mynclex set 9- 37

A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the best action by the nurse? 1. Explain that the client's depression is being treated with medications (2%) 2. Explain that the client's depression will not be relieved by a ritual (0%) 3. Plan a meeting with the health care provider (HCP), family, nurse, and medicine healer to make arrangements for the ceremony (94%) 4. Tell the family that such practices are not allowed in the hospital (2%) OmittedCorrect answer 3 94%Answered correctly

The medicine healer, or shaman, is an important component of Native American culture and is often consulted by both clients and HCPs when a client is ill or hospitalized. The medicine healer uses a variety of practices, including herbs, plants and roots, singing, and healing ceremonies. The medicine healer needs to be included in this client's treatment. Making arrangements for the healing ritual gives credibility and respect to the client's cultural beliefs and ensures that the client's spiritual needs will be met. In providing culturally sensitive care, the nurse needs to recognize and be tolerant of various practices associated with beliefs that are different from those of traditional Western medicine. Denying the medicine healer the opportunity to perform a ritual could interfere with the client's response to therapy. (Option 1) Although it may be true that the client's depression is being treated with antidepressants, the medications do not meet the client's spiritual needs. (Option 2) This response demeans the client's beliefs and does not acknowledge the importance of the medicine healer to the client's health. (Option 4) Allowances and accommodations should be made by health care facilities to ensure that clients' spiritual needs are met. Educational objective:Medicine healers, or shamans, are an important component of Native American and other cultural groups. Allowing medicine healers to perform rituals and ceremonies will ensure that clients' spiritual needs are met and may contribute to the healing process. The nurse needs to recognize and be tolerant of health practices and beliefs that are different from those of traditional Western medicine.

/The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? 1. Administer oxygen via nasal cannula for client comfort and safety (2%) 2. Clean area with povidone iodine in a circular motion moving outward (10%) 3. Hold the child with the head and knees tucked in and the back rounded out (77%) 4. Monitor and record vital signs every 15 minutes throughout the procedure (9%) OmittedCorrect answer 3 77%Answered correctly

The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion. (Option 1) Unless the client has improper air exchange, oxygen administration is not needed. The nasal cannula will most likely bother the child and lead to unnecessary movement during needle placement. (Option 2) The HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and prepare the chosen area for needle insertion. (Option 4) Unless the client is unstable, there is no need to record vital signs every 15 minutes. The client should be awake and alert, and the procedure should be fairly short in duration. Educational objective:Performing a lumbar puncture on a child is a very sensitive procedure that requires accuracy. The correct position and ability to hold the child still are important to achieve the best result and minimize the risk for complications. Additional Information Reduction of Risk Potential NCSBN Client Need

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP? Select all that apply. 1. "Elevate the right leg on two pillows." 2. "Measure client for compression stockings." 3. "Please let me know what the urine looks like." 4. "Tell me what the client eats at lunch." 5. "Verify wrist restraints are on correctly." OmittedCorrect answer 1,4 29%Answered correctly

Directions to the unlicensed assistive personnel (UAP) should be for tasks (versus total client responsibility) with specific and explicit requirements versus those requiring analysis/judgment/evaluation (the nursing process). Elevate leg on 2 pillows is very specific and does not require specialized knowledge or skill (Option 1). Report what the client eats at lunch is data collection only (Option 4). The RN will analyze the data to see if the amount of food is adequate. (Option 2) The UAP may apply compression stockings or devices, but the RN or LPN should measure the client to choose the appropriate size as this is beyond the UAP's scope of practice. (Option 3) This involves an assessment that the RN should perform. The RN could ask for specific data, such as amount of urine or presence of blood clots. (Option 5) This requires a judgment (is the restraint tight enough/too tight and causing impaired circulation?) that the RN should make. The UAP could be assigned a specific task, such as offering a drink to the client. Educational objective:Assign a new UAP specific tasks that do not require specialized knowledge or skills. The UAP can gather data but should not be asked to assess/analyze/evaluate or measure client for compression devices. Additional Information Management of Care NCSBN Client Need

/SEE EX T/he nurse is preparing to perform cardioversion in a client in supraventricular tachycardia shown in the exhibit that has been unresponsive to drug therapy. The client has become hemodynamically unstable. Which step is most important in performing cardioversion? Click on the exhibit button for additional information. 1. Charge the defibrillator (14%) 2. Push the synchronize button (56%) 3. Sedate the client (15%) 4. Select energy level (13%) OmittedCorrect answer 2 56%Answered correctly

The synchronizer switch must be turned on when cardioversion is planned. The synchronize circuit in the defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the electrocardiogram (ECG). This allows the unit to sense this client's rhythm and time the shock to avoid having it occur during the T wave. A shock delivered during the T wave could cause this client to go into a more lethal rhythm (eg, ventricular tachycardia, ventricular fibrillation). If this client becomes pulseless, the synchronize function should be turned off and the nurse should proceed with defibrillation. Synchronized cardioversion is indicated for ventricular tachycardia with a pulse, supraventricular tachycardia, and atrial fibrillation with a rapid ventricular response. (Options 1 and 4) Charging the defibrillator and selecting an energy level are important but not as essential as turning on the synchronize function. If the synchronize button is not activated, the unit will defibrillate without sensing this client's rhythm, potentially causing the client to go into a more lethal rhythm. (Option 3) If this client is awake and hemodynamically stable, sedation is indicated. Educational objective:To perform safe cardioversion, the synchronizer button must be activated prior to discharging the unit. The synchronizer function allows the unit to sense the client's rhythm and not deliver a shock during a vulnerable time that could cause the client to go into a more lethal rhythm. Additional Information Physiological Adaptation NCSBN Client Need

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next? 1. Leave the catheter in place and insert a new catheter higher up in the perineal area (46%) 2. Leave the catheter in place for 30 minutes and then recheck (13%) 3. Notify the prescribing health care provider that there is an obstruction (21%) 4. Remove the catheter and reinsert it at a position higher than the initial insertion (18%) OmittedCorrect answer 1 46%Answered correctly

Urine output would be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina. (Option 2) There sometimes can be a brief (15 second) delay from the water-based lubricant partially blocking the opening before quickly "melting." 30 minutes is too long a delay without an additional intervention. There is no reason to wait that long. (Option 3) There is no sign that there is an obstruction; the catheter was not adequately inserted. (Option 4) A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract; a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re-insert it into the same (wrong) opening. Educational objective:If no urine is returned from Foley catheter insertion in a female client after a short time, the nurse has probably not inserted it into the correct opening. The nurse should leave the original catheter in place and reinsert a new sterile catheter above the original position. Additional Information Reduction of Risk Potential NCSBN Client Need

Four children are brought to the emergency department. Which child should be assessed first? 1. A 13-month-old who ingested an unknown quantity of children's multivitamins (18%) 2. A 15-month-old with a fever of 100.5 F (38.1 C) after being vaccinated (0%) 3. A 3-year-old with a forehead laceration and colorless nasal drainage (73%) 4. A 4-year-old with enlarged tonsillar lymph nodes who is crying in pain (7%) OmittedCorrect answer 3 73%Answered correctly

Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. (Option 1) Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This child should be seen second. (Option 2) A low-grade fever is common after immunizations; this child can be seen last. (Option 4) Although infection and pain are important, this child can be seen third. Educational objective:The child with head trauma who is leaking cerebrospinal fluid (CSF) is at risk for meningitis and intracerebral bleeding. If the drainage is clear, a dextrose test is used to determine if the drainage is CSF. The nurse should assess for signs of bleeding (eg, change in level of consciousness) and infection (eg, increased temperature) and anticipate a CT scan and prophylactic antibiotics.

/The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client? 1. How to transmit the readings over the phone (2%) 2. Keep a diary of activities and any symptoms experienced (71%) 3. Refrain from exercising while wearing the monitor (5%) 4. The monitor may be removed only when bathing (20%) OmittedCorrect answer 2 71%Answered correctly

A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities. Client instructions include the following: Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances Do not bathe or shower during the test period (Option 4) Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record (Option 3) (Option 1) The data are not generally transmitted over the phone. The client simply takes the monitor back to the HCP's office. Educational objective:The nurse should instruct the client with a Holter monitor to keep a diary of activities and any symptoms that occur while wearing it. The client should also be taught not to bathe during the testing period but to continue all other normal activities. Additional Information Reduction of Risk Potential NCSBN Client Need

/The nurse is caring for a client newly diagnosed with mild Alzheimer disease. Which action should the nurse prioritize at this time when teaching the client and family? 1. Demonstrate behavioral management techniques to caregivers (29%) 2. Encourage the client to make an advance directive before cognitive decline worsens (35%) 3. Inform the client that mentally stimulating activities can slow disease progression (32%) 4. Provide information about local adult daycare programs (2%) OmittedCorrect answer 2 35%Answered correctly

Alzheimer disease (AD) is a progressive neurocognitive disorder resulting in memory loss, personality changes, and inability to perform self-care. Due to the progressive course of AD, it is important to discuss advance directives (eg, living will, medical power of attorney) while the client can make informed decisions (Option 2). (Option 1) Disruptive behaviors (eg, agitation, aggression) are common as the disease progresses to moderate or late stages and can be very unsettling. However, caregivers can learn behavioral management techniques at any stage of AD. (Option 3) Remaining mentally active (eg, doing crossword puzzles) may assist in slowing disease progression. However, it is more important to put an advance directive in place in the early stages of the disease. (Option 4) Assistive services (eg, assisted living, adult day care, respite care, meal assistance) are very helpful, especially for clients with moderate to severe dementia. However, caregivers can make decisions regarding assistive services at any disease stage. Educational objective:Clients with Alzheimer disease should be encouraged to make advance directives in the early stages of the disease, while they can make informed decisions. Additional Information Management of Care NCSBN Client Need Copyright © UWorld. All rights reserved.

The registered nurse has completed a well-baby assessment of an 18-month-old. Which assessment findings prompted the nurse to make a referral for a formal developmental screening test? 1. Cannot climb steps by self, pulls a toy, turns the pages of a book (16%) 2. Is bottle fed, can hold a spoon, creeps down stairs (12%) 3. Throws a ball, is able to point to 2 or 3 body parts, cannot draw a picture (1%) 4. Uses 2 words, cannot hold a cup, can seat self in a small chair (69%) OmittedCorrect answer 4 69%Answered correctly

An 18-month-old should have a vocabulary of 10 or more words and be able to hold and drink from a cup. Both of these types of delays (communication and language development, and fine motor skills) may be more apparent at age 18 months than at earlier ages. Either finding should prompt the nurse that further evaluation is needed. (Option 1) An 18-month-old can climb stairs with assistance, use a pull-toy, and turn the pages of a book. (Option 2) An 18-month-old may continue to be bottle fed at times, can hold and clumsily use a spoon, and can creep down stairs. (Option 3) An 18-month-old might be able to scribble but would not be able to draw a picture; an 18-month-old can throw a ball and point to body parts. Educational objective:An 18-month-old should have a vocabulary of at least 10 words and be able to use a spoon. Additional Information Health Promotion and Maintenance NCSBN Client Need

///The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain (54%) 2. Severe lower back pain after lifting heavy boxes (0%) 3. Sharp calf ache with ambulation that improves with rest (11%) 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip (33%) OmittedCorrect answer 1 54%Answered correctly 01 secTime Spent 04/29/2020Last Updated

An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure. (Option 2) Severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening. (Option 3) This is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain (due to the buildup of lactic acid from anaerobic metabolism) related to exercise that resolves with rest. (Option 4) This is a description of a deep venous thrombosis (DVT) resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism; the client with aortic dissection already has a life-threatening condition. Educational objective:An aortic dissection, which classically includes moving, "ripping" back pain, is a medical emergency. Hypertension is the most important contributing factor.

/Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit? 1. Aphasia (49%) 2. Apraxia (23%) 3. Dysarthria (22%) 4. Dysphagia (4%) OmittedCorrect answer 1 49%Answered correctly

Aphasia refers to impaired communication due to a neurological condition (eg, stroke, traumatic brain injury). The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice (Option 1). The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual. (Option 2) Apraxia refers to loss of the ability to perform a learned movement (eg, whistling, clapping, dressing) due to neurological impairment. (Option 3) Dysarthria is weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficult to understand (eg, mumble, lisp). (Option 4) Dysphagia refers to difficulty swallowing. The term dysphagia is often confused with dysphasia. Clients with motor deficits after a stroke may have dysphagia, which requires swallowing precautions to prevent aspiration. Educational objective:Aphasia refers to a neurological impairment of communication. Clients may have impaired speech and writing, impaired comprehension of words, or a combination of both.

The clinic nurse reviews telephone messages left by 4 clients. Which client is the priority to call back first? 1. Client recovering from opioid addiction having cravings after losing job (0%) 2. Client with schizophrenia hearing voices advising to harm a neighbor (55%) 3. Parent of a client with conduct disorder who refuses to leave a locked room (0%) 4. Spouse of a client with depression reporting the client is threatening suicide (43%) OmittedCorrect answer 2 55%Answered correctly

Auditory hallucinations are the most common form of hallucination, noted by falsely perceived sounds, most often in the form of voices. Command hallucinations are a specific type of auditory hallucination, during which voices instruct the client to perform specific actions, often demanding harm to the client or others. Clients who are alone and experiencing command hallucinations that are homicidal or suicidal in nature require immediate intervention to ensure the safety of themselves and others (Option 2). (Option 1) A client experiencing addiction cravings needs assistance but is not a priority over a client with command hallucinations demanding harm to others. (Option 3) Parents of clients with conduct disorder need guidance and training to appropriately respond to problem behavior; however, this is not an immediate safety risk. (Option 4) A spouse calling about a suicidal client is not the first priority; the client is not alone, and the spouse can call others for help (eg, police, suicide hotline) if necessary while awaiting the nurse's return call. This should be the second returned call. Educational objective:A client who is alone with command hallucinations that are homicidal or suicidal in nature requires immediate intervention to prevent harm. Clients who are homicidal or suicidal but are with another person should be addressed after those who are alone. Additional Information Management of Care NCSBN Client Need

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply. 1. Contact the clinic if any hot areas or foul odors develop in the cast 2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3. Elevate the affected extremity above heart level for the first 48 hours 4. Expect some numbness and tingling of the fingers during the first week 5. Use only soft, padded objects to scratch the skin under the cast OmittedCorrect answer 1,2,3 53%Answered correctly

Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). Regularly perform isometric and range of motion exercises to prevent muscle atrophy. (Option 4) The client should also be instructed to contact the health care provider about symptoms of impaired circulation in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is unrelieved by ice, elevation, and pain medication. Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia due to compression of blood vessels and nerves within the extremity's internal compartments. (Option 5) The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching. Educational objective:Cast care instructions include reporting foul odors or hot areas in the cast; preventing the cast from getting wet; elevating the affected extremity above heart level for the first 48 hours; regularly exercising the affected extremity; and reporting symptoms of impaired circulation (eg, numbness, tingling, pallor, coolness). Clients should never insert objects inside the cast. Additional Information Basic Care and Comfort NCSBN Client Need

/The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client's WBC count has increased from 11,200/mm3 (11.2 × 109/L) to 14,600/mm3 (14.6 × 109/L) over the last 24 hours. The nurse understands that which of the following assessment findings indicate potential infection? Select all that apply. 1. Client rating left shoulder pain as 4 on a scale of 0-10 2. Greenish-gray drainage noted on surgical dressing 3. Productive cough with thick, green sputum 4. Stiff abdomen with rebound tenderness on palpation 5. Warm, reddened area around the incision site OmittedCorrect answer 2,3,4,5 32%Answered correctly

Cholecystectomy (removal of the gallbladder) is performed through laparoscopic or open surgery. Signs of postoperative infection typically appear 3-7 days after surgery. Systemic signs may include fever, elevated WBC count, and fatigue. Some potential postoperative infections include: Pneumonia can occur when atelectasis (alveolar collapse) prevents clearing of secretions, promoting bacterial growth. Symptoms include cough with or without sputum, tachypnea, and shortness of breath. Postoperative incentive spirometry, ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia (Option 3). Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and sterile dressing changes help prevent infection (Options 2 and 5). Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency, urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs. Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing related to abdominal distension. Peritonitis may lead to sepsis and death if untreated (Option 4). (Option 1) Clients recovering from laparoscopic surgery may experience referred left shoulder pain during the first few postoperative days. This is due to diaphragmatic nerve irritation caused by the carbon dioxide used to inflate the abdomen during laparoscopic surgery. Educational objective:Some potential postoperative infections related to abdominal surgery include pneumonia, surgical site infection, and peritonitis. Signs of infection may include cough, tachypnea, and shortness of breath; warmth or redness around the incision; purulent incisional drainage; or rigid, painful abdomen. Additional Information Physiological Adaptation NCSBN Client Need

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? 1. 15-year-old student athlete in the emergency department with a fractured femur (4%) 2. 46-year-old with a large abdominal incision and 2 peripheral IV lines (56%) 3. 72-year-old who received a permanent pacemaker 24 hours ago (3%) 4. 80-year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator (36%) OmittedCorrect answer 4 36%Answered correctly

Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. The 80-year-old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator. (Option 1) A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment. MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin integrity. (Option 2) This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed immunity. (Option 3) This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery. Educational objective:Clients at highest risk for developing hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, invasive tubes or lines, or in the ICU. Nurses should follow infection control procedures diligently with these clients. Additional Information Health Promotion and Maintenance NCSBN Client Need

The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask? 1. "Are you taking any over-the-counter medicines for your cold?" (87%) 2. "Are you taking extra vitamin C?" (0%) 3. "Did you babysit your granddaughter this past week?" (1%) 4. "Did you get a flu shot in the past week?" (9%) OmittedCorrect answer 1 87%Answered correctly

Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations. It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. The resulting decreased nasal blood flow relieves nasal congestion. These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis. (Option 2) Taking extra vitamin C may offer some protection for the immune system, but it does not cause an increase in blood pressure. (Option 3) Exposure to young children increases the risk for contracting a contagious respiratory illness, but it does not directly increase blood pressure. (Option 4) A flu shot would not offer protection against the flu within a week and does not cause an increase in blood pressure. Educational objective:Clients with hypertension should be instructed not to take potentially high-risk over-the-counter medications, including high-sodium antacids, appetite suppressants, and cold and sinus preparations, as they can increase blood pressure.

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube. The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route? Select all that apply. 1. Enteric-coated ibuprofen 200-mg tablet 2. Extra-strength acetaminophen 500-mg tablet 3. Metoprolol extended-release 50-mg tablet 4. Sulfamethoxazole double-strength 800-mg tablet 5. Tamsulosin 0.4-mg slow-release capsule OmittedCorrect answer 1,3,5 60%Answered correctly

Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification. (Options 2 and 4) Double- and extra-strength drugs such as sulfamethoxazole and acetaminophen may be crushed and administered separately through an NG tube as long as they are not enteric-coated. The nurse should flush the tube with water before and after each drug administration. Educational objective:Crushing an enteric-coated, slow-release, extended-release, or sustained-release drug disrupts its designed time of release and is contraindicated. The nurse should contact the PHCP for an alternate prescription if such a drug is prescribed via NG route.

The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway. Which nursing interventions are appropriate? Select all that apply. 1. Administer morphine IV PRN for pain after flushing the line 2. Elevate the affected extremity above the level of the heart 3. Establish a new IV access proximal to the affected site 4. Notify the health care provider and prepare phentolamine 5. Stop the infusion immediately and disconnect the IV tubing OmittedCorrect answer 2,4,5 23%Answered correctly

Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect the IV tubing (Option 5). Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema (Option 2). Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine) (Option 4). (Options 1 and 3) The nurse should not flush the infiltrated IV site or use it for further drug administration. Although new IV access must be obtained, access should be established ideally through a central line or on an unaffected extremity. Educational objective:If extravasation of IV norepinephrine occurs, the nurse should stop the infusion immediately, aspirate the drug, remove the IV catheter, elevate the extremity, and administer the antidote phentolamine into affected tissues as prescribed. IV access is reestablished on an unaffected extremity or through a central line.

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing (8%) 2. Hypoactive or absent bowel sounds (16%) 3. Inability to cough or lift the head (65%) 4. Warm, tender, and swollen leg (9%) OmittedCorrect answer 3 65%Answered correctly

GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: Inability to cough Shallow respirations Dyspnea and hypoxia Inability to lift the head or eye brows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure. Educational objective:Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barré syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation. Additional Information Physiological Adaptation NCSBN Client Need

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services? 1. Contacting other social service agencies (30%) 2. Knocking on doors (12%) 3. Putting up flyers (4%) 4. Reporting in to the local command center (52%) OmittedCorrect answer 4 52%Answered correctly

Individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services. Clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and anxiety. Mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster. Services may be provided in shelters, food distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes. However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because: Clients may not know where or how to seek help Clients may be afraid or unable to leave their homes Telephone services and other lines of communication may be disrupted Potential clients may leave their homes and go to shelters or alternate housing Transportation may be severely limited It is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services. The mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments. (Option 1) Contacting other social service agencies may be part of an effort to coordinate services once the team has reported in to the local command center. (Option 2) This is an appropriate outreach strategy after the mobile crisis team has checked in at the local command center and has received the assignments. (Option 3) Putting up flyers may not be a particularly effective way to provide outreach to those affected by a disaster as clients may be afraid to leave their homes or they may be unable to get to where the services are being provided. Educational objective:Individuals impacted by natural disasters or emergencies are often in need of mental health services for assistance in coping with a wide range of reactions and emotions including fear, confusion, hopelessness, and anxiety. Outreach strategies in the aftermath of a disaster need to be centrally coordinated by the various community agencies providing services in order to maximize efficiency and avoid duplicative efforts. Additional Information Safety and Infection Control NCSBN Client Need

A client of the Orthodox Jewish faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty. At noon, the client consumed a lean roast beef sandwich with lettuce and mustard, carrot and celery sticks, and fresh fruit. What would be the most appropriate 2:00 PM snack for this client? 1. Angel food cake and fresh strawberries (13%) 2. Crackers and low-fat cheese (27%) 3. Hard-boiled egg and blueberries (37%) 4. Nonfat plain yogurt (22%) OmittedCorrect answer 3 37%Answered correctly

Individuals who practice Orthodox Judaism follow Kosher dietary laws. These regulations are strict regarding the consumption of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of meat/poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product is consumed. Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time. Hard-boiled eggs and blueberries are nondairy foods and would be an appropriate snack (Option 3). This choice also provides a combination of carbohydrates and protein, which would help in regulating blood glucose. (Option 1) This choice might be allowable under Kosher rules; however, it is not the best choice for a client with diabetes due to the high carbohydrate content. (Option 2) Low-fat cheese is a dairy product and cannot be consumed within 3-6 hours of a meat/poultry meal. (Option 4) Yogurt is a dairy product and may not be consumed within 3-6 hours of meat or poultry. Educational objective:Clients of the Orthodox Jewish faith follow Kosher dietary rules. These include no pork, shellfish, or fish without scales. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product may be consumed. Additional Information Psychosocial Integrity NCSBN Client Need

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan? 1. Assign different staff members to care for the client each day (17%) 2. Continue assigning the client's stated preferred nurse to care for the client (13%) 3. Frequently reassure the client that all staff members are competent in their jobs (48%) 4. Reinforce unit rules and consequences of inappropriate behaviors (20%) OmittedCorrect answer 1 17%Answered correctly

Individuals with borderline personality disorder (BPD) live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving. For this client, the nursing care plan must include the assignment of different staff members. This will help diminish the client's dependence on a particular individual and help the client learn to relate to more than one person. (Option 2) Continuing to assign the client's stated preferred nurse will reinforce the manipulative behavior and the need to cling to one person. (Option 3) Simply telling the client about staff competency will not facilitate behavior change. The client is engaging in this behavior as a protection against abandonment. (Option 4) It is important to reinforce unit rules and the consequences of inappropriate behaviors. However, this is not the best action to address the client's attempt to manipulate the staff. Educational objective:Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client.

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to provide which instruction to the client? 1. Avoid a high-potassium diet (22%) 2. Exercise regularly and maintain a high-fiber diet (5%) 3. Maintain oral hygiene (8%) 4. Report excessive urination and increased thirst (62%) OmittedCorrect answer 4 62%Answered correctly

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals. (Option 1) Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. (Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. (Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia. Educational objective:Risk factors for lithium toxicity include dehydration, decreased renal function, low-sodium diet, and drug-drug interactions (eg, NSAIDs and thiazide diuretics). Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia).

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client? 1. Encourage client to eat bulk-forming foods such as whole grain bread (3%) 2. Encourage rest, fluids, and acetaminophen for the fever (34%) 3. Make an appointment for the client with the health care provider today (60%) 4. Take 2 tablets of loperamide followed by 1 tablet after each loose stool (2%) OmittedCorrect answer 3 60%Answered correctly

Most bouts of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a health care provider (HCP). Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment (eg, Clostridium difficile). (Option 1) Instructions on eating bulk-forming foods may be helpful with diarrhea; however, this option does not seek to address the underlying problem causing the 4 days of diarrhea and fever. The client should see the HCP. (Option 2) Instructions on rest, fluids, and acetaminophen are helpful and would be the primary choice if the diarrhea had been occurring ≤48 hours without other symptoms. (Option 4) Loperamide (Imodium) is a synthetic opioid used as an antidiarrheal. It slows peristalsis and subsequently increases fluid absorption. It should not be used more than 2 days or if fever is present as retention of bacteria or toxins inside the colon can make the process worse and cause toxic megacolon. Educational objective:Clients experiencing diarrhea lasting >48 hours or accompanied by fever or bloody stool should see their health care provider for assessment of fluid status, electrolyte levels, and identification of underlying causes. Additional Information Physiological Adaptation NCSBN Client Need

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? Select all that apply. 1. Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss OmittedCorrect answer 4,5,6 61%Answered correctly

Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). TB, regardless of location, commonly presents with constitutional symptoms, including: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. (Option 1) Dysuria is a symptom of extrapulmonary genitourinary TB. (Option 2) Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid). (Option 3) Back pain indicates spinal TB. Educational objective:The characteristic signs and symptoms associated with pulmonary TB disease include cardinal (major) signs (eg, cough, sputum production, dyspnea) and constitutional (minor) signs (eg, anorexia, weight loss, fatigue, fever, night sweats).

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply. 1. Difficulty arousing from sleep 2. Excessive daytime sleepiness 3. Morning headaches 4. Postural collapse and falling 5. Snoring during sleep 6. Witnessed episodes of apnea OmittedCorrect answer 2,3,5,6 25%Answered correctly

Obstructive sleep apnea (OSA) is the most common type of breathing disorder during sleep and is characterized by repeated periods of apnea (>10 seconds) and diminished airflow (hypopnea). A partial or complete obstruction occurs due to upper airway narrowing that results from relaxation of the pharyngeal muscles or from the tongue falling back on the posterior pharynx due to gravity. During periods of apnea, desaturation (hypoxemia) and hypercapnia occur; these stimulate the client to arouse and breathe momentarily to restore airflow. These cycles of apnea and restored airflow can occur several hundred times per night, resulting in restless and fragmented sleep. Partners of clients with OSA witness loud snoring, apnea episodes, and waking with gasping or a choking sensation (Options 5 and 6). During the day, clients experience morning headaches, irritability, and excessive sleepiness. Excessive daytime sleepiness can lead to poor work performance, motor vehicle crashes, and increased mortality (Options 2 and 3). (Option 1) Frequent (not difficult) arousal from sleep is associated with OSA. (Option 4) Cataplexy is a brief loss of skeletal muscle tone or weakness that can result in a client falling down. It is associated with narcolepsy, a chronic neurologic sleep disorder. Educational objective:At night, clients with obstructive sleep apnea experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common. Additional Information Physiological Adaptation NCSBN Client Need

The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department. All ICU beds are currently full. Which client should the charge nurse consider as most appropriate for transfer out of the ICU? 1. Client 1 hour post arterial sheath removal who just received alprazolam for anxiety (19%) 2. Client admitted 2 hours ago who is on continuous diltiazem infusion (9%) 3. Client extubated yesterday who has oxygen saturation of 95% on 2 L by nasal cannula (53%) 4. Client scheduled to receive a permanent pacemaker tomorrow (17%) OmittedCorrect answer 3 53%Answered correctly

Occasional premature ventricular contractions (PVCs) are common dysrhythmias that may be precipitated by several factors, including electrolyte imbalances (eg, potassium), stimulants (eg, caffeine, nicotine), and stress. Occasional PVCs typically do not cause hemodynamic instability. The client who is stable one day post extubation can be safely transferred to a telemetry or medical-surgical unit, where the occasional PVCs may be further investigated and treated (Option 3). (Option 1) Sinus tachycardia may not present an immediate risk of hemodynamic instability; however, the client who recently underwent arterial sheath removal may be tachycardic due to bleeding. This client requires further investigation and continuous monitoring, and is not appropriate for transfer. (Option 2) The client with atrial fibrillation and rapid ventricular response has decreased cardiac output and may progress to hemodynamic instability. Treatment goals include reducing the ventricular rate to <100/min with medications (eg, diltiazem), preventing thrombotic events (eg, ischemic stroke) with anticoagulants (eg, warfarin), and possibly conversion to normal sinus rhythm with antiarrhythmics (eg, amiodarone). This client is not the best choice for transfer. (Option 4) Complete heart block (ie, third-degree atrioventricular block) requires temporary pacing followed by permanent pacemaker insertion. This client, who is at risk for severe bradycardia and hemodynamic instability, should not be transferred. Educational objective:Occasional premature ventricular complexes are common dysrhythmias and usually do not cause hemodynamic instability. Clients with atrial fibrillation and rapid ventricular response, complete heart block, or other threats to cardiovascular stability require continuous observation in the intensive care unit. Additional Information Management of Care NCSBN Client Need

/The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis? 1. A client with asthma who uses an albuterol nebulizer once a day (34%) 2. A septic client receiving intravenous broad-spectrum antibiotics daily (36%) 3. A teenage client with braces who drinks several sugary drinks daily (1%) 4. An elderly client with poor oral hygiene and inadequate nutrition (27%) OmittedCorrect answer 2 36%Answered correctly

Oropharyngeal candidiasis, or thrush (moniliasis), is an infection of the mucous membranes generally caused by the yeastlike fungus Candida albicans. The fungus causes pearly, "milk-curd" lesions on the oral or laryngeal mucosa that may bleed when removed. Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation, or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced, allowing other opportunistic infections to arise (Option 2). Individuals with dentures and infants also commonly experience monilial infections. Treatment is antifungal medications (eg, nystatin) and proper oral hygiene. (Option 1) Inhaled beta-2 agonists (eg, albuterol) do not increase the risk for fungal infections. However, individuals taking an inhaled corticosteroid (eg, budesonide, fluticasone) are at increased risk for oral candidiasis. To reduce this risk, the client should rinse the mouth after each inhaled dose and maintain good oral hygiene. (Options 3 and 4) Proper oral hygiene and nutrition are important in prevention of oral candidiasis. However, the client with braces or poor hygiene and inadequate nutrition is at lower risk than one who is immunosuppressed or taking antibiotics. Educational objective:Immunosuppressed clients (eg, taking steroids, undergoing chemotherapy or radiation, with immunodeficient states) and those taking prolonged or high-dose antibiotics are at increased risk of oral candidiasis. Elderly clients with dentures are also at high risk. Infection is treated with antifungals (eg, nystatin) and proper oral hygiene.

A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the "Y" site. The nurse reviews a prescription from the health care provider to discontinue the normal saline. What is the most appropriate nursing action? 1. Change the rate of the normal saline to 10 mL/hr (3%) 2. Clarify the prescription with the health care provider (33%) 3. Flush the IV with normal saline and then convert it to a saline lock (24%) 4. Turn off the normal saline and disconnect it from the "Y" site (37%) OmittedCorrect answer 2 33%Answered correctly 01 secTime Spent 02/20/2020Last Updated

Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA medication through the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the prescription to discontinue the normal saline. (Option 1) A "keep-vein-open" rate (eg, 5-20 mL/hr) may be appropriate; however, a prescription is necessary before the nurse can implement this. (Option 3) This client is still receiving PCA, so it is inappropriate to convert the IV to a saline lock. In addition, this does not address the need to flush the PCA medication through the line. (Option 4) Continuous IV fluids may be required to deliver the PCA boluses; before discontinuing the normal saline, the nurse should receive clarification from the health care provider. Educational objective:Continuous IV fluids are often necessary with use of a patient-controlled analgesia (PCA) pump; the fluids maintain an open vein and provide a vehicle for PCA delivery. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

/The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure? Select all that apply. 1. Instruct the client to hold the breath when changing the injection caps and tubing 2. Instruct the client to keep the head to the right side during the dressing change 3. Perform hand hygiene before and after the procedure 4. Place the client in the Trendelenburg position before the procedure 5. Wear sterile gloves and a surgical mask when changing the dressing OmittedCorrect answer 1,3,5 22%Answered correctly

Peripherally inserted central venous catheters (PICC) are commonly used for long-term antibiotic administration, chemotherapy treatments, and nutritional support with total parenteral nutrition (TPN). Complications related to the PICC are occlusion of the catheter, phlebitis, air embolism, and infection due to bacterial contamination. Prior to a central line dressing change, the nurse performs hand hygiene (Option 3). The central line dressing change is performed using sterile technique with the nurse wearing a mask to prevent contamination of the site with microorganisms or respiratory secretions (Option 5). During injection cap and tubing changes, the client is instructed to hold the breath (or perform the Valsalva maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism (Option 1). (Option 2) When performing the dressing change, the client should be instructed to turn the head away from the PICC site to prevent potential contamination of the insertion site by microorganisms from the client's respiratory tract. (Option 4) During dressing, injection caps, and tubing changes, the client is placed in the supine position. If an air embolism is suspected, the client should be placed in the Trendelenburg position (head down) on the left side, causing any existing air to rise and become trapped in the right atrium. Educational objective:The central line dressing change is performed using a sterile technique that includes wearing sterile gloves and mask to prevent contamination of the site with microorganisms or respiratory secretions. During injection cap, tubing, and dressing changes, the client is instructed to turn the head away from the peripherally inserted central venous catheter site to prevent site contamination by the client's respiratory secretions. During cap/tubing changes, the client is instructed to hold the breath (or perform the Valsalva maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The clinic nurse is reviewing the plan of care with a client who has phenylketonuria (PKU) and plans to become pregnant this year. Which statement from the client requires the nurse to intervene? 1. "I will consume more high-protein, iron-rich foods, such as meat and eggs, before and during pregnancy." (44%) 2. "I will use a special, low-phenylalanine formula for infant feeding if my baby is also diagnosed with PKU." (14%) 3. "It would be beneficial for my partner and I to have genetic counseling even though he does not have PKU." (14%) 4. "My baby will need to have adequate milk intake after birth to help ensure the screening test for PKU is accurate." (26%)

Phenylketonuria (PKU) is characterized by deficiency or absence of an enzyme required to metabolize phenylalanine, an amino acid found in protein foods. High levels of phenylalanine can cause intellectual disability by interfering with brain growth and development, which is particularly concerning for the developing fetus and infant. Clients with PKU should follow a low-phenylalanine diet before and during pregnancy to prevent potential teratogenic effects (eg, microcephaly, mental disability, heart defects). Avoiding high-protein foods (eg, meat, dairy, dry beans, nuts, eggs) helps to maintain phenylalanine levels in a safe range (Option 1). (Option 2) If the newborn is also diagnosed with PKU, special formulas with low-phenylalanine will likely be required. Exclusive breastfeeding may pose harm to the newborn with PKU because phenylalanine is transferred via breast milk. (Option 3) PKU is acquired genetically via autosomal recessive inheritance. Partners may not realize they are potential carriers of a recessive gene. Prior to conceiving, couples may benefit from genetic counseling to better understand their risk of having an affected child. (Option 4) Newborn screening tests are typically offered before hospital discharge to detect inborn errors of metabolism (eg, PKU) and other serious conditions. Adequate newborn intake is important for obtaining accurate results. Educational objective:Phenylketonuria is characterized by deficiency or absence of an enzyme required to metabolize phenylalanine found in protein foods. To prevent teratogenic effects, the client should follow a low-phenylalanine diet by avoiding meat, eggs, and other high-protein foods before and during pregnancy. Additional Information Health Promotion and Maintenance NCSBN Client Need

A client at 38 weeks gestation is brought to the emergency department after a motor vehicle crash. She reports severe, continuous abdominal pain. The nurse notes frequent uterine contractions and mild, dark vaginal bleeding. What actions should the nurse take? Select all that apply. 1. Anticipate emergent cesarean birth 2. Apply continuous external fetal monitoring 3. Assess routine vital signs every 4 hours 4. Draw blood for type and crossmatch 5. Initiate IV access with a 22-gauge catheter OmittedCorrect answer 1,2,4 35%Answered correctly

Placental abruption occurs when the placenta separates prematurely from the uterine wall, causing hemorrhage beneath the placenta. Abruptions are classified as partial, complete, or marginal and may be overt (visible vaginal bleeding) or concealed (bleeding behind placenta). Risk factors include abdominal trauma, hypertension, cocaine use, history of previous abruption, and preterm premature rupture of membranes. Symptoms and their severity depend on extent of abruption and include abdominal and/or back pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. Tachysystole (ie, excessive uterine contractions), with or without fetal distress, is often present, and continuous fetal monitoring is necessary (Option 2). A type and crossmatch should be drawn as treatment may include blood transfusion (Option 4). In severe cases, emergent cesarean birth is indicated (Option 1). Although blood loss is maternal, the loss of functional placental surface area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death. (Option 3) Maternal vital signs should be assessed frequently for signs of shock (eg, tachycardia, hypotension) as client condition can decline rapidly. In this acute scenario, assessment of vital signs every 4 hours is not sufficient. (Option 5) Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated. Educational objective:Placental abruption usually presents with abdominal pain and dark red vaginal bleeding. The main concerns are maternal blood loss resulting in hypotension and shock and fetal compromise. Maternal stabilization and expedited birth are indicated. Additional Information Physiological Adaptation NCSBN Client Need

/A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first? 1. Administer prescribed analgesic medication for incisional pain (55%) 2. Encourage use of incentive spirometer every 2 hours while awake (13%) 3. Offer an additional pillow to splint the incision while coughing (27%) 4. Promote increased oral fluid intake (2%) OmittedCorrect answer 1 55%Answered correctly

Postoperative clients are at risk for atelectasis and possibly for pneumonia following surgery as a result of retained secretions. Effective coughing is essential to prevent these complications. The nurse can promote many client actions that will facilitate effective coughing. These include splinting the incision while coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer, and hydrating adequately to thin the secretions. However, all of these interventions are less effective if the client is in pain. The nurse should instruct the client to request pain medication before the pain becomes intense. Pain relief should be addressed prior to implementing coughing exercises and ambulation. (Options 2, 3, and 4) These are appropriate interventions but will be more effective if pain is managed first. Educational objective:The nurse should ensure that the postoperative client has effective pain relief before performing coughing exercises. Additional Information Physiological Adaptation NCSBN Client Need

/The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the client would cause the nurse to intervene? 1. Client applies sterile adhesive dressing over gauze without touching the wound bed (12%) 2. Client applies sterile gauze moistened with sterile saline to wound surface (64%) 3. Client cleanses site with a sterile saline swab in a spiral pattern from the center out (15%) 4. Client removes old dressing with clean gloves and checks site for signs of infection (3%) OmittedCorrect answer 2 64%Answered correctly

Prior to discharge, the nurse must evaluate the client's ability to perform home wound care. When performing a simple dry dressing change, the client should: Don clean gloves and perform hand hygiene before and after removing the old dressing Cleanse the wound bed using sterile saline (or a prescribed cleanser) by moving from "clean" to "dirty," or from the center of the wound outward (Option 3) Thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration (breakdown) of underlying tissues Monitor the site for signs of infection (eg, redness, warmth, purulent drainage) (Option 4) Apply dry, sterile gauze over the wound bed Cover the gauze with an occlusive sterile dressing to keep gauze in place and maintain asepsis. The covering should be applied without touching the wound bed (Option 1) (Option 2) When performing a dry dressing change, the client must make sure that the bandaging materials applied (ie, gauze) are dry. Sterile gauze moistened with sterile saline is used for wet-to-dry dressing changes and is not appropriate for a dry dressing change. Educational objective:The nurse must evaluate a client's ability to perform home wound care before discharge. Instructions for a dry dressing change should include performing hand hygiene, properly cleansing the wound bed, drying the wound, monitoring for signs of infection, and securing a dry, sterile dressing to the wound surface.

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV). Which action by the new RN indicates the need for further education? 1. Administers morphine to relieve anxiety and restlessness (7%) 2. Applies suction when inserting the catheter into the airway (80%) 3. Increases the oxygen concentration on the MV before suctioning (2%) 4. Suctions when MV high-pressure alarm continues to sound and rhonchi are present (9%) OmittedCorrect answer 2 80%Answered correctly

Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing, not inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated. Aerosols of sterile normal saline or mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol). (Option 1) Morphine is administered to promote breathing synchrony with the mechanical ventilator, reduce anxiety, and promote comfort in clients receiving MV. (Option 3) Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the recommended practice to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac dysrhythmias. (Option 4) It is appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations drop, rhonchi are auscultated, and secretions are audible or visible. These manifestations can indicate excessive secretions impairing airway patency. Educational objective:To minimize removal of oxygen and mucosal trauma, suction should be applied only when removing the catheter, not when inserting it. Other interventions to reduce the risks associated with suctioning (eg, hypoxemia, microatelectasis, cardiac dysrhythmias) include assessment for the need to suction, preoxygenating with 100% oxygen, and limiting suction time to 10-15 seconds.

//A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation OmittedCorrect answer 1,2,4,5 23%Answered correctly

Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option 4). During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option 1). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option 2). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room (Option 5). (Option 3) Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered to decrease visual stimuli and risk for seizures. Educational objective:Magnesium sulfate is commonly prescribed to clients with severe preeclampsia to prevent seizures and is a central nervous system depressant. Safety measures for preeclampsia include seizure precautions and decreasing environmental stimuli.

A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider? 1. Albumin of 3.0 g/dL (30 g/L) in a client with chronic hepatitis (3%) 2. B-type natriuretic peptide of 400 pg/mL (400 pmol/L) in a client with heart failure (18%) 3. Magnesium of 1.7 mEq/L (0.85 mmol/L) in a client with alcohol withdrawal (8%) 4. Sodium of 120 mEq/L (120 mmol/L) in a client with small cell lung cancer (68%) OmittedCorrect answer 4 68%Answered correctly

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider. (Option 1) Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a protein formed in the liver. Hepatocytes lose the ability to synthesize albumin when the cells are diseased. Hypoalbuminemia (<3.5 g/dL [<35 g/L]) should be expected in this client. (Option 2) B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is a substance secreted from the cardiac ventricles in response to increases in ventricular pressures and volume. Therefore, BNP is a marker for heart failure and is elevated in clients with both stable and decompensated heart failure. BNP is an expected finding in this client. (Option 3) Clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia (<1.5 mEq/L [<0.75 mmol/L]) results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This finding is within normal limits (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]). Educational objective:Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic hormone secretion (SIADH). When serum sodium drops below 120 mEq/L (120 mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH.

A nurse is teaching the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply. 1. Encourage smaller, frequent feedings 2. Offer a pacifier when the infant begins to cry 3. Promote a quiet period upon waking in the morning 4. Swaddle the infant during procedures 5. Turn the infant frequently during sleep OmittedCorrect answer 1,2,3,4 30%Answered correctly

Tetralogy of Fallot is a complex heart defect that results in decreased pulmonary blood flow, mixing of oxygenated and unoxygenated blood, and inadequate blood flow into the left side of the heart. Hypercyanotic episodes (ie, "tet" spell) occur when unoxygenated blood enters the systemic circulation, resulting in cyanosis and hypoxemia. Tet spells usually occur during stressful or painful procedures; on waking; and with hunger, crying, and feeding. Home interventions to reduce the incidence of tet spells include: Providing a calm environment, particularly on waking (Option 3) Soothing and quieting the infant when crying or distressed Offering a pacifier (Option 2) Swaddling or holding the infant during procedures or times of stress (Option 4) Providing frequent smaller feedings to reduce frustration due to hunger and limit sucking fatigue (Option 1) During an acute tet spell, the infant may be placed in the knee-chest position to improve pulmonary blood flow by increasing systemic vascular resistance; older children may assume a squatting position. Intermittent oxygen can also be used to treat the spell, if necessary. (Option 5) Tet spells occur more often during stressful situations or on waking, so sleep should not be interrupted whenever possible. Educational objective:Hypercyanotic or tet spells usually occur during stressful or painful procedures; on waking; and with hunger, crying, and feeding. Providing a calm environment; reducing hunger with small, frequent meals; and swaddling during procedures can help prevent hypercyanotic spells. Additional Information Physiological Adaptation NCSBN Client Need Copyright © UWorld. All rights reserved.

A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse? 1. Dizziness on standing (19%) 2. Fasting blood glucose of 160 mg/dL (8.9 mmol/L) (10%) 3. Presence of muscle cramps (63%) 4. Sunburn on both arms (7%) OmittedCorrect answer 3 63%Answered correctly

Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) are prescribed to treat hypertension and edema. The major side effects of thiazide diuretics include: Hypokalemia - manifests as muscle cramps (Option 3) Hyponatremia - manifests as altered mental status and seizures Hyperuricemia - may precipitate or worsen gout attacks Hyperglycemia - may require adjustment of diabetic medications Hypokalemia is the most serious side effect of thiazide diuretics as it can lead to life-threatening cardiac dysrhythmias. (Option 1) Orthostatic hypotension may be a side effect of any diuretic. The nurse should teach the client to sit for a few minutes before standing and rise slowly. The nurse should also check that the client's blood pressure is not too low. (Option 2) Mild to moderate hyperglycemia is common with thiazides and needs to be addressed. However, it is not life-threatening and therefore not a priority. (Option 4) Most thiazide diuretics are sulfa derivatives and can therefore cause photosensitivity. The nurse should encourage the client to use sunscreen and wear protective clothing. Educational objective:The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to dangerous ventricular dysrhythmias.

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? 1. Administer IV normal saline (50%) 2. Determine if urinary occult blood is present (1%) 3. Perform a neurological assessment (41%) 4. Verify that there is no stool impaction (6%) OmittedCorrect answer 1 50%Answered correctly

This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion. (Option 2) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation stability is a priority. (Option 3) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]). (Option 4) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury. Educational objective:Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion. Additional Information Physiological Adaptation NCSBN Client Need

/The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? 1. Encourage increased fluid intake (19%) 2. Provide frequent rest periods (10%) 3. Teach the client to get up slowly from the bed or a sitting position (55%) 4. Tell the client to wear sunglasses when outdoors (14%) OmittedCorrect answer 3 55%Answered correctly

Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients. Due to the increased risk of falling, the priority nursing action is to teach the client to get up slowly from the bed or a sitting position. (Options 1, 2, and 4) These are important instructions but not priority ones. Educational objective:The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question? 1. Allopurinol 200 mg PO every 24 hours (22%) 2. Normal saline IV at 150 mL/hr continuous (10%) 3. Sevelamer 800 mg PO 3 times daily with meals (25%) 4. Spironolactone 25 mg PO every 12 hours (41%) OmittedCorrect answer 4 41%Answered correctly

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia (Option 4). Loop or osmotic diuretics may be prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also helps to reduce potassium. (Options 1 and 2) Hypouricemic agents (eg, allopurinol) prevent the formation of uric acid, and aggressive fluid hydration (eg, IV normal saline) flushes out the kidneys to avoid the accumulation of toxins. Hydration therapy also dilutes serum potassium, lowering the risk for lethal dysrhythmias. (Option 3) Health care providers often prescribe mealtime phosphate binders (eg, sevelamer, lanthanum carbonate, calcium acetate) to prevent absorption of additional nutritional phosphorus. Educational objective:Tumor lysis syndrome is an oncologic emergency that results in hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia. Treatment includes aggressive hydration, correction of electrolyte abnormalities (eg, loop diuretics, phosphate binders), and hypouricemic agents (eg, allopurinol). Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need Copyright © UWorld. All rights reserved.

//A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools (2%) 2. Greasy, foul-smelling stools (6%) 3. Stools mixed with blood and mucus (56%) 4. Thin, "ribbon-like" stools (34%) OmittedCorrect answer 3 56%Answered correctly

Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. (Option 1) Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. (Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. (Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective:The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior. Additional Information Physiological Adaptation NCSBN Client Need

The registered nurse is counseling the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription for methylphenidate immediate-release tablet. Which statement by the parent demonstrates that teaching has been effective? 1. "An additive-free, low-sugar diet will reduce my child's symptoms." (21%) 2. "I can now manage my child's condition on my own." (3%) 3. "My child should not take the last daily dose after 6 PM." (74%) 4. "Once medication is started, I will not have to monitor my child anymore." (1%) OmittedCorrect answer 3 74%Answered correctly

Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of attention-deficit hyperactivity disorder (ADHD). Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6 PM (Option 3). The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response. (Option 1) Contrary to popular myth, sugar does not increase hyperactivity; although an additive-free diet may be a healthy approach for children, eliminating additives or food colorings does not decrease the symptoms of ADHD. (Option 2) A team approach (parents, teachers, health care providers) is the most effective way to help a child with ADHD. School-based interventions may include specific classroom modifications or accommodations to be incorporated into the treatment plan. (Option 4) Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy. Educational objective:Methylphenidate is a stimulant drug with the potential to cause insomnia. Parents are instructed to administer the last dose no later than 6 PM to prevent sleep disruption.

/A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client? 1. Apply an ice pack to the left shoulder (1%) 2. Elevate the affected arm on a pillow (72%) 3. Help the client ambulate frequently (11%) 4. Obtain a pneumatic compression sleeve (14%) OmittedCorrect answer 2 72%Answered correctly

After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level (eg, on a pillow) is crucial to reduce fluid retention and prevent lymphedema in the affected arm (Option 2). Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within 4-6 weeks. Additional nursing care for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "No blood pressure, venipuncture, or injections on left arm," as these actions could cause lymphedema. (Option 1) Ice reduces inflammation, swelling, and pain. Although this reduces discomfort, it does not directly contribute to restoring arm function and is not the priority. (Option 3) Frequent ambulation is not the priority in the initial postoperative period as it does not facilitate lymph drainage or help restore arm function. (Option 4) Pneumatic compression devices may be used to facilitate lymph drainage when lymphedema is present. Elevating and exercising the arm help prevent lymphedema from developing and are priority in this client. Educational objective:A priority goal for a client following a mastectomy is restoring function in the affected arm. Elevation of the arm and institution of arm exercises begin immediately following surgery to prevent lymphedema.

A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy. Which statement indicates that the client understands the advantages of using this therapy? 1. "I won't need a bolus dose of insulin before my meals anymore." (26%) 2. "I'm glad my blood sugars won't go way up and way down, like they did before." (48%) 3. "I'm so glad I don't have to stick my finger 4 times a day to test my sugar anymore." (23%) 4. "It'll finally be easier for me to lose some weight." (2%) OmittedCorrect answer 2 48%Answered correctly

An insulin pump is a small, battery-operated device about the size of a pager. The infusion set holds a syringe (reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2 ways: As a steady, measured, and continuous dose (basal rate) 24 hours a day As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose to correct pre- or postprandial hyperglycemia. CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and syringe, or pen. (Option 1) Although the pump can calculate and deliver a more precise dose to regulate blood glucose levels more effectively, a bolus dose must be administered manually at mealtime to cover carbohydrate intake. (Option 3) Pumps used most commonly (open-loop) cannot respond to changes in the client's glucose levels. The American Diabetes Association recommends that clients using CSII check their blood glucose levels 4-8 times a day: fasting, pre-meal, 2-hours postprandial, bedtime, at 3:00 AM weekly, when experiencing symptoms of hypoglycemia, after treating low blood sugar, and before exercise. Some insulin pumps (closed-loop system) are equipped with continuous blood glucose monitoring (CBGM) systems, which can detect blood glucose levels without a fingerstick. However, CBGM does not completely eliminate the need to test blood sugar because some machines must be calibrated every day to validate accuracy. (Option 4) Use of the insulin pump facilitates tighter glucose control, leading to more normal metabolism. However, if the client continues to take in more calories than needed for a given amount of activity or exercise, glucose that is not used by the cells accumulates as fat and results in weight gain. Educational objective:A client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least 4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is planning care for a newborn client at term gestation who is large for gestational age. Which of the following are appropriate interventions to include in the plan of care? Select all that apply. 1. Assess newborn for birth-related injuries 2. Discuss the need for feeding supplementation if symptoms of hypoglycemia occur 3. Encourage the mother to breastfeed the newborn every 2-3 hours 4. Notify the health care provider if capillary blood glucose is <45 mg/dL (2.5 mmol/L) 5. Perform capillary blood glucose checks prior to feedings OmittedCorrect answer 1,2,3,4,5 24%Answered correctly

CLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Newborns who are large for gestational age (LGA) are diagnosed after birth by plotting their birth weight and gestational age on a growth chart; weight must be at least >90th percentile and is commonly >8 lb 13oz (4000 g). Risk factors include gestational diabetes; excessive gestational weight gain or elevated prepregnancy BMI; history of a prior newborn who was LGA; postterm gestation; and genetics (eg, male sex, maternal birth weight, ethnicity). The nurse should prioritize assessment of birth injuries and hypoglycemia. When developing the plan of care for a newborn who is LGA, the nurse should include the following interventions: Document gestational age assessment, weight, length, and head circumference to identify newborns who are LGA. Assess the newborn for birth-related injuries (eg, cephalohematoma, clavicular fracture, lacerations) and review the birth record to determine if an operative vaginal birth occurred (eg, forceps) (Option 1). Discuss the need for possible feeding supplementation (eg, breastmilk, formula) if the newborn is hypoglycemic (Option 2). Assist the mother to feed the newborn soon after birth and every 2-3 hours thereafter to prevent hypoglycemia (Option 3). Obtain a capillary blood glucose (BG) before feeding to assess for hypoglycemia, and notify the health care provider when a capillary BG reading is <40-45 mg/dL (2.2-2.5 mmol/L) (Options 4 and 5). Educational objective:Newborns who are large for gestational age have a birth weight that is >90th percentile. The nurse should create a plan of care for the newborn that prioritizes assessment of birth injuries and hypoglycemia in addition to routine newborn care. Additional Information Health Promotion and Maintenance NCSBN Client Need

What intervention is essential prior to starting a client on atorvastatin therapy? 1. Assessing for muscle strength (16%) 2. Assessing the client's dietary intake (9%) 3. Determining if the client is on digoxin therapy (11%) 4. Monitoring liver function tests (61%) OmittedCorrect answer 4 61%Answered correctly

Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. (Option 1) Statins can also cause muscle aches and, rarely, severe muscle injury (rhabdomyolysis). Clients should be educated to report the development of muscle pains while on therapy. Assessment of muscle strength is not necessary prior to starting therapy. (Option 2) Assessment of dietary intake prior to therapy is not essential. Dietary teaching would have been performed prior to determining that medication therapy was necessary. (Option 3) Atorvastatin may slightly increase serum digoxin levels; however, it is not essential to determine if the client is on this medication prior to starting therapy. Educational objective:Statin medications (eg, rosuvastatin, atorvastatin) can cause hepatotoxicity and muscle aches. Liver function tests should be assessed prior to the start of therapy. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is assessing a client with severe mitral valve stenosis for the presence of a murmur. Select the best site to auscultate a murmur in this client. IncorrectCorrect answer Refer to Hotspot 31%Answered correctly

Mitral valve stenosis often produces a diastolic murmur heard best at the apex of the heart (5th intercostal space, midclavicular line) with a stethoscope. Educational objective:When auscultating for a murmur associated with mitral valve stenosis, the nurse should place the stethoscope at the 5th intercostal space, midclavicular line. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse educates a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which instruction(s) should the nurse include in the teaching plan? Select all that apply. 1. "A pregnancy test must be obtained prior to RAIU test administration." 2. "All jewelry or metal around the neck area should be removed before the RAIU test." 3. "Antithyroid medications should be held for 5-7 days before the RAIU test." 4. "Conscious sedation will be used to help with relaxation during the RAIU test." 5. "It is important to refrain from eating or drinking for at least 12 hours before the RAIU test." OmittedCorrect answer 1,2,3 19%Answered correctly

A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. You will be awake during the procedure but there should be no discomfort (Option 4). Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume. Educational objective:RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders. For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration. Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry should be removed. Additional Information Reduction of Risk Potential NCSBN Client Need

//Vital signs Blood pressure 92/40 mm Hg Apical pulse 140/min and regular Respirations 36/min and labored Oxygen saturation 89% Admission notes 14:00 Diaphoretic; urticaria noted on upper extremities and torso. Bilateral inspiratory and expiratory wheezing on auscultation. Notes "chest tightness, trouble breathing, and itching." __________, RN A client allergic to bee stings was stung about 20 minutes ago at a picnic. Based on the assessment data, the nurse anticipates which immediate actions? Select all that apply. Click on the exhibit button for additional information. 1. Inhaled albuterol 2. Intramuscular epinephrine 3. Intravenous methylprednisolone 4. Intravenous metoprolol 5. Intravenous nitroglycerine OmittedCorrect answer 1,2,3 49%Answered correctly

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). It is caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs, foods, and venom. Anaphylactic shock results in hypotension and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine); these can lead to cardiac and respiratory arrest. The management of anaphylactic shock includes: Call for help (activate emergency management systems) - first action Maintain airway and breathing - administer high-flow O2 via non-rebreather mask Epinephrine, intramuscular - the drug of choice and should be given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM route is better than the subcutaneous route. The dose should be repeated every 5-15 minutes if there is no response. Elevate the legs Volume resuscitation with IV fluids Bronchodilator such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction (Option 4) Metoprolol (beta blocker) should not be given as the blood pressure is already low. (Option 5) Nitroglycerine would also cause hypotension and should not be given. Morphine is avoided as it can worsen pruritus and hypotension. Educational objective:Diphenhydramine (Benadryl), IM epinephrine, inhaled beta agonists, and methylprednisolone (Solu-Medrol) are administered to treat the manifestations associated with anaphylactic shock. They modify the histamine response and treat pruritus, reverse bronchoconstriction, and decrease airway inflammation, respectively. IM epinephrine can be repeated for poor response.

T client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply. 1. Disposable gown 2. Face shield 3. Gloves 4. N95 respirator 5. Surgical mask OmittedCorrect answer 1,2,3,5 33%Answered correctly

Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option 5). Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care) (Options 1, 2, and 3). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection. (Option 4) For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplet splashing and for filtration of large respiratory particles. Educational objective:When caring for clients on droplet precautions, a surgical mask is needed for routine care, such as assessment or medication administration. If there is risk of contact with body fluids during procedures (eg, wound care, suctioning), gloves, gown, and face shield are used. Additional Information Safety and Infection Control NCSBN Client Need

/A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? 1. Frequent vomiting since birth (18%) 2. Tiny blood streaks in the vomit (24%) 3. Vomit that is green (28%) 4. Vomiting through the nose (28%) OmittedCorrect answer 3 28%Answered correctly

Bile made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. (Option 1) Newborns vomit or spit up frequently as they adjust to eating and digesting food. They also have a loose lower esophageal sphincter that allows food to come up from the stomach easily. Hydration status and weight gain should be monitored. (Option 2) Tiny blood streaks may be noted due to rupture of pressured esophageal veins from frequent vomiting. This is not a cause for concern unless the vomit contains a large amount of blood or blood-streaked vomiting persists. Scant amounts seen in vomit can be normal. (Option 4) It is not uncommon for a newborn to have vomiting through the nose because the esophagus is connected to the nose and mouth. The vomit comes up through the esophagus and, if forceful enough, will come out of both orifices. Educational objective:It is common for newborns to vomit frequently as they learn to eat and digest. Hydration status and weight gain should be monitored. Green vomit represents bile from the intestine, which could indicate a bowel obstruction. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply. 1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in a central area OmittedCorrect answer 2,3,5 75%Answered correctly

Bulimia nervosa is an eating disorder common among adolescent girls and characterized by cycles of uncontrollable overeating (binging) followed by compensating behaviors to avoid weight gain (purging). Weight-maintenance behaviors include self-induced vomiting, fasting, laxative abuse, and excessive exercise. Clients may be of normal weight, which contributes to the hidden nature of this disorder. Clients with bulimia often experience extreme guilt associated with their increasing lack of control and attempt to hide evidence of their actions (eg, hidden food wrappers from binging, discarded food from unfinished meals). Clients should be monitored around meal times, and particularly for 1-2 hours after eating to observe for purging. Purging behaviors, particularly vomiting, may result in electrolyte imbalances, such as hypokalemia, that can cause cardiac arrhythmias. (Option 1) Clients with bulimia nervosa often use laxatives inappropriately to rid their bodies of undigested food in an effort to control their weight. Such measures should not continue in the treatment setting. (Option 4) A food diary helps the client and caregivers track the type and amount of food that the client has eaten. It is also an excellent means of helping the client understand the health implications of the disorder. Educational objective:Clients with bulimia nervosa should be monitored for signs of hidden binging or purging activity, particularly for 1-2 hours after meals. Excessive vomiting may result in electrolyte imbalances, including hypokalemia. Additional Information Psychosocial Integrity NCSBN Client Need

A 2-month-old recently diagnosed with developmental dysplasia of the hip (DDH) is beginning treatment with a Pavlik harness. Which instructions should the nurse provide to the parents? Select all that apply. 1. "Apply lotion under the straps to protect the skin." 2. "Dress the child in a shirt and knee socks under the straps." 3. "Lightly massage the skin under the straps daily." 4. "Place the diaper under the straps." 5. "Remove the harness during diaper changes." OmittedCorrect answer 2,3,4 22%Answered correctly

Developmental dysplasia of the hip (DDH) is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods, such as a harness or cast, are most successful when initiated during the first 6 months of life. After this time, surgery is frequently required. A Pavlik harness, the most common tool used in treating early DDH, maintains the infant's hips in a slightly flexed and abducted position, allowing for proper hip development. Pavlik harnesses are typically worn for about 3-5 months or until the hip joint is stable. The straps are adjusted periodically by the health care provider to account for infant growth. Instructions on care for the infant wearing a Pavlik harness are as follows: Regularly assess skin for redness or breakdown under the straps Dress the child in a shirt and knee socks under the harness to protect the skin (Option 2) Avoid lotions and powders to prevent irritation and excess moisture (Option 1) Lightly massage the skin under the straps every day to promote circulation (Option 3) Only apply 1 diaper at a time as wearing ≥2 diapers (previous treatment practice) increases risk of incorrect hip placement Apply diapers underneath the straps to keep harness clean and dry (Option 4) (Option 5) The Pavlik harness is usually worn all the time, particularly during the first few weeks of treatment. Some providers may allow the harness to be removed for a short bath once a day, but it should be left in place for all other care activities, including diaper changes. Educational objective:The Pavlik harness maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Care of the infant with a harness includes dressing the child in a shirt and knee socks, keeping the skin dry, regularly assessing for skin breakdown, massaging the skin to promote circulation, and applying diapers under the straps. Additional Information Reduction of Risk Potential NCSBN Client Need

/SEE EX A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? Click on the exhibit button for additional information. 1. Document and continue to monitor chest drainage (46%) 2. Immediately clamp the chest tube (5%) 3. Notify the health care provider (38%) 4. Request repeat hematocrit and hemoglobin levels (8%) OmittedCorrect answer 1 46%Answered correctly

Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow) over a period of a few days. A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red drainage indicates active bleeding and would be of immediate concern. (Option 2) The chest tube should not be clamped because it is placed to drain the fluid leaking after surgery. (Option 3) The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage (>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin). This is not the appropriate action. (Option 4) It would be appropriate to request repeat serum hematocrit and hemoglobin levels if active bleeding is suspected, but the postoperative levels are stable at this time. This is not the appropriate action. Educational objective:A client will usually have a chest tube in place for several days following a thoracotomy to drain blood from the pleural space. A rush of dark bloody drainage from the tube when the client coughs, turns, or is repositioned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red chest drainage indicates active bleeding and would be of immediate concern. Additional Information Physiological Adaptation NCSBN Client Need

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? 1. Femoral line inserted in emergency department post cardiac arrest 48 hours ago (19%) 2. Internal jugular line inserted 6 days ago in operating room (6%) 3. Peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago (39%) 4. Subclavian line with slight redness at anchor suture sites inserted in intensive care unit 72 hours ago (33%) OmittedCorrect answer 1 19%Answered correctly

In adult clients, central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize the risk of infection. Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and it is difficult to place an occlusive dressing over these sites. A central venous catheter (CVC) should be placed where aseptic technique can be applied. The site should be assessed daily for signs/symptoms of infection (eg, redness, swelling, drainage). The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection. (Option 2) Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the operating room, where surgical asepsis was easily accomplished. The site can be used as long as there is a clinical need and no evidence of infection. (Option 3) Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter. (Option 4) The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture sites, it is not located at the insertion site. The femoral line is still at higher risk for infection. Educational objective:Femoral central venous catheters may be placed in emergency situations but should be removed/replaced as soon as possible due to the high risk of contamination and infection. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply. 1. Administer dextrose 50 mg intravenous (IV) push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline OmittedCorrect answer 3,4,5 40%Answered correctly

The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present. Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur. The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy. Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed (Option 2). (Option 1) IV dextrose is administered during acute hypoglycemic episodes and would worsen DKA. Educational objective:DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin and should be treated first with rehydration (normal saline) and then insulin administration.

Vital signs Temperature 101.2 F (38.4 C) Blood pressure 126/70 mm Hg Heart rate 102/min Respirations 20/minSpO298%

The nurse is caring for a client with acute diverticulitis who has nausea, vomiting, and rates pain as 8 on a scale of 0-10. Which of the following interventions should be included in the plan of care? Select all that apply. Click the exhibit button for additional information. 1. Administer morphine sulfate as prescribed for pain control 2. Insert a rectal tube to protect the client's skin from diarrhea 3. Instruct the client to avoid straining 4. Maintain NPO status 5. Start IV infusion of normal saline OmittedCorrect answer 1,3,4,5 51%Answered correctly

/A client who underwent open reduction and internal fixation of a right tibial fracture 10 hours ago reports worsening leg pain that is unrelieved by PRN morphine. The nurse assesses that the client's right foot is cooler than the left. What is the nurse's priority action? 1. Administer the client's next dose of pain medication (0%) 2. Assess the client's vital signs (12%) 3. Maintain the extremity in a dependent position to promote blood flow (8%) 4. Report these findings to the health care provider immediately (79%) OmittedCorrect answer 4 79%Answered correctly

Compartment syndrome (CS) results from compression of vascular structures by either external compression (restrictive dressings/casts) or increased pressure within a compartment (bleeding, inflammation, and edema). After an injury or trauma (eg, surgery), the vessels surrounding the injury site are compressed by swelling muscle and connective tissues. Muscle is encapsulated by a fibrous layer of fascia (ie, a compartment), which does not yield to swelling. Eventually, compression of tissues within the compartment restricts blood flow to the extremity. Signs of CS include the 6 Ps - pain (unrelieved by repositioning or analgesics), pallor, pulselessness, paresthesias, poikilothermia (coolness), and paralysis. The nurse should notify the health care provider immediately as CS is a limb-threatening emergency and requires immediate surgery (fasciotomy) (Option 4). (Options 1 & 2) If the client is in pain, blood pressure and pulse may increase. However, assessing the client's vital signs and giving the client more analgesic medication do not address the signs of CS. These actions delay emergency intervention. This client has enough evidence for suspicion of CS. (Option 3) If CS is suspected, the nurse should place the extremity at heart level to promote venous return and limit swelling and loosen tight bandaging/casting material. If conservative measures fail, a fasciotomy (incision to open the fascia of the affected muscle compartment) may be required to relieve the compression. Educational objective:A client with signs of compartment syndrome (eg, pain, pallor, pulselessness) after a fracture or orthopedic surgery should be evaluated by the health care provider (HCP) immediately. After notifying the HCP, the nurse should position the affected extremity at heart level and loosen any restrictive bandaging/casting material.

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume related to osmotic diuresis (35%) 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose (3%) 3. Ineffective breathing pattern related to the presence of metabolic acidosis (55%) 4. Ineffective health maintenance related to the inability to manage DM during illness (5%) OmittedCorrect answer 1 35%Answered correctly

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management. Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1). (Option 2) When the supply of insulin is insufficient and glucose cannot be metabolized for energy, the body breaks down fat stores leading to ketosis (fruity breath) and metabolic acidosis. However, it does not pose the greatest risk to survival and is not the priority ND. (Option 3) Tachypnea and deep labored respirations (ie, Kussmaul) are the body's attempt to eliminate excess acid (pCO2) through hyperventilation and normalize the pH. However, it does not pose the greatest risk to survival and is not the priority ND. (Option 4) Ineffective health maintenance related to inability to manage a condition during illness (evidenced by DKA development in this client) is an appropriate ND. However, it does not pose the greatest risk to survival at this time and is not the priority ND. Educational objective:Hyperglycemia associated with DKA leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Deficient fluid volume related to osmotic diuresis is an appropriate ND for a client with DKA.

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches? Select all that apply. 1. Keep a clear path to the bathroom 2. Look down at the feet when walking 3. Remove scatter rugs from floors 4. Use a small backpack/shoulder bag to hold personal items 5. Wear rubber-soled shoes, preferably without laces OmittedCorrect answer 1,3,4,5 29%Answered correctly

Interventions to promote safety when using crutches in the home include the following: Keep the environment free of clutter and remove scatter rugs to reduce fall risk (Options 1 and 3) Look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint strain, maintain balance, and reduce fall risk (Option 2) Use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will keep hands free when walking (Option 4) Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk (Option 5) Rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard Keep crutch rubber tips dry. Replace them if worn to prevent slipping. Educational objective:Interventions to promote safety and reduce the risk of falling when using axillary crutches in the home include looking forward when walking, maintaining a clutter-free environment, resting crutches upside down on the axilla pads when not in use, using a small bag to hold personal items, wearing sturdy rubber-soled shoes, and keeping crutches in good repair. Additional Information Safety and Infection Control NCSBN Client Need

A nurse receives the following change-of-shift morning report for the assigned clients. Which client should the nurse assess first? 1. Client 1 day postoperative with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning (10%) 2. Client 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F (38 C) (10%) 3. Client 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale (1%) 4. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours (77%) OmittedCorrect answer 4 77%Answered correctly

Low urine output in the first 24 hours after surgery is expected due to fluid restriction before surgery, hormonal responses to the physiological stress of surgery, and fluid losses during surgery. Urine output should increase by the second postoperative day. The total intravenous intake for this client for the last 24 hours is 3000 mL (125 mL x 24 hours). The urine output for an adult of average weight (154 lb [70 kg]) should be at least 0.5 mL/kg/hr (ie, 70 kg x 0.5 mL/hr = 35 mL/hr x 8 hours = 280 mL in 8 hours). This client is becoming oliguric (100 mL in 8 hours). The nurse should take vital signs to assess for hypotension, which can result in decreased renal perfusion, prerenal failure, and acute kidney injury, and assess for bladder distension and Foley catheter patency before notifying the health care provider (HCP). This assessment takes priority due to the potential for prerenal failure and acute kidney injury. (Option 1) Auscultating fine crackles in the base of the lungs is common 1 day postoperative and is usually related to atelectasis caused by hypoventilation, especially in a client who has not yet ambulated. This assessment does not take priority. (Option 2) A surgical dressing with serosanguineous drainage and a low-grade temperature related to the inflammatory response due to stress of surgery are expected findings 1 day postoperative. This assessment does not take priority. (Option 3) Epidural analgesia (eg, continual, intermittent bolus, patient-controlled) provides excellent long-lasting postoperative pain control as it distributes the opioid medication directly to the opioid receptors in the spinal cord through a catheter placed in the epidural space. The nurse will perform a pain assessment and report to the anesthesia HCP, as a bolus of pain medication through the catheter may be needed. This assessment does not take priority. Educational objective:Low-grade temperature, serosanguineous wound drainage, fine crackles in the lung bases on auscultation, and decreased urine output are expected findings during the first 24-hour postoperative period. If the client has decreasing urine output with oliguria (<400 mL/24 hr) by the second postoperative day, the nurse assesses for hypotension and for bladder distension and Foley catheter patency. Additional Information Management of Care NCSBN Client Need

/A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take? 1. Arouse the client and ask what the current month is (55%) 2. Document "relief apparently obtained" and recheck at 03:00 AM (6%) 3. Let the client sleep but verify respiratory rate (25%) 4. Wake the client up and check for paresthesia (12%) OmittedCorrect answer 1 55%Answered correctly

Serial neurologic assessments are important as neurologic abnormalities are often initially subtle, making it important to note the trend. Interventions for neurologic issues are most effective when made early. A neurologic assessment includes: Glasgow Coma Scale (GCS)—best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive). Pupils—equal, round, response to light, and accommodate (PERRLA) Motor—strength and movement in all four extremities Vital signs—especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP). This client is not admitted in the hospital to get a good night sleep. The client is admitted due to the need for serial neurologic assessments by a professional nurse, and that is the priority. (Option 2) Although pain relief has probably been achieved, this option does not reflect any neurologic assessment. One of the early signs of increased ICP is change in level of consciousness. This option does not assess the client's arousability. (Option 3) Checking the respiratory rate and characteristics is part of the neurologic assessment. However, this alone is insufficient for assessing a neurologic status after a blunt head injury. (Option 4) It is good to awaken the client, but paresthesia is part of a neurovascular assessment. Neurovascular assessment, commonly known as the 5 Ps, consists of paresthesia, pain, pallor, paralysis, and pulselessness. A neurovascular assessment is used when circulation is a primary concern. It is not the primary neurologic assessment needed in a closed head injury. Educational objective:Clients must be awakened for a prescribed, necessary neurologic assessment. A neurologic assessment consists of GCS, PERRLA, movement and strength of the extremities, and vital signs. Additional Information Reduction of Risk Potential NCSBN Client Need

The parent of a 15-month-old calls the nurse and says that the child developed a rash and mild fever after receiving a routine measles, mumps, rubella, and varicella (MMRV) vaccine in the pediatric clinic 5 days ago. What is the best response by the nurse? 1. "Apply over-the-counter hydrocortisone cream to the rash." (1%) 2. "Bring your child to the clinic this afternoon." (17%) 3. "This is a common reaction to the MMRV vaccine." (29%) 4. "What is your child's temperature right now?" (51%) OmittedCorrect answer 4 51%Answered correctly

Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site, irritability, and restlessness. Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the child's temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C). Children with a history of seizures should be vaccinated with separate MMR and varicella vaccines instead of the combination MMRV vaccine. (Option 1) This is not an appropriate intervention. The rash should disappear in 2-3 days. (Option 2) The child seems to be experiencing a normal reaction to the vaccine; a clinic visit is not necessary. (Option 3) Although this is an appropriate response, it is most important for the nurse to first determine the child's temperature and the extent of the fever. Educational objective:The normal MMRV vaccine reactions that occur within 5-12 days after vaccination include mild fever and rash, irritability and restlessness, and swelling and erythema at the injection site. Febrile seizure is a rare but more serious reaction to the vaccine.

The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse instructs the client to take this medication in which manner? 1. At noon with a meal (1%) 2. In the morning on an empty stomach (25%) 3. In the morning with breakfast (26%) 4. With the evening meal (46%) OmittedCorrect answer 4 46%Answered correctly

Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) are prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. Most of the cholesterol in the body is synthesized by the liver during the fasting state, at night. Trials have found greater reductions in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day. (Options 1 and 3) Medications that can cause stomach upset (eg, NSAIDs) should be taken with food. (Option 2) Medications such as levothyroxine should be taken on an empty stomach in the morning. Acid-suppressing medications (eg, proton pump inhibitors, H2 blockers) should also be taken 30 minutes before the meal. Educational objective:The client taking a statin drug such as simvastatin should be taught to take the medication with the evening meal or at bedtime to promote maximal effectiveness. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

//The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf (65%) 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago (3%) 3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers (21%) 4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice (10%) OmittedCorrect answer 1 65%Answered correctly

The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a deep vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic anticoagulation. This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a venous embolus can lead to a pulmonary embolus, which is potentially life-threatening. (Option 2) Itching is to be expected due to drying of the skin under the cast. The nurse can suggest directing the air from a hair dryer on a cool setting under the cast to help relieve itching. This is not a potentially life-threatening event. (Option 3) This client is most likely using the crutches incorrectly or they are not fitted correctly. Pressure on the ulna or radial nerves can lead to numbness and tingling of the fingers and hand weakness. This symptom needs intervention, but it is not potentially life-threatening. (Option 4) Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE (rest, ice, compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may require aspiration, but the condition is not potentially life-threatening. Educational objective:Cramping calf pain following joint replacement surgery can indicate the presence of a venous thrombosis and needs immediate intervention with diagnostic testing as the condition is potentially life-threatening.

/Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence? 1. Coaching related to Kegel exercises (45%) 2. Importance of voiding every 2 hours (30%) 3. Minimizing caffeine and alcohol (19%) 4. Use of incontinence pads and pessary (4%) OmittedCorrect answer 2 30%Answered correctly

The nursing care plan for a client experiencing stress incontinence includes pelvic floor exercises, bladder training, incontinence products, and lifestyle modifications. The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks (Option 2). Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an essential part of the teaching plan but are not the priority for this client (Option 1). It will take approximately 6 weeks for pelvic floor muscle strength to improve. Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the priority in this client (Option 3). Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This client should receive initial instruction on the importance of emptying the bladder often (Option 4). Educational objective:Nursing interventions related to stress incontinence include bladder training (eg, voiding every 2 hours), pelvic floor exercises (eg, Kegel exercises), lifestyle modifications (weight loss, reduction of dietary bladder irritants, smoking cessation), and incontinence products.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? 1. "Are you having any pain in your lower back or flank area?" (54%) 2. "Do you wipe from front to back after urinating?" (12%) 3. "Have you found that you urinate more frequently since becoming pregnant?" (1%) 4. "Have you had a urinary tract infection in the past?" (31%) OmittedCorrect answer 1 54%Answered correctly

Urinary tract infections (UTIs) are common during pregnancy due to physiologic renal system changes (eg, ureter dilation, urine stasis). Most UTIs are confined to the lower urinary tract (ie, cystitis, or bladder infection). Symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness. Diagnostic testing includes urinalysis and urine culture. Oral antibiotics are required to appropriately treat cystitis. If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis (eg, flank pain, fever) in clients who report UTI symptoms to ensure appropriate diagnosis and treatment (Option 1). (Option 2) Wiping front to back after urination may help prevent Escherichia coli (a common UTI pathogen found in stool) from contaminating the urethra. Reviewing toileting hygiene is important but does not help assess current symptoms. (Option 3) Urinary frequency and nocturia are common during pregnancy. However, the nurse should not focus on the normalcy of urinary frequency since the client has reported additional symptoms (eg, dysuria). (Option 4) Pregnancy predisposes clients to UTIs. Furthermore, assessing for history of UTI does little to address the client's current symptoms. Educational objective:Urinary tract infections are common during pregnancy. If the client reports signs and symptoms of cystitis, the nurse's priority is to rule out ascending infection (ie, pyelonephritis), which would require hospitalization and IV antibiotics. Additional Information Physiological Adaptation NCSBN Client Need

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal? 1. 450 kcal/day (27%) 2. 625 kcal/day (46%) 3. 860 kcal/day (17%) 4. 1,000 kcal/day (8%) OmittedCorrect answer 2 46%Answered correctly

A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal). Over a period of 16 weeks, this would require a daily reduction of: 625 kcal (70,000 kcal / [16 weeks x 7 days] = 625 kcal/day) Adding an exercise regimen to the client's daily routine would facilitate additional weight loss and/or reduce the need for severe caloric restriction. (Option 1) Reducing intake by 450 kcal/day over 16 weeks would result in a weight loss of 14.5 lb (6.5 kg). (Option 3) Reducing intake by 860 kcal/day over 16 weeks would result in a weight loss of 27.5 lb (12.4 kg). (Option 4) Reducing intake by 1000 kcal/day over 16 weeks would result in a weight loss of 32 lb (14.5 kg). Educational objective:A reduction or energy expenditure of 3500 calories (kcal) will result in a weight loss of 1 lb. Additional Information Health Promotion and Maintenance NCSBN Client Need

The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating (16%) 2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait (31%) 3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL (11%) 4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL (41%) OmittedCorrect answer 4 41%Answered correctly

A client with a neurological injury (eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately. (Option 1) Autonomic dysreflexia (eg, throbbing headache, flushing, hypertension) is a life-threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher. This is not the priority assessment as this client's injury is at L3. This client likely has acute urinary retention and needs catheterization. (Option 2) Phenytoin toxicity commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus. These are expected symptoms and therefore are not a priority. (Option 3) A brain tumor can also cause increased intracranial pressure; clients report morning headache, nausea, and vomiting. Dexamethasone (Decadron) can be prescribed short-term to decrease the surrounding edema. A tumor usually grows more slowly than a possible hematoma and is therefore not the priority assessment. Educational objective:Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure.

The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation? 1. 10% weight loss since birth (56%) 2. Cracked, peeling skin (17%) 3. Feeds every 2-3 hours (2%) 4. Runny, seedy, yellow stools (22%) OmittedCorrect answer 1 56%Answered correctly

During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation. The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning, effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is adequate (Option 1). (Option 2) Peeling of the term newborn's skin is a sign of physical maturity and is expected around the third day of life. Cracked, peeling skin may be present at birth in post-term (ie, >42 weeks gestation) newborns. (Option 3) Feeding every 2-3 hours is normal for breastfed newborns; breastmilk is easily digested and more frequent feeding is noted than in formula-fed newborns. (Option 4) After passing meconium, newborns produce transitional stools that are thin and yellowish-brown or yellowish-green. Stools of breastfed newborns progress to a seedy, yellow paste. Bottle-fed newborns have firmer, light brown stools. Educational objective:During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion through urine, stool, and respirations. Weight loss >7% may indicate the need for breastfeeding support and formula supplementation and require evaluation. Additional Information Basic Care and Comfort NCSBN Client Need

/SEE EX /A client with dilated cardiomyopathy has the rhythm shown in the exhibit. Which action should the nurse take first? 1. Assess the client for a pulse (45%) 2. Assess the oxygen saturation (8%) 3. Initiate cardiopulmonary resuscitation (CPR) (13%) 4. Prepare to defibrillate the client (32%) OmittedCorrect answer 1 45%Answered correctly

Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure. The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol). (Option 2) Oxygen saturation should be assessed after the presence of a pulse has been established. (Options 3 and 4) CPR and defibrillation should be initiated only in a client who is pulseless. Educational objective:The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion. Additional Information Physiological Adaptation NCSBN Client Need Copyright © UWorld. All rights reserved.