NURX213 Health Differences Across The Life Span 3

Infectious Disease A patient with human immunodeficiency virus (HIV) is discussing antiretroviral therapy (ART) with their caregivers. Which diagnostic test would help inform the patient on the decision of whether to start ART? CD4 level Vitamin D level Western blot assay levels Enzyme-linked immunosorbent assay (ELISA) level

*1) "The CD4 count serves as the major laboratory indicator of immune function, is one of the key factors in deciding whether to initiate ART and prophylaxis for opportunistic infections, and is the strongest predictor of subsequent disease progression and survival (Panel on Antiretroviral Guidelines, 2011)." 2) This is not a marker to reflect immune function. 3) Western blot confirms sero-positivity when ELI positive. 4) This identifies antibodies directed against HIV.

Musculoskeletal Dysfunction A patient diagnosed with a sprain should receive which immediate nursing intervention? Apply an elastic wrap to the affected extremity. Perform active range of motion exercises. Raise and lower the affected extremity. Immerse the extremity in warm water.

*1) Treatment of a sprain consists of rest, ice, compression, and elevation. 2) See 1). 3) See 1). 4) See 1).

Neurological Dysfunction An RN is teaching parents how to prevent aspiration of saliva, should their child experience a tonic-clonic seizure. Which instruction does the RN give to parents? "Turn your child on the side with the head flexed forward." "Turn your child on the side with the head flexed back." "Turn your child to the supine position." "Turn your child to the prone position."

*1) Turning the child on his side with head flexed forward allows for flow of saliva out of his mouth. 2) Turning the child on his side with head flexed back should not be used because it can contribute to aspiration of saliva. 3) Turning the child to the supine position may contribute to aspiration of saliva. 4) The prone position should not be used during a seizure because of risk of suffocation.

Infectious Disease An RN is conducting a focused assessment for infection. Which laboratory test value would support the finding that an infection is present in the patient? Decreased international normalized ratio (INR) Elevated erythrocyte sedimentation rate (ESR) Decreased white blood cell (WBC) count Elevated blood urea nitrogen (BUN)

1) A decreased international normalized ratio (INR) does not indicate an infection. *2) An elevated erythrocyte sedimentation rate (ESR) indicates an infection. 3) A decreased white blood cell (WBC) count does not indicate an infection. 4) Elevated blood urea nitrogen (BUN) does not indicate an infection.

Musculoskeletal Dysfunction A patient is hospitalized for an above-the-knee amputation. The patient reports that the elastic dressing itches and questions why they need to wear it. What rationale for the use of elastic dressings should the RN explain to the patient? It keeps the stump covered to help prevent infection. It decreases pain and phantom limb sensations. It reduces edema and promotes rehabilitation. It prevents postoperative bleeding.

1) A dressing is used to prevent infection, but the elastic bandage provides compression to reduce edema. 2) See 3). *3) The elastic bandage provides compression to reduce edema and promote rehabilitation. 4) Suturing is done to prevent postoperative bleeding.

Neurological Dysfunction A 10-month-old infant is admitted to the pediatric intensive care unit (PICU) after having a craniotomy for evacuation of a brain abscess. Which assessment would indicate to the RN the need to collaborate with the health care provider? Fever Headache Abdominal pain Bulging fontanelles

1) A fever would most likely be a sign of infection, such as meningitis, and could be adding to the increased intracranial pressure (ICP). 2) At 10 months old, the infant cannot report a headache; therefore, a headache is not an appropriate symptom for this age group. 3) A 10-month-old infant cannot report abdominal pain, nor is abdominal pain a sign of increased ICP. *4) Bulging fontanelles indicates increased intracranial pressure (ICP) and should be reported to the surgeon immediately.

Musculoskeletal Dysfunction A patient presents with deep throbbing pain, passive range of motion (ROM), pallor, and edema after having a cast placed for a fracture 48 hours earlier. Based on this assessment, what should be the RN's initial priority intervention? Assess for infection. Administer pain medication. Continue to monitor the patient. Notify the health care provider.

1) Assessing for infection is important but will not stop compartment syndrome. 2) Pain medication should be administered, but is not the priority for this patient. 3) Continuing to monitor the patient will not correct the problem. *4) The surgeon needs to be notified immediately because this is potentially compartment syndrome.

Musculoskeletal Dysfunction An RN is assessing the pin sites of a patient who had an external fixator placed 48 hours earlier. During the assessment, the RN discovers purulent drainage around the pin site. What should be the priority nursing intervention for this patient? Continue to monitor the pin site. Administer pain medication as ordered. Clean the pin sites using normal saline (NS). Notify the health care provider of the assessment finding.

1) Continuing to monitor the pin site is not acceptable practice when there are signs and symptoms of an infection present. 2) Administering pain medication is important, but it is not the priority intervention for a possible infection. 3) An aseptic technique and Chlorhexidine are used for pin care. *4) The health care provider should be notified at the first signs of infection.

Neurological Dysfunction A patient diagnosed with a brain tumor has a deficit of cranial nerve (CN) V (trigeminal). Upon assessment, the RN determines that which consultation could be necessary? Occupational therapy Physical therapy Speech therapy Dietary

1) Cranial nerve V (trigeminal) helps control the masseter muscles used for chewing. Occupational therapy cannot help with this deficit. 2) Cranial nerve V (trigeminal) helps control the masseter muscles used for chewing. Physical therapy cannot help with this deficit. 3) Cranial nerve V (trigeminal) helps control the masseter muscles used for chewing. Speech therapy helps with swallowing deficits. *4) Cranial nerve V (trigeminal) helps control the masseter muscles used for chewing. Dietary can assist with food options and consistencies that would be best for this patient.

Musculoskeletal Dysfunction Due to their ability to control pain and irritability, which classification of medication is the analgesic of choice for pediatric patients with juvenile idiopathic arthritis (JIA)? Disease modifying anti-rheumatic drugs (DMARDs) Nonsteroidal anti-inflammatory drugs (NSAIDs) Slow-acting, anti-rheumatic drugs (SAARDs) Methotrexate

1) DMARDs are slow-acting, anti-rheumatic drugs. Their effects take weeks to months to work. *2) NSAIDs such as ibuprofen (Motrin) or naproxen (Naprosyn) are the analgesics of choice for children with JIA. 3) SAARDs are slow-acting, disease-modifying anti-rheumatic drugs (DMARDs) and take weeks to months to take effect. 4) Methotrexate, a cytotoxic drug, is the second drug usually prescribed.

Tissue Trauma An adult female patient is being prepared for an ambulatory surgical procedure. Which patient statement indicates the need for further preoperative nursing instruction? "I expect to go to the postanesthesia care unit (PACU) after the operating room." "My spouse can accompany me into the operating room (OR)." "My spouse will hold on to my personal things." "I will not be staying in the hospital overnight."

1) Demonstrates understanding of what will happen after surgery. *2) Unauthorized personnel may not enter the operating room (OR). 3) Demonstrates understanding that spouse will safeguard valuables. 4) Demonstrates understanding of meaning of ambulatory surgery.

Tissue Trauma Which assessment finding is the most critical for the safety of a postoperative patient? Dysrhythmias Blood seepage at incision site Compromised airway patency Increased central venous pressure (CVP)

1) Dysrhythmias may be caused by a variety of factors and should be monitored. Some are more serious than others. 2) Blood seepage must be monitored but is not the most critical concern. *3) The primary objective in the immediate postoperative period is to maintain ventilation. 4) Increased CVP may indicate a need to modify intravenous rates, but it is not the most crucial factor in safety.

Tissue Trauma An adult patient is being prepared for application of a lower leg external fixator. Which statement made by the RN would be most appropriate in preparing the patient? "Patients usually remain on complete bed rest for about 1 week." "Patients usually have some drainage around the pins for about 1 week." "Patients usually experience a lot of discomfort, but pain medication offers relief." "Patients usually figure out creative ways to cover up their external fixator devices."

1) Early mobilization is generally anticipated. 2) Pin drainage lasts generally for first 48 to 72 hours. 3) Discomfort is usually minimal. *4) Fixator devices can be covered up to help with body image issues.

Infectious Disease An RN is educating a new graduate RN on the symptoms of pneumonia in the older population. Which symptom does the RN distinguish as possibly being unique to this population? Rapid breathing or difficulty breathing Confusion or low alertness Chest pain Cough

1) Rapid and difficult breathing are not unique to the older population. *2) Older adults with pneumococcal pneumonia may experience confusion or low alertness, rather than the expected presenting signs of pneumonia such as rapid breathing, fever and chills, and chest pain. 3) Chest pain is not unique to the older population. 4) A cough is not unique to the older population.

Infectious Disease During assessment, an RN notes changes in a patient with an infection. Which assessment data would alert the RN to the fact that the patient is developing systemic inflammatory response syndrome (SIRS)? Fatigue and loss of appetite Generalized discomfort Redness at the intravenous (IV) site Tachycardia and tachypnea

1) This symptom needs further assessment. 2) This symptom is too broad and needs further assessment. 3) This is a symptom of a localized inflammation at the IV site. *4) SIRS criteria include a patient with an infection and T > 38°C (100.4°F); P > 90 bmp; R > 20 bpm.

Infectious Disease An RN is providing caregiver instruction to prevent infection via droplet transmission. For which infection would this teaching be necessary? Impetigo Giardiasis Pertussis Tetanus

1) Transmission of impetigo is via contact, so contact precautions are required to prevent spread. 2) Transmission of giardia is via ingestion of cysts of the protozoa from dirty hands; it is not transmitted by droplets. *3) Droplet precautions are used for 5 days after the child is started on antibiotic therapy to prevent spread. 4) Transmission of tetanus occurs via direct or indirect contamination of a closed wound, not by droplets.

Neurological Dysfunction A patient was admitted with the diagnosis of a cerebrovascular accident. Which priority patient information should the RN provide the LPN/LVN about the patient's condition? The patient's blood pressure is 140/90. The patient has any change in level of consciousness. The patient has an emotional outburst. The patient complains of a headache rated 5 on a scale of 1 to 10.

1) Blood pressure is usually kept slightly higher so that the brain is perfused. *2) Alteration in level of consciousness in often the first earliest sign of deterioration in a patient with a cerebral vascular accident. 3) Emotional outbursts are common with left-sided cerebral vascular accidents. 4) It is common for patients with cerebral accidents to have headaches. A headache rating of 5 is not severe.

Infectious Disease An RN is administering gentamicin sulfate to treat a patient with methicillin-resistant Staphylococcus aureus. The health care provider has ordered a peak and trough prior to today's dose. What should be the priority action by the RN? Change the gentamicin intravenous (IV) tubing. Call the laboratory for a blood draw for the peak level. Call the laboratory for a blood draw for the trough level. Check the current complete blood count (CBC) lab values.

1) Changing IV tubing is not necessary for the peak and trough. 2) The trough level is drawn first. *3) Call the lab for the trough level to be drawn prior to administration. 4) CBC lab values do not affect the peak and trough.

Infectious Disease An RN reviews the laboratory data for a patient suspected of having tuberculosis (TB). Which diagnostic test would be used to confirm a TB diagnosis? Chest X ray Lung volume measures Sputum culture Positive purified protein derivative test (PPD)

1) Chest X ray does not confirm the diagnosis of TB. 2) Lung volume measures are used for COPD diagnosis. *3) Sputum culture for AFB is diagnostic for TB. 4) A positive purified protein derivative test (PPD) is not the definitive test for TB; a false positive can occur.

Infectious Disease A community health nurse is completing a health assessment on a new patient. The RN asks the patient about their medications, occupation, sexual history, any cough or fever, history of travel, and vaccination history. Which risk is the nurse assessing? Ebola Hepatitis Lyme disease Infectious disease

1) While some of the assessments relate specifically to Ebola, not all do. 2) While some of the assessments relate specifically to hepatitis, not all do. 3) While some of the assessments relate specifically to Lyme disease, not all do. *4) All of the assessments relate to determining the risk of infectious disease.

Tissue Trauma The laboratory report on a 26-month-old infant who tested for lead poisoning indicates a finding of 6 micrograms per deciliter (μ/dL) in the patient. Which requirement for follow-up care should the RN stress to the patient's parents? The patient needs to be retested for confirmation of the lead level. Lead in the patient's environment needs to be removed immediately. The patient needs to be started on an oral chelating agent immediately. The patient needs to be removed from the environment where the lead is found.

*1) A child with a blood lead level over 5 micrograms per deciliter (μ/dL) needs to be rescreened to confirm the level, since lead poisoning is defined as 2 successive levels over 5 micrograms per deciliter (μ/dL). If the second level is over 5 micrograms per deciliter (μ/dL), then active interventions to prevent further lead exposure (such as removal of the child from the environment containing the lead source or removal of the source of lead from the child's environment), are initiated. If the lead levels are greater than 10 to 20 micrograms per 100 mL, an oral chelating agent such as dimercaptosuccinic acid (DMSA) or succimer will be prescribed. Children with blood lead levels of greater than 45 micrograms per 100 mL are treated with stronger chelation therapy such as dimercaprol innervated (INN) or edetate calcium disodium (CaEDTA). 2) See 1). 3) See 1). 4) See 1).

Neurological Dysfunction An RN and a school RN are collaborating on the plan of care for a pediatric patient with epilepsy. What should the RN and school RN include in this patient's plan of care? (Select all that apply.) Administer antiepileptic drugs as directed by the health care provider. Call the health care provider for every seizure that occurs. Place the child in a classroom with other children who have epilepsy. Call the parent in the event of a tonic-clonic seizure. Establish Risk for Fall protocol.

*1) A steady blood level of antiepilepticdrugs is crucial in controlling epilepsy. 2) Nursing personnel, in most cases, can effectively care for a patient with epilepsy in the school setting. As long as a seizure plan is in place, there is no need to contact the health care provider. 3) Federal law forbids children from being placed in a highly restrictive environment. Children should be placed in the least restrictive environment possible. *4) Parents are a crucial part of the health care and educational team. *5) Epileptic persons are at high risk for fall and injury.

Infectious Disease Which is the most important personal protective equipment (PPE) an RN should use when obtaining an apical pulse on a patient with tuberculosis (TB)? N95 respirator Face shield Gloves Gown

*1) An N95 respirator is a protective mask effective in trapping small, airborne droplets, thereby preventing their inhalation. Health care providers should wear an N95 respirator at all times when in the room with a patient hospitalized with tuberculosis. 2) A face shield protects the wearer against contamination with spatters of infected blood or body fluids. 3) Gloves protect from contact with patient secretions or excretions such as urine, fecal matter, blood, saliva, and drainage. 4) Gowns are worn to protect against contact contamination of clothing with any biologic material.

Infectious Disease An RN is educating the parents of an infant who has been newly diagnosed with hepatitis B. Which teaching points should be included? (Select all that apply.) "Even though the infant does not show signs of jaundice, the infant is still infectious." "Your water source at home needs to be checked for contamination." "When changing the baby's diapers, make sure to wear gloves." "Lamivudine (Epivir) may help reduce the virus." "Vaccination is not available for this type of hepatitis."

*1) An infant with hepatitis B is infectious even though they have no symptoms. 2) Hepatitis B is not contracted through contaminated water; hepatitis A is contracted this way. *3) Hepatitis B can be spread via contaminated blood, plasma, and semen. *4) Lamivudine (Epivir), an antiviral agent, may be effective in reducing viral replication with hepatitis B. 5) Vaccination is available for hepatitis B and is recommended for infants and close family contacts.

Musculoskeletal Dysfunction A patient is receiving corticosteroid injections to treat a rotator cuff tear. The RN recognizes that the patient will have an increased risk for which side effect, due to the corticosteroid injections? Decreased wound healing Increased constipation Hypoglycemia Hypotension

*1) Corticosteroids cause a decrease in wound healing. 2) Constipation is not a side effect of corticosteroids. 3) Hypoglycemia is not a side effect of corticosteroid use; hyperglycemia is. 4) Hypotension is not a side effect of corticosteroid use; hypertension is.

Tissue Trauma Which data found in the assessment of an adult patient being admitted for bowel surgery would the RN cluster, to determine a nursing diagnosis label of Anxiety? (Select all that apply.) frequency of urination complaints of a dry mouth preoccupied manner pulse 62 bpm and strong flatulence

*1) Defining characteristics of anxiety include urinary frequency, dry mouth, fidgeting and preoccupation. Other signs and symptoms are increased pulse and respirations, sweating, nausea, shortened attention span, poor eye contact, hand tremor, and quivering voice. *2) See 1). *3) See 1). 4) A pulse that is 62 and strong is within normal range for a 40-year-old woman; it is not abnormally increased, as would be characteristic of anxiety. 5) Flatulence is not a defining characteristic of anxiety.

Musculoskeletal Dysfunction A patient with an amputation secondary to diabetes mellitus reports of phantom limb pain. The patient is prescribed amitriptyline (Elavil) for the pain. Which statement made by the patient would indicate to the RN that patient teaching is successful? "This medicine may also help my mood." "This medicine won't make me drowsy." "It's okay to take my blood pressure medicine with this medicine." "This medicine won't make me feel light headed or dizzy like my pain medicine."

*1) Elavil is a broad spectrum, tricyclic antidepressant and can improve mood. 2) Elavil is a broad spectrum, tricyclic antidepressant and can cause drowsiness. 3) Elavil is a broad spectrum, tricyclic antidepressant and can interfere with potential antihypertensive medications. 4) Elavil is a broad spectrum, tricyclic antidepressant and can cause light headedness and dizziness.

Infectious Disease An order says to administer Amoxicillin orally (po) 20 to 40 mg/kg/day in 3 divided doses. If the patient weighs 99 lb, what would be a maximum safe single dose for this pediatric patient? 600 mg 660 mg 1320 mg 1800 mg

*1) To calculate, first find kg = 99 lb/2.2 = 45 kg. Then, multiply 45 kg by 40 mg (maximum dose for the child) = 1800 mg. Then divide in 3 doses = 600 mg per single dose can be administered. 2) See 1). This answer is if one used 20 mg (minimum dose requirement), so it is not the answer. 3) See 1). In this answer, pounds were not converted to kg; this is a very common mistake. 4) See 1). This answer is for the whole 24 hrs; the question asked for a single dose.

Neurological Dysfunction What is the best method of assessing a 4-year-old child's cerebral function? Ask simple questions that engage a child in conversation. Ask the parent if there have been any changes in the child's behavior. Observe the child's eyes as they follow an object moved in all directions. Determine if the child has reached developmental milestones appropriate to their age.

*1) Engaging a child in conversation is the best way to determine alertness and orientation, which are the most important indicators of cerebral function. 2) Level of consciousness is the best way to assess cerebral function, so direct assessment of the child is the only way to determine cerebral function. 3) Ability to follow objects with eyes assesses cranial nerve function (2nd cranial nerve, optic). 4) Developmental milestones are complex tasks that involve more than cerebral function.

Infectious Disease A 52-year-old patient has repeatedly visited a clinic, reporting multiple generalized signs and symptoms. The patient's laboratory test results reveal a positive HBsAg. What would this laboratory test result indicate to the RN? The patient has active hepatitis B. The patient has immunity to hepatitis B. The patient has had the hepatitis vaccine. The patient has not been exposed to hepatitis B.

*1) HBsAg is the hepatitis B surface antigen and is a marker of active infection. An elevated level would demonstrate active hepatitis B. 2) HBsAg does not demonstrate immunity. 3) See 1). 4) This is not possible, since the patient has active hepatitis B.

Infectious Disease The Institute for Healthcare Improvement's Surviving Sepsis Campaign identified evidence-based screening tools to recognize sepsis and guide early treatment to improve patient outcomes. Which assessments, consistent with the screening tool, would help an RN identify a patient with sepsis? (Select all that apply.) Systolic blood pressure less than 90 or drop 40 below baseline Serum lactate greater than 4 mmol/L Urine output less than 0.5 mL/kg/h Decreased oxygen saturation levels Negative blood cultures

*1) Hypotension can signal sepsis. *2) Anaerobic metabolism results from septic compromise. *3) Renal dysfunction results from sepsis. 4) Decreasing oxygen saturation indicates decline in respiratory function. 5) Positive blood cultures indicate sepsis.

Infectious Disease The RN is providing education about the transmission of infectious diseases through the fecal-oral route to a group of unlicensed assistive personnel (UAP) who will be working on the pediatric unit. Which infections should be included in the teaching session? (Select all that apply.) Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

*1) In children, ways of spreading hepatitis A include ingestion of fecally contaminated water or shellfish; or day care center spread from contaminated changing tables. 2) Mode of transmission for hepatitis B includes transfusion of contaminated blood and plasma or semen; inoculation by a contaminated syringe or needle through intravenous (IV) drug use; or it may be spread to the fetus if the mother has an infection in third trimester of pregnancy. 3) Transmission, as with hepatitis B virus (HBV), is primarily by blood or blood products, intravenous (IV) drug use, or sexual contact. 4) Hepatitis D is a co-exister with hepatitis B. *5) The E form of hepatitis is entericallytransmitted similarly to hepatitis A (that is, through fecally contaminated water).

Musculoskeletal Dysfunction A 10-year-old patient speaks fluent English but has non-English speaking parents. The patient arrives at the emergency department (ED) following a knee injury caused from playing soccer. When providing plan of care education to the patient and parents, which action should the RN take to effectively provide teaching? Seek assistance from an interpreter provided by the hospital. Speak directly to the patient and ask the patient to explain to the parents. Use hand gestures and diagrams to explain the procedure to the parents. Ask the parents to recommend a trusted friend or family member to interpret.

*1) Interpreter services should be provided by the agency to allow best communication practices. 2) Children should not be relied upon to interpret medical information to parents. 3) Verbal communication that allows for clear two-way discussion must be promoted. 4) Although trust is important, clearer information is conveyed if the interpreter is not related to the family.

Tissue Trauma An RN is assessing a pediatric patient. The RN allows the patient to play with the medical equipment and help apply the bandages. By involving the patient in this manner, what is the RN attempting to accomplish? The RN is helping the patient become comfortable with the equipment while decreasing anxiety and maintaining appropriate self-care activities. The RN is just playing with the patient and shouldn't let the patient play with expensive medical equipment. The RN is having fun with the patient, so as long as the RN is not neglecting other patients, it is fine. The RN is not a babysitter; the parent should be the one minding the patient.

*1) Involving patients in procedures to implement care not only meets the Quality and Safety Education for Nurses (QSEN) competencies, it also best meets a family's total needs. 2) Allowing the patient to get used to the equipment decreases the fear and anxiety; it is not wrong to let the patient use the equipment. 3) Developing a relationship with the patient increases the trust of the patient, but that is not complete reason this is occurring. 4) Spending time with a patient is not babysitting.

Infectious Disease An RN is assessing the most recent laboratory test results for a patient diagnosed with shock. Which laboratory test result would lead the RN to determine that the patient is in the progressive stage of shock? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

*1) Metabolic acidosis occurs as a result of accumulated lactic acid. 2) Metabolic alkalosis cannot occur with the build-up of lactic acid. 3) Respiratory acidosis occurs in late shock. 4) Respiratory alkalosis occurs in early shock.

Neurological Dysfunction A patient is hospitalized with a spinal cord injury and is prescribed subcutaneous heparin for venous thromboembolus prophylaxis. Which laboratory value should the RN monitor when a patient is given this medication? Partial thromboplastin time Prothrombin time International ratio Bleeding time

*1) Partial thromboplastin time is used to measure intrinsic clotting factors, which are affected by heparin. 2) Prothrombin time is used to measure extrinsic factor, which is affected by oral anticoagulants, such as warfarin. 3) International ratio is used to measure extrinsic factor, which is affected by oral anticoagulants, such as warfarin. 4) Bleeding time is not routinely used to measure the effects of anticoagulants.

Musculoskeletal Dysfunction A patient was recently admitted to the medical-surgical unit with an exacerbation of scleroderma. On admission the patient appears melancholy and states, "I cannot stand to look at myself. I am so ugly!" Which nursing diagnosis statement will the RN apply to the patient's plan of care to document this statement? Disturbed Body Image related to skin changes Impaired Skin Integrity related to fibrotic changes Fear of Death related to having an incurable illness Self-care Deficit related to pain and impaired mobility

*1) Scleroderma is an inflammatory response that causes edema, with a resulting taut, smooth, and shiny skin appearance. The skin then undergoes fibrotic changes, leading to loss of elasticity and movement. Eventually, the tissue degenerates and becomes nonfunctional. The patient's response is related to how they look as a result of the disease process. 2) Although this patient has impaired skin integrity, this nursing diagnosis does not address the statement the patient made regarding ugliness. 3) Although this patient may have a fear of death, this nursing diagnosis does not address the patient's feeling of ugliness, and there is nothing in the stem of the question that would allude to the patient fearing death at this time. 4) This patient is experiencing an exacerbation of scleroderma, which causes pain and immobility; however, this nursing diagnosis does not address the patient's statement of being ugly as a result of the disease process.

Infectious Disease An RN is reviewing the laboratory test results of a patient with acquired immunodeficiency syndrome (AIDS) who is on antiretroviral agents (ART). Which laboratory value would best determine the effectiveness of this group of medications? CD4+ T-cell count Complete blood count (CBC) Enzyme-linked immunosorbent assay (ELISA) Enzyme immunoassay (EIA)

*1) The CD4 T-cell count serves as the major laboratory test of immune function. 2) The CBC determines the values of the red cells, white cells, and platelets. 3) The ELISA identifies antibodies directed against HIV. 4) EIA is a variant of the ELISA test.

Neurological Dysfunction An RN is working with an LPN/LVN who is caring for a child with a spinal cord injury. Which observation should the RN instruct the LPN/LVN to report immediately? No urine in the Foley catheter bag after 2 hours. Spastic movement of a lower extremity. The child does not want to take a bath. The child reports that he feels cold.

*1) The Foley could be kinked and this could lead to autonomic dysreflexia. 2) This is an expected assessment that happens in the second recovery phase. 3) This is not a priority. 4) This can be taken care of by giving a blanket and is not a symptom that needs to be reported.

Tissue Trauma A febrile patient requires nursing care for a complex, draining abdominal wound. The wound requires irrigation, a sterile dressing, and reapplication of Montgomery straps. Which nursing decision would provide the least fragmentation of care for this patient? The RN completes the wound care. The RN delegates the wound care to an LPN/LVN. The RN assigns the wound care to another RN to complete. The RN delegates the wound care to unlicensed assistive personnel (UAP).

*1) The assigned RN can provide enhanced continuity of care by providing wound care for this febrile patient rather than delegating the task. 2) The wound care is too complex and the patient is too ill. The wound care should not be delegated to an LPN/LVN who does not have the needed professional judgment. 3) This leads to fragmentation of care. 4) Wound care may not be delegated to UAP.

Musculoskeletal Dysfunction An RN is caring for a patient with osteomyelitis. Which assessment finding would the RN expect to find when completing a musculoskeletal assessment? Bone pain in the affected bone Foul odor from the extremity Tingling in the extremity Altered mental status

*1) The patient may describe a constant, pulsating pain. 2) There is no break in the skin, no foul odor. 3) Tingling represents nerve damage. 4) Altered mental status represents fat emboli.

Tissue Trauma An RN is assessing a patient who has sustained burns. Which nursing intervention should be included in the plan of care for this patient? Keep the patient's burn wound clean and dry with gauze. Apply wet to dry dressings 2 times daily to the patient's burn wound. Wear a gown and clean the wounds with peroxide. Increase the patient's pain medication dose before changing dressings.

*1) This is an appropriate nursing intervention. 2) Wet to dry dressings is for wound debridement. 3) Burn wounds should not be cleaned with peroxide. 4) The health care provider must order an increase in pain medications.

Infectious Disease Unlicensed assistive personnel (UAP) are assisting an RN in providing care to a patient who has an infection. What information should the RN direct the UAPs to report whenever it is noted? Systolic blood pressure that is less than 90 mm Hg Assessment of the central venous line insertion site Analysis of pending laboratory work Urinary output that is dark in color and less than what is expected

*1) This is specific and is a sign that the patient is developing septic shock and requires immediate action. 2) This is out of the scope of practice of an unlicensed assistive personnel (UAP). 3) The UAP would not be analyzing lab work results. 4) This information is nonspecific and does not provide clear direction to the UAP.

Tissue Trauma An RN calls a health care provider about a patient who has a urinary tract infection (UTI), with potential urosepsis. Which statement best describes the situation component of the situation, background, assessment, recommendation (SBAR) technique? The patient is incontinent of urine and stool, reports a burning sensation when urinating, and has poor oral intake and no appetite. The patient is showing early signs of Altered Level of Consciousness. Vital signs are: 39°C (102.2°F), 96 beats per minute, 32 breaths per minute, 98/70 mm Hg, and O2 saturation is 91%. The patient, an 88-year-old widow with no children, was admitted 3 days earlier from a nursing home with a stage III sacral pressure ulcer that tested positive for Escherichia coli (E coli). The patient is considered frail and weighs 94 lb. The RN is concerned that the patient's condition is deteriorating due to a possible UTI with potential urosepsis. The RN needs the health care provider to come to the unit and evaluate the patient immediately.

*1) This is the situation component of SBAR. 2) This is the background component of SBAR. 3) This is just the assessment (A) component. 4) This is just the recommendation (R) component.

Tissue Trauma An RN is assessing a patient with a burn. Which is an appropriate outcome for this patient? The patient will have adequate and equal intake and output (I and O) during each nursing shift. The patient will maintain a body temperature between 36.4°C (97.6°F) and 37.2°C (99.0°F). The patient will remain pain-free for a week. The patient will have a patent airway.

*1) This outcome is written correctly with time frame. 2) This outcome is written without a time frame. 3) This outcome is unrealistic. 4) See 2).

Tissue Trauma An older patient who is moderately obese requires total assistance to move from the bed to the bathroom. An unlicensed assistive personnel (UAP) asks the RN to help them perform this task. Which is the safest action the RN can take to preserve the functional ability of the patient and prevent lifting injury to nursing staff? Obtain a hydraulic lift to transfer the patient out of bed. Suggest the use of a bedpan for all elimination management. With the UAP, assist the patient into the bathroom using a gait belt. Ensure a clear path to the bathroom and instruct the patient on the use of a walker.

*1) Use of hydraulic lifts limits the physical strain on staff that would result from lifting patients. A patient who requires total assistance should be lifted with an appropriate device rather than by staff. 2) Optimal function is promoted when patients are out of bed for activities like eating and elimination. 3) Staff injuries frequently result when providing assistance to patients who are not self-mobile. 4) A walker will not provide adequate assistance to a person who needs total assistance.

Infectious Disease An RN is administering a skin test for tuberculosis (TB) to a patient. The patient asks how the test will reveal TB. The RN should base the response on which knowledge? A chest X ray will be done after the Mantoux test. A negative skin test excludes TB infection or disease. Induration does not have to be present to reveal a positive test. A positive reaction does not necessarily mean active disease is present in the body.

1) A chest X ray done with a positive skin test, blood test, or sputum culture for acid-fast bacilli. 2) A negative skin test does not exclude TB infection or disease because immunosuppression may cause the inability of the body to produce a positive skin test. 3) A reaction occurs when both induration and erythema are present. *4) A positive Mantoux test does not mean active disease. Over 90% of people who are tuberculin-positive reactors do not develop clinical TB. Additional test required for diagnosis.

Tissue Trauma An RN is collaborating with a dietician to plan the diet for a patient with irritable bowel syndrome (IBS). The RN contacts the health care provider to request an order for a high-fiber diet. What is the most important reason to request a high-fiber diet for this patient? The diet will cure the syndrome. The dietician does not have the authority to ask for a diet order. The diet is needed to help control the diarrhea and/or constipation. The RN should not do this, as it would not be an adequate diet for this patient.

1) A high-fiber diet will not cure IBS. IBS has no organic cause and therefore cannot be cured. 2) Dieticians will assess the patient needs and then request an order form the health care provider. The RN may be the one to transcribe the order; however, the dietician can request. *3) IBS symptoms are often alterations in bowel patterns. A high-fiber diet is recommended to help facilitate bowel movements. 4) Patients with IBS should have a dietary intake of at least 20 g/day, so a high-fiber diet would be appropriate.

Tissue Trauma What explains the development of deficient fluid volume in a patient with a full-thickness (third-degree) burn wound? Nerve injury Increased capillary permeability Decreased body temperature Upper airway obstruction

1) A nursing diagnosis of Acute Pain, not Deficient Fluid Volume, is related to tissue and verve injury. *2) A nursing diagnosis of Deficient Fluid Volume is related to increased capillary permeability and evaporative losses from the burn wound. 3) A nursing diagnosis of Hypothermia is related to loss of skin microcirculation and open wounds. 4) A nursing diagnosis of Impaired Gas Exchange is related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction.

Neurological Dysfunction An RN is assessing a 4-year-old patient who has a concussion. The RN is evaluating the patient's responses on the Glasgow Coma Scale. Which score would indicate the patient's condition reflects moderate head trauma? a score of 1 a score of 3 a score of 9 a score of 15

1) A score of 1 is not possible; 3 is the lowest number that can be obtained on the Glasgow Coma Scale. 2) A score of 3 indicates severe trauma. *3) A score of 9 indicates moderate trauma. 4) A score of 15 is the best score possible.

Infectious Disease A patient with tuberculosis (TB) is being admitted to the hospital. The RN knows the Centers for Disease Control and Prevention (CDC) has recommended interventions for the care of a patient with TB. Which of the following interventions does the CDC recommend using for a patient with TB? (Select all that apply.) Private positive pressure room Private negative pressure room Disposable particulate respirator facemasks Reusable acid-fast bacilli (AFB) respirator facemasks Television channel that shows infection control and prevention videos

1) AFB isolation precautions include the use of a private room with negative pressure (not positive) in relation to surrounding areas and a minimum of 6 air exchanges per hour. (CDC recommendations). *2) AFB isolation precautions include the use of a private room with negative pressure in relation to surrounding areas and a minimum of 6 air exchanges per hour. *3) Persons entering the AFB isolation room should use disposable particulate respirators that fit snugly around the face. (CDC recommendations). 4) Facemasks should be disposable particulate respirators that fit snugly around the face. (CDC recommendations). 5) While helpful, this is not required, and is not recommended by CDC.

Tissue Trauma An RN is assessing a patient for the use of negative pressure wound therapy (NPWT) for a non-infected lower leg wound. Which should the RN consider as a positive outcome for this patient? Air leak alarm sounds frequently. Wound dressing is requiring daily changes. Wound drainage in fluid chamber is increasing. No skin maceration beneath the dressing is observed.

1) Air leak is not a positive outcome for the patient with NPWT. 2) Daily dressing changes are often needed for infected wounds. A dressing change after the first 48 hours and then 2 to 3 times per week is usual for non-infected wounds. 3) Increased drainage is not a positive outcome for a patient with NPWT for a non-infected wound. *4) No skin maceration is a positive outcome. If observed, a skin barrier may be necessary.

Musculoskeletal Dysfunction A patient recently diagnosed with scleroderma expresses concern about returning to work. Which is the best response by the RN? "As long as you do not smoke, your employment should not be restricted." "It will be important to avoid a job that requires exposure to a cold environment." "Look for a job that involves using a keyboard, so you will be able to sit while working." "With current treatment methods, you do not need to worry about your ability to work."

1) Although it is important to avoid smoking, the degenerative changes associated with scleroderma will affect employment. *2) People with scleroderma must avoid cold due to Raynaud's disease. 3) With scleroderma, the skin and subcutaneous tissue becomes rigid and the extremities stiffen and lose mobility, making it difficult to type on a keyboard. 4) Medications are available to treat organ system involvement, but the disease process continues to deteriorate. The RN should address patient concerns, not provide false reassurance.

Musculoskeletal Dysfunction A home care nurse is assessing a patient who is 72 hours post-operative for a total hip arthroplasty. As the RN completes the assessment, the RN becomes aware that immediate intervention is needed for which assessment finding? The patient is using an abductor pillow to support the extremity. The patient sits in a position with the hips higher than the knees. The patient requires assistance for some activities of daily living (ADLs). The patient mentions a noticeable shortening of the affected extremity.

1) An abductor pillow keeps the hip in a neutral position and prevents dislocation. 2) This is proper positioning for sitting after a total hip arthroplasty. Acute flexion of the hip >90° should be avoided. 3) The patient may require assistance with some activities of daily living because of limited range of motion of hip. *4) This is a sign of dislocation, which needs immediate intervention.

Tissue Trauma Which nursing intervention is the most effective method for preventing surgical wound infection when a break in the integrity of the skin occurs and there is an increased risk for infection? Antibiotic therapy Occlusive dressings Sterile dressing changes Appropriate hand hygiene

1) Antibiotic therapy is used when a bacterial infection is already present. 2) Occlusive dressings do not always prevent infections. 3) Hand hygiene is used first before performing either a sterile or clean technique dressing change. *4) Careful hand hygiene before caring for a wound is probably the single most effective method for preventing wound infections.

Neurological Dysfunction A patient who is experiencing disorientation arrives to the emergency department (ED) in pain and with an elevated temperature. Analysis of cerebrospinal fluid (CSF) shows low chloride and glucose levels, a cloudy appearance, and viscosity. Which action should the RN take? Administer 0.9% dextrose with D5W. Place patient on droplet precautions. Keep the patient on observation for 24 hours. Cohort the patient with a newly diagnosed stroke patient.

1) Even though these fluids have CL and Dextrose, it will not treat the issue. *2) Patient might have bacterial meningitis because signs/symptoms of acute generalized meningitis are low chloride and cloudy CSF with possible low glucose level and high WBC count. Droplet precautions are used for meningococcus organisms that can be transmitted by respiratory or pharyngeal secretions. 3) This action does not address the issue that this patient is facing. 4) If the patient has bacterial meningitis (which needs to be ruled out), this cohorting should not be done.

Infectious Disease A patient has an initial positive result for the enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The patient is upset and begins to cry. Which is the most appropriate response for the RN to make? "Be glad the disease was detected early." "This test is the best test for HIV diagnosis." "You do not have symptoms, so the test is not accurate." "Additional testing is needed before a definitive diagnosis is made."

1) HIV is not diagnosed with a single test. 2) Multiple tests are performed for an accurate diagnosis. 3) Patients do feel well in the early stages, but additional tests are necessary to confirm the diagnosis. *4) False positive results can occur, so multiple tests must be performed before a definitive diagnosis is made.

Infectious Disease An RN is working with a nursing team that includes the RN, an LPN/LVN, and unlicensed assistive personnel (UAP) who are caring for several patients with infectious diseases. Which action performed by a team member would require the RN to intervene? Continually washing hands when entering and exiting each room Shutting the room door of a patient on airborne precautions Wearing the same mask and gown when taking vital signs for the group of patients Leaving the stethoscope when exiting a room with a contact precautions sign posted

1) Hands should be washed between rooms, even if the patient does not have an infectious disease. 2) The door should be closed when a patient is on airborne precautions. *3) The UAP should apply a separate mask and gown for each room and wash their hands between rooms. 4) Dedicated equipment is utilized when caring for patients on contact precautions so other patients are not placed at risk.

Infectious Disease An RN is reviewing patient care needs with unit staff. Which patients would the RN identify as requiring droplet precautions? (Select all that apply.) A 2-year-old patient with hepatitis E diagnosed 24 hours earlier A 3-year-old patient with scarlet fever A 5-year-old patient with primary tuberculosis (TB) started on medication 48 hours earlier An 8-year-old patient with suspected mumps A 10-year-old patient with Shigella A 12-year-old patient with a history of Clostridium difficile (C-diff) infection

1) Hepatitis E is spread by contact, not droplets. *2) Scarlet fever as well as Group A streptococcal pneumonia and pharyngitis in infants and young children is spread by large particle droplets and therefore require droplet precautions. 3) Tuberculosis requires airborne precautions because it is spread by airborne droplet nuclei. These are small droplets, 1 to 5 micrometers in diameter, which are released by talking, laughing, sneezing, or coughing. They remain suspended in the air and are inhaled. *4) Mumps is spread by large particle droplets and therefore requires droplet precautions. 5) Shigella is an enteric infection and requires contact precautions. 6) Clostridium difficile is a spore forming bacteria that proliferates in the intestine. It is spread by contact and therefore requires contact, not droplet precautions.

Tissue Trauma A veteran who had an above-the-knee amputation to the right leg is seen at the clinic and is asking for additional medications for depression. In addition to consulting with the psychiatrist about the medication regimen, which action should the RN take to promote positive coping for this patient? Suggest the patient develop a hobby that will benefit others, like training service dogs. Discuss with the patient participation in a support group focused on veterans. Instruct family members to carefully monitor the patient's medication use. Teach the patient the dangers of increased doses of antidepressants.

1) Hobbies can be helpful in dealing with depression. Assessment of the patient's interests must precede suggestion of specific activities. *2) Social support is strongly related to positive coping, especially if contact includes a group of individuals who have shared a common experience. 3) Family members can contribute to social support but there is no indication that the adult patient is unable to manage medication administration appropriately. 4) Antidepressant medication is an element of treatment for depression; while the nurse should teach about medications, focusing on the dangers of medication use will not promote positive coping.

Infectious Disease An RN instructs an unlicensed assistive personnel (UAP) to perform appropriate hand hygiene using soap and water only when caring for a patient with which infection? Staphylococcus aureus Clostridium difficile Neisseria meningitidis Haemophilus influenza

1) If hands are not visibly soiled, health care providers are strongly encouraged to use alcohol-based, waterless antiseptic agents for routine hand decontamination. These solutions are superior to soap or antimicrobial hand washing agents in their speed of action and effectiveness against most microorganisms. *2) The spore form of the bacterium Clostridium difficile is resistant to alcohol and other hand disinfectants; therefore, the use of gloves and hand washing (soap and water for physical removal) are required when C. difficile has been identified. 3) See 1). 4) See 1).

Infectious Disease A 20-year-old patient with meningitis is in critical condition and the patient's prognosis is guarded. Which action is most essential for the RN to include in the plan of care to support patient and family coping? Update the family on the patient's condition at regular intervals. Arrange for a family conference with social services. Request the chaplain meet with the family. Allow for periodic family visits.

1) Providing regular updates to the family on the patient's condition is important to family coping, but it does not directly impact the patient's coping. 2) A conference with social services may be needed and may be helpful to the family; it does not directly impact the patient's coping. 3) A meeting with the chaplain may be desired and helpful to the family, but it will not directly impact the patient's coping ability. *4) Periodic family visits can support both the patient and the family. Seeing, hearing, touching, even the very presence of a loved one is comforting and reassuring.

Tissue Trauma During the assessment of a 14-year-old patient with an acute exacerbation of ulcerative colitis, the RN asks the patient how they feel about the disease. The patient replies, "I hate it. I hate the pain. I hate the diarrhea. I hate being different from all my friends." When the RN asks the patient about activities they are involved in, the patient says, "All my friends are trying out for the drama club. I really need to make it or I'll be left out." Based on this data, for which nursing diagnosis label will this adolescent be at risk, related to potential side effects of the ordered steroid therapy? Ineffective Health Maintenance Chronic Low Self-esteem Ineffective Coping Noncompliance

1) Ineffective health maintenance is the inability to identify, manage, and/or seek out help to maintain health. There is nothing in the assessment data provided that would indicate that there could be a potential problem in this area as a result of the side effects of steroid therapy. 2) Chronic low self-esteem refers to long-standing negative self-evaluating/feelings about self or self-capabilities. There is nothing in the assessment data provided that indicates the presence of any defining characteristics of chronic low self-esteem or that there could be a potential problem in this area as a result of steroid therapy. *3) It is characteristic of teens to want to "fit in" with their peer group and this patient's comments confirm her concern with this. Her comments about hating the disease suggest it is a struggle to cope, but so far she manages most of the time. The side effects of steroid therapy (which include weight gain, moon facies, and facial acne) have the potential to make her even more different from her peers, which thereby makes coping more difficult. Thus, steroid therapy and its side effects will put her at risk for ineffective coping. 4) Noncompliance refers to failure to follow an agreed-upon health promotion or therapeutic plan. There is nothing in the provided assessment data that suggests the patient will be at particular risk for noncompliance when the steroid therapy is initiated.

Infectious Disease An RN is admitting a patient who is experiencing manifestations of acquired immunodeficiency syndrome (AIDS). During the assessment, the RN would note which sign? Jaundice Bradypnea White patches in the mouth Urine specific gravity of 1.010

1) Jaundice is not present with AIDS. 2) Dyspnea occurs with AIDS. *3) White patches in the mouth indicate candidiasis, an opportunistic infection. 4) AIDS patients are frequently dehydrated, not adequately hydrated.

Neurological Dysfunction An RN is preparing family members for the discharge of a 13 year old who had a traumatic brain injury that resulted in severe cognitive impairment but minimal physical disability. How can the RN best assess the needs of the family for education on coping with taking the child home? Holding a health team conference to gather information and determine community resources available to the family to meet the physical, financial, emotional, and spiritual needs of both patient and family Observing the family dynamics, including communication between family members and the level of support and concern shown for the child Asking the family about their feelings about how the injury has changed their relative and the impact it will have on their lives Reassuring the family that the nurses will be available to help families develop the strength and ability to care for loved ones

1) Knowledge of community resources does not help assess the needs of the family. 2) Observing family dynamics provides limited information about ability to cope at home. *3) Every family is unique and the best way to determine the family response is to directly ask about their feelings and perception of the impact of the situation on their lives. 4) Offering reassurance is considered nontherapeutic, as it provides no direct or clear support.

Infectious Disease A public school RN is offering an educational session to parents of children who are ages 5 and 6 years and who will be entering elementary school next fall. Which immunizations should be current for children in this age group? MMR and meningitis HPV and varicella MMR, DTP, HPV IPV, DTP, 2nd booster of MMR

1) MMR and meningitis are not enough of the required immunizations. 2) HPV is not recommended for this age group. 3) HPV is not recommended for this age group. *4) Inactivated Polio Vaccine, Diphtheria/Tetanus/Pertussis, 2nd booster of MMR will be current.

Tissue Trauma Which example of nursing care can an RN delegate to an unlicensed assistive personnel (UAP) or an LPN/LVN? Evaluation of healing of a diabetic foot ulcer Teaching a patient prior to hospital discharge Assessing the condition of a newly admitted patient Measuring and recording intake and output (I and O)

1) May be assigned only to another RN, not delegated. 2) See 1). 3) See 1). *4) May be delegated to UAP or LPN/LVN.

Tissue Trauma A 10-year-old patient who is newly diagnosed with rheumatoid arthritis (RA) reports pain after 5 weeks of using ibuprofen (Motrin), as prescribed. What nursing education would the RN provide to the patient? Usually patients do not improve only on ibuprofen (Motrin). Ask the physician for methotrexate. Medication should be taken for at least 6 to 8 weeks to ensure affectiveness. Discuss with the health care provider about doubling the dose. Tell the patient to stop taking the Motrin and look for other options.

1) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. This drug is a second drug prescribed, but the patient still did not finish appropriate therapy with Motrin. *2) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. 3) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. This is not appropriate teaching. 4) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. This does not help a patient and it is not appropriate teaching.

Tissue Trauma Which postoperative patient would be a good candidate for a patient-controlled analgesic device (PCAD)? A patient whose caregiver is there all the time and willing to help with the PCAD A developmentally delayed 8-year-old male patient A drowsy and sleepy 45-year-old female patient A 95-year-old patient with slight vision loss

1) PCAD is to be used by the patient, not by a family member who is assisting with health care. 2) Two requirements for PCAD are an understanding of the need to self-dose and the physical ability to self-dose. We do not know anything else about this patient to ensure that the patient will understand and do it correctly. 3) This patient would not be able to comprehend and use PCAD properly. *4) Two requirements for PCAD are an understanding of the need to self-dose and the physical ability to self-dose. This patient can use the button and self-medicate because there are no other impairments identified.

Tissue Trauma Following a patient's endoscopy and diagnosis of gastrointestinal reflux disease, which instruction should be included in the discharge teaching provided by the RN to the patient? Carry sugar-free peppermints to treat heartburn symptoms. Sleep with knees raised 6 to 8 inches on pillows. Consume a snack 1 hour before bedtime. Avoid caffeinated food and drink.

1) Peppermint can relax the lower esophageal sphincter, allowing reflux and esophageal irritation. It should be avoided. 2) The head of the bed should be raised 6 to 8 inches on blocks. Alternatively, a foam wedge can be used to elevate the upper body. 3) Food should be avoided for 2 hours before bedtime. *4) Caffeine can decrease the lower esophageal sphincter pressure, allowing reflux and esophageal irritation. It should be avoided.

Infectious Disease A 33-year-old patient with acquired immunodeficiency syndrome (AIDS) explains that they are uncomfortable being with and talking to people, because they feel stigmatized by having the disease. The patient expresses feelings of being alone, without friends, and separate from the world. Which nursing intervention would best support the patient's coping? Role-play social interactions with the patient. Request a psychiatric consult for the patient. Refer the patient to an AIDS support group. Encourage the patient to join a recreational club.

1) Role playing general social interactions will not address the issue of feeling stigmatized and alone. If the patient was trying to cope with how to tell a significant other/family member that they have AIDS, role playing to practice what to say could be valuable. 2) There is no information in the question which suggests that the patient is in need of psychiatric help. The patient feels stigmatized and alone, but is not acting out or threatening harm to self or others. *3) Referral to an AIDS support group would best support coping because of the feelings of stigma and separateness. In an AIDS support group, the patient will not be different because of the disease. 4) Before this patient will be ready to join a recreational club and meet new people, they must cope with feelings of being stigmatized; this can best be done within a supportive group of fellow AIDS victims.

Infectious Disease An RN is assessing an adolescent patient in the emergency department (ED) who engaged in unprotected sex 24 hours earlier. For which infection is the patient most at risk? Salmonella Hepatitis A Escherichia coli (E. coli) Human immunodeficiency virus (HIV)

1) Salmonella is spread through contaminated foods. 2) Hepatitis A is spread through contaminated foods. 3) Escherichia coli (E. coli) is spread through contaminated foods. *4) Human immunodeficiency virus (HIV) is spread through bodily fluids.

Musculoskeletal Dysfunction An RN is educating a community group about the risk factors for osteoporosis. Which statement, if made by one of the participants, indicates to the RN that clarification needs to be made in the teaching information? "Quitting smoking can decrease my chances of osteoporosis." "I will add swimming to my exercise routine to strengthen my bones." "Limiting alcohol to less than two drinks per day is good for my bones." "I am at higher risk for osteoporosis because I am small framed and Asian."

1) Smoking decreases blood supply to bones, slows osteoblast production, and impairs calcium absorption. *2) Weight-bearing exercises, like walking are needed to increase osteoblast growth and activity; swimming is not weight-bearing. 3) Alcohol intoxication suppresses bone formation; heavy alcohol use is often associated with nutritional deficiencies. Moderate alcohol consumption has positive effects on bone mineralization. 4) Small-framed Asian and Caucasian women are at greatest risk for osteoporosis.

Neurological Dysfunction A tetraplegic patient develops a pounding headache while getting occupational therapy at a rehabilitation facility. On assessment, the nurse finds the blood pressure is 190/96, and heart rate of 54. Which complication of spinal cord injury does this indicate? Spasticity Epilepsy Spinal shock Autonomic dysreflexia

1) Spasticity does not affect vital signs. 2) Epilepsy is a complication of traumatic brain injury. It is not a complication of spinal cord injury. 3) Spinal shock causes hypotension with bradycardia and occurs in the acute stage of spinal cord injury. *4) Headache with hypertension and bradycardia are classic signs of autonomic dysreflexia.

Infectious Disease A patient is admitted with a diagnosis of tuberculosis (TB). An RN should implement which isolation procedure? Standard precautions Contact precautions Droplet precautions Airborne precautions

1) Standard precautions are used to prevent exposure to blood and body secretions. 2) Contact precautions are used for wounds. 3) Droplet precautions are used for infections spread by coughing or sneezing. *4) Tuberculosis is spread by air current; patient should be placed in negative air pressure rooms where air does not cross contaminate.

Musculoskeletal Dysfunction Which laboratory test results should the RN expect to assess when a patient has been diagnosed with acute rheumatoid arthritis? Clear synovial fluid Elevated uric acid level Positive rheumatoid factor (RF) Elevated erythrocyte sedimentation rate (ESR)

1) Synovial fluid is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. 2) Elevated uric acid is found in gout. 3) Rheumatoid factor is present in about 80% of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis. *4) The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression.

Musculoskeletal Dysfunction Which laboratory test results should the RN expect to assess when a patient has been diagnosed with acute rheumatoid arthritis? (Select all that apply.) Clear synovial fluid Elevated uric acid level Positive rheumatoid factor (RF) Elevated erythrocyte sedimentation rate (ESR) Elevated C-reactive protein (CRP)

1) Synovial fluid is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. 2) Elevated uric acid levels are found in gout. *3) Rheumatoid factor is present in about 80% of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis. *4) The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. *5) See 4).

Musculoskeletal Dysfunction A 12-year-old visits the school RN with reports of pain in the leg upon ambulation. The school RN notices a dried scab of the child's calf, mild edema, and warmth in the area. The RN should suspect which serious condition? Synovitis Septic arthritis Osteomyelitis Legg-Calve-Perthes (LCP) disease

1) Synovitis is an inflammation of the synovial membrane of a joint and occurs most commonly in the hip joint in young children. 2) Septic arthritis is an infection of a joint caused by a bacterial or fungal infection. *3) Osteomyelitis is infection within the bone secondary to a bacterial infection. 4) LCP occurs when the blood supply is temporarily interrupted to the ball part (femoral head) of the hip joint.

Neurological Dysfunction A community health nurse is planning a primary prevention program for traumatic brain injury (TBI) in school-aged children. Which topic would be best suited for primary prevention of this condition? Use of appropriate diving techniques during school swim classes Use of mouth guards while playing soccer Use of shoulder pads while playing football Use of helmets while riding a bicycle

1) Teaching appropriate diving techniques would impact a small amount of the population in the community, as compared to other activities. 2) This will not prevent traumatic brain injuries (TBI). 3) This will not prevent traumatic brain injuries (TBI). *4) Most school-aged children frequently ride bicycles, so teaching school-aged children to wear helmets would address the largest incidence for head injury in this age group.

Infectious Disease Which intervention can an RN delegate to an LPN/LVN who is caring for a 3-month-old infant with shigellosis (dysentery)? Call the health care provider for an order of pain reliever when new pain occurs. Teach the parents about the intravenous therapy being used. Weigh soiled diapers and record the number of grams (g). Assess skin turgor every 4 hours.

1) The LPN/LVN should report any new findings to the RN prior to calling the health care provider, so that the child can be assessed. 2) This is an intervention that should be done, but teaching is out of the LPN/LVN scope of practice. *3) Weighing soiled diapers will indicate output and is in the scope of practice for an LPN/LVN. 4) This is an intervention that should be done, but assessing is out of the scope of practice for an LPN/LVN.

Infectious Disease A 31-year-old patient presents with dehydration due to infectious diarrhea that has lasted for 2 days. Which assessment data would indicate to the RN the need to consult with the health care provider about potential intravenous therapy? (Select all that apply.) Mucus in stool Hyperactive bowel sounds Cold extremities Pale nailbeds Tachycardia

1) The most important assessment in the patient with diarrhea is to determine hydration status. While mucus in the stool would help with determining the type and severity of the disease, it does not help determine hydration status. 2) Hyperactive bowel sounds does not support the presence of severe dehydration. *3) When assessing for hydration status, the nurse knows cold extremities may be a symptom of severe dehydration and require IV replacement until improvement is evident. 4) Pale nailbeds would indicate anemia rather than dehydration. *5) When assessing for hydration status, the nurse knows that tachycardia may be a sign of dehydration and can be corrected with IV rehydration.

Infectious Disease A patient in the intensive care unit (ICU) with septic shock is showing signs of multiple organ dysfunction syndrome (MODS). The RN plans to increase which focused assessment, recognizing that organ system is first to show signs of dysfunction? Neurological Respiratory Cardiovascular Hepatic

1) The neurological response will progress to unresponsiveness or coma once the cardiovascular system is unresponsive to vasoactive agents. *2) The lungs are typically the first to show signs of dysfunction with progressive dyspnea and respiratory failure. 3) The cardiovascular system usually follows the respiratory system and will require vasoactive agents to support the BP and cardiac output. 4) The hepatic system will show signs of dysfunction with an elevated bilirubin and liver function tests in less than 2 weeks from the onset.

Musculoskeletal Dysfunction An RN observes the surgeon beginning to mark the wrong leg on a patient in preparation for an above-the-knee amputation. After recognizing the error, the correct leg is marked, but a smudge remains on the incorrect leg. Which action performed by the RN is most important? Obtain a marker and enlarge the mark on the correct leg. Complete an incident report and file it with the supervising RN. Assemble the surgical team for proper completion of marking the site. Remove the marks on both legs, requiring the surgical team to check the consent form for the proper site.

1) The person responsible for the procedure holds responsibility for completion of surgical site marking. 2) Although completion of an incident report allows the staff to track errors and near-miss events, it is not the priority at this time. *3) The universal protocol includes a check of surgical site marking and should be completed by the surgical team. 4) Surgical sites should be clearly marked prior to entering the operating room.

Neurological Dysfunction An RN is assessing a patient who is recovering from a T4 spinal cord injury. The patient reports a severe headache, diaphoresis, and bradycardia. Which priority intervention should the RN implement for this patient? Place the patient in a supine position. Place the patient in a sitting position. Place the patient in a prone position. Place the patient in the Trendelenburg position.

1) The supine position does not decrease a patient's blood pressure as needed in autonomic dysreflexia. *2) Autonomic dysreflexia patients are immediately placed in this position to lower blood pressure. 3) This position would not have an effect on decreasing the blood pressure. 4) Trendelenburg position is used to increase blood pressure in a patient.

Neurological Dysfunction An RN is teaching a patient with Parkinson's disease about the medication benztropine mesylate (Cogentin). The RN should teach the patient which strategy to avoid the potential side effects of this medication? Take with food to eliminate nausea and vomiting. Increase fluid and fiber intake to prevent constipation. Change positions slowly to prevent orthostatic hypotension. Do not take with grapefruit or grapefruit juice to improve absorption.

1) There are no food interactions with this drug. *2) Constipation and gastrointestinal motility are side effects. Fluids and fiber intake prevent it from occurring. 3) Adverse reactions include tachycardia and palpitations but not hypotension. 4) There are no benefits to take medication with juice.

Musculoskeletal Dysfunction A patient who was hospitalized with a tibia/fibula fracture states that the pain is currently worse than it was before taking pain medication. While assessing the patient, an RN notes increased pain with passive range of motion (PROM), greater than 5 capillary refill time, dusky cold toes, and a weak peripheral pulse found only by using a Doppler ultrasound. The RN suspects which complication is causing these changes in the patient's condition? Shock Fasciotomy Fat emboli syndrome Compartment syndrome

1) There are no signs of hypovolemic shock in this patient. 2) A fasciotomy is often indicated to treat compartment syndrome. It is a form of treatment, not a complication of the presenting condition. 3) The classic triad of clinical manifestations of fat emboli syndrome is hypoxemia, neurologic changes, and petechial rash, not the manifestations described. *4) The hallmark signs of compartment syndrome are pain, increased passive range of motion, and the five Ps: pain, pallor, paresthesia, pulselessness, and paralysis.

Tissue Trauma A patient has sustained a third-degree burn to the right forearm and received a skin graft. The patient's right fingers are pale and cool to touch, there is a moderate amount of serosanguinous strike through on the gauze dressing, lab results indicate elevated potassium levels and low sodium levels, and urinary output is less than 30 mL per hour. The patient states, "I don't have much pain, but I feel pins and needles." Which complication is indicated by the RN's assessment data presented here? Graft rejection Wound infection Compartment syndrome Fluid volume overload

1) There is no information about the appearance of the graft provided. 2) The data provided do not indicate wound infection. *3) Compartment syndrome is a common complication of a severe burn. Pale, cool fingertips, diminished sensation, decreased urinary output, and low serum sodium are all indications of compartment syndrome. 4) The data presented do not indicate fluid volume overload. Blood pressure is low and pulse is high.

Tissue Trauma An RN is assigned care of a patient with a left tibia fibula fracture. While doing the peripheral neurovascular assessment, the RN notes the patient's foot is warm, but cannot palpate a dorsalis pedis pulse. Which of the following would be the RN's priority intervention? Apply a splint. Use a Doppler to check for pulses. Notify the health care provider of the findings. Reposition the extremity to proper alignment.

1) This action would not benefit circulation if the extremity was not aligned. *2) When the pulse is not palpable, the RN would use a Doppler device to determine if there was perfusion to the extremity. 3) The RN would notify the health care provider soon, as any intervention that could be done to prevent further damage has been completed. 4) This is the first action to help restore circulation.

Tissue Trauma An RN manager overhears nursing personnel making unprofessional remarks about a bariatric surgery patient who was readmitted with wound complications, suggesting that the patient's current health status is self-inflicted. What should be the RN manager's priority in planning a response to these comments? Plan a staff development session on bias against obesity. Find out which members of the unit staff are responsible. Plan a staff development session on cultural sensitivity. Re-examine the unit's bariatric surgery discharge protocols.

1) This is a good secondary action for the nurse manager to plan. 2) This is a punitive action which will likely make the situation worse. *3) Staff behavior suggests that cultural bias may be the underlying problem. Planning a cultural sensitivity session is the priority action for the nurse manager. 4) This is a good secondary action for the nurse manager to plan.

Infectious Disease An RN is supervising an unlicensed assistive personnel (UAP) at a nursing home. The UAP states that they have viral conjunctivitis and will be glad when the shift is over. Which is the most immediate instruction the RN should provide to the UAP? "Make sure not to share towels or makeup." "Wear dark glasses if the light bothers you." "Cold compresses applied for 10 minutes, 4 to 5 times a day, may help with the pain." "You will need to go home and not return to work until your medical doctor has cleared you to return to work."

1) This is a true statement, but not the most important. 2) This is a true statement, but not the most important. 3) This is a true statement, but not the most important. *4) Viral conjunctivitis is very contagious. The UAP should stay home and not return for 7 days or when a medical doctor allows. There is too high of a risk to spread this to the residents.

Musculoskeletal Dysfunction A patient arrives at the emergency department (ED) with an arm in a sling, describing pain and an inability to move the fingers. After obtaining a medical history from the patient and completing an assessment, the RN documents that the fingertips are a dusky color and there is edema of the hand and fingers. The patient has no mobility in the fingers. The RN recognizes that these symptoms are related to which patient action? Using a sling to immobilize the arm when ambulating Distributing the weight of the sling on the back of the neck Removing the arm from the sling and elevating it frequently Elevating the immobilized arm above the level of the heart on a pillow

1) This is not a problematic patient action. A sling should be used for immobilizing the arm when ambulating. *2) The weight of the sling should be evenly distributed across the back, neck, and shoulders. Weight just on the back of the neck obstructs the blood flow to the hand and arm. 3) The sling should be removed and the arm elevated frequently when not ambulating. 4) This is not a problematic patient action. The arm should be elevated on pillows above the level of the heart when not ambulating.

Infectious Disease A 46-year-old patient has returned from a hiking trip. During the health history, the patient tells the RN about removing a tick that was imbedded in the leg. Which data from the RN's focused assessment would indicate the need to collaborate with the health care provider regarding treatment for Lyme disease? Increased thirst Red, circular rash Reports of excessive hunger Reports of nausea and vomiting

1) This is not a sign or symptom of Lyme disease. *2) Rash occurs in approximately 70 to 80% of infected persons and begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days). Parts of the rash may clear as it enlarges, resulting in a "bull's-eye" appearance. 3) This is not a sign or symptom of Lyme disease. 4) This is not a sign or symptom of Lyme disease.

Infectious Disease A patient with multiple health problems including an open, weeping skin infection is admitted to the medical-surgical unit. Which action can the RN delegate to unlicensed assistive personnel (UAP) to assist with the patient's care? Teaching the patient and family members about ways to prevent transmission of scabies Communicating with other departments when the patient is transported for ordered tests Monitoring the results of ordered laboratory cultures and sensitivity tests Implementing contact precautions when providing care for the patient

1) This is out of the scope of practice for an unlicensed assistive personnel (UAP). 2) This should be done by the RN. 3) This is out of the scope of practice for an unlicensed assistive personnel (UAP). *4) Contact precautions should be implemented by all that provide care for this patient until it is determined whether the wound is not infectious.

Neurological Dysfunction An RN is assessing a patient with increased intracranial pressure (ICP). The patient has experienced a change in level of consciousness, has slowed speech, and the patient's condition continues to deteriorate. Which additional assessment would indicate to the RN that immediate intervention is needed? Agitation Restlessness Increasing drowsiness Decerebrate posturing

1) This occurs in the early stages of intracranial pressure (ICP). 2) This occurs in the early stages of intracranial pressure (ICP). 3) This occurs in the early stages of intracranial pressure (ICP). *4) Decerebrate posturing is late-stage deterioration from increased intracranial pressure (ICP); it requires immediate intervention.

Tissue Trauma An RN observes an unlicensed assistive personnel (UAP) making a negative remark about providing care to a patient who has a new ostomy. What should be the initial priority action taken by the RN? Report the UAP to the nursing supervisor. Tell the UAP to take a break and provide the care instead. Ask another UAP to switch assignments with the first UAP. Take the UAP aside and discuss their readiness to provide care.

1) While the nursing supervisor may need to be involved, the first action is for the nurse to address the behavior. 2) This action does not address the UAP's behavior and provides a reward for substandard actions. 3) The behavior must be addressed. If the UAP cannot provide nonjudgmental care, a substitution may be made, but this would not be the initial action. *4) The nurse is responsible for providing leadership to the care team and is accountable for safe, effective, and respectful care.

Infectious Disease A 6-year-old patient has been diagnosed with acute conjunctivitis on three separate occasions over the last 4 months. When assessing the patient, what should be the nursing priority in educating the caregivers and patient? How to apply cool, moist, compresses to the affected eye Hpw to keep the affected eye covered at all times How and when to perform hand hygiene Proper nutrition to build up immunity

1) While this would help with any inflammation of the eye, it would not be a priority. 2) This helps prevent the infection from transferring to the unaffected eye, but it would not be a priority to prevent the reoccurring infection. *3) The child has had the same infection every month for 3 months. This eye infection is common in children who rub their eyes with their hands frequently. Therefore, a priority would be to make sure the parents and child understand how and when to perform hand hygiene. 4) While nutrition is important, it would not be a priority for this child.

Tissue Trauma A patient who was severely burned is being discharged. Under which circumstances should the RN consider a referral for home physical therapy for this patient? Extensive wound care is needed to prevent infection. Family coping is compromised and social support is limited. Patient is interested in resources to help improve perceptions of body image. Mobility is inadequate to allow performance of activities of daily living (ADLs).

1) Wound care is facilitated by home care nurses through direct assistance or teaching. 2) Coping needs can be addressed by referral to mental health counseling. 3) Home care nurses can provide information about resources that improve body image. *4) Physical therapy is necessary and effective to improve mobility and range of motion.

Neurological Dysfunction Magnesium sulfate is ordered for a pregnant patient who has a history of seizures and is diagnosed with preeclampsia. The physician's orders are to administer magnesium sulfate with an initial dose of 4 gm intravenously (IV) in 250 mL D5W over 90 minutes. At what pump rate should the RN set the IV pump, in milliliters per hour? (Provide your answer to the nearest whole number in the input box below.)

Rationale: 250 mL is ordered over 90 minutes. Set up an equation: 250 mL/90 min = x mL/60 minutes (60 min in an hour) Cross multiply: 250 x 60 = 90x Solve for x: 15000/90 = x/90; x = 166.7 or 167 mL/hr (most IV pumps are in whole numbers)

Neurological Dysfunction A 19-year-old patient is diagnosed with meningococcal meningitis. The physician's orders are to administer Ceftriaxone 1.5 gm intramuscular (IM) every 12 hours. The drug availability is Ceftriaxone 2 gm, powder in vial, reconstituted to yield 2 gm/2 mL. How many milliliters (mL) should the RN administer IM? (Provide your answer to 1 decimal place in the input box below.)

Rationale: When reconstituted with fluid, the yield is 2 gm/2 mL. Simplify to 1gm/mL Solve: 1 gm/mL = 1.5 gm/x mL Cross multiply: 1x = 1.5 Solve for x = 1.5 mL

Neurological Dysfunction A 12-year-old patient, weighing 108 lb, presents with decreased sensation and movement below the cervical neck region. The physician's orders are to administer methylprednisolone 30 mg/kg intravenously (IV) bolus over 15 minutes. Methylprednisolone powder has been reconstituted to a solution of 2 gm/5 mL. How many milliliters does the RN administer? (Provide your answer to 1 decimal place in the input box below.)

Rationale: 108 lb = 49.1 kg 30 mg/kg = 30 x 49.1 = 1473 mg 2 gm/5mL concentration = 1473 mg/x 2 gm Converted to 2000 mg Solve for x: 2000 mg/5 mL = 1473 mg/x Cross multiply 2000x = 5 x 1473 = 7365 Solve for x: 7365/2000 = 3.7 mL