Archer Review 7

The nurse has instructed a pregnant patient who is scheduled for a nonstress test (NST). Which of the following statements by the patient would require a follow-up? A. "I cannot have anything to eat eight hours prior to this test." [80%] B. "I will have an external monitor across my abdomen." [3%] C. "A reactive result means my baby is doing well." [13%] D. "If this test is abnormal, I will need further testing." [5%]

Explanation Choice A is correct. A Nonstress test does not require a patient to abstain from eating or drinking prior to the test. This statement is false and would require follow-up. Choices B, C, and D are incorrect. An external fetal heart rate monitor will be applied across the patient's abdomen during this test, and results that are reactive indicate fetal well-being. Abnormal testing does require additional testing, such as a biophysical profile or a contraction stress test. Additional information: A nonstress test is performed in the third trimester if the patient has indications such as a high-risk pregnancy that may result in a stillbirth or complications such as fetal hypoxia. A reactive finding indicates fetal well-being, specifically, that the fetal heart rate increased by 15 beats-per-minute lasting for 15 seconds. A nonreactive NST is non-reassuring and indicates decreased variability with an absence in a fetal heart rate acceleration.

A client is about to receive 1 unit of packed red blood cells. Before beginning the blood transfusion for the client, the nurse should ask which initial question? A. "Have you experienced receiving a blood transfusion before?" [69%] B. "Do you know why you need the transfusion?" [6%] C. "Have you experienced going into shock for any reason in the past?" [8%] D. "Are you aware of the complications and risks of a blood transfusion?" [17%]

Explanation Choice A is correct. Asking about the client's personal experience with transfusion therapy provides a chance for the nurse to evaluate the client's understanding and is a good starting point for the client's education about this procedure. Choice B is incorrect. Although determining whether the client knows the reason for the transfusion is important, this is not a therapeutic way of eliciting information from the client regarding an understanding of the need for the transfusion. Choices C and D are incorrect. These are not helpful questions because they may cause fear in the client.

A patient with a chest tube drainage system has just been admitted to the unit. The nurse notes that the fluid in the water seal column is not fluctuating. The nurse knows that the best explanation of fluctuation cessation is that: A. There may be fibrin clots in the tubing [29%] B. The lung is collapsing [7%] C. There has been an increase in intrapleural pressure [12%] D. The tubing may have become dislodged from the chest [52%]

Explanation Choice A is correct. Fibrin clots from the lungs sometimes become lodged in the chest tube system resulting in the cessation of fluctuations in the water seal column. This may also occur when the lung becomes fully expanded. Choice B is incorrect. A collapsing lung is usually the indication for a chest tube. Choice C is incorrect. An increase in pleural pressure is healthy and fluctuates, causing movement in the water seal chamber. Choice D is incorrect. All functions and displays will cease to function correctly if the tubing is dislodged from the chest. This is not the most likely option. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

A patient is started on a daily amount of phenytoin 200 mg PO in two divided doses. What instruction by the nurse is incorrect? A. "You will need annual labs to determine the medication level in your body." [62%] B. "Remember to never skip a dose of this medication." [4%] C. "You need to increase your intake of vitamin D while taking this medication." [26%] D. "Maintain good oral hygiene and visit your dentist regularly." [8%]

Explanation Choice A is correct. Proper instruction includes telling the client that, initially, weekly labs need to be drawn, not annual labs. Dilantin acts by desensitizing sodium channels in the CNS. It may cause dysrhythmias, such as bradycardia, severe hypotension, and hyperglycemia. Weekly monitoring of phenytoin levels should be done weekly until therapeutic levels are reached. After therapeutic levels are reached, most physicians request levels to be checked at least every three months. Choices B, C, and D are incorrect. Each of these statements reflects correct nursing instruction for a client taking phenytoin. It is essential for a patient newly started on phenytoin to receive weekly labs initially to check the CBC. Patients need to have their RBCs, WBCs, and platelets monitored because phenytoin can cause those numbers to fall. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies

The nurse is taking care of a client who underwent a left lung resection two days ago. During her assessment, she finds that the client's apical pulse is 125 beats per minute; his peripheral pulses are weak and thready. His blood pressure is 79/51 mmHg and lungs are clear to auscultation. He is on intravenous Normal Saline at 100 mL/hour. Which of the following is the nurse's initial intervention? A. Increase the IV fluid rate to 180 mL/hr [31%] B. Administer dopamine [5%] C. Assess the client's wound [24%] D. Notify the physician [40%]

Explanation Choice A is correct. The client is manifesting signs and symptoms of hypovolemic shock with systolic blood pressure less than 90 mmHg and signs of inadequate tissue perfusion (weak and thready peripheral pulses) on physical examination. This represents a low circulatory fluid volume. In the setting of hypovolemia, the heart rate is increased as the heart attempts to maintain adequate cardiac output. The priority action for the nurse in this situation is to restore circulating blood volume. Increasing his IV normal saline flow rate will provide the client with circulatory blood volume immediately; therefore, this is the first intervention. Many independent nursing interventions are crucial to the care of the person in shock. It starts with assessment and monitoring for shock symptoms and signs. Trauma is defined by the presence of signs of inadequate tissue perfusion +/- systolic blood pressure less than 90 mmHg or mean arterial blood pressure less than 65 mmHg or a drop of systolic blood pressure of more than 40 mmHg from baseline. Different types of shock include hypovolemic, distributive (i.e. septic, neurogenic, anaphylactic, shock in adrenal crisis), obstructive, or cardiogenic shock. It is important to remember a couple of formulas here; knowing these formulas makes understanding interventions easier: Blood pressure = Cardiac Output (CO) x Peripheral Vascular Resistance (PVR) Mean Arterial Pressure (MAP) = 1/3 (Systolic blood pressure) + 2/3 (Diastolic blood pressure) Cardiac Output = Heart Rate x Stroke Volume. Please note that interventions may change based on the type of shock: For most types of shock, the initial intervention is to give adequate IV fluids (i.e. isotonic normal saline) to target a mean arterial pressure of 65 mmHg. Successful treatment of trauma will restore peripheral pulses to baseline. Vasopressors are not the first-line treatment in hypovolemic shock. Even in the setting of septic shock, the first step would be to increase IV fluids to restore the pressure. In septic shock, peripheral vasodilation from toxins results in decreased peripheral vascular resistance (low PVR results in low blood pressure, apply this in the above formula). Increasing fluids will fill up the PVR. The goal is to target a MAP of 65 mmHg. If the target is not achieved after adequate IV fluids, vasopressors such as dopamine or norepinephrine are added. These vasopressors restore blood pressure to the target level by increasing cardiac output (by increasing stroke volume and heart rate; Cardiac output = Stroke Volume x Heart rate). In cardiogenic shock, IV hydration is contraindicated since lungs are often congested. Interventions in cardiogenic shock are aimed to reduce preload (nitroglycerin), decrease afterload, and increase cardiac output (i.e. dobutamine, dopamine, norepinephrine). In obstructive shock (i.e. air embolism, tension pneumothorax, cardiac tamponade), intervention is aimed at relieving the obstruction. For example, placing the client in Trendelenburg position for the management of air-embolism, thoracentesis in tension pneumothorax, and pericardiocentesis in cardiac tamponade. Choice B is incorrect. The client may need medications like dopamine to increase their blood pressure. However, the immediate intervention in the situation is to increase the IV fluid rate, which will increase the circulating blood volume. If the MAP target is not achieved despite increasing IV fluids, then vasopressors (i.e. dopamine) are used. Choice C is incorrect. Assessment of the client's surgical wound for possible infection or bleeding/hematoma should be done. However, the client is manifesting signs of diminished circulation, leading to shock. The nurse should support the client's flow by increasing the IV fluid rate. Choice D is incorrect. The physician should be notified, but the nurse should initiate an emergency nursing intervention first since the client is visibly in shock. The nurse has enough evidence of reduced tissue perfusion based on her assessment; maintaining an adequate circulating blood volume is a priority.

When entering a patient's room to administer medications, what should the nurse's first action be? A. Verify the patient's full name and date of birth. [94%] B. Ask the patient to verify any medication allergies. [2%] C. See if the patient had breakfast. [0%] D. Review medications and potential side effects. [3%]

Explanation Choice A is correct. The first nursing action when preparing to administer medications is to identify the correct patient. This helps decrease the risk of errors and is the safest way to administer care. Choices B and D are incorrect. While verifying medication allergies, it is important to know what medications are ordered and their potential side effects. The nurse's first action should be to verify that they have the right patient. Choice C is incorrect. Some medications are recommended to be taken with food. However, verifying if the client has eaten breakfast is not the nurse's first action. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Medication Administration

While caring for a patient who has recently suffered from a fracture, the nurse sees that the patient's injured extremity will be placed in traction. Which of the following actions should the nurse refrain from performing? A. Keeping the pulley system tightened so that they may not move freely [73%] B. Check the ropes for fraying or breaks [3%] C. Keep the weights above the floor [18%] D. Ensure proper body alignment [6%]

Explanation Choice A is correct. The nurse caring for a patient in traction should avoid keeping the pulley system tight. The pulley system should move freely uninhibited by knots or tension. Traction is used to reduce and immobilize a fracture. Choice B is incorrect. The nurse should check the rope for fraying or breaks once per shift to ensure no sudden breaks in the system, which may cause injury to the patient. Choice C is incorrect. Keeping the weights off of the floor is an appropriate nursing action and should be maintained while the patient remains in traction. Choice D is incorrect. Proper body alignment should be maintained all while the patient is in traction. NCSBN client need Topic: Physiologic integrity, reduction of risk potential

The nurse just finished a shift in the emergency department during winter when she notices a homeless man outside with frostbite on his hands. The nurse brings the man into triage and starts to treat the frostbitten area by rewarming it. Which action by the nurse is most appropriate? A. Immerse the affected area in heated water at 40-46°C. [66%] B. Immerse the affected area in heated water at 80-90°C. [9%] C. Remove the blood-filled blisters. [3%] D. Apply snug, sterile dressings. [23%]

Explanation Choice A is correct. The nurse should immerse the frostbitten area in heated water at 40.6 - 46.1°C to rewarm the area. Choice B is incorrect. Engaging the frostbitten part in 80 - 90 °C water is too hot and would cause burns to the patient. Therefore, the nurse should immerse the frostbitten area in heated water at 40.6 - 46.1°C to rewarm the area. Choice C is incorrect. The nurse should handle the frostbitten area gently, taking care not to burst the blood-filled blisters. Choice D is incorrect. Loose, sterile, bulky dressings should be applied, not snug or tight-fitting ones.

Which of the following is a late sign of increased intracranial pressure or ICP? A. Presence of Babinski reflex [35%] B. Altered level of consciousness [43%] C. Headache [6%] D. Elevated blood pressure [16%]

Explanation Choice A is correct. The presence of the Babinski reflex, or the extension of the big toe when the sole is stimulated, is a late sign of increased ICP. Other new symptoms include decorticate or decerebrate postures and seizures. Choices B, C, and D are incorrect. An altered level of consciousness is an early sign of an increased ICP, as is a headache and elevated blood pressure. NCSBN client need Topic: Physiological Integrity, medical emergencies

The nurse has received the following prescriptions for newly admitted clients. The nurse should initially Review the prescriptions below in the options and select the prescription that should be administered first A. initiate intravenous fluids for a client with anorexia nervosa. [39%] B. administer venlafaxine for a client with persistent depressive disorder. [7%] C. consult the social worker to begin discharge planning for a client. [2%] D. obtain a blood sample to evaluate a client's lithium level. [52%]

Explanation Choice A is correct. The priority is to attend to a client's physiological needs. Initiating intravenous fluids for a client with anorexia nervosa prioritizes over the other prescriptions because of the condition's ability to cause dehydration and severe fluid and electrolyte disturbances. Choices B, C, and D are incorrect. Administering venlafaxine for a client with a chronic depressive disorder is not the priority. This is a chronic problem, and acute problems come first. Consulting with the social worker for discharge planning is a low-priority task and is akin to providing discharge teaching. Obtaining a blood sample to evaluate a client's lithium level does not prioritize over a client-ordered intravenous fluid for a circulation problem. Additional Info Prioritizing client care is central to functioning as a nurse. High-priority patient situations include a client who is unstable or reporting an acute change. The nurse should always address high-priority items and appropriately delegate intermediate to low priority items, if necessary. Focus on the model of airway, breathing, circulation, and problems that may arise associated with each. In this question, anorexia nervosa is a circulation issue, and the treatment of intravenous fluids should be promptly initiated.

The nurse is evaluating the laboratory results of a client with severe pressure ulcers. Which of the following should prompt the nurse to intervene? A. Serum albumin level of 2.5 g/dL [74%] B. Serum potassium level of 4 mmol/L [5%] C. Serum sodium level of 140 mEqL [2%] D. WBC count of 9000 cells/uL [19%]

Explanation Choice A is correct. The serum albumin level is low. The normal range of serum albumin is 3.5-5.5 g/dL. This lab value is a matter of concern to the nurse because serum albumin levels indicate the adequacy of protein stores available for tissue repair. A low albumin level may delay the healing process of the pressure sore. Hypoalbuminemia is seen in malnutrition, chronic illness, wasting syndromes, starvation, nephrotic syndrome, malignancy, and gastrointestinal losses. Choices B, C, and D are incorrect. The levels of serum potassium, sodium, and WBCs are all within the normal range. The normal range for sodium is 135 to 145 mEq/L (milli-equivalents per liter). Normal range for potassium is 3.6 to 5.3 mmol/L (millimoles per liter). Normal white blood cell count ranges from 4500 to 11000 cells/uL (cells per microliter).

You are attending to a male client who is postoperative day one following mitral valve replacement. He is getting ready to ambulate for the first time. His heart rate is 102 beats/minute and the stroke volume based on the echocardiogram is 72 mL. Which of the following represents his cardiac output (CO)? A. 7.344 L/min [49%] B. 30 L/min [20%] C. 55% [12%] D. 73.444 mL/min [19%]

Explanation Choice A is correct. To answer this question correctly, you must know the right formula for Cardiac Output (CO). CO = Heart Rate (HR) x Stroke Volume (SV). Heart rate is measured in beats per minute and stroke volume is measured in milliliters (mL). The HR is simply the number of times per minute that the heart beats, whereas the SV is the mL of blood that the heart pumps out with each contraction. By multiplying the two together, you get how many mL of blood the heart is pumping out each minute. This is the cardiac output. Cardiac output is usually reported in liters/min; the average is about 5 L/min but varies greatly depending on the size of the patient. A decreased cardiac output (low-output failure) is seen in congestive heart failure. A high cardiac output state refers to resting cardiac output more significant than 8 L/min. An increased cardiac output (high-output failure) may be seen in hyperthyroidism, thiamine deficiency, and severe uncorrected anemia. For this problem: Cardiac Output (CO) = 102 beats per minute (HR) x 72 mL (SV) = 7,344 mL/min or 7.344 L/min. Choices B, C, and D are incorrect. Choice C appears to represent an ejection fraction, which can be obtained from an echocardiogram. Cardiac output should not be confused with ejection fraction. Ejection fraction (EF) is a "fraction" and is often reported as a percentage (%). Left ventricular ejection fraction is the amount of blood pumped out of the left ventricle during asystole. An ejection fraction of 55 percent means that 55 percent of the total amount of blood in the left ventricle is pumped out with each heartbeat. The normal EF is 55% to 70%. Ejection fraction is decreased in systolic heart failure, whereas it remains normal in diastolic heart failure. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic care, comfort; cardiac

A 7-year-old child in the pediatric ward does not want to ambulate after surgery. Which action by the nurse is most appropriate? A. Ask the child when he wants to ambulate; whether at 9 AM or at 1 PM. [74%] B. Insist that the child ambulate in the hall now. [1%] C. Refer the child to a child psychiatrist. [1%] D. Tell the child that he can have ice cream after he ambulates. [23%]

Explanation Choice A is correct. To ensure cooperation with the regimen, the nurse should offer the child choices. The most appropriate choice to give the child is whether he wants to ambulate at 9 AM or at 1 PM. Choice B is incorrect. Forcing the child to cooperate in the therapeutic regimen may cause more resistance to the intervention. Choice C is incorrect. The child psychiatrist may help, but the nurse can take control of the situation to ensure that the client ambulates. This is not the most appropriate action for the nurse. Choice D is incorrect. This action of the nurse resembles bribery and should not be done.

The nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals? A. Blood Pressure 128/63 mmHg [65%] B. Creatinine 2.3 mg/dL [21%] C. Proteinuria [3%] D. Sodium 132 mEq/L [11%]

Explanation Choice A is correct. Treatment goals for a patient with Polycystic Kidney Disease (PKD) include maintaining normotension, the glomerular filtration rate (GFR), and the prevention of sodium wasting, which is evidence of a decline in renal function. Hypertension is a cardinal finding in PKD, and if a client is achieving the treatment goals, they will maintain regulated blood pressure. Choices B, C, and D are incorrect. An elevated creatinine indicates that kidney function is declining. Proteinuria and sodium in the urine are also evidence of decreased renal function. Both findings would not indicate that the client is improving; rather, they would indicate that the client's renal function is declining. Additional Info Polycystic Kidney Disease is a genetic disorder manifested by fluid-filled cysts that grow on the kidneys. Additional findings in PKD include: • Abdominal or flank pain • Hypertension • Nocturia • Frequent urinary tract infections • Increased abdominal girth • Constipation • Hematuria (bloody urine) • Sodium wasting and inability to concentrate urine in the early stage • Progression to kidney failure with anuria

You have been assigned to serve on the Quality Assurance/Performance Improvement Committee. You would expect that the primary focus of this committee is which of the following? A. Outcome measurements [71%] B. Process measurements [15%] C. Structural measurements [9%] D. To identify those who erred [5%]

Explanation Choice A is correct. You would expect that the primary focus of this committee is outcome measurements and outcome-oriented clinical indicators such as the rate of urinary tract infections over time. The focus of quality assurance and performance improvement activities has evolved from the structure to process outcome-oriented clinical indicators and related activities. All quality assurance and performance improvement activities are conducted in a blame-free environment that aims to identify why things have occurred, rather than on who erred. Choice B is incorrect. The focus of quality assurance and performance improvement activities has evolved from process measurements to another type of analysis and indicators. Choice C is incorrect. The focus of quality assurance and performance improvement activities has evolved far beyond structural measurements to another type of analysis and indicators. Choice D is incorrect. All quality assurance and performance improvement activities are conducted in a blame-free environment that aims to identify why things have occurred, rather than on who erred.

After experiencing a traumatic amputation and related body image disturbance. The nurse documents the nursing diagnosis of body image disturbance related to changes in appearance secondary to: A. Severe trauma [10%] B. Loss of a body part [84%] C. Chronic disease [1%] D. Loss of body function [4%]

Explanation Choice B is correct. Although the amputation was related to severe trauma, being specific about what type of injury (the loss of a body part) gives precise information to other health care team members who may assume care of this client. The nursing diagnosis is body image disturbance. When referencing a nursing diagnosis that is secondary to a condition/experience, it is essential to be specific. Choice A is incorrect. The loss of a limb was caused by severe trauma but is not the most appropriate answer to this question. Choice C is incorrect. Amputation is a chronic condition but is not a disease. Choice D is incorrect. While the loss of body function will become evident, it is about the loss of the limb, which is the most appropriate answer. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Body Image

The nurse is watching the monitor of a patient wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first? A. Press record on the electrocardiogram [1%] B. Check the patient's lead placement [93%] C. Call the code team [5%] D. Contact the health care provider [1%]

Explanation Choice B is correct. Before calling a code or contacting the physician, the nurse should ensure that the leads are correctly placed on the patient and have not been removed. Physically looking and assessing the patient as well as the associated equipment should be the first action when an abnormal rhythm is noticed on the cardiac monitor. Choice A is incorrect. The first action is to ensure proper lead placement. Choice C is incorrect. Calling a code is not appropriate until the nurse has confirmed the patient is experiencing asystole. Choice D is incorrect. Contacting the care provider should not be completed until the nurse is sure that the patient's leads are working correctly. NCSBN client need Topic: Physiological Integrity, physiological adaptation

A primigravida patient in her 2nd trimester calls the OB office to report a dark line on her skin in the middle of her abdomen. The phone triage nurse would recognize this as which of the following? A. Chloasma [1%] B. Linea nigra [92%] C. Goodell Sign [1%] D. Striae gravidarum [7%]

Explanation Choice B is correct. Linea nigra refers to the linear hyperpigmentation of the midline of the abdomen (from sternal notch to pubis). This is a frequent change that occurs during the 2nd trimester. Choice A is incorrect. Chloasma refers to a butterfly-shaped pigmentation on the face that is seen during the 1st trimester. Choice C is incorrect. Goodell sign describes the softening of the cervix due to increased vascularity, congestion, and edema. This change occurs during the 1st trimester of pregnancy. Choice D is incorrect. Striae gravidarum describes the presence of stretch marks due to weight gain, commonly seen on the breast and abdomen during pregnancy. NCSBN Client Need Subject: Topic: Reproductive, Subtopic: Pathophysiology, antepartum care

The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG). Which observation requires follow-up? A. Uses one washcloth for washing each major body part [13%] B. Rinses the skin after bathing with the CHG solution [39%] C. Washes the client's face with warm water and mild soap [6%] D. Allows the CHG solution to dry on the client's skin [41%]

Explanation Choice B is correct. CHG is an effective antimicrobial agent that inhibits bacterial growth for 24 hours. The solution should not be rinsed off once it is applied, as it will leave a sticky residue. That is sticky sensation is normal. Choices A, C, and D are incorrect. These observations do not require follow-up because they are appropriate. When using CHG in a bath basin of water, use one washcloth to wash each major body part. Then dispose of the cloth and use a new cloth for the next body part. CHG should not be applied to the face or the eyes. Only use warm water or mild soap, and water should be used on the face. CHG should be allowed to dry on the client's skin and should leave a residue-type sensation. Additional Info When using CHG in a bath basin of water, use one washcloth to wash each major body part. Then dispose of the cloth and use a new cloth for the next body part. Dipping cloth back into basin contaminates solution and makes CHG less effective. Do not rinse after bathing with CHG solution. Allow CHG to dry on the skin to achieve antimicrobial effects. CHG is safe to use on the perineum and external mucosa. However, cleansing of the urinary meatus is best performed with soap and water

Which of the following is the likely contributing factor of an elevated red blood cell count in a patient with a history of chronic bronchitis? A. Hypercapnia [32%] B. Chronic hypoxia [53%] C. Insensible water loss [6%] D. Decreased fluid intake [8%]

Explanation Choice B is correct. Chronic hypoxia, from reduced air exchange, leads to low oxygen levels in the body. The kidneys respond to chronic hypoxia by releasing erythropoietin (EPO), which stimulates red blood cell production. The red blood cell count is elevated to compensate for hypoxia or low oxygen levels. More cells are available to carry and deliver the maximum amount of oxygen. Polycythemia is a condition in which there is an increased number of red blood cells in the blood. There are two types of polycythemia; 1) primary polycythemia and 2) secondary polycythemia. The two main conditions of primary polycythemia are polycythemia vera (PV) and primary familial and congenital polycythemia (PFCP). Causes of secondary polycythemia include conditions as a result of chronic hypoxia such as COPD, emphysema, chronic bronchitis, pulmonary hypertension, congestive heart failure, obstructive sleep apnea, and certain cancers. Examples of symptoms of polycythemia include easy bruising or bleeding, blood clot formation, headache, itching, and fatigue. Treatment for polycythemia depends on the cause. Untreated polycythemia generally has a poor outcome for the patient. Choice A is incorrect. Hypercapnia, or hypercarbia, is too much carbon dioxide (CO2) in the bloodstream. It usually happens as a result of hypoventilation. Choices C and D are incorrect. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse is working with a child who has a learning disability. The child is ten years old and has trouble reading and interpreting words, letters, and symbols. What is the most likely diagnosis? A. Phonologic processing deficit [19%] B. Dyslexia [61%] C. Tourette's syndrome [5%] D. Apraxia [14%]

Explanation Choice B is correct. Dyslexia is defined as a disorder that involves trouble reading and interpreting words, letters, and symbols. It does not affect general intelligence, but children may need special assistance at school when learning to read. They may not understand at their appropriate grade level, depending on the severity of the disorder. Choice A is incorrect. Phonologic processing deficit is not described as trouble reading and interpreting words, letters, or symbols. Instead, it is a specific deficit where the child has difficulty discriminating and processing different speech sounds. Choice C is incorrect. Tourette's syndrome is a neurological disorder characterized by involuntary tics and vocalizations. It is often best known for the compulsive utterance of obscenities that sometimes occurs. Tourette's syndrome is not characterized by trouble reading and interpreting words, letters, or symbols. Choice D is incorrect. Apraxia is defined as the inability to perform particular purposive actions, as a result of brain damage. It is not a learning disability and is not characterized by trouble reading and interpreting words, letters, or symbols. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Neurology

In a staff meeting, the nurses were asked by the nurse manager what their thoughts are on the solutions presented to them regarding medication errors. They were also asked to vote whether to apply the changes proposed or to veto it. Which management style is the unit practicing? A. Autocratic [3%] B. Democratic [66%] C. Participative [27%] D. Laissez-faire [4%]

Explanation Choice B is correct. In a democratic style of management, staff members are encouraged to participate in the decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in this management style. Choice A is incorrect. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit. Choice C is incorrect. In a participative style of management, problems are identified by the manager and presented to the staff with several solutions. Staff members are encouraged to provide input however, the manager makes the final decision. Choice D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of management. The manager abdicates responsibility and decision-making whenever possible in this type of management.

Which of the following terms describes the soft, down hairs present on the shoulders, back, and forehead of newborns? A. Milia [7%] B. Lanugo [88%] C. Vernix [3%] D. Mongolian spot [2%]

Explanation Choice B is correct. Lanugo is the soft, down hairs present on the shoulders, back, and forehead of newborns. Choice A is incorrect. Milia are tiny white bumps that commonly appear on newborns' foreheads. Choice C is incorrect. Vernix is the "cheese-like" substance coating the skin of newborns after birth. Choice D is incorrect. Mongolian spots are a type of birthmark. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic Care & Comfort, Newborn

The nurse is working at a women's health clinic. A patient comes in suspected of having trichomoniasis. Upon physical examination of the perineal region, the nurse should expect which type of sign? A. White, "cheesy" discharge [25%] B. Malodorous, thin, yellow discharge [40%] C. Grayish-white, malodorous discharge [31%] D. No vaginal discharge [4%]

Explanation Choice B is correct. Trichomoniasis patients would yield a malodorous, thin, yellow discharge. Trichomoniasis is caused by a protozoon, Trichomonas vaginalis. Choice A is incorrect. A white, "cheesy" discharge is indicative of moniliasis or candidiasis, which is caused by Candida albicans. Choice C is incorrect. Grayish-white, malodorous discharges would indicate bacterial vaginosis. Choice D is incorrect. Patients with trichomoniasis yield a malodorous, thin, yellow discharge.

A patient with Cushing's disease asks the nurse to help him choose a meal for dinner later. Which of the following meals is the best option? A. Hamburger with french fries and apple slices. [2%] B. Pork chops in cream sauce with mashed potatoes and carrots. [7%] C. Roasted chicken with corn and green beans. [86%] D. Mexican-style beef with guacamole and beans on the side. [5%]

Explanation Choice C is correct. A patient with Cushing's disease needs to eat a low sodium, high protein, and low-fat diet. Roasted chicken has high protein with little fat. Cushing's disease is a severe condition with an excess of the steroid hormone, cortisol, in the blood caused by a pituitary tumor secreting adrenocorticotropic hormone (ACTH). Because cortisol is essential for metabolic processes, hypercortisolism associated with Cushing's can significantly affect how the body processes nutrients. Patients with Cushing's disease are encouraged to reduce sodium intake (to reduce the risk of hypertension and weight gain), increase calcium and vitamin D (Cushing's disease can cause decreased bone density and osteoporosis). Cortisol stimulates the liver to increase blood sugar levels, so people with Cushing's — who have perpetually high cortisol levels — may also have elevated blood sugar. Chronic, heavy drinking can damage the hypothalamic-pituitary-adrenal axis hormone network, resulting in symptoms nearly identical to those of Cushing's. The so-called pseudo-Cushing syndrome can intensify the symptoms of existing Cushing's disease as well as make it more challenging to diagnose and treat. A common manifestation of Cushing's is high cholesterol levels. Avoiding fatty foods and eating more high-fiber foods such as kidney beans, apples, pears, barley, and prunes may help offset the effects of higher cholesterol associated with Cushing's. Choices A, B, and D are incorrect. Hamburgers and french fries are high in fat, pork chops in cream sauce are also high in fat, and guacamole is high in fat. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation

The nurse is caring for a patient with a percutaneous endoscopic gastrostomy tube. Prior to starting the scheduled bolus feeding, the nurse is unable to auscultate the patient's bowel sounds and notes 80 mL gastric residual volume. Of the following, which action would be the nurse's priority? A. Notify physician [16%] B. Hold bolus and recheck residual volume in 1 hour [10%] C. Check for abdominal distension [51%] D. Reposition the patient in semi-Fowler's position [23%]

Explanation Choice C is correct. According to current American Society for Parenteral and Enteral Nutrition ( ASPEN) guidelines for nutrition support, enteral nutrition should not be stopped for a gastric residual volume (GRV) of less than 500 mL unless there are other signs of feeding intolerance. Signs/symptoms of feeding intolerance include nausea, vomiting, abdominal distention, constipation, and abdominal pain. If no bowel sounds are present, the nurse should assess the patient's abdomen for changes from the baseline, such as tenderness or distension. If no changes from the baseline, the feeding bolus may be administered as ordered Choice A is incorrect. Assessment data of the absence of bowel sounds and a gastric residual volume less than 200 mL would not warrant immediately notifying the physician. The nurse should first assess the signs of feeding intolerance. In the absence of signs of feeding intolerance, the feeding can be continued as long as the GRV is less than 500 mL. However, the providers should implement methods to reduce aspiration risk for the GRVs ranging from 200 to 500 mLs. Such measures include administering prokinetic agents such as metoclopramide and erythromycin ( to stimulate gastric motility), optimizing glucose control (hyperglycemia can delay gastric emptying), and using continuous rather than bolus feeding for high-risk patients. Choice B is incorrect. The absence of bowel sounds and a gastric residual volume less than 500 mL would not be a contraindication for administering scheduled feedings, but an additional assessment of the abdomen should first be performed and compared to the patient's baseline. In patients who are not critically ill, GRV should be checked every four hours during the first 48 hours of gastric feeding and, after that, every six to eight hours. Choice D is incorrect. Prior to administering bolus feedings, the patient should be positioned with the head of the bed elevated (semi-Fowler's or high-Fowler's position) to reduce the risk of aspiration, but this intervention would not impact the gastric residual volume or the lack of bowel sounds. Learning objective: Understand that the in the absence of signs of feeding intolerance, enteral feedings can be continued as long as the GRV is less than 500 mL. Signs of feeding intolerance such as emesis, abdominal distension, and tenderness must be assessed before calling the physician and/or before stopping the scheduled feeding. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Reduction of Risk Potential

Analyze the following ABG: pH 7.36, CO2 69, HCO3 37 A. Compensated metabolic acidosis [15%] B. Uncompensated metabolic acidosis [7%] C. Compensated respiratory acidosis [66%] D. Uncompensated respiratory alkalosis [11%]

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

Which of the following psychological symptoms, occurring at the end of life, is accurately paired with an appropriate intervention that you would incorporate into your client's plan of care? A. Spiritual distress: Diazepam [16%] B. Delirium: Lorazepam [33%] C. Hallucinations: Dopamine antagonist [20%] D. Agitation without delirium: Haloperidol [30%]

Explanation Choice C is correct. Hallucinations can be treated with a dopamine antagonist like haloperidol, which is an antipsychotic drug that is also used to treat psychotic disorders such as schizophrenia and bipolar disease. It is also a preferred agent in treating end-of-life delirium. Choice A is incorrect. Spiritual distress should be treated with a referral to the clergy and psychosocial support of the client after assessing the client for the sources of their mental pain rather than diazepam. For example, if the cause of the mental illness is unresolved guilt, the nurse and other members of the healthcare team should educate the client about the purpose of sin, they should facilitate the person's making amends to others, and also advise the client that all humans have faults; nobody is perfect and without errors. Choice B is incorrect. Antipsychotic agents such as dopamine antagonists (haloperidol) are often used as an initial pharmacological treatment in terminal delirium. Benzodiazepines (lorazepam) are not recommended in treating delirium because they may cause paradoxical excitation that worsens delirium. Benzodiazepines (BZDs) are indicated if the dopamine antagonist fails to relieve agitation or if more sedation is desired. BZDs are also used in treating agitation without delirium. Choice D is incorrect. Agitation without delirium is better treated with benzodiazepines (lorazepam) rather than dopamine antagonists (haloperidol). Note that while agitation can be a common symptom of delirium, it can occur without delirium, i.e. patients can be agitated without having acute changes in consciousness. On the other hand, "Terminal agitation" is often associated with anxiety, distress, or restlessness at the end of life. These patients are often delirious. If the patient is in the active dying phase, the use of lorazepam may be limited. In this setting, appropriate alternatives to treat terminal restlessness include haloperidol, midazolam, or chlorpromazine. Haloperidol does not have much sedative effect. If sedation is needed, chlorpromazine and midazolam offer the additional benefit of being sedatives for highly agitated patients. Learning Objective Recognize the medications that are commonly used to treat hallucinations, agitation, and delirium. Understand the differences between delirium and agitation. Additional Info Delirium is an altered sensorium. It is characterized by acute changes in the patient's level of consciousness. Hyperactive delirium is characterized by agitation, restlessness, and emotional lability. Hypoactive delirium is characterized by flat affect, apathy, lethargy, or decreased responsiveness. Causes: Many causes of delirium include medications (dexamethasone, opioid toxicity), nicotine withdrawal, dehydration, uncontrolled pain, constipation, urinary retention, infection, hypoxia, renal failure, hyponatremia, hypercalcemia, hypoglycemia, and emotional distress. Management: Initially, non-pharmacological interventions should be attempted to identify and address reversible etiology and relieve terminal agitation/delirium. For example, address the reversible causes such as treating constipation or discontinuing medications such as dexamethasone, modifying precipitating factors such as sensory deprivation or uncontrolled pain, etc. If no rapidly reversible factors are identified or if the patient is terminal, dopamine antagonists must be used.

The nurse notes that the 39-week pregnant client is experiencing placenta previa. Knowing the contexts surrounding this condition, the nurse refrains from performing which of the following standard procedures? A. Ultrasonography of the uterus [4%] B. Palpating the uterus to determine fetal arrangement [13%] C. Checking the cervix for dilation [79%] D. Placing the patient on the left side [4%]

Explanation Choice C is correct. If the prenatal client has a current case of placenta previa, the cervix should not be assessed for dilation. Placenta previa arises when the placenta develops in a problematic spot, either close or over the cervical os. To prevent bleeding or premature labor, women with placenta previa shouldn't have their cervix checked manually. Instead, an ultrasound may be performed. Choice A is incorrect. Ultrasounds may be used safely in women with placenta previa. Ultrasounds are the safest way to assess cervical dilation in a woman with this issue. Choice B is incorrect. If required by the physician, the nurse may safely palpate the abdomen and thus the uterus of a woman whose pregnancy is difficult because of placenta previa. Choice D is incorrect. Laying on her left side is an often-used position for pregnant women, including those with placenta previa. This position increases circulation to the fetus and is often a comfortable position for laboring women. NCSBN client need Topic: Health Promotion and Maintenance, Ante / Intra / Postpartum care

The nurse notices bruises on a client's arm as well as observes that the patient seems afraid and is not speaking much. Since these are possible signs of physical abuse, what is the nurse's most appropriate action? A. Ignore the bruises, as this is not why the patient is being treated, and it is not appropriate for the nurse to address. [0%] B. Report the suspected abuse to one of the other nurses and work together on how to handle it. [1%] C. Report the findings to the appropriate authorities based on the state requirements and protocols. [72%] D. Use therapeutic communication to talk to the patient and attempt to get evidence of suspected abuse. [26%]

Explanation Choice C is correct. It is the responsibility of any healthcare provider/team member to report any type of suspected abuse to the police or designated agency, per state policy. Choice A is incorrect. Any signs of suspected abuse should never be ignored but reported to the appropriate agency or police. Choice B is incorrect. Discussing the suspected abuse with another nurse is not indicated. Choice D is incorrect. Although measures to promote therapeutic communication may help get a history from the patient and may lead to the patient disclosing abuse, the nurse is still legally required to report any suspected abuse. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Identifying Victims of Violence

A client with hyperthyroidism is scheduled to have a thyroidectomy. The physician prescribes Lugol's solution and the nurse is about to administer it to the client. The client asks the nurse about the medication's purpose. The nurse's most appropriate response would be: A. To prevent hypocalcemia [24%] B. To decrease the client's anxiety during surgery [3%] C. To reduce the size of the thyroid and reduce bleeding [67%] D. To increase the effects of anesthesia [5%]

Explanation Choice C is correct. Lugol's solution is also known as the iodine solution. The client may receive Lugol's solution for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding. Choice A is incorrect. Lugol's solution does not increase calcium levels. It does not act to prevent hypocalcemia. Choice B is incorrect. Anxiolytics reduce anxiety during surgery, not Lugol's solution. Choice D is incorrect. Lugol's solution does not increase the effects of anesthesia.

A client you are taking care of is 38-years-old. She has a history of rheumatoid arthritis and has recently been suffering from severe seasonal allergies. She has been self-medicating with aspirin and diphenhydramine. At her visit today, she reports that these medications no longer work. The physician prescribed loratadine and phenylephrine nasal spray. What instructions should the nurse give the client regarding the use of phenylephrine? A. Use only once per day [27%] B. Use as often as needed [15%] C. Use only for 3-5 days [38%] D. Use only at night [20%]

Explanation Choice C is correct. Phenylephrine should not be used for longer than 3-5 days, to help reduce the risk of rebound congestion. Phenylephrine is a sympathomimetic medication that is effective at relieving the nasal congestion associated with allergic rhinitis. Because of their local action, intranasal sympathomimetics produce few systemic effects. However, one side effect associated with their use is rebound congestion. Prolonged use causes hypersecretion of mucus and worsened nasal congestion once the drug effects wear off. This rebound effect sometimes leads to a cycle of increased drug use as the condition worsens. Because of the risk of rebound congestion, intranasal sympathomimetics should be used for no longer than 3-5 days. Choices A, B, and D are incorrect. The medication can be used every 3-4 hours as needed for 3-5 days. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological & Parenteral Therapies

Among the patients in a long term care facility. Which client is at the highest risk for developing a decubitus ulcer? A. An incontinent client who had 3 diarrheal stools. [8%] B. An 80-year-old ambulatory diabetic client. [3%] C. A 79-year-old malnourished client on bed rest. [82%] D. An obese client who uses a wheelchair. [7%]

Explanation Choice C is correct. Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue. These three conditions reduce the amount of padding between the skin and bones, thus increasing the risk of pressure ulcer development. More specifically, inadequate intake of protein, carbohydrates, fluids, zinc, and vitamin C contributes to pressure ulcer formation. Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions. Choice A is incorrect. Incontinence can be a source of skin irritation, but it is not a stand-alone risk factor for developing a decubitus ulcer. Choice B is incorrect. While diabetics may be prone to developing skin ulcers and may experience slower healing times, an ambulatory patient is not at risk for developing pressure sores. Choice D is incorrect. Obesity is not a risk factor for developing a decubitus ulcer. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

A nurse is caring for a 45-year-old woman diagnosed with Systemic Lupus Erythematosus (SLE). Which of the following findings would indicate a need for an additional assessment? A. The client complains that she has trouble covering up her rashes on her nose [9%] B. She requests the unlicensed assistive personnel to close the blinds in her room complaining about the sunlight [6%] C. The client reports a bright red color in the commode while urinating [81%] D. The client reports joint pain and requests pain medication [5%]

Explanation Choice C is correct. Systemic Lupus Erythematosus (SLE) is associated with an elevated risk of lupus nephritis ( renal involvement), a severe complication. Bright red coloring in the commode while urination indicates fresh blood ( gross hematuria), alerting the nurse to possible renal involvement in SLE clients. Hematuria may be accompanied by elevated creatinine (renal insufficiency). The nurse should assess the client for renal dysfunction and inform the physician to facilitate further diagnostic tests. Choice A is incorrect. A rash across the face, otherwise known as a butterfly malar rash, is an expected manifestation of SLE; this does not warrant immediate attention from the nurse. Choice B is incorrect. Clients with SLE are expected to have photosensitivity; this does not alert the nurse of a new problem. Choice D is incorrect. Joint stiffness is an expected clinical manifestation of SLE; this does not require immediate attention by the nurse.

A registered nurse has encountered an ethical dilemma regarding euthanasia in the medical unit earlier in the day. The nurse verbalizes to the manager that she is concerned about what she witnessed. The manager should suggest which resource for the RN to utilize? A. Rights for the Mentally Ill [2%] B. Client's Bill of Rights [18%] C. Code of Ethics [61%] D. Nurse Practice Act (NPA) [19%]

Explanation Choice C is correct. The Code of Ethics for nurses provides ethical guidelines regarding nursing practice. Choice A is incorrect. The Rights for the Mentally Ill provides people with mental illness the civil liberties that are due to them. Choice B is incorrect. The client's Bill of Rights outlines the rights that are due to them when admitted and seeking health care. Choice D is incorrect. The Nurse Practice Act describes the scope of nursing practice. It directs the philosophy and standards of nursing.

Which of the following regions is known as McBurney's point? See the exhibit. A. Region "a" [9%] B. Region "b" [10%] C. Region "c" [73%] D. Region "d" [8%]

Explanation Choice C is correct. The RLQ (Right Lower Quadrant) of the abdomen is where McBurney's point is located. Pain in this region can indicate appendicitis. Choice A is incorrect. The RUQ (Right upper quadrant) of the abdomen does not indicate McBurney's point. Choice B is incorrect. The LUQ (Left Upper Quadrant)of the abdomen does not indicate McBurney's point. Choice D is incorrect. The LLQ (Left Lower Quadrant) of the abdomen does not indicate McBurney's point. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Pediatrics - Gastrointestinal

The nurse is caring for a client post-angiography using a contrast medium via the femoral approach. Which intervention should the nurse include in the patient's plan of care? A. Keep the hips bent for 6-8 hours after the procedure. [13%] B. Discontinuation of IV fluids immediately after the procedure. [3%] C. Assessment of kidney function tests the next day. [67%] D. Keep the client on NPO 4 hours after the procedure. [18%]

Explanation Choice C is correct. The contrast media is a substance that is excreted in the kidneys. Aside from hydration, the nurse should check the client's kidney function tests to determine whether there has been any damage to his kidneys during the trial. Choice A is incorrect. The nurse should keep the punctured extremity in straight alignment, not bent. Choice B is incorrect. IV fluids should be continuously infused for 6 - 8 hours to hydrate the client to aid in the excretion of the contrast media. Choice D is incorrect. The client can immediately resume his regular diet after the test.

An independent nursing intervention related to the oral administration of opioid narcotic analgesics includes: A. Collecting comparative pain assessment data just before the administration of the opioid narcotic analgesic. [8%] B. Collecting comparative pain assessment data a half-hour after the administration of the opioid narcotic analgesic. [5%] C. Collecting comparative pain assessment data just before and 1 hour after the administration of the opioid narcotic analgesic. [45%] D. Collecting comparative pain assessment data just before and a half-hour after the administration of the opioid narcotic analgesic. [43%]

Explanation Choice C is correct. The independent nursing intervention related to administering oral opioid narcotic analgesics includes collecting comparative pain assessment data just before and 1 hour after administering the oral opioid. In the case of intravenous opioids, a pain assessment must be performed 30 minutes after the opioid administration. This helps determine the effectiveness of these opioid narcotic analgesics in pain reduction. Choice A, B, and D are incorrect. Although the nurse is expected to collect pain assessment data before and after administering the opioid narcotic analgesic, there are specific guidelines concerning the timing of pain assessments, and these must be followed. Pain assessment must be made 30 minutes after the opioid if given by intravenous route whereas 1 hour after administration if given by oral route ( Choice B) Learning Objective Recognize that the time at which the nurse should assess pain after opioids differs based on the route of administration: assess at 30 minutes after intravenous route whereas at 1 hour after oral route.

The nurse is preparing to administer a regular insulin IV bolus to a client. The primary health care provider (PHCP) has prescribed an initial bolus dose of 0.1 unit/kg. The client weighs 242 lbs. How much regular insulin should the nurse administer to the client as an IV bolus? A. 9 units [4%] B. 10 units [7%] C. 11 units [86%] D. 12 units [3%]

Explanation Choice C is correct. To solve this problem, the client's weight needs to be converted to kilograms. 242 lbs / 2.2 = 110 kg. Next, multiply the ordered dose of 0.1 units by the weight of 110 kg. This should equate to 11 units. Choices A, B, and D are incorrect. The other answer choices are incorrect when dose x weight (kg) is calculated. Additional Info Regular insulin drips are ordered for clients experiencing diabetic ketoacidosis. Insulin is a high-risk medication, and the nurse must double-check the dose with another nurse prior to initiation. To solve this problem, the patient's weight needs to be converted to kilograms. 242 lbs / 2.2 = 110 kg. Next, multiply the ordered dose of 0.1 units by the weight of 110 kg. This should equate to 11 units.

When a hospice patient tells the nurse, "I feel no real connection with God," what is the nurse's most appropriate response? A. Give the patient a hug and tell her that her life still has meaning [1%] B. Arrange for a spiritual adviser to visit the patient [8%] C. Ask the patient if she would like to talk about her feelings [91%] D. Call in a close friend or relative to talk with the patient [0%]

Explanation Choice C is correct. When caring for a patient who is in spiritual distress; the nurse should listen to the patient first. Goals and expected outcomes for patients in spiritual distress need to be individualized and may include a patient achieving some of the following: Exploring the origin of spiritual beliefs and practices Identifying factors in life that challenge spiritual beliefs Exploring alternatives given these challenges: denying, modifying, or reaffirming beliefs, developing new beliefs Identifying spiritual supports Reporting or demonstrating a decrease in spiritual distress after successful intervention Choice A is incorrect. A hug and false reassurances do not address the diagnosis of spiritual distress. Choice B is incorrect. After listening to the patient, the nurse can ask if the patient would like a consultation with a spiritual adviser. However, the nurse should not arrange for a spiritual adviser to visit without the patient's consent. Choice D is incorrect. Talking to friends or relatives may be helpful, but should only be done if the patient expresses wishes to do so. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Spirituality

The occupational health nurse administers a Mantoux intradermal skin test. Which teaching is correct regarding the results of this test? A. A positive result indicates the patient has tuberculosis. [22%] B. Redness around the injection site within 24 hours will be recorded as a positive result. [11%] C. The patient will return in one week for visualization of the injection site. [5%] D. A 3 mm induration after 48 hours indicates a negative result. [62%]

Explanation Choice D is correct. 3mm induration after 48 hours would be recorded as a negative result. Induration, less than 5mm after 48-72 hours, is considered an adverse reaction. Choice A is incorrect. A positive Mantoux intradermal skin test result does not necessarily mean the patient has tuberculosis. A positive result indicates the patient has been exposed to TB and only confirms the presence of antibodies. A patient who tests positive for this test would need additional testing to confirm or rule out tuberculosis. Standard tests to establish a positive Mantoux test include a chest x-ray and sputum culture. Choice B is incorrect. Localized redness occurring the day of the injection is healthy and would not indicate a positive reaction. Choice C is incorrect. The patient should return in 48-72 hours to have the site assessed for induration, not one week later. If the patient is unable to return at the appropriate time, the test needs to be repeated. NCSBN Client Need Topic: Infectious disease, Subtopic: Health screening, expected actions/outcomes

Some intravenous therapies often consist of electrolyte replacement solutions. Select the electrolyte that is accurately paired with one of its functions. A. Phosphate: Operation of the sodium-potassium pump [15%] B. Potassium: Regulation of extracellular fluid (ECF) [42%] C. Chloride: Regulation of intracellular fluid (ICF) [21%] D. Calcium: Blood clotting [23%]

Explanation Choice D is correct. Among other functions, calcium plays a role in blood clotting. Other features of calcium include the formation of teeth and bones, nerve impulse transmission, and controlling muscular contractions. Choice A is incorrect. Phosphate does not control the operation of the sodium-potassium pump. Instead, phosphate plays a role in the production of DNA and ATP (adenosine triphosphate), and it also manages the acid-base balance of the body. Choice B is incorrect. Potassium regulates the intracellular fluid, not the extracellular fluid. Choice C is incorrect. Chloride regulates the extracellular fluid, not the intracellular fluid.

A pregnant woman with preexisting hypertension is being seen in the clinic. Her blood pressure continues to rise despite attempting first-line therapy with anti-hypertensives. Which of the following medications will be used for the prenatal patient resistant to other blood pressure-lowering medications? A. A calcium channel blocker [26%] B. Methyldopa [17%] C. Labetalol [21%] D. Hydralazine [36%]

Explanation Choice D is correct. Hydralazine is the second-line therapy for high blood pressure in prenatal patients who are not seeing any results from other medications. Choice A, B, and C are incorrect. Calcium channel blockers, methyldopa, and labetalol are all common first-line anti-hypertensives for treating prenatal clients with high blood pressure. NCSBN client need Topic: Pharmacologic and Parenteral Therapies: Parenteral/Intravenous Therapies

A 37-week pregnant client is brought to the emergency department by her husband. She is complaining of bright red blood running down her legs and states that she is in severe pain. Which assessment method should the nurse refrain from performing? A. Fetal Heart Rate monitoring [9%] B. Abdominal palpation [9%] C. Measurement of vital signs [1%] D. Internal Vaginal Examination [81%]

Explanation Choice D is correct. In the presence of vaginal bleeding, an internal vaginal examination is contraindicated unless inside an environment prepared to do an emergency delivery or cesarean section. Also, the nurse is not allowed and properly trained to perform an internal vaginal examination. Choice A is incorrect. Fetal heart rate monitoring should be done to determine fetal health once any alarming signs and symptoms regarding pregnancy arise. Choice B is incorrect. Abdominal palpation can give the nurse information regarding uterine contractions and abdominal tenderness to determine the cause of bleeding. Choice C is incorrect. The nurse needs to take the blood pressure and pulse of the mother to determine the mother's health status.

Minimizing and challenging the client's report of pain and pain intensity is: A. Often necessary if the client has a history of substance abuse. [13%] B. Often necessary if the client has a history of drug seeking behavior. [13%] C. Contrary to and in violation of the Nightingale oath. [5%] D. Contrary to and in violation of the American Nurses Association's standard of care. [68%]

Explanation Choice D is correct. Minimizing and challenging the client's report of pain/pain intensity is in violation of the American Nurses Association's standards of care about pain/pain management. Specifically, the American Nurses Association's Standards of Professional Performance for Pain Management Nursing. For example, nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be true and accurate. Choice A is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not often necessary if the client has a history of substance abuse; this expression and reporting of pain must be considered valid and accurate. Nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be accurate. Choice B is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not often necessary if the client has a history of drug-seeking behavior; this expression and reporting of pain must be considered valid and accurate. Nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be accurate. Choice C is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not in violation of the Nightingale oath. There is no mention of pain management in the Nightingale oath.

A client has acute bone pain related to metastases of cancer. The best way for a hospice nurse to assess the client's level of pain is: A. Check vital signs after giving pain medication. [2%] B. Note observations about the client's behavior. [4%] C. Evaluate verbal and non-verbal actions. [17%] D. Ask the client to rate their pain on a scale from 1-10. [76%]

Explanation Choice D is correct. Only the client can report on their level of pain; it is a subjective perception that should not be judged or dismissed. Asking them to rate their pain on a scale of 1-10 should be the guide for managing care and pain relief. Three aspects of the definitions of pain have essential implications for nurses. First, pain is a physical and emotional experience, not all in the body or all in the mind. Second, it is in response to actual or potential tissue damage, so laboratory or radiographic reports may not be abnormal despite the real pain. Finally, anxiety is described in terms of such loss (e.g. neuropathic pain). Given that some clients are reluctant to disclose the presence of pain unless asked, nurses will be unaware of a client's pain until they assess for it. Additionally, it is clear that even clients who are nonverbal (e.g. preverbal children, intubated clients, people with cognitive impairments, or those who are unconscious) experience pain that demands nursing assessment and treatment even though the clients are unable to describe their discomfort. Pain interferes with functional abilities and quality of life. Severe or persistent pain affects all body systems, causing potentially dangerous health problems while increasing the risk of complications, delays in healing, and an accelerated progression of fatal illnesses. Choice A is incorrect. Although vital signs should be measured and may indicate an increased or decreased level of pain, it is not the most accurate way to assess the client's level of pain. Choices B and C are incorrect. Observation and verbal and nonverbal cues from the client can be noted but are also not the best way to gauge a person's level of pain. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Pain Assessment

After receiving client reports on the medical-surgical floor. Which of the following clients should the nurse see first? A. A client with a respiratory rate of 24 and an oxygen saturation of 92%. [21%] B. A client who is scheduled for gastric surgery related to peptic ulcer disease in two hours. [1%] C. A client who is six hours post-op from a hysterectomy and is complaining of nausea. [6%] D. A client who had a cast applied two hours ago and now has complaints of her arm feeling like it is "sleeping". [71%]

Explanation Choice D is correct. The patient with a cast who describes her arm as feeling like it's asleep is likely experiencing impaired circulation. This patient should be assessed first and the physician should be notified. Prioritizing patient care related to the status of each patient in the nurse's care is a critical skill. While all patients are important and must be monitored, the ability to recognize a potential complication before it gets out of hand and causes more damage is crucial. Choice A is incorrect. Although the increased respiratory rate and lower O2 saturation may cause concern, there is nothing in this scenario that suggests the patient is in distress. Choice B is incorrect. This patient has no complaints and can be evaluated after the patient that is experiencing compromised circulation. Choice C is incorrect. Complaining of nausea after a hysterectomy is a potential problem that is often expected. It is not, however, of immediate concern. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

Which statement below relating to pain and pain perception is accurate? A. Allodynia is the pathophysiological absence of pain when a painful stimulus is applied. [5%] B. Scientific evidence does not support the presence of pain during neonatal circumcision. [2%] C. Hyperanalgesia is the opposite of hyperpathia, both of which are abnormal pain responses. [4%] D. The perception of pain and its impact on our clients greatly varies among people. [89%]

Explanation Choice D is correct. The perception of pain and its impact on our clients greatly varies among people. For example, gender, cultural beliefs, and individuals' unique pain thresholds all impact our clients' perceptions of pain. Choice A is incorrect. Allodynia is the pathophysiological perception of pain when no painful stimulus is applied. Allodynia, like other abnormal pain processing and pain perception processes, indicates the presence of a neuropathic process. Choice B is incorrect. Scientific evidence supports the presence of pain during neonatal circumcision, something that was not recognized in the past. Choice C is incorrect. Hyperalgesia is a synonym for hyperpathia. Hyperalgesia is an abnormal pain response that is characterized by an intense and severe perception of pain when the stimulus is not at all severe.

You are a nurse working in a medical unit with a trained aide. You have admitted a new patient and have received the following orders: Amoxicillin 250 mg by mouth every 6 hours Insulin 2 units Humulin subcutaneous now CBC, electrolytes, urinalysis, and two sets of blood cultures Vital signs every 4 hours The task you can safely delegate to the aide working with you is: A. Amoxicillin 250 mg by mouth every 6 hours [2%] B. Insulin 2 units Humulin subcutaneous now [1%] C. Collect lab work [6%] D. Vital signs every 4 hours [92%]

Explanation Choice D is correct. The performance of vital signs is a task that you can safely and legally delegate to an unlicensed, trained team member. The question stipulates that she is trained, so it is safe to assume that she can do vital signs accurately. Collecting blood and giving medications are usually tasks that cannot be delegated to an unlicensed person. The nurse needs to understand the limits of unauthorized personnel as defined by facility policy, state regulations, and the scope of practice of the team member. When in doubt about the appropriate delegation of a task, the nurse should never delegate the responsibility. Any time the nurse delegates a job, it is critical that the nurse follow up to ensure that the task was completed accurately. The nurse should also be aware of the five rights of delegation: right job, right circumstance, right person, proper direction/communication, and correct supervision. NCSBN Client Need Topic: Management of Care, Sub-Topic: Delegation

The nurse is evaluating a patient's response to peripheral pain. Which technique should the nurse use to perform this evaluation? A. Pressure on the patient's mid-back [8%] B. Sternal rub [11%] C. Squeezing the sternocleidomastoid muscle [9%] D. Pressing on the patient's nail bed [72%]

Explanation Choice D is correct. To test peripheral responses to pain, health care providers should apply pressure to outer body parts such as the toes or fingers. Pressing on the patient's nail bed is the most appropriate action. Choice A is incorrect. Applying pressuring on the patient's mid-back does not evaluate peripheral pain. Choice B is incorrect. Sternal rubs are most often used to test consciousness. Choice C is incorrect. Squeezing, the patient's sternocleidomastoid muscle does not evaluate peripheral pain. NCSBN client need Topic: Pharmacological Integrity, Reduction of Risk Potential

The nurse is caring for a client receiving total parenteral nutrition (TPN) started twelve hours ago. The priority assessment should be the client's A. urine output. [26%] B. oral temperature. [12%] C. weight. [3%] D. capillary blood glucose. [59%]

Explanation Choice D is correct. When TPN is initially started, an increase in blood glucose may be observed. The client's blood glucose should be monitored every 4-6 hours, and insulin coverage may be prescribed. Further, regular insulin may be added to the bag of TPN (by the pharmacy) if the client's blood glucose continues to be elevated. Choices A, B, and C are incorrect. Urine output is not critical to monitor during the course of TPN. For the nurse to determine if the TPN is being effective, the client should have their daily weight obtained. Urine output is a crude way of measuring fluid status pertaining to TPN. TPN solution is an excellent medium for bacterial growth. The client is at high risk for a central line associate bloodstream infection (CLABSI), but this would not manifest within the first twelve hours of the infusion. Weight should be monitored for a client receiving TPN; however, a weight shift is not expected within the first twelve hours, and the most likely complication would be hyperglycemia. Additional Info TPN is a risk factor for infection as the high glucose content makes the client more likely to develop a bacterial or fungal infection. During an infusion of TPN, the nurse should monitor the client's vital signs and blood glucose. Hyperglycemia may delay healing and should be managed with a prescribed insulin protocol.

The nurse is caring for a client with a sodium level of 130 mEq/L. Which of the following medications may cause this abnormality? Select all that apply. A. Spironolactone [30%] B. Hydrochlorothiazide [33%] C. Prednisone [15%] D. Sodium polystyrene [12%] E. Tolvaptan [9%]

Explanation Choices A and B are correct. Spironolactone is a diuretic that retains potassium but causes the loss of water and sodium. Hydrochlorothiazide is a thiazide diuretic that may contribute to hyponatremia because while it does raise serum calcium levels, it depletes every other electrolyte. Choices C, D, and E are incorrect. Prednisone is a corticosteroid used for inflammatory conditions. This drug causes an increase in aldosterone, which increases sodium and water retention. Sodium polystyrene is used for individuals with hyperkalemia, and its use will not only lower potassium but may also raise sodium. Tolvaptan is a medication used to treat syndrome of inappropriate antidiuretic hormone (SIADH). It depletes the water but not the sodium. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse effects/Contraindications/Side Effects/Interactions Question Type: Analysis Additional Info Hyponatremia is sodium less than 135 mEq/L. The cause of hyponatremia is multifactorial and may include diuretics, lithium, alcoholism, and certain forms of dehydration. For severe hyponatremia, the nurse should institute seizure precautions.

Which of the following falls under the right dose of the 8 rights of medication administration? Select all that apply. A. Using a drug reference to verify that the dose ordered is appropriate. [29%] B. Identify the patient using 2 separate identifiers. [25%] C. Have a second nurse independently calculate the medication dosage. [22%] D. Double-check the last time that the medication was administered. [24%]

Explanation Choices A and C are correct. A is correct. Using a drug reference to verify the dose ordered is appropriate is a part of the right dose check in the 8 rights of medication administration. The nurse should always verify that the dose is appropriate by checking a current drug reference for the medication and verifying that what is ordered is in the safe range. C is correct. Having a second nurse independently calculate the medication dosage is an important part of verifying the right dose. This check ensures that two nurses both calculate the dosages and come up with the same answer, decreasing the chance of an error in calculation. Choice B is incorrect. Identifying the patient using 2 separate identifiers falls under the right patient in the 8 rights of medication administration, not the right dose. The nurse should always verify the correct patient by using 2 separate identifiers, such as name and medical record number, but this is a part of verifying the right patient, not the right dose. Choice D is incorrect. Double-checking the last time that the medication was administered is a part of the right time step in the 8 rights of medication administration. This is important because the nurse needs to verify that she is giving the dose at the correct time and that it is not being administered too frequently based upon the previous administration. This is not a part of the right dose step, however. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Fundamentals - Medication Administration

The nurse is assessing a patient with Dependent Personality Disorder. Which of the following would be an expected finding? Select all that apply. A. Difficulty with decision-making [33%] B. Flamboyant behaviors [5%] C. Intense and unstable relationships [21%] D. Avoiding social relationships [9%] E. Feels helpless when alone [32%]

Explanation Choices A and E are correct. Individuals with Dependent Personality Disorder manifest difficulty with decision making and initiating projects. Choices B, C, and D are incorrect. Flamboyant behaviors and provocative dressing is a hallmark characteristic of histrionic personality disorder. Intense and unstable relationships are a cardinal manifestation of Borderline Personality Disorder. Finally, the avoidance of social relationships and situations is a finding with Avoidant Personality Disorder. Additional information: Dependent Personality Disorder is a personality disorder characterized by difficulty with making decisions, problems with expressing disagreement, and often feels helpless when alone. The nurse should encourage decision-making but never make decisions for the patient.

Select the normal physiological changes associated with the aging process that can adversely affect the excretion and elimination of medications in the human body. Select all that apply. A. Diminished glomerular filtration [25%] B. Decreased enzyme functioning [16%] C. Decreased peristalsis [21%] D. Lower pH of the gastric secretions [9%] E. Increased acidity of the gastric secretions [6%] F. Low functioning nephrons [23%]

Explanation Choices A and F are correct. As people age, several physiological changes occur. Many of these changes impact the pharmacokinetics and pharmacodynamics of medications. The regular physiological changes associated with the aging process that can adversely affect the excretion and elimination of drugs in the human body are the aging population's low functioning nephrons and diminished glomerular filtration. These changes can lead to the accumulation of medications in the body because they are not properly eliminated. Choice B is incorrect. Decreased hepatic enzyme functioning slows down the metabolism of medications, but not the excretion and elimination of medications in the human body. Choice C is incorrect. Decreased peristalsis slows down the absorption of medications, but not the excretion and elimination of drugs in the human body. Choice D is incorrect. Increased pH of the gastric secretions, rather than lower pH, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body. Choice E is incorrect. Increased alkalinity, not acidity, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body.

According to the National Council of State Boards of Nursing, the five rights of delegation include: Select all that apply. A. Right task [29%] B. Right circumstance [21%] C. Right person [28%] D. Right direction and communication [22%]

Explanation Choices A, B, C, and D are all correct. All of these are among the five rights of delegation, according to the NCSBN. The fifth right is the right supervision and evaluation. The proper task means that the responsibility falls within the scope of practice and job description of the person delegated the responsibility. The right circumstance implies that the patient/client is stable enough to have someone other than an RN be responsible for the job. The right person implies that the person doing the job has the skill and knowledge to complete it safely. The right direction and communication mean that the RN must be very specific in what the job involves and how it should be done. This right also means that the LPN/LVN must also communicate back to the RN about the completion of the task or any problems with the completion. Finally, every job must be monitored by the RN to evaluate the outcomes of the procedure. Documentation should be completed per facility policy, but the RN should always ensure that the documentation is correct and complete. NCSBN Client Need Topic: Management of Care, Sub-topic: Assignment and Delegation

The nurse is assisting a client who has left-sided weakness and uses a cane. Which of the following actions should the nurse perform when assisting this client to ambulate? Select all that apply. A. Place a gait belt around the client's waist. [22%] B. Stand on the client's left side during ambulation. [26%] C. Instruct the client to put the cane in the left hand. [4%] D. Measure the cane from the client's wrist crease. [16%] E. Instruct the client to put the cane in the right hand. [26%] F. Instruct the client to look down while ambulating. [5%]

Explanation Choices A, B, D, and E are correct. When instructing a client to ambulate with a cane, the nurse should apply a gait belt to the client's waist. The nurse should stand on the client's left (weaker) side if the client has difficulty. The client should have the cane in their right hand (stronger side), and the height of the cane should be measured from the client's wrist crease. Choices C and F are incorrect. The client should have the cane on the unaffected/stronger side. In this question, it would be the right side. Finally, the client should be instructed to look ahead as they ambulate - not down at the ground. Additional Info When a client ambulates with a cane, the nurse should ensure that a gait belt is applied before getting out of bed. The nurse is positioned on the client's affected (weaker) side, slightly behind the client. Measure the height of the cane from the wrist crease or greater trochanter The cane should be held on the unaffected (stronger) side The elbow should be flexed 15-30 degrees The cane should be advanced first, 6-10 inches Advance the affected (weaker) leg to the cane Finally, advance the stronger leg just past the cane A rubber tip should always be applied to a cane to ensure appropriate traction with the ground.

There are several hormonal changes in patients immediately after a burn. Which of the following hormones are secreted in burn patients? Select all that apply. A. Epinephrine [23%] B. Antidiuretic Hormone [37%] C. Aldosterone [30%] D. Thyroid Stimulating Hormone [10%]

Explanation Choices A, B, and C are correct. A is correct. Epinephrine is secreted in a burn patient. This causes vasoconstriction, raises blood pressure, and perfuses the vital organs of the body. B is correct. Antidiuretic hormone (ADH) is secreted in a burn patient. This is to help the patient retain water and increase the blood volume. By increasing the blood volume, BP will rise. This helps perfusion. C is correct. Aldosterone is secreted in a burn patient. This is to help the patient retain sodium and water leading to an increase in blood volume. By increasing the blood volume, BP will rise. This helps perfusion. Choice D is incorrect. Thyroid-stimulating hormone (TSH) is not secreted in a burn patient. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Burns

The nurse is caring for a client with the following clinical data. Based on the vital signs, which medications would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the exhibit. Select all that apply. A. Atenolol 50 mg PO Daily [35%] B. Spironolactone 50 mg PO Daily [23%] C. Albuterol 2.5 mg via nebulizer Daily [9%] D. Fentanyl 50 mcg IV Push q 6 hours PRN Pain [19%] E. Modafinil 100 mg PO Daily [13%]

Explanation Choices A, B, and D are correct. The vital signs show hypotension (90/60 mm Hg). The nurse should clarify the prescriptions of atenolol, spironolactone, and fentanyl. All these medications decrease blood pressure and considering how low the client's blood pressure is, it would be highly detrimental. Choices C and E are incorrect. Albuterol is a beta-adrenergic agonist; thus, this medication would cause an increase in blood pressure and heart rate. Modafinil is a stimulant medication used in the management of narcolepsy. Thus, this medication has the tendency to raise blood pressure not lower. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Question Type: Analysis Additional Info Atenolol is a beta-blocker and would lower blood pressure and heart rate. The nurse should assess both prior to administration. Spironolactone is a potassium-sparing diuretic. This medication decreases fluid volume, therefore, reducing blood pressure. Fentanyl is an opioid and causes vasodilation, therefore, lowering blood pressure.

The nurse writes the following care plan for a patient with epilepsy. Based on the care plan, which interventions would be appropriate for the nurse to include? Select all that apply. A. Remove hard or sharp objects from the patient's environment [27%] B. Place a bite block during seizure activity [2%] C. Monitor compliance in taking antiseizure medications [22%] D. Apply padded side rails to the bed [27%] E. Position the patient in a side-lying position [22%]

Explanation Choices A, C, D, and E are correct. A: Hard or sharp objects should be removed from this patient's environment to reduce the risk of injury during seizure activity. C: Monitoring compliance with antiseizure medications is an important intervention to determine this patient's risk for seizure activity. D: Padding the siderails of the bed would be an appropriate intervention to reduce this patient's risk of injury in the event of a seizure. E: Placing the patient in a side-lying position reduces the risk of aspiration when the client is in a post-ictal state, thus preventing injury. Choices B is incorrect. B: Nothing, including a bite block, should be placed in the patient's mouth during seizure activity.

Select the urinary elimination problems that are accurately paired with its possible etiology. Select all that apply. A. Anuria: End stage renal failure [26%] B. Anuria: The effects of general anesthesia [7%] C. Oliguria: Dehydration [27%] D. Polyuria: Chronic nephritis [9%] E. Dysuria: Stress [7%] F. Dysuria: Urinary tract infection during pregnancy [25%]

Explanation Choices A, C, D, and F are correct: Choice A is correct. Anuria can occur as the result of end-stage renal failure as well as a severe shock when the perfusion of the kidneys is impaired. Choice C is correct. Oliguria can result from dehydration as well as other causes such as hypotension and a decrease in terms of the client's fluid intake. Choice D is correct. Polyuria can occur secondary to chronic nephritis and excessive fluid intake among other causes such as diabetes mellitus and diabetes insipidus. Choice F is correct. Dysuria can occur as a result of any urinary tract infection and other causes such as trauma. Choices B and E are incorrect: Choice B is incorrect. Urinary retention, rather than anuria, can occur as a result of the effects of general anesthesia. Choice E is incorrect. Dysuria does not occur as a result of stress. Dysuria, however, can occur as the result of a urinary tract infection and other causes such as trauma.

The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions? Select all that apply. A. Respiratory syncytial virus [11%] B. Psoriasis [13%] C. Pediculosis [21%] D. Rubella [7%] E. Scabies [27%] F. Clostridium difficle [21%]

Explanation Choices A, C, E, and F are correct. Conditions requiring contact precautions include RSV, pediculosis, Clostridium difficle, and scabies. Pediculosis refers to infestation with head lice. Clostridium difficle is a spore-forming bacteria that causes diarrhea. RSV may be transmitted by the droplet route but is primarily spread by direct contact with infectious respiratory secretions. Droplet precautions are not routinely warranted but are appropriate if the infecting agent is not known. Choices B and D are incorrect. Rubella (German measles) is isolated using droplet precautions. Psoriasis is an autoimmune condition that does not require isolation. Learning Objective Recognize the conditions where contact isolation precautions are used. Understand that hand hygiene can be performed using alcohol-based hand rubs or soap and water; however, in the case of spore-forming bacteria such as Clostridium difficle, hand hygiene must always be performed using soap and water. Additional Info Contact isolation precautions are a type of infection control precautions used to prevent the spread of pathogenic organisms spread through contact. These organisms may spread through contact with infected secretions, fecal matter, large droplets, and bedding. Contact precautions include: Hand hygiene: Hand hygiene must be performed upon entering and exiting the client's room. Alcohol-based disinfectants or cleaning with soap and water are permissible hand hygiene measures. However, only soap and water must be used in the case of Clostridium difficle and Norovirus. Gloves: Put on gloves before entering the room and discard gloves before exiting the room. Gown: Put on a gown before entering the room and discard the gown before exiting the room. The client should be placed in a private room. Conditions requiring contact isolation precautions: Herpes simplex virus ( HSV) Varicella-Zoster Virus ( VZV) - requires both contact and airborne precautions until all the lesions crust over. Respiratory Syncytial Virus (RSV) - although transmitted by large droplets, the spread is through contact with droplets. Hence, droplet isolation is not necessary for RSV. Enterovirus Scabies Impetigo Abscesses Pediculosis Enteric infections ( Norovirus, Clostridium difficle) Multidrug-resistant bacteria [Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci ( VRE), multidrug-resistant gram-negative bacteria]

The charge nurse is observing infection control practices in the nursing unit. Which observation by the charge nurse requires follow-up? Select all that apply. A. Soiled linens are placed on the floor during a bed bath and linen change. [31%] B. A disposable blood pressure cuff is used for a client on contact precautions. [3%] C. Disposable dishes are placed in the room for a client on droplet precautions. [10%] D. Reusable eye protection is cleaned and disinfected after each client encounter. [5%] E. A surgical hand scrub is performed with the hands lower than the elbows. [23%] F. Gloves are doffed last while removing personal protective equipment (PPE). [27%]

Explanation Choices A, C, E, and F are correct. If the charge nurse observes these actions, they require follow-up because they are incorrect. Soiled linens should not be placed on the floor because they contaminate other surfaces in the facility. Once soiled linens are removed, they should go in the appropriate fluid-resistant containers. The hot water and detergents used in dishwashers are sufficient to decontaminate dishware and eating utensils. Reusable dishware and utensils may be used for clients requiring transmission-based Precautions. If a surgical hand scrub is being performed, the appropriate technique is to avoid contamination by holding hands above the elbows as fluid flows in the direction of gravity. Gloves are removed first during the doffing of PPE. The sequence for doffing (removing PPE) is gloves, face shield or goggles, gown, and mask or respirator. Choices B and D are incorrect. These observations do not require follow-up because they adhere to appropriate practices. Disposable equipment should be utilized for a client on contact precautions. This equipment includes thermometers and blood pressure cuffs. Eye protection that is reusable may be disinfected and cleaned after each client encounter. The eye protection should be allowed to dry before its next use. NCLEX Category: Safety and Infection Control Related Content: Standard Precautions/ Transmission-Based Precautions/Surgical Asepsis Question type: Analysis Additional Info The nurse can prevent disease transmission by exercising meticulous hand hygiene, educating others, and correcting inappropriate actions. The appropriate sequence of donning of PPE is gown, mask or respirator, goggles or face shield, and gloves. The appropriate sequence for doffing PPE is gloves, face shield or goggles, gown, and mask or respirator.

You are on the team in the delivery room caring for a newly born infant. After completing the initial assessment of the infant, you know that positive-pressure ventilation is indicated if which of the following is evident? Select all that apply. A. The infant is apneic. [33%] B. The bottom of the infant's feet are blue. [11%] C. The infant's heart rate is < 100 beats per minute. [23%] D. The infant is gasping. [33%]

Explanation Choices A, C, and D are correct. Apnea, gasping, or heart rate less than 100 bpm are clear indications that the team should begin positive pressure ventilation (PPV) within one minute after birth. The unit can also consider a trial of PPV if it cannot maintain oxygen saturation despite the use of oxygen or continuous positive airway pressure (CPAP). Choice B is incorrect. It is not unusual for some degree of cyanosis to be apparent following birth, so the fact that the bottoms of the infant's feet are blue would NOT indicate the need for PPV. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Changes/Abnormalities in Vital Signs; Newborn

The nurse is teaching a client about the newly prescribed medication, esomeprazole. Which statement, if made by the client, would require further teaching? Select all that apply. A. "I should take this medication with meals and with water." [24%] B. "I should not take this with any other medication or food." [13%] C. "The medication will coat my ulcer so I can eat without pain." [18%] D. "I will need frequent laboratory tests while taking this medication." [23%] E. "I may need to take magnesium supplements while on this medication." [20%]

Explanation Choices A, C, and D are correct. These statements are incorrect and require follow-up. Esomeprazole is a proton pump inhibitor (PPI) in treating esophageal erosion, GERD, and peptic ulcer disease. The medication should be taken one hour before meals and with an ample amount of water. The medication does not fortify an existing ulcer, like sucralfate. The client does not require frequent laboratory testing while on this medication. Choices B and E are incorrect. Correct teaching for a client receiving esomeprazole would include taking the medication independent of any other food or medicine as it will decrease its absorption. PPIs have the proclivity of causing hypomagnesemia, and thus, magnesium supplementation may be recommended by the PHCP. Additional Info PPIs are the gold standard in the treatment of GERD. The client should be instructed to take the medication first thing in the morning without any food or other medications. The long-term use of a PPI has been linked to osteoporosis and hypomagnesemia. Therefore, it is reasonable to recommend weight-bearing exercises as well as magnesium and calcium supplements approved by the primary healthcare provider (PHCP).

A nurse is caring for a client who is receiving a blood transfusion. Which actions should the nurse take if a mild allergic transfusion reaction is suspected? (Select all that apply.) A. Discontinue the infusion [8%] B. Monitor the client for hypertension [21%] C. Ensure 0.9% sodium chloride is infusing through the existing tubing [40%] D. Initiate an infusion of 0.9% sodium chloride through new IV tubing [31%] E. Administer diphenhydramine [0%] F. Administer acetaminophen [0%] G. Initiate an infusion of Lactated Ringer's through new IV tubing at a rate of 125 mL/hour [0%] H. null [0%]

Explanation Choices A, D, and E are correct. When any transfusion reaction occurs, the initial intervention is always to discontinue the transfusion. Next, you would initiate an infusion of 0.9% sodium chloride (NS) through new IV tubing. Additionally, for a mild allergic transfusion reaction, you would administer diphenhydramine per facility transfusion protocol orders. Choice B is incorrect. Typically, blood pressure is only affected when a client experiences an anaphylactic transfusion reaction. In those instances, the blood pressure is typically hypotensive. Choice C is incorrect. The existing tubing would not be used to infuse 0.9% sodium chloride. Despite immediately stopping the infusion upon signs of an allergic transfusion reaction, the existing tubing would still contain the blood which caused the reaction. By failing to change the IV tubing before initiating the 0.9% sodium chloride, the nurse is allowing additional allergic transfusion reaction blood to be administered to the client. Choice F is incorrect. Acetaminophen (or another antipyretic) is typically administered in the event of a febrile transfusion reaction, not a mild allergic transfusion reaction. The onset of a febrile transfusion reaction is typically less than two hours after the initiation of the transfusion. Choice G is incorrect. 0.9% sodium chloride (NS) is the only solution that should be utilized when transfusing a blood product. Lactated Ringer's should not be involved during the blood transfusion process or in the event of a transfusion reaction. Learning Objective Identify the actions the nurse should take following the identification of mild allergic transfusion reaction symptoms in a client. Additional Info An allergic transfusion reaction onset occurs during or up to 24 hours after the transfusion. Findings are usually mild and consist of itching, urticaria, and flushing. In the event of an anaphylactic reaction transfusion, symptoms may include bronchospasm, laryngeal edema, hypotension, and shock.

Which of the following are considered early signs of heart failure in a pediatric patient? Select all that apply. A. Bradycardia [18%] B. Tachypnea [34%] C. Diaphoresis [35%] D. Weight loss [13%]

Explanation Choices B and C are correct. Tachypnea is an early sign of heart failure. The child's body is working hard to compensate for the decrease in cardiac output, so they breathe more quickly to try and make up for the decreased oxygen delivery (Choice B). Diaphoresis is a ubiquitous sign of heart failure, especially in the infant. The child's body is fatigued as it works hard, trying to compensate for the decreased cardiac output. Therefore they sweat profusely during exertion and sometimes even at rest (Choice C). Choice A is incorrect. Bradycardia is a late and ominous sign of heart failure. Tachycardia is an early sign of heart failure. Due to the decrease in cardiac output, the child's body compensates and increases the heart rate to try to keep up. This is why tachycardia is an early sign of heart failure. Choice D is incorrect. Weight gain rather than weight loss would be an early sign of heart failure. The child's body will be retaining fluids as the perfusion to their kidneys decreases. When kidney function starts to decline, such as in early heart failure, then there will be a sudden weight gain. NCSBN Client Need Topic: Physiological Integrity Subtopic: Physiological Adaptation, Cardiovascular

While triaging in the pediatric emergency department, you see a child with a temperature of 103 degrees F, malaise, anorexia, and rash. The parent reports that the outbreak started on the chest two days ago and spread to the face, arms, and legs this morning. Based on your clinical suspicion, which of the following nursing interventions are appropriate? Select all that apply. A. Initiate contact and droplet precautions. [30%] B. Administer acyclovir as prescribed. [27%] C. Administer amoxicillin as prescribed. [9%] D. Explain to the parents the need to isolate the child until crusts have formed over the vesicles. [34%]

Explanation Choices B and D are correct. The nurse suspects varicella (chickenpox) based on the description. While many conditions present with fever, malaise, and anorexia, the pattern of this rash starting on the trunk and then spreading to the face and extremities is highly suspicious for varicella. Acyclovir is an antiviral agent that may be used to treat varicella. It can decrease the number of lesions, shorten the duration of fever as well as decrease itching, lethargy, and anorexia. Therefore, this would be an appropriate intervention (Choice B). There is a need to continue isolation until the blisters have dried or crusted over. Varicella is communicable starting 1 to 2 days before the onset of the rash until the vesicles have crusted over. Once the lesions crust over, the child is no longer contagious, and it is appropriate to discontinue isolation. Educating parents about this isolation is a necessary intervention (Choice D). Choice A is incorrect. The method of transmission of varicella is airborne. When varicella is suspected in the hospital setting, contact and airborne precautions must be initiated, not droplet. Contact and droplet precautions alone would not adequately prevent the spread of the infection to other vulnerable clients. Choice C is incorrect. Amoxicillin is an antibacterial agent. The nurse suspects varicella, which is viral. Administering antibiotics is not appropriate in this case unless there is a bacterial superinfection. If amoxicillin is prescribed, the nurse needs to question if this is the appropriate medication.

The nurse is caring for a client experiencing pain. What barriers would the nurse recognize that the client may have in terms of reporting pain? Select all that apply. A. A feeling that the nursing staff will not answer their call for complaints of pain. [17%] B. Not wanting to be viewed as a complainer or drug seeker. [24%] C. A cultural bias. [24%] D. An ethnic bias. [19%] E. Fears about incurring more healthcare costs. [16%]

Explanation Choices B, C, D, and E are correct. Barriers that clients may have in terms of them reporting pain to the nursing staff include: Fears revolving around addiction and dependence on pain medications Not wanting to be viewed as a complainer or drug seeker A cultural bias An ethnic bias Fears about incurring more healthcare costs Choice A is incorrect. Although some clients may have a feeling that the nursing staff will not answer their call bell for complaints of pain, this is not a client barrier to them reporting pain to the nursing staff; it is, however, a nursing barrier to effective pain management and control. Additional Info Pain is often not adequately addressed across most healthcare settings. Clients most at risk for inadequate treatment of pain include: Older adults, especially in nursing homes Clients with a history of substance use Clients with a language barrier Unrelieved pain can result in a prolonged stress response, physiological changes (such as increased heart rate, blood pressure, and oxygen demand), reduced GI motility, delayed healing and immune response, and increased risk for chronic pain issues. Clients need nurses to assess and intervene to manage their pain, and nurses should consider factors that may inhibit reporting of pain.

What instructions should be given to the nursing assistant who is helping a patient on IV heparin with activities of daily living? Select all that apply. A. Use a rectal thermometer to obtain a more accurate body temperature. [1%] B. Use a soft-bristled toothbrush or tooth sponge for oral care. [38%] C. Use an electric razor when shaving the patient. [34%] D. Use a lift sheet when moving or positioning the patient in bed. [27%]

Explanation Choices B, C, and D are correct. Use a soft-bristled toothbrush or tooth sponge for oral care. Use an electric razor when shaving the patient. Use a lift sheet when moving or positioning the patient in bed. Choice A is incorrect. A rectal thermometer should not be used, as it could cause a tear in the rectal tissue. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies; Heparin Therapy

You have just arrived for your shift and are assigned a 32-year-old client who arrived at your facility four days ago following a motor vehicle accident. The client sustained a traumatic head injury in the collision and was intubated in the field. Earlier today, the client was extubated. During your focused neurological assessment, you are required to calculate the client's Glasgow Coma Scale and, if required, anticipate any forthcoming interventions. Upon performing your assessment, you find the client opens his eyes once you begin speaking but fails to obey your commands. He does withdraw from pain but does not make any purposeful movements. Additionally, the client does not answer your questions. His responses seem somewhat incoherent, consisting primarily of incomprehensible sounds and mumbling. What is this client's Glasgow Coma Scale (GCS) score, and what would your next steps be? A. This client's GCS score is 6. Respiratory therapy needs to be contacted, and the client needs to be intubated immediately. [27%] B. This client's GCS score is 7. The provider needs to be contacted to obtain an order for intubation. Once the order is in place, respiratory therapy will be contacted, and the client will be intubated. [54%] C. This client's GCS score is 11. The client will continue to be monitored. [11%] D. This client's GCS score is 9. The client's current GCS score will be compared to prior GCS scores, and although the score is not currently <8, intubation equipment would be in or directly outside the room.

Explanation The correct answer is D. Here, the client opens his eyes to voice (3), withdraws to pain (4), and makes incomprehensible sounds (2), therefore totaling a Glasgow Coma Scale (GCS) score of 9. Due to the score of 9, the nurse should first compare the calculated GSC score to the prior scores to ensure this is not a dramatic shift in the client's trajectory. For example, if the client was extubated earlier today with a documented GCS score of 11, then the health care provider should be contacted immediately. Regardless, with the GCS score of 9, the nurse should ensure that intubation equipment is in or directly outside the room and in working condition. Choice A is incorrect. This client's Glasgow Coma Scale score is 9, not 6. With a GCS score of 6, the client should currently be intubated. Moreover, depending on facility policy, often, other individuals are capable of intubating in a timelier manner (i.e., resident health care providers, fellows, rapid response nurses, etc.). Choice B is incorrect. This client's Glasgow Coma Scale score is 9, not 7. With a GCS score of 7, the client should currently be intubated. Moreover, depending on facility policy, there may be a standing order for intubation in emergencies, so you must be aware of the policies and procedures at every facility you staff. Additionally, frequently other individuals are capable of intubating in a timelier manner (i.e., resident health care providers, fellows, rapid response nurses, etc.). Choice C is incorrect. This client's Glasgow Coma Scale score is 9, not 11. Learning Objective Calculate the client's Glasgow Coma Scale (GSC) score and determine what nursing interventions should occur next. Additional Info The Glasgow Coma Scale is a valuable tool for completing a rapid assessment of one's level of consciousness. The Glasgow Coma Scale score ranges from 3 to 15, scoring in three categories: eye opening, motor response, and verbal response. In terms of the Glasgow Coma Scale (GCS), remember the phrase: "Less than eight, intubate."

The nurse has received a prescription to administer a dopamine 200 mg/250 mL D5W at a rate of 5 mcg/kg/min to a client who weighs 180 lbs. At what rate should the nurse set the client's infusion pump? Fill in the blank. Round to the nearest whole number. 31 mL/hr

Explanation To solve this multistep problem, the formula of dose ordered / dose on hand x volume will be used First, convert the weight to kilograms 180 / 2.2 = 81.81 kg Next, determine the hourly dosage 5 mcg x 81.81 kg x 60 minutes = 24543 mcg Next, convert the micrograms to milligrams 24543 mcg / 1000 mg = 24.54 mg Next, divide the dose ordered by the amount on hand x the volume 24.54 mg / 200 mg x 250 mL = 30.67 mL/hr Finally, round the answer to the nearest whole number 30.67 mL/hr = 31 mL/hr Additional Info Dopamine is a vasopressor utilized in the treatment of shock. Dopamine needs to be administered through a patent IV as it may cause extravasation.

The nurse is caring for a client diagnosed with Generalized Anxiety Disorder (GAD). The nurse should anticipate a prescription for which medication? A. Haloperidol [21%] B. Fluphenazine [19%] C. Buspirone [54%] D. Methylphenidate [6%]

Incorrect Correct Answer(s): C 54% of peers have answered correctly. 24 s Time Spent 24-06-2022 Last Updated Explanation Choice C is correct. Buspirone is a serotonergic agent that is efficacious in the treatment of anxiety. This medication takes time to work (approximately two to four weeks), and the client should be counseled accordingly. Choices A, B, and D are incorrect. Haloperidol and fluphenazine are typical antipsychotics indicated in the treatment of schizophrenia. These medications do not modulate serotonin; therefore, they have no use in anxiety disorders. Methylphenidate is indicated in the treatment of ADHD. Its stimulating effects may even worsen anxiety. Additional Info Buspirone is a non-controlled medication indicated in the treatment of anxiety. This medication does not cause dependence or withdrawal symptoms. Essential patient teaching points include - The time of onset may be delayed up to two weeks to four weeks. This medication should be taken consistently with or without food. The medication is not a benzodiazepine and should not be taken during acute anxiety. Rather, this medication helps attenuate the response to triggers of anxiety. Sexual dysfunction is unlikely with this medication.

A patient who is receiving treatment for Varicella asks for assistance in the bathroom. Before entering the room, you must wear personal protective equipment (PPE). Organize the following in the correct ordered sequence in which you will wear the personal protective equipment: A. Wear gloves B. Wear gown C. Perform hand hygiene D. Wear N95 Mask Perform hand hygiene Wear gown Wear N95 Mask Wear gloves

Perform hand hygiene Wear gown Wear N95 Mask Wear gloves Explanation The correct order is C, B, D, and A. This patient will be in contact and airborne precautions, which will include a gown, gloves, and an N95 respirator mask. The first step is to perform hand hygiene Second, wear gown Third, wear N95 mask Lastly, wear gloves NCSBN Client Need Topic: Safe and Effective Care Management, Subtopic: Safety & Infection Control

Arrange the following in the correct order of steps for drawing up medication from an ampule. Tap the ampule to move the solution to the bottom. Cover neck of ampule with a gauze pad and break off the top. Insert the filter needle into the ampule and draw up medication. Apply the correct needle for administering a dose. Remove any air from the syringe and ensure it measures the correct dose.

Tap the ampule to move the solution to the bottom. Cover neck of ampule with a gauze pad and break off the top. Insert the filter needle into the ampule and draw up medication. Apply the correct needle for administering a dose. Remove any air from the syringe and ensure it measures the correct dose. Explanation When drawing up medication from an ampule, The nurse should first tap the top of the ampule to move the medication to the bottom of the ampule. Cover the neck of the ampule with an alcohol pad or gauze pad Break off the top of the ampule Deposit the glass from the top into a sharps container, Use a "filter needle" to draw up the medication. Replace the filter needle with the correct non-filter needle for administration. Remove any air from the syringe and ensure the correct dose is in the syringe before administering it. Additional Info Breaking the ampule at the neck can cause small glass shards to fall undetected into the vial. If medication is administered with glass pieces, it can lead to inflammation and infection of the veins. Therefore, a filter needle is used. A filter needle places a glass filtering device at the base of a syringe needle and creates a one-way flow. A filter needle can only be pulled or pushed in one direction, therefore, can only be used either for injecting into or withdrawing out of the ampule, never both at the same time.