mynclex set 8- 38

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? Select all that apply. 1. Blood pressure 2. Blood urea nitrogen 3. Liver enzymes 4. Potassium 5. White blood cell count OmittedCorrect answer 1,2,4 57%Answered correctly

Loop diuretics (furosemide, torsemide, bumetanide) are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, a medical emergency that can result in other life-threatening complications such as heart arrythmias, as well as muscle cramps and weakness (Option 4). Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. Therefore, these levels should be assessed (Options 1 and 2). (Options 3 and 5) Loop diuretics typically do not cause abnormalities in white blood cell counts or liver function tests, so these do not need to be assessed routinely. Educational objective:When administering furosemide, it is important to closely monitor the client's vital signs, serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury.

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider? 1. "I don't have much interest in sex lately." (1%) 2. "I feel like I might be getting a cold." (46%) 3. "My periods have been heavy lately." (39%) 4. "These hot flashes are occurring a lot." (12%) OmittedCorrect answer 3 39%Answered correctly

Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer (Option 3). Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis). Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important. (Options 1 and 4) Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning symptoms. (Option 2) Tamoxifen is not associated with significant immunosuppression although it may rarely cause leukopenia. Educational objective:Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues. It is used for several years in estrogen-responsive breast cancer. However, it is associated with increased risk of endometrial cancer and venous thromboembolism. Menopausal symptoms (eg, vaginal dryness, hot flashes) are the most common side effect. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg. The client reports "feeling a little cold." Based on this assessment, in what order should the nurse complete the following actions? All options must be used. Your Response/ Incorrect Response . Correct Response 1. Administer prescribed vasopressor 2. Collect urine specimen 4. Stop the blood transfusion 5. Using new tubing, infuse normal saline into the vein 3. Document the occurrence OmittedCorrect answer 4,5,1,2,3 69%Answered correctly

It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately (Option 4). Using new tubing, infuse normal saline to keep the vein open (Option 5). Continue to monitor hemodynamic status and notify the health care provider and blood bank. Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids (Option 1). Collect a urine specimen to be assessed for a hemolytic reaction (Option 2). Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis (Option 3). Educational objective:If signs or symptoms of a blood transfusion reaction occur, the nurse should stop the infusion immediately and use new tubing to keep the vein open with normal saline. The nurse should continue to monitor the client's hemodynamic status, and administer prescribed drugs. The nurse should also collect a urine specimen to be assessed for a hemolytic reaction. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months. Which instructions should the nurse include in teaching the client how to prevent UTI recurrence? Select all that apply. 1. Douche with a water and vinegar solution after intercourse 2. Increase daily intake of fluids 3. Use a spermicidal contraceptive jelly 4. Use fragrance-free perineal deodorant products 5. Void immediately after intercourse 6. Wear underwear with a cotton crotch OmittedCorrect answer 2,5,6 51%Answered correctly

The nurse should encourage a sexually active female client to implement the following interventions to help prevent recurrent UTIs: Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be present Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis. The client should void at least every 2-4 hours. Some health care providers recommend drinking cranberry juice as it inhibits bacterial attachment to the bladder wall, but there is no clinical evidence to support its effectiveness in preventing UTIs (Option 2). Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra Avoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead (Option 6). Void after sexual intercourse to flush out bacteria that may have entered the urethra (Option 5). (Options 1 and 4) Avoid douching and using feminine perineal products (eg, deodorants, powders, sprays), as they can alter the vaginal pH and normal flora, increasing the risk for infection. Take showers instead of baths as bath products (eg, bubble bath, oils) and bacteria in bath water can irritate the urethra and increase the risk of infection. (Option 3) Avoid spermicidal contraceptive jelly as it can suppress the production of protective vaginal flora. Discontinue diaphragm use temporarily (until symptoms subside and antibiotic course is completed); a diaphragm increases pressure on the urethra and bladder neck, which may inhibit complete bladder emptying. Educational objective:Interventions to help prevent recurrent UTIs in sexually active female clients include avoiding use of feminine perineal products, vaginal douches, and spermicidal contraceptive jelly. Protective factors include wearing cotton underwear, increasing water intake, and voiding immediately after sexual intercourse. Additional Information Health Promotion and Maintenance NCSBN Client Need Copyright © UWorld. All rights reserved.

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client is most appropriate for the charge nurse to assign to the L&D nurse? 1. Client with an occluded arteriovenous fistula receiving IV heparin infusion (7%) 2. Client with cirrhosis and ascites who requires bedside paracentesis (4%) 3. Client with diabetes who is one day postoperative below-the-knee amputation (22%) 4. Client with pyelonephritis who is febrile and receiving IV antibiotics (65%) OmittedCorrect answer 4 65%Answered correctly

Nurses must sometimes "float" to a nursing unit outside of their normal area of practice based on staffing needs. A nurse who floats to an unfamiliar practice area should be assigned clients who do not require specialized knowledge and can be safely managed with similar skills as with their usual client population. It is the responsibility of the floated nurse to inform the supervisor of any lack of experience with the client population and to request orientation to the unit. Labor and delivery (L&D) nurses possess focused knowledge and training to care for the obstetric population but are able to generalize many skills to other client populations. L&D nurses frequently care for pregnant women with urinary tract infections and would be familiar with the management of a client with pyelonephritis. The administration of IV antibiotics is a general nursing skill with which all nurses should be familiar (Option 4). (Option 1) The L&D nurse is likely unfamiliar with IV heparin administration, which requires close monitoring and specific knowledge of infusion titration. (Option 2) The L&D nurse likely lacks the specific knowledge required to assist with bedside paracentesis and monitor for potential post-procedure complications. (Option 3) A client who undergoes an amputation has unique educational and care needs, with which the L&D nurse is likely unfamiliar. Educational objective:A float nurse should be assigned clients who require care similar to the nurse's usual client population. Clients requiring care from a nurse with specialized knowledge should not be assigned to a float nurse. Additional Information Management of Care NCSBN Client Need

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis. Place the procedural steps in the correct order. All options must be used. Your Response/ Incorrect Response . Correct Response 2. Check the medical record for parental consent 3. Gather the lumbar puncture tray and supplies 4. Have the child empty the bladder 1. Assist the child into the side-lying position with the knees drawn up 5. Label specimen vials as they are collected 6. Place a bandage on the insertion site

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following: Verify informed consent Gather the lumbar puncture tray and needed supplies Explain the procedure to older child and adult Have client empty the bladder Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) Assist the client in maintaining the proper position (hold the client if necessary) Provide a distraction and reassure the client throughout the procedure Label specimen containers as they are collected Apply a bandage to the insertion site Deliver specimens to the laboratory Educational objective:When assisting with a lumbar puncture, the nurse verifies informed consent, gathers supplies, explains the procedure, has the client void, and then assists the client into position. During the procedure, the nurse provides a distraction, helps the client stay in position (if needed), and labels specimens as they are collected. Afterward, the nurse applies a bandage and ensures that the specimens are delivered to the laboratory. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first? 1. Client in neurogenic shock from a spinal cord injury, with pulse of 56/min, blood pressure of 120/60 mm Hg, and warm and pink skin (4%) 2. Client with a concussion from closed-head injury due to a fall, Glasgow Coma Scale score of 15, headache, and memory loss (3%) 3. Client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light (78%) 4. Client with central diabetes insipidus from a head injury, hypernatremia, and urine output of 210 mL/hr (13%) OmittedCorrect answer 3 78%Answered correctly

A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt force head trauma. It is life-threatening, as increased pressure from the hematoma on the brain can lead to decreased cerebral perfusion and herniation (mid-line shift). Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad (hypertension, bradycardia, and irregular respirations), ipsilateral pupil dilation, headache, and vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be necessary. (Option 1) Manifestations of neurogenic shock include hypotension and bradycardia. Although the client has bradycardia and requires monitoring, the client is normotensive and has normal skin color and temperature, which indicate adequate perfusion. (Option 2) Headache, transient change in level of consciousness, and inability to remember the injury (retrograde amnesia) are expected manifestations of a concussion. The Glasgow Coma Scale score of 15 (range: 3-15) indicates complete orientation. (Option 4) Central diabetes insipidus results from head trauma. Damage to the hypothalamus or pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum osmolality (>295 mOsmol/kg [295 mmol/kg]). Treatment is necessary, but polyuria (>200 mL/hr) and hypernatremia (sodium >145 mEq/L [145 mmol/L]) due to dehydration are expected manifestations. Educational objective:A subdural hematoma is caused by bleeding into the subdural space outside the brain. Surgical evacuation of the hematoma may be necessary to relieve the pressure on the brain, as increased intracranial pressure can lead to decreased cerebral perfusion, herniation (mid-line shift), and death. Additional Information Management of Care NCSBN Client Need

/The nurse prepares a client for discharge following a vasectomy. The client asks, "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse? 1. "Discontinue alternative birth control after at least 5 ejaculations." (14%) 2. "There is no need to use alternative birth control following today's procedure." (15%) 3. "Use alternative birth control for 6 months following today's procedure." (19%) 4. "Use alternative birth control until cleared by the health care provider." (50%) OmittedCorrect answer 4 50%Answered correctly

A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia (ie, ducts that carry sperm from the testicles to the urethra) are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms (eg, hormone production, erection, orgasm). Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take several months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the health care provider confirms that semen samples taken at a follow-up appointment are free of sperm; otherwise, pregnancy can occur (Option 4). (Options 1, 2, and 3) The length of time and number of ejaculations necessary to evacuate remaining sperm will vary. The only way to ascertain that the ejaculate no longer contains sperm is to test a client's semen samples. Educational objective:To prevent an unwanted pregnancy following a vasectomy, alternative methods of birth control should be used until semen samples are found to be free of sperm. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior? 1. Muscle rigidity and shuffling gait (70%) 2. Nihilistic delusions (15%) 3. Tangentiality (5%) 4. Waxy flexibility (8%) OmittedCorrect answer 1 70%Answered correctly

Benztropine (Cogentin) is an anticholinergic medication used to treat some extrapyramidal symptoms, which are side effects of some antipsychotic medications. These side effects include: Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation [bradykinesia]) Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions (eg, torticollis, oculogyric crisis, opisthotonos) (Options 2, 3, and 4) Delusions are a symptom of schizophrenia. Tangentiality (deviating from the original topic of discussion) is an abnormal thought process seen in schizophrenia. Waxy flexibility (tendency to remain in an immobile posture) is a motor disturbance seen in schizophrenia. All are treated with antipsychotic medications. Educational objective:Benztropine (Cogentin) is an anticholinergic drug used to treat extrapyramidal symptoms, which are side effects of some antipsychotic medications. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply. 1. Assist the client into left lateral position with right knee flexed 2. Encourage the client to retain the enema for as long as possible 3. Insert tubing into the rectum with the tip directed toward the umbilicus 4. Keep the enema solution refrigerated until ready to administer 5. Slow administration rate if the client reports abdominal cramping OmittedCorrect answer 1,2,3,5 30%Answered correctly

Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon (Option 1). Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation (Option 3). Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) (Option 2). Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration (Option 5). (Option 4) Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water. Educational objective:When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, insert the tubing into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/The nurse receives report on 4 clients. Which client conditions require priority assessment? 1. 34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations (5%) 2. 54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain (5%) 3. 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea (85%) 4. 70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg (4%) OmittedCorrect answer 3 85%Answered correctly

Clients who are bedridden, have undergone major surgery (eg, hip or knee replacement), or are taking estrogen-containing contraceptive pills are at high risk of developing deep venous thrombosis. This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of the blood clot. (Option 1) Clients with acute pericarditis have chest pain that is worse with inspiration/coughing and improves with leaning forward. This is an expected finding. Large pericardial effusion with resultant cardiac tamponade is more serious and is evidenced by jugular venous distension, hypotension, and muffled heart sounds. (Option 2) This client who underwent femoropopliteal surgery likely has acute occlusion of the graft and is at risk of limb loss if flow is not restored. However, loss of life is a priority over loss of limb. (Option 4) Atrial fibrillation requires assessment but is not immediately life-threatening in most situations. This client has stable blood pressure and is not the priority. Educational objective:Pulmonary embolism is a life-threatening emergency. Clients who have had major surgery, prolonged immobilization, or are taking estrogen-containing contraceptive pills are at high risk. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client with a history of heroin abuse. Which clinical finding may indicate withdrawal? 1. Constipation (1%) 2. Constricted pupils (15%) 3. Drowsiness (11%) 4. Tachycardia (71%) OmittedCorrect answer 4 71%Answered correctly

Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4). Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions. (Options 1, 2, and 3) Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects. Educational objective:Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped or dosage is reduced. Symptoms of opioid withdrawal (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity.

The nurse cares for a child newly diagnosed with cystic fibrosis. What should be included in the client's multidisciplinary plan of care to be discussed with the parents? Select all that apply. 1. Aerobic exercise 2. Chest physiotherapy 3. Financial needs 4. Low-calorie diet 5. Oral fluid restriction OmittedCorrect answer 1,2,3 30%Answered correctly

Cystic fibrosis (CF) is a genetic disorder involving the cells lining the respiratory, gastrointestinal (GI), and reproductive tracts. A defective protein responsible for transporting sodium and chloride causes secretions in these areas to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the GI tract, which can impair digestive enzymes and result in ineffective absorption of essential nutrients. These sticky respiratory secretions lead to a chronic cough and inability to clear the airway, eventually causing chronic lung disease (bronchiectasis). As a result of these changes, the client's life span is shortened; most affected individuals live only into their 30s. Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance (Option 2). Aerobic exercise is beneficial to promote removal of airway secretions, improve muscle strength, and increase lung capacity (Option 1). Financial needs must be discussed, as clients with CF have a large financial burden due to health care costs, medications, and special equipment (Option 3). (Option 4) A diet high in fat and calories is recommended due to defective digestive enzymes and impaired nutrient absorption. (Option 5) Fluids are not restricted; liberal intake is recommended to assist in thinning respiratory secretions. Educational objective:Clients with cystic fibrosis should have a diet high in fat and calories to combat nutrient malabsorption. Liberal fluid intake is encouraged to loosen thick secretions. Chest physiotherapy and aerobic exercise are performed to remove airway secretions. Financial needs are addressed as clients have a large financial burden. Additional Information Management of Care NCSBN Client Need

The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include? 1. Disulfiram is not a cure for alcoholism (21%) 2. Importance of continuing to see a therapist (7%) 3. List of everyday items containing hidden alcohol (59%) 4. Medical alert bracelet should identify disulfiram therapy (12%) OmittedCorrect answer 3 59%Answered correctly

Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2). Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: Avoid hidden alcohol in:liquid cold and cough medicationsaftershave lotions, colognes, and mouthwashesfoods such as sauces, vinegars, and flavor extracts Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur Wear a bracelet alerting others of being on disulfiram therapy (Option 4) Educational objective:Disulfiram is a medication that promotes abstinence from alcohol by causing uncomfortable, potentially fatal reactions when alcohol is consumed. Clients must avoid sources of hidden alcohol (eg, liquid cough medicine, aftershave, mouthwash). Effects of the drug can last 2 weeks after the last dose.

/////(ex23) The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow, and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action? 1. Administer prescribed intravenous morphine 2 mg to relieve anxiety (9%) 2. Page respiratory therapist to administer inhaled bronchodilator nebulizer treatment (7%) 3. Place head of the bed in Fowler's or high Fowler's position (44%) 4. Stay with client and encourage client to discuss feelings about the surgery (38%) OmittedCorrect answer 3 44%Answered correctly

Elevating the head of the bed to Fowler's or high Fowler's position is the priority nursing action to help relieve shortness of breath, facilitate oxygenation (breathing), and promote lung expansion (airway). Alternate positions to high Fowler's include the following: Orthopneic position: Sitting in a chair, on the side, or in bed leaning over the bedside table, with one or more pillows under the arms or elbows for support Tripod position: Sitting in a chair leaning forward with hands or elbows resting on the knees. Sitting upright and leaning forward pulls the scapulae apart, promotes lung expansion, and decreases the diaphragmatic pressure produced by the viscera. (Option 1) Morphine is effective in relieving anxiety and decreasing the work of breathing by slowing respirations. It can cause hypoventilation and decrease gas exchange in the lungs and is not the priority action, especially as the client's respirations are shallow. (Option 2) The cause of the wheezing could be from lung tumor or true bronchoconstriction. Paging the respiratory therapist to administer a bronchodilator nebulizer treatment to relieve wheezing is an appropriate intervention, but it is not the priority action. (Option 4) Encouraging the client to talk about the diagnosis and upcoming surgery is an appropriate intervention to help alleviate anxiety and address self-actualization needs, but is not the priority action. Educational objective:Elevating the head and chest in the Fowler's, high Fowler's, orthopneic, and tripod positions allows for maximum lung expansion and promotes oxygenation, especially in clients with dyspnea.

/The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply. 1. "A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week." 2. "I am proud that I was able to lose 10 lb, but I'm still considered obese for my height." 3. "I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently." 4. "I have struggled with daily episodes of acid reflux for years, especially at nighttime." 5. "I snack on a lot of salted foods like popcorn and peanuts." OmittedCorrect answer 1,2,3,4 24%Answered correctly

Esophageal cancer is a rare, rapidly growing malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part. Major risk factors include smoking (eg, cigarettes, pipe, cigars) and excessive alcohol consumption (ie, approximately >15 drinks/week for men, >8 drinks/week for women) (Options 1 and 3). Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the esophagus develops precancerous changes. Obesity (which allows stomach acid to flow upward into the esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus; they are both closely linked with esophageal cancer (Options 2 and 4). (Option 5) Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of nitrosamine-containing foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury), and deficient intake of fruits and vegetables. Educational objective:Esophageal cancer is a rapidly growing malignancy of the esophageal lining. Risk factors for esophageal cancer include smoking, excessive alcohol consumption, obesity, and gastroesophageal reflux disease. Additional Information Health Promotion and Maintenance NCSBN Client Need

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting OmittedCorrect answer 2,4,5 30%Answered correctly

Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Tub baths should be avoided due to risk of introducing infection (Option 3). Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3). Report any redness, swelling, and increase in drainage or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling (Option 5). Educational objective:The nurse should instruct the client with chest and leg incisions from CABG to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions, to report any redness, swelling or increase in drainage, and to wear an elastic compression hose on the legs.

The nurse is caring for a 2-week-old client who has tetralogy of Fallot. Which assessment finding is a priority to report to the health care provider? 1. Hemoglobin level of 24.9 g/dL (249 g/L) (38%) 2. Murmur noted on heart auscultation (10%) 3. Newborn becomes fatigued during feeding (31%) 4. Newborn has gained 0.6 lb (0.3 kg) since birth (19%) OmittedCorrect answer 1 38%Answered correctly

Infants with tetralogy of Fallot (TOF), a cyanotic cardiac defect, experience chronic hypoxemia due to decreased pulmonary blood flow and circulation of poorly oxygenated blood. To compensate for prolonged tissue hypoxia, erythropoietin production increases to produce additional oxygen-carrying RBCs. Increased RBCs result in increased circulatory viscosity or polycythemia (ie, hemoglobin >22 g/dL [220 g/L] or hematocrit >65%). Polycythemia increases the risk for blood clotting (ie, thrombus formation), which can cause stroke. Therefore, a hemoglobin level of 24.9 g/dL (249 g/L) is a priority to report to the health care provider because close observation and additional interventions such as IV hydration and (possibly) partial exchange transfusion are required (Option 1). (Option 2) A loud, systolic ejection murmur is characteristic of TOF and not a priority to report because the diagnosis is established. (Options 3 and 4) Infants with TOF may commonly experience frustration or fatigue due to increased oxygen demands during feedings. Therefore, poor weight gain is not unusual. Healthy infants gain about 1 ounce (30 g) per day or 0.5 lb (0.2 kg) per week for the first 3 months. The nurse should report these findings, but they are not more important than polycythemia, which requires immediate assessment and intervention. Educational objective:Clients with tetralogy of Fallot are at risk for polycythemia (ie, increased RBCs resulting in increased circulatory viscosity) due to prolonged tissue hypoxia. Hemoglobin >22 g/dL (220 g/L) or hematocrit >65% are a priority because increased circulatory viscosity increases the risk for thrombus formation and stroke. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Clarify the prescription for oseltamivir with the health care provider 2. Instruct the client to cover the mouth and nose while coughing or sneezing 3. Place a mask on the client when transporting the client through the halls 4. Plan discharge teaching about the importance of annual influenza vaccination 5. Use contact precautions when providing care for the client OmittedCorrect answer 2,3,4 52%Answered correctly

Influenza (flu) is a contagious viral infection that affects the respiratory tract. Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise. Influenza treatment includes rest, hydration, humidified air, and antipyretics/analgesics. Antiviral medications (eg, zanamivir [Relenza], oseltamivir [Tamiflu]) are given to clients with symptom onset within the last 48-72 hours. These medications inhibit viral reproduction and can shorten the duration of the illness. Annual vaccination is recommended to prevent influenza (Option 4). To prevent spreading influenza, infected clients should be on droplet precautions (eg, surgical mask, private room), wear a mask when being transported out of the room, and be taught to cover the mouth and nose while coughing or sneezing (Options 2 and 3). Hand hygiene should also be emphasized as the influenza virus can persist on unwashed hands and surfaces. (Option 1) Oseltamivir is an appropriate antiviral medication for this client who reports onset of influenza symptoms 36 hours ago. (Option 5) The influenza virus is spread via droplet transmission when infected persons cough or sneeze. Hospital personnel caring for clients with influenza should adhere to droplet precautions in addition to standard (universal) precautions. Educational objective:Clients hospitalized with influenza should be on droplet precautions, wear a mask during transport, be instructed to cover coughs and sneezes, and be assisted in performing hand hygiene frequently. Antiviral medications (eg, zanamivir [Relenza], oseltamivir [Tamiflu]) are most beneficial if given within 48-72 hours of symptom onset. Additional Information Physiological Adaptation NCSBN Client Need

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply. 1. Ask the parents if they would like to help bathe the infant 2. Discourage the parents from naming the infant 3. Discuss the importance of organ donation with the parents 4. Encourage the parents and family members to hold the infant 5. Offer to obtain handprints, footprints, and photographs of the infant OmittedCorrect answer 1,4,5 70%Answered correctly

Intrauterine fetal demise, or stillbirth, is the birth of an infant who is not alive. The nurse can assist with the perinatal bereavement process by using therapeutic communication, encouraging the parents and family to hold the infant, and providing privacy. Parents and family members may wish to help bathe and dress the infant, and should be encouraged to view and hold the body before discharge to the funeral home (Options 1 and 4). The nurse should offer to obtain handprints and footprints, cut a lock of the infant's hair, and photograph the infant (Option 5). These keepsakes are often precious mementos for grieving families who must leave the hospital without a child. However, none of these actions should be forced if the parents decline. (Option 2) The nurse should encourage family members to name the infant, which helps them identify the child as part of the family. The staff should refer to the infant by name during care. (Option 3) The nurse or primary health care provider should call the designated organ procurement organization, according to facility protocol. Discussions surrounding organ donation are best performed by trained personnel. Educational objective:Intrauterine fetal demise (ie, stillbirth) is the birth of an infant who is not alive. The nurse should encourage family members to hold and name the infant. Mementos (eg, hand/foot prints, photographs) should be made for the family to keep. However, none of these actions should be forced if the parents decline. Additional Information Psychosocial Integrity NCSBN Client Need

A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago. The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should be delayed? Select all that apply. 1. Haemophilus influenzae type b (Hib) 2. Hepatitis B (Hep B) 3. Measles, mumps, rubella (MMR) 4. Pneumococcal conjugate (PCV) 5. Varicella OmittedCorrect answer 3,5 35%Answered correctly

Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines. Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity (Options 3 and 5). (Option 1) Hib vaccine is not a live vaccine, and final dose (fourth) is recommended between age 12-15 months, according to the Centers for Disease Control and Prevention (CDC). (Option 2) Hep B vaccine is not a live vaccine; the CDC recommends that the final dose (third) be administered between age 6-18 months. (Option 4) PCV is also not a live vaccine, and the final dose (fourth) is recommended between age 12-15 months, according to the CDC. Educational objective:Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG administration as IVIG therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity. Additional Information Health Promotion and Maintenance NCSBN Client Need

A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child? 1. Gastrointestinal bleeding (8%) 2. Growth retardation (9%) 3. Neurocognitive impairment (66%) 4. Severe liver injury (15%) OmittedCorrect answer 3 66%Answered correctly

Lead poisoning still occurs in the United States, although not as often as in previous decades. A common source of exposure is lead-based paints found in houses built before 1978, when such paint was banned. Blood lead level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 if not previously tested. Because lead poisoning particularly affects the neurological system, elevated BLLs (≥5 mcg/dL [0.24 µmol/L]) are dangerous in young children due to immature development of the brain and nervous system. A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure can cause developmental delays, reading difficulties, and visual-motor issues. Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death. (Option 1) Gastrointestinal bleeding is a concern for clients with iron poisoning but has no link to lead toxicity. (Option 2) Although delays in physical growth can result from chronic lead toxicity, the danger of permanent damage to the neurological system is a higher priority, particularly for young children. Growth retardation more commonly occurs with chronic anemia or pituitary disorders. (Option 4) Lead poisoning is most threatening to the kidneys and neurological system; liver injury typically does not occur. Severe liver damage is closely associated with acetaminophen overdose or Reye syndrome. Educational objective:Lead poisoning can lead to many severe complications of the neurological system (eg, developmental delays, cognitive impairment, seizures). Elevated blood lead levels are particularly dangerous in young children due to immature development of the brain and nervous system. Additional Information Physiological Adaptation NCSBN Client Need

During assessment of a client who underwent a coronary artery bypass graft 10 hours ago, the nurse notes that the amount of drainage from the mediastinal chest tube has decreased from 100 mL to 20 mL over the last hour. Which of the following nursing actions is appropriate? 1. Auscultate the client's heart sounds (54%) 2. Notify the client's health care provider (8%) 3. Position the tubing with a dependent loop (23%) 4. Strip the chest tube to remove possible clots (12%) OmittedCorrect answer 1 54%Answered correctly

Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated. If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade (Option 1) and if no such signs are present should troubleshoot other possible causes of chest tube occlusion. (Option 2) The health care provider should be notified after relevant assessment data has been gathered and troubleshooting has been performed. (Option 3) The chest tube should be kept free of dependent loops and kinks. This assists with proper drainage and prevents fluid from accumulating and backflowing into the mediastinum. (Option 4) Stripping (or milking) a chest tube should not be performed, unless specifically prescribed, as it can exert excessively high negative pressure and traumatize tissues within the mediastinum. Educational objective:A marked decrease in mediastinal chest tube drainage warrants immediate assessment for signs of cardiac tamponade (eg, muffled heart tones, pulsus paradoxus, hypotension). If there are no signs of tamponade, the nurse should troubleshoot other possible causes of chest tube occlusion and contact the health care provider. Additional Information Reduction of Risk Potential NCSBN Client Need

/An adolescent client with a sore throat is diagnosed with infectious mononucleosis. Which comment by the caregiver would alert the nurse that additional instruction is necessary? 1. "I need to go to the pharmacy to pick up an antibiotic prescription." (33%) 2. "It is acceptable for my child to have ibuprofen for discomfort or fever." (24%) 3. "My child will be on bed rest with few activities for the next 2 weeks." (18%) 4. "Participation in soccer practice will not be allowed for the next month." (23%) OmittedCorrect answer 1 33%Answered correctly

Mononucleosis is caused by the Epstein-Barr virus. It is typically seen in adolescence from the sharing of drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Antibiotic treatment is inappropriate for a viral infection. Inadvertent intake of antibiotics (amoxicillin) can cause a rash. Treatment for mononucleosis is management of symptoms and includes hydration, rest, control of pain, and reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches. Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph nodes around the neck and severe abdominal pain (splenic rupture). These should be reported to the health care provider (HCP) immediately. (Option 2) Ibuprofen or acetaminophen is appropriate treatment to control pain and manage fever in the child with mononucleosis. Aspirin should be avoided in children due to the risk of Reye syndrome. (Option 3) Fatigue is a symptom of mononucleosis. Rest is very important in the care of a client with mononucleosis. (Option 4) Mononucleosis may cause splenomegaly or hepatomegaly. Contact sports such as soccer should be avoided to prevent injury to the spleen or liver. Educational objective:Treatment for mononucleosis is largely symptomatic. It includes rest, hydration, pain control for sore throat, and fever reduction. Clients should avoid contact sports such as soccer to prevent injury to the spleen or liver. Breathing difficulty or abdominal pain should be reported to the HCP. Additional Information Physiological Adaptation NCSBN Client Need

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? 1. "I can continue to take my prescription of sildenafil." (3%) 2. "I should take the patch off when I shower." (2%) 3. "I will remove the patch if I develop a headache." (2%) 4. "I will rotate the site where I apply the patch." (90%) OmittedCorrect answer 4 90%Answered correctly

Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. (Option 1) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. (Option 2) Patches may be worn in the shower. (Option 3) Headaches are common with the use of nitrates. The client may need to take an analgesic. Educational objective:Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing? 1. Altered mental status (29%) 2. Easy bruising (14%) 3. Loss of body hair (8%) 4. Pitting edema (47%) OmittedCorrect answer 4 47%Answered correctly

Oncotic pressure (or colloid osmotic pressure) is a form of osmotic pressure exerted by plasma proteins (albumin) in the blood that pulls water into the circulatory system. Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemia because the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. When serum albumin is low, oncotic pressure decreases and fluid leaks from the intravascular compartment into the interstitial spaces, causing pitting edema of the lower extremities, periorbital edema, and ascites (Option 4). (Options 1, 2, and 3) Altered mental status, easy bruising, and loss of body hair are manifestations of liver disease, not hypoalbuminemia. Altered mental status (hepatic encephalopathy) is due to elevated serum ammonia levels. Easy bruising is caused by an inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism. Educational objective:Serum albumin plays an important role in maintaining intravascular oncotic pressure. Very low levels of albumin result in fluid leak from the vessels into the interstitial tissue and can lead to pitting edema of the lower extremities, periorbital edema, and ascites. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse teaches a client with newly diagnosed Sjögren's syndrome how to self-administer ophthalmic lubricating ointment medication. Which statement that the client makes indicates the need for further teaching? 1. "After applying the ointment, I'll tightly close my eyes and rub the lid for 2-3 minutes." (80%) 2. "I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge." (7%) 3. "I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment." (7%) 4. "I'll use my ointment at bedtime and my eye drops during the day." (4%) OmittedCorrect answer 1 80%Answered correctly

Ophthalmic lubricants (drops, ointment, gel) replace tears and add moisture to the eyes. They are prescribed to treat dry eyes, a common symptom in clients with Sjögren's syndrome, an autoimmune disorder. Administering an ophthalmic ointment by tightly closing the eyes and rubbing the lid for 2-3 minutes can squeeze the ointment out of the eye and cause injury. The client is taught to gently close the eyes for 2-3 minutes to distribute the medication after applying the ointment. (Option 2) This statement indicates the client's understanding that when self-administering the medication, the client should squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge, and without letting the tube touch the eye to prevent contamination. (Option 3) This statement indicates the client's understanding that when self-administering the medication, the client tilts the head back, pulls the lower lid down, and looks toward the ceiling to help decrease blink reflex. (Option 4) Some clients use the ophthalmic ointment at bedtime and the eye drops during the day due to blurred vision that ointments and gels can cause. Educational objective:Teach client the following steps for self-administration of ophthalmic ointments: Perform hand hygiene Tilt the head back, pull the lower lid down, and look upward Squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge Close the eyes gently for 2-3 minutes after applying the ointment Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

//////SEE EX The nurse is caring for a laboring client receiving an oxytocin infusion. One hour ago, the nurse administered 50 mg meperidine hydrochloride IV for pain. After review of the fetal heart rate strip, which action by the nurse is most appropriate? Click the exhibit button for additional information. 1. Assess labor progress by vaginal examination and prepare for imminent birth (8%) 2. Contact the health care provider to suggest placement of a fetal scalp electrode (4%) 3. Document fetal assessment and make note of recent opioid administration (53%) 4. Stop the oxytocin infusion immediately and apply oxygen via face mask at 10 L/min (33%) OmittedCorrect answer 3 53%Answered correctly

Opioid medications administered during pregnancy (eg, meperidine hydrochloride [Demerol]) cross the placenta, resulting in minimal variability or pseudosinusoidal fetal heart rate (FHR) patterns and neonatal respiratory depression after birth. This FHR strip shows a baseline of 140/min, minimal variability, periodic early decelerations, positive accelerations, and 60-second contractions every 4 minutes. It is a category II FHR tracing due to minimal variability. The most appropriate nursing action is to continue monitoring the FHR as long as nonreassuring signs are absent (eg, late decelerations, persistent minimal variability, bradycardia), making sure to document recent opioid administration (Option 3). (Option 1) Invasive assessments (eg, sterile vaginal examinations) are unnecessary unless signs of imminent birth (eg, urge to push, bearing down, nonreassuring FHR patterns) are present. (Option 2) A more accurate tracing of minimal variability can be obtained with a fetal scalp electrode instead of external monitoring. However, invasive internal monitors are unnecessary because minimal variability will likely resolve after the narcotic wears off. (The duration of action for IV meperidine hydrochloride is 2-4 hours.) (Option 4) Discontinuation of oxytocin is not generally indicated for minimal variability associated with opioid administration. If further nonreassuring signs (eg, persistent minimal variability, late decelerations, tachysystole) occur, oxytocin should be discontinued. Educational objective:The nurse can continue to monitor a fetal heart tracing with minimal variability after recent administration of narcotics (eg, meperidine hydrochloride) when other reassuring features are present (eg, accelerations, no late or variable decelerations, normal baseline and uterine activity).

A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action? 1. Assess the client's orthostatic blood pressure (14%) 2. Assist the client to a sitting position (81%) 3. Hold and walk with the client (0%) 4. Keep the client on bed rest (4%) OmittedCorrect answer 2 81%Answered correctly

Opioids, including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider. (Options 1 and 4) Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. (Option 3) Walking with the client is not recommended when the client is symptomatic on standing. Educational objective:Client safety is the priority action in any situation. The nurse should assist the client to a safe position prior to proceeding with other interventions. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

///A graduate nurse is caring for a client at 39 weeks gestation who is receiving an oxytocin infusion. Oxytocin is infusing at 20 mU/min. Based on the electronic fetal monitoring strip, which action by the graduate nurse would cause the registered nurse to intervene? Click the exhibit button for additional information. 1. Administers oxygen by face mask at 10 L/min (14%) 2. Decreases oxytocin to 10 mU/min (52%) 3. Notifies the health care provider (11%) 4. Repositions the client in left lateral position (21%) OmittedCorrect answer 2 52%Answered correctly

Oxytocin (Pitocin) is a uterotonic (uterine stimulant) medication used for labor induction/augmentation. A common adverse effect of oxytocin is uterine tachysystole (ie, >5 contractions in 10 minutes averaged over 30 minutes). If not corrected, uterine tachysystole can lead to reduced placental blood flow, impaired fetal oxygenation, and abnormal fetal heart rate (FHR) patterns. If nonreassuring FHR patterns (eg, late decelerations, fetal tachycardia, bradycardia) occur, the nurse should stop oxytocin immediately to decrease uterine stimulation and increase blood flow to the fetus. Simply decreasing the dose is inappropriate (Option 2). Other appropriate actions include: Repositioning client to a side-lying position, which increases placental blood flow (Option 4). Administering oxygen via face mask at 8-10 L/min and an IV fluid bolus to improve oxygen availability and blood volume to the fetus (Option 1). These interventions are most effective after repositioning to maximize blood and oxygen delivery. Preparing to administer a subcutaneous injection of terbutaline (Brethine) to relax the uterus if other interventions are unsuccessful Notifying the health care provider (HCP) after implementing initial interventions (eg, positioning, oxygen, fluids) (Option 3). Another nurse can also notify the HCP while the primary nurse is implementing resuscitative measures. Documenting findings, actions, and HCP notification as soon as possible Educational objective:Uterine tachysystole is identified when >5 contractions are present in 10 minutes averaged over 30 minutes. Uterine tachysystole with late decelerations requires discontinuation of oxytocin, repositioning to side-lying, administration of oxygen by face mask at 8-10 L/min, and an IV fluid bolus. Additional Information Reduction of Risk Potential NCSBN Client Need

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question? 1. Hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain (65%) 2. Increase continuous IV normal saline rate from 75 to 100 mL/hr (13%) 3. Insert nasogastric tube and attach to wall suction (17%) 4. Ondansetron 4 mg IVP every 4 hours PRN for nausea (3%) OmittedCorrect answer 1 65%Answered correctly

Paralytic ileus is characterized by temporary paralysis of a portion of the bowel, which affects peristalsis and bowel motility. Signs and symptoms include abdominal discomfort, distension, and nausea/vomiting. Risk factors for paralytic ileus include: Abdominal surgery Perioperative medications (eg, anesthesia, analgesics) Immobility (eg, stroke) To prevent further abdominal distension and resulting nausea, the client should remain NPO. Nasogastric tube to wall suction may be necessary to decompress the stomach (Option 3). IV fluid and electrolyte replacement (eg, normal saline) may be necessary to correct losses that occur from nasogastric suction (Option 2). Nausea can be treated with prescribed antiemetics (eg, ondansetron, promethazine) (Option 4). (Option 1) The client should not take medications by mouth (due to NPO status), and opioid medications should be avoided as they prolong paralytic ileus. Instead, non-opioid IV analgesics (eg, ketorolac, ibuprofen, acetaminophen) should be administered as prescribed if the client is in pain. Educational objective:Opioid medications can worsen constipation and paralytic ileus and therefore should be avoided in high-risk clients (eg, stroke, post abdominal surgery).

//A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first? 1. Client who reports nosebleed that has not resolved after holding pressure for 1 hour (28%) 2. Client who reports sinus congestion with thick nasal drainage and severe facial pain (3%) 3. Client with a sore throat who reports difficulty in opening mouth and swallowing (64%) 4. Client with seasonal allergies who reports new onset of unilateral ear pain and pressure (3%) OmittedCorrect answer 3 64%Answered correctly

Peritonsillar, or retropharyngeal, abscess is a serious complication that can result from tonsillitis or pharyngitis. The presenting features of peritonsillar abscess, in addition to fever, include a "hot potato" (muffled) voice, trismus (inability to open the mouth), pooling of saliva (drooling), and deviation of the uvula to one side. The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction (Option 3). (Option 1) A client with epistaxis (ie, nosebleed) that does not resolve with external pressure will require further hemostatic interventions, such as cauterization or nasal packing (eg, gauze, nasal tampon, balloon catheter). This client should be assessed after the client with signs of impending airway obstruction. (Option 2) Symptoms of acute sinusitis include severe facial pain, nasal congestion with purulent nasal drainage, and fever. In most cases, the etiology is viral but can be complicated by secondary bacterial infection. This client likely requires antibiotics and supportive care but is not the priority. (Option 4) Acute otitis media (ie, infection of the middle ear) may develop secondary to rhinitis (eg, common cold, seasonal allergies) due to inflammation of the Eustachian tube. This client with otitis media will likely require antibiotics and pain management but is not the priority. Educational objective:Peritonsillar abscess is an emergent complication of tonsillitis that can lead to life-threatening airway obstruction. Symptoms of peritonsillar abscess include fever, trismus (inability to open the mouth), drooling, muffled voice, and deviation of uvula to one side. Additional Information Management of Care NCSBN Client Need

The nurse is providing education about the vitamin K injection to the parents of a newborn client. Which statement by the nurse is appropriate? 1. "After the first week of life, vitamin K deficiency poses no risk to the newborn." (1%) 2. "If your prenatal diet was high in vitamin K, the vitamin K injection provides little benefit to the newborn." (0%) 3. "Vitamin K deficiency is known to cause growth delays in newborns." (4%) 4. "Vitamin K is essential for preventing bleeding, which can occur spontaneously or after procedures such as circumcision." (93%) OmittedCorrect answer 4 93%Answered correctly

Physiologically, vitamin K levels in the newborn are very low immediately after birth and may result in vitamin K deficiency bleeding (VKDB) (ie, hemorrhagic disease of the newborn). Several factors contribute to vitamin K deficiency. First, vitamin K does not readily cross the placenta, and nonpathogenic bacteria necessary for vitamin K synthesis are absent from the newborn's gut for several days after birth. In addition, low amounts of vitamin K are present in breastmilk. The nurse should educate parents of newborns that vitamin K supplementation is necessary for promoting blood coagulation and reducing the risk of life-threatening hemorrhage from various sources (eg, circumcision site, umbilical stump, brain, intestines) (Option 4). Therefore, an IM injection of vitamin K is routinely recommended for newborns in the first hours of life. (Option 1) VKDB is most common during the first week of life (early-onset and classical) but may occur in infants up to age 6 months (late-onset), especially if exclusively breastfed and not given the vitamin K injection. (Option 2) Prenatal diets rich in vitamin K do not decrease the risk of VKDB because it is a fat-soluble vitamin and does not easily cross the placental barrier. (Option 3) Vitamin K deficiency affects blood coagulation and has no effect on growth and development. Educational objective:Newborns should routinely receive an IM injection of vitamin K soon after birth. The nurse should teach parents that vitamin K supplementation is necessary for promoting blood coagulation and reducing the risk of life-threatening hemorrhage.

The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis. Which question is most important for the nurse to ask? 1. "Have the assistive devices helped with dressing and grooming?" (5%) 2. "How do you feel about the changes in your appearance?" (4%) 3. "How is your pain control with the current medication regimen?" (59%) 4. "Is your level of energy adequate for completing your daily activities?" (30%) OmittedCorrect answer 3 59%Answered correctly

Rheumatoid arthritis is an autoimmune disorder that affects joints and other body systems. Chronic inflammation of the synovial joints causes increasing pain and swelling in the joints and eventual joint deformities with decreased or absent range of motion and loss of function. Clients become easily fatigued and must learn to pace themselves and use assistive devices to accomplish activities of daily living. Goals of treatment are to manage pain, minimize loss of joint mobility, maximize self-care, and maintain self-esteem and a positive body image. Assessing for adequate pain control is the priority, as inadequate pain control will cause disuse of joints, leading to stiffness and decreased joint mobility (Option 3). (Options 1, 2, and 4) If pain is not adequately controlled, the client will be unlikely to use assistive devices and be too fatigued to perform activities of daily living. This can lead to being dependent on others, causing frustration and poor self-esteem and body image. Educational objective:Pain control is the priority assessment for clients with rheumatoid arthritis. Without adequate pain control, clients will have decreased ability to self-manage activities of daily living, maintain mobility and activity tolerance, and maintain self-esteem and a positive body image.

Which of these instructions is appropriate teaching for a 60-year-old woman? Select all that apply. 1. Consume adequate sources of calcium and vitamin D and take supplements 2. Increase intake of food sources of iron and take supplements 3. Observe for unilateral leg swelling when taking hormone replacement therapy (HRT) 4. Remain upright for 30 minutes when taking a bisphosphonate 5. Vaginal spotting after menopause is a common, insignificant sign of aging OmittedCorrect answer 1,3,4 25%Answered correctly

The average age of menopause in the United States is 50-52. Major health risks of menopause include osteoporosis and heart disease. Bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), or ibandronate (Boniva), decrease bone resorption so that loss of bone density is minimized. They must be consumed in the morning, on an empty stomach, with at least 30 minutes before other drugs. The medication is taken with a full glass of water and the client must remain upright for at least 30 minutes to aid absorption and prevent esophageal irritation (Option 4). Adequate sources (both food and supplements) of calcium and vitamin D are required to build bone mass (Option 1). HRT can improve bone mass and prevent osteoporosis but is associated with increased risk of thrombotic complications (deep vein thrombosis, stroke, myocardial infarction) and some cancers (breast, uterine). Therefore, it is used only in clients who have disabling hot flashes. Unilateral leg swelling is a classic symptom of venous thromboembolism (Option 3). (Option 2) Anemia in older adults is usually not related to lack of iron intake, especially once menstruation has stopped. Excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging. (Option 5) Postmenopausal bleeding or abnormal premenopausal bleeding is the most common symptom of endometrial cancer and requires follow-up. Educational objective:A postmenopausal woman (usually after age 51) is at risk for osteoporosis and heart disease. Clients should remain upright after taking a bisphosphonate and consume calcium and vitamin D for bone health. Clotting disorder is a risk with HRT. Intermittent vaginal spotting after menopause can be a sign of endometrial cancer.

/SEE EX The nurse is caring for a ventilator-dependent client with neuromuscular degenerative disease and observes the plethysmograph waveform in the image below. What is the nurse's immediate action? 1. Assess level of consciousness, skin temperature, and color (64%) 2. Disconnect pulse oximeter device from the client and restart it (13%) 3. Preoxygenate with 100% oxygen and perform endotracheal suction (16%) 4. Reset the high and low alarm parameters on the pulse oximeter device (5%) OmittedCorrect answer 1 64%Answered correctly

The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion. When an electronic assessment reading is questionable, the nurse should always assess the client first for possible etiology. The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the correct analysis of the tracing. (Option 2) The artifact is most likely from movement or loose contact between the sensor and the area of the body to which it is attached. It is not an electrical artifact and does not require the device to be disconnected from this client. (Option 3) The pulse oximeter reading is 95%. Unless there are audible or visual secretions, increased ventilator peak pressure readings, coughing, or rhonchi, this client does not require immediate endotracheal suctioning. (Option 4) The reading on the device is 95% and the low alarm is set to 90%. Therefore, alarm parameters do not need to be reset. Educational objective:When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact. This assessment data guides the nurse in the correct analysis of the tracing. Additional Information Reduction of Risk Potential NCSBN Client Need

/The charge nurse is making rounds and should immediately intervene when making which observation? 1. A new nurse is using gentle pressure to flush a kidney pelvis catheter with 5 mL of fluid (14%) 2. A nursing assistant is hanging a urinary drainage bag on the back of a wheelchair when transporting a client (73%) 3. Indwelling urinary catheter is taped to a male client's inner thigh (3%) 4. Total oral fluid intake in 24 hours for a client with a urinary diversion device is 2,800 mL (9%) OmittedCorrect answer 2 73%Answered correctly

The flow of urine is dependent on gravity. In order to maintain gravity flow, the drainage bag should be hung below the level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder. (Option 1) Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of sterile saline solution (≤5 mL at one time) to avoid damaging renal tissues. (Option 3) Securing an indwelling urinary catheter by taping it to a client's leg is acceptable to maintain gravity flow and prevent kinks and occlusions. Also, Velcro securement devices may be available at certain facilities. (Option 4) Fluid intake of 3,000 mL per day should be encouraged in clients after surgery involving the urinary system. Increased fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection. Dilute urine is less irritating to the skin surrounding the stoma site. Electrolyte reabsorption from reservoirs may increase risk for calculi. However, high fluid intake and urine output reduce this risk. Educational objective:The flow of urine is dependent on gravity. The drainage bag should be hung below the level of the bladder to maintain gravity flow.

The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the infection from spreading. What is the nurse's most appropriate response? 1. "Avoid close contact for about a week." (61%) 2. "It's impossible to avoid contact with the client. Just wash your hands often." (27%) 3. "You are sick already, and so you are not contagious anymore." (2%) 4. "You don't have to worry as long as the client has received the influenza vaccination." (8%) OmittedCorrect answer 1 61%Answered correctly

The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins (Option 1). (Option 2) Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission. (Option 3) Individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the infection. It is not appropriate to assume that the spouse can no longer transmit the infection. (Option 4) Although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system. Educational objective:Influenza is a highly contagious respiratory infection transmitted by airborne droplets and direct contact. It has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins. Vaccination does not offer complete protection against all virus strains. Additional Information Safety and Infection Control NCSBN Client Need

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply. 1. Covering client with warm blankets 2. Logrolling the client from side to side frequently 3. Mechanical ventilation 4. Warmed blood administration 5. Warmed IV fluids OmittedCorrect answer 1,3,5 33%Answered correctl

The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3). Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated (Option 2). There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options 1 and 5). (Option 4) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated. Educational objective:Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation, establishing IV access and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid imbalances. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is caring for a client with a history of headaches. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is critical to report to the health care provider (HCP)? 1. Blood pressure 136/88 mm Hg (2%) 2. Flat affect and drowsiness (82%) 3. Poor appetite (0%) 4. Respiratory rate 12/min (14%) OmittedCorrect answer 2 82%Answered correctly

The level of consciousness is the most important, sensitive, and reliable indicator of the client's neurological status. Changes in the level of consciousness can represent increased intracranial pressure and reduced cerebral blood flow. Changes in vital signs usually do not appear until intracranial pressure has been elevated for some time, or they may be sudden in cases of head trauma. (Option 1) The blood pressure is slightly elevated but does not warrant immediate action or signify an emergency situation. (Option 3) A poor appetite is not an emergency finding or situation. (Option 4) The respiratory rate is slightly low, but if it is not irregular it is not an emergency as a single observation. This finding would warrant further assessment and continued monitoring, but it is not as significant as the change in level of consciousness. Educational objective:A change in level of consciousness for the neurological client should be reported to the HCP. The level of consciousness is the most sensitive and reliable indicator of the client's neurological status.

/The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likely expect? Select all that apply. 1. Ecchymosis over the thigh and hip 2. Groin and hip pain with weight bearing 3. Internal rotation of the affected extremity 4. Muscle spasm around the affected area 5. Shortening of the affected extremity OmittedCorrect answer 1,2,4,5 14%Answered correctly

The most common clinical manifestations of hip fractures include: Ecchymosis and tenderness over the thigh and hip - occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL) (Option 1) Groin and hip pain with weight bearing (Option 2) Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area (Option 4) Shortening of the affected extremity - occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward (Option 5) Abduction or adduction of the affected extremity depending on location and mechanism of injury. (Option 3) The affected extremity is usually externally rotated. Educational objective:The characteristic clinical manifestations of most hip fractures include external rotation, abduction, muscle spasm, and shortening of the affected extremity. Additional Information Physiological Adaptation NCSBN Client Need

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider? 1. Fasting blood glucose 99 mg/dL (5.5 mmol/L) (6%) 2. Serum creatinine 2.0 mg/dL (177 µmol/L) (86%) 3. Serum potassium 3.9 mEq/L (3.9 mmol/L) (4%) 4. Serum sodium 140 mEq/L (140 mmol/L) (2%) OmittedCorrect answer 2 86%Answered correctly

The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal. The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney. Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy. (Option 1) Normal serum fasting blood glucose is 70-99 mg/dL (3.9-5.5 mmol/L). (Option 3) Normal serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). (Option 4) Normal serum sodium is 135-145 mEq/L (135-145 mmol/L). Educational objective:The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). Serum creatinine provides an estimation of the glomerular filtration rate and is an indicator of kidney function.

The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. 1. Conduct teaching sessions while a family member is present 2. Discourage the client from using the internet to look up health information 3. Have client watch a DVD about heart failure management 4. Print out pictures of a food label and review where to look for sodium content 5. Speak slowly and loudly so the client can understand you OmittedCorrect answer 1,3,4 59%Answered correctly

The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language. (Option 2) Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view. (Option 5) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning. Educational objective:For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational programs, pictures with simplified text, and inclusion of a family member during teaching sessions. Additional Information Health Promotion and Maintenance NCSBN Client Need

A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescription is the highest priority at this time? 1. Administer enteral feedings at the return of bowel sounds (74%) 2. Assist the client in activities of daily living as tolerated (10%) 3. Contact the client's religious advisor for spiritual support (2%) 4. Educate the client's family about dressings and medications (12%) OmittedCorrect answer 1 74%Answered correctly

The nurse should consider Maslow's Hierarchy of Needs to determine the importance of various interventions. This client in the acute phase of burn management continues to have increased physiological needs. Clients with burns have increased metabolism and calorie requirements that must be met for healing to occur. The nutrition needed for healing increases proportionally with the percentage of burned tissue. Therefore, providing proper nutrition as soon as possible is the highest priority (Option 1). (Option 2) Although it is important to promote activities of daily living, physiological needs such as nutrition are priorities. (Option 3) Psychological and spiritual needs are important but do not take precedence over the client's physiological needs. (Option 4) Physiological needs include direct care for the burned area, infection prevention, and giving the client prescribed medications for healing. Education of the family comes after meeting any type of physiological need. Educational objective:Consider Maslow's Hierarchy of Needs when prioritizing nursing concerns. Physiological needs should be met first (eg, oxygen, fluids, nutrition). Proper nutrition is vital for healing to occur after a burn injury.

//The registered nurse, licensed practical nurse (LPN), and unlicensed assistive personnel are assigned a client who is being transferred from the post-anesthesia care unit (PACU). Which tasks are the most appropriate to delegate to the LPN? Select all that apply. 1. Assess the client on admission 2. Measure vital signs and pulse oximetry 3. Monitor pain level and administer pain medications 4. Receive verbal report from the PACU nurse 5. Reposition client every 2 hours 6. Titrate oxygen based on unit protocols OmittedCorrect answer 3,6 34%Answered correctly

The registered nurse (RN) should consider the 5 rights of delegation prior to delegating a task. Tasks such as monitoring pain, administering medications, and titrating oxygen may be delegated by the RN to the licensed practical nurse (LPN) (Options 3 and 6). (Options 1 and 4) The RN receives report from the post-anesthesia care unit nurse, performs initial assessments, and performs other tasks requiring critical judgment (eg, initial teaching, care planning). (Options 2 and 5) Client positioning and measurement of vital signs and pulse oximetry may be delegated to unlicensed assistive personnel (UAP). Although LPNs can carry out these tasks, their time is better spent performing more complex client care (eg, medication administration) if UAP is available. Educational objective:The registered nurse (RN) is responsible for the client's initial assessment, plan of care development, evaluation, and initial teaching. The RN can delegate most medication administration, client monitoring, education reinforcement, and routine procedures to the licensed practical nurse. Additional Information Management of Care NCSBN Client Need

A 15-month-old begins to seize during assessment for a high-grade fever. What is the most appropriate nursing action? 1. Administer aspirin to lower the client's body temperature (1%) 2. Prepare client for administration of anti-seizure medication (6%) 3. Stay with the client and monitor oxygen saturation levels (84%) 4. Use a bag valve mask to ensure proper ventilation (6%) OmittedCorrect answer 3 84%Answered correctly

This client likely has febrile seizures. It is important to never leave seizing clients alone as the goal is to prevent them from causing self-injury. The nurse should call out for help if needed. The main objective is to ensure that seizing clients maintain their airway; therefore, it is important to monitor their oxygen saturation levels. If these levels begin to drop or cyanosis occurs, prompt intervention is needed, which may be as simple as a head tilt or jaw thrust. (Option 1) Aspirin should not be used in children to treat fever, except in a setting such as Kawasaki disease; this is because aspirin use is associated with Reye syndrome (swelling of the liver and brain). Fever in children is treated with ibuprofen or acetaminophen. (Option 2) Most clients experiencing a febrile seizure do not require anti-seizure medications to stop convulsions. Once seizing has stopped, the fever needs to be treated. If seizing is continuous, medication administration may be necessary. (Option 4) Many clients experiencing a febrile seizure are able to maintain their own airway with no intervention needed. It would not be necessary to bag mask this client if there are no signs of hypoxia or distress. Educational objective:Most clients experiencing a febrile seizure remain stable but still need continuous monitoring for hypoxia. They usually do not require anti-seizure medication. Ensuring client safety is important; therefore, the nurse should never leave a seizing client alone and stay to monitor oxygen saturation levels. Additional Information Physiological Adaptation NCSBN Client Need

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team? 1. Need for discharge to a skilled nursing facility (18%) 2. Nutritional consult with instructions on a high-calorie diet (29%) 3. Option of palliative care (48%) 4. Physical therapy prescription to promote activity (3%) OmittedCorrect answer 3 48%Answered correctly

This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments (Option 3). Palliative care may eventually include hospice care, after it is determined that the client has a life expectancy of less than 6 months. The nurse should advocate for the client and collaborate with members of the health care team to explore care options based on the client's wishes. (Option 1) This client has not clearly demonstrated a need for skilled nursing; additional assessment is needed to determine the most appropriate discharge setting. (Option 2) A high-calorie diet is appropriate for a client with weight loss, but many clients may have difficulty maintaining weight due to factors such as advanced disease and poor appetite. It is not the highest priority in this client, who is nearing the end of life and has expressed an interest in avoiding further testing and hospitalization. (Option 4) Physical therapy may be appropriate to help this client maintain current abilities. However, a client with disease this advanced is not likely to tolerate more activity or gain much additional functional capacity. Therefore, physical therapy is not the highest priority at this point. Educational objective:The client with an advanced, terminal disease (eg, chronic obstructive pulmonary disease) is often an appropriate candidate for palliative care. Palliative care emphasizes quality of life and symptom control and may eventually include hospice care based on the client's life expectancy. Additional Information Management of Care NCSBN Client Need

A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity? 1. "Do you prefer being referred to as 'he' or 'she'?" (16%) 2. "How would you describe your gender?" (52%) 3. "What gender were you originally?" (1%) 4. "What is your preferred name?" (29%) OmittedCorrect answer 2 52%Answered correctly

Transgender clients may fear judgment or embarrassment and withhold information, avoid seeking treatment, or refuse care as a result. This is often related to past experiences of discrimination or stigma when receiving health care. Therefore, it is important to use therapeutic communication and avoid stereotypes to establish trust. Transgender clients may identify as male or female or as neither or both genders. It is important for the nurse to determine clients' gender identity by asking open-ended questions that allow clients to explain their identities in their own words (Option 2). (Option 1) The client may not identify as simply male or female. Asking closed-ended questions (eg, whether the client prefers "he" or "she") does not allow for client elaboration. (Option 3) Because the client does not identify with the gender designated at birth, referring to a transgender client's "original gender" may cause distress and discomfort. The nurse should instead ask what sex the client was assigned on the original birth certificate. (Option 4) Asking "What is your preferred name?" is not open-ended and does not thoroughly assess gender identity. However, the client's preferred and legal names may be different. The nurse should use the client's preferred name to show respect and to develop a therapeutic relationship. Educational objective:Transgender clients may identify as male or female or as neither or both genders. The nurse should use open-ended questions that allow clients to explain their identities in their own words.

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds (16%) 2. 35 seconds (21%) 3. 60 seconds (52%) 4. 85 seconds (9%) OmittedCorrect answer 3 52%Answered correctly

Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed. (Options 1 and 2) These are normal aPTT levels for clients not being anticoagulated. (Option 4) This aPTT is too high. This client is at risk for bleeding. The heparin should be titrated down based on the heparin drip protocol. Educational objective:The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5-2 times normal, or an aPTT of 46-70 seconds.

The nurse supervisor tells the psychiatric nurse to go to the telemetry unit ("float") as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the psychiatric nurse? 1. Clarify the skills/knowledge that the nurse is able/unable to perform (81%) 2. Read the policy and procedure book for the unit before providing care (5%) 3. Refuse to go due to concerns about client safety (10%) 4. Tell the supervisor to send someone else instead (2%) OmittedCorrect answer 1 81%Answered correctly

When asked to "float" to help out in another unit, the nurse should clarify the duties to be performed. Many skills/knowledge, such as vital signs and routine medication administration, are the same in all units. The nurse should be given a unit orientation. The nurse should then clarify applicable skills. For instance, the nurse could perform basic care but not feel comfortable watching the telemetry cardiac monitors or assisting with insertion of a pacemaker. These limitations are usually understood and respected. The qualified and experienced registered nurses on the unit perform specialized client needs, and the "float" nurse performs basic client needs. The nurse is liable to provide safe care for the assigned duties and perform them in a competent manner. The nurse should personally document any concerns raised with the supervisor and avoid discussing personal feelings about the "float" with clients or other staff. (Option 2) There will be neither time nor need to read an entire policy book on specialized care. (Option 3) There is legal precedence that refusal to go when asked to "float" can result in disciplinary action. Options in which the nurse can provide safe care rather make an across-the-board refusal should be explored. The hospital is required to provide safe care and is liable if a unit is insufficiently staffed. (Option 4) This would be considered a refusal. The supervisor probably has considered options (eg, staff in other units) and has chosen this nurse. If a more qualified individual was available, the supervisor probably would have already sent this person. Educational objective:When a nurse is asked to care for clients in an unfamiliar population ("float"), the duties to be performed and the nurse's limitations in skills or knowledge of specialized care should be clarified. Refusing to go can result in disciplinary action, including termination. Additional Information Management of Care NCSBN Client Need

/The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. 1. "I will apply the prescribed bacitracin ointment after collecting the wound culture." 2. "I will cleanse the wound by gently flushing it with normal saline." 3. "I will obtain a sample of the drainage accumulated since the last dressing change." 4. "I will perform hand hygiene and apply new gloves before obtaining the wound culture." 5. "I will swab the wound from the outermost margin toward the center." OmittedCorrect answer 1,2,4 33%Answered correctly

Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris (Option 2). Remove and discard gloves. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin (Options 4 and 5). Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification (Option 1). Apply new dressing. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure. (Option 3) Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue. Educational objective:Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply. 1. Blood pressure of 90/70 mm Hg 2. Bounding peripheral pulses 3. Decreased breath sounds on left side 4. Distant heart tones 5. Jugular venous distension OmittedCorrect answer 1,4,5 22%Answered correctly

Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Signs and symptoms of cardiac tamponade include: Hypotension with narrowed pulse pressure (Option 1) Muffled or distant heart tones (Option 4) Jugular venous distension (Option 5) Pulsus paradoxus Dyspnea, tachypnea Tachycardia (Option 2) Bounding pulses may be present during fluid overload or hypertension. They may also be present with anxiety or fever. The client with possible tamponade will have evidence of decreased cardiac output and is more likely to have weak, thready pulses. (Option 3) Decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax. Educational objective:The client with a moderate to large pericardial effusion is at risk for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, narrowed pulse pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The nurse should report these findings to the health care provider immediately and prepare for a pericardiocentesis. Additional Information Reduction of Risk Potential NCSBN Client Need Copyright © UWorld. All rights reserved.

/The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan? 1. Apply body lotion or powder under the brace to prevent skin irritation (6%) 2. Avoid any exercises that require the use of spinal muscles (13%) 3. Keep the brace on for all activities, including showering (11%) 4. Wear a cotton t-shirt under the brace at all times (68%) OmittedCorrect answer 4 68%Answered correctly

The Boston brace, Wilmington brace, thoracolumbosacral orthosis (TLSO) brace, and Milwaukee brace are used to diminish the progression of deformed spinal curves in scoliosis. Braces do not cure the existing spinal deformities but do prevent further worsening. These braces are also sometimes used for clients who undergo spinal fusion. The braces are molded plastic shells worn around the trunk of the body under the client's outer clothing. Due to the risk for skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb sweat. Compliance is a major problem in most adolescents as they are preoccupied with body image and appearance. Psychosocial issues (eg, body image, sense of control, socialization) are very important to discuss. Many clients may find it helpful to meet other individuals their age who also wear the braces. (Option 1) The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace. (Option 2) It is important to build and maintain strength in the spinal muscles to promote stabilization throughout treatment. Most prescribed bracing courses allow brace removal for such exercises. (Option 3) The exact course of bracing treatment varies based on the type of brace and severity of spinal curvature. Most braces are worn for 18-23 hours per day and removed for bathing and exercise. Clients should never shower while wearing a hard brace as padding will absorb moisture and promote skin breakdown. Educational objective:Clients wearing a brace during treatment for scoliosis must perform proper skin care, wear a cotton t-shirt under the brace, and understand the importance of wearing the brace as prescribed to slow curvature progression. Psychosocial issues (eg, body image, socialization) should also be addressed to promote compliance. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse plans care for a 3-year-old who was admitted with suspected pertussis infection. Which instructions will the nurse include in the plan of care? Select all that apply. 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small amounts of fluids frequently 4. Place the child in a negative-pressure isolation room 5. Request an order for cough suppressant OmittedCorrect answer 1,2,3 33%Answered correctly

Pertussis (whooping cough) is a very contagious communicable disease caused by the Bordetella pertussis bacteria. These organisms attach to the small hairs in the airway and release a toxin that causes swelling and irritation. Pertussis is spread from person to person by coughing, sneezing, and close contact. As a result, an affected client should be placed in standard (universal) and droplet isolation precautions when hospitalized. At first, symptoms similar to the common cold and a mild fever occur, but eventually these clients develop a characteristic violent, spasmodic cough. Coughing is so severe that the person is forced to inhale afterward, resulting in a distinctive, high-pitched "whooping" sound. Coughing episodes may continue until a thick mucus plug is expectorated and are sometimes followed by vomiting (posttussive emesis). Treatment consists of antibiotics and supportive measures. Humidified oxygen and adequate fluids will help loosen the thick mucus. Suction as needed is important in infants. Respiratory status should be monitored for obstruction. The client should be positioned on the left side to prevent aspiration if vomiting occurs. Vaccination against whooping cough is available, but some individuals will still develop the disease, although in a milder form. (Option 4) An airborne precaution such as placing the client in a negative pressure isolation room is needed for individuals with measles, tuberculosis, and varicella zoster (chicken pox) infections (airing MTV). (Option 5) Cough suppressants are not used as they are not very effective for pertussis. In addition, the child needs to cough up any mucus plugs that might develop to keep the airway clear. Educational objective:Pertussis can occur despite vaccination. Characteristic features include a cough lasting ≥2 weeks with ≥1 of the following: paroxysms of cough, inspiratory whooping sound, and posttussive vomiting. Clients need oral antibiotics, droplet precautions, and supportive measures (humidified oxygen and oral fluids). Additional Information Physiological Adaptation NCSBN Client Need

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? 1. Ask the UAP to go back and ask the client what the current needs are (14%) 2. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room (3%) 3. Tell the UAP to inform the client in the next room that the nurse will be there shortly (21%) 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room (60%) OmittedCorrect answer 4 60%Answered correctly

With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door. (Option 1) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. (Option 2) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. (Option 3) The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation. Educational objective:The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure. Additional Information Reduction of Risk Potential NCSBN Client Need

A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for? 1. Erectile dysfunction (22%) 2. Dizziness (42%) 3. Dry cough (16%) 4. Leg edema (18%) OmittedCorrect answer 2 42%Answered correctly

Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. The most important adverse effects of calcium channel blockers include dizziness (Option 2), flushing, headache, peripheral edema (Option 4), and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods. (Option 3) Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, which may produce a nonproductive cough in susceptible individuals. Discontinuation of the medication stops the cough. (Option 1) Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction. Educational objective:Calcium channel blockers are utilized to treat hypertension and chronic stable angina. Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? Select all that apply. 1. Checks for residual every 4 hours 2. Places client in semi-Fowler's position 3. Plugs the air vent if gastric content refluxes 4. Provides mouth care every 4 hours 5. Turns off suction when auscultating bowel sounds OmittedCorrect answer 1,3 15%Answered correctly

Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding (Option 1). The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux (Option 3). General interventions to maintain gastric suction using a Salem sump tube include: Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help prevent gastric reflux (Option 2). Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort (Option 4). Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds (Option 5). Inspect the drainage system for patency (eg, tubing kink or blockage). Educational objective:General interventions to maintain gastric suction when using a Salem sump tube include: Maintaining client in semi-Fowler's position Accurate assessment of bowel sounds Keeping the air vent (blue pigtail) open and above the level of the client's stomach Providing mouth care every 4 hours to maintain moisture of oral mucosa and promote comfort Inspecting the drainage system for patency Additional Information Reduction of Risk Potential NCSBN Client Need

Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply. 1. Administering hydromorphone without a prescription 2. Being habitually tardy to work 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift OmittedCorrect answer 1,3,4,5 36%Answered correctly

The National Council of State Boards of Nursing advises any individual who has knowledge of a potential violation of a nursing law or rule to file a complaint with the appropriate state board of nursing. A nurse should be knowledgeable concerning the presiding board's stance on mandatory reporting and which actions are considered reportable. In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law. Practicing outside of the scope of the license is reportable even if the practice meets quality standards (Option 1). Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action (Option 3). Stealing narcotics is a criminal offense (a violation punishable by the state that can result in prison or a fine) and is reportable in all states. Many states offer an alternate rehabilitation program to nurses who diverted or abused drugs (Option 4). Abandonment (eg, leaving without proper replacement of personnel and transfer of responsibility for client care) is reportable in all states (Option 5). (Option 2) Work habits are handled under the facility's management policies and are often part of the criteria for discipline and/or termination. If the facility has 24-hour care, the off-going nurse cannot leave without someone assuming responsibility for the clients or waiting for the tardy nurse. Educational objective:Nurse offenses reportable to the state board of nursing include criminal acts (such as theft), practicing outside of the scope, falsification of records, and client abandonment. Any individual may file a complaint regarding an action that is potentially unethical, incompetent, impaired, or in violation of nursing law.

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place. Answer: (mL) OmittedCorrect answer 1.2 49%Answered correctly 01 secTime Spent 01/18/2020Last Updated

Weight in kg = Weight (lb) = 187 lb = 85 kg2.22.2 Desired dose = Prescribed amount (mg/kg) x Weight (kg) = (10 mg / 70 kg) x 85 kg = 12.1428 mg Dose to administer = Desired (mg) x Quantity (mL) = 12.1428 mg x 1 mL = 1.214 mL (round down 1.2 mL)Available (mg)10 mg The client is in active labor with an established contraction pattern and pain in the severe range. This is considered a safe time in labor to administer pain medication. The usual dose of nalbuphine hydrochloride is 10-20 mg, and the dose prescribed is within the normal dose range for labor. The nurse must convert the client's weight to kilograms (1 kg = 2.2 lb) and then determine the desired dose in milligrams. Finally, the nurse must calculate the dose to be administered in milliliters. Educational objective:The usual and safe dose of nalbuphine hydrochloride is 10-20 mg/70 kg of body weight given intramuscularly or by IV push. The nurse should convert weight to kilograms and then calculate the dose in milliliters based on the client's body weight and using the 2 formulas: Desired dose = Prescribed amount (mg/kg) x weight (kg) Dose to administer = Desired (mg) x Quantity (mL)Available (mg)

A nurse is reviewing the laboratory results of a client admitted for an asthma exacerbation. Elevation of which of these cells indicates that the client's asthma may have been triggered by an allergic response? 1. Eosinophils (69%) 2. Lymphocytes (9%) 3. Neutrophils (14%) 4. Reticulocytes (6%) OmittedCorrect answer 1 69%Answered correctly

Normal eosinophil count is 1%-2%. Elevated eosinophils are seen in allergy. In a client with an asthma exacerbation, a high eosinophil count would indicate an allergic trigger for the asthmatic response. The nurse should explore the client's allergy history and ways to reduce the allergic exposure that may be contributing to the exacerbation. (Option 2) Lymphocytes form the major part of immune system. Elevated levels are seen with viral infections and hematologic malignancies. (Option 3) Normal neutrophils are 55%-70%. Elevated neutrophils indicate infection. (Option 4) Reticulocytes are immature red blood cells. Normal reticulocyte count is 0.5%-2.0%. Levels are elevated in hemolytic anemia or hemorrhage when the marrow is attempting to compensate for lost blood. Educational objective:An elevated eosinophil count in the complete blood count is associated with allergy. Allergies are frequently triggers of asthma exacerbation.

/SEE EX A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? Click on the exhibit button for additional information. 1. Atrial flutter (15%) 2. Sinus rhythm with premature atrial contractions (PACs) (26%) 3. Sinus rhythm with premature ventricular contractions (PVCs) (53%) 4. Ventricular tachycardia (4%) OmittedCorrect answer 3 53%Answered correctly

A PVC is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement). (Option 1) Atrial flutter is an atrial dysrhythmia identified by recurring, regular, sawtooth-shaped flutter waves that originate from a single ectopic focus in the atria. (Option 2) A PAC is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape than the P wave that originated in the sinus node. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. Educational objective:PVCs are wide and distorted and occur early in the underlying rhythm. They are usually not harmful in the client with a healthy heart. PVCs in the client with myocardial infarction indicate ventricular irritability and should be assessed immediately. Additional Information Physiological Adaptation NCSBN Client Need

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Client with diet-controlled gestational diabetes (2%) 2. Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg (12%) 3. Client with premature rupture of membranes 6 hours ago at 37 weeks gestation (9%) 4. Client with spontaneous rupture of membranes with greenish amniotic fluid (75%) OmittedCorrect answer 4 75%Answered correctly

Green amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4). Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning is no longer necessary. (Option 1) Neonates born to mothers with gestational diabetes are at risk for hypoglycemia after birth and should be monitored closely during the first 6 hours of life. The risk of newborn hypoglycemia is lower if the mother's diabetes is well-controlled and not insulin-dependent. (Option 2) Clients with severe preeclampsia may need magnesium sulfate therapy for seizure prevention. Maternal magnesium therapy can cause newborn respiratory depression at birth. However, this client's mild preeclampsia does not require magnesium therapy. (Option 3) Premature rupture of membranes (PROM) refers to the rupture of membranes prior to the onset of labor at term gestation (≥37wk 0d). PROM on its own does not harm the fetus. However, if labor does not begin after PROM, induction of labor may be necessary to decrease the risk for infection (eg, chorioamnionitis). Educational objective:Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome. A skilled neonatal resuscitation team should be present at birth for immediate newborn evaluation and stabilization. Additional Information Management of Care NCSBN Client Need

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? 1. Instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds (15%) 2. Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (4%) 3. Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus (73%) 4. Rests hand on client's forehead and holds dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac (6%) OmittedCorrect answer 3 73%Answered correctly

If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct (Option 3) Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination (Option 4) Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (Option 2) Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption (Option 1) Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination Wait 5 minutes before instilling a different medication into the same eye Educational objective:To administer ophthalmic medications, follow these steps: (1) Remove secretions from the eyelid by wiping from the inner to outer canthus; (2) pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; and (3) apply pressure to the lacrimal duct if medication has systemic effects (eg, beta blocker, timolol maleate).

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? 1. "I will let my child drink cocoa as usual the morning of the procedure." (7%) 2. "I will wash my child's hair using shampoo the morning of the procedure." (46%) 3. "My child may have scalp tenderness where the electrodes were applied." (35%) 4. "My child will not remember the procedure." (10%) OmittedCorrect answer 2 46%Answered correctly

An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. The test is not painful, and no analgesia is required. (Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure. Educational objective:An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair. Additional Information Reduction of Risk Potential NCSBN Client Need

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider? 1. 2+ pitting edema of the extremity with the arteriovenous fistula (21%) 2. Loud swooshing sound auscultated over the arteriovenous fistula (4%) 3. Pale skin of the hand of the arm with the arteriovenous fistula (73%) 4. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises (0%) OmittedCorrect answer 3 73%Answered correctly

Arteriovenous fistula (AVF) is a permanent hemodialysis access surgically created by connecting an artery to a vein, typically in the forearm or upper arm. This anastomosis diverts arterial blood into the vein, which increases intravenous blood flow and causes the vein to thicken and expand (ie, "mature"). The matured AVF can then sustain frequent access by large-bore needles during hemodialysis. Arterial steal syndrome is an AVF complication that occurs when the anastomosed vein "steals" too much arterial blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb necrosis (Option 3). (Option 1) After AVF creation, edema may occur due to venous congestion but typically improves spontaneously. Extremity elevation helps reduce edema. Severe or prolonged edema (eg, >2 weeks) could indicate venous hypertension that may require surgery to prevent AVF failure. (Option 2) A loud swooshing sound (ie, bruit) auscultated over the AVF is expected due to turbulent blood flow at the arteriovenous anastomosis. (Option 4) Hand-grip exercises (eg, ball squeezing, hand flexing) are encouraged after AVF creation to promote fistula maturation. Postoperative surgical site pain is expected; however, pain distal to the AVF may indicate tissue ischemia. Educational objective:Arterial steal syndrome is a complication of arteriovenous fistula (AVF) creation that impairs distal extremity perfusion and may result in tissue ischemia and necrosis. Symptoms include skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill distal to the AVF.

///The nurse is caring for a client in the acute phase of meningococcal meningitis. Which nursing actions should be included in the client's plan of care? Select all that apply. 1. Assign client to a private room 2. Don mask before entering room 3. Elevate head of bed 10-30 degrees 4. Keep padded tongue blade at bedside 5. Maintain dimmed room lighting OmittedCorrect answer 1,2,3,5 47%Answered correctly

Bacterial meningitis is an inflammation of the membranes that cover the brain and spinal cord and is caused by bacterial infection. Symptoms include headache, neck stiffness, nausea, vomiting, photophobia, fever, and altered mental status. The client with meningitis is at risk for seizure due to increased neuroirritability from fever and alterations in intracranial pressure. Bacterial meningitis is frequently caused by Neisseria meningitidis (meningococcus) in adults. Meningococcal meningitis is highly infectious and requires strict droplet isolation precautions (eg, surgical mask, private room, client masked during transport) (Options 1 and 2). For clients with meningitis, a restful, reduced stimulus environment (eg, quiet, dimly lighted, cool temperature) promotes healing and reduces neuroirritability and seizure risk (Option 5). The client should be on bed rest with the head of the bed elevated 10-30 degrees to promote venous return from the brain and reduce sudden changes in intracranial pressure (Option 3). (Option 4) Seizure precautions (eg, padded bed rails, oxygen and suction equipment at bedside) should be maintained for a client with meningitis. The client may require suction after a seizure has occurred, but nothing should be inserted into the client's mouth during a seizure, including a padded tongue blade, due to the risk of damaging the teeth or oral mucosa. Educational objective:Care for the client with meningococcal meningitis includes droplet isolation precautions, seizure precautions, reduced stimulus environment (eg, quiet, dimly lit), and bed rest with the head of the bed elevated between 10-30 degrees. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client with Graves disease who has a heart rate of 110/min and blood pressure of 122/85 mm Hg (7%) 2. Client with pneumonia and temperature of 101.8 F (38.8 C) who is unable to receive antibiotics due to an occluded IV catheter (44%) 3. Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour (42%) 4. Client with type 2 diabetes whose fingerstick glucose level is 220 mg/dL (12.2 mmol/L) (6%) OmittedCorrect answer 3 42%Answered correctly

Sickle cell disease (SCD) is a group of hereditary blood disorders characterized by RBCs that become sickle-shaped, rather than oval, when deoxygenated. Sickled RBCs are prone to clump together and obstruct blood vessels, particularly during periods of dehydration or stress (eg, infection), which causes a sickle cell crisis (SCC). When caring for clients with SCD, it is critical to observe for indicators of SCC. Severe, acute pain is a common symptom of SCC due to impaired capillary blood flow (ie, vasoocclusion) and tissue ischemia. Without prompt recognition and intervention, vasoocclusion may lead to irreversible tissue damage (eg, myocardial infarction, limb necrosis, stroke) and death (Option 3). (Option 1) New or worsening tachycardia in clients with Graves disease, a common cause of hyperthyroidism, may be an indicator of acute thyrotoxicosis (thyroid storm). However, tachycardia can also occur normally in clients with hyperthyroidism and is less concerning in the presence of other normal vital signs. This client requires further assessment but is not the priority. (Options 2 and 4) Administration of antibiotics (after changing the occluded catheter) and correction of hyperglycemia can be safely addressed after resolving potentially life-threatening complications. Educational objective:Severe, acute pain in clients with sickle cell disease is a common indicator of vasoocclusion and tissue ischemia from a sickle cell crisis. The nurse should immediately report signs of sickle cell crisis so that interventions may be implemented to prevent irreversible tissue damage (eg, myocardial infarction) and death. Additional Information Management of Care NCSBN Client Need

Vital signs Blood pressure 110/60 mm Hg Pulse 80/min Respirations 22/min Oxygen saturation 90% on room air Assessment data - Crackles in middle & lower lung fieldsModerate jugular venous distension3+ pedal edema Medications - Aspirin 81 mg daily Metoprolol 50 mg twice daily Furosemide 40 mg IV daily Atorvastatin 20 mg daily A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Click on the exhibit button for additional information. 1. Aspirin (14%) 2. Atorvastatin (18%) 3. Furosemide (13%) 4. Metoprolol (53%) OmittedCorrect answer 4 53%Answered correctly

Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility. In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this client has stabilized and exacerbation of ADHF has resolved with diuresis. (Options 1 and 2) Aspirin is contraindicated if the client has evidence of bleeding. Statins are contraindicated if there is evidence of severe liver or muscle injury. It is appropriate to administer both of these medications to this client who has coronary artery disease and peripheral vascular disease. (Option 3) This client has crackles, JVD, and peripheral edema, indicating the need for furosemide (Lasix). Therefore, the nurse should continue to monitor the client's BP with the administration of furosemide as it can lower BP. When excess fluid is removed through diuresis, the heart will be able to pump more effectively, which will increase cardiac output and BP. Educational objective:The nurse should question administration of beta blockers in a client with symptoms of acute ADHF due to the possibility of further clinical deterioration. Beta blockers are most useful for chronic heart failure. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply. 1. Administer an anticholinesterase drug AC 2. Anticipate a need for an anticholinergic drug 3. Develop a bladder training schedule 4. Encourage semi-solid food consumption 5. Teach the necessity for annual flu vaccination OmittedCorrect answer 1,4,5 7%Answered correctly

Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal (Option 1). Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk) (Option 4). All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted. It is especially important in clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles (Option 5). (Option 2) An anticholinergic drug, such as atropine, is used for treatment in a cholinergic crisis (eg, the medication is too high or there is excess acetylcholine). The need would not be anticipated during a myasthenic crisis (eg, exacerbation of myasthenia gravis), which is usually a result of too little medication related to noncompliance, illness, or surgery. (Option 3) The skeletal muscles are involved in myasthenia gravis; dysfunction of the reflexes or central nervous system affects bowel and bladder control. This issue is classic with multiple sclerosis. Educational objective:Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations. Additional Information Physiological Adaptation NCSBN Client Need

A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? Select all that apply. 1. Cervical softening on examination 2. Fetal heart tones detected by Doppler device 3. Positive serum human chorionic gonadotropin test 4. Report of fetal movement felt by client 5. Visualization of fetus by ultrasound OmittedCorrect answer 2,5 28%Answered correctly

Positive (diagnostic) signs of pregnancy represent conclusive evidence of pregnancy and cannot be attributed to any other etiology. These signs include a discernible fetal heartbeat heard by Doppler device, ultrasound visualization of the fetus, and fetal movement palpated or observed by the health care provider (HCP) (Options 2 and 5). Presumptive (subjective) signs of pregnancy are self-reported by the client (eg, breast tenderness, nausea, amenorrhea). These signs may be related to other medical conditions and therefore cannot be considered diagnostic of pregnancy. Probable (objective) signs of pregnancy are observed by the HCP during assessment and examination (eg, cervical changes, positive pregnancy test). Combined with subjective signs, objective signs may be more indicative of pregnancy but may still have alternate causes. (Option 1) Cervical softening is an objective sign of pregnancy as it may also be caused by other conditions that result in pelvic congestion (eg, use of hormonal contraceptives, uterine tumors). (Option 3) A positive serum pregnancy test, which reports elevated levels of human chorionic gonadotropin, is considered an objective sign of pregnancy. Gestational trophoblastic disease can also cause positive results. (Option 4) The client's perception of fetal movement, known as quickening, is a presumptive sign of pregnancy. Educational objective:Positive signs of pregnancy represent conclusive evidence of pregnancy. These signs include ultrasound visualization of the fetus, a distinguishable fetal heartbeat heard by Doppler device, and fetal movement palpated or observed by the health care provider.

/The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply. 1. Avoid excessive caffeine 2. Immerse hands in cold water 3. Practice yoga or tai chi 4. Refrain from using tobacco products 5. Wear gloves when handling cold objects OmittedCorrect answer 1,3,4,5 27%Answered correctly

Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: Wear gloves when handling cold objects (Option 5). Dress in warm layers, particularly in cold weather. Avoid extremes and abrupt changes in temperature. Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). Avoid excessive caffeine intake (Option 1). Refrain from use of tobacco products (Option 4). Implement stress management strategies (eg, yoga, tai chi) (Option 3). If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes. (Option 2) Cold water will cause vasoconstriction and worsen the condition. Educational objective:Raynaud phenomenon is a vasospastic disorder triggered by exposure to cold or stress. Key elements of client teaching include management of acute attacks, avoidance of vasoconstrictive substances (eg, tobacco, cocaine, caffeine), stress reduction, and appropriate clothing (eg, gloves, warm layers). Additional Information Physiological Adaptation NCSBN Client Need

//The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? 1. Blisters with a garlic scent near the wrists (12%) 2. Circular bruised blemishes on the back (9%) 3. Markings appearing to be human bites on the arms (64%) 4. Welt-like linear lesions on the back (13%) OmittedCorrect answer 3 64%Answered correctly

The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures in North America can present with dermatologic findings. Markings that appear to be human bites would require further follow-up as these are not common in alternative medicine. Although nurses should be aware of various cultural practices, any marks consistent with child abuse (eg, bite marks, cigarette burns, bruises in various stages of healing) should be reported to the appropriate authorities. (Option 1) Garlic application involves placing crushed garlic directly on the skin. It is thought to heal infections but can cause contact dermatitis and burns on the wrists. This is appropriate to include in a culturally competent care in-service. (Option 2) Cupping is used by many cultures to remove illness from the body. The mouth of a steam-filled cup is placed on the skin, causing circular, bruised blemishes. This is appropriate to include in a culturally competent care in-service. (Option 4) Coining is believed by some cultures (eg, Chinese, Vietnamese) to remove illness from the body. A rounded surface (eg, coin, spoon) is firmly stroked on the lubricated skin of the back and can produce weltlike linear lesions. This is appropriate to include in a culturally competent care in-service. Educational objective:To provide culturally competent care, nurses should be aware of alternative medicine practices that can present with dermatologic findings. Any marks consistent with child abuse should be reported to the appropriate authorities.

A client had a levonorgestrel-releasing intrauterine device placed during a well-woman visit. Which teaching is appropriate for the nurse to include? 1. "Avoid oil-based personal lubricants, which can damage the device's silicone." (14%) 2. "Notify the health care provider if the string feels longer or shorter after menses." (40%) 3. "Placement will need to be reassessed if you lose or gain significant weight." (34%) 4. "The device will provide protection from pregnancy for up to 10 years." (9%) OmittedCorrect answer 2 40%Answered correctly

Priority teaching related to intrauterine devices (IUDs) for long-term contraception focuses on prevention of sexually transmitted infections, which increase the risk for pelvic inflammatory disease, and early recognition of a dislodged device, which places the client at risk for pregnancy. The nurse may use the acronym PAINS to discuss potential complications of IUDs. The client should assess the string position weekly for the first 4 weeks and then after each menses to ensure that the device remains in place. A longer, shorter, or missing string may indicate that the IUD is no longer in the uterus; the client should notify the health care provider and abstain from intercourse or use a barrier method (eg, condom) until placement is verified (Option 2). (Option 1) Clients using latex condoms should use water-based personal lubricants; oil-based lubricants (eg, baby oil) can weaken the condom and cause damage or breakage. IUD integrity is not affected by lubricants. (Option 3) IUD placement is not affected by significant weight changes. Significant weight loss and childbirth are considerations for women using a diaphragm barrier contraceptive device. (Option 4) Copper IUDs (eg, ParaGard) provide 10 years of contraception. Levonorgestrel-releasing IUDs provide 3 years (eg, Skyla) or 5 years (eg, Mirena) of contraception. Educational objective:Priority teaching related to intrauterine devices focuses on prevention of sexually transmitted infections and early recognition of a dislodged device. A longer, shorter, or missing string may indicate that the device is no longer in the uterus and should be reported to the health care provider.

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building? 1. Insist the client sign the AMA form (40%) 2. Provide the client with a copy of hospital results (3%) 3. Reassure that the client can return later (10%) 4. Remove the intravenous catheter (45%) OmittedCorrect answer 4 45%Answered correctly

A competent client can refuse medical treatment and leave against medical advice (AMA). The nurse should inform the health care provider (HCP) immediately. If the client decides to leave the facility, even after the HCP and nurse explain the consequences (including death), or cannot wait until the HCP speaks with the client, the client should be allowed to do so. It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter. (Option 1) The goal is for the client to always have an informed refusal and to sign the legal form to indicate understanding of that information. However, if the client refuses to sign, the client is still allowed to leave (failure to do so constitutes false imprisonment). The nurse should have witnesses to the events and clearly document in the chart what happened and that the client refused to sign. (Option 2) Discharge instructions, results, and prescriptions can be given despite the client leaving AMA. However, it is not essential to provide the clients with results. Removing the catheter is the priority. (Option 3) Reassuring that a client can return is ethical as the desire is for the client to receive needed care. However, it is not a priority over removal of the catheter. Educational objective:When a client leaves against medical advice (AMA), it should be an informed refusal. The nurse should inform the health care provider immediately. The most important action is for the nurse to remove the IV catheter prior to discharge. A client cannot be held against his/her will if the client refuses to sign an AMA form. Additional Information Management of Care NCSBN Client Need

The nurse is caring for a client who has undergone a colonoscopy. Which client assessment finding should most concern the nurse? 1. Abdominal cramping (12%) 2. Frequent, watery stools (7%) 3. Positive rebound tenderness (78%) 4. Recurring flatus (1%) OmittedCorrect answer 3 78%Answered correctly

A risk of a colonoscopy (or any procedure in which a firm scope is inserted into a "hollow tube" organ) is perforation. Signs of perforation include abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen. Another potential complication is rectal bleeding. (Option 1) Abdominal cramping post procedure is an expected finding. It is caused by the stimulation of peristalsis as the bowel is constantly inflated with air during the procedure. (Option 2) The preparation for the procedure, emptying the colon of stool, includes clear liquids, cathartics, and/or enemas. The stool is watery and copious and may continue for a short time after the procedure. It is not a concerning finding. (Option 4) During the procedure, air is inflated into the colon. The client needs to expel this "gas" afterward. It is an expected finding. Educational objective:The complication risks of a colonoscopy are perforation and rectal bleeding. Abdominal cramping, flatus, and watery stool are expected findings. Perforation can lead to peritonitis, with positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen. Additional Information Reduction of Risk Potential NCSBN Client Need