mynclex set 4 - 42

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply. 1. Assess for bruising 2. Assess for tarry stools 3. Monitor intake and output 4. Monitor liver function tests 5. Monitor platelets OmittedCorrect answer 1,2,5 48%Answered correctly

Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5). (Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients without hepatic impairment. Educational objective:Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The clinic nurse supervises a graduate nurse who is teaching the parents of a 2-year-old with acute diarrhea about home management. The nurse would need to intervene when the graduate nurse provides which instruction? 1. "Do not administer antidiarrheal medications to your child." (26%) 2. "Follow the bananas, rice, applesauce, and toast diet for the next few days." (32%) 3. "Record the number of wet diapers and return to the clinic if you notice a decrease." (28%) 4. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides." (12%) OmittedCorrect answer 2 32%Answered correctly

During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, using oral rehydration solutions (ORSs) to increase reabsorption of water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at frequent intervals. Continuing the child's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy. (Option 1) Use of antidiarrheal medications is discouraged as these have little effect in controlling diarrhea and may actually be harmful by prolonging some bacterial infections and causing fatal paralytic ileus in children. (Option 3) Parents should be taught to monitor their child for signs of dehydration by checking the amount of fluid intake, number of wet diapers, presence of sunken eyes, and the condition of the mucous membranes. (Option 4) Protecting the perineal skin from breakdown during bouts of diarrhea can be accomplished by using skin barrier creams (eg, petrolatum or zinc oxide). Educational objective:When a child is experiencing acute diarrhea, the priority is to monitor for dehydration. Treatment is accomplished with oral rehydration solutions and early reintroduction of the child's normal diet (usual foods). Additional Information Physiological Adaptation NCSBN Client Need

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe? 1. Decreased rate and depth of respirations (6%) 2. Deficits in visual perception (81%) 3. Expressive aphasia (7%) 4. Inability to recognize touch (3%) OmittedCorrect answer 2 81%Answered correctly

A coup-contrecoup head injury occurs when the head strikes an object and the brain receives an injury under the area of impact (coup), after which it rebounds to the opposite side of the skull and sustains injury on that side as well (contrecoup). This type of injury is common in motor vehicle accidents and shaken baby syndrome. Visual processing occurs in the occipital lobe. (Option 1) The rate and depth of respirations are regulated by the medulla oblongata at the base of the brainstem. (Option 3) Expressive aphasia, the inability to express spoken words, occurs after a transient ischemic attack or stroke. This will occur if the frontal lobe (Broca aphasia) or temporal lobe (Wernicke aphasia) is injured. (Option 4) Inability to recognize being touched is indicative of injury to the parietal lobe of the brain. Educational objective:Coup-contrecoup head injuries are common in motor vehicle accidents and shaken baby syndrome. Damage to the occipital lobe of the brain during coup-contrecoup head injury will result in visual disturbances.

A client suffering from bladder prolapse and subsequent stress urinary incontinence has discussed treatment options with the health care provider (HCP). The nurse evaluates that the client understands support pessary use when the client makes which statement? 1. "After the pessary is surgically placed, I'll experience bladder discomfort for several weeks." (23%) 2. "I can remain sexually active while my pessary is in place." (32%) 3. "I need to schedule weekly appointments to have the pessary removed and replaced." (15%) 4. "I should report any vaginal discharge to my HCP immediately." (29%) OmittedCorrect answer 2 32%Answered correctly

A pessary is a vaginal device that provides support for the bladder. Clients can remain sexually active while wearing a pessary. They are fitted for the proper type and size by an HCP in the office. Surgery is not required for pessary placement; clients who are able can insert and remove the pessary themselves (Option 1). If a pessary or other treatment (eg, pelvic muscle exercises, estrogen replacement therapy) is ineffective, reconstructive surgery may be indicated. (Option 3) Clients who are able to remove and reinsert the pessary on their own will have the choice to remove it weekly, possibly even nightly, for cleaning. Clients who are sexually active may prefer to remove the pessary prior to intercourse, although this is not necessary. When the client cannot remove the pessary regularly, removal by an HCP at 2- to 3-month intervals is recommended. (Option 4) Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be instructed to notify the HCP to be treated for a possible infection. Educational objective:A pessary is a vaginal support device recommended for pelvic organ prolapse. Pessaries are fitted by an HCP; many clients can then remove, clean, and replace these themselves. Clients can remain sexually active with a pessary in place.

When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization? 1. Dysuria (10%) 2. Hypotension (34%) 3. Infection (47%) 4. Tachycardia (6%) OmittedCorrect answer 2 34%Answered correctly

Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option 2). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option 3). (Option 1) Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and adequate blood pressure is the priority concern. (Option 4) With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system. Educational objective:Acute urinary retention is best treated with rapid complete bladder decompression. The nurse should carefully assess for hypotension and bradycardia, which are potential complications.

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply. 1. Client diagnosed with lumbar spinal cord compression has paraplegia 2. Client's Glasgow Coma Scale (GCS) score is 3 3. Client is refusing a life-saving treatment due to religious beliefs 4. Client with intracerebral hemorrhage has aphasia 5. Oriented client has cancer and is on a ventilator OmittedCorrect answer 2,4 48%Answered correctly

Advance directives give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. The 2 most common forms are living wills and durable power of attorney for health care (health care surrogate/proxy). A client who is alert and oriented can directly address a health care decision. Clients in a coma (GCS score ≤7) or with expressive aphasia would need an advance directive to make treatment decisions because they cannot directly express their wishes. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing (Options 2 and 4). (Option 1) Mental capacity is not affected in spinal cord compression. The client is able to speak. (Option 3) An adult who is mentally capable of making decisions has the right to refuse treatment for any reason at any time whether the health care provider believes it is in the client's best interest or not. (Option 5) A client who is oriented can make and communicate decisions for him/herself although unable to verbalize. The client could nod or write out wishes. Educational objective:Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing.

The nurse reviews the most current laboratory results of assigned clients. Which result should the nurse report to the health care provider immediately? 1. Client who has cellulitis of the leg with a white blood cell (WBC) count of 13,000/mm3 (13.0 × 109/L) (4%) 2. Client who has chronic kidney injury with a hematocrit of 28% (0.28) and hemoglobin of 9 g/dL (90 g/L) (18%) 3. Client who has type 2 diabetes mellitus with a 2-hour postprandial serum glucose of 165 mg/dL (9.2 mmol/L) (2%) 4. Client who is 1 month post kidney transplant with a urinalysis showing WBCs and bacteria (74%) OmittedCorrect answer 4 74%Answered correctly

Almost all post kidney transplant clients are prescribed immunosuppressant drugs (eg, cyclosporine, azathioprine, prednisone) to help prevent organ rejection. This client's immunocompromised condition increases the risk for developing infection. Therefore, early recognition and prompt treatment of infection are critical to survival. The nurse should notify the health care provider (HCP) immediately of any signs or symptoms of an infection as well as abnormal urinalysis findings. (Option 1) Cellulitis is a bacterial infection (eg, Staphylococcus aureus, streptococci) that causes inflammation of the subcutaneous tissues. An increased WBC count (normal 4,000-11,000/mm3 [4.0-11.0 × 109/L]) would be expected in this client, so immediate notification of the HCP is not necessary. (Option 2) Clients with chronic kidney injury have a decreased level of the hormone erythropoietin, resulting in decreased erythrocyte production. Decreased hematocrit (normal 39%-50% [0.39-0.50] for males, 35%-47% [0.35-0.47] for females) and hemoglobin (normal 13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L for females) levels would be expected in this client, so immediate notification of the HCP is not necessary. (Option 3) An elevated postprandial serum glucose (>140 mg/dL [7.8 mmol/L]) would be expected in a client with type 2 diabetes mellitus, so immediate notification of the HCP is not necessary. Educational objective:Clients who have undergone kidney (or any organ) transplantation are prescribed immunosuppressant drugs to help prevent organ rejection and are therefore at increased risk for developing infection. The nurse should notify the HCP immediately of any signs or symptoms of an infection.

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room? 1. 4-year-old girl in Buck traction and 5-year-old boy post laparoscopic appendectomy (61%) 2. 6-year-old girl with varicella and 7-year-old girl with measles (18%) 3. 9-month-old boy with rotavirus infection and 8-month-old boy with salmonella infection (7%) 4. 14-year-old girl with sickle cell anemia and 13-year-old girl with periorbital cellulitis (12%) OmittedCorrect answer 1 61%Answered correctly

Although placing pediatric clients of different sexes in a semi-private room is not ideal, the charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5, the male-female pair can room together. The client in Buck traction does not have a transmittable illness. The client post laparoscopic appendectomy is also not infectious. Given the options above, this is the safest room assignment. (Option 2) Children with infections requiring airborne precautions (eg, varicella, tuberculosis, measles) should be placed in a private, airborne infection isolation room (eg, negative airflow room). If required, clients infected with the same organism can be roomed together, but a private room is preferred. (Option 3) Rotavirus is a viral gastroenteritis, and salmonella is a bacterial gastroenteritis. The risk for cross contamination is high, especially with caregivers sharing the facilities. (Option 4) A client with sickle cell anemia is at risk for infection due to spleen dysfunction (repeated infarctions), and a client with periorbital cellulitis has an infection. Although compatible in age and sex, these clients should not share a room. Educational objective:Pediatric room placement should be based on disease process, sex, and developmental stage. When assigning children to semi-private rooms, the charge nurse must consider client safety first. Additional Information Safety and Infection Control NCSBN Client Need

A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat. The client has a pulse of 135/min, respirations 32/min, and oxygen saturation 84%. The client also has circumoral cyanosis and decreased level of consciousness. Place the nurse's actions while awaiting the arrival of the rapid response team in priority order. All options must be used. Your Response/ Incorrect Response 4. Perform oropharyngeal suctioning 1. Administer 100% oxygen by nonrebreather mask 5. Place client in high Fowler's position 2. Assess lung sounds 3. Notify the primary health care provider (HCP) . Correct Response 5. Place client in high Fowler's position 4. Perform oropharyngeal suctioning 1. Administer 100% oxygen by nonrebreather mask 2. Assess lung sounds 3. Notify the primary health care provider (HCP) OmittedCorrect answer 5,4,1,2,3 33%Answered correctly

Alzheimer disease is a neurological condition that increases the risk for aspiration and aspiration pneumonia, a common cause of death in clients with swallowing dysfunction. The nurse activates a rapid response because the client is in acute respiratory distress. While waiting for the team, the nurse should implement the following actions in order: Place in high Fowler's position - quickly maximizes ability to expand lungs, promotes oxygenation, and helps to decrease risk of further aspiration Perform oropharyngeal suctioning - the priority is clearing the airway after the client has been placed in a position that prevents further aspiration Administer 100% oxygen by nonrebreather mask - corrects hypoxemia/hypoxia once the airway has been cleared to allow passage of oxygen. The nurse has already gathered focused assessment data and determined the need for emergent oxygen delivery (eg, tachycardia, tachypnea, hypoxia, cyanosis, decreased level of consciousness). Assess lung sounds - determines air movement and presence of adventitious sounds (eg, crackles, wheezing, stridor) that can indicate obstruction, secretions, atelectasis, or fluid. This assessment is performed once emergency measures are in place (eg, oxygen) and the client has been stabilized. Notify the primary HCP - to report the situation and assessment data To provide more efficient care, any of these tasks can be delegated to a second RN. Educational objective:While waiting for the rapid response team to respond to an adult client with acute respiratory distress, the nurse implements the following actions: positioning; suctioning to clear the airway, administering high-concentration oxygen; assessing lung sounds; and notifying the HCP. Additional Information Physiological Adaptation NCSBN Client Need

The client with suspected active pulmonary tuberculosis (TB) has a positive tuberculin skin test (TST). Which prescription from the health care provider does the nurse anticipate will confirm the diagnosis in this client? 1. Collect 2 blood cultures from different intravenous sites after cleansing with a chlorhexidine swab (2%) 2. Collect 2 early morning nose specimens (swabs) from each nare using sterile culturettes (2%) 3. Collect an early morning sterile sputum specimen on 3 consecutive days (74%) 4. Collect blood for the QuantiFERON-TB test after cleansing the site with a chlorhexidine swab (20%) OmittedCorrect answer 3 74%Answered correctly

Bacteriologic testing is performed in clients with suspected TB disease to confirm the diagnosis. A stained sputum smear is examined microscopically for the presence of Mycobacterium tuberculosis (tubercle bacillus), and a culture identifies the growth of the microorganisms. Collect an early morning sputum sterile specimen on 3 consecutive days for an acid-fast bacilli (AFB) smear and culture. Fluids and/or expectorants can be given at bedtime to help liquefy secretions. It is usually easier for clients to produce a specimen upon awakening as secretions collect in the airways during the night. (Option 1) Blood cultures that identify microorganism in the blood are not usually obtained to confirm a diagnosis of TB. (Option 2) Nose cultures are routinely performed to determine the presence of methicillin-resistant Staphylococcus aureus but are not performed to confirm a diagnosis of TB. (Option 4) The QuantiFERON-TB blood test is performed to screen for TB and can be used as an alternate to the TST. The advantages it offers include the following: there are fewer false-positive results, only a single client visit is required, and results are available in 24 hours. However, it is more expensive. Educational objective:An AFB sputum culture and smear test are performed to detect the presence of M. tuberculosis and confirm a diagnosis of TB. Additional Information Reduction of Risk Potential NCSBN Client Need

//A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma. Which clinical finding warrants immediate intervention? 1. Hairnet-like effect across vision (54%) 2. Loss of memory about the collision (20%) 3. Temporal headache (11%) 4. Tongue laceration oozing blood (12%) OmittedCorrect answer 1 54%Answered correctly

Blunt-force trauma to the head is associated with potentially severe complications (eg, brain damage and herniation, retinal detachment, seizures). Prompt recognition of potential complications is essential to prevent irreversible changes to the client's neurological status and level of function. Retinal detachment is a separation of the retina from the posterior wall of the eye that may occur following head trauma. This is an ocular emergency as permanent blindness may result without intervention. Signs of retinal detachment include perception of lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the visual field (Option 1). (Option 2) Loss of memory about the accident, or retrograde amnesia, is commonly reported after mild head injuries. The client should be monitored for decreased level of consciousness or alterations in mental status, which may indicate intracranial bleeding. (Option 3) Headache is expected after mild head injury, and is not innately concerning except if the pain acutely worsens or is not relieved by over-the-counter analgesics (eg, acetaminophen, ibuprofen). (Option 4) A bleeding tongue laceration may occur when the force of the trauma causes the client to accidentally bite the tongue. Oozing blood, although disturbing to the client, does not pose an immediate threat. Educational objective:Retinal detachment is a separation of the retina from the posterior wall of the eye, and may result from blunt-force trauma. If not promptly recognized and treated, permanent blindness may occur. Signs of detachment include lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the field of vision.

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? 1. Haloperidol for a client with a fall history who keeps getting out of bed without assistance (70%) 2. Lorazepam for a client who is in alcohol withdrawal and is extremely agitated (5%) 3. Olanzapine for a client with schizophrenia who is exhibiting violent behavior (4%) 4. Propofol for a client who is intubated and receiving mechanical ventilation (19%) OmittedCorrect answer 1 70%Answered correctly

Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of movement or to control socially disruptive behavior in clients who have no medical indications for them. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol (Haldol) in this client (Option 1). (Option 2) Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control agitation in the client in alcohol withdrawal. (Option 3) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to control violent behavior in the client with schizophrenia. (Option 4) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort. Educational objective:Medications that are standard treatments for specific conditions (eg, alcohol withdrawal, schizophrenia, mechanical ventilation) are not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety. Additional Information Safety and Infection Control NCSBN Client Need

The nurse practicing on a medical surgical unit cares for a client with type I diabetes mellitus. Which action should the nurse delegate to experienced unlicensed assistive personnel (UAP)? 1. Assess the client for signs and symptoms of hypoglycemia (0%) 2. Check the blood glucose before meals and report it to the primary nurse (92%) 3. Teach the client to cut toenails straight across and file with rounded curves of the toes (2%) 4. Update the care plan to include client's preference for nighttime diabetic snack (4%) OmittedCorrect answer 2 92%Answered correctly

Key components of the nursing process, such as assessment, diagnosis, planning, and evaluation, fall under the scope of practice of the registered nurse (RN) and should not be delegated. In addition, teaching falls within the scope of practice of the RN and should not be delegated to UAP. Some skills, such as obtaining a blood glucose level, can be delegated to UAP as long they have received documented training and have demonstrated competency. Remember that the 5 rights of delegation are: Right task Right circumstance Right person Right direction and communication Right supervision and evaluation (Option 1) Assessment falls within the scope of practice of the RN and should not be delegated. When UAP report an observation or communicate a client symptom to the nurse, it is the nurse's responsibility to assess the client. (Option 3) Teaching falls within the scope of practice for the registered nurse. Other members of the health care team, such as licensed vocational nurses or licensed practical nurses, may reinforce teaching as outlined in the care plan after it has been initiated by the RN. (Option 4) Planning includes initiating and updating the client's plan of care and falls within the scope of practice of the RN and should not be delegated to UAP. Educational objective:Key components of the nursing process, such as assessment, diagnosis, planning, evaluation, and teaching, fall under the scope of practice of the RN and should not be delegated. However, some skills, such as obtaining a blood glucose level, can be delegated to UAP as long they have received documented training and have demonstrated competency.

/A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks? 1. Daily sleep disturbance or significant weight loss (7%) 2. Decreased ability to think or low energy (4%) 3. Depressed mood or loss of interest or pleasure (51%) 4. Thoughts of worthlessness or recurrent thoughts of death (37%) OmittedCorrect answer 3 51%Answered correctly

Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2 weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure. Signs & symptoms of major depression - SIGECAPS Sleep (increased or decreased) Interest deficit (anhedonia) Guilt (worthless, hopeless) Energy deficit Concentration deficit Appetite (increased or decreased) Psychomotor retardation or agitation Suicidality (Option 1) Daily sleep disturbance or significant weight loss is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 2) Decreased ability to think or low energy is a symptom of depressive disorders; these are not key clinical features necessary for diagnosis. (Option 4) Thoughts of worthlessness or recurrent thoughts of death are symptoms of depressive disorders; these are not key clinical features necessary for diagnosis. Educational objective:The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made.

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately? 1. Difficult to arouse (14%) 2. Muscle stiffness (20%) 3. Pinpoint pupils (36%) 4. Temperature 94 F (34.4 C) (28%) OmittedCorrect answer 2 20%Answered correctly

Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) (Option 2). (Options 1 and 3) A client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse; and to have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain. (Option 4) Hypothermia (<95 F [35 C]) is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment. This can be managed by the nurse. Hyperthermia (fever) is also common due to the blood products and trauma from surgery. However, stiffness/rigidity in the presence of elevated temperature is more concerning. Educational objective:Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia. Additional Information Reduction of Risk Potential NCSBN Client Need

A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene? 1. Cyanosis of hands and feet (7%) 2. Heart rate of 165/min while crying (1%) 3. Jitteriness (86%) 4. Respirations of 60/min (4%) OmittedCorrect answer 3 86%Answered correctly

Newborns whose mothers have diabetes mellitus are at increased risk for complications after birth, most commonly hypoglycemia but also hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. During intrauterine life, exposure to elevated maternal glucose levels causes the fetus to produce high levels of insulin. After birth, the newborn loses the maternal supply of glucose but continues to produce high levels of insulin, as during intrauterine life, increasing the risk of hypoglycemia (ie, blood glucose <40-45 mg/dL [2.2-2.5 mmol/L]). Symptoms of hypoglycemia, usually noted in the first several hours after birth, include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability. Immediate intervention is required to prevent neurologic damage (Option 3). (Option 1) Cyanosis of the hands and feet (acrocyanosis) is a benign, transient finding during the transition to extrauterine life. (Option 2) The newborn's heart rate should be assessed by auscultation of the apical pulse for a full minute. A normal heart rate for a newborn is 110-160/min but may increase to 180/min during crying or may decrease to 100/min during sleep. (Option 4) The newborn's respiratory pattern should be assessed for one full minute. Normal newborn respirations are 30-60/min and decrease to an average of 40/min after the transition period. Educational objective:Newborns whose mothers have diabetes mellitus are at increased risk for hypoglycemia, especially in the first several hours after birth. A common symptom of newborn hypoglycemia is jitteriness. Newborn hypoglycemia requires immediate intervention to prevent neurologic damage.

//A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? 1. Assess and compare blood pressure in each arm (12%) 2. Assess character and quality of peripheral pulses (62%) 3. Assess for presence or absence of hair on lower extremities (2%) 4. Assess for presence of bowel sounds (21%) OmittedCorrect answer 2 62%Answered correctly

Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm. Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require reoperation. (Option 1) Comparison of blood pressures in each arm may be helpful in an assessment of an upper aortic dissection or congenital aortic coarctation, but not in assessing an abdominal aortic aneurysm. (Option 3) Absence of hair growth on the lower extremities is more specific for peripheral artery disease. (Option 4) Although auscultation of bowel sounds is part of a basic assessment, it is not considered a key assessment preoperatively. It will become more of a priority postoperatively in assessment of ileus. Educational objective:Preoperative assessment of the character and quality of peripheral pulses provides a baseline for rapid postoperative assessment and identification of emergent complications (embolization, graft occlusion).

//The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply. 1. "I need to avoid taking medicines like ibuprofen without a prescription." 2. "I should avoid drinking excess coffee or cola." 3. "I should enroll in a smoking cessation program." 4. "I should reduce or eliminate my intake of alcoholic beverages." 5. "I will eliminate whole wheat foods, like breads and cereals, from my diet." OmittedCorrect answer 1,2,3,4 69%Answered correctly

Peptic ulcer disease (PUD) is characterized by ulceration of the protective layers (ie, mucosa) of the esophagus, stomach, and/or duodenum. Mucosal "breaks" allow digestive enzymes and stomach acid to digest underlying tissues, leading to potential gastrointestinal bleeding and perforation. Risk factors for PUD include gastrointestinal Helicobacter pylori infections, genetic predisposition, chronic NSAID (eg, aspirin, ibuprofen, naproxen) use, stress, and diet and lifestyle choices. Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors: NSAIDs: Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing (Option 1). Caffeine: Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion (Option 2). Smoking: Tobacco increases secretion of stomach acid and delays ulcer healing (Option 3). Alcohol: Alcohol should be avoided as it stimulates stomach acid secretion and impairs ulcer healing (Option 4). Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion. (Option 5) Evidence does not support the standard elimination of specific foods from the diet in clients with PUD. However, clients should avoid foods that exacerbate their symptoms. Educational objective:Peptic ulcer disease (PUD) is a gastrointestinal illness caused by breaks in the gastrointestinal mucosa, leading to ulcer formation. To reduce ulcer formation risk, clients with PUD should be instructed to stop smoking; avoid chronic NSAID use; avoid meals or snacks before sleeping; and limit alcohol and caffeine consumption.

The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain? 1. The client has a history of three previous cesarean births (13%) 2. The client has a signed consent form for a cesarean hysterectomy (24%) 3. The client has removed all metal jewelry and contact lenses (1%) 4. The client has two 18-gauge IVs and a blood type and crossmatch (60%) OmittedCorrect answer 4 60%Answered correctly

Placenta accreta is a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. Prenatal ultrasound usually detects placenta accreta, although detection can rarely occur after birth when the placenta is adherent (ie, retained placenta). A cesarean birth before term gestation at a facility with adequate resources (eg, blood products, intensive care unit) is recommended for clients with placenta accreta. The major complication of placenta accreta is life-threatening hemorrhage, which occurs during attempted placental separation. At least two large-bore IVs (eg, 18-gauge) and a blood type and crossmatch are priority concerns in case blood transfusions are necessary (Option 4). (Option 1) Previous cesarean birth is a risk factor for placenta accreta. Knowing the client's medical/surgical history is important but is not prioritized over the client's readiness for a blood transfusion. (Option 2) A hysterectomy during cesarean birth with the placenta left in place may be required to reduce blood loss. The client should understand the implications of the procedure (ie, no future childbearing), but this is not a priority over ensuring readiness for a potential blood transfusion. (Option 3) Metal and, occasionally, contact lenses should be removed prior to surgery to protect the client from injury, but this is not a priority over IV access and blood product availability. Educational objective:Placenta accreta occurs when the placenta adheres abnormally to the myometrium; attempted separation can result in life-threatening hemorrhage. Priority concerns include presence of at least two large-bore IVs and available blood products should hemorrhage occur.

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Graves' disease. Which action is most important for the nurse to take? 1. Ask client when her last menstrual cycle occurred (7%) 2. Confirm pregnancy test result is negative (77%) 3. Obtain a baseline assessment of the mouth and throat (7%) 4. Teach the client the signs and symptoms of hypothyroidism (7%) OmittedCorrect answer 2 77%Answered correctly

RAI is the primary treatment for nonpregnant adults with hyperthyroid disorders such as Graves' disease (a type of autoimmune hyperthyroid disease). The use of RAI is contraindicated in pregnancy and could cause harm to a fetus. Pregnancy results should therefore be confirmed using a valid pregnancy test in all clients who still have menstrual cycles rather than using a subjective form of assessment such as asking when the last menstrual period occurred (Option 1). (Option 3) Radiation thyroiditis and parotitis, which cause dryness and irritation to the mouth, may occur after RAI treatment. A baseline assessment is helpful but is not the most important action listed. The nurse can teach the client to take sips of water frequently or to use a salt and soda gargle solution 3-4 times daily to relieve these symptoms. (Option 4) RAI damages or destroys the thyroid tissue, thereby limiting thyroid secretion, and can result in hypothyroidism. Clients need to take thyroid supplementation (levothyroxine) for life. Because these symptoms are delayed, this teaching can occur before or after the procedure. It is not as important as assessing pregnancy status. Educational objective:RAI destroys the thyroid gland, making clients permanently hypothyroid and requiring life-long thyroid supplements. In female clients, a nonpregnant status should be confirmed with a valid pregnancy test prior to administering RAI. RAI is contraindicated in pregnancy and may cause harm to a fetus. Additional Information Physiological Adaptation NCSBN Client Need

A clinic nurse examines a client with a tentative diagnosis of primary Sjögren's syndrome. Which finding observed by the nurse would most likely be associated with this syndrome? 1. Dry eyes and mouth (57%) 2. Low back stiffness (5%) 3. Multiple tender points (15%) 4. Thickening of the skin (20%) OmittedCorrect answer 1 57%Answered correctly

Sjögren's syndrome is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help (Option 1). (Option 2) Early-morning low back stiffness is seen with ankylosing spondylitis. (Option 3) Multiple tender points are characteristic of fibromyalgia. (Option 4) Thickening of the skin is seen with scleroderma. Educational objective:Sjögren's syndrome is an autoimmune condition that can cause dry eyes and mouth. Clients are instructed to use artificial tears and saliva.

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse? 1. Client with alcohol withdrawal who needs IV lorazepam every 2 hours (6%) 2. Client with emphysema and an oxygen saturation of 89% on room air (26%) 3. Client with sickle cell crisis requiring IV morphine every 2 hours (48%) 4. Client with type 2 diabetes mellitus who needs discharge teaching (17%) IncorrectCorrect answer 3 48%Answered correctly

The most appropriate assignment for the pediatric nurse is the client with sickle cell anemia requiring IV morphine every 2 hours. Sickle cell anemia is a common disorder in children and the pediatric nurse would be familiar with the assessment, plan of care, and treatment of clients with sickle cell crisis. (Option 1) Alcohol withdrawal is predominantly a disease of adults. A pediatric nurse would have little experience managing clients with delirium tremens. (Option 2) Emphysema is a chronic obstructive lung disorder not commonly seen in pediatric clients. It occurs later in life as a result of long-term smoking. (Option 4) Type 2 diabetes mellitus is increasing in incidence in the pediatric population. However, discharge teaching would be performed better by a nurse from the adult medical surgical unit who has more experience with the disease and discharge paperwork. Educational objective:A pediatric nurse who is floated to an adult medical surgical unit should be assigned clients with diagnoses common to the pediatric client population. Some examples include sickle cell anemia, diabetic ketoacidosis, pneumonia, and acute appendicitis.

/What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply. 1. After insertion, secure the catheter with a sterile, semipermeable dressing 2. Clean ports with an alcohol swab prior to accessing the catheter system 3. Prior to insertion, apply chlorhexidine, using friction, to the venipuncture site 4. Prior to insertion, shave excess hair over the selected venipuncture site 5. Replace or remove the venous catheter every 48 hours OmittedCorrect answer 1,2,3 37%Answered correctly

The nurse should select an IV catheter site on an upper extremity, preferably the hand or forearm. To reduce the incidence of catheter-related infections, the selected site should be cleaned with antiseptic solution using friction (preferably chlorhexidine, using a back-and-forth motion) and then allowed to air-dry completely (Option 3). Chlorhexidine is preferred as it achieves an antimicrobial effect within 30 seconds, whereas povidone-iodine takes ≥2 minutes. After insertion, the catheter hub should be secured with a narrow strip of sterile tape to prevent accidental removal or excessive back-and-forth motion, which can introduce microorganisms into the vein. In addition, a sterile, transparent, semipermeable dressing (eg, Tegaderm) should be used to secure the catheter hub to reduce infection risk and allow visualization of the site (Option 1). When the catheter is accessed, the needleless port should be cleansed with an alcohol swab to kill externally colonized microorganisms (Option 2). (Option 4) Excessive hair may be clipped but never shaved as shaving may cause microabrasions and potential portals of entry for microorganisms. (Option 5) Peripheral IV catheters should not be removed or replaced more frequently than every 72-96 hours unless signs of complications (eg, infiltration, infection, phlebitis) occur. Educational objective:To reduce catheter-related infections from peripheral IV catheters, the nurse should clean the site with chlorhexidine in a back-and-forth motion using friction and allow it to dry completely. The catheter hub is secured with a sterile, semipermeable dressing, and access ports are cleaned with alcohol swabs prior to use. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client's spouse is at the bedside and appears angry. Which action is the priority at this time? 1. Call social services to assist the client in community resources for domestic violence victims (2%) 2. Clean the facial laceration and prepare to assist the health care provider with suture placement (11%) 3. Have the spouse leave the room so that the client can be spoken with and examined in private (72%) 4. Place the arm in a shoulder sling for immobilization and prepare for an immediate x-ray (13%) OmittedCorrect answer 3 72%Answered correctly

The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff (Option 3). (Option 1) Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are removed and after physiological needs are met. This should not be done in the presence of any potential abusers. (Option 2) Cleaning the laceration and preparing for sutures are appropriate interventions but are done after a suspected abuser is removed. The nurse also follows facility guidelines for documenting, gathering evidence, and/or photographing injuries before cleaning and further treatment. (Option 4) The arm should be x-rayed to assess for fractures and may require a sling for immobilization, but potential sources of harm are removed from the room first. Educational objective:If a client shows possible signs of abuse or neglect, the priority is to remove any sources of immediate danger (eg, suspected abuser) from the room to prevent further harm. Assessments and further interventions can occur after ensuring the client's safety.

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply. 1. Auscultate breath sounds 2. Increase amount of suction 3. Instruct client to cough and deep breathe 4. Milk the chest tube 5. Reposition the client OmittedCorrect answer 1,3,5 62%Answered correctly

When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds (Option 1) helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe (Option 3) and repositioning the client (Option 5). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. (Option 2) A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H2O is not indicated. (Option 4) Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space. Educational objective:The nurse should assess breath sounds, encourage coughing and deep breathing, and reposition the client who has a decrease in chest tube drainage.

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply. 1. Bumetanide in the client with heart failure who has hypokalemia 2. Calcium acetate in the client with chronic kidney disease who has hyperphosphatemia 3. Carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level 4. Isoniazid in the client with latent tuberculosis who has elevated liver enzymes 5. Metronidazole in the client with Clostridium difficile infection who has leukocytosis OmittedCorrect answer 1,4 20%Answered correctly

Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance (Option 1). Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4). (Option 2) Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces. (Option 3) Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription. (Option 5) Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection. Educational objective:Loop diuretics (eg, bumetanide, furosemide, torsemide) can cause hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]). Elevated liver enzymes in clients receiving the antitubercular drug isoniazid can indicate development of drug-induced hepatitis. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply. 1. Date of birth 2. First and last name 3. Health care provider 4. Medical record number 5. Room number OmittedCorrect answer 1,2,4 75%Answered correctly

"The right client" is one of the "6 rights" of medication administration. Two identifiers are used to compare client statements and information on the identification band with the client's medication administration record. An identifier should be permanent and unique to the client. Acceptable identifiers include first and last name and date of birth (Options 1 and 2). These two identifiers are commonly used together because there is a chance that more than one client may share a similar surname or date of birth, which increases the risk of administering a medication to the wrong client. Medical record numbers are also an acceptable form of identification and may help further differentiate clients (Option 4). (Options 3 and 5) The name of the health care provider and room number are not specific or unique to the client and are subject to change based on the client's plan of care or condition. Educational objective:During medication administration, the nurse identifies "the right client" using information that is permanent and unique to the client. Acceptable identifiers are first and last name, date of birth, and medical record number.

/SEE EX Vital signs Temperature 97.7 F (36.5 C) 98.9 F (37.2 C) 101.3 F (38.5 C) Blood pressure 124/84 mm Hg 142/90 mm Hg 160/100 mm Hg Pulse 86/min 112/min 132/min Respirations 12/min 16/min 22/min O2 saturation 96% 94% 95% Admission1 hour2 hours The nurse in the emergency department is caring for a client recently diagnosed with Graves' disease who was admitted following a motor vehicle accident. The nurse notes the vital signs shown in the exhibit. The nurse alerts the primary health care provider that the client may be experiencing which condition? Click on the exhibit button for additional information. 1. Hypertensive crisis (15%) 2. Malignant hyperthermia (5%) 3. Serotonin syndrome (2%) 4. Thyroid storm (77%) OmittedCorrect answer 4 77%Answered correctly

hyroid storm is a life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves' disease when a stressful incident, such as this client's motor vehicle accident, triggers a sudden surge of thyroid hormone. Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure. The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary. (Option 1) Hypertensive crisis alone would not cause fever. (Option 2) Malignant hyperthermia would occur in the perioperative setting in response to anesthesia. This client has no risk factors for malignant hyperthermia. (Option 3) Serotonin syndrome would occur in the client taking more than one or an overdose of antidepressant medication that increases serotonin levels. Educational objective:Thyroid storm is a life-threatening complication of Graves' disease (hyperthyroidism). Assessment findings include a rapid increase in temperature, heart rate, and blood pressure in response to stress. Additional Information Physiological Adaptation NCSBN Client Need

//The nurse is reviewing medical histories with several clients during a community health screening event. Which of the following client statements indicate a risk factor for cervical cancer? Select all that apply. 1. "I have had four sexual partners during my lifetime." 2. "I have smoked cigarettes for many years." 3. "I never used birth control pills because my partners wore condoms." 4. "I received treatment for chlamydia when I was younger." 5. "I tested positive for human papillomavirus a few years ago." OmittedCorrect answer 1,2,4,5 25%Answered correctly

Cervical cancer is a malignancy of the cervix (a portion of the uterus) that normally occurs near the meeting point of the vaginal and uterine epithelia (the transformation zone), located in the endocervical canal. Uterine epithelial cells in this area are rapidly and constantly replaced with squamous cells (ie, squamous metaplasia), a natural process that also increases the risk for abnormal cell changes and cancer. The most important risk factor for cervical cancer is persistent human papillomavirus (HPV) infection, a common, transient, and often asymptomatic sexually transmitted infection (STI) that can be identified in almost all clients with cervical cancer (Option 5). Most other risk factors are related to acquiring, clearing, or increasing the cancer-causing effects of HPV infection, including: Having multiple sexual partners (ie, >1 lifetime partner), which increases the chance of HPV exposure (Option 1) Smoking tobacco, which is believed to promote cell mutation and increase the likelihood of HPV infection (Option 2) Being infected with other STIs (eg, gonorrhea, chlamydia), which increases the likelihood of HPV infection (Option 4) (Option 3) Condoms help to prevent HPV transmission between partners, and not taking oral contraceptives is associated with a decreased risk for cervical cancer. Educational objective:Cervical cancer is a malignancy of the cervix associated with persistent human papillomavirus (HPV) infection. Most other risk factors for cervical cancer relate to increasing risk for or ability to clear HPV infections, including multiple sexual partners, history of other sexually transmitted infections, and smoking.

//The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this." How should the nurse respond? 1. "You can cry and get it all out; I will stay with you." (18%) 2. "You have dealt with diabetes; you can conquer dialysis." (2%) 3. "You sound very discouraged and frightened." (78%) 4. "You still have a lot to live for; think about your family." (1%) OmittedCorrect answer 3 78%Answered correctly

Clients may feel overwhelmed when managing chronic illnesses. The nurse should assist them in processing difficult news or events through discussion of thoughts and feelings, which also fosters rapport. Reflecting, or referring the statement back to the client, is a therapeutic communication technique that promotes open dialogue and encourages the client to recognize feelings (Option 3). Acknowledging feelings is an important step in successfully navigating difficult circumstances. (Option 1) Encouraging the client to cry if needed conveys concern but does not encourage further discussion of feelings. (Option 2) Giving false reassurance is an example of a nontherapeutic communication technique that may seem supportive; however, it inappropriately offers hope for an outcome that the nurse cannot guarantee. False reassurance also invalidates and hinders discussion of the client's feelings. (Option 4) Making cliché statements or automatic responses (eg, "you have a lot to live for") or shifting the focus to others' feelings (eg, "think about your family") invalidates the client's feelings and impedes open communication. Educational objective:Nurses should assist clients in processing difficult news or events through discussion of thoughts and feelings. Reflecting is an appropriate technique that promotes open communication and encourages the client to recognize feelings. Additional Information Psychosocial Integrity NCSBN Client Need

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply. 1. Apply moisture barrier cream to dry skin 2. Clean perineal area after incontinent episodes 3. Massage bony prominences frequently 4. Place foam-padded seat cushions on chairs 5. Reposition clients in bed every 6 hours OmittedCorrect answer 1,2,4 64%Answered correctly

Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries (using the Braden scale) upon admission and at least once daily during hospitalization. To prevent pressure injuries: Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option 1). Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option 4). Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin (Option 2). Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur. (Option 3) Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin. (Option 5) Clients must be repositioned and turned every 2 hours. Turning clients every 6 hours is too infrequent and will not confer the same protection against pressure and associated tissue ischemia. Educational objective:Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping prevent pressure injuries. Massage over the bony prominences is not recommended for pressure injury prevention. Additional Information Basic Care and Comfort NCSBN Client Need

The nurse is managing assigned clients on the evening shift. Which client presentation is a priority? 1. Blunt head trauma with projectile vomiting (96%) 2. History of Alzheimer disease with agitation (1%) 3. History of carpal tunnel syndrome with hand numbness (1%) 4. History of third cranial nerve pathology with double vision (1%) OmittedCorrect answer 1 96%Answered correctly

A client with a traumatic head injury from blunt force can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. Signs and symptoms are similar to those of increased intracranial pressure and include change in level of consciousness, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated. (Option 2) Neuropsychiatric symptoms such as agitation, aggression, delusions, hallucinations, wandering, and depression are very common in clients with dementia. Some may have an underlying etiology (eg, pain, infection) that requires identification and treatment. This client is the second priority as the condition is not immediately life-threatening. (Option 3) Carpal tunnel syndrome is a compression of the median nerve within the carpal tunnel at the wrist. Clinical manifestations are weakness, pain, numbness, and impaired sensation in the median nerve distribution. Numbness is an expected symptom; a splint is worn to relieve the pressure. (Option 4) The third cranial nerve controls the majority (4/6) of the extraocular muscles. As a result, the lesion can cause weakness in eye movements with resultant diplopia, which is an expected finding. Educational objective:A client with a head injury and signs of increased intracranial pressure (eg, change in level of consciousness, projectile vomiting, pupil dilation, ataxia) is a priority.

/Which client should the nurse assess first after receiving the hand-off morning report? 1. Client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants (15%) 2. Client with a peripherally inserted central catheter who has a 5-cm (2-in) increase in external catheter length since yesterday (70%) 3. Client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line (5%) 4. Client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9% (7%) OmittedCorrect answer 2 70%Answered correctly

A peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of catheter tip placement. (Option 1) After abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel sounds for 24-72 hours due to postoperative paralytic ileus would be expected. (Option 3) The client with malabsorption syndrome is unable to digest and absorb nutrients by the gastrointestinal tract. Peripheral parenteral nutrition with 10% dextrose is an expected treatment. (Option 4) The hemoglobin A1C level of 9% is above the recommended level (ie, <7%) and reflects inadequate glycemic control, which can be expected in a client with diabetes mellitus. Educational objective:A change in the length of the external portion of a peripherally inserted central catheter (PICC) can indicate migration of the catheter from its original position. If migration is suspected, the nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider immediately for evaluation and x-ray verification of placement of the catheter tip.

/The graduate nurse (GN) is caring for a laboring client with epidural anesthesia. After the client pushes for 3 hours during the second stage of labor, the health care provider (HCP) decides to use forceps to assist the client to deliver secondary to maternal exhaustion. Which action by the GN requires the nurse preceptor to intervene? 1. Begins to apply fundal pressure when the HCP applies traction to forceps (58%) 2. Drains the client's bladder using a catheter before the placement of forceps (20%) 3. Notes the exact time the forceps are applied on a card for documentation in the birth record (9%) 4. Palpates for contractions and notifies the HCP when they are present (11%) OmittedCorrect answer 1 58%Answered correctly

An operative vaginal birth uses a vacuum extractor or forceps to shorten the second (pushing) stage of labor. Indications may be maternal (eg, exhaustion, cardiac or cerebrovascular disease) or fetal (eg, abnormal fetal heart rate, arrest of rotation). In a forceps-assisted birth, the health care provider (HCP) gently applies the blades to the sides of the fetal head and locks the handles in place. The HCP applies traction to the forceps during contractions to facilitate rotation and descent of the fetal head. The nurse should never apply fundal pressure during an operative vaginal birth because it may cause uterine rupture (Option 1). (Option 2) To avoid bladder damage, the nurse should ensure that the client has an empty bladder (eg, catheterization) before the forceps are applied. (Option 3) Documentation should reflect birth events accurately for legal purposes and be done in a timely fashion. Birth events can happen quickly, but noting the time when forceps or a vacuum extractor is applied is essential. (Option 4) The nurse notifies the HCP when contractions are palpated so that downward/outward traction can be applied to the forceps or a vacuum extractor during the contraction, which helps facilitate the birth. Educational objective:In an operative vaginal birth, forceps or a vacuum extractor is used to shorten the second (pushing) stage of labor. The nurse ensures that the client's bladder is empty, monitors for contractions, and documents the time that forceps or a vacuum extractor was applied. Fundal pressure should never be applied during this procedure or labor/birth.

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? 1. Antecubital fossa (47%) 2. Dorsal surface of hand (34%) 3. Dorsum of foot (1%) 4. Lateral surface of wrist (15%) OmittedCorrect answer 2 34%Answered correctly

Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed. (Option 1) The antecubital fossa is commonly selected in emergency situations due to its size and ease of cannulation but is problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. (Option 3) The foot is not typically accessed in adults without a specific health care provider prescription. It is occasionally used in emergency situations; however, veins in the legs and feet may have decreased venous return, and complications can lead to thrombophlebitis or deep vein thrombosis. (Option 4) The radial vein is present on the lateral side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage. Educational objective:Peripheral IV sites should be selected in the hand or forearm to reduce the risk of catheter-related bloodstream infections. Sites on the upper extremities located at flexion sites (eg, wrist, bend of arm) and the lower extremities should be avoided. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The health care provider prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply. 1. Apply pads to the side rails 2. Have oxygen supplementation available 3. Prepare to insert a urinary catheter 4. Remove all linen from the bed 5. Set up bedside suction equipment OmittedCorrect answer 1,2,5 85%Answered correctly

Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can help protect a client during a seizure. These precautions typically include: Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails during a seizure (Option 1). During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen equipment are set up at the bedside (Options 2 and 5). Some facilities also encourage the use of a continuous pulse oximeter. (Option 3) Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a urinary tract infection. (Option 4) It is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions. Educational objective:Seizure precautions are safety measures that typically include raising the upper side rails, placing padding on the side rails, and preparing bedside suction and oxygen equipment.

A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching? 1. "Give acetaminophen or ibuprofen every 6 hours to control the fever." (45%) 2. "Give the infant frequent tepid sponge baths to control the fever." (36%) 3. "If the infant develops another seizure, wait 15 minutes to see if it subsides." (3%) 4. "Place ice bags under the arms and around the neck to reduce the fever." (14%) OmittedCorrect answer 1 45%Answered correctly

Febrile seizures are an alarming experience for parents. They most commonly occur in children between ages 6 months to 6 years, with the peak of incidence occurring at age 18 months. The etiology is unknown. Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use antipyretics such as acetaminophen or ibuprofen (in children age >6 months) to control fever and make the child more comfortable (Option 1). However, there is no evidence that antipyretics reduce the risk of future febrile seizures. After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing. (Options 2 and 4) Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort for the child. (Option 3) Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes. Neurologic damage can occur with frequent and prolonged seizures. Educational objective:Febrile seizures, although alarming, are generally benign. Parents should be instructed on appropriate cooling methods (eg, antipyretics, cool compresses), seizure safety precautions, and the avoidance of shivering. Additional Information Physiological Adaptation NCSBN Client Need

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Increasing the level of continuous IV sedation during nighttime hours 3. Leaving the television on for diversion at night 4. Opening the window blinds/shades in the morning 5. Scheduling interventions and activities during the day when possible 6. Turning off equipment alarms in the client's room at night OmittedCorrect answer 1,4,5 52%Answered correctly

It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, providing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. (Option 2) Continuous IV sedation, if indicated, should be given at the lowest dose adequate for pain management. (Option 3) Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. (Option 6) Turning the alarms off in the client's room would pose a risk to safety, as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening. Educational objective:To prevent disorientation and delirium in the ICU, it is important to develop a plan of care that includes maintaining the client's normal circadian rhythm.

A parent brings a 6-month-old child to the primary health care provider after the child abruptly started crying and grabbing intermittently at the abdomen. The client's stool has a red, currant jelly appearance. What intervention does the nurse anticipate? 1. Administer epoetin alfa (erythropoietin) (7%) 2. Give air (pneumatic) enema (32%) 3. Have the parent give 2 ounces of extra juice a day for constipation (1%) 4. Perform hemoccult test on stool (58%) OmittedCorrect answer 2 32%Answered correctly

Intussusception is a process in which one part of the intestine prolapses and then telescopes into another part. It is one of the most frequent causes of intestinal obstruction during infancy. Initially, the telescoping is intermittent, resulting in periodic pain in association with the legs drawn up toward the abdomen. Pain is severe, progressive, and associated with inconsolable crying. Ongoing obstruction can compromise circulation, causing mucosal ischemia, occult bleeding, and, if untreated, grossly bloody "currant jelly" stools (mixture of blood and mucus). A contrast enema is used for diagnostic purposes and often reduces the intussusceptions. An air enema is considered safer than a barium enema. (Option 1) Human recombinant erythropoietin (epoetin alfa [Epogen, Procrit]) stimulates bone marrow to form red blood cells and is used to combat the effects of chemotherapy (due to bone marrow suppression) and/or kidney disease (erythropoietin is secreted by the kidneys). Human recombinant erythropoietin is not indicated in this client. (Option 3) Constipation during infancy usually can be corrected by increasing fluids or adding 2 ounces of pear or apple juice to the daily diet. In addition, eliminating constipating foods and increasing high-fiber foods can help. In this client, it is more important to treat the intussusception as there is no evidence of constipation. (Option 4) A hemoccult test is performed typically when occult (hidden) blood is suspected due to a dark and tarry stool. Blood is evident in intussusception, and so the priority in this client is to treat the cause of the bloody mucus stool. Educational objective:Intussusception (the intestine telescoping into itself) causes intermittent cramping and progressive abdominal pain, inconsolable crying, and currant jelly stool (from blood or mucus). It is often treated successfully with an air enema. Additional Information Physiological Adaptation NCSBN Client Need

Interdisciplinary client care rounds and hand-off communication are examples of strategies used to improve communication in health care settings. What is the most important outcome of effective communication among care givers? 1. Decreased length of hospital stay (10%) 2. Less obvious needs of clients met accordingly (5%) 3. Properly educated clients (9%) 4. Reduced number of medical errors (74%) OmittedCorrect answer 4 74%Answered correctly

Miscommunication between health care providers may cause serious medical errors when clients are handed off or transferred. Medical errors can be effectively reduced by employing strategies (eg, Situation, Background, Assessment, and Recommendation [SBAR] reporting technique, nurse-to-nurse change of shift reports, multi-professional bedside rounds) to improve communication and collaboration. Nurses should be as proficient in their communication skills as they are in their clinical skills. (Options 1, 2, and 3) Improved communication may aid in assessing a client's educational needs and meeting less obvious needs; it can also contribute to a shorter length of stay. However, these are not the most important outcomes. Educational objective:Effective communication among caregivers is necessary to deliver safe client care and reduce the number of medical errors. Additional Information Management of Care NCSBN Client Need

Vital signs at 0800 Temperature -98.4 F (36.9 C) Blood pressure -126/81 mm Hg Heart rate -49/min Respirations -16/min Laboratory results at 0600 Hematocrit - 40% (0.40) Hemoglobin -14.0 g/dL (140 g/L) Platelets -200,000/mm3 (200 × 109/L) Potassium -4.0 mEq/L (4.0 mmol/L) HDL cholesterol -21 mg/dL (0.54 mmol/L) LDL cholesterol -200 mg/dL (5.18 mmol/L) The nurse is preparing to administer medications after assessing a client with a myocardial infarction. Based on the collected data, which of the following prescribed medications are appropriate for the nurse to administer? Click on the exhibit button for additional information. Select all that apply. 1. Aspirin 2. Atorvastatin 3. Docusate sodium 4. Lisinopril 5. Metoprolol OmittedCorrect answer 1,2,3,4 20%Answered correctly

Myocardial infarctions (MIs) damage heart muscle and require medications to improve heart function and prevent reinfarction (eg, aspirin). Aspirin, an antiplatelet agent, inhibits platelet aggregation, prevents thrombus formation, and reduces heart inflammation. Clients without signs of bleeding or low platelet levels may safely receive aspirin (Option 1). Atorvastatin is a lipid-lowering medication given to clients to lower cholesterol levels (ie, LDL cholesterol), which reduces plaque and reinfarction risk (Option 2). However, statins may cause rhabdomyolysis and require monitoring for muscle weakness and pain. Docusate sodium is a stool softener that reduces straining during bowel movements, thereby decreasing the workload on the heart. Straining can also cause bradycardia due to vagal response (Option 3). Lisinopril is an ACE inhibitor often prescribed to clients after an MI to prevent ventricular remodeling and progression of heart failure. Lisinopril may cause hyperkalemia and hypotension, and should be administered only to clients with normokalemia and normotension (Option 4). (Option 5) Metoprolol is a beta blocker prescribed to clients after MI to reduce the risk of reinfarction and heart failure. Metoprolol lowers blood pressure and heart rate; therefore, the nurse should hold the medication and notify the health care provider of hypotension or a heart rate <50/min. Educational objective:Nurses should use clinical data and assessment to determine prescription safety. Beta blockers require monitoring of heart rate and blood pressure. ACE inhibitors require monitoring of potassium and blood pressure. Aspirin requires monitoring of platelet levels and signs of bleeding. Statins require monitoring for muscle pain.

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation? 1. 10 mg isosorbide dinitrate twice daily (23%) 2. 20 mg atorvastatin once daily (3%) 3. 500 mg naproxen twice daily (52%) 4. 2,000 mg fish oil once daily (21%) OmittedCorrect answer 3

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) are common medications used for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. The nurse should investigate the reason a client with cardiovascular disease is taking an NSAID and alert the health care provider of the medication usage (Option 3). (Option 1) Isosorbide dinitrate (Isordil) is a long-acting nitrate medication prescribed to prevent angina in clients with CAD. Nitrate medications prevent angina by causing vasodilation of the peripheral vessels (decreasing cardiac workload) and the coronary arteries (improving coronary artery perfusion). (Option 2) Atorvastatin (Lipitor) is a statin drug prescribed to lower cholesterol, which can reduce the risk of atherosclerosis and coronary artery disease. (Option 4) Fish oil is an over-the-counter nutritional supplement often taken by clients with heart disease or individuals at risk. Fish oil contains omega-3 fatty acids, which may decrease blood triglyceride levels with consistent use. Educational objective:Clients with cardiovascular disease (eg, coronary artery disease) are cautioned against taking nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen), which increase the risk of thrombotic events (eg, heart attack, stroke). Nurses who identify clients with cardiovascular disease taking NSAIDs should investigate the reasons for use and notify the health care provider. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is providing discharge instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? 1. "I am looking forward to our summer vacation at the beach." (57%) 2. "I plan to eat more fruits and vegetables to prevent constipation." (10%) 3. "I should not drive until I know how this drug affects me." (17%) 4. "I will drink at least 6-8 glasses of water daily." (14%) OmittedCorrect answer 1 57%Answered correctly

Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: New-onset constipation Dry mouth Flushing Heat intolerance Blurred vision Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity (Option 1). (Options 2 and 4) Increasing dietary intake of fluids and bulk-forming foods (eg, fruits, vegetables) promotes normal bowel function and prevents constipation. (Option 3) Sedation is a common side effect of anticholinergic drugs. Clients should be taught not to drive or operate heavy machinery until they know how the drug affects them. Educational objective:Anticholinergic medications are commonly associated with constipation, urinary retention, flushing, dry mouth, and heat intolerance. Clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming foods (prevents dry mouth and constipation) and by avoiding locations or activities that may lead to hyperthermia. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client? 1. Diet recall for this current week (1%) 2. Fluid intake for the past 2 days (4%) 3. Medications and dosages taken over the past 2 days (8%) 4. Presence of shortness of breath, coughing, or edema (85%) OmittedCorrect answer 4 85%Answered correctly

The client with chronic heart failure is at risk for exacerbations that may require hospitalization. The priority for the nurse on the phone is to ascertain if the client is experiencing any physiological symptoms such as shortness of breath, coughing, or edema (Option 4). These could indicate fluid overload. This information can help the nurse direct the client to come in for further assessment, follow a protocol to make changes in medications/dosages, or restrict fluids. (Options 1, 2, and 3) These are all important in assessment of the possible cause of the weight gain. They should be addressed after the nurse has questioned the client about physiological symptoms. Educational objective:The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.

/The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply. 1. Avoid rubbing or scratching the affected eye 2. Avoid straining when having a bowel movement 3. Expect occasional flashes of light during recovery 4. Report any sudden pain to the health care provider 5. Rest the eyes by refraining from reading and writing OmittedCorrect answer 1,2,4,5 58%Answered correctly

Retinal detachment is separation of the sensory retina from the underlying pigment epithelium. Clients experiencing retinal detachment may report a gradual, curtain-like loss of the visual field. Traumatic retinal detachment may also result in abrupt vision loss. Retinal detachment requires emergency surgery to attempt to restore vision. Surgical repair involves rebinding the choroid and retina. After repair, interventions focus on promoting retinal reattachment. Postoperative teaching should include: Avoiding activities that increase intraocular pressure (eg, rubbing the eye, straining) (Options 1 and 2) Reporting sudden pain, flashes of light, vision loss, or bleeding, which may indicate detachment or infection, to the health care provider (Option 4) Avoiding focused activities (eg, reading, writing, sewing), which can cause rapid eye movements and increase the risk for detachment (Option 5). Wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye and minimize eye movement Ensuring appropriate positioning as instructed by the surgeon because clients may receive intravitreal oil or gas, which holds the retina in a specific position to allow healing (Option 3) Signs of retinal detachment include floaters, sudden flashes of light, and loss of vision. If signs of detachment occur, the surgeon should be notified immediately. Educational objective:After retinal detachment repair, clients should avoid activities that increase intraocular pressure (eg, rubbing the eye, straining); report pain, flashes of light, or floaters; wear an eye patch; avoid focused activities that may cause eye strain; and minimize eye movement.

A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80 mm Hg (2%) 2. Heart rate 100/min (7%) 3. Serum creatinine 2.5 mg/dL (221 µmol/L) (85%) 4. Serum potassium 3.5 mEq/L (3.5 mmol/L) (4%) OmittedCorrect answer 3 85%Answered correctly

The dosage of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril, ramipril) should be adjusted for clients with renal impairment. A serum creatinine of 2.5 mg/dL (221 µmol/L ) indicates renal impairment (normal 0.6-1.3 mg/dL [53-115 µmol/L]). The nurse should notify the health care provider so that the dosage can be decreased or held. (Options 1, 2, and 4) The client's blood pressure, heart rate, and serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) are within normal limits. They do not require immediate action. Hyperkalemia and hypotension are contraindications for giving ACE inhibitors. Educational objective:Evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury. These include ACE inhibitors (eg, lisinopril, enalapril), aminoglycosides (eg, gentamicin), and digoxin. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client is brought to the emergency department after sustaining third-degree burns over 50% of the body. Which solution is the best choice for fluid resuscitation in this client? 1. 0.45% normal saline (7%) 2. 5% dextrose in 0.9% normal saline (D5NS) (12%) 3. 5% dextrose in water (D5W) (2%) 4. Lactated Ringer's solution (77%) OmittedCorrect answer 4 77%Answered correctly

The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes. Lactated Ringer's (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma (Option 4). LR remains in the intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock. (Option 1) Hypotonic solutions (eg, 0.45% normal saline) quickly leave the intravascular space and are not useful in replacing intravascular volume. They may also contribute to peripheral and interstitial edema, which can lead to pulmonary complications. (Option 2) Hypertonic solutions (eg, 5% dextrose in 0.9% normal saline [D5NS], 3% saline) can cause further electrolyte imbalances in a client with severe burns, resulting in hypernatremia, hyperchloremia, and arrhythmias. (Option 3) Although technically an isotonic solution, 5% dextrose in water (D5W) behaves as a hypotonic solution when dextrose is metabolized by the body and free water is released to the tissues rather than remaining in the intravascular space. Educational objective:Lactated Ringer's is the standard for fluid resuscitation in burn clients due to its similarity in chemical composition to human plasma. Hypotonic, hypertonic, and dextrose-containing solutions should not be used for fluid resuscitation. Additional Information Physiological Adaptation NCSBN Client Need

A client with an acute head injury cannot accurately identify the sensation felt when the nurse touches the intact skin with a cotton ball or paper clip. The nurse is aware that the deficit reflects injury to which area of the brain? IncorrectCorrect answer Refer to Hotspot 46%Answered correctly

The parietal lobe of the brain integrates somatic and sensory input. Injury to the parietal lobe could result in a deficit with sensation. The nurse would verify the client's injuries and documented imaging studies to confirm that this was an expected deficit and document it accordingly. If it is a new or unexpected deficit, the nurse should inform the health care provider immediately. The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes. The temporal lobe integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot understand verbal or written language. The occipital lobe of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision. Educational objective:The frontal lobe controls executive function and personality. The temporal lobe receives auditory input. The parietal lobe receives sensory input. The occipital lobe receives visual images. Additional Information Physiological Adaptation NCSBN Client Need

// SEE EXHIBIT ON VISION PAGE A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor? Click on the exhibit button for additional information. 1. Atrial paced rhythm (17%) 2. Atrioventricular paced rhythm (41%) 3. Biventricular paced rhythm (19%) 4. Ventricular paced rhythm (21%) OmittedCorrect answer 2 41%Answered correctly

An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy. (Option 1) An atrial paced rhythm would have a pacer spike before the P wave only. The P wave may appear normal or abnormal; the QRS complex will appear normal. (Option 3) Biventricular pacemakers (also known as sequential biventricular pacemakers) generate impulses in both ventricles. Two ventricular pacing spikes may be seen on the ECG, and one spike may appear after the beginning of the QRS complex. (Option 4) A ventricular paced rhythm would only have a pacer spike prior to a wide QRS complex. Impulses are generated in only one ventricle (typically the right ventricle). Educational objective:An atrioventricular pacemaker (also known as sequential or dual chamber) paces the right atrium and right ventricle in sequence. Two pacer spikes are visible on the ECG, one prior to the P wave and a second prior to the QRS complex. Atrioventricular pacemakers improve cardiac synchrony between the atria and ventricles. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse receives new prescriptions for a 6-month-old client with bacterial meningitis. Which action is the priority of care? 1. Administer 400 mg ceftriaxone IV every 12 hours (36%) 2. Apply padding to the crib siderails (17%) 3. Implement low-stimulation environment (21%) 4. Monitor head circumference daily (24%) OmittedCorrect answer 1 36%Answered correctly

Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord (ie, meninges) caused by a bacterial infection. The inflammatory process and bacterial growth within the meninges lead to increased volumes of cerebrospinal fluid and, subsequently, increased intracranial pressure (ICP). Without intervention, increased ICP may lead to nerve ischemia, permanent functional impairment (eg, hearing loss, visual impairment, paralysis), brain damage, herniation, and death. The initial priority of nursing care is protecting other clients and staff from exposure, as bacterial meningitis is highly contagious and transmitted by droplets. After isolating the client, the nurse should initiate prescribed antibiotics as quickly as possible, as bacterial meningitis can progress rapidly and lead to death without treatment (Option 1). (Options 2 and 3) Clients with meningitis are at increased risk for seizures. Implementation of a low-stimulation environment (eg, low lighting, minimal noise, uninterrupted rest periods) and seizure precautions (eg, padded side rails) are important interventions. However, initiating antibiotic therapy is the priority. (Option 4) An increasing head circumference may indicate increasing volumes of cerebrospinal fluid and increased ICP. Monitoring for new or worsening signs of increased ICP is important but may be performed after initiating prescribed antibiotics. Educational objective:Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord that can lead to severe complications (eg, hearing loss, brain damage) or death without treatment. To reduce the risk of complications, the nurse should prioritize initiation of prescribed antibiotic therapy as soon as possible.

The public health nurse identifies which of the following clients as being at high risk for developing colorectal cancer? Select all that apply. 1. A 28-year-old female client with a body mass index of 38 kg/m2 2. A 38-year-old male client with a 15-year history of ulcerative colitis 3. A 48-year-old male client whose father has a history of colorectal cancer 4. A 58-year-old male client who consumes a diet high in fruits and vegetables 5. A 68-year-old female client with a 40-year history of cigarette smoking OmittedCorrect answer 1,2,3,5 23%Answered correctly

Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths affecting both genders equally. Various risk factors for colorectal cancer include: Personal or family (first-degree relative) history of colorectal cancer/polyps Personal history of inflammatory bowel disease, Crohn's disease, or ulcerative colitis History of hereditary non-polyposis colorectal cancer (Lynch syndrome) Lifestyle factors such as obesity, a diet high in red meat, cigarette smoking, and alcohol consumption (Option 4) Eating fruits, vegetables, and grains may decrease colorectal cancer risk but diets high in fat and low in fiber increase this risk. Educational objective:Medical risk factors for colorectal cancer include a personal or family history of inflammatory bowel disease. Lifestyle risk factors include a history of obesity, a diet high in red meat, cigarette smoking, and alcohol consumption.

A client at 34 weeks gestation reports constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which recommendations should the nurse make for this client? Select all that apply. 1. Decreased daily dairy intake 2. Increased fruit and vegetable intake 3. Moderate-intensity regular exercise 4. One laxative twice daily for a week 5. Two cups of hot coffee each morning OmittedCorrect answer 2,3 40%Answered correctly

Constipation is a common discomfort of pregnancy and is due to an increase in the hormone progesterone, which causes decreased gastric motility. Ferrous sulfate (iron) supplementation may also cause constipation. Interventions to prevent or treat constipation include: High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes High fluid intake: 10-12 cups of fluid daily Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics) Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin (Option 1) Dairy is a great source of calcium, which is essential for fetal bone development. However, dairy products should be consumed at least 2 hours before or 1 hour after iron supplements as they bind to iron and decrease absorption. (Option 4) Laxatives are not recommended during pregnancy due to the risk of dehydration and electrolyte imbalance, which can lead to uterine cramping and contractions. The client should consult with the health care provider before using any over-the-counter stool softeners or laxatives. (Option 5) Caffeine consumption in pregnancy should be limited to 200-300 mg/day. Coffee may contain 100-200 mg caffeine per cup and should therefore be consumed in moderation during pregnancy. Educational objective:Constipation in pregnancy may be caused by increased progesterone levels and iron supplementation. It is best treated with 10-12 cups of fluid daily, a high-fiber diet/supplementation, and regular exercise. Clients should not take laxatives without first discussing this with the health care provider.

The nurse practicing in an out-patient clinic cares for a client recently diagnosed with hyperthyroidism. Which diet-related teaching should the nurse add to the client's plan of care? Select all that apply. 1. Emphasize the importance of a low-carbohydrate diet 2. Encourage the client to increase high-fiber foods in the diet 3. Include meals and snacks high in protein content 4. Teach avoidance of caffeine-containing liquids 5. Teach the client about consumption of a high-calorie diet of 4000-5000 calories/day OmittedCorrect answer 3,4,5 41%Answered correctly

Hyperthyroidism refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid hormones (T3, T4); this leads to an increased metabolic rate. In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include: Adherence to a high calorie diet (4000-5000 calories per day). Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals (Option 1). Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea) (Option 2). However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). Avoidance of spicy foods as these can also increase GI stimulation. Educational objective:Hyperthyroidism leads to a high metabolic rate. It is important for the nurse to teach the client nutritional measures, including consumption of a diet high in calories (high in protein, carbohydrates, vitamins, and minerals) to satisfy hunger and prevent weight loss and tissue wasting.

//Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider? 1. Clean the perineal area (1%) 2. Gently pull on the cord (4%) 3. Keep the infant warm (57%) 4. Massage the fundus (36%) OmittedCorrect answer 3 57%Answered correctly

Precipitous birth occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is unable to arrive in time. Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or respiratory distress (Option 3). If the newborn is stable, the cord can be clamped and cut with sterile scissors after it has stopped pulsating or after the placenta has been expelled. (Option 1) The perineal area can be cleansed if needed once the placenta has been expelled. (Option 2) To avoid uterine inversion or cord avulsion (tearing or snapping), the nurse should not pull on the cord. Once placental separation occurs, signified by cord lengthening, a gush of blood, uterine cramping, and vaginal pressure, the mother can bear down gently to expel the placenta. (Option 4) Fundal massage is performed after expulsion of the placenta to increase uterine tone and decrease bleeding. Educational objective:Precipitous birth occurs when delivery takes place ≤3 hours after the onset of contractions. The nurse should prevent newborn cold stress by promptly drying and placing the newborn on the mother's abdomen for skin-to-skin contact. Additional Information Health Promotion and Maintenance NCSBN Client Need

/The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply. 1. Administer prescribed oral narcotics for throat pain 2. Administer warmed, humidified oxygen via facemask 3. Give the client ice chips to moisten the mouth 4. Provide mouth care with oral sponges 5. Start the client on incentive spirometer OmittedCorrect answer 2,4,5 25%Answered correctly

Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and respiratory distress. To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa (Option 2). Oral care is provided to decrease bacteria and contaminants as well as promote comfort (Option 4). Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis (Option 5). (Options 1 and 3) Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside swallow screen or a more formal swallow evaluation by a speech therapist prior to swallowing any food, drink, or medication. Educational objective:Recently extubated clients are immediately placed on humidified oxygen and monitored for aspiration, airway obstruction, and respiratory distress. Clients should remain NPO until swallowing function has been evaluated. In addition, clients should be given routine oral care as well as instructions on coughing, deep breathing, and use of incentive spirometry.

The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response? 1. "As long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern." (14%) 2. "Because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible." (23%) 3. "Newer research shows that thumb sucking has little effect on a child's teeth." (15%) 4. "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth." (47%) OmittedCorrect answer 4 47%Answered correctly

Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant to feel secure. Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the behavior. As a rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be avoided. Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior. (Options 1, 2, and 3) These options are incorrect. Use of a pacifier or thumb sucking prior to eruption of the permanent teeth does not tend to cause dental issues such as teeth misalignment or malocclusion. Educational objective:The risk of teeth misalignment and malocclusion occurs when a child uses a pacifier or sucks the thumb after the eruption of the permanent teeth.

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse? 1. "Engaging in regular exercise decreases the risk of AD." (52%) 2. "Having a family history of AD is not a risk factor." (29%) 3. "Try not to worry about this now as you can't do anything to prevent AD." (11%) 4. "You should avoid aluminum cans and cookware to prevent AD." (6%) OmittedCorrect answer 1 52%Answered correctly

The development of Alzheimer disease (AD) is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at age ≥65. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease. For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD (Option 2). Trauma to the brain has been associated with the development of AD in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls. Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing AD (Options 1 and 3). (Option 4) Research has failed to confirm that exposure to aluminum products (eg, cans, cookware, antiperspirant deodorant) is related to the development of AD. Educational objective:Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing Alzheimer disease.

/A 6-year-old client was diagnosed with type 1 diabetes mellitus 2 years ago. The nurse would like to encourage the client to participate in disease management. Which of the following diabetes care tasks are appropriate for the child to perform? Select all that apply. 1. Choose insulin injection site with parental oversight of rotation schedule 2. Push plunger of insulin syringe after a parent inserts and stabilizes the needle 3. Select and clean the site for finger-stick blood glucose testing 4. Use a chart to determine insulin dose based on glucometer reading 5. Verbalize two or three signs and symptoms of hypoglycemia OmittedCorrect answer 1,2,3,5 33%Answered correctly

The nurse should offer school-aged children (age 6-12) as much opportunity as possible to participate in care to promote psychosocial development (industry versus inferiority) and provide a sense of control. Parents should transfer management of care to the child in small steps based on the child's skill level and cognitive ability. School-aged children are in the concrete operational stage of development and are most successful performing simple, concrete tasks with a limited number of steps. Appropriate diabetes management tasks for school-aged children include: Choosing and cleaning a finger for blood glucose testing before a parent or caregiver performs the puncture (Option 3) Selecting the site for insulin injection, with a parent or caregiver verifying appropriate site rotation (Option 1) Pushing the syringe plunger to administer insulin after a parent or caregiver inserts the needle (Option 2) Identifying signs and symptoms of hypoglycemia and hyperglycemia (Option 5) (Option 4) Adjusting insulin doses based on glucose readings is too complicated for school-aged children, and mistakes can be life-threatening. Children develop the cognitive ability to analyze test results and adjust insulin doses at approximately age 14. Educational objective:Children should participate in their diabetes management. The school-aged child can choose and clean a finger for a blood glucose reading, select the insulin injection site, push the plunger to administer insulin after parents or caregivers insert the needle, and identify signs of hypoglycemia and hyperglycemia.

A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which is the most appropriate action by the nurse? 1. Act as a witness for the informed consent process (5%) 2. Provide additional information about what the client can expect (1%) 3. Report the surgeon to the ethics board for using an inappropriate consent process (2%) 4. Talk to the surgeon privately about using a trained Spanish-language medical interpreter (91%) OmittedCorrect answer 4 91%Answered correctly

The nursing role in advocating for the client includes ensuring the use of interpreters for clients who speak a different language, particularly during the informed consent process. The person interpreting for the client should ideally possess the following: Training in medical terminology and procedures Ability to protect the client's rights in a medical setting Fluency in the language Understanding of cultural beliefs and nuances For these reasons, and to protect client confidentiality, family members should not be used as medical interpreters unless the situation is urgent and a family member is the only one available to fill this role. (Option 1) The nurse may act as a witness, but this is less important than ensuring appropriate resources are used to carry out the informed consent process. (Option 2) The nurse is responsible to provide preoperative teaching, but this is less important in this situation than ensuring that an appropriate informed consent process is followed. (Option 3) The use of family members as translators of medical information is not ideal but may be used when necessary, particularly when a situation is urgent and an interpreter is not available. Educational objective:The nurse acting as a client advocate should ensure the appropriate use of medical interpreters to promote adequate client understanding and participation in the decision-making process. This is particularly important during the informed consent process. Additional Information Management of Care NCSBN Client Need

////SEE EXHIBIT ON VISION PAGE The nurse is caring for a client who experienced an anterior wall myocardial infarction 24 hours ago. The nurse recognizes the rhythm on the cardiac monitor as which rhythm? Click on the exhibit button for additional information. 1. Premature ventricular contractions (4%) 2. Sinus tachycardia (3%) 3. Ventricular fibrillation (23%) 4. Ventricular tachycardia (68%) OmittedCorrect answer 4 68%Answered correctly

Ventricular tachycardia (VT) is a potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-250/min. The rhythm is often regular, but it can be irregular. QRS complexes are wider than 0.12 seconds and the P wave is usually buried in the QRS complex, making a PR interval unmeasurable. Pulseless VT is treated with cardiopulmonary resuscitation (CPR) and defibrillation. (Option 1) A premature ventricular contraction (PVC) is a contraction originating from an ectopic foci in the ventricle. It appears early in the rhythm and has a wide and distorted shape as compared to the underlying rhythm. A consecutive run of ≥3 PVCs is considered VT. (Option 2) The rate in sinus tachycardia is 101-200/min and regular. The P wave, PR interval (0.12-0.20 sec), and QRS complex (<0.12 sec) will be normal. Sinus tachycardia may be caused by hypovolemia, hypotension, pain, anxiety, stress, or fever. Treatment is based on the underlying cause. (Option 3) Ventricular fibrillation is characterized on the electrocardiogram by irregular waveforms of varying shapes and amplitude. It represents the firing of multiple ectopic foci in the ventricle. The client in ventricular fibrillation will not have a pulse, and defibrillation is essential in addition to CPR under the ACLS guidelines. Educational objective:VT has a rate of 100-250/min with monomorphic, wide QRS complexes. Pulseless VT is treated with CPR and defibrillation.

//SEE EX PAGE Laboratory results Activated partial thromboplastin time (aPTT)- 53 sec International normalized ratio (INR) -2.3 Medication administration record Allergies: None Medications Time Epoetin: 3,500 units subcutaneously, M-W-F -0800 Vitamin K: 10 mg subcutaneously, today -0800 Sodium polystyrene sulfonate: 15 g orally, today only- 0800 Warfarin: 5 mg orally, daily -2000 A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question? Click on the exhibit button for additional information. 1. Epoetin (6%) 2. Sodium polystyrene sulfonate (9%) 3. Vitamin K (57%) 4. Warfarin (25%) OmittedCorrect answer 3 57%Answered correctly

Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for warfarin-related bleeding. This medication prescription should be questioned as vitamin K reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the therapeutic range (aPTT 46-70 sec, INR 2-3). (Option 1) Epoetin (Procrit) is a synthetic hormone that stimulates the production of erythropoietin and is used to treat anemia associated with chronic kidney disease. This is an appropriate prescription. (Option 2) Sodium polystyrene sulfonate (Kayexalate) is a sodium exchange resin administered to reduce elevated serum potassium levels in clients with chronic kidney disease and hyperkalemia. This is an appropriate prescription for this client. (Option 4) Warfarin (Coumadin) is a vitamin K antagonist used for long-term anticoagulation that is started about 5 days before a continuous heparin infusion is discontinued. An overlap of the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes warfarin to reach therapeutic level. This is an appropriate prescription for this client. Educational objective:Anticoagulants stop thrombus formation by interfering with the coagulation cascade. Parenteral heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for the 2 drugs is required. This allows warfarin to reach a therapeutic level before the continuous heparin infusion is stopped.

The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply. 1. Assess client for lethargy and decreased deep tendon reflexes 2. Assess skin for flushing and red rash on face and torso 3. Infuse medication over at least 60 minutes 4. Monitor blood pressure during infusion 5. Observe IV site every 30 minutes for pain, redness, and swelling OmittedCorrect answer 2,3,4,5 11%Answered correctly

When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications (Option 3). Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option 4) Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities (Option 2). Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy (Option 5). (Option 1) Assessment of deep tendon reflexes is appropriate with magnesium sulfate administration. Manifestations of hypermagnesemia include lethargy, nausea, vomiting, and decreased deep tendon reflexes. Educational objective:Nursing care of clients receiving IV vancomycin includes drawing prescribed trough levels before drug administration, infusing the drug over at least 60 minutes, monitoring the client during administration (eg, blood pressure, respiratory status, signs of hypersensitivity/anaphylaxis), and assessing the IV site during and after administration.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? 1. Administer an inhaled bronchodilator (10%) 2. Check marked insertion depth of the tube (70%) 3. Request a prescription for a diuretic (10%) 4. Start the client on incentive spirometry (9%) OmittedCorrect answer 2 70%Answered correctly

A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately. (Option 1) An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration. (Option 3) Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse should initially hold feedings and assess tube placement. (Option 4) Incentive spirometry promotes expansion of the lungs and resolves atelectasis; however, the priority for this client is assessing for and preventing aspiration. Educational objective:Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration.

The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur. Which client information is most important to report to the primary health care provider (PHCP)? 1. Blood pressure change from 128/80 mm Hg to 90/50 mm Hg (64%) 2. Development of a 1st-degree atrioventricular (AV) block on electrocardiogram (ECG) (22%) 3. Reports of right femur pain of 7 on a scale of 1-10 (1%) 4. Vesicular breath sounds auscultated over the lung tissue (11%) OmittedCorrect answer 1 64%Answered correctly

Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. A deficiency in all 3 classes of adrenal corticosteroids, including glucocorticoids, mineralocorticoids, and androgens, is present in Addison's disease. Addisonian crisis, or acute adrenocortical insufficiency, is a potentially life-threatening complication of Addison's disease. It can lead to shock and should be reported immediately to the PHCP. Addisonian crisis is triggered by stress, and its manifestations include the following: Hypotension and tachycardia Dehydration Hyperkalemia and hyponatremia Hypoglycemia Fever Weakness and confusion (Option 2) Although any new ECG changes should be assessed and investigated, this finding is typically non-consequential and is not life-threatening. (Option 3) Although pain should be assessed carefully and managed, it is expected with a fractured femur and is not life-threatening. (Option 4) Vesicular breath sounds auscultated over the lung tissue are a normal and expected finding. Educational objective:Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. A potential life-threatening complication is Addisonian crisis. Signs and symptoms include hypotension, tachycardia, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion; these should be reported to the PHCP immediately. Additional Information Reduction of Risk Potential NCSBN Client Need

///The nurse is caring for a client with end-stage heart failure. The rhythm shown in the exhibit is seen on the cardiac monitor, and the nurse finds the client unresponsive with no palpable pulse. What is the correct interpretation of this rhythm? Click on the exhibit button for additional information. 1. Asystole (89%) 2. Complete heart block (2%) 3. Disconnected lead wire (1%) 4. Pulseless electrical activity (6%) OmittedCorrect answer 1 89%Answered correctly

Asystole is characterized by no electrical activity or obvious wave. Clients will have no pulse or respirations, and will be unresponsive (Option 1). Clients with advanced cardiac disease or heart failure are at increased risk for developing asystole. Cardiopulmonary resuscitation (CPR) should be initiated, followed by advanced cardiac life support measures, including administration of epinephrine, placement of an advanced airway, and treatment of any reversible causes. (Option 2) Complete heart block (third-degree atrioventricular block) is characterized by dissociated atrial and ventricular rhythms. The ECG will still show electrical activity. (Option 3) Lead connections should be checked when the ECG shows asystole, but the nurse has already assessed for the absence of pulse and unresponsiveness in the client. (Option 4) Pulseless electrical activity is characterized by organized electrical activity on the ECG but no discernible pulse. The ECG for this client shows no electrical activity. Educational objective:Asystole is characterized by complete absence of electrical activity on the ECG. The client will have no pulse or respirations, and will be unresponsive. The nurse should immediately initiate cardiopulmonary resuscitation, advanced cardiac life support measures, and treatment of any reversible causes. Additional Information Physiological Adaptation NCSBN Client Need

/In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse expect to implement? 1. Check serum BUN and creatinine levels every hour (43%) 2. Discontinue insulin infusion when blood glucose is <350 mg/dL (19.4 mmol/L) (31%) 3. Increase insulin infusion rate when blood glucose level decreases (4%) 4. Initiate potassium IV when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L) (20%) OmittedCorrect answer 4 20%Answered correctly

Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss. Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4). (Option 1) Serum potassium, glucose, and anion gap or bicarbonate levels are regularly monitored in DKA to monitor treatment effectiveness. Although serum creatinine and BUN levels may be elevated due to dehydration and may be monitored, hourly monitoring is not indicated. (Option 2) IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L). (Option 3) As blood glucose is reduced, the insulin infusion rate is decreased to prevent a hypoglycemic event. Educational objective:Hypokalemia often occurs with resolution of diabetic ketoacidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent life-threatening arrhythmias.

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1. Client on chemotherapy who started antibiotics today for cellulitis of the leg (12%) 2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours (83%) 3. Client with diabetes who has nausea, abdominal pain, and vomiting (2%) 4. Client with ulcerative colitis and diarrhea who has developed fever and vomiting (1%) OmittedCorrect answer 2 83%Answered correctly

Disaster events cause a sudden increase in admissions to local hospitals. The nurse identifies clients who are safe to recommend for discharge to make room for newly admitted clients. A client with acute asthma exacerbation may require treatment in the emergency department or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids (Option 2). (Option 1) Clients who have received chemotherapy may be immunocompromised due to neutropenia. An immunocompromised client is at greater risk of sepsis from an infection. Close monitoring and antibiotic therapy are required. (Option 3) Clients with diabetes may develop diabetic ketoacidosis (DKA) during illness or infection. Features of DKA (eg, lethargy, abdominal pain, hyperglycemia, urine ketones) are a medical emergency. Untreated DKA may progress to loss of consciousness and coma. Treatment includes frequent laboratory monitoring and IV insulin, fluids, and potassium. (Option 4) Clients with ulcerative colitis are at risk for developing toxic megacolon (ie, severe inflammatory colon distension). Symptoms include fever, nausea, vomiting, pain, and abdominal distension. Clients require close monitoring, nasogastric tube for decompression, IV fluids, and antibiotics. Emergency surgery may be required. Educational objective:In response to a local disaster, the nurse identifies clients who can be safely discharged to make room for newly admitted clients. A client with acute asthma exacerbation can be safely discharged home when respiratory status has stabilized.

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important? 1. Allowing the client's husband to be with her during clinical examinations (17%) 2. Assigning the client to a private room (2%) 3. Ensuring that female health care workers are available to provide care to the client (79%) 4. Obtaining the services of a local Muslim imam (1%) OmittedCorrect answer 3 79%Answered correctly

For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently. (Option 1) A husband will often request to be with his wife during an examination; efforts should be made to fulfill this request, but it is not the priority consideration. (Option 2) A private room may not be necessary. This client should be assigned to a room with another Muslim woman or a woman with similar practices regarding modesty. Otherwise, male visitors to the client's roommate could be problematic and cause distress. (Option 4) Consulting with a local Muslim imam or hospital chaplaincy staff may enhance culturally congruent care; however, this is not the most pressing consideration. Educational objective:In the care of female Muslim clients, modesty is highly valued and most body parts are covered. Female health care workers should be available to provide care and conduct examinations. If a male health care provider must be involved in care, female clinical staff should also be present whenever possible.

A nurse is caring for a client who is intubated and has a subclavian central venous catheter. Which nursing intervention is most important to prevent the spread of infection to this client? 1. Frequent hand hygiene (86%) 2. No artificial nails (1%) 3. Use of chlorhexidine bath wipes (5%) 4. Wearing personal protective equipment (6%) OmittedCorrect answer 1 86%Answered correctly

Hand hygiene is the most important factor in preventing infection transmission. The nurse should perform hand hygiene before and after client contact, before donning and after removing gloves, and after contact with bodily fluids (Option 1). Principles for proper hand hygiene include: Apply alcohol-based hand rubs liberally, covering the entire surface of the hands, and allow hands to dry completely. Do not use an alcohol-based hand rub if hands are visibly soiled. When using soap and water, wet the hands; apply soap; scrub all hand surfaces, wrists, and beneath the nails for at least 20 seconds; rinse; dry hands with a paper towel; and then use a new, dry paper towel to turn off the faucet. (Option 2) The nurse should not wear artificial nails, especially in high-risk areas (eg, intensive care unit), because artificial nails harbor microorganisms, even after hand washing. However, the priority intervention for infection prevention is hand hygiene. (Option 3) The nurse should use chlorhexidine to bathe clients who are critically ill, have central venous catheters, or are scheduled for surgery; and for indwelling catheter care. However, the risk for infection transmission would remain high if the nurse implements client care without performing hand hygiene. (Option 4) Personal protective equipment (eg, gloves) is appropriate but is not as important as (and does not replace) hand hygiene to prevent the spread of infection. Educational objective:Hand hygiene is the most important nursing intervention to prevent the spread of infection to clients.

The nurse administers 8 units of regular insulin subcutaneously at 11:30 AM to a client with type 1 diabetes mellitus and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated, and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction? 1. 12:30 PM (40%) 2. 2:00 PM (49%) 3. 5:00 PM (8%) 4. 6:00 PM (2%) OmittedCorrect answer 2 49%Answered correctly

Insulin is a medication commonly used to control and lower blood glucose levels in clients with diabetes mellitus. The nurse must be familiar with the various insulin types and their times of peak effect, which are the periods of highest risk for hypoglycemic events. Regular insulin is a short-acting insulin that reaches the peak effect within 2-5 hours after subcutaneous administration. Therefore, clients who receive regular insulin subcutaneously at 11:30 AM are at highest risk for hypoglycemia between 1:30 PM and 4:30 PM (Option 2). (Option 1) Rapid-acting insulins (eg, lispro, aspart) take peak effect in 30 minutes to 3 hours. Clients who receive rapid-acting insulin at 11:30 AM would be most at risk for hypoglycemia from 12:00-2:30 PM. (Options 3 and 4) Both insulin NPH, an intermediate-acting insulin, and insulin detemir, a long-acting insulin, have peak effect times that may cause hypoglycemia at 5-6 PM in clients who receive the medication at 11:30 AM. Educational objective:Insulin is a medication used to control and lower blood glucose levels in clients with diabetes mellitus. Peak effect times vary according to insulin type and represent the time of highest risk for hypoglycemic events. Regular insulin, a short-acting insulin, reaches peak effect 2-5 hours after subcutaneous administration. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug? 1. "I know my resistance to germs will be lower, so I should get a flu shot this year." (23%) 2. "I should take precautions to prevent pregnancy while I take this medicine." (16%) 3. "I will have an eye examination every 6 months to check for damage caused by my medication." (38%) 4. "It will be a difficult change for me, but I will not have wine with dinner anymore." (21%) OmittedCorrect answer 3 38%Answered correctly

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis. The client's statement about getting an eye examination every 6 months indicates that further teaching is necessary as these examinations are not indicated for clients prescribed methotrexate (Option 3). However, frequent eye examinations are required for clients prescribed the nonbiologic antimalarial DMARD hydroxychloroquine (Plaquenil) as it can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection and should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated. (Option 2) Clients should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic and can cause congenital abnormalities and fetal death. (Option 4) Clients taking methotrexate should avoid alcohol as the prescription drug is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity. Educational objective:Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis and psoriasis. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, congenital abnormalities, and fetal death.

Four clients in labor are requesting pain relief. The nurse understands that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time? 1. Multipara at 6 cm dilation with recent heroin use (14%) 2. Multipara at 9 cm dilation with an urge to push (9%) 3. Nullipara at 3 cm dilation desiring to ambulate (32%) 4. Nullipara at 7 cm dilation moaning with contractions (43%) OmittedCorrect answer 4 43%Answered correctly

Opioid agonist-antagonist medications used in labor include butorphanol tartrate (Stadol) and nalbuphine hydrochloride (Nubain). Maternal adverse effects include sedation, dizziness, and nausea. Butorphanol tartrate crosses the placental barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours. If given near the time of birth, there is a risk for newborn respiratory depression, which may require naloxone (Narcan) to reverse the effects. IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to wear off before the birth. IV opioids are also best for clients in active labor or those with a well-established contraction pattern because opioid administration may slow labor progression in the latent phase (Option 4). (Option 1) Although this client is in active labor, recent heroin use is a contraindication to opioid agonist-antagonists because of the risk for maternal and/or fetal withdrawal symptoms. (Option 2) An urge to push may indicate imminent birth, especially in a multiparous client. To ensure newborn safety, imminent birth is a relative contraindication for the administration of narcotics. (Option 3) Opioid administration in latent labor may slow labor progression. In addition, medication adverse effects (eg, sedation, dizziness) are a safety concern for a client desiring to ambulate. Educational objective:Opioid agonist-antagonist medications (eg, butorphanol tartrate [Stadol]) are most appropriate for clients in active labor with no contraindications (eg, imminent birth, opioid dependence). Opioids have maternal adverse effects (eg, sedation, dizziness, slow labor progression) and may cause newborn respiratory depression.

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first? 1. 36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur (5%) 2. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension (51%) 3. 67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min (32%) 4. 70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV (10%) OmittedCorrect answer 2 51%Answered correctly

The client with pericardial effusion should be seen first. This client is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distension) of developing cardiac tamponade, a life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart. The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Emergency pericardiocentesis is needed. Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. (Option 1) These are symptoms typically seen in the client with endocarditis. The nurse should further assess the murmur to see if it has worsened or changed, but this should be done after the client with pericardial effusion is seen. (Option 3) The new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable; this client is not a priority over the client with possible tamponade. Atrial fibrillation is often a chronic arrhythmia and is managed with ventricular rate control and anticoagulation. (Option 4) Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic. IV diuretics can worsen the hypotension. The client is watching TV, an indication that the client is stable. The nurse can delegate to the unlicensed assistive personnel directions for the client to stay in bed due to the hypotension until the nurse can perform further assessment. Educational objective:Clients with pericardial effusion should be monitored and assessed closely for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular venous distension, and pulsus paradoxus.

Which client is in need of follow-up education by the nurse? 1. Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping (26%) 2. Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out (9%) 3. Client with venous leg ulcer who refuses to wear elastic compression stockings during the day (57%) 4. Postsurgical client who points and flexes feet when lying in bed (6%) OmittedCorrect answer 3 57%Answered correctly

The nurse needs to provide education to the client with a venous leg ulcer who refuses to wear compression stockings. Compression is essential for the treatment of chronic venous insufficiency, venous ulcer healing, and prevention of ulcer recurrence. The client will need individual evaluation to determine what level of compression is needed. Assessment of the ankle-brachial index (ABI) should be performed as well. An ABI of <0.9 suggests concurrent PAD and the need for lower levels of compression therapy. There are several options that the nurse can explore with the client to decide which compression device will work best in the situation (custom-fitted elastic compression stockings, elastic tubular support bandages, Velcro wrap, paste bandage with elastic wrap, or a multilayer bandage system). (Option 1) Dangling a limb over the side of the bed is a common practice among PAD clients to relieve pain. There is no need for this client to discontinue this practice as it allows gravity to maximize blood flow. (Option 2) Immersing hands in warm water can decrease vasospasm in this client with Raynaud's phenomenon. (Option 4) This practice should be encouraged by the nurse. It can help prevent venous thromboembolism following surgery. Educational objective:The nurse needs to educate the client with a venous leg ulcer that wearing some kind of compression stockings is essential for healing and prevention of ulcer recurrence. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? 1. Bend at the waist (2%) 2. Keep the feet close together (2%) 3. Pivot on the foot proximal to the chair (29%) 4. Use a transfer belt (64%) OmittedCorrect answer 4

When transferring a client from bed to chair the following are recommended for client safety: Clients should wear nonskid shoes (first step) Make sure the bed and chair (wheelchair) brakes are locked Use a transfer belt. A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety. Transfer the client toward the stronger (not the weaker) side. If the client is weak on the left side, ask the client to pivot on the right side. (Option 1) Bending at the waist often requires the nurse to use the back for lifting, making for poor body mechanics. (Option 2) The nurse should provide a wide body stance for more stability. Keeping the feet close together would not be good body mechanics and could cause injury. (Option 3) The nurse using proper body mechanics would pivot on the foot distal to the chair. Educational objective:A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety.