "continuous" feeding, it is assumed that the head end is already kept elevated all the time. About 40% of clients on enteral feeding aspirate have associated complications/ morbidity. Elevating the head of the bed to 30-45 degrees helps prevent or reduce the risk of aspiration. Aspirate the gastric contents. Measure the aspirate: Aspirate should first be measured, so the nurse knows how much to subtract from the feeding. Return the aspirate and subtract the amount of the aspirate from the feeding. This is done to maintain the gastric enzymes and acid-base balance. Begin the prescribed nasogastric feeding.