Archer Review 5b

The client that is under sodium restrictions is asking the nurse about which seasonings he can use that are low in sodium. The nurse should respond by saying: A. "You can use soy sauce as a dip." [3%] B. "You can use ketchup to make it taste better." [3%] C. "You can add some rosemary to increase your food's flavor." [93%] D. "Steak sauce is a nice way to enhance your food." [2%]

Explanation Choice C is correct. Rosemary is a low-sodium seasoning that only has 26 mg of sodium per 100 grams. Choice A is incorrect. Soy sauce is a high-sodium seasoning that has 291.1 mg of sodium per teaspoon. Choice B is incorrect. Ketchup is also a high-sodium seasoning that has 154.2 mg of sodium per tablespoon. Choice D is incorrect. Steak sauce is also a high-sodium seasoning that has 280 mg of sodium per tablespoon.

Which of the following images demonstrates the rash typical of varicella?

Explanation Choice A is correct. This rash is typical of varicella. Varicella (Chickenpox) is caused by the varicella-zoster virus (VZV) of the herpes group. The outbreak clearly shows macules, papules as well as vesicles. The lesions evolve from red macules to form small papules, and then a clear blister develops on this base. Such evolution of rash has been described as a "dewdrop (vesicle) on a rose petal (erythematous base)". Over the next several days, these blisters rupture and then crust. The rash begins on the chest and back then spreads centrifugally to involve the face, scalp, and extremities. These blisters and the fact that patient with varicella typically has lesions in different stages of development on the front, trunk, and extremities helps differentiate it from other common viral disease rashes. Isolation precautions for varicella: A nurse needs to be able to recognize this rash because this disease is highly contagious, and appropriate isolation precautions should be started. Varicella transmission occurs via contact with aerosolized droplets from nasopharyngeal secretions or by direct cutaneous contact with the vesicular fluid. The nurse should place the varicella patient on airborne infection isolation (i.e. unfavorable air-flow rooms) and contact precautions until all lesions have crusted. A person with varicella is contagious beginning 1 to 2 days before rash onset until all the chickenpox lesions have crusted. Choice B is incorrect. This is the rash typical of rubella. In the image, you can notice the outbreak is on the face, and there are no blisters. Rubella manifests with sudden onset of a maculopapular rash consisting of pinpoint, pink maculopapular, and concomitant low-grade fever. It appears on the face first and then spreads to the trunk and extremities. On average, the rash lasts three days. Although the outbreak may be similar to Rubeola (measles), rubella rash spreads more rapidly and does not darken or coalesce. Rubella does not have vesicles and lacks different stages of lesions, unlike varicella (Chickenpox). Isolation precautions for Rubella: Droplet precautions and exclusion from school or child care for seven days after the onset of the rash. Choice C is incorrect. This is the rash typical of roseola. In the image, you may notice that the face is spared, but the trunk is involved—Roseola Infantum (exanthem subitum or sixth disease or three-day fever) is caused by Human Herpes Virus-6 (HHV6). The rash is maculopapular and blanching. Very high temperature (as high as 104 degrees F) starts first and lasts about 3 to 5 days. Once fever abates, the rash develops. The outbreak is similar to rubella and is often referred to as pseudo-rubella. However, there are some differences: Rubella: Low-grade fever occurs concomitant with a rash. The rash starts on the face and spreads to extremities. Roseola: Fever starts first, and then comes the rash. The rash begins on the trunk and neck then later spreads to the face and extremities. Isolation precautions for roseola: Roseola spreads by contact and is self-limiting. Simple hygienic measures such as "handwashing" are recommended after contact. Choice D is incorrect. This is the rash typical of Measles (Rubeola). In the image, you may notice that the lesions of the outbreak are coalescing. It is a highly contagious viral illness. It begins with fever and "3 Cs" (conjunctivitis, coryza, and cough). Following this, 1 to 3 mm white/grayish or blue raised spots to appear on the buccal mucosa as well as the hard and soft palate. These are called "Koplik spots" and are very helpful in accurately diagnosing measles. Two to four days after the onset of fever, the rash appears - it is an erythematous, maculopapular, blanching rash that begins on the face and spreads centrifugally to involve the neck, trunk, and extremities. The cranial to the caudal progression of the rash is characteristic of measles. Still, a similar pattern of progress is also seen with measles- however, the lesions coalesce in Measles, but they do not blend in rubella. Isolation precautions for measles: In the healthcare settings, airborne transmission precautions are indicated for four days after the onset of rash in measles. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Integumentary

The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply. A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow. [9%] B. Obtains orthostatic blood pressure by having the client stand first. [28%] C. Places the cane on the unaffected side of a client who had a stroke. [6%] D. Provides a hot foot soak for a client with diabetes mellitus. [33%] E. Obtains a urine culture from an indwelling urinary catheter. [24%]

Explanation Choices A, B, D, and E are correct. When supervising a UAP, the nurse should intervene if the UAP is flexing and extending the client's elbow as that is not an active range of motion. The UAP doing the exercise for the client would be considered a passive range of motion ( Choice A). The UAP starting the orthostatic vital signs with the client standing is inappropriate. The correct sequence is supine, sitting, and standing when obtaining orthostatic blood pressures ( Choice B). During the orthostatic vitals, the observer looks for a drop in the blood pressure when the client stands up from a lying or sitting position. Neuropathy is a common manifestation in diabetic clients. Loss of sensation in the feet resulting from diabetic neuropathy may impair the client's ability to remove the feet despite the heat damage. A client with diabetes mellitus should not have feet soaked in hot water, which could impair their skin integrity and cause ulceration ( Choice D). Finally, UAPs may not perform any tasks involving sterility. This includes aspirating urine from an indwelling catheter's tubing using a sterile syringe. UAP can collect urine specimens from the urine bag for other tests. However, obtaining a specimen for urine culture ( Choice E) is a sterile procedure because contaminated urine can lead to false positive results. A sterile syringe and sterile specimen container are used during this procedure. Choice C is incorrect. When a client ambulates with a cane, the cane should be placed on the stronger side (or unaffected) side of the body. This allows the client to maintain stability as they ambulate. This action by the UAP is appropriate and does not require intervention. Learning Objective Recognize the actions within the scope of the UAP and understand when to intervene. Additional Info A UAP can perform tasks such as ambulation, vital signs, intake and output, and range of motion. The UAP may not perform any sterile tasks but may assist with urine specimen collections that are clean catches. When a urine specimen is prescribed from an indwelling catheter, it should not be obtained from the bag; rather, the tubing is clamped and then aspirated with a sterile syringe from the port after cleaning with alcohol. This procedure cannot be delegated to the UAP because it involves a procedure involving sterile supplies.

You are educating a new nurse regarding sentinel events. Which of the following are examples of sentinel events? Select all that apply. A. An untimely assessment of the client. [7%] B. An incomplete assessment of the client. [12%] C. A client falls from the chair to the floor and sustains a humerus fracture. [28%] D. The wrong client is almost sent to the operating room. [24%] E. A client undergoes colectomy instead of appendectomy. [28%]

Explanation Choices C and E are correct. A sentinel event is defined as an event that has reached the patient and caused harm (death, permanent harm, or severe, temporary harm). A sentinel event is unrelated to the patient's illness or underlying condition. Such events are called "sentinel" because they signal a need for immediate investigation and response. All sentinel events must be reviewed by the hospital and are subject to review by the Joint Commission. A sentinel event may occur due to medical errors like wrong-site, wrong-procedure, wrong-patient surgery. Please note that the terms "sentinel event" and "medical error" are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events. Patient safety events occur commonly in health systems worldwide. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. Safety events can be categorized into sentinel events, adverse events, near misses, and no harm events. Sentinel events are just one category of patient safety events. Others include: An adverse event: a patient safety event that resulted in harm to a patient. (e.g. an adverse event could include side effects to medications/vaccines, medical procedures. They may or may not be from negligence. For example, a patient sustaining an embolic stroke after coronary angiography is an adverse event, but not due to medical negligence.) A no-harm event is a patient safety event that reaches the patient but does not cause harm. A close call (or a "near-miss" or a "good catch") is a patient safety event that did not reach the patient. A hazardous (or unsafe) condition(s) is a circumstance (other than a patient's own disease process or condition) that increases the probability of an adverse event. "A client falls from the chair to the floor and sustained humerus fracture" is an actual event that has occurred and caused harm. This event (fall causing injury) is not a medical error but constitutes a sentinel event (Choice C). "A client undergoing colectomy instead of appendectomy" is a sentinel event due to a medical error (Choice E). Other examples of sentinel events include patients committing suicide while receiving care in the hospital or within 72 hours of discharge, hemolytic transfusion reaction, unanticipated death of a full-term infant, rape, assault, sexual abuse, invasive procedure on the wrong site/wrong person/wrong procedure, discharge of infant to the wrong family, any intrapartum maternal death, and so on. Choice D is incorrect. The event "when an incorrect client is almost sent to the operating room" did not occur here and did not cause patient harm. This event is referred to as "near-miss," not a sentinel event. The WHO defines "near-miss" as the one with the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is prevented. According to the Institute of Medicine, a "near-miss" is an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation. An error caught before reaching the patient is another definition. It is also referred to as a close-call or potential adverse event. Near misses also must be reported, so root cause analysis can be completed. The root causes of near misses and adverse/sentinel events are similar. Therefore, detecting root causes of near misses can help us correct these causes and prevent future adverse events. Choices A and B are incorrect. Although an untimely assessment of the client and an incomplete assessment of the client can be contributory factors that led to a sentinel event, these are considered deviations from a standard of care and not sentinel events. Learning objective: Understand the various categories of patient safety events. Sentinel event is just one category of patient safety events and is defined as the one that has reached the patient and caused harm. NCSBN Client need: Topic: Management of care; Subtopic: Quality improvement

Explanation Choices A, B, C, and D are correct. For a negligent lawsuit to proceed, the plaintiff (injured client) must prove the following elements: 1. A duty of care was owed to the injured party. 2. There was a breach of that duty. 3. The breach of the duty caused the injury (causation). 4. The plaintiff suffered actual harm or damages. Choice E is incorrect. Beneficence is an ethical principle and has no legal implications in negligence. Beneficence is defined as an individual acting in positive regard for others with a kind spirit. Additional Info Negligence is defined as the failure to exercise the care toward others that a reasonable or prudent person would do in the circumstances or taking action that such a reasonable person would not. The plaintiff must establish all four elements if a negligent lawsuit can be litigated.

The nurse is teaching a staff conference on negligence. It would be correct for the nurse to include which element must be met in a negligent lawsuit? Select all that apply. A. Duty owed [14%] B. Breach of duty owed [29%] C. Causation [20%] D. Harm or damages [32%] E. Beneficence [4%]

The nurse is caring for a client who recently had a dosage increase of prescribed levothyroxine. Which of the following is a priority? A. Weight [14%] B. Heart rate [70%] C. Activity status [7%] D. Oral temperature [9%]

Explanation Choice B is correct. For a client who has a dosage increase of levothyroxine, the nurse should assess the client for hyperthyroidism. Signs and symptoms of hyperthyroidism would include tachycardia, weight loss, increased temperature, and increased motor activity. It is a priority to assess the client's heart rate because tachydysrhythmias may occur. Choices A, C, and D are incorrect. It is important to monitor weight, activity status, and oral temperature while a client is taking levothyroxine. However, an increase of these would not be imminently life-threatening as tachydysrhythmias. Additional Info When a client is prescribed levothyroxine, the nurse should educate the client to: Take the medication first thing in the morning. Do not take the medication with food or other medications. Follow-up with prescribed laboratory tests to monitor thyroid function. Report signs of hyperthyroidism as that could indicate that the dose needs to be decreased.

The primary healthcare provider (PHCP) prescribes a bolus of regular insulin prior to a continuous infusion. The prescription is for 0.1 units/kg. The client weighs 256 lbs. How many units of insulin should the nurse administer to the client? Fill in the blank. Round your answer to the nearest whole number. 12 units

Explanation The first step is to convert the client's weight from pounds (lbs) to kilograms (kg) 256 lbs → 116.36 kg Next, multiply the prescribed dosage by the client's weight 0.1 units x 116.36 kg = 11.6 units Finally, take the answer and round it to the nearest whole number 11.6 units = 12 units

A 28-year-old female presents to the obstetrics office, suspecting she may be pregnant. Which of the following would the nurse recognize as a presumptive sign of pregnancy? A. Amenorrhea [73%] B. Positive fetal cardiac activity on ultrasound [8%] C. Enlarged uterus [9%] D. Auscultation of fetal heart tones [10%]

Explanation Choice A is correct. Amenorrhea (absence of menstrual period) is a presumptive sign of pregnancy. Presumptive signs of pregnancy are symptoms and signs that the patient experiences. Presumptive signs may resemble pregnancy signs and symptoms but may also be caused by other etiologies. While amenorrhea is a presumptive sign of pregnancy, missing a period can also result from other conditions such as stress, hypothyroidism, and anorexia. Choices B and D are incorrect. A positive cardiac activity on ultrasound (Choice B) and auscultation of fetal heart tones (Choice D) would be a positive sign of pregnancy. Positive signs of pregnancy are signs that cannot, under any circumstances, be mistaken for other conditions. Positive signs confirm that the pregnancy has occurred. Choice C is incorrect. An enlarged uterus would be detected by the examiner and would be a probable sign of pregnancy. Probable pregnancy signs indicate pregnancy in most cases; however, there is still the chance they can be caused by conditions other than pregnancy. While an enlarged uterus is a probable pregnancy sign, other conditions such as uterine tumors, fibroids, and adenomyomas may also cause such a finding. Another example of a probable sign of pregnancy is a positive urine pregnancy test. NCSBN Client Need Topic: Pregnancy, Subtopic: Antepartum care, system-specific assessment Additional Info

A 12-year-old client with chronic asthma exacerbations has decided to try guided imagery as a way to manage the anxiety that is contributing to frequent asthma attacks. Which statement by the client indicates an understanding of this stress-reduction technique? A. "I can do this anytime and anywhere when I feel anxious." [82%] B. "I must be lying down to practice guided imagery." [5%] C. "My mom will have to be with me any time I try this." [3%] D. "I will play music every time I do my guided imagery to make sure it works." [10%]

Explanation Choice A is correct. Guided imagery is a stress-reduction technique that can be done in any place at any time. In fact, this is one of the biggest advantages of this technique. Anytime the patient begins to feel anxious, they can practice guided imagery. Choice B is incorrect. Guided imagery can be done in any position that the patient is most comfortable in. They do not have to by lying down unless they choose to. Choice C is incorrect. It is not necessary for the client's mom or anyone else to be present for guided imagery unless they choose so. Any person, or no one at all, can be present depending on the client's preferences. Choice D is incorrect. Music can but does not have to be played during guided imagery, again it depends on the client's preferences. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Fundamentals - Alternative Medicine

At 25 weeks gestation, a pregnant client presents with a uterine growth size that is less than expected, decreased fetal movement, and an easily palpable fetus. Which of the following is this likely related to? A. Oligohydramnios [72%] B. Macrosomia [11%] C. Hydramnios [11%] D. Amniotic fluid embolism [7%]

Explanation Choice A is correct. Oligohydramnios results from a severe reduction in the amount of amniotic fluid. It results in less than expected fetal growth. Also, because of the low amount of amniotic fluid, the fetus will be more easily outlined and palpated. Choice B is incorrect. Macrosomia is defined as a newborn that is significantly larger than average. These babies have a birth weight of more than 8 lbs, 13 oz. Choice C is incorrect. Hydramnios is a condition in which excessive amounts of amniotic fluid accumulates during pregnancy. Choice D is incorrect. Amniotic fluid embolism is characterized by an acute collapse of mother and baby due to an allergic-type response to amniotic fluid entering the mother's circulatory system. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Care of the Woman and Fetus at Risk

The nurse is discussing the use of medications to prevent organ rejection with the health care provider. Which of the following medicines is not used to avoid organ rejection? A. Oxybutynin chloride [49%] B. Prednisone [21%] C. Tacrolimus [16%] D. Cyclosporine

Explanation Choice A is correct. Oxybutynin chloride is an anti-cholinergic medication often used for overactive bladder. This medication is not used to prevent organ rejection. Choice B is incorrect. Prednisone, a glucocorticoid medication, is frequently used in conjunction with other medicines to prevent organ rejection. Choice C is incorrect. Tacrolimus is an immunosuppressive medication used to prevent organ rejection. Choice D is incorrect. Cyclosporine is an immunosuppressive medication used to prevent organ rejection. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral therapies

The nurse is preparing to suction a client to obtain a sputum sample. Before performing this procedure, the nurse should: A. Hyperoxygenate the client [84%] B. Provide the client with a small snack [0%] C. Initiate NPO status [6%] D. Confirm the order with the physician [10%]

Explanation Choice A is correct. Patients about to undergo a suctioning procedure should first be hyper-oxygenated. Suctioning interrupts the patient's breathing, so hyperoxygenation prevents harm. Choice B is incorrect. Providing the patient with a snack is not a necessary action before suctioning. Choice C is incorrect. A patient about to undergo a suctioning procedure does not require NPO status. Choice D is incorrect. There is no reason to confirm this procedure with the physician. Suctioning is a popular way to collect a sputum sample. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse is supervising a student nurse caring for a newborn. Which of the following reflexes, if elicited by the student nurse, would be the plantar reflex?

Explanation Choice A is correct. This image shows the plantar reflex, which is also known as the Babinski reflex. The plantar reflex occurs after the sole has been stroked upwards. It causes the big toe to move upward and then the other toes fan out. Choice B is incorrect. This image shows the rooting reflex. This reflex is seen in normal newborn babies. It occurs when they turn their face toward stimulation (such as stroking their cheek) and make sucking motions with the mouth. These sucking motions are what is referred to as root. This reflex helps to ensure successful feeding. Choice C is incorrect. This image shows the stepping reflex. The stepping reflex in newborns is seen when a baby is held upright, and the baby's feet are touching the ground. Their feet will make stepping motions as if they are walking. This reflex is prevalent from birth until 2 to 3 months. Choice D is incorrect. This image shows the tonic neck reflex. This reflex is elicited when the head is turned to one side. The baby will extend their arm and leg on the side that the head is turned towards while the opposite arm and leg bend. This reflex dissipates by six months of age. Additional Info To assess for the Babinski reflex, stroke the lateral sole of the foot from the heel to across the base of the toes.

Select the domain of pain that is accurately paired with its appropriate nonpharmacological, alternative, complementary pain management intervention. A. The spirit domain of pain: Reiki [41%] B. The mind domain of pain: Massage [14%] C. The body domain of pain: Self-hypnosis [8%] D. The social domain of pain: Music therapy [36%]

Explanation Choice A is correct. Reiki is a nonpharmacological, alternative, complementary pain management intervention for the spirit or spiritual, domain of pain. Reiki is performed by the reiki therapist by placing their hands above the person, or lightly on the person, to promote the client's own healing processes including the management and control of pain. Examples of other nonpharmacological, alternative, complementary pain management interventions for the spirit, or spiritual, domain of pain include prayer, meditation, and spiritual healing. Choice B is incorrect. Massage is not a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain; massage, instead, is a nonpharmacological, alternative, complementary pain management intervention for the body domain of pain. Choice C is incorrect. Self-hypnosis is not a nonpharmacological, alternative, complementary pain management intervention for the body domain of pain; self-hypnosis, instead, is a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain. Choice D is incorrect. Music therapy is not a nonpharmacological, alternative, complementary pain management intervention for the social domain of pain; music therapy, instead, is a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain.

A pregnant client who is Rh-negative is ordered an indirect Coomb's test. The nurse understands that the purpose of this test is to determine if A. antibodies are present from previous exposure to Rh-positive blood. [57%] B. the amount of time that it takes for fetal blood to clot. [1%] C. blood type, Rh factor, and antibody titer of the newborn [38%] D. the fetus has a risk of developing pernicious anemia later in life. [2%]

Explanation Choice A is correct. Rh-negative women should have an indirect Coombs' test to determine whether they are sensitized (have developed antibodies) as a result of previous exposure to Rh-positive blood. This testing is done at the first prenatal visit. Choices B, C, and D are incorrect. Coombs' testing (direct or indirect) does not measure clotting time (either maternal or fetus). The blood type, Rh factor, and antibody titer of the newborn are determined by the direct Coomb's test. These tests do not determine the probability of pernicious anemia, as this anemia is predicated on the lack of vitamin B12. Additional Info Rh-negative women should have an indirect Coombs' test to determine whether they are sensitized (have developed antibodies) due to previous exposure to Rh-positive blood. If the indirect Coombs' test is negative, it is repeated at 28 weeks of gestation to identify whether they have developed subsequent sensitization. In direct Coombs' testing, if the mother is Rh-negative, the umbilical cord blood is taken at delivery to determine the blood type, Rh factor, and antibody titer of the newborn.

The nurse is triaging clients in the emergency department (ED). Which client should the nurse recommend to the primary healthcare provider (PHCP) to be assigned to the intensive care unit (ICU)? A. 28-year-old admitted with S. pneumoniae meningitis and has a Glasgow Coma Scale of 13. [44%] B. 59-year-old admitted with decompensated heart failure receiving oxygen therapy and hospice services. [18%] C. 33-year-old admitted with cholecystitis and is receiving patient-controlled analgesia. [6%] D. 67-year-old admitted with intractable pain and vomiting secondary to metastatic ovarian cancer. [31%]

Explanation Choice A is correct. S. pneumoniae meningitis is a life-threatening central nervous system infection. This client requires aggressive and prompt administration of antibiotics following a lumbar puncture. Neurological decline, including seizures, may occur in a client experiencing meningitis. Coupled with the potential for bacteremia leading to sepsis, this client requires intensive care. Choices B, C, and D are incorrect. Decompensated heart failure is a serious illness; considering this client is receiving hospice care, critical care admission is highly unlikely. The major tenet of hospice care is symptom control and not life-prolonging therapy, which may be achieved on a medical floor or at home. Cholecystitis may be treated on the medical floor as this is not a critical illness as it pertains to acuity. The client with metastatic ovarian cancer experiencing persistent pain and nausea should be maintained in an oncology unit with optimal pain control and fluid repletion. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected actions/outcomes Question type: Knowledge/comprehension Additional Info Neurological functioning is best assessed with scales such as the Glasgow Coma Scale. The highest score is 15 as it measures the best eye, verbal, and motor responses. Mortality rates were reduced for clients with bacterial meningitis with the prompt administration of antibiotics and steroids as well as admission to the intensive care unit. Intensive/critical care services include the ability to hemodynamically monitor a client, titrate vasoactive medications, and provide highly skilled nursing care.

Which of these critical thinking and supervision skills is necessary for effective and appropriate supervision after the nurse assigns and delegates tasks to staff members? A. The ongoing observation and determination of staff's time management skills. [25%] B. The ongoing one-to-one observation and staff competency validation and documentation. [37%] C. The observation and determination of staff's time management skills at the end of the shift. [9%] D. The one-to-one observation and staff competency validation and documentation at the end of the shift. [29%]

Explanation Choice A is correct. The critical thinking and supervision skills necessary for effective and appropriate supervision after the nurse assigns and delegates tasks to staff members are the ongoing observation and determination of staff's time management skills to ensure that complete care is given to the clients before the end of the shift. Choice B is incorrect. Ongoing one-to-one observation and staff competency validation and documentation are not routinely necessary for effective and appropriate supervision after the nurse assigns and delegates tasks to staff members. However, this would be a determination of the completion of client care. Choice C is incorrect. The observation and determination of the staff's time management skills at the end of the shift are too late. This supervision is an ongoing process to ensure that all client care is provided promptly. Choice D is incorrect: The one-to-one observation and staff competency validation and documentation at the end of the shift is not routinely necessary for the effective and appropriate supervision after the nurse assigns and delegates tasks to staff members. However, this would be a determination of the completion of client care.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A. Check the amount of oxygen in the cylinder before using it. [70%] B. Use a cylinder for a patient transfer that indicates available oxygen is at 500 psi. [6%] C. Place the oxygen cylinder on the stretcher next to the patient. [6%] D. Discontinue oxygen flow by turning the cylinder key counter-clockwise until it is tight. [18%]

Explanation Choice A is correct. The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. Choice B is incorrect. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. Choice C is incorrect. A cylinder that is not secured correctly may result in injury to the patient during transfer. Choice D is incorrect. Oxygen flow is discontinued by turning the valve clockwise until it is tight. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Providing Supplemental Oxygen

Which stage of cognitive development does the nurse expect her 6-month-old patient to be in? A. Sensorimotor [84%] B. Preoperational [13%] C. Concrete operational [2%] D. Formal operational [1%]

Explanation Choice A is correct. 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. Choice B is incorrect. The preoperational 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 ready to think complex abstract thoughts. Choice C is incorrect. The concrete operational 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. Choice D is incorrect. The formal operational 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 becomes possible. They can learn concepts in one area and apply them to another area. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Pediatrics - Development

The nurse is transfusing one unit of packed red blood cells (PRBCs) to a client. The nurse initiated the transfusion at 1400. After completing the 1545 vital signs, the nurse should take which action? See the image below. A. Stop the transfusion [56%] B. Verify the blood product with another nurse [1%] C. Apply nasal cannula oxygen [1%] D. Document the findings and continue the transfusion [42%]

Explanation Choice A is correct. The increase in the client's temperature (compared to the baseline) is concerning and meets the threshold for a febrile reaction to the blood product. For any transfusion reaction the client may be experiencing, the nurse must stop the transfusion. While febrile reactions are generally not life-threatening, the nurse needs to temporarily suspend the transfusion, maintain vascular access, and notify the primary healthcare provider (PHCP). The client would likely be prescribed antipyretics such as ketorolac or acetaminophen. Choices B, C, and D are incorrect. Verifying the blood product with another nurse should have already occurred. This should take place prior to the initiation of a blood transfusion. Nasal cannula oxygen is not indicated because the oxygen saturation is optimal. The client is exhibiting signs of a transfusion-related non-hemolytic reaction, and documenting the findings and continuing the transfusion without intervention would be inappropriate. Additional Info The clinical criteria for a febrile reaction to a blood product are a fever of greater than 38°C with an accompanying temperature increase of >1°C (compared to baseline) or chills/rigors. This reaction is generally not life-threatening and requires symptomatic care such as antipyretics. The etiology of this reaction occurs because of mediation both by donor leukocytes (WBCs) and by the generation and accumulation of cytokines that arise during the storage of blood components and after transfusion.

The nurse is caring for a client with a hyphema. The nurse should plan to take which action? A. Shield the affected eye. [62%] B. Place the client supine. [14%] C. Apply a cold compress to the eye. [22%] D. Request a prescription for aspirin. [3%]

Explanation Choice A is correct. The initial nursing priorities for a hyphema are shielding the affected eye and raising the head-of-the bed to 30 degrees. Choices B, C, and D are incorrect. Placing a client supine would aggravate the injury. The purpose of raising the head-of-the-bed to 30 degrees is because it promotes the settling of blood in the anterior chamber away from the visual axis. Cold compression of the eye would not be helpful. This compression may raise intraocular pressure which would be contraindicated. Aspirin and NSAIDs should be avoided because of their platelet inhibition which will promote more bleeding. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Knowledge/comprehension Additional Info A hyphema is an ocular emergency that has been caused by blood in the anterior chamber. This injury results from trauma and should be addressed promptly. Initial nursing actions include: Elevation of the head of the bed to 30 degrees. This will keep the blood below the visual axis. Application of an eye shield to the affected eye. This will prevent further injury. Prescribed pain medication that should not include aspirin or NSAIDs. Educating the client to avoid any activity to raise the intraocular pressure such as bending at the waist, vomiting, or coughing.

The nurse is caring for a client receiving digoxin. It would be a priority for the nurse to monitor the client's A. potassium. [91%] B. calcium. [2%] C. sodium. [6%] D. phosphorus. [1%]

Explanation Choice A is correct. The nurse must monitor potassium levels while the client is taking digoxin. Low levels of potassium may precipitate digoxin toxicity. Choices B, C, and D are incorrect. Calcium, sodium, and phosphorus do not have a relationship with digoxin. While the nurse should always monitor all electrolyte levels, potassium is what the nurse should watch most closely while the client takes digoxin because of its ability to precipitate toxicity. Additional Info Digoxin is a cardiac glycoside utilized in the treatment of atrial fibrillation and heart failure. While this medication has fallen out of favor because of its numerous interactions, this medication is still available. The apical pulse must be obtained prior to administering this medication. The apical pulse must be at least 60/minute for adults; 70/minute for children; and 90/minute for infants. The therapeutic level for digoxin is 0.5-2 ng/mL

The nurse is assessing a patient for bladder trauma after a car accident. Bladder trauma is suspected when the patient experiences referred pain to which of the following areas? A. Shoulder [22%] B. Umbilicus [31%] C. Hip [16%] D. Costovertebral angle (CVA) [30%]

Explanation Choice A is correct. The nurse would be right to suspect a bladder injury if the pain is radiating (referred) to the patient's shoulder. When there is pain sensation at a site other than the original location of the painful stimulus/injury, it is known as referred pain. Choice B is incorrect. Bladder pain does not radiate to the umbilicus. Choice C is incorrect. Bladder pain does not radiate to the hip. Choice D is incorrect. Bladder pain does not radiate to the costovertebral angle.

The nurse has received word that their patient is leaving the postoperative unit and being transferred to the medical-surgical floor. Upon arrival, the nurse would be correct to perform which of the following priority actions? A. Assess the patient for a patent airway. [73%] B. Check the patient's abdomen for bowel sounds. [2%] C. Order laboratory draws to check hemoglobin levels. [1%] D. Compare preoperative vital signs with current vital signs. [23%]

Explanation Choice A is correct. Upon receiving a patient from the post-operative unit, the priority action is to assess the patient for a patent airway and respiratory status. The nurse would be correct in performing this action immediately. By using ABC ( airway, breathing, circulation) prioritization strategy, one can answer these questions by first focusing on the airway options. Choice B is incorrect. While appropriate during the initial post-operative assessment, checking for bowel sounds is not the necessary action in this situation. Choice C is incorrect. Ordering labs is a job for the primary health care provider. Tracking down labs and their associated results takes away prime time to assess the patient's airway, thus putting them at risk for respiratory complications. Choice D is incorrect. While vital signs should be taken and compared to the preoperative measurements, this should be performed after the patient's airway status has been established. Counting respiratory rate alone does not give information regarding impending airway obstruction or respiration pattern. NCSBN client need Topic: Reduction of Risk Potential: Potential for Complications for Surgical Procedures and Health Alterations

A 68-year-old woman arrives at the emergency department after feeling dizzy. After assessing the patient, the nurse notices hypotension, muffled heart tones, and jugular venous distention. What does the nurse suspect that this patient has? What is this triad called? A. Pericarditis; Cushing's triad [16%] B. Pericardial tamponade; Beck's triad [68%] C. Increased ICP; Cushing's triad [9%] D. Pleural effusion; Beck's triad [7%]

Explanation Choice B is correct. Beck's triad is a symptom triad that indicates pericardial tamponade. Hypotension occurs because the patient is actively losing blood into the pericardial space. This sac can hold as little as 150 mL to 1,000 mL and impedes cardiac output. Jugular vein distention (JVD) occurs because the heart is compressed, which leads to delayed venous return. Blood pools in the veins and this can be assessed as jugular vein distention. Choice A is incorrect. Cushing's triad is associated with increased ICP and is characterized by irregular respirations, widened pulse pressure, and bradycardia. Choice C is incorrect. Increased ICP and Cushing's triad is not what this patient is suffering from. Choice D is incorrect. This patient is experiencing symptoms that are called Beck's triad. However, this triad is indicative of pericardial tamponade, not a pleural effusion. A pleural effusion is known as fluid in the pleural space of the lung. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Pathophysiology, Cardiovascular System

A client is admitted to the psychiatry ward because of anorexia nervosa. Which assessment parameter should the nurse prioritize? A. The client's weight and height. [25%] B. The client's electrolyte levels. [71%] C. The concerns of the client's family. [0%] D. The client's medical history. [3%]

Explanation Choice B is correct. Clients with anorexia nervosa have altered serum electrolyte levels. The nurse should initially assess the client for hypokalemia, which can pose difficult, life-threatening situations to the client. Choice A is incorrect. Taking the client's weight and height is a necessary parameter to be assessed; however, it should not take priority over the client's electrolyte levels. Choice C is incorrect. The nurse should address concerns of the client's family; however, this should not take priority over the client's physiological needs. Choice D is incorrect. The client's medication history is a critical assessment, but physiological needs should be met first.

A client is scheduled for electroconvulsive therapy. The nurse caring for him notes that there is no signed consent form. Upon further assessment, the nurse finds out that the client is admitted to the unit involuntarily. The nurse understands that in this case: A. Informed consent needs to be obtained from the wife. [16%] B. Informed consent needs to be obtained from the client. [46%] C. Informed consent is not necessary. [14%] D. Informed consent needs to be obtained from court. [23%]

Explanation Choice B is correct. Even though the client is involuntarily admitted, the client does not lose the right to informed consent. Informed consent must be obtained from the client. Choice A is incorrect. Unless declared legally incompetent, the client's wife does not have the authority to give consent on behalf of the client. Choice C is incorrect. Electroconvulsive therapy needs informed consent from the client to proceed. Choice D is incorrect. Unless deemed legally incompetent, informed consent must be obtained from the client.

The nurse is caring for assigned clients. The nurse should immediately follow up with the client who A. has influenza and their most recent temperature was 102°F (39°C). [17%] B. is recovering from a thoracentesis and reports a nagging cough. [52%] C. reports reddish-brown sputum immediately following a bronchoscopy. [22%] D. has pulmonary tuberculosis and is wearing a surgical mask while ambulating to radiology. [9%]

Explanation Choice B is correct. Following a thoracentesis, the nurse must assess the client for the most common complication of pneumothorax. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube may be needed. Choices A, C, and D are incorrect. A fever is common with influenza and would not necessitate the need for immediate follow-up. Following a bronchoscopy, reddish-brown sputum is expected because as the scope passes by the mucosa, it may irritate. Finally, no follow-up is necessary for a client with pulmonary tuberculosis wearing a surgical mask. This is an appropriate infection control measure. It is the healthcare worker that should wear the respirator (N95 mask). Additional Info Thoracentesis is the needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes. This test can be performed at the bedside and typically involves using ultrasound to guide the needle. Nursing considerations for this procedure involve witnessing the informed consent, positioning the client over a bedside table, and supporting the client during the procedure. The provider will insert a needle (after the skin has been anesthetized) attached to a syringe and will slowly aspirate fluid. This fluid may be sent for laboratory analysis. A sterile pressure dressing will be applied, and a follow-up chest x-ray will be performed. The most common complication following this procedure is a pneumothorax.

You are taking care of a client who is taking warfarin and lovastatin. Which statement about the interaction warfarin and lovastatin should you incorporate into your plan of care? A. Lovastatin decreases the effects of the warfarin. [25%] B. Lovastatin increases the effects of the warfarin. [39%] C. Lovastatin has no known effects on the warfarin. [26%] D. Combining lovastatin and warfarin causes respiratory depression. [9%]

Explanation Choice B is correct. Lovastatin increases the effects of warfarin, so the nurse should incorporate this knowledge related to an increased influence of the anticoagulant, warfarin, into the plan of care. Choice A is incorrect. Lovastatin increases the effects of warfarin. Choice C is incorrect. Lovastatin has known effects on warfarin, an anticoagulant medication, so the nurse should consider this when planning care. Choice D is incorrect. Combining lovastatin and warfarin does not cause respiratory depression.

The nurse is caring for a client 2 days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to: A. Stabilize the knee joint during ambulation [18%] B. Promote knee flexion [34%] C. Reduce post-surgical swelling [8%] D. Prevent blood clots [39%]

Explanation Choice B is correct. Maintaining joint flexion and mobility is a high priority for the post-op total knee replacement (TKR) client. The continuous passive motion (CPM) device would be worn intermittently while the client is in bed to flex and extend the knee, reduce scar tissue formation, and to help the client maintain optimal joint mobility. Choice A is incorrect. The CPM machine will assist the client to flex and extend the knee joint through passive range of motion while in bed. If needed, a knee brace or immobilizer would be used to support and stabilize the knee during ambulation/activity. Choice C is incorrect. The CPM machine is not intended to limit swelling after surgery. Ice packs and cold therapy may be ordered to improve post-op swelling. Choice D is incorrect. Although leg exercises would have the effect of reducing the client's risk of DVT, the primary purpose of the CPM machine is to promote flexion and mobility of the joint, not to prevent blood clots.

The nurse is teaching a client about newly prescribed nitroglycerin sublingual tablets. What information should the nurse give the client about storing this medication? A. Nitroglycerin should be stored in the refrigerator [1%] B. Keep tablets in a dark place, away from heat or moisture [95%] C. Nitroglycerin should be stored in a clear bottle [3%] D. Tablets should be frozen prior to use [0%]

Explanation Choice B is correct. Nitroglycerin should be stored in a dark place, in an opaque container, away from heat or moisture. This prevents a decrease in medication potency. Choices A, C, and D are incorrect. These are all inappropriate options for storing nitroglycerin. Additional Info Nitroglycerin is a potent vasodilator (it decreases preload and afterload). It is indicated in angina. It is given in a variety of preparations, including sublingual, translingual, and topical. Dosing for sublingual nitroglycerin is one tablet under the tongue every five minutes (as long as the chest pain is persisting). The maximum tablet (or sprays) is three. The client should be instructed that emergency care should be sought if the pain is not relieved after the first dose. Nitroglycerin expires after six months, and the client should be instructed to keep their supply current. Nitrates are contraindicated if the client is taking medications such as vardenafil, tadalafil, or sildenafil. The client should take the nitroglycerin in a sitting or laying down position because sudden movement changes may cause orthostatic hypotension. Headache is an expected side effect of this medication and may be treated with acetaminophen. Nitroglycerin cannot be applied to a client for 24 hours as the client will develop a tolerance. Blood pressure should be monitored closely.

An 8-year-old client is admitted with rheumatic fever. Which clinical finding indicates to the nurse that the client needs to continue taking the salicylates he had received at home? A. Chorea [14%] B. Polyarthritis [47%] C. Subcutaneous nodules [14%] D. Erythema marginatum [25%]

Explanation Choice B is correct. Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates. Rheumatic fever is an inflammatory disease that can develop when strep throat or scarlet fever, which are caused by streptococcus bacteria, isn't adequately treated. It most often affects children who are between 5 and 15 years old, though it can develop in younger children and adults. Although strep throat is frequent, rheumatic fever is rare in the United States and other developed countries. However, rheumatic fever remains common in many developing nations. Rheumatic fever can cause permanent damage to the heart, including damaged heart valves and heart failure. Treatments can reduce inflammation, lessen pain, and prevent the recurrence of rheumatic fever. Choice A is incorrect. Chorea is restless, sudden aimless, and irregular movements of the extremities suddenly seen in persons with rheumatic fever, especially girls. Choice C is incorrect. Subcutaneous nodules are non-tender swellings over bony prominences sometimes seen in people with rheumatic fever. Choice D is incorrect. Erythema marginatum is a skin condition characterized by a nonpruritic rash, affecting the trunk and proximal extremities, seen in people with rheumatic fever. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse observes that an 85-year-old man at an adult daycare center fondly shares stories about traveling on the "orphan trains" prior to being adopted. The nurse should perform which intervention? A. Refer him for a geriatric psychiatric evaluation. [6%] B. Listen and ask him questions about his life. [76%] C. Distract him and change the conversation. [4%] D. Involve him in more social activities. [14%]

Explanation Choice B is correct. Taking the time to listen and ask the client questions about his life shows that the nurse is interested in the patient. It also helps increase his self-concept. Reminiscence about past life events, doing a life review, especially if the experiences were positive, is considered to be a regular psychosocial activity for older adults. It helps them to focus on past accomplishments and contributions to society, thus increasing their self-concept. Choice A is incorrect. If behavioral or significant memory problems had been noted, a geriatric psychiatric consult would be appropriate, but that is not so in this situation. Choices C and D are incorrect. While social activities and conversations should be encouraged, it should not be done to the point of demeaning the importance of his life stories. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Promoting health in older adults

The client with a communicable disease just expired. Which information should the nurse provide to the mortuary staff? A. The nurse cannot release information to the mortuary staff. [10%] B. The nurse should inform them of the client's diagnosis. [70%] C. Inform the mortuary staff that the nurse will first obtain permission from the client's family. [15%] D. Instruct the mortuary personnel to call the physician. [6%]

Explanation Choice B is correct. The mortuary team should be informed of the client's diagnosis since they are also part of the health care team. Choice A is incorrect. The mortuary team should be informed of the client's diagnosis since they are also part of the health care team. Choice C is incorrect. The nurse does not need permission from the client's family to inform the mortuary personnel of the client's diagnosis. Choice D is incorrect. The nurse is the one that releases the body into the mortuary, not the physician.

The nurse receives a call from a post-abdominal surgery client. He reports some numbness in his right leg and a funny feeling in his toes. What should the nurse do next? A. Elevate the client's legs by placing a pillow underneath and tell him to drink more water. [8%] B. Tell the client to stay in bed and call the physician. [55%] C. Instruct the client to rub or massage his legs to stimulate the blood flow. [4%] D. Encourage the client to ambulate and educate him on the dangers of prolonged bed rest. [33%]

Explanation Choice B is correct. These signs and symptoms may indicate nerve injury, impaired circulation, or thrombophlebitis/venous thrombosis. These conditions may be related to injury during surgery or post-surgical complications. The nurse should let the patient lie down, limit their activity, and then call the physician. Choice A is incorrect. While elevating the client's legs on a pillow may be beneficial to reduce swelling and discomfort by increasing venous return, fluids should be withheld until the physician is notified. In this post-surgical patient, if any injury is suspected, procedures may be required, and it may be necessary that the client refrains from oral intake before some methods. Choice C is incorrect. If the diagnosis is acute venous thrombosis, rubbing or massaging the leg is contraindicated since it may dislodge the thrombus. If an alternative diagnosis such as nerve-related discomfort is proven, rubbing/massaging may ease the pain. However, until the physician is notified, and deep vein thrombosis is excluded, such measures should be withheld. Choice D is incorrect. This option can be a distractor since early ambulation is often encouraged in post-operative patients. However, this patient has symptoms of nerve injury, impaired circulation, or thrombophlebitis/venous thrombosis, therefore the diagnosis must be established. In an acute deep vein thrombosis (DVT), most clinicians historically preferred recommending bed rest to avoid dislodgement of the possible thrombus. Recent studies have shown that early ambulation can be recommended even for those with a new DVT since there was no increased incidence of pulmonary embolism in patients with DVT who were ambulatory. Early ambulation decreases the duration as well as the severity of the symptoms. Irrespective of this debate, the first step is to tell the client to stay in bed and then call the physician because the diagnosis is not established yet.

The RN is caring for patients on a med-surge unit. Which result would warrant immediate intervention by the nurse? A. A blood glucose level of 250 in a type 2 diabetic being treated for pneumonia. [9%] B. A patient on a heparin drip with a 50% decrease in platelets over the past week. [40%] C. A type 2 diabetic patient with A1C 10.5 complaining of tingling and numbness in the toes. [35%] D. An acute poststretococcal glomerulonephritis patient with a BP of 140/88 mmHg, proteinuria, and rust-colored urine. [16%]

Explanation Choice B is correct. This patient is showing signs of heparin-induced thrombocytopenia (HIT): 50% decrease in platelets 5-10 days after heparin therapy was initiated. This is a thrombotic emergency and the nurse should assess the patient, notify the physician, and discontinue the heparin drip. Choice A is incorrect. This patient is being treated for pneumonia and is likely on antibiotics and corticosteroids. Both of these medications are known to increase blood glucose levels. This blood glucose result is high and the patient may require a change in the insulin dose, but this would not be an emergency or the nurse's top priority. Choice C is incorrect. This patient has an elevated A1C level (the ideal range is less than 7.0%). Hemoglobin A1C reflects blood sugar control over the past three months, so this would not be the highest priority. The patient complaining of tingling and numbness in the toes indicates peripheral neuropathy, a common problem in diabetic patients, mainly when blood sugars are poorly controlled. The nurse should determine what teaching/interventions the patient needs to achieve better control of blood sugars and manage symptoms of neuropathy. Choice D is incorrect. This patient is presenting with symptoms typical of acute post-streptococcal glomerulonephritis (APSGN): hypertension due to fluid retention, rust-colored hematuria due to upper urinary tract bleeding, and proteinuria due to decreased filtration. The symptoms that are expected are not the highest priority. Most patients with APSGN recover fully with conservative treatment and rest. NCSBN Client Need Topic: Prioritization, Subtopic: Establishing priorities, diagnostic tests, the potential for alterations in body systems, changes/abnormalities in vital signs

The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following? A. Wear gloves and a gown. [10%] B. Perform hand hygiene. [82%] C. Review the client's viral load. [4%] D. Obtain a disposable stethoscope. [3%]

Explanation Choice B is correct. When caring for a client who has AIDS, the nurse should maintain standard precautions. Applying PPE such as a gown, pair of gloves, and mask would be inappropriate. Standard precautions require appropriate hand hygiene and other PPE as needed. Choices A, C, and D are incorrect. The diagnosis of AIDS requires standard precautions which mandate appropriate hand hygiene. It would be inappropriate for gowns or gloves to be worn during client care. Assessing the client's viral load prior to obtaining vital signs would not change the fact that this client requires standard precautions. A disposable stethoscope and blood pressure cuff may be useful for a client with contact precautions, but it would not be necessary for a client with AIDS. Additional information: For a client with standard precautions, hand hygiene is required before and after client care. The nurse may use alcohol-based hand sanitizers only if the hands are not visibly soiled. Another exception to the use of alcohol-based hand sanitizers is if the client has a pathogen such as C. difficile which requires that the hands be washed with soap and water. Gloves should only be worn when contact with mucous membranes, blood, or non-intact skin will be anticipated. This type of contact is not expected during the collection of vital signs. NCSBN Client need: Topic: Safety and Infection Control; Subtopic: Transmission Based Precautions

The nurse is caring for a client with schizophrenia. The nurse should anticipate a prescription for which medication? A. Lithium [26%] B. Bupropion [7%] C. Sertraline [15%] D. Risperidone [52%]

Explanation Choice D is correct. Schizophrenia is treated with antipsychotic medications. Typical (or first-generation) antipsychotic drugs include haloperidol, fluphenazine, and chlorpromazine. Atypical (second generation) antipsychotic medications include quetiapine, ziprasidone, and risperidone. Choices A, B, and C are incorrect. Lithium is indicated for the treatment of Bipolar disorder. Bupropion is an atypical antidepressant indicated in major depressive disorder. Sertraline is a selective serotonin reuptake inhibitor and is indicated for major depressive and anxiety disorders. Additional Info Schizophrenia is a psychotic disorder characterized by positive (hallucinations) and negative symptoms (lack of motivation). Most cases of schizophrenia have an onset in adolescence. Acute stabilization and maintenance treatment is accomplished by prescribed antipsychotic medications such as risperidone, haloperidol, or fluphenazine.

The nurse is caring for an adolescent taking prescribed paroxetine. Which of the following statements, if made by the client, would require immediate follow-up? A. "This medication makes me feel so tired." [3%] B. "I have gained weight since starting this medicine." [5%] C. "Since starting this medicine, I feel like giving up." [87%] D. "This medicine always makes my stomach upset." [5%]

Explanation Choice C is correct. An adolescent taking prescribed paroxetine, a selective serotonin reuptake inhibitor (SSRI), should be monitored for suicidal ideations. Statements suggesting a sense of hopelessness are highly concerning and should be the immediate priority. Choices A, B, and D are incorrect. Fatigue, weight gain, and nausea are common side effects associated with SSRIs. Paroxetine has the tendency to cause significant weight gain compared to the other SSRIs. The weight gain, nausea, and fatigue are concerning side effects but do not prioritize over the statement that is suggesting hopelessness. Additional information: SSRIs are an effective medication for the treatment of depression, anxiety, and obsessive-compulsive disorders. Adolescents have been shown to be quite sensitive to the adverse effect of suicidal ideations and thus, the client should be closely monitored for this effect. Therapeutic effects of SSRIs should be observed between two and six weeks. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Adverse Effects/Contraindications/Side Effects/Interactions

Chronic pain is most effectively relieved when analgesics are administered in what manner? A. On a PRN basis [13%] B. Conservatively [4%] C. Around the clock [78%] D. Intramuscularly [5%]

Explanation Choice C is correct. Around the clock, doses of analgesics are more useful for the management of chronic pain. Choice A is incorrect. A PRN protocol is inadequate for patients experiencing chronic pain. Choice B is incorrect. Conservative protocols may prove ineffective. Choice D is incorrect. Intramuscular administration for pain management is not practical on a long-range basis for a patient with chronic pain. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies; Administering Analgesics

The nurse is assessing a cardiac rhythm strip with the characteristics shown in the exhibit. The nurse should plan to document this rhythm as which of the following? See the exhibit. A. Ventricular fibrillation [6%] B. Complete (3rd degree) heart block [6%] C. Sinus tachycardia [83%] D. Sinus bradycardia [5%]

Explanation Choice C is correct. Based on the information provided, this rhythm is sinus tachycardia. The PR and QRS intervals as well as the rhythm are normal. The rate of 105 is high, suggesting tachycardia. Choices A, B, and D are incorrect. Ventricular fibrillation is irregular and has no discernible P or QRS waves. The rate of ventricular fibrillation is also having a rate ranging anywhere from 150 - 500. A complete heart block has a variable PR interval because it is completely separate from the QRS. The rate of a complete heart block is typically less than 60. Sinus bradycardia has a normal rhythm as well as a normal PR and QRS interval, but the rate is less than 60. Additional information: The PR interval represents the amount of time for atrial depolarization. The normal PR interval is 0.12 - 0.20 seconds. The normal QRS interval represents the time for ventricular depolarization. The normal is 0.04 - 0.12 seconds. When assessing a cardiac rhythm strip, the nurse should first determine the rate. The rate can be determined by examining a six-second strip, taking each QRS complex, and multiplying it by ten. The second step would be to determine the heart rhythm. To assess atrial regularity, use a pair of calipers to determine the distance between the P-P waves. Ventricular regularity may be assessed by using the calipers to measure the RR interval. The third step would be to analyze the P waves. The P waves should be present, occurring in regularity and in front of each QRS complex. Finally, the PR interval and QRS duration should be measured. The ST segment should then be analyzed, followed by the T-wave. The last measurement in this step would be assessing the QT interval. NCSBN Client need: Topic: Reduction of Risk Potential; Subtopic: System Specific Assessments

Primary nutrients that are essential for optimal body function include: A. Iron, zinc, and calcium [4%] B. Folate, vitamin B12, and iron [4%] C. Carbohydrates, proteins, and fats [80%] D. Vitamins A, D, E, and K [12%]

Explanation Choice C is correct. Carbohydrates, proteins, and fats provide the energy that is necessary for cellular function. Choice A is incorrect. Iron, zinc, and calcium are three essential minerals. Choice B is incorrect. Folate, vitamin B12, and iron are necessary for oxygenation as well as optimal hemoglobin and hematocrit counts. Choice D is incorrect. Vitamins A, D, E, and K are fat-soluble. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Primary Nutrients

The nurse is preparing to prime a new line of IV tubing. They understand that priming intravenous tubing is crucial because it prevents which dangerous treatment complication? A. Medication toxicity [4%] B. Infiltration [7%] C. Air embolism [86%] D. Extravasation [3%]

Explanation Choice C is correct. Priming new intravenous tubing is done to prevent a medical emergency known as an air embolism. This condition occurs when a blockage of blood supply caused by an air bubble results in breathing problems, chest pain, or cardiac arrest. Choice A is incorrect. A worry over medication toxicity is not the reason for priming new IV tubing. Choice B is incorrect. Infiltration occurs when fluids from IV parenteral therapy enter surrounding tissues. This is not prevented by priming new IV tubing. Choice D is incorrect. Extravasation is the leaking of harmful IV fluids into the tissue surrounding an IV site. This is not the primary concern when priming new IV tubing. NCSBN client need Topic: Pharmacologic and Parenteral Therapies: Parenteral/Intravenous Therapies

The nurse is educating a new graduate nurse on different methods of therapeutic communication. Select the form of therapeutic communication which is accurately paired with the correct description of the communication. A. Seeking Clarification: Utilizing open-ended questions rather than closed-ended questions [55%] B. Offering General Leads: Ensuring the client fully understands the sent message [7%] C. Reflection: Conveys the nurse's observations of the client when sensitive issues are being discussed [32%] D. Offering Self: Giving the client advice based on the opinion of the nurse [6%]

Explanation Choice C is correct. Reflection is a way of helping clients better understand their own thoughts and feelings. By using a question or simple statement, the nurse may convey their observations of the client when discussing sensitive topics. Choice A is incorrect. Seeking clarification helps clients clarify their thoughts and maximizes the mutual understanding between the nurse and the client. Choice B is incorrect. When offering general leads, the nurse allows the client to take direction in the discussion. By using phrases such as "go on" or "and then?" the nurse conveys interest in what occurs next in the client's story. Choice D is incorrect. Hospital stays can be lonely and stressful at times. When nurses are present with their clients, it shows clients that the nurses value them and are willing to provide them time and attention. The mere offering by a nurse to be present with a client for a few minutes is a powerful way to create a caring connection. Learning Objective Identify which therapeutic communication technique is accurately paired with an accurate description of the therapeutic communication technique named. Additional Info The forms of communication listed above (i.e., seeking clarification, offering general leads, reflection, and offering self) are all techniques used to enhance communication. When appropriately used, silence, active listening, and clarifying techniques are valuable tools for nurses when communicating with clients. For each form of communication, the table below provides a more in-depth description and examples of each technique.

A nurse listens to a 2-year old's lungs and hears inspiratory stridor. After suspecting an upper airway obstruction, what is the nurse's first action? A. Tell the patient to cough to relieve the obstruction [23%] B. Apply a bag valve mask [11%] C. Perform the Heimlich maneuver [42%] D. Perform a blind finger sweep [11%] E. Place the patient in prone position [13%]

Explanation Choice C is correct. Since this patient has inspiratory stridor, the nurse can infer that the patient has an upper airway obstruction. Performing a blind finger sweep is not recommended. The nurse should only attempt a finger sweep if the object is visible. Performing the Heimlich maneuver should be the first action to relieve the obstruction. After that, if the patient's oxygenation is worsening, oxygen should be applied to the patient. Choice A is incorrect. This patient is too young and won't be able to cough up the obstruction. Choice B is incorrect. As explained above, oxygen can be given if the respiratory system starts to fail, but it should not be the first intervention performed. Choice D is incorrect. The nurse should never perform a blind finger sweep if the object is not visible. This could cause the object to become further dislodged in the airway. Choice E is incorrect. Placing the patient in a prone position is done on infants. NCSBN Client Needs Topic: Safe and Effective Care Environment, Sub-Topic: Care Management, Airway Obstruction

Which of the following is a normal value for bicarbonate in the intravascular space? A. 10 mEq/L [4%] B. 82 mEq/L [1%] C. 24 mEq/L [87%] D. 40 mEq/L [7%]

Explanation Choice C is correct. The average value for bicarbonate in the intravascular space ranges from 22 mEq/L to 29 mEq/L. Choice A is incorrect. The average value for bicarbonate in the intravascular space ranges from 22 mEq/L to 29 mEq/L. Choice B is incorrect. The average value for bicarbonate in the intravascular space ranges from 22 mEq/L to 29 mEq/L. Choice D is incorrect. The average value for bicarbonate in the intravascular space ranges from 22 mEq/L to 29 mEq/L. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies, Renal

The nurse is observing the newly registered nurse prepare and administer insulin to a patient. Which action by the new RN would necessitate further instructions from the supervising nurse? A. The new RN asks the client which site the insulin was last injected. [2%] B. The new RN checks the client's blood glucose levels prior to administering the insulin injection. [1%] C. The new RN shakes the insulin vial before withdrawing insulin. [76%] D. The new RN places the insulin in the medication fridge after drawing the needed amount of insulin.

Explanation Choice C is correct. The new RN should not shake the vial but gently rotate it to ensure uniform suspension of insulin. Choice A is incorrect. Insulin injection sites should be rotated to prevent lipodystrophy. Asking the patient where the insulin was last injected gives the nurse an idea of where to insert the insulin next. Choice B is incorrect. The nurse should check the client's blood glucose levels before the administration of insulin to prevent hypoglycemia and to assess if the insulin dose needs to be adjusted. Choice D is incorrect. The insulin should be stored in a cool place away from direct sunlight. After it's opened; storing the insulin vial either in a refrigerator or at room temperature are both acceptable actions. Storing it in the fridge is recommended by the drug manufacturers. Injecting refrigerated insulin can be painful so patients may choose to store it at the room temperature after it is opened. Because both storing in the fridge or at room temperature are acceptable for the opened insulin vial, D is an appropriate nursing action and does not need further instructions.

The nurse is reassessing her female patient diagnosed with appendicitis. At her last assessment, the patient expressed 8/10 pain but now states that she has no pain. The nurse did not administer any pain medication. What is the priority nursing action? A. Document the pain score and continue monitoring [6%] B. Check the WBC count [2%] C. Notify the healthcare provider [83%] D. Palpate McBurney's point [9%]

Explanation Choice C is correct. The nurse should immediately notify the healthcare provider of this change in the patient's status. A sudden change of 8/10 pain to 0/10 pain in the patient diagnosed with appendicitis could indicate rupture, so the healthcare provider needs to be immediately notified. This sudden pain relief is usually followed by a gradual increase in pain once again and guarding in the right lower quadrant. A ruptured appendix may result in infection, peritonitis, and abscess. Tachycardia, tachypnea, fever, restlessness, and irritability may follow. Choice A is incorrect. When a patient with appendicitis has sudden pain relief, it is a sign of a possible rupture of the appendix. Appendiceal rupture is a surgical emergency, and the patient must be taken to the operating room quickly. It is not appropriate for the nurse to just document the pain score without further intervention. Choice B is incorrect. WBC count can be checked to look for signs of infection such as leukocytosis; however, this is not the priority action. Sudden relief of pain is concerning for rupture of the appendix. The physician must be notified right away. Choice D is incorrect. The patient with appendicitis will likely have tenderness at McBurney's point, but this patient is expressing a sudden relief of pain already. She needs to be evaluated for possible rupture and therefore the nurse should immediately notify the healthcare provider. The provider may order CT imaging to confirm the diagnosis. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk potential reduction; Pediatrics - Gastrointestinal Additional Info

A newly registered nurse is tasked by the nurse educator to do a wet-to-dry dressing change on a stage 3 pressure ulcer. Which of the following actions would indicate to the nurse that the RN is observing proper technique? A. The new RN cleans the ulcer from the outside, rotating into the inside of the ulcer. [7%] B. The new RN packs the incision with sterile gauze, then pours sterile NSS over the dressing. [10%] C. The new RN packs wet gauze into the ulcer without overlapping it onto the skin. [48%] D. The new RN saturates the old dressing with sterile saline before it is removed. [34%]

Explanation Choice C is correct. The wet dressing should not touch the intact skin as it will cause skin breakdown. Choice A is incorrect. The RN should clean from the inside going outside. Choice B is incorrect. Dressings need to be soaked before being applied to the client's tissue. Choice D is incorrect. The old dressing should be removed dry so that debris and necrotic tissue are removed together with the dressing.

The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding? Select all that apply. A. Diplopia [21%] B. Butterfly rash [3%] C. Facial muscle weakness [31%] D. Shuffling gait [16%] E. Ptosis [27%]

Explanation Choices A, C, and E are correct. Key clinical features of myasthenia gravis (MG) include diplopia, ptosis, facial muscle weakness, and may progress to respiratory failure. Some of the earlier manifestations associated with MG are ocular. Choices B and D are incorrect. Shuffling gait is a classic manifestation associated with Parkinson's disease. A butterfly rash is a common dermatological finding associated with lupus. Additional Info Myasthenia gravis is a rare and serious autoimmune disorder that impairs the acetylcholine receptors. Commonly occurring more in women, this disorder impacts motor nerves which impair facial and eye muscles. In its severe form, myasthenia gravis may impact respiratory muscles causing respiratory failure.

You are caring for a 25-year-old male patient in the Intensive Care Unit. He was involved in a motor vehicle accident and required endotracheal intubation. He has been on mechanical ventilation for 24 hours. You draw ABGs. You receive results of the arterial blood gas that show: pH = 7.50 PaCO2 = 28 Bicarbonate = 25 You determine that this ABG shows: A. Metabolic alkalosis [12%] B. Respiratory acidosis [5%] C. Respiratory alkalosis [82%] D. Metabolic acidosis

Explanation Choice C is correct. This ABG shows respiratory alkalosis. The first clue in this patient is the fact that he is intubated and on mechanical ventilation. Respiratory alkalosis is the most common acid-base disturbance in patients on mechanical ventilation. If the rate is set too high, hyperventilation will occur. This hyperventilation will cause a decrease in PaCO2 level resulting in respiratory alkalosis. The registered nurse must know the basics of ABG interpretation, including the normal ranges for each of the values. First, the nurse should look at the pH. The normal range is 7.35-7.45. A value below 7.35 indicates an acidosis; a value above 7.45 indicates an alkalosis. The normal partial pressure of carbon dioxide (PaCO2) is 35-45 mmHg. Standard bicarbonate for a man this age is 22-29 mmol/L. The high pH in this patient shows that the condition is alkalosis. The low PaCO2 indicates that it is a respiratory problem. The pH and PaCO2 define respiratory disorders. Respiratory acidosis is defined as a pH below 7.35 and a PaCO2 above 45 mmHg. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mmHg. Metabolic disorders are defined by the pH and the bicarbonate (HCO3). Metabolic acidosis is defined as a pH below 7.35 and an HCO3 below 22 mmol/L. Metabolic alkalosis is defined as a pH above 7.45 and an HCO3 above 29 mmol/L. Choices A, B, and D are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-Topic: Fluid and Electrolyte Imbalances, Critical Care

You are working in an adult telemetry step-down unit and have five patients to manage. You see the following rhythms on the monitor from your patients. Which patient should you assess first? Select the image of the ECG for the patient you would assess first. A . B . C . D .

Explanation Choice C is correct. This patient is showing sustained ventricular tachycardia on the monitor. This is a fatal rhythm and the nurse must immediately assess the patient as they could quickly arrest and necessitate a code blue. This is the correct patient to assess first. Choice A is incorrect. This patient is in normal sinus rhythm. They are not the priority for assessment. Choice B is incorrect. This patient is demonstrating normal sinus rhythm with one unifocal premature ventricular contraction (PVC). While the nurse does need to assess them, they are not the priority. PVCs can be well-tolerated and a singular one is not immediately dangerous. Choice D is incorrect. This patient is in sinus tachycardia. This could be caused by a fever, dehydration, or could be the patient's baseline. While the nurse should assess the patient and determine the cause of the tachycardia, he is not the priority of the five patients shown. NCSBN Client Need Topic: Reduction of Risk Potential Subtopic: Diagnostic Tests

Which of the following vaccines contains a live virus? A. IPV [9%] B. DTaP [10%] C. Varicella [77%] D. Hepatitis B [4%]

Explanation Choice C is correct. Varicella is a live virus. Currently, the available live attenuated viral vaccines are measles, mumps, rubella, vaccinia, varicella, zoster (which contains the same virus as varicella vaccine but in a much higher amount), yellow fever, rotavirus, and influenza (intranasal). Choice A is incorrect. IPV is an inactivated polio vaccine. Choice B is incorrect. DTaP contains inactivated forms of the toxin produced by the bacteria that cause the three diseases Diphtheria, Tetanus, and Pertussis. Choice D is incorrect. Hepatitis B vaccine is a genetically engineered (human-made in the laboratory) piece of the virus. It does not contain a live virus. NCSBN Client Need, Topic: Health Promotion and Maintenance, Subtopic: Immunizations

The nurse is talking to a group of women about the dangers and ways of acquiring toxic shock syndrome (TSS). The nurse would mention that all of the following women have a high risk of acquiring TSS, except: A. A teenage girl using an absorbent tampon. [15%] B. A 29-year-old woman using a cervical cap. [4%] C. A 31-year-old woman using a diaphragm. [5%] D. A 35-year-old woman using oral contraceptives.

Explanation Choice D is correct. A woman using oral contraceptives is not at risk for toxic shock syndrome (TSS) since there is no area where the Staphylococcus aureus bacteria can infect/build a colony. Choices A, B, C are incorrect. Toxic shock syndrome is an accumulation of toxins that are produced by the microorganism, Staphylococcus aureus. Women who are using tampons, cervical caps, and diaphragms are at risk for TSS due to the build-up of S. aureus colonies in the areas where they are located.

The nurse is caring for a patient with a nasogastric tube. Irrigation should be performed every 4 hours to assess for NG tube patency. The nurse should instill how many milliliters of water or normal saline? A. 15 - 25 mL [14%] B. 20 - 30 mL [49%] C. 20 - 40 mL [6%] D. 30 - 50 mL [30%]

Explanation Choice D is correct. NG tubes should be watered every 4 hours with 30 - 50 mL of water or normal saline. Choices A, B, and C are incorrect. These are the inaccurate measurements necessary. NCSBN client need Topic: Basic Care and Comfort: Nutritio

A nurse is caring for a client receiving nitroglycerin. It is essential to monitor the client's A. Temperature [0%] B. Respirations [10%] C. Urinary output [1%] D. Blood pressure

Explanation Choice D is correct. Nitroglycerin is used in the treatment of angina, pulmonary edema, and hypertensive emergencies. Nitroglycerin decreases both preload and afterload, which may result in hypotension. Thus the client's blood pressure needs to be monitored closely. Choices A, B, and C are incorrect. The effects of nitroglycerin do not impact these options. Additional Info Nitroglycerin is a potent vasodilator (it decreases preload and afterload). It is indicated in angina. It is given in a variety of preparations, including sublingual, translingual, and topical. Dosing for sublingual nitroglycerin is one tablet under the tongue every five minutes (as long as the chest pain is persisting). The maximum tablet (or sprays) is three. The client should be instructed that emergency care should be sought if the pain is not relieved after the first dose. Nitroglycerin expires after six months, and the client should be instructed to keep their supply current. Nitrates are contraindicated if the client is taking medications such as vardenafil, tadalafil, or sildenafil. The client should take the nitroglycerin in a sitting or laying down position because sudden movement changes may cause orthostatic hypotension. Headache is an expected side effect of this medication and may be treated with acetaminophen. Nitroglycerin cannot be applied to a client for 24 hours as the client will develop a tolerance. Blood pressure should be monitored closely.

The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client A. reporting pleuritic chest pain with a productive cough. [26%] B. who is pregnant and reporting intermittent nausea and vomiting. [3%] C. who has an isolated area of reddened vesicles and malaise. [6%] D. with sudden onset of ataxia and dysarthria. [64%]

Explanation Choice D is correct. Sudden onset of dysarthria and ataxia concerns for stroke. These manifestations require emergent prioritization because treatment is necessary to prevent further tissue damage. Choices A, B, and C are incorrect. Pleuritic chest pain would not be categorized as urgent because coughing indicates airway patency. Intermittent nausea and vomiting, without abdominal pain and cramping, would be triaged as nonurgent as this could be a normal part of pregnancy. An area of vesicles and the client reporting malaise would also be categorized as nonurgent. Additional Info The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections.

The nurse is preparing a client for a stress test. Which teaching by the nurse should not be included? A. The client will have to wear a device on her ankles that measures blood pressure. [34%] B. The client should wear loose fitting clothes during the test. [9%] C. The client will be walking at a speed of 1.5 - 2 miles per hour. [21%] D. The client can stop the test anytime she wants. [36%]

Explanation Choice D is correct. The client should be informed that exercise will be stopped at the maximal level of exertion or when manifestations become disabling. Choice A is incorrect. The nurse should tell the client that her performance on the treadmill test is also gauged by the measurement of ankle systolic pressure. Choice B is incorrect. The client should be instructed to wear comfortable clothing during the stress test. Choice C is incorrect. The client is made to walk on the treadmill at speeds of 1.5 - 2 miles per hour at a grade elevation of 10% - 20% and a time limit of 5 minutes.

Which of the following hormones are secreted by the thyroid gland? Select all that apply. A. Calcitonin [26%] B. Thyroid stimulating hormone [35%] C. Triiodothyronine [36%] D. Insulin [2%]

Explanation Choices A and C are correct. The thyroid gland secretes calcitonin. Calcitonin is essential for the regulation of calcium in the body. When released by the thyroid gland, it increases the amount of calcium that is deposited in the bones, therefore decreasing the amount in the blood (Choice A). Triiodothyronine, or T3, is secreted by the thyroid gland. T3 and T4 are the primary hormones secreted by the thyroid gland. They act upon metabolism and 'speed up' everything in the body. Their levels are low in hypothyroidism and high in hyperthyroidism (Choice C). Choice B is incorrect. The pituitary gland secretes thyroid-stimulating hormone (TSH). This can be confusing since the word thyroid is in the name, but the thyroid gland itself does not secrete TSH. Instead, this hormone is secreted by the pituitary and then acts upon the thyroid gland. The more TSH is acting upon the thyroid gland, the less T3 and T4 that will be released. This is why TSH levels are high in hypothyroidism. The less TSH is acting upon the thyroid gland, the more T3 and T4 that will be secreted. This is why TSH is low in Graves Disease. Choice D is incorrect. Insulin is secreted by the pancreas. This is a complex hormone that helps regulate glucose levels in the cells and bloodstream. Insulin transports glucose into the cells so that they may have the energy for metabolism. We typically think of diabetes as the endocrine disorder that is associated with insulin. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic care, comfort

You are providing education to a mother who has been laboring for 18 hours with hypotonic contractions. Which of the following educational points are appropriate to include? Select all that apply. A. The pain she is experiencing is expected and she has options for pain medication should she choose it. [27%] B. Bedrest is the safest for the fetus. [20%] C. Oxytocin may be prescribed. [41%] D. Right-side lying is the best position for her to rest. [12%]

Explanation Choices A and C are correct. This mother is experiencing dystocia, or prolonged, difficult labor. Her hypotonic contractions have been ineffective in causing dilation and effacement, and she is not progressing. Dystocia is known to be extremely painful but there are many options for pain medication. Some mothers may feel ashamed asking for pain medication, so education regarding her options is critical (Choice A). Oxytocin, or Pitocin, is a medication that could be prescribed for hypotonic contractions. This medication will help to coordinate and intensify the mother's contractions, hopefully helping her progress past the prolonged labor (Choice C). Choice B is incorrect. The best rest is not appropriate for this mother, considering her labor is hypotonic. Dystocia can present in different forms, but for this mother, her hypotonic contractions have been ineffective in causing dilation and effacement, and she is not progressing. She should be encouraged to walk, which could help get her contractions into a coordinated pattern. Choice D is incorrect. The left-side lying is the best position for her to rest, not the right-side. The left-side lying is the encouraged position of rest for all expectant mothers, as it promotes optimal oxygenation to the placenta and fetus. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery

The nurse is caring for an elderly client. The nurse would recognize which of the following statements as false regarding sensory changes in an older adult? Select all that apply. A. Increased acuity for high-pitched tones. [27%] B. Decreased sensitivity to glare. [24%] C. Increased tympanic membrane flexibility. [27%] D. Diminished sound discrimination. [18%] E. Decreased taste reception. [4%]

Explanation Choices A, B, & C are correct. These choices are incorrect regarding changes in the older adult and therefore the correct responses to the question. Older adults commonly experience a loss of acuity for high-pitched frequencies (presbycusis) due to changes in the inner ear such as sclerosis. As adults age, changes in the eye such as smaller pupils and decreased light accommodation can result in increased sensitivity to glare. Age-related changes in the ear also include a thickening of the tympanic membrane, rather than increased flexibility. Choice D & E are incorrect. These answers describe correct changes in the older adult and therefore are incorrect responses to the question. Sound discrimination is altered in the aging adult, which makes it difficult to hear voices in areas with background noise, such as a television. A decrease in the number of taste buds often causes older clients to have difficulty distinguishing between sweet, sour, and bitter tastes. NCLEX Category: Health Promotion and Maintenance Related Content: Aging Process Question Type: Knowledge/Comprehension Additional Info Physiological sensory changes in the older adult include: Decreased visual acuity, light accommodation, and increased glare sensitivity due to retinal damage, decreased pupil size/slower pupillary reaction, lens opacities, and loss of lens elasticity Presbyopia, a progressive decline in accommodation from near to far vision Presbycusis, changes in the inner ear bones resulting in decreased ability to hear high-pitched frequencies Thickening of the tympanic membrane, increased cerumen build-up Decreased taste due to taste bud atrophy and loss of sensitivity, as well as decreased smell Decreased touch sensation due to reduces skin receptors

Which of the following does the nurse know are possible causes of constipation in the pediatric patient? Select all that apply. A. Hirschsprung's disease [31%] B. Spina bifida [15%] C. Iron supplements [35%] D. Psychosocial factors [19%]

Explanation Choices A, B, C, and D are all correct. A is correct. Hirschsprung's disease can be a structural cause of constipation. In Hirschsprung's disease, there is a lack of innervation in the colon's nerve cells, leading to an inability for the child to pass stool. B is correct. Spina bifida can be a structural cause of constipation. In spina bifida, there is a loss of tone and sensation in the bowel, making them prone to constipation. C is correct. Iron supplements are a medication that commonly causes constipation, which is one of the most common side effects. Patients should be educated about this side effect and measures to prevent constipation. Sometimes a bowel regimen may be necessary. D is correct. Several psychosocial factors can cause constipation in pediatric patients. For example, a fear of using the toilet in public, a change in routine, difficult experiences passing stool, or painful stooling can cause constipation. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatrics - Gastrointestinal

The nurse is caring for a child with eczema. Which of the following findings should the nurse expect? Select all that apply. A. Erythema [34%] B. Pruritus [35%] C. Papules [13%] D. Skin ulcers [9%] E. Scaly circular rash [9%]

Explanation Choices A, B, and C are correct. Erythema is superficial reddening of the skin. This redness is one of the most common symptoms of eczema and would be an expected assessment finding for all types of eczema. Pruritus is severe itching of the skin. Itching is one of the most common symptoms of eczema and would be an expected assessment finding for all types of eczema. Papules are solid elevations of skin with no visible fluid less than 1 cm in diameter. Although not all patients with eczema will necessarily have papules, they are a common assessment finding. Choices D and E are incorrect. Skin ulcers are round sores that develop because of a lack of oxygen-rich blood flow. This can be caused by excessive pressure placed on the skin. A scaly circular rash is a common manifestation associated with a fungal infection. This is known as ringworm. This contagious infection may affect the skin and the scalp. Additional Information: Eczema, also known as atopic dermatitis (AD), is a broad term to describe skin inflammation. This condition may develop as early as infancy. Itching is a common manifestation associated with this skin condition and may become so severe that the lesions start to bleed. Most children with infantile AD have a family history of eczema, asthma, food allergies, or allergic rhinitis, which strongly supports a genetic predisposition. Treatment is aimed at hydrating the skin and avoiding irritating soaps and lotions. Topical steroids may be used in severe cases.

Which of the following are risk factors for Respiratory Syncytial Virus (RSV)? Select all that apply. A. Prematurity [35%] B. Smokers in the home [33%] C. Age 7-10 years [12%] D. Trisomy 21 [21%]

Explanation Choices A, B, and D are correct. A is correct. Prematurity (birth at gestational age less than 37 weeks), is a risk factor for RSV. Infants who are born prematurely have a weakened immune system and are at heightened risk for contracting this acute respiratory virus. They will receive the vaccination palivizumab (Synagis) as a preventative measure. B is correct. Any exposure to smoke will increase a child's risk for all respiratory tract infections, including RSV. Children are very susceptible to smoke exposure. If they are exposed to secondhand smoke, such as being near their parents when they smoke, they will be at risk for RSV. They can even be at risk with exposure to third-hand smoke, such as exposure to the clothes of their parents after they smoke. D is correct. Trisomy 21, or Down's syndrome, is a congenital disability where there are two copies of chromosome 21. This congenital disability causes a weakened immune system, and puts children at a higher risk of infection, including RSV. Any congenital disorder is considered a risk factor for RSV and could include other disorders such as congenital heart disease, spina bifida, or PKU. Choice C is incorrect. The age group that is most at risk for RSV includes children less than two years old. Although 7 to 10-year-olds can contract RSV, this age group is not a risk factor. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Respiratory

The nurse is assessing a client with hepatitis A. Which of the following would be an expected finding? Select all that apply. A. Pruritus [20%] B. Bloody stools [17%] C. Abdominal pain [34%] D. Scleral icterus [22%] E. Periumbilical bruising [7%]

Explanation Choices A, C, and D are correct. Hepatitis A produces an array of symptoms that usually last for 28 days. The symptoms have an abrupt onset and include nausea, vomiting, abdominal pain, fever, anorexia, dark urine, scleral icterus, pale stools, jaundice, and pruritus. Choices B and E are incorrect. Bloody stools and periumbilical bruising are not a feature of hepatitis A. Bloody stools may be a feature of ulcerative colitis, diverticulitis, or a gastrointestinal bleed. Periumbilical bruising is a concerning feature associated with necrotizing pancreatitis. Additional Info Hepatitis A is an infection contracted through the consumption of raw or undercooked food, fecal-oral route, or contaminated water. Most cases are self-limiting with complete clinical recovery within three to six months. Vaccination for hepatitis A is a two-dose series beginning as early as six months for international travel; 12 months for routine vaccination.

The nurse is assisting a client to pick out food options appropriate for Dumping Syndrome. Which food items would be appropriate to select? Select all that apply. A. Rice cereal [24%] B. Pastries [6%] C. Chicken breast [35%] D. Cola [1%] E. Scrambled eggs [33%]

Explanation Choices A, C, and E are correct. Dumping syndrome is characterized by rapid peristalsis, especially with foods that are simple carbohydrates (refined sugars). Rice cereal, chicken breast, and scrambled eggs reflect foods that are not simple carbohydrates. Foods recommended for clients with dumping syndrome include complex carbohydrates, high protein, and high fiber. Choices B and D are incorrect. Clients with Dumping Syndrome should avoid simple carbohydrates (refined sugars). These foods include candy, cookies, pastries, cola, and anything with concentrated sugars. Pastries and cola have a high amount of sugar and are not recommended for a client with or at risk for dumping syndrome. Additional Info Dumping syndrome is a common complication following gastric bypass surgery. Early dumping syndrome has a rapid onset, usually within 15 minutes. It is the result of rapid emptying of food into the small bowel. Due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response. Clients often present with colicky abdominal pain, diarrhea, nausea, and tachycardia. At worst, the client runs the risk of hypoglycemia.

Which of the following are appropriate to include in a teaching plan for a teen with acne? Select all that apply. A. Wash the skin twice daily with a mild cleanser and warm water. [30%] B. Use cosmetics liberally to cover blackheads. [1%] C. Use emollients on the affected areas. [14%] D. Squeeze blackheads as soon as they appear. [1%] E. Keep hair off the face and wash hair daily. [26%] F. Avoid sun-tanning booths and use sunscreen. [28%]

Explanation Choices A, E, and F are correct. Washing the skin removes oil and debris. Hair should be kept away from the face and washed daily to help prevent oil from the hair from getting on the forehead. Sunbathing should be avoided when using acne treatments. Acne is a condition that is characterized by clogged pores caused by dead skin cells and sebum sticking together in the orifice. Inside the pore, the bacteria have a perfect environment for multiplying very quickly. With a large number of bacteria inside, the pore becomes inflamed. If the inflammation goes deep into the skin, an acne cyst or nodule appears. Acne can appear on the face, back, chest, neck, shoulders, upper arms, and buttocks. Treatment includes avoiding squeezing or picking the infected areas, as this may spread the infection and cause scarring. The face should be washed twice daily with a mild cleanser and warm water. Oil-free, water-based moisturizers and make-up should be used. Choices B, C, and D are incorrect. Liberal use of cosmetics and emollients can clog pores. Squeezing blackheads is always discouraged because it may lead to infection. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort; Teaching Patients About Skin Care

The nurse is caring for a client who claims to have frequent anxiety attacks. While performing the nursing assessment, it becomes evident that some of the client's responses were due to fear rather than anxiety. Which of the following are true of stress? Select all that apply. A. Anxiety is a cognitive response. [16%] B. Anxiety is related to a future or anticipated event. [23%] C. The source of anxiety is often not identifiable. [17%] D. Anxiety results from a physical threat. [8%] E. Anxiety initiates the release of epinephrine. [20%] F. If it is mild or moderate, anxiety can be beneficial. [16%]

Explanation Choices B, C, E, and F are correct. Fear is an emotion/feeling of apprehension or dread. It stems from an identified danger, threat, or pain. The danger may be real or perceived. NANDA International defines anxiety as a "vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a sense of apprehension caused by anticipation of danger." Anxiety is related to an anticipated event. Fear is associated with a present fact (Choice B). The source of anxiety may not be easily identifiable. However, the source of concern can be identified (Choice C). Both anxiety and fear initiate the release of epinephrine, which stimulates the sympathetic nervous system in preparation for the "fight or flight" response (Choice E). Mild to moderate anxiety can be a sign of adaptation, as it mobilizes and motivates a person to action (Choice F). Choice A is incorrect. Anxiety is an emotional response, not cognitive. Choice D is incorrect. Anxiety results from psychological conflict rather than a physical threat. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Types of Stressors

While participating in interdisciplinary rounds on the Mother-Baby floor, the provider mentions that your 2-day old patient is at risk for phenylketonuria (PKU). Which of the following statements are true regarding this condition? Select all that apply. A. It is a genetic disorder that is autosomal dominant. [22%] B. Children with phenylketonuria commonly have a musty odor to their urine [29%] C. Hypopigmentation of the hair, skin, and irises is a prominent sign of the disorder. [19%] D. All 50 states require routine screening of newborns for phenylketonuria. [30%]

Explanation Choices B, C, and D are correct. Phenylketonuria, or PKU, is a genetic disorder that results in central nervous system damage from toxic levels of the essential amino acid phenylalanine. The musty odor urine smell and hypopigmentation of the hair, skin, and irises are signs of PKU. It is also true that all 50 states require routine screening of newborns for this disorder. Choice A is incorrect. The disease is inherited in an autosomal recessive manner. NCSBN client need: Topic: Physiological Adaptation Subtopic: Alterations in Body Systems

The nurse is teaching a client about prescribed doxycycline. Which of the following statements, if made by the client, requires follow-up? Select all that apply. A. "I will use sunscreen when I plan on spending time outdoors." [5%] B. "I am glad that, unlike most antibiotics, I won't have to use a backup method of birth control." [37%] C. "If I get a white coating on my tongue, I will immediately stop the medication." [30%] D. "I should take this medication after I eat a meal." [19%] E. "I will follow up with my doctor visits and get my labs checked." [9%]

Explanation Choices B, C, and D are correct. These statements require further teaching. This client will have to use a backup method of birth control (Option B). Birth control pills also may not work if the client is taking Doxycycline. The mechanism underlying this is due to antibiotics' effects on reducing small intestinal bacteria. Decreased bacteria lead to decreased hydrolysis of the hormone, resulting in increased fecal loss of the hormone and lower circulating levels of ethinylestradiol. This long-held belief has been challenged in recent studies. Still, until the availability of extensive studies, it is advised that clients take a backup method (other forms of birth control) while taking this medicine. The white coating (Option C) is glossitis, a common side effect of Doxycycline, but the client should not stop the medication. This should not be confused with thrush since thrush presents more with painful whitish patches involving both the tongue and the palate. The medication needs to be taken on an empty stomach because food can interfere with its absorption and reduce efficacy. The client should not take Doxycycline after eating (Option D). Choices A and E are incorrect. These statements reflect correct understanding and do not require follow-up. Option A- This statement reflects a correct understanding and does not need further teaching. With Doxycycline, there is increased photosensitivity. The nurse should advise clients on using a high sun protection factor (SPF) sunscreen. A broad-spectrum sunscreen to protect against UVB and UVA wavelengths should be recommended. Option E- This client needs to follow up and have their labs checked. No further teaching is required. Additional Info Doxycycline is a tetracycline antibiotic that fights bacteria in the body. It treats many different bacterial infections, such as acne, urinary tract intestinal, respiratory, and eye infections, gonorrhea, chlamydia, syphilis, periodontitis.

Which of the following interventions does the nurse anticipate when caring for a patient after repair of an anorectal malformation? Select all that apply. A. Imodium administration [12%] B. Initiation of a high-calorie diet [15%] C. Colace administration [34%] D. Initiation of a high-fiber diet [38%]

Explanation Choices C and D are correct. The nurse would expect to administer colace (Docusate) after the patient has a repair of an anorectal malformation. Colace is a stool softener that will help to pull water into the intestines and soften the stool. This will make bowel movements easier for the patient after surgery (Choice C). Initiation of a high fiber diet after surgery for an anorectal malformation is an expected intervention. A high fiber diet will assist the patient in passing stool more quickly, which is vital after repairing anorectal malformation (Choice D). Choice A is incorrect. Administration of imodium after repair of an anorectal malformation is not appropriate. This is an anti-diarrheal that would be administered to the patient experiencing diarrhea. This is not expected with an anorectal malformation repair. Choice B is incorrect. Initiation of a high-calorie diet is not necessary after repair of an anorectal malformation. Instead, a high fiber diet should be initiated. A high fiber diet will assist the patient in passing stool more easily, which is essential after repair of an anorectal malformation. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Pediatrics - Gastrointestinal

A patient has recently been diagnosed with leukemia. Which of the following symptoms would a healthcare professional expect? A. Dyspnea, malaise, and hypotension. [14%] B. Bruising, fatigue, and bone pain. [80%] C. Bradycardia, hypotension, and palpitations. [4%] D. Paresthesia, facial rash, and abdominal pain. [2%]

Explanation Leukemia is a form of cancer of the blood, which increases the production of abnormal white blood cells. Although white blood cells fight infection, those that are produced when leukemia is present are ineffective in combating disease. When leukemia occurs, the overproduction of white blood cells crowds red blood cells in the body, which are needed to maintain homeostasis. Common symptoms of leukemia include: Tire quickly, feel weak, or have little energy Pale skin tone Fever Easy bruising and bleeding (Nosebleeds and bleeding gums. Petechiae) Bone or joint pain and tenderness Swollen lymph nodes in the neck, underarm, groin or stomach; enlarged spleen or liver Frequent infections Unplanned weight loss Night sweats Shortness of breath Pain or full feeling under the ribs on the left side Choice B is correct. Because the bone marrow is not making an adequate amount of red blood cells and platelets, the patient will experience fatigue due to anemia, and bruising due to decreased platelets. The stretching of the periosteum causes bone pain because of the excessive white blood cells. The CBC may show increased blasts, or immature white blood cells, crowding out the healthy RBCs and platelets. Choices A, C, and D are incorrect. Although dyspnea, bradycardia, hypotension may occur as a side effect of the treatment of leukemia, they are likely not caused by leukemia itself. Also, while some patients may present with signs of skin irritation, it is not usually attributed to leukemia alone and can often be treated with OTC medications/creams. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse is caring for a client prescribed IV heparin. The client is prescribed 15 units/kg/hr. The client weighs 154 pounds. The heparin is labeled with 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round your answer to the nearest whole number. Fill in the blank. 11 mL/hr

Explanation The first step to solving this problem is to convert the client's weight from pounds to kilograms (kg) 154 pounds / 2.2 = 70 kg Next, establish the dosage that the client is to receive. 15 units x 70 kg = 1050 units Next, take the ordered amount and divide it by the dose on hand and then multiply it by the volume. 1050 units / 25000 units x 250 mL = 10.5 mL/hr Finally, round the mL/hr to the nearest whole number 10.5 mL = 11 mL/hr Additional Info Intravenous heparin is typically administered as a bolus dose first, then as a continuous infusion to achieve therapeutic aPTT. A baseline aPTT should be collected 6 hours after the first dose and 6 hours following any dose adjustments. The goal is to prolong the aPTT from 1.5 to 2.5 times the control value. The normal aPTT value is 30-40.

The primary healthcare provider (PHCP) prescribes one liter of 0.9% saline to infuse over 6 hours. How many mL per hour will be administered to the client? Fill in the blank. Round your answer to the nearest whole number. 167 mL/hr

Explanation To solve this problem, the formula of volume / time (hours) will be used. First, convert the prescribed liters to milliliters to determine the total volume ordered 1 liter x 1000 mL = 1000 mL Next, divide the prescribed total volume by the infusion time 1000 mL / 6 hours = 166.66 Finally, take the mL/hour and round to the nearest whole number 166.66 = 167 mL/hr Additional Info 0.9% saline is an isotonic solution utilized in the treatment of standard dehydration.

You are working in the emergency department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), all of the tasks listed below should be done for this patient. What is the correct sequence for these tasks? Neurologic assessment by the stroke team General assessment and stabilization Determine if the patient is a candidate for fibrinolytic therapy Administer rtPA

General assessment and stabilization Neurologic assessment by the stroke team Determine if the patient is a candidate for fibrinolytic therapy Administer rtPA Explanation Correct ordered sequence: According to the AHA's suspected stroke algorithm, the correct course for the treatment of the stroke patient is: General assessment and stabilization within 10 minutes of arrival to the ED Neurologic evaluation by the stroke team within 25 minutes of entry to the ED CT scan and determination if there is intracranial hemorrhage within 45 minutes of entry to the ED If ischemic stroke, determine if the patient is a candidate for fibrinolytic therapy using the fibrinolytic checklist Administer rtPA within 60 minutes of entry to the ED Admit to the stroke unit within 3 hours of entry to the ED NCSBN Client Need Topic: Management of Care, Sub-Topic: Establishing Priorities, Neurologic