Easy/Medium Missed Questions on Archer

Total parenteral nutrition (TPN) is being considered for your client. Your client tells you, "My doctor is thinking about hyperalimentation, and I know nothing about it. Can you tell me what it is?". You should respond to this client's statement with:

"Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line." (You should respond to this client's statement with, "Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line." Parenteral nutrition, which is synonymous with hyperalimentation and IV hyperalimentation, provides the client with complete food when it is indicated for a client such as one who is adversely affected)

The nurse is providing discharge education regarding a newly prescribed medication, apixaban. Which of the following statements by the client would require follow-up?

"I should maintain a balanced diet and avoid excessive intake of foods high in vitamin K, like leafy greens." ( Indicates that the client does not understand the education provided regarding apixaban. Aside from alcohol there are no specific foods that are recommended to avoid while taking apixaban.)

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

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

The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?

"I will be prescribed an anticoagulant and need to take it with a sip of water on the day of surgery." (After the surgery, the client will be prescribed VTE prevention (sequential compression devices, subcutaneous enoxaparin). The client should not take an anticoagulant or antiplatelet for 5-7 days or as directed by the surgeon before the surgery. This would raise the risk for intra- and postoperative hemorrhage. Other medications such as vitamin E, garlic, and aspirin should be avoided because these will increase the risk of bleeding.)

The nurse reviews a client's understanding of newly prescribed nitroglycerin sublingual tablets. Which of the statements, if made by the client, would require follow-up?

"I will take one tablet every 2 minutes if chest pain occurs."

The nurse educator is talking to a group of students regarding anorexia nervosa. Which statement by the students indicates an understanding of the condition?

"Impulsivity and perfectionism are personality traits highly associated with anorexia nervosa." (Clients with anorexia nervosa have the desire to please others; thus, impulsivity and perfectionism are personality traits highly associated with anorexia nervosa. These clients often feel the need to be "perfect" to cope with stress or other self-perceived concerns.)

The nurse is performing teaching for a client scheduled for gastric bypass surgery. Which client statement requires follow-up by the nurse?

"Once I am home, I can advance my diet as tolerated" (This statement requires follow-up because it is untrue. After bariatric surgery, clients follow a strict diet plan the physician's orders. A clear liquid diet is ordered for up to one week following surgery. The clear liquid cannot include sugars or caffeine, which may cause the client gastrointestinal upset and hamper weight loss. The physician will then advance the client to a full liquid diet which should still omit concentrated sugars.)

The newly hired nurse cares for a client with venous thromboembolism (VTE) prescribed a heparin infusion and warfarin. Which statement, if made by the newly hired nurse, requires follow-up?

"The infusion should be discontinued once the INR is 4.0." (This statement requires follow-up because the INR should be between 2.0 and 3.0 before the heparin infusion is discontinued. An INR of 4.0 is conce)

The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include?

"You will need to lay flat immediately after this procedure." (A percutaneous kidney biopsy will be required to lay supine immediately following the procedure to achieve and maintain hemostasis. A back roll may be used to provide additional support.)

The nurse is caring for a client who is receiving prescribed quetiapine. Which of the following findings would indicate the client has an adverse effect?

-Fever -(Drowsiness) -Stooped posture -Shuffling gait -(Increased appetite) (Quetiapine is an atypical antipsychotic used to treat schizophrenia and bipolar disorder. Fever is an adverse reaction because this could be strongly suggestive of Neuroleptic Malignant Syndrome (NMS). Stooped posture and shuffling gait are quite concerning because these are symptoms of an extrapyramidal syndrome (EPS). These symptoms should be reported to the primary healthcare provider.)

The procedure for checking the client's blood glucose levels in the correct sequential order is as follows:

-Verify and confirm that the code strip corresponds to the meter code. -Disinfect the client's finger with an alcohol swab. -Prick the side of the finger using the lancet. -Turn the finger down so the blood will drop with gravity. -Wipe off the first drop of blood using sterile gauze. -Collect the next drop on the test strip. -Hold the gauze on the client's finger after the specimen has been obtained. -Read the client's blood glucose level on the monitor.

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

28 lbs (A healthy child is expected to quadruple their weight by age 2.)

A 70-year old man in the ICU experiences sudden cardiac arrest. The code team arrives and performs CPR. After about five minutes, the patient obtains a return of spontaneous circulation (ROSC). A carotid pulse is found, but femoral and radial pulses are not. What is this patient's approximate minimum systolic blood pressure?

60 mmHg (Cardiac arrest is the spontaneous cessation of perfusion by the heart. Following a successful cardiopulmonary resuscitation (CPR), there is a resumption of sustained heart rhythm that perfuses the body leading to the return of pulse rate and blood pressure. This is referred to as the return of spontaneous circulation (ROSC). The signs of ROSC include significant spontaneous breathing effort, coughing, movement, palpable pulse, measurable blood pressure, or abrupt sustained increase in end-tidal CO2 (PETC02). ROSC is detected by arterial pulse palpation and end-tidal CO2 monitoring. When pulses are palpable, it can be clinically inferred that a patient with a carotid pulse has a systolic blood pressure (SBP) of at least 60 mmHg, the one with a femoral pulse has an SBP of at least 70 mmHg, and the one with a radial pulse has an SBP of at least 80 mmHg.)

The emergency department (ED) triage nurse is assigned to see the following clients. Which of the following clients requires the most rapid action in the ED?

A pregnant woman with a blister-like rash on the face who possibly has varicella. (The primary responsibility of the triage nurse is to perform an initial nursing assessment and determine which patient(s) require immediate care or isolation. The triage nurse should be able to identify patients who pose a potential risk to others by being familiar with commonly occurring illnesses/infections. Emergency department nurses and triage nurses must be adept at prioritization. Prioritization refers to the concept of deciding which duties/clients require immediate attention and which ones could be delayed until later. None of the clients in the options above show any signs of unstable vitals. Therefore, the safety of the client and other clients takes priority.)

The nurse is having difficulty locating a vein, to start intravenous therapy, on a client who is dark-skinned. Which of these devices or procedures may be of benefit to you at this time?

A transillumination device (A transillumination device may be of benefit to you when you are having difficulty locating a vein for this venipuncture and have to begin an intravenous therapy line for a client who is dark-skinned. Transillumination devices light up the area, and this light is sufficient to locate veins regardless of the client's skin color. These devices are also capable of identifying veins that are not palpable or visible when the client is obese.)

The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who

A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C). (A major complication of Hirschsprung's disease is the development of enterocolitis manifested by fever, abdominal distention, vomiting, and increased abdominal pain. Emergent intervention is necessary because the child may develop sepsis leading to septic shock.)

apply the PPE in what order?

Apply the gown Secure the mask Apply the goggles/face shield Don gloves

The nurse is preparing to administer ten units of regular insulin and twenty units of NPH insulin. Which of the following actions is correct when mixing the insulins?

Aspirate the regular insulin first (Regular (short-acting) insulin is clear. NPH (intermediate-acting) is cloudy. Giving one injection is more efficient and comfortable for the client. It is correct for the nurse to aspirate (which means remove) the regular insulin first, then aspirate the NPH insulin. This is performed after the air has been instilled in both vials, creating a negative pressure.)

The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below.

Assess the client's level of consciousness (This tracing depicts ventricular fibrillation. This rhythm is highly concerning because it can be fatal. Because the nurse has just seen this tracing on the telemetry monitor, the first action the nurse should take is to assess the client. Artifact may be confused for ventricular fibrillation, therefore the nurse should always assess the client first and not the monitor.)

One of the complications associated with the improper use of crutches is:

Axillary nerve damage (One of the complications associated with the improper use of crutches is axillary nerve damage Supporting one's weight on the upper support of crutches is not recommended because it can lead to axillary nerve damage. Despite this warning, improper axillary weight bearing frequently occurs due to various factors (i.e., a lack of arm strength, fatigue, improper client instruction, inappropriate crutch fit, etc.))

The nurse cares for a client receiving terbutaline infusion to prevent preterm labor. Which clinical findings indicate that the nurse should continue the infusion

Blood glucose 104 mg/dL (5.7 mmol/L) [70-110 mg/dL (4-6 mmol/L)] (Terbutaline may increase the client's blood glucose level. The nurse should monitor the client's blood sugar levels while on this medication. This glucose level is normal and indicates to the nurse that the infusion may continue.)

A four-year-old client is recovering from abdominal surgery on the pediatric unit. As the nurse caring for the client, which of the following activities would you prioritize for the client?

Blowing bubbles (Encouraging a four-year-old pediatric client to blow bubbles will stimulate the expansion of the client's lungs, thus decreasing the likelihood of surgery-related respiratory complications. General anesthesia and mechanical ventilation impair pulmonary function, resulting in decreased oxygenation in the post-anesthesia period. Additionally, the functional residual capacity of up to 50% of the pre-anesthesia value may be reduced. More specifically, following abdominal surgery, respirations are not as efficient, as anesthesia hampers respirations due to the pain associated with inspiration. Consequently, mucus may accumulate, potentially causing one or more lung to collapse fully or partially (atelectasis), with pneumonia potentially following. A collapsed lung may result in dyspnea and/or respiratory failure, complicating the client's post-operative recovery. To attempt to circumvent these potential complications, health care providers (HCPs) routinely order incentive spirometers for clients to use in the immediate post-operative period to reduce the risk of respiratory complications following abdominal surgery. However, if a pediatric client is under the age of five or cannot use an incentive spirometer due to other reasons (i.e., developmental delays, anatomical anomaly, etc.), the client should be encouraged to blow bubbles for two to three minutes every hour, as blowing bubbles may serve as an alternative to incentive spirometry in these clients.)

The most serious adverse effect of tricyclic antidepressant (TCA) overdose is:

Cardiac arrhythmias (The excessive ingestion of tricyclic antidepressants (TCAs) results in life-threatening wide QRS complex tachycardia. Tricyclic antidepressants are approved by the Food and Drug Administration (FDA) for treating several types of depression, obsessive-compulsive disorder, and bedwetting.)

The nurse is assessing a female client with syphilis. Which of the following would be an expected finding?

Chancre lesion (Syphilis is a sexually transmitted infection caused by T. pallidum. This insidious infection causes a client to experience a painless chancre in the area where the infection was contracted. That could be the penis, vagina, or rectum. This chancre lesion will eventually disappear and cause constitutional symptoms such as a generalized macular rash and malaise.)

A pediatric client with pulmonary tuberculosis (TB) is scheduled to be admitted to the pediatric unit when the charge nurse learns the remaining private room on the unit was filled on the prior shift. No other pediatric TB clients are currently admitted. What is the most appropriate action for the charge nurse?

Contact the infection control nurse (The charge nurse should consult the infection control nurse for client placement alternatives, as the pediatric client with pulmonary tuberculosis requires airborne isolation.)

A nurse is caring for a newborn with a myelomeningocele. Prior to surgery, the most appropriate intervention to keep the sac sterile and protected is to:

Cover the sac with moist, saline dressings. (Prior to surgical closure, the sac is kept from drying by the application of a sterile, moist, nonadherent dressing. The moistening solution is usually sterile normal saline. Dressings are changed frequently [every 2 to 4 hours], and the sac is closely inspected for leaks, abrasions, irritation, and signs of infection)

The nurse is educating a new graduate about alterations in cortisol levels. Which of the following conditions does she explain cause an increased cortisol levels in a client?

Cushing's disease (Cushing's disease produces elevated cortisol levels. Cortisol is best known for helping support the body's natural "fight-or-flight" instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance.)

The nurse cares for a client who has tolerated their prescribed clear liquid diet. The nurse obtains a full liquid diet order and should offer which item from this menu?

Custard (A full-liquid diet includes food items such as plain ice cream, strained soups, sherbet, milk, pudding, custard, breakfast drinks, refined cooked cereals, and strained vegetable juices. Custard is under the full liquid diet specification and is appropriate for the nurse to introduce to the client considering their diet has just been advanced.)

nurse is caring for a client who has recently arrived at the emergency department after experiencing a very traumatic event. The client appears calm and in control. The nurse assesses this behavior as which of the following defense mechanisms?

Denial (Denial is a coping mechanism used to protect a client from a traumatic experience. A client in denial will behave as though the trauma never occurred. Based on the available information this client is likely experiencing denial)

The nurse is administering medications to a 5-year-old client diagnosed with pneumonia. The health care provider has ordered a cough suppressant. Which medication does the nurse administer?

Dextromethorphan (Dextromethorphan is a cough suppressant. It is the ingredient in many over the counter cough medicines such as Delsym, Robitussin, and NyQuil. Dextromethorphan works by signaling the brain to stop triggering the cough reflex.)

The nurse is caring for a client who has rubella. The nurse should isolate the client using which of the following?

Droplet precautions (Rubella is known as German measles and requires droplet precautions. The nurse is right to wear a surgical mask when engaging with the client. The transmission mode for rubella is a droplet mode of communication where the spread occurs with particle drops larger than 5 microns.)

The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?

Encourage the consumption of high-protein foods (High-protein foods are encouraged because they promote wound healing and prevent fluid shifting, which may lead to a pressure ulcer. The prevention of fluid shifting (edema) contributes to a pressure ulcer. Optimal protein intake is key to preventing (and healing) a pressure ulcer.)

The nurse is caring for a client who is mechanically ventilated and receiving multiple intravenous medications. The client's family member is upset and overwhelmed by the client's clinical condition. Which therapeutic action would be appropriate for the nurse to take?

Explain the different types of medications and therapies the client is receiving (From the perspective of a family member, seeing a loved one receiving mechanical ventilation and multiple IV therapies can be overwhelming. The nurse must take an empathetic approach with the client's family, as this is a necessary caring behavior. Explaining to the family member the therapies the client is receiving can provide reassurance. It is the unknown that is likely causing the family member emotional distress and explaining the current treatments would provide valuable information, thereby lessening anxiety.)

The nurse is teaching a new grad about contractures. The nurse knows which statement about contractures secondary to immobility is accurate?

Flexion contractures are the most commonly occurring contracture. (Flexion contractures are the most commonly occurring type of contracture in a variety of client demographics. For example, lower extremity flexion contractures are commonly found in clients with neuromusculoskeletal disorders and those with lower extremity amputations, respectively. Three-fourths of institutionalized elderly clients with chronic health conditions have been shown to have knee flexion contractures. Furthermore, age-related muscle loss (i.e., sarcopenia) can contribute to prolonged sitting or lying by the client, subsequently increasing the client's risk of developing one or more hip flexion contractures.)

A patient presents with a round, non-tender nodule on the left wrist that is more pronounced upon flexion. The nurse would recognize this as which of the following conditions?

Ganglion cyst (Ganglion cysts are common, benign tumors over a tendon sheath or joint capsule. They are typically non-tender unless the tumor puts pressure on a nerve. When on the wrist, they become more noticeable with flexion. A ganglion cyst generally resolves on its own and does not require treatment, but can be drained/removed if causing discomfort.)

The nurse is caring for a patient who has recently had a femoral vein catheter placed. The nurse would be most correct in advising the patient to do which of the following?

Refrain from sitting up more than 45 degrees (Patients who have undergone a femoral vein catheter should refrain from sitting up more than 45 degrees because this could kink the catheter, thus interfering with treatment.)

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

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

The nurse is caring for a client with urge incontinence. Which of the following actions would be appropriate for the nurse to take?

Have the client void on a timed schedule. (Urge incontinence is also known as overactive bladder (OAB). The essential manifestation of this incontinence is the involuntary loss of urine associated with a strong desire to urinate. Thus, it would be appropriate for a client to void on a timed schedule. Timed voiding enables an individual to gradually increase the amount of urine they may hold without an abrupt urge to go to the bathroom. The goal is also to prolong the time interval between urinating - up to a minimum of three or more hours.)

Religious and cultural rituals/practices often surround death. Which of the following populations prefer cremations rather than burying the remains of the deceased person?

Hindus (The Hindus prefer cremations rather than burying the remains of the deceased person. The ashes are then typically spread over the holy river. Cremations are viewed as discouraged or forbidden among those who practice Islam, Mormonism, and the Eastern Orthodox religion.)

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

Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.

The nurse is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up?

Hydrochlorothiazide

The nurse is caring for a client who has sickle cell disease (SCD). Which prescription from the primary healthcare provider (PHCP) should the nurse anticipate?

Hydroxyurea is an effective treatment for SCD. This medication increases fetal hemoglobin and decreases hemoglobin S. By increasing fetal hemoglobin, the sickling effect can be reduced, and oxygen carrying capacity can be improved.

The nurse is participating in a committee reviewing strategies to reduce falls in the older adult. Which of the following recommendations by the nurse would be appropriate to make?

Increase the number of bedside commodes in the client rooms (Utilizing more bedside commodes for older adults may reduce falls because it shortens the distance a client needs to travel to the bathroom. Bedside commodes are especially effective for those receiving medications such as diuretics and undergoing bowel prep. Thus, a bedside commode is an effective intervention to reduce falls for the older adult.)

The nurse is performing a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are

Janeway lesions (Janeway lesions are common with infective endocarditis (IE). The cause of these findings are the cause of the lesions are septic microemboli from the valvular lesion. These macules are not painful and are typically located on the toes' palms, soles, and plantar surfaces.)

Parenting styles are most similar to whose theory of leadership?

Kurt Lewin's theory of leadership is the most similar to the styles of parenting. (Lewin describes the leadership styles as the autocratic, participative, democratic, and laissez-faire styles of leadership, which are the same as the different parenting styles. All these styles of leadership and parenting styles have their distinct advantages and disadvantages.)

Parenting styles are most similar to whose theory of leadership?

Lewin (Kurt Lewin's theory of leadership is the most similar to the styles of parenting)

An 8-month-old infant has been brought into an emergency department (ED) for acute diarrhea and decreased oral intake. Which assessment finding would an ED nurse anticipate

Low hematocrit (Decreased skin turgor is often present in dehydrated infants, resulting in the child's skin taking longer than average to return to a normal state after it has been pinched into a tent-like position. This response, known as skin tenting, would be an anticipated symptom in an infant with dehydration. Skin tenting in an individual with decreased skin turgor is demonstrated in the illustration above.)

Which of the following best describes a newborn reflex that includes a hand opening with abducted and extended extremities following a jarring motion?

Moro reflex (The Moro reflex occurs in response to a slight drop, sudden movement of the crib, or a loud noise; the newborn quickly makes a symmetrical abduction of the extremities and places the index fingers and thumbs into a "C" shape.)

The nurse should notify the physician immediately to assess the client and prepare for surgery since this could signify a rupture of the appendix; any delay could cause peritonitis.

Notify the physician (The nurse should notify the physician immediately to assess the client and prepare for surgery since this could signify a rupture of the appendix; any delay could cause peritonitis.)

The nurse is educating a new graduate nurse on different forms of therapeutic communication. Select the form of therapeutic communication which is accurately paired with the correct description of that form of therapeutic communication.

Reflection: By repeating the client's words back to the client, the nurse conveys that they are actively listening while concurrently encouraging further expression from the client (Reflection is a way of helping clients better understand their thoughts and feelings. By utilizing a question, simple statement, or the client's own words, the nurse may convey their observations of the client.)

The nurse is caring for an infant with a congenital abnormality whose abdominal contents protrude through the umbilicus while remaining in the peritoneal sac. The nurse knows the infant will be diagnosed with which of the following?

Omphalocele (This infant has an omphalocele. An omphalocele is a congenital abnormality where the abdominal contents come through the umbilicus while remaining in the peritoneal sac. Omphalocele is associated with an abdominal wall defect, and it occurs because the gut contents fail to rotate and return to the abdominal cavity during development. Advanced maternal age is a significant risk factor for omphalocele. With successful repair, 90% of infants with an omphalocele can survive.)

The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)?

Oseltamivir (Oseltamivir is an antiviral agent approved for the treatment of influenza. This medication should be initiated within 48 hours of symptom onset)

Which of the following anticholinergics does the nurse recognize as appropriate for a patient diagnosed with urinary bladder urgency and incontinence?

Oxybutynin (Oxybutynin is used to treat urinary bladder urgency and incontinence. Anticholinergics are drugs that have actions opposite those of the parasympathetic branch. Their action mimics the fight-or-flight response.)

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority?

Palpate pedal pulses (The most significant complications this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain.)

A 60-year old adult walks into the clinic with a forehead laceration. He was going 45 mph on his motorcycle when he skidded on the gravel and fell off his bike. He isn't sure if he hit his head. After checking for significant bleeding and apparent signs of injury, what is the first intervention the nurse should do?

Place a c-collar on the patient's neck. (After checking for apparent signs of illness, this patient needs c-spine precautions placed immediately. This patient was going faster than 30 mph on a motorcycle. We are not sure if he was wearing a helmet, but with the mechanism of injury, he could have a possible c-spine injury. This is important in preventing any spinal cord damage from occurring.)

The nurse is caring for a client with right-sided weakness. When transferring the client from the bed to a wheelchair, the nurse should perform which action?

Place the wheelchair as close to the bed as possible on the client's unaffected side (This is the correct technique in getting the client transferred from the bed to the wheelchair. This would involve getting the client mobilized to the side of the bed and placing the wheelchair on the unaffected side. The nurse should not pull on any of the client's extremities because this could result in a joint dislocation or subluxation.)

The nurse is caring for a female client who is receiving prescribed isotretinoin. Which laboratory data is essential prior to the initiation of this therapy?

Pregnancy test (Isotretinoin is indicated in the treatment of moderate to severe acne vulgaris. This medication is highly teratogenic, and a negative pregnancy test is essential prior to the initiation of therapy.)

The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to:

Prevent client injuries (The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to prevent client injuries.)

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?

Progressive (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.)

After failing a final anatomy exam, a student is angry with the instructor and talks negatively about her. What defense mechanism is this an example of?

Projection (The client is placing blame on others and not taking responsibility for her behavior.)

This statement requires follow-up because it is untrue. After bariatric surgery, clients follow a strict diet plan the physician's orders. A clear liquid diet is ordered for up to one week following surgery. The clear liquid cannot include sugars or caffeine, which may cause the client gastrointestinal upset and hamper weight loss. The physician will then advance the client to a full liquid diet which should still omit concentrated sugars.

Quality of the client's peripheral pulses (As the nurse caring for this client, the priority should focus on assessing the client's respiratory status, as hypokalemia-related respiratory changes may occur due to respiratory muscle weakness, resulting in shallow respirations. Clients experiencing hypokalemia should have their respiratory status assessed at least every two (2) hours, as respiratory insufficiency caused by shallow respirations is a significant cause of death in individuals experiencing hypokalemia. Therefore, the nurse should ensure assessing this hypokalemic client's respiratory status is prioritized.)

A nurse cares 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 defense mechanism?

Rationalization (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, rationalizing 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.)

The nurse performs a physical assessment on a client and observes the client demonstrate palmar flexion while obtaining the blood pressure. The nurse should take which action?

Request an order for a magnesium level (Palmar flexion while obtaining blood pressure demonstrates the trousseau's sign. This sign is associated with severely low levels of magnesium or calcium. It would be appropriate for the nurse to obtain a magnesium level to discern if this level is low, which, if it is, may be replaced as prescribed.)

A patient being treated for hypertension is assessed by the nurse and found to have poor gait and impaired balance. What would the nurse's appropriate action be?

Speak with the attending physician about his concerns and request a referral to physical therapy. (Nurses need to be aware of the patient's needs even if they do not pertain to the reason for hospitalization and treatment. Observation is a crucial nursing skill. The nurse should always be alert for any changes in a patient's condition, regardless of the initial diagnosis. Being aware of the patient's status will equip the nurse to be a better advocate for patients and to request referrals when concerns or issues arise during care.)

The nurse is caring for a client who has generalized urticaria. The nurse should implement which disease transmission precautions?

Standard precautions (Generalized urticaria typically manifests when the client is experiencing an allergic reaction. This skin condition does not require isolation. The nurse should plan to care for this client using standard precautions.)

Which of the following outcome statements would be most appropriate for a newly hospitalized client experiencing an impairment of the second cranial nerve (CN II)?

The client will remain free of falls while hospitalized.

The nurse is preparing to administer a vaccine to an infant. Which location should the nurse select for administration? See the images in the options below.

This image shows an injection given in the vastus lateralis. This is the preferred injection site for IM injections in infants less than 12 months of age. The injection should be administered into the bulkiest part of the vastus lateralis muscle.

The nurse is caring for a client who is receiving clozapine. Which of the following findings would warrant immediate follow-up?

WBC 3,000 mm3 (N 4.5-11,000) (Follow-up laboratory work is essential for a client taking clozapine. The medication may adversely cause neutropenia. The client will be instructed to obtain this necessary laboratory work to ensure they are not experiencing agranulocytosis, which enhances the risk of infection. This WBC count is quite low and requires follow-up.)

The nurse is starting a peripheral vascular access device (VAD) and suffers a needlestick injury following the initiation of VAD. The nurse should take what action?

Wash the affected extremity with soap and water (The nurse should immediately wash the affected area with soap and water for a needlestick injury. Once this is completed, the nurse should notify the supervisor and implement the facility's needlestick injury protocol which may involve assessing the client for bloodborne pathogens. This protocol may also require post-exposure prophylaxis for blood-borne pathogens such as human immunodeficiency virus (HIV). Applying pressure to a finger or hand to make it 'bleed' is not recommended and only causes more trauma to the affected area.)

The nurse is admitting a 72-year-old patient hospitalized for a medical diagnosis of Mycoplasma pneumonia. Which transmission-based precaution is necessary?

Wearing a surgical mask within 3 feet of the patient (Droplet precautions are indicated for patients with Mycoplasma pneumonia. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, proper hand hygiene, and placement in a private room or with a cohort of patients. Other examples where droplet precautions are indicated include Pertussis, Influenza, Diphtheria, and invasive Neisseria meningitides. There are three types of transm)

What is the best time to assess the respiratory rate of a young child?

While the child is quietly sitting on the parent's lap (Respirations are best determined while the child is sleeping or quietly awake.)

The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when

after advancing to the point of bifurcation.

The nurse takes a phone call from a parent of an adolescent with a cast following a tibia fracture. The client's parent indicates that they have excessive itching. The nurse should recommend for the parent to

apply cool air under the cast with a blow-dryer. (Itching underneath a cast is common and can be relieved by using a blow-dryer set to the cool setting. Instructing clients and caregivers on proper cast care will help reduce the risk of further injury or complications.)

The occupational health nurse assesses a health care worker's purified protein derivative (PPD) test and measures 11 mm of induration. The nurse should interpret this finding as

further testing is required. (An 11 mm induration after 48 to 72 hours would be recorded as a positive result. However, this does not confirm pulmonary tuberculosis, as further testing (chest x-ray) is required to determine if the client has latent pulmonary tuberculosis. The PPD is not a confirmatory test for pulmonary tuberculosis - a sputum sample is used to confirm an active infection, and a chest x-ray is used for latent infection.)

The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe

gentamicin.

The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who

had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing. (A subtotal thyroidectomy requires the nurse to monitor the client for complications such as laryngeal edema. This may be manifested as a hoarse voice, difficulty swallowing, and stridor. The primary healthcare provider (PHCP) may prescribe post-operative steroids to prevent this complication. The nurse needs to follow up with this client to assess the client's airway patency)

The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is at risk for hypokalemia? A client with

hyperemesis gravidarum. (Hyperemesis gravidarum is a pregnancy complication characterized by severe nausea, vomiting, weight loss, and possibly dehydration. The intense vomiting is why this condition puts the patient at risk for hypokalemia. The hypokalemia associated with hyperemesis gravidarum is related to the metabolic alkalosis the client experiences due to the vomiting.)

The nurse is caring for assigned clients. The nurse should immediately follow up with the client who

is recovering from a thoracentesis and reports a nagging cough. (Following a thoracentesis, the nurse must assess the client for the most common complication of pneumothorax. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube may be needed.)

The nurse is caring for a pregnant client with a decreased alpha-fetoprotein level. The nurse plans to

notify the primary healthcare provider (PHCP) of the results. (Alpha-fetoprotein (AFP) is a substance produced by the developing baby, which can enter both the amniotic fluid and the mother's bloodstream. Normally, a small amount of AFP is present in both the amniotic fluid and the maternal blood. However, in cases where a woman is carrying a baby with Down syndrome, AFP blood levels may be lower. Conversely, if AFP levels are elevated, it serves as a signal for the physician to conduct further investigations, as it may indicate the possibility of a neural tube defect or be related to a multifetal pregnancy. Regardless of the underlying cause of these variations in AFP levels, it is essential for the nurse to promptly inform the primary healthcare provider (PHCP) of the test results.)

The nurse is caring for a client with pneumothorax with a chest drainage system in place. On assessment, the system has become dislodged from the client. The nurse should initially

place an occlusive dressing over the site and tape on three sides. (Tympany refers to a high, loud, drum-like tone that can be heard with percussion over air-containing organs. The stomach and intestines would produce tympany in a healthy adult.)

The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student

positions the handgrips so that the axillae support the client's body weight.

The nurse is caring for a client admitted to the acute care facility. The nurse takes a phone call from the client's neighbor who wants to know where the client is located. The nurse should

provide the caller with the client's current location. (HIPAA allows directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated.)

The nurse is discharging a client home who has pulmonary tuberculosis. To prevent disease transmission of the client's infection to others, the nurse should recommend that

your mouth should be covered with a tissue when you cough or laugh and dispose of it in a trash receptacle. (Pulmonary TB is only spread via aerosolized droplets. TB is not spread via contact with surfaces, handshakes, sitting on toilet seats, or dishes. The essential teaching point to a client with pulmonary TB is to instruct the client to exercise respiratory etiquette, such as covering your mouth with a tissue when you cough or laugh. The tissues should be disposed of in a trash can. The client is at the highest risk of transmitting TB while symptomatic. Once the client begins antitubercular medications, the risk of transmission drops after two to three weeks.)