Archer Review 9a

The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient? A. Pain [89%] B. Anxiety [4%] C. Depression [2%] D. Fluid volume deficit [5%]

Explanation Choice A is correct. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. The transmission of information without the use of words is termed nonverbal communication. It is also known as body language. Nonverbal communication helps nurses to understand subtle and hidden meanings in what a patient is trying to say verbally. Additionally, nonverbal communication is reflected in a person's actions, such as the way he/she walks or uses facial expressions. Nurses must be aware of nonverbal messages that they send and the ones they receive from patients so they can identify patients who are suffering from or at risk of certain conditions. Choices B, C, and D are incorrect. The nonverbal expressions of stooped gait and gasping sounds do not indicate anxiety, depression, or fluid-volume deficit. Nonverbal signs associated with generalized anxiety (Choice B) disorder include tenseness, difficulty sleeping, and stomach problems. Nonverbal expression of depression (Choice C) may include head and lips in the downwards expression, adaptive hand gestures, social withdrawal, frowning, crying, and decreased levels of eye contact and smiling. Nonverbal expression of fluid-deficit (Choice D) may include slowed responses and agitation.

A client has been admitted to the hospital with findings of urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement and has returned to normal hydration status if the blood urea nitrogen level is which of the following? A. 5 mg/dL [7%] B. 15 mg/dL [84%] C. 27 mg/dL [7%] D. 34 mg/dL [2%]

Explanation Choice B is correct. The average blood urea nitrogen (BUN) level is 8 to 25 mg/dL. Choice A is incorrect. This reflects a lower than average value, which may occur with fluid volume overload, among other conditions. Choices C and D are incorrect. These values indicate continued dehydration.

Which of the following are clinical manifestations of the aging immune system and should alert the nurse of increased susceptibility to illness? A. Increased lymph tissue [16%] B. Increased autoimmune responses [47%] C. Increased circulation of lymphocytes [17%] D. Increased T and B cell production [20%]

Explanation Choice B is correct. The elderly experience increased autoimmune responses. This increases the risk of diseases such as rheumatoid arthritis and other collagen disorders. Choice A is incorrect. Lymphoid tissue is decreased in the elderly, which results in lowered immune responses. Choice C is incorrect. The number of circulating lymphocytes reduces by nearly 15 percent. In addition to a decline in antibody-antigen reaction, this makes the older client more susceptible to infection. Choice D is incorrect. The number of T and B cells produced by the older client is decreased. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Immunity in the Elderly

The nurse is conducting patient teaching to a client with a level T4 spinal cord injury to transfer from the bed to the wheelchair independently. The nurse should emphasize to the client to move: A. His upper and lower body should move together into the wheelchair. [23%] B. His upper body moves into the wheelchair first. [25%] C. His lower body into the wheelchair first, placing his feet on the pedals, and then his hands to the wheelchair arms. [39%] D. His buttocks to the wheelchair first and then place his feet to the floor. [13%]

Explanation Choice B is correct. When transferring a patient with paralysis of the lower extremities from a bed to a wheelchair, move the big part of the body (upper) to the chair first. This is the proper technique and the safest. The client should move his upper body to the wheelchair first, then his legs from the bed to the wheelchair. Choices A, C, and D are incorrect. Other methods are not as secure and can lead to injury.

Select the developmental age group that is accurately paired with the normal number of hours of sleep (over the span of 24 hours). A. The neonate: 14 to 15 hours of sleep each day [30%] B. The infant: 13 to 14 hours of sleep each day [25%] C. The toddler: 12 to 14 hours of sleep each day [35%] D. The preschool age child: 12 to 14 hours of sleep each day [9%]

Explanation Choice C is correct. Under normal circumstances, the toddler is expected to have 12 to 14 hours of sleep each day over the span of 24 hours. Under normal circumstances, the average number of hours of sleep over 24 hours that are expected for these developmental age groups are: The neonate: 16 to 18 hours of sleep each day The infant: 14 to 15 hours of sleep each day The preschool-age child: 11 to 13 hours of sleep each day Choice A is incorrect. The neonate is expected to have more than 14 to 15 hours of sleep each day. Choice B is incorrect. The infant is expected to have more than 13 to 14 hours of sleep each day. Choice D is incorrect. The preschool-age child is expected to have less than 12 to 14 hours of sleep each day.

This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response? A. Decreased mood lability [65%] B. Steady gait [28%] C. Urinary continence [4%] D. Increased bone mass [2%]

Explanation Choice A is correct. Carbamazepine is indicated for the prevention of seizures—neuropathic pain. And the treatment of certain mood disorders. The client demonstrating decreased mood lability would be the desired outcome. Choices B, C, and D are incorrect. Increased bone mass, urinary continence, and steady gait are all outcomes irrelevant to carbamazepine.

The nurse notes the inflammation of the gums along with recession and bleeding. This observation should be documented using which term? A. Glossitis [18%] B. Caries [3%] C. Cheilosis [8%] D. Periodontitis [70%]

Explanation Choice D is correct. Periodontitis is marked by inflammation of the gums. Choice A is incorrect. Glossitis is inflammation of the tongue. Choice B is incorrect. Caries refer to the presence of tooth decay. Choice C is incorrect. Cheilosis is the ulceration of the lips. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Oral Health

Which of the following patients would be the best candidates for total parenteral nutrition (TPN)? Select all that apply. A. A patient with inflammatory bowel disease who has intractable diarrhea. [15%] B. A patient with celiac disease who is not absorbing nutrients. [21%] C. A patient who is underweight and needs short-term nutritional support. [8%] D. A patient who is comatose and needs long-term nutritional support. [20%] E. A patient who has anorexia and refuses to take foods via the oral route. [12%] F. A patient with burns who has not been able to eat adequately for 6 days. [24%]

Explanation Choices A, B, and F are correct. The assessment criteria used to determine the need for total parenteral nutrition (TPN) include an inability to achieve or maintain enteral access. Examples include motility disorders, intractable diarrhea (Choice A), impaired absorption of nutrients from the gastrointestinal tract (Choice B), and when oral intake has been inadequate for a period over seven days. TPN promotes tissue healing and is an excellent choice for a patient with burns who has an improper diet. Please note that oral intake is the best feeding method; the second best method is via the enteral route. Total parenteral nutrition (TPN) is indicated only in specific cases. TPN provides calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. TPN can also promote tissue and wound healing and healthy metabolic function. TPN may be used to improve a patient's response to surgery. TPN is a highly concentrated, hypertonic nutrient solution. Hence, it is given intravenously through a central venous access device, such as a multi-lumen, tunneled catheter into the subclavian vein, or a peripherally inserted central catheter (PICC). Strict surgical asepsis should be followed due to the risk of infections. Choice C is incorrect. For short-term use (less than four weeks), a nasogastric or gastrointestinal route is usually selected. Choice D is incorrect. A gastrostomy is a preferred route to deliver enteral nutrition in a comatose patient because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Choice E is incorrect. Patients who refuse to take food should not be force-fed nutrients against their will. NCSBN Client Need - Topic: Physiological Integrity; Subtopic: Physiological Adaptation; Providing Parenteral Nutrition

The postpartum nurse is monitoring a new mother for signs of illness following vaginal delivery of a newborn infant. Which of the following is an early sign of excessive blood loss? A. Heart rate change from 80 to 125 bpm [77%] B. Blood pressure change from 125/90 to 119/82 mmHg [14%] C. A decrease in respiratory rate from 22 to 16 breaths per minute [5%] D. Reports of perineal soreness [4%]

Explanation Choice A is correct. An early sign of illness involves an increase in the patient's heart rate. Tachycardia is a rapid response to hypovolemia. A heart rate change from 80 to 125 bpm warrants further investigation into a possible illness. Choice B is incorrect. A blood pressure change from 125/90 to 119/82 mmHg is not a significant drop enough to indicate hypovolemia or considerable hemorrhage. Shock is defined as mean arterial pressure less than 65 mmHg or systolic blood pressure less than 90 mmHg. Choice C is incorrect. A respiratory rate decrease from 22 to 16 breaths per minute is an expected finding after delivery and is not alarming. Moreover, significant bleeding or hemorrhagic shock is associated with tachypnea (increase in the respiratory rate), not a decrease. Choice D is incorrect. Some perineal soreness is normal after delivery and does not necessarily indicate impending hemorrhage. NCSBN client need Topic: Health Maintenance and Promotion, Postpartum Care

A 35-week pregnant client comes into the emergency room concerned that she had not felt her baby kick for 3 days now. She also complains to the nurse that she had black stools in the morning. The nurse notices bruising in the client's arm and elbows. The nurse should suspect: A. Disseminated intravascular coagulation (DIC) [62%] B. Abuse [29%] C. Abruptio placentae [7%] D. Sepsis [1%]

Explanation Choice A is correct. Disseminated intravascular coagulation (DIC) is a maternal condition in which the clotting cascade is activated, resulting in clots in the microcirculation. The patient states that she has not felt her baby kick or move for three days. This could mean that her fetus has died in utero, and an intrauterine fetal death is a predisposing condition for DIC. Other symptoms like black stools and bruising are indicative of bleeding. The nurse should suspect DIC and initiate appropriate measures. Choice B is incorrect. All client symptoms are indicative of DIC; however, abuse should not be ruled out and requires further assessment by the nurse. Choice C is incorrect. Signs of an abruptio placentae include a contracted and firm uterus as well as a slowed fetal heart rate. The patient does not manifest any of these signs or symptoms. Choice D is incorrect. The client is manifesting signs of DIC; however, sepsis may arise from the intrauterine fetal death and should be removed through the delivery of the demised fetus.

A nurse is precepting a new graduate nurse. They are working with a client with numerous family members at the bedside. Once they exit the room, the nurse asks the new graduate nurse to define "family." The new graduate nurse is correct when they state: A. "A family is a group of people who care about each other and work together to accomplish common goals or overcome hurdles." [60%] B. "A family includes a man and a woman who are married and the children they have together." [34%] C. "In order to be considered family, you have to be related through blood, marriage, or adoption." [2%] D. "Although there may be extended family elsewhere, the people who live in someone's house are their family members." [4%]

Explanation Choice A is correct. Families consist of groups of emotionally connected individuals who function as a unit. Choice B is incorrect. A family consisting of a man, woman, and any children they may have together is known as a nuclear family. Choice C is incorrect. While some benefits require relation through marriage, blood connection, or adoption (i.e., health insurance benefits, tax credits, etc.), these requirements are not mandated to be considered as one's family member. Choice D is incorrect. Although one may reside with members of their immediate family, an individual may also choose to reside alone, with a pet, with a roommate, with a friend, or with a romantic partner. The physical proximity in which one lives with another individual does not affect whether that person is considered family. Learning Objective Define the word "family." Additional Info A family unit is what an individual considers the family to be. As a nurse, encourage clients to verbalize their thoughts regarding their support system. Each family is as diverse as the individuals who comprise them. Unique cultural and ethnic influences often influence the family unit. No two families are alike; each has individual strengths, weaknesses, resources, and challenges. The concept of family is highly individualized and consistently evolving. Never release healthcare information to an individual simply because they are the client's "family member" or "relative." Always verify the individual's identity and check the client's signed Health Insurance Portability and Accountability Act (HIPAA) form to ensure the client has authorized the individual to receive the healthcare information.

You are on the team preparing to give positive-pressure ventilation to a newborn. You have selected the correct size mask and suctioned the infant's mouth and nose. You know that you should start positive-pressure ventilation with: A. 21% oxygen (room air) [39%] B. 28% oxygen [13%] C. 50% oxygen [17%] D. 100% oxygen [31%]

Explanation Choice A is correct. The current recommendation from the American Heart Association and the American Academy of Pediatrics is to start PPV with 21% oxygen. Research shows that beginning resuscitation with room air is as adequate as beginning with 100% oxygen and avoids the possible ill effects of using high levels of oxygen. The team should titrate the oxygen to achieve a specific level of oxygen saturation at particular times after birth. Therefore, the team must implement pulse oximetry early in the newborn resuscitation process. Choices B, C, and D are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Alterations in Body Systems, Newborn

The patient with septic shock presents with anasarca, weak pulses, decreased urine output, decreased responsiveness, and BP 88/52 mmHg, HR 160. The nurse would recognize these symptoms as indicators of which stage of shock? A. Progressive [51%] B. Compensatory [32%] C. Irreversible [11%] D. Nonprogressive [6%]

Explanation Choice A is correct. The progressive stage occurs when compensatory mechanisms begin to fail. Signs/symptoms of the progressive stage include anasarca (generalized edema), decreased responsiveness, decreased urine output, weak pulses, hypotension, and tachycardia. Choice B is incorrect. The compensatory stage of shock is the first stage, characterized by hypotension, vasoconstriction, decreased blood flow to the lungs, and cold/clammy skin. Choice C is incorrect. The irreversible stage is the final stage of shock, characterized by decreased perfusion due to decreased cardiac output, hypotension, hypoxemia, cyanotic skin, vasoconstriction, bradycardia, and unresponsiveness. Choice D is incorrect. The nonprogressive stage is an alternative term for the compensatory stage. NCSBN Client Need Topic: Critical Care Concepts (shock), Subtopic: Changes/abnormalities in vital signs, medical emergencies, pathophysiology

You are providing care to an alert and oriented client who is on complete bed rest. What type of self-care requisites, according to the self care theory, reflects this client's need for a range of motion exercises? A. A health deviation self-care requisite [16%] B. An immobilization self-care requisite [63%] C. A developmental self-care requisite [10%] D. A universal self-care requisite [11%]

Explanation Choice A is correct. The self-care requisite, according to the self-care theory, which reflects this client's need for a range of motion exercises, is a health deviation self-care requisite because the need for a variety of motion exercises is indicated because this client is immobilized with complete bed rest. The self-care requisites, according to Orem's self-care theory are the developmental self-care requisites, the health deviation self-care requisites, and the universal self-care requisites. These consist of maturational and situational needs as well as needs during an acute or chronic disorder/disease and meeting basic physical demands that are common among all human beings, respectively. Choice B is incorrect. This client does not have an immobilization self-care requisite because the self-care requisites, according to Orem's self-care theory, do not include immobilization self-care requisites. Choice C is incorrect. Although developmental self-care requisites exist according to Orem's self-care theory, they address developmental needs and not the requirements of this client who is immobilized with complete bed rest. Choice D is incorrect. Although universal self-care requisites exist according to Orem's self-care theory, these address comprehensive needs like the need for air and water and not the specific needs of this client who is immobilized with complete bed rest.

The nurse is reviewing clinical data for a client. Which of the following actions should the nurse take? See the exhibit. A. Initiate a client referral to a registered dietician. [69%] B. Inform the client that the results are within normal limits. [4%] C. Request a prescription for occupational therapy. [1%] D. Review the client's family history. [26%]

Explanation Choice A is correct. This client is showing evidence of metabolic syndrome and needs prompt intervention to mitigate the risk of diabetes mellitus. Nutritional intervention is necessary because this client needs to modify their diet and reduce their intake of sodium, fats, and simple carbohydrates. Thus, it would be appropriate for the nurse to initiate a referral to a registered dietician. Choices B, C, and D are incorrect. The results are not within normal limits. The client has an elevated BMI, cholesterol, and blood pressure. The hemoglobin A1C is also elevated, showing prediabetes. The client's family history is not pertinent based on this data as it will not guide the treatment plan. The most appropriate action is for the nurse to refer the client to a dietician for nutritional counseling (not occupational therapy). Additional Info Metabolic syndrome is when the client has three out of the five abnormalities - Hypercholesterolemia (> 200 mg/dl) High triglycerides (> 150 mg/dl) High fasting blood glucose (>100 mg/dl) Abdominal obesity (> 40 inches in men; > 35 inches in females) Elevated blood pressure (> 130/85 mmHg) Low High-Density Lipoproteins (<50 mg/dl)

An emergency room nurse is assigned to triage. Four people check-in at the same time. Which patient should receive priority care? A. A 29-year-old female two-week post-cesarean section that complains of a headache and leg swelling [82%] B. An 8-year-old female with LLQ pain for three days [6%] C. A 55-year-old male with RUQ pain & a history of pancreatitis [9%] D. A 3-year-old female with pain upon urination [2%]

Explanation Choice A is correct. This patient is at risk for preeclampsia, which is a severe condition that can lead to seizures. The woman is at risk for preeclampsia anytime throughout pregnancy, as well as six weeks post-partum. Symptoms include headache, blurred vision, proteinuria, swelling in the hands/face, and high blood pressure. If treatment is started, this condition can be controlled. Choices B, C, and D are incorrect. These patients are less of a priority. The patient with preeclampsia is most important in this situation. The patient in answer choice B most likely has constipation issues. The patient in answer choice C is most likely having a pancreatitis flare-up, but this can wait longer than the 29-year old with preeclampsia. The patient in answer choice D is most likely suffering from a UTI, which is common at this age because of potty training, female anatomy, not wiping correctly. She will need an antibiotic, but this is not urgent. NCSBN Client Need Topic: Safe and Effective Care Environment; Sub-topic: Care Management

You are working with geriatric clients in a long-term care facility. What knowledge should you continuously integrate into your role as the nurse administering medications to the aging population? A. The knowledge that the elderly population is more at risk for an accidental overdose than other age groups. [61%] B. The knowledge that the elderly population is more at risk for low therapeutic levels of medications than other age groups. [26%] C. The knowledge that elderly clients cannot swallow medications, so all these medications should be crushed and placed in apple sauce or pudding before administration. [10%] D. The knowledge that elderly clients often reject their medications, so all these medications should be crushed and placed in apple sauce or pudding to conceal them. [3%]

Explanation Choice A is correct. You should integrate the knowledge that the aging population is more at risk for an accidental overdose to medications when compared to other age groups. This risk for an unintentional overdose of drugs occurs due to some of the regular changes in the aging process, such as decreased metabolism. Choice B is incorrect. You would not integrate the knowledge that the aging population is more at risk for low therapeutic levels of medications than other age groups because this is not true. Choice C is incorrect. You would not integrate the knowledge that the aging population cannot swallow medications, so all these medications should be crushed and placed in apple sauce or pudding before administration. Some medicines cannot be broken and placed in apple sauce or pudding before administration, and many members of the elderly population can swallow pills and tablets. Choice D is incorrect. You would not integrate the knowledge that the aging population often rejects their medications, so all these medications should be crushed and placed in apple sauce or pudding to conceal them. Although clients have the right to refuse drugs, this is rare; additionally, concealing medications is unethical.

The nurse is administering medications to a client when the nurse notices that his heart rate is at 51 beats per minute. Which medication should the nurse withhold? A. Regular insulin 5 units SC [1%] B. Amlodipine 5 mg PO [94%] C. Ibuprofen 500 mg PO [2%] D. Ciprofloxacin 500 mg PO [2%]

Explanation Choice B is correct. Amlodipine is a calcium channel blocker that prevents the movement of calcium into the cardiac and smooth muscle cells. This results in vasodilation and a slowed heart rate. This drug should be withheld as it may exacerbate the client's condition. Choice A is incorrect. The client is experiencing bradycardia. The nurse should withhold medications that may exacerbate his situation. Insulin does not have any effect on the client's heart rate; therefore, it can be given. Choice C is incorrect. Ibuprofen is an NSAID. It does not affect the client's heart rate and can, therefore, be given regardless of the client's heart rate. Choice D is incorrect. Ciprofloxacin is antibacterial and can be given even if the client's heart rate is low.

A 29-year-old is pregnant for the first time. She calls her family care provider and tells the nurse that the first day of her last period was May 5th. She used Nagele's rule to determine this. The nurse anticipates that her estimated due date will be on what date? A. February 5th [1%] B. February 12th [94%] C. January 28th [3%] D. April 12th [1%]

Explanation Choice B is correct. February 12th. Remember, the equation for Nagele's Rule is subtract three months from the first day of the woman's last menstrual period plus seven days. Choices A, C, and D are incorrect. Recalculate using the equation for Nagele's Rule. NCSBN client need Topic: Health Care Promotion and Maintenance, Ante / Intra / Postpartum Care

The nurse is assessing a client who is taking prescribed digoxin and furosemide. Which assessment findings require follow-up? A. Night sweats and headache [3%] B. Vomiting and halos around lights [73%] C. Fatigue and dry, flaky skin [4%] D. Low blood pressure and dark urine [19%]

Explanation Choice B is correct. Furosemide causes the client to lose potassium. If taken with a low potassium level, digoxin can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. Furosemide and digoxin may be used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Clients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats. One of the earliest signs of digoxin toxicity is lack of appetite and nausea. Choices A, C, and D are incorrect. While night sweats, headaches, and dry skin are essential and should not be ignored, these are not the most urgent symptoms that need to be assessed. Low blood pressure and dark urine are symptoms of dehydration. These symptoms should be assessed but are not the most urgent. Additional Info Digoxin is a cardiac glycoside indicated for the treatment of atrial fibrillation and congestive heart failure (CHF). This medication has lost popularity in recent decades because newer agents do not require therapeutic monitoring. For a client taking digoxin, the apical pulse needs to be obtained prior to administration. The apical pulse needs to be at least 60/minute for adults; 70/minute for children; 90 for infants.

A client in her second trimester came into the maternity clinic and expressed her concern to the nurse regarding a dark line in the midline of her abdomen. She is afraid that the described finding may pose a danger to her baby. What should be the nurse's most appropriate action? A. The client will need to be assessed further by a dermatologist [0%] B. Educate the client that this is a common occurrence in pregnancy called linea nigra [98%] C. Ask the client the type of foods she has been ingesting [0%] D. Inform the client that it is a stretch mark due to the expansion of the uterus [1%]

Explanation Choice B is correct. Linea nigra are dark pigmentations on the abdomen caused by increased hormones during pregnancy and later disappear after pregnancy. Choice A is incorrect. There is no need for further assessment, as this is a common occurrence of pregnancy. Choice C is incorrect. There is no connection between food intake and the pigmentation of the abdomen. Choice D is incorrect. Stretch marks are usually dark red and become silver over time.

The RN educates a patient with chronic renal failure on the early signs of hypercalcemia. Which information would be important for the nurse to include? A. Slow heart rate [13%] B. Muscle weakness [47%] C. Diarrhea [9%] D. Paresthesia of the lips and extremities [31%]

Explanation Choice B is correct. Patients experiencing hypercalcemia would be expected to present with muscle weakness due to changes in neuromuscular response with higher-than-normal levels of calcium in the blood. Choice A is incorrect. Patients experiencing hypercalcemia would be expected to have increased heart rate initially. Choice C is incorrect. Patients experiencing hypercalcemia would be expected to present with nausea, vomiting, and/or constipation due to a decrease in peristaltic activity. Choice D is incorrect. Paresthesia of the lips (circumoral) and extremities would be expected in a patient with low calcium levels (hypocalcemia), not high.

Which psychosocial interventions would be appropriate for a patient in the intensive care unit? A. Limit visitors to conserve the patient's energy. [29%] B. Use clocks and calendars. [34%] C. Silence alarms during sleeping hours to promote a quiet environment. [7%] D. Dim the lights to decrease sensory overload. [30%]

Explanation Choice B is correct. The use of clocks and calendars in the ICU helps with orientation and reduces the patient's risk of developing delirium. Choice A is incorrect. Reducing the number of visitors does not lessen an ICU patient's risk of adverse physiologic consequences. Additionally, the presence of a familiar person/caregiver may help to reduce agitation. Choice C is incorrect. Sleep deprivation and sensory overload are common in ICU patients, but alarms should never be silenced for prolonged periods. Choice D is incorrect. Lights may be dimmed at night to promote restful sleep, but lights should be turned on during waking hours to assist patients with orientation and maintaining the structure of the natural sleep-wake cycle. NCSBN Client Need Topic: Critical Care Concepts (psychological considerations in ICU), Subtopic: perceptual alterations, support systems, therapeutic environment, rest and sleep

The nurse working on the medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Teaches a patient scheduled for discharge how to ambulate with crutches. [6%] B. Witnesses informed consent for a patient needing an emergency laparotomy. [60%] C. Irrigates a patient's ostomy who reports abdominal cramping. [22%] D. Calculates the intake and output of a patient with diabetes insipidus (DI). [12%]

Explanation Choice B is correct. Witnessing consent is within the scope of an RN. The patient needing emergency surgery will require the RN's initial attention to avoid a delay in care. Choices A, C, and D are incorrect. Discharge teaching is a low-priority task, and the nurse should focus on patient situations that are of immediate concern. Irrigating an ostomy for a patient with abdominal cramping is a priority but does not override the patient needing emergency surgery. Calculating intake and output is a low-priority task. Additional information: Prioritizing patient care is central to functioning as a nurse. High-priority patient situations include a patient 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.

The nurse is caring for a hospitalized infant due to dehydration and failure to thrive. The nurse notes that her mother is a drug user. With this knowledge, the nurse would expect the child to develop: A. Autonomy [4%] B. Trust [5%] C. Mistrust [81%] D. Shame and doubt [11%]

Explanation Choice C is correct. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in this case of the infant with a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. Choice A is incorrect. Autonomy develops when toddlers are left to assert their independence. Choice B is incorrect. Infants develop a sense of trust when their needs are met consistently. Choice D is incorrect. Preschoolers develop a sense of guilt when their sense of initiative is thwarted.

The nurse caring for a patient with Guillain-Barre syndrome is gathering supplies to keep near the patient's bedside. The patient is experiencing paralysis up to his waist. Which of the following instruments is of the highest priority? A. Blood pressure cuff [6%] B. Pulse oximeter [9%] C. Intubation tray [84%] D. Stethoscope [2%]

Explanation Choice C is correct. Ascending paralysis is an attribute of Guillain-Barre syndrome; therefore, these patients are at risk for respiratory failure. An intubation tray should be kept near the patient's bedside. Choice A is incorrect. A blood pressure cuff is helpful to have on hand but not the highest priority in a patient with ascending paralysis related to Guillain-Barre syndrome. Choice B is incorrect. A pulse oximeter is helpful to have on hand but not the highest priority in a patient with ascending paralysis related to Guillain-Barre syndrome. Choice D is incorrect. A stethoscope is helpful to have on hand but not the highest priority in a patient with ascending paralysis related to Guillain-Barre syndrome. NCSBN client need Topic: Physiologic Integrity, Reduction of Risk Potential

While monitoring a client with myocardial infarction, who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following? A. Observe for neurological changes [23%] B. Monitor for any signs of renal failure [6%] C. Observe for signs of bleeding [70%] D. Check the client's food diary [1%]

Explanation Choice C is correct. Bleeding is the priority concern for any patient who is taking a thrombolytic medication. Choices A and B are incorrect. Although neurological status and renal function are monitored, they are not the primary concern. Choice D is incorrect. The client's food diary is not related to the use of this medication. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation - Myocardial Infarction

Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm? A. Ozone [2%] B. Nitrous oxide [7%] C. Carbon monoxide [81%] D. Carbon dioxide [10%]

Explanation Choice C is correct. Carbon monoxide is a hazardous gas that can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm. This odorless and colorless gas can be deadly, so it is recommended that all homes have a carbon monoxide alarm. Choice A is incorrect. Although ozone can be present and harmful in buildings, there is not a simple and relatively inexpensive monitor and alarm for ozone that is similar to a smoke alarm. Choice B is incorrect. Although nitrous oxide is a medical gas, there is not a simple and relatively inexpensive monitor and alarm for nitrous oxide that is similar to a smoke alarm. Choice D is incorrect. Although carbon dioxide is a gas, there is not a simple and relatively inexpensive monitor and alarm for carbon dioxide that is similar to a smoke alarm.

A client is scheduled to undergo electroconvulsive therapy (ECT). The nurse understands, which action needs to be performed prior to the ECT? A. Assess the client for contrast dye allergy. [11%] B. Administer an anti-convulsant. [24%] C. Apply a blood pressure cuff to the client's arm. [42%] D. Check if the client is on Metformin. [22%]

Explanation Choice C is correct. ECT procedure involves administering an electric current to create a generalized seizure. Prior to this, the client is given intravenous sedation or general anesthesia. Anesthetic/sedative medications such as barbiturates (thiopental, methohexital), propofol, and etomidate are often used. In addition, a neuromuscular blockade agent (succinylcholine) is also used to reduce the risk of physical injury that may result from unopposed tonic-clonic muscle contractions during a seizure. During the procedure, one should continuously monitor the vital signs, oxygen saturation, ECG, EEG (electroencephalogram) activity as well as, motor component of the seizure activity. But because of the neuromuscular blockade agent (NMBA) used during anesthesia/sedation, one cannot readily appreciate the motor activity of the seizure. In order to monitor whether electrical stimulation has produced a tonic-clonic seizure, a blood pressure (BP) cuff is wrapped around an ankle or arm and is inflated above systolic pressure before the NMBA is injected. This prevents NMBA from entering that foot or arm allowing the provider to visually observe the motor component of seizure activity in that foot/arm. Choice B is incorrect. The client is given intravenous sedation or general anesthesia before ECT. ECT involves inducing a cerebral seizure. Anticonvulsants should not be used. Choice A is incorrect. The nurse does not need to assess the client for allergies to contrast dye. Iodinated contrast agents are not used during ECT. Choice D is incorrect. While the medication list needs to be checked, there is no particular reason to give specific attention to metformin prior to the ECT. The nurse does not need to stop metformin prior to the ECT. Metformin should be held prior to administering intravenous contrast dye. ECT does not involve administering IV contrast.

The nurse has instructed a client with type 1 diabetes mellitus about proper exercise. Which of the following client statements indicates a correct understanding of the teaching? A. "I should carry a snack rich in protein just in case I feel shaky." [44%] B. "I will not take my prescribed daily glargine insulin if I plan on exercising." [10%] C. "I can initially expect my glucose level to rise with vigorous exercise." [27%] D. "I should start my exercise near the time that my insulin peaks." [18%]

Explanation Choice C is correct. For the client with type 1 diabetes mellitus, glucose levels will initially rise with exercise. The epinephrine released from the adrenal gland will cause the liver to discharge more glucose into the body. Prolonged exercise is likely to cause hypoglycemia because of the uptake of glucose from the muscles. Choices A, B, and D are incorrect. The client should be instructed to carry a simple carbohydrate with them in the event they develop hypoglycemia. Protein would have limited effects on blood glucose. Glargine insulin should be taken because this insulin does not peak (long-acting insulin) and is necessary to provide appropriate basal glucose control. The client should not be instructed to exercise when their insulin peaks as this may cause hypoglycemia. Additional Info Exercise is an effective treatment for both types of diabetes. Exercise can be safely done for a client with diabetes if the client plans for adverse hypoglycemia by carrying a quick-acting carbohydrate. The client should not exercise during periods of hypoglycemia and hyperglycemia. When a client exercises, the blood glucose will initially increase because of the release of epinephrine; as the exercise is sustained and the muscles are consuming the glucose, the blood glucose will begin to fall.

Which of the following is the nurse's priority nursing action for the infant experiencing a tetralogy of Fallot (tet) spell? A. Administer propranolol [8%] B. Administer sodium bicarbonate [4%] C. Calm the infant [64%] D. Notify the healthcare provider [23%]

Explanation Choice C is correct. Immediately calming the infant is the nursing priority during a tet spell. While the infant is crying, their pulmonary vascular resistance is increasing leading to decreased oxygenated blood and more cyanosis. By calming them down you will immediately be decreasing their pulmonary vascular resistance so that blood can flow to the lungs and provide oxygen to the body. This is the first action that the nurse should take. Choice A is incorrect. While propranolol may be used in children with tetralogy of Fallot, it will not be the priority nursing action for the infant experiencing a tet spell. It will be given much later if necessary. Choice B is incorrect. Sodium bicarbonate may be needed at some point during a tet spell if it is not resolving, but would not be indicated as soon as it starts and would not be the priority nursing action. Choice D is incorrect. While the nurse will need to notify the healthcare provider of the spell and may need additional assistance, this still isn't the priority action. There is another action listed that will immediately help the infant and should be the priority. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic care, comfort, Pediatrics - Cardiac

The nurse is collecting the health history from a pregnant patient. Which of the following conditions would not put this patient at an increased risk of developing preeclampsia? A. Obesity [3%] B. Chronic hypertension [10%] C. Frequent urinary tract infections [70%] D. Multifetal gestation [16%]

Explanation Choice C is correct. Preeclampsia is a dangerous complication in pregnancy that is characterized by high blood pressure and protein in the urine. A history of frequent urinary tract infections would not put this patient at increased risk for developing preeclampsia. Choice A is incorrect. Obesity is associated with an increased risk of preeclampsia in pregnancy. Choice B is incorrect. Chronic hypertension is associated with an increased risk of preeclampsia in pregnancy. Choice D is incorrect. Multifetal gestation is associated with an increased risk for preeclampsia in pregnancy. NCSBN Client Need Topic: Maternal and newborn health, Subtopic: Antepartum care, alterations in body systems, pathophysiology

The nurse is providing education to a student nurse assigned to care for a pregnant mother with preeclampsia. The nursing student would not need to be corrected if they said which of the following about this condition? A. "If a woman develops high blood pressure at her first prenatal appointment she likely has preeclampsia." [11%] B. "The kidneys cause fluid overload leading to preeclampsia." [5%] C. "High blood pressure is one of the findings in preeclampsia and occurs after 20 weeks gestation." [77%] D. During preeclampsia episodes, the mother experiences frequent nausea and vomiting, sometimes preventing weight gain. [7%]

Explanation Choice C is correct. Preeclampsia occurs when a woman develops high blood pressure after 20 weeks of gestation. Choice A is incorrect. High blood pressure that presents before 20 weeks, usually is preexisting hypertension unrelated to pregnancy. Choice B is incorrect. Kidney function can be affected by high blood pressure but is not the defining factor of preeclampsia. Choice D is incorrect. Frequent nausea and vomiting, which sometimes limit weight gain during pregnancy, are known as hyperemesis gravidarum, not preeclampsia. NCSBN Client need Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care

Which action should the nurse take to most effectively reduce the incidence of hospital-associated urinary tract infections? A. Teach assistive personnel how to provide good perineal hygiene. [22%] B. Ensure that clients have adequate fluid intake. [9%] C. Limit the use of an indwelling foley catheter. [67%] D. Perform dipstick urinalysis for clients with risk factors for UTI. [1%]

Explanation Choice C is correct. The most effective way to reduce the incidence of UTIs in the hospital setting is to avoid using retention catheters. Any time a foreign object, such as a catheter, is inserted into the body, the risk for infection is increased. The main objective in reducing the risk of disease is to reduce or remove the need for treatment that increases the risk. Choices A, B, and D are incorrect. These actions also reduce the risk for and detect UTI, but avoidance of indwelling catheters will be more effective. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control

The nurse is about to give a blood transfusion to a client with Hepatitis B. 5% Dextrose in Lactated Ringer's solution is currently being infused into the client, with 500 mL of solution remaining. What should be the nurse's action? A. Notify the physician. [7%] B. Wait until the IV fluids are consumed and then start the blood transfusion. [5%] C. Stop the IV infusion, flush the line with normal saline, then transfuse the blood. [64%] D. Insert a new IV line and start the blood transfusion. [24%]

Explanation Choice C is correct. The nurse should stop the IV fluids and flush the line with normal saline to prevent any blood from hemolyzing. Once the line is flushed, then the nurse can transfuse the blood. Choice A is incorrect. Administering a blood transfusion does not necessitate informing the physician. As long as the order for the blood is valid, and there are no pressing issues with the client, there is no need for the nurse to contact the physician. Choice B is incorrect. There is no need to wait for the IV fluids to be finished in order to start the blood transfusion unless specifically instructed by the physician. The nurse can stop the IV, administer the blood, and resume it after the bleeding is finished. Choice D is incorrect. The nurse does not need to insert a new IV line to transfuse the blood unless there are specific contraindications to administering the blood at that site.

The nurse is caring for a client receiving total parenteral nutrition for 2 weeks. Which action by the nurse is the most important? A. Determining weight changes in the client. [8%] B. Monitoring laboratory results. [5%] C. Maintaining strict asepsis during dressing changes in the IV line. [29%] D. Monitoring of blood glucose levels. [58%]

Explanation Choice C is correct. Total parenteral nutrition (TPN) has high glucose content making it an ideal medium for bacterial growth. The nurse should perform strict asepsis during dressing changes in the TPN line. Choice A is incorrect. Obtaining the client's weight is essential to assess the client's nutritional status. However, this is not the nurse's priority intervention. Choice B is incorrect. The nurse should monitor laboratory results to monitor changes in electrolytes. However, this is not a priority action. Choice D is incorrect. TPN may cause an increase in blood sugar levels in the first 48 hours of administration as the client has not yet adjusted to the glucose load of the patient. However, since it is already two weeks of administering the solution, the client should have already changed to the TPN solution.

The nurse has become aware of the following client situations. The nurse should first assess the client who A. has Cushing's syndrome and their blood glucose has increased from 156 mg/dL to 243 mg/dL. [26%] B. is admitted with acute glomerulonephritis and has had 80 mL of urine output over the past four hours. [27%] C. is nothing by mouth (NPO) awaiting surgery and receiving glargine insulin two hours ago. [14%] D. had a transurethral resection of the prostate six hours ago and has urine output turned burgundy in color. [32%]

Explanation Choice D is correct. A client who has had a TURP is at high risk for hemorrhage during the first twenty-four hours following this procedure. Signs concerning hemorrhage include large clots and urine that has turned burgundy in color. The nurse should obtain vital signs to validate the findings as hemorrhage would be supported by the client having tachycardia and decreased blood pressure. Choices A, B, and C are incorrect. Cushing's syndrome/disease is characterized by excessive cortisol and aldosterone. This causes hypokalemia, hypernatremia, and hyperglycemia. While the blood glucose has increased, this is not a priority for the nurse to address because it is not life-threatening. A client admitted with acute glomerulonephritis would have oliguria. This is a classic finding that does not require follow-up as it is an expected finding with this disease process. Insulin glargine is long-acting insulin with no peak. This insulin is safe to give to a client who is NPO because it does not peak. Additional Info Following a TURP procedure, the nurse must maintain the patency of the continuous bladder irrigation via the 3-way indwelling catheter. The outflow should always be greater than the inflow. Ensure strict assessment of the intake and output. Bladder spasms are expected, and the client states the need to void despite the catheter being present. Hemorrhage would be evidenced by the urine turning burgundy or bright red with large clots. This is quite concerning and may be accompanied by tachycardia and hypotension.

The nurse working on the medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Initiates a referral for a patient needing home health care. [7%] B. Performs a central line dressing change on a patient receiving 0.9% saline infusion. [10%] C. Collects a urine specimen from a patient's indwelling urinary catheter. [6%] D. Obtains capillary blood glucose for a patient receiving continuous regular insulin. [77%]

Explanation Choice D is correct. A patient receiving continuous regular insulin infusion requires hourly capillary blood glucose checks because of the high risk of hypoglycemia. Regular insulin via intravenous infusion peaks within fifteen to thirty minutes. Thus, the nurse needs to watch for signs of hypoglycemia, including tachycardia, palpitations, and diaphoresis. Choices A, B, and C are incorrect. Initiating a patient referral, performing a central line dressing change, and obtaining a urine specimen are low priority items compared to a patient receiving a high-risk medication, especially via a route that allows for a rapid peak. Additional information: Prioritizing patient care is central to functioning as a nurse. While obtaining blood glucose may appear as an intermediate priority, when a patient is receiving a high-risk medication such as insulin or magnesium, the nurse must assess the patient for any potential complications.

The nurse is precepting a graduate nurse as they perform resuscitation on an adult with cardiac arrest. Which action by the graduate requires immediate follow-up by the nurse? A. Assesses the client's pulse by palpating the carotid artery. [9%] B. Allows for chest recoil after every chest compression. [10%] C. Compresses at a depth of 2 inches on the center breastbone. [17%] D. Asks for an automatic external defibrillator after one cycle of CPR. [64%]

Explanation Choice D is correct. An automatic external defibrillator (AED) should be requested immediately upon establishing that the client is in cardiac arrest. Waiting to request an AED could result in the delay of life-saving care. Choices A, B, and C are incorrect. An adult client should have their pulse palpated using the carotid artery. Chest recoil after every compression is essential to ensure optimal perfusion. Chest compressions for an adult should have a depth of two inches and be over the center breastbone. Additional information: The key to successful basic life support is high-quality CPR and prompt defibrillation. When responding to a confirmed cardiac arrest, the nurse should immediately initiate an emergency response (call a code blue or 911). Start chest compressions at a rate of 30 compressions to 2 rescue breaths. A request for an AED should be made as soon as possible; it should be applied and used immediately. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Medical Emergencies

The nurse is educating a parent about the growth and development of their 2-month-old infant. Which of the following statements is true regarding growth and development during infancy? Select all that apply. A. Birth weight doubles by 4 months of age. [13%] B. The posterior fontanelle should be soft and flat at 3 months of age. [26%] C. The anterior fontanelle closes between 1 and 2 months of age. [13%] D. Birth weight triples by 12 months of age. [48%]

Explanation Choice D is correct. Birth weight should in fact triple by the infant's first birthday. For example, if the infant was born to weigh 7 pounds, he or she should be 21 pounds by the time they are 12-months-old. This is an important milestone in the growth that occurs during infancy. Choice A is incorrect. This statement is incorrect. Birth weight should double by 6 months of age in the normal infant. Infancy is a period of rapid growth and development, and monitoring weight gain is very important. The infant should be weighed at each check-up with their pediatrician, so that their growth may be plotted on the growth chart to ensure they are meeting goals. By 6 months of age, birth weight should have doubled. Choice B is incorrect. This statement is incorrect. The posterior fontanelle should close between 1 and 2 months of age. The assessment finding of a soft, flat fontanelle is a normal assessment finding if the fontanelle is still open, but it is not normal for a 3-month-old infant to still have an open posterior fontanelle. The anterior fontanelle should still be open at 3 months of age, as it does not close until 9 to 18 months. Choice C is incorrect. This statement is incorrect. The anterior fontanelle closes between 9 and 18 months of age. The posterior fontanelle closes between 1 and 2 months of age. Until the anterior fontanelle closes, it should be assessed to ensure it is soft and flat. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Development

The client had just given birth and is resting in the postpartum unit when suddenly she feels a sharp pain in the chest and is having difficulty breathing. Upon assessment by the nurse, she has a heart rate of 120 and a respiratory rate of 24. She is suspected of having a pulmonary embolism. What should be the initial action of the nurse? A. Start an IV line. [12%] B. Monitor the client's blood pressure. [4%] C. Draw up morphine sulfate. [5%] D. Give oxygen via face mask at 8-10 liters per minute. [80%]

Explanation Choice D is correct. During a pulmonary embolism, circulation in the pulmonary bed is altered, thus affecting the oxygenation of the patient. Oxygen should be started immediately at 8-10 liters per minute to decrease hypoxia. Choice A is incorrect. Starting an IV line is necessary but it is not the priority. Choice B is incorrect. Checking the client's blood pressure is a necessary action, but it should not be the first action for the nurse to take. Choice C is incorrect. Morphine sulfate may be given for pain management; however, the nurse's initial action would be to provide oxygen.

The nurse is teaching a group of students the causes of metabolic alkalosis. It would indicate a correct understanding of the student to state which condition causes this acid-base imbalance? A. Hyperventilation [9%] B. Urinary retention [4%] C. Opioid toxicity [3%] D. Excessive vomiting [83%]

Explanation Choice D is correct. Excessive vomiting would cause the discharge of hydrochloric acid and would therefore leave the patient with more bicarbonate. This would put the patient in an alkalotic state (pH greater than 7.45). Choices A, B, and C are incorrect. Hyperventilation would cause the patient to exhale an excessive amount of CO2. This would cause a patient to develop respiratory alkalosis. Urinary retention would not lead to any specific acid-base derangement. Opioid toxicity would cause a decrease in respiration which therefore would lead to respiratory acidosis because of the accumulation of the CO2. Additional information: Metabolic Alkalosis is a condition in which the patient eliminates more acid than bicarbonate. Common causes of metabolic alkalosis include excessive vomiting, diuretics, and suctioning from a nasogastric tube (NGT). Metabolic alkalosis is associated with hypokalemia, and thus, the nurse must watch for this effect.

The nurse is providing discharge education regarding the client's eye drop medications. Which of the following actions does the nurse instruct the client to implement to minimize the eye drops' systemic effects? A. Instill the eye drops before meals. [5%] B. While instilling the eye drops, swallow several times. [4%] C. Blink vigorously after instilling the eye drops. [18%] D. Place a finger over the inner canthus for 30 - 60 seconds after instilling the eye drops. [73%]

Explanation Choice D is correct. Eye drops are often prescribed for their topical effects in relieving local eye conditions. Occasionally, side effects may occur due to systemic absorption of the active medication in the eye drop solutions. Certain precautions can help reduce systemic absorption and minimize side effects. Mucous membranes of the eye serve as the routes of systemic absorption. Placing a finger over the inner canthus occludes the nasolacrimal duct preventing the eye drop solution from reaching the mucous membranes and being absorbed into the systemic circulation. Choices A, B, and C are incorrect. These instructions do not help minimize systemic side effects of eye drops. Unlike orally administered medications, the absorption of instilled eye drops is not affected by gastric contents (Choice A). Swallowing at the time of instilling the eye drops does not affect the absorption (Choice B). Finally, blinking vigorously forces the solution out of the eyes, decreasing its local therapeutic effect and is not recommended (Choice C).

A nurse is assessing a patient for possible domestic violence. The nurse should know that all of the following are warning signs of the presence of violence except: A. Stating that everything is "just fine" [6%] B. Expressing sadness over a previous loss [23%] C. Displaying mood and behavior changes [2%] D. Wanting to have family involved [69%]

Explanation Choice D is correct. In most cases of abuse/violence, the victim does not want the family involved. Many times the perpetrator of violence will try to control the victim by threatening his/her family with harm. If the client wants the family to be involved, it is often "not" a warning sign of the presence of violence. Recognizing signs of the possible presence of violence are essential nursing skills, as many victims will not immediately report abuse. Often victims will seem dismissive of what the nurse feels is a sign of violence. The victim may state, "everything is fine" or "we have good days and bad days." Being observant of mood and behavior changes will give the nurse a sense of when there are changes in a patient. Suspicion of violence is not something that should be taken lightly or second-guessed. It's always best to observe and identify warning signs rather than wait for the patient to complain first. Choices A, B, and C are incorrect. Warning signs of violence include behavior changes, withdrawal, depression, agitation, hyperarousal, a new display of anger, noncompliance, sexualized behavior, bowel or bladder problems, sleep problems, and unexplained/curious injuries.

A nurse is caring for a client who has missed their last appointment with the primary healthcare provider (PHCP). The client states, "I missed my appointment because I overslept, but I knew it would be pointless anyway." The client is demonstrating which of the following? A. Projection [9%] B. Reaction formation [16%] C. Denial [8%] D. Rationalization [67%]

Explanation Choice D is correct. Rationalization is a higher-level defense mechanism that involves an individual justifying behavior that is often offensive or abnormal through statements that they believe provide validation. However, the rationalization of the behavior is done to avoid authentic feelings such as guilt if they have done something wrong. The client missing their appointment because they overslept is rationalizing this choice because they perceived the appointment as pointless. Choices A, B, and C are incorrect. The client is not demonstrating projection because they are not attributing their unacceptable feelings and thoughts to someone else. Reaction formation is when an individual acts in an opposite way of their true feelings or actions. Denial is not exhibited because the client is acknowledging the missed appointment. Denial is when the individual blocks a situation because they refuse to embrace the situation and associated emotions. Additional information: Defense mechanisms are employed to protect the ego. These mechanisms may be overused, and that may suggest a personality disorder. The nurse should be aware of defense mechanisms and understand that they are often executed when a client is experiencing anxiety. NCSBN Client need: Topic: Psychosocial Integrity; Subtopic: Defense Mechanisms

You are caring for a 65-year-old female patient in the surgical unit. She had an ileostomy two days ago and had ongoing nausea and vomiting since then. She has an NG tube in place set to low, intermittent suction. She is weak and has muscle spasms. Her electrolytes show low potassium and calcium levels. Her blood pressure is 165/80 mmHg, and her heart rate is 85. You draw ABGs. You receive results of the arterial blood gas that show: pH = 7.50 PaCO2 = 42 Bicarbonate = 35 You determine that this ABG shows: A. Respiratory acidosis [2%] B. Respiratory alkalosis [9%] C. Metabolic acidosis [4%] D. Metabolic alkalosis [85%]

Explanation Choice D is correct. This ABG shows metabolic alkalosis. The first clue in this patient is the diagnosis of ileostomy and continuous NG suction from the stomach. When a patient's stomach contents are removed through vomiting or suctioning, acidic gastric secretions are lost, and bicarbonate ions begin to accumulate in the extracellular space. The registered nurse must know the basics of ABG interpretation, including the normal ranges for each of the values. First, the nurse should look at the pH. The normal range is 7.35-7.45. A value below 7.35 indicates an acidosis; a value above 7.45 indicates an alkalosis. The normal partial pressure of carbon dioxide (PaCO2) is 35-45 mmHg. Standard bicarbonate for a woman this age is 22-29 mmol/L. The pH in this patient shows that the condition is alkalosis. The high bicarbonate indicates that it is a primary metabolic problem. These values would support the assumption of metabolic alkalosis based on the diagnosis of ileostomy, nausea, vomiting, and gastric suction. The respiratory system begins to compensate very quickly when metabolic alkalosis develops. It is not unusual to see an increased PaCO2 in metabolic alkalosis as the body attempts to correct the underlying alkalosis. Respiratory disorders are defined by the pH and the PaCO2. Respiratory acidosis is defined as a pH below 7.35 and a PaCO2 above 45 mmHg. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mmHg. Metabolic disorders are defined by the pH and the bicarbonate (HCO3). Metabolic acidosis is defined as a pH below 7.35 and an HCO3 below 22 mmol/L. Metabolic alkalosis is defined as a pH above 7.45 and an HCO3 above 29 mmol/L Choices A, B, and C are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-Topic: Fluid and Electrolyte Imbalances, Gastrointestinal/Nutritional

The nursing assessment of an older adult focuses the health history on which of the following? A. Birth history, immunizations, as well as growth and development [3%] B. Previous pregnancies, obstetrical history, and psychosocial factors [3%] C. Religion, spirituality, culture, and values [4%] D. Sensory deficits, illness history, and lifestyle factors [90%]

Explanation Choice D is correct. This answer choice includes items that are significant with aging. When obtaining a health history from an older adult, it is essential to be aware of the increased risk for deficits that might alter the history taking, such as loss of vision or hearing. Older adults may have more complex histories because of their increased prevalence of disease and may require some additional time to process information. It's necessary to identify the pattern of any illnesses and how they may be related. Nurses should take note of a patient's family history and lifestyle choices, as these may influence health later in life. Choice A is incorrect. Birth history, immunizations, and growth history are most important for children to identify the risk for problems, provide primary prevention, and assess current issues. Choice B is incorrect. Pregnancies and obstetric history are pertinent to the pregnant female. Choice C is incorrect. Religion and culture are assessed during the cultural assessment. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

The nurse is taking care of a patient with cardiac arrhythmias—the physician orders to give an additional dose of digoxin. The nurse finds that the patient's heart rate is only 40 bpm, serum potassium level is critically low, and so she relays her findings to the physician. The physician, however, insists and threatens, "Give the digoxin now, or I will have you sacked!". The best response by the nurse would be: A. "Fine. I'll give the digoxin now but this patient will die." [1%] B. "I don't have to listen to anyone like you." [0%] C. "Don't you raise your voice at me again or we'll see who gets fired." [1%] D. "I think we should discuss this with the pharmacist or the unit manager now." [98%]

Explanation Choice D is correct. This is an appropriate and assertive response that does not infringe on the physician's rights, yet you are inclined to keep the patient safe. Choice A, B, and C are incorrect. These are all aggressive forms of communication and unprofessional.

The nurse performs an EKG on a 62-year-old female and sees the rhythm shown below. What treatment should the nurse recommend that the doctor order? See the exhibit. A. Sodium supplement [6%] B. Potassium rider [41%] C. Calcium rider [12%] D. Magnesium rider [41%]

Explanation Choice D is correct. This patient is demonstrating an EKG rhythm called Torsades de pointes. It is a polymorphic ventricular tachycardia that can be caused by low magnesium levels. The treatment for this patient is the management of symptoms, including cardiac arrest and IV magnesium to increase magnesium levels. Choice A is incorrect. Torsades de pointes is caused by low magnesium levels and can be corrected by administering IV magnesium. Choice B is incorrect. Torsades de pointes is caused by low magnesium levels and can be corrected by administering IV magnesium. Choice C is incorrect. Torsades de pointes is caused by low magnesium levels and can be corrected by administering IV magnesium. NCSBN Client Need Topic: Reduction of Risk Potential, Subtopic: Dysrhythmias

While emptying the foley catheter bag for her patient, the nurse sees the following (shown in the exhibit). Which urine specific gravity level does the nurse expect to see when she reviews the patient's labs, based on this assessment of his urine? See the exhibit. A. 0.990 [12%] B. 1.000 [8%] C. 1.020 [11%] D. 1.060 [69%]

Explanation Choice D is correct. Urine specific gravity measures the concentration of urine. The nurse notes that this urine is very dark and therefore very concentrated. She suspects that the patient is dehydrated based on this assessment of his urine color. In dehydrated patients, there are more particles in the urine, creating a higher urine specific gravity. Normal urine specific gravity is 1.005 to 1.030, so the nurse expects his lab value to be higher than 1.030. This is the only lab value showing an increased urine specific gravity. Choice A is incorrect. The normal urine specific gravity is 1.005 to 1.030, so a value of 0.990 would be slightly low, indicating dilute urine. Based on the observation of this patient's urine, it is dark and concentrated. The nurse anticipates a high urine specific gravity, so 0.990 is incorrect. Choice B is incorrect. The normal urine specific gravity is 1.005 to 1.030, so a value of 1.000 would be slightly low, indicating dilute urine. Based on the observation of this patient's urine, it is dark and concentrated. The nurse anticipates a high urine specific gravity, so 1.000 is incorrect. Choice C is incorrect. The normal urine specific gravity is 1.005 to 1.030, so a value of 1.020 would be reasonable. Based on the observation of this patient's urine, it is dark and concentrated. The nurse anticipates a high urine specific gravity, so 1.020 is incorrect. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care

The nurse is caring for a critically ill client receiving enteral nutrition through a nasogastric tube. Before initiating the next bolus feed, the nurse checks the residual and notes 225 mL of bright green fluid. Which actions by the nurse are appropriate? Select all that apply. A. Auscultate for bowel sounds [31%] B. Document the residual [38%] C. Discard the residual [8%] D. Do not administer the tube feeding [23%]

Explanation Choices A and B are correct. ( Choice A) Generally, residuals over 150 mL are considered above-normal volumes, although there is no need to withhold feeding for gastric residual volume (GRV) less than 500ml. The nurse should auscultate bowel sounds to detect potential signs of delayed gastric emptying in a patient with a large residual. According to a research study, the gastric emptying delay is classified into three levels based on the amount of residual volume - an amount of more than 150mL up to 250 mL is considered a mild delay. In contrast, amounts greater than 350 mL are classified as a severe delay. Per the American Society of Parenteral and Enteral Nutrition (ASPEN) and many other critical care society guidelines, the nurse should not hold feeding for a GRV of less than 500 mL in the absence of any clinical signs of intolerance. Therefore, the nurse should auscultate for bowel sounds and assess any nausea, emesis, or abdominal distention. Should there be any clinical signs of intolerance, the nurse should hold the feeding. When a large-volume residual is aspirated, it may indicate delayed gastric emptying. A prokinetic agent can be given to enhance gastric emptying. ( Choice B) The nurse should document the color, odor, consistency, and amount of the residual. One can remember this documentation from the mnemonic COCA: color, odor, consistency, and amount. For example, the nurse can document the aspirate as bright green, non-odorous, thin, 250 mL residual in this case. Such documentation will help establish a baseline for the client and identify changes that could indicate a concern. Choice C is incorrect. There is no information regarding feeding intolerance in the question stem. In the absence of feeding intolerance, the nurse should not discard the residual if it is less than 250 ml. Residuals up to 250 mL can be safely returned to the client. The nurse has aspirated stomach contents rich in electrolytes such as potassium and chloride. If the nurse discards the residual, the electrolytes will be lost, potentially exacerbating the imbalance. Choice D is incorrect. Guidelines recommend holding tube feeding only when the residual is greater than 500 mL or in the presence of any clinical signs of feeding intolerance. It is premature not to administer tube feeding without auscultating the bowel sounds and checking for signs of intolerance. If there are no signs of intolerance, the nurse should return this residual to the client, flush the tube with saline to ensure it remains patent, continue the tube feeding, and notify the physician. Additional Info Refer to ASPEN guidelines recommending 500 ml GRV cut-off for holding feeds - ASPEN Guidelines Refer to guidelines recommending up to 250 mL GRV be returned to the client - click here

You are administering propranolol to a patient in the PICU that is going in and out of SVT. Knowing the most dangerous side effects of this medication, what will you monitor for while administering it? Select all that apply. A. Difficulty speaking or breathing [24%] B. Decreased heart rate [40%] C. Complete heart block [22%] D. Polymorphic ventricular tachycardia [14%]

Explanation Choices A and B are correct. The most life-threatening side effect of propranolol is laryngospasm and bronchospasm. This sudden spasm of the vocal cords makes it difficult to speak or breathe; therefore, it can be challenging to intubate the patient if needed. The nurse should monitor closely for this adverse reaction (Choice A). Bradycardia is a side effect of propranolol. The nurse should continuously monitor heart rate and keep emergency medications such as atropine or epinephrine as ordered at the bedside (Choice B). Choice C is incorrect. Complete heart block is a side effect of a different anti-arrhythmic medication called propafenone. The nurse would not expect propranolol to cause complete heart block as a side effect. Choice D is incorrect. Polymorphic ventricular tachycardia is a side effect of a different anti-arrhythmic medication called sotalol. This is not a risk of propranolol.

Malignant hyperthermia is a serious adverse reaction that can occur after the administration of which of the following medications? Select all that apply. A. Halothane [36%] B. Vancomycin [18%] C. Succinylcholine [42%] D. Omeprazole [4%]

Explanation Choices A and C are correct. Malignant hyperthermia is a severe adverse medication reaction. The nurse should know to monitor for this adverse reaction when administering induction agents such as halothane and succinylcholine. These medications can cause excess calcium to build up in the cells, resulting in the patient experiencing sustained skeletal muscle contractions. These contractions cause a hypermetabolic state, fever, and can lead to death. Choice B is incorrect. Vancomycin does not carry the risk for malignant hyperthermia. It is an antibiotic that has many other adverse reactions. Choice D is incorrect. Omeprazole is a proton-pump inhibitor (PPI) used to treat reflux. It does not cause malignant hyperthermia. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Pharmacological and Parenteral Therapies

Your client comes to the clinic during the second trimester of her pregnancy. She is in the clinic for a "quad screen" and exam. In teaching her about the quad screen, you tell her that this procedure evaluates the chance of carrying a baby with: Select all that apply. A. Down syndrome [37%] B. Tay-Sachs disease [17%] C. Spina bifida [32%] D. Cystic fibrosis [14%]

Explanation Choices A and C are correct. The quad screen, or quadruple marker test, is done in the second trimester of pregnancy and includes measuring levels of AFP, HCG, estriol, and inhibin A. The clinician uses this test to evaluate the chance of carrying a baby with Down syndrome and spina bifida. These conditions can also be diagnosed when an ultrasound during the first trimester is not done or is not conclusive. As DNA screening improves, that diagnostic method might be used instead of the quad screen. Choices B and D are incorrect. The screen does not test for Tay-Sachs disease or cystic fibrosis. NCSBN Client Need Topic: Reduction of Risk Potential, Subtopic: Diagnostic Tests; Antepartum

Which of the following assessment findings would you expect for your patient diagnosed with iron deficiency anemia? Select all that apply. A. Tachycardia [27%] B. Pica [25%] C. Pallor [39%] D. Insomnia [8%]

Explanation Choices A, B, and C are correct. A is correct. Tachycardia is an expected assessment finding for a patient with iron deficiency anemia. When the patient has decreased oxygen delivery to the tissues, the body increases the heart rate to try to compensate. B is correct. Pica is an expected assessment finding for a patient with iron deficiency anemia. Pica is defined as "a tendency or craving to eat substances other than normal food (such as clay, plaster, or ashes)" This is due to the low iron level in the body. C is correct. Pallor is an expected assessment finding for a patient with iron deficiency anemia. Due to low iron levels, there is decreased oxygen delivery to the tissues and reduced perfusion. This causes pallor and other signs of decreased perfusion. Choice D is incorrect. Insomnia is not an expected assessment finding for iron deficiency anemia. These patients are typically frail and fatigued due to the decreased oxygen delivery to their organs and tissues. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Hematology

Which of the following is an internal disaster? Select all that apply. A. A loss of electrical power to the facility [29%] B. The sudden cessation of internal communication [25%] C. A toxic chemical spill in the lobby of the facility [34%] D. A serious life threatening medication error [13%]

Explanation Choices A, B, and C are correct. A loss of electrical power to the facility, the sudden cessation of internal communication, and a toxic chemical spill in the lobby of the facility are all examples of domestic disasters. Other cases of civil emergencies include things like a fire, a bomb threat, a cyclone, a flood, a tornado or hurricane that affects the healthcare facility. Choice D is incorrect. A medication error is not considered an internal disaster or an external disaster.

A 30-year-old man comes into the clinic after being bitten by a wild skunk approximately 12 hours ago. The nurse knows that treatment for this patient is likely to include: Select all that apply. A. Rabies immune globulin and vaccine [32%] B. Wound cleansing with povidone-iodine or saline solution and debridement [29%] C. Treatment with an appropriate antibiotic [28%] D. Suturing of the wound [11%]

Explanation Choices A, B, and C are correct. Wild skunks have a high incidence of rabies and should be considered rabid. The patient should receive rabies immune globulin and vaccine. The CDC recommends the irrigation of the wound with povidone-iodine since that solution is virucidal and may help prevent infection. In the clinical judgment of the provider, saline can be safely substituted for povidone-iodine. Debridement of the wound edges may also help to prevent disease by cutting away tissue, clots, and other material in the wound. Any bite wound should be considered potentially infected, so an appropriate antibiotic and tetanus prophylaxis will be administered. Choice D is incorrect. The primary suturing of the injury is NOT recommended in this case. The bite is older than 8 hours and from an animal that has a high infection risk. Suturing the wound will close any potential infectious agents into the injury leading to an increased risk for infection. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Health Promotion/Disease Prevention, Infectious diseases

The nurse is caring for a client with dementia who is unable to self-report pain. Which of the following would the nurse recognize as appropriate actions included in the Hierarchy of Pain Assessment? Select all that apply. A. The identification of underlying conditions that are associated with pain. [19%] B. The use of the qualitative pain scale for pain measurement. [12%] C. The physiological indicators of pain. [21%] D. Assumption that the client is in pain. [3%] E. The behavioral indicators of pain. [22%] F. Attempts to get self-reports of pain. [16%] G. An analgesic trial to confirm pain. [6%]

Explanation Choices A, C, E, F, and G are correct. The following are included in the "Hierarchy of pain assessment" that is used when a client is unable to self-report pain: The identification of underlying conditions associated with pain The physiological indicators of pain The behavioral indicators of pain Attempts to get self-reports of pain An analgesic trial to confirm pain Choices B and D are incorrect. The clients who are unable to self-report pain are not able to use a qualitative pain scale. When a client is unable to self-report pain, the nurse should not automatically assume that the client is in pain. Additional Information: Self-report is considered the gold standard for assessing pain, and clients who are not able to self-report are at increased risk for undertreated pain. At-risk populations include: Clients with cognitive impairment Clients who are critically ill or comatose Clients receiving neuromuscular blocking drugs or sedatives The Hierarchy of Pain Assessment is a tool that can be applied to identify and assess pain in clients who are not able to communicate their pain. NCLEX Category: Basic Care and Comfort Related Content: Non-Pharmacological Comfort Interventions Question Type: Application

The terms used to describe the patterns of growth and development according to individual growth patterns and developmental levels include which of the following? Select all that apply. A. Orderly [21%] B. Simple [8%] C. Sequential [26%] D. Unpredictable [6%] E. Differentiated [19%] F. Integrated [20%]

Explanation Choices A, C, E, and F are correct. Growth and development are orderly and sequential, as well as continuous and complex. All humans experience the same general growth patterns and developmental levels, but because these patterns and levels are individualized, a wide variation in biological and behavioral changes is reasonable. Within each developmental level, certain milestones can be identified, such as the first time the infant rolls over, crawls, walks, or says his/her first words. Although growth and development occur in distinct ways for different people, certain generalizations can be made about the nature of human development for everyone. Choices B and D are incorrect. Growth and development follow regular and predictable trends. Both are differentiated and integrated. NCSBN Client Need Topic: Health Promotion and Maintenance; Subtopic: Principles of Growth and Development

The nurse is caring for a patient with atrial fibrillation, who is on warfarin. Which of the following alternative therapies should the nurse advise this patient to avoid? Select all that apply. A. Ginger [28%] B. Aloe [3%] C. Garlic [31%] D. Ginko biloba [38%]

Explanation Choices A, C, and D are correct. This patient is at risk of bleeding due to the blood-thinning medication warfarin. The nurse should educate the patient to avoid any substances that may further increase the risk of bleeding. Ginger is used in alternative/complementary medicine to relieve nausea and vomiting but may increase bleeding risk (Choice A). Garlic is used in alternative/complementary medicine for reducing high cholesterol levels but may increase the risk of bleeding (Choice C). Ginkgo Biloba is used in alternative/complementary medicine to relieve symptoms of intermittent claudication but may affect blood glucose levels and increase the risk of bleeding (Choice D). Choice B is incorrect. Aloe is used in alternative/complementary medicine to relieve constipation. It may cause electrolyte imbalances and decreased blood glucose levels, but is not known to increase the risk of bleeding. NCSBN Client Need Topic: Pharmacology - Hematology, Subtopic: Adverse effects/contraindications/side effects/interactions, hemodynamics

The nurse is reviewing the laboratory results of assigned clients. Which of the following results would require immediate follow-up? Select all that apply. A. Creatinine 2.7 mg/dl for a patient receiving vancomycin. [35%] B. Hemoglobin A1C of 6.9% for a patient with diabetes mellitus. [8%] C. Platelet count of 152,000 mm3 for a patient receiving methotrexate. [5%] D. Potassium 3.1 mEq/dl for a patient receiving bumetanide. [35%] E. Calcium 10.8 mg/dL for a patient receiving hydrochlorothiazide. [16%]

Explanation Choices A, D, and E are correct. Vancomycin is a nephrotoxic antibiotic, and the nurse must monitor the patient's creatinine. This creatinine is elevated (normal 0.6-1.2 mg/dl). A patient receiving the loop diuretic, bumetanide, must be monitored for hypokalemia (normal 3.5 - 5.0 mEq/dl). Finally, the patient receiving hydrochlorothiazide has elevated calcium which adversely occurs with this medication (normal 9.0 - 10.5 mg/dl). Choices B and C are incorrect. A hemoglobin A1C of 6.9% is normal for a patient with diabetes mellitus. The goal is to keep the hemoglobin A1C less than 7% for an individual with diabetes. Methotrexate may cause pancytopenia (low red blood cells, white blood cells, and platelets); however, this patient's platelet count is within range (normal 150,000 - 400,000). Additional Info Vancomycin is a glycopeptide antibiotic indicated for infections caused by MRSA. Bumetanide is a loop diuretic and is indicated for individuals with heart failure or pulmonary edema. Hydrochlorothiazide is a thiazide diuretic and indicated for urolithiasis or hypertension.

You overhear a nursing assistant tell a client that they will have to get a feeding tube if they do not start eating more at mealtimes. What has this nursing assistant done? Select all that apply. A. The nursing assistant has committed battery. [10%] B. The nursing assistant has emotionally abused the client. [43%] C. The nursing assistant has committed assault. [39%] D. The nursing assistant has been negligent. [8%]

Explanation Choices B and C are correct. The nursing assistant has committed assault and they have also emotionally abused the client. Charge like emotional abuse occurs when someone causes another person, like a client, to feel fearful and threatened. Choice A is incorrect. The nursing assistant has not committed battery; battery is the actual wrongful and inappropriate touching of a client or an intentional act to do physical harm. Choice D is incorrect. The nursing assistant has not been negligent. Negligence is failing to do something that should have been done according to established standards of care and practice.

Which of the following signs and symptoms are expected for your patient experiencing placental abruption? Select all that apply. A. Painless bleeding [10%] B. Dark red bleeding [33%] C. Hypotension [27%] D. Rigid abdomen [30%]

Explanation Choices B, C, and D are correct. B is correct. A massive amount of dark red bleeding is a prominent sign of placental abruption. This is due to the placenta separating from the wall of the uterus. This enormous amount of bleeding causes hypotension as the mother enters hypovolemic shock and fetal distress as perfusion to the baby decreases dramatically. C is correct. Due to the massive amounts of dark red bleeding, hypotension is a sign of placental abruption. When the mother loses large amounts of blood, her blood pressure will drop. This hypovolemia is treated with IV fluids and blood products such as PRBCs. D is correct. A rigid, board-like abdomen is a sign of placental abruption. This is also due to massive blood loss. As the placenta separates from the wall of the womb, blood starts to accumulate in the abdomen, causing it to become rigid, and board-like. Choice A is incorrect. Painless bleeding is NOT a sign of placental abruption. Instead, it is a sign of placenta previa. In placenta previa, the placenta is covering the cervix. This causes painless bleeding. In placental abruption, the placenta separates from the wall of the womb. This creates a massive amount of very painful dark red bleeding. It is important to remember the difference between these two emergencies. Placenta previa presents with painless bleeding, whereas placental abruption presents with painful bleeding. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery

While on your first posting at a Sleep clinic, you are reviewing the stages of sleep. Place the following steps or phases of sleep in an appropriate sequential order of the sleep cycle. The stage of the sleep cycle that is characterized with a brief period of very light sleep. The stage of the sleep cycle that is characterized with 10 to 20 minutes duration. The stage of the sleep cycle that is characterized by delta waves. The stage of the sleep cycle that is characterized with vivid dreams.

The stage of the sleep cycle that is characterized with a brief period of very light sleep. The stage of the sleep cycle that is characterized with 10 to 20 minutes duration. The stage of the sleep cycle that is characterized by delta waves. The stage of the sleep cycle that is characterized with vivid dreams. Explanation Several clients suffer from sleep-related disorders and insomnia. Knowing the sleep cycle and its various stages helps the nurse to understand the sleep pattern disturbances better. Each sleep cycle lasts 90 to 120 minutes and repeats throughout the night. In general, the sleep cycle has two components based on whether it is accompanied by rapid eye movements (REM): The phases or stages of sleep in an appropriate sequential order of the sleep cycle are: NREM Stage 1: The stage of the sleep cycle that is characterized by a brief period of light sleep. This is a transition period from wakefulness to sleep and lasts about 5 to 10 mins. NREM Stage 2: During this period, both heart rate and body temperature drop. The brain produces bursts of rapid, rhythmic brain wave activity known as "sleep spindles" - most people spend about 50% of the total sleep in this stage. NREM Stage 3: This was previously divided into stages 3 and 4. This is the stage of the sleep cycle that is characterized by difficulty in terms of awakening (Deep Sleep). During this period, muscles relax, blood pressure, and breathing rate decrease. It is also referred to as delta sleep because it is characterized by deep, slow brain waves (low frequency, high amplitude) known as delta waves. This stage represents 10 to 20 percent of the total sleep time in young to middle-aged adults but decreases with age. Most parasomnias such as sleepwalking (somnambulism) occur during this stage. REM Sleep: This is the stage that follows NREM deep sleep and is characterized by vivid dreams (REM sleep). In this stage, the brain becomes more active, the body becomes relaxed and immobilized, and eyes rush. REM sleep, on an average, begins 90-minutes after falling asleep. When REM sleep is complete, the cycle returns to stage 2 sleep. Sleep cycles through these stages about four to five times throughout the night. NCSBN Client Need Topic: Basic Care and Comfort, Sub-Topic: Rest and Sleep.

A patient is being intubated in the trauma bay after falling from a 20-ft deer stand. The doctor instructs the nurse to prepare intubation drugs. Which drug should the nurse administer first? A. Propofol [54%] B. Vecuronium [7%] C. Succinylcholine [35%] D. Rocuronium [4%]

Explanation Choice A is correct. Propofol is a sedative agent, which needs to be administered first before a paralytic agent. Choices B, C, and D are incorrect. These are all paralytic agents. Whatever paralytic agent the doctor orders will need to be given after the sedative. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Expected Actions/Outcomes, Critical Care

Hospitalization may affect or delay the progression of which physical development of a 1-yr-old patient? A. Walking [82%] B. Running [4%] C. Sitting [4%] D. Crawling [10%]

Explanation Choice A is correct. At 1-year-old, children should be beginning to walk. Hospitalization during this age could delay this stage of development. Choice B is incorrect. The patient should just be learning to walk at this age, not running. Choice C is incorrect. The child should be sitting up by six months of age. Choice D is incorrect. The child should already be crawling before age 1. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Growth and Development of the Infant

Which of the following is the correct interpretation for the following arterial blood gas? pH: 7.31 PCO2: 40 HCO3: 18 A. Metabolic acidosis [79%] B. Respiratory acidosis [16%] C. Metabolic alkalosis [3%] D. Respiratory alkalosis [2%]

Explanation Choice A is correct. This ABG shows metabolic acidosis. The pH is less than 7.35, which is acidosis. The PCO2 is between 35 and 45, which is normal. Lastly, the HCO3 is less than 22, which is acidotic. The HCO3 shows acidosis like the pH, so we know this is metabolic acidosis. Choices B, C, and D are incorrect. These are not the correct acid-base disorder for the patient. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Laboratory Values

Which interventions are appropriate for venous thromboembolism prophylaxis when caring for a non-ambulatory client? Select all that apply. A. Floating both of the heels using a pillow [11%] B. Apply sequential compression devices to the lower extremities [29%] C. Encourage range of motion exercises in the lower extremities [31%] D. Apply compression hose to the lower extremities [18%] E. Administer enoxaparin subcutaneously, as prescribed [11%]

Explanation Choices B, C, D, and E are correct. Sequential compression devices (SCDs) provide DVT prophylaxis by applying intermittent external pressure, pushing blood into deep veins, reducing stasis, and improving venous return. Range of motion exercises should be encouraged for a non-ambulatory client to encourage venous return. Thromboembolic deterrent (TED) hose promotes venous blood flow, prevents venous dilation, improves venous valve function, and stimulates endothelial fibrinolytic activity. Enoxaparin is a low molecular weight-based heparin given subcutaneously in the abdomen. This is a form of chemical VTE (venous thromboembolism) prophylaxis. Choice A is incorrect. Floating the heels is a measure to prevent a pressure ulcer. The heels may be floated using pillows or a specialty mattress that relieves the pressure. This would not be a measure to prevent a VTE. NCLEX Category: Reduction of Risk Potential Related Content: Potential for Alteration in Body Systems Question Type: Application Additional Info Prophylaxis for VTE includes mechanical and chemical agents. Mechanical prophylaxis involves SCDs and TED hose. Chemical prophylaxis includes medications such as enoxaparin or heparin. Risk factors for VTE include • Active cancer • Previous VTE (excluding superficial vein thrombosis) • Reduced mobility • Known thrombophilic condition • Recent (≤1 month) trauma and/or surgery • Older adult (≥70 years) • Cardiac and/or respiratory failure • Acute MI and/or ischemic stroke • Acute infection and/or rheumatologic disorder • Obesity (body mass index [BMI] ≥30) • Ongoing hormonal treatment

The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to: A. Prevent client injuries [57%] B. Comply with regulations [5%] C. Determine the cause [16%] D. Correct mistakes [21%]

Explanation Choice A is correct. The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to prevent client injuries. Choice B is incorrect. Although regulations mandate the reporting of incidents, accidents, medical errors, and sentinel events, compliance is not the primary and ultimate purpose of it. Choice C is incorrect. Although determining the cause of incidents, accidents, medical errors, and sentinel events is an outcome of this reporting, this is not the primary and ultimate purpose of it. Choice D is incorrect. Although correcting mistakes and faulty processes are outcomes of this reporting, this is not the primary and ultimate purpose of it.

The nurse is caring for a group of clients. Which client should the nurse see first? Drag and drop each client in order of priority starting with the first client to be seen. A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. A 65-year-old newly admitted client with an acute coronary syndrome (ACS) who is receiving a heparin infusion. A 51-year-old client who has a discharge prescription following a heart failure exacerbation. A 31-year-old client three days post-operative who requires a sterile dressing change.

A 65-year-old newly admitted client with an acute coronary syndrome (ACS) who is receiving a heparin infusion. A 46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site. A 31-year-old client three days post-operative who requires a sterile dressing change. A 51-year-old client who has a discharge prescription following a heart failure exacerbation. Explanation The nurse initially should see the client with ACS because of the instability that coincides with this condition. The client who is two days post-operative complaining of burning at the urinary catheter site should be assessed next. After that, the client requiring a sterile dressing change who is three days post-operative should be evaluated. Finally, the client requesting discharge teaching should be seen last because this would be considered low priority.

Which of the following integumentary assessments in the newborn are normal? Select all that apply. A. Lanugo [28%] B. Milia [22%] C. Mongolian spots [24%] D. Vernix caseosa [26%]

Explanation Choices A, B, C, and D are all correct. A is correct. Lanugo is fine, soft hair that covers the body and limbs. This is a common finding in newborns and is considered normal. B is correct. Milia are small white bumps typically found on the noses and cheeks of newborns. They are very common, considered normal, and usually go away on their own. C is correct. Mongolian spots are usual in newborns. They are a type of birthmark due to the extra pigment in certain parts of the skin. D is correct. Vernix caseosa is the "cheese-like" coating that covers the skin of a newborn immediately after birth. This is a normal finding and should not be removed from the baby until their first bath, as it provides moisture to their skin. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn

Place the following stages of Freud's psychosexual development in the correct order: Genital stage Phallic stage Oral stage Latency stage Anal stage

Oral stage Anal stage Phallic stage Latency stage Genital stage Explanation Correct ordered sequence: C, E, B, D, A. The oral stage is first. According to Freud's psychosexual stages, children from 0 to 1-years-old are in the oral stage. In this stage, children are interested in putting things in their mouths, sucking, and tasting. They will put unfamiliar objects in their mouth and derive pleasure from oral activities. Second is the anal stage. Children from 2-3 years old are in the anal stage. This is the stage when toilet training occurs. If children can complete this activity, they pass out of the anal stage, but if they struggle, then they may become 'stuck' in their psychosexual development. The third is the phallic stage. Freud believes that 3-6-year-old children are in the phallic stage of psychosexual development. In this stage, boys become very attached to their mother, whereas girls become very attached to their father. Fourth is the latency stage. According to Freud's psychosexual stages, children from 6-years-old until puberty starts are in the latency stage. In the latency stage, children tend to spend most of their time with peers of the same sex. This is when they begin school and tend to interact mostly with those of the same sex. Lastly is the genital stage. This stage occurs from puberty and beyond. In the genital stage, individuals are attracted to opposite-sex peers. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Development

A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself forming an obstruction is called what? A. Intussusception [74%] B. Pyloric stenosis [8%] C. Hirschsprung's disease [14%] D. Omphalocele [4%]

Explanation Choice A is correct. A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself, forming an obstruction, is called intussusception. Choice B is incorrect. Pyloric stenosis is the enlargement and stiffening of the pylorus, the opening from the stomach into the duodenum. This prevents the passage of food into the duodenum and results in projectile vomiting. Choice C is incorrect. Hirschsprung's disease is a congenital anomaly that results in mechanical obstruction. Choice D is incorrect. Omphalocele is a congenital disability in which an infant's intestine or other abdominal organs are outside of the body, protruding through a hole in the umbilical region. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - GI

A nurse is tending to a client who has been having sleep problems. Which of the following are possible independent nursing functions that can be implemented to promote sleep and rest? Select all that apply. A. The administration of over-the-counter diphenhydramine. [4%] B. The administration of zolpidem at the hours of sleep. [7%] C. Recommending vigorous exercise at bedtime to promote fatigue. [2%] D. Offering a soothing back massage. [34%] E. Providing a hot beverage of the client's choice. [18%] F. Encouraging exercise and activity during the daytime hours. [35%]

Explanation Choices D and F are correct. A soothing back massage and encouraging exercise/activity during the daytime hours are both sleep promotion interventions that can and should be done without a doctor's order. These interventions are considered independent nursing functions because a doctor's prescription is not necessary to perform them. Choices A, B, C, and E are incorrect. Although the administration of diphenhydramine and zolpidem would promote sleep, these interventions are not independent nursing functions. The administration of all medications, even over-the-counter drugs, cannot be done without a doctor's order. Vigorous exercise at bedtime is not appropriate to recommend; vigorous activity should be avoided for at least one hour before bedtime to promote sleep. Although hot beverages can promote sleep, the client's beverage of choice may impair sleep. For example, caffeinated beverages, including soft drinks and coffee, are not used to promote sleep. Additional Information: Sleep problems are common for clients in the hospital environment. Independent nursing interventions to promote sleep for the hospitalized client include: Ensuring pain is adequately managed Reducing environmental noise Clustering care to minimize interruptions to rest Dimming lights as much as possible during sleep Therapeutic relaxation techniques Encouraging activity during waking hours to promote normal sleep cycles Emulating the client's normal bedtime routine as much as possible NCLEX Category: Basic Care and Comfort Related Content: Rest and Sleep Question Type: Application