Archer Review 3t

The nurse assesses a 65-year-old patient on the medical-surgical floor who complains of being too warm. Upon assessment, the nurse finds the patient to be tachycardic and diaphoretic, with fine muscle tremors, and protruding eyeballs. Which diagnosis would the nurse suspect? A. Myxedema [10%] B. Bell's palsy [2%] C. Grave's disease [82%] D. Cushing syndrome

Explanation Choice C is correct. Grave's disease is the most common cause of hyperthyroidism and is characterized by increased heart rate, excessive sweating, heat intolerance, exophthalmos (bulging eyeballs), fatigue, tachycardia, shortness of breath, fine muscle tremor, thin silky hair/skin, and infrequent blinking. Choice A is incorrect. Myxedema, or hypothyroidism, is characterized by severe, non-pitting edema, puffy, edematous face and periorbital area, coarse facial features, dry skin, as well as dry, coarse hair. Choice B is incorrect. Bell's palsy is caused by a lower motor neuron lesion resulting in damage to cranial nerve VII and is characterized by unilateral paralysis of the face. Choice D is incorrect. Cushing syndrome is caused by excessive secretion of ACTH and chronic steroid use. It is characterized by a large, rounded face, prominent jowls, red cheeks, hirsutism on the upper lip, lower cheeks, and chin, as well as acneiform rash on the chest.

Due to a recent flood, the only staff that were able to make it to work are two nursing assistants and one licensed practical nurse with the nurse manager. Knowing the different nursing delivery systems, which system should the nurse manager implement to care for the 20 clients admitted in their ward? A. Primary nursing [6%] B. Team nursing [48%] C. Functional nursing [42%] D. Case management [4%]

Explanation Choice C is correct. In functional nursing, each caregiver on a specific nursing unit is given specific tasks that fall into their scope of practice. In this situation, the nurse manager may administer medications to the entire group, while a licensed practical nurse performs treatments, and the client care attendants provide physical care. Choice A is incorrect. A registered nurse plans and organizes care for a group of clients and cares for this group during their entire hospitalization. This type of care delivery cannot be useful in this situation. Choice B is incorrect. An RN leads nursing staff who work together to provide care for a specific number of clients. The team typically consists of RNs, LPNs, and client care attendants. The team leader assesses client needs, plans client care, and revises the care plan based on changes in the client's condition. The leader assigns tasks to team members as needed. This cannot be done in this situation, as this requires too many staff members. Choice D is incorrect. Case management is a form of primary nursing that involves a registered nurse who manages the care of an assigned group of clients. This nurse coordinates care with the entire health care team. There is only one RN in the situation. Therefore, it cannot be used.

You are selecting a toy to purchase for your 3-year-old niece. Which of the following choices are most appropriate for her age group? A. Brightly colored foam blocks [39%] B. Detailed coloring books and crayons [20%] C. Lincoln logs [26%] D. Light up mirror toy

Explanation Choice C is correct. Lincoln logs are an excellent choice for a three-year-old. These building blocks will allow the use of both fine and gross motor skills and imaginative play. The normal three-year-old should be able to assemble these blocks and have a long enough attention span to work on building something with them. Choice A is incorrect. Brightly colored foam blocks are more appropriate for a 12-month-old. This toy would allow a 12-month-old to practice their pincer grasp and use both fine and gross motor skills in pouring out the blocks and stacking the blocks. Choice B is incorrect. While three-year-olds are beginning to learn how to color, the ability to color inside the lines in detailed coloring books is not developed yet. This activity could become frustrating to a three-year-old. There is a more age-appropriate option. Choice D is incorrect. A light-up mirror toy is more appropriate for a 7-month-old child than a three-year-old child. This toy is meant for an infant who is just developing color vision and intrigued by sights and sounds of the mirror toy. A three-year-old should be more interested in activities that they are able to be involved in, such as building something. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatric development

The nurse is caring for a patient with a potassium of 3.2 mEq/dl. Which of the following medications may cause this abnormality? A. Spironolactone [34%] B. Triamterene [13%] C. Prednisone [31%] D. Lisinopril

Explanation Choice C is correct. Prednisone is a corticosteroid and increases aldosterone, which is responsible for sodium retention and potassium elimination. Therefore, a patient's potassium level will decrease while taking this medication. Choices A, B, and D are incorrect. Spironolactone, Triamterene, and Lisinopril are all medications that increase potassium. Therefore, the nurse must monitor the patient for potential hyperkalemia. Additional information: Hypokalemia is potassium less than 3.5 mEq/l and may be induced by medications such as albuterol, furosemide, prednisone, and bumetanide. The priority when dealing with a patient who has a disturbance in their potassium is to obtain a 12-lead electrocardiogram.

The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate? A. Prepare for intubation. [7%] B. Prepare to administer a dopamine infusion. [3%] C. Administer naloxone. [79%] D. Start an IV infusion of normal saline. [10%]

Explanation Choice C is correct. The client is suffering from morphine toxicity. The nurse needs to administer the antidote, which is naloxone (Narcan). Choice A is incorrect. The client is in morphine toxicity. The nurse needs to administer an antidote to reverse the symptoms of respiratory depression. Preparing for intubation should not be the nurse's initial action. Choice B is incorrect. The drop in blood pressure is a result of morphine toxicity. Dopamine infusion is not yet necessary as of the moment. Choice D is incorrect. Starting an IV infusion may be necessary; however, in this case, the first action of the nurse would be to administer an antidote to morphine.

What is the normal level for creatinine in a healthy adult male? A. 0.4 to 0.8 mg/dL [3%] B. 0.1-0.4 mg/dL [1%] C. 0.6-1.2 mg/dL [91%] D. 1.5-2.0 mg/dL [5%]

Explanation Choice C is correct. The normal creatinine range is 0.6 to 1.2 mg/dL in a healthy adult male. Creatinine values reflect both the amount of muscle a person has and their amount of kidney function. Hence, the levels are slightly lower in women due to lesser muscle mass. Most men with normal kidney function have 0.6 to 1.2 milligrams/deciliters (mg/dL) of creatinine. Most women with normal kidney function have between 0.5 to 1.1 mg/dL of creatinine. Choice A is incorrect. This is not the normal lab value range for creatinine in a healthy adult male. Choice B is incorrect. This is not the normal lab value range for creatinine in a healthy adult male. Choice D is incorrect. This is not the normal lab value range for creatinine in a healthy adult male. NCSBN Client Need: Topic: Health Promotion, Subtopic: Renal

Select the parenting style that is accurately paired with one of its advantages. A. The democratic style of parenting: It is relatively quick and easy to solve problems. [36%] B. The autocratic style of parenting: It gives the impression that the family is strong. [18%] C. The permissive style of parenting: It facilitates satisfaction among the members of the family. [37%] D. The laissez-faire style of parenting: It gives the impression that the family is loving. [9%]

Explanation Choice C is correct. The permissive style of parenting, like other parenting styles, has its advantages and its disadvantages. The permissive style of parenting facilitates satisfaction among the members of the family, however, it is disadvantageous because it can lead to undesirable behaviors because young children of the family may need more structure and clearer boundaries to develop appropriate behaviors. Choice A is incorrect. The democratic style of parenting is not a quick and easy way to solve problems; the democratic style of parenting is time-consuming but it also allows all members of the family to have input and a voice that is heard. Choice B is incorrect. The autocratic style of parenting does not give the impression that the family is strong; the impression that it gives is one that the family is rigid and highly structured. Choice D is incorrect. The laissez-faire style of parenting does not give the impression that the family is loving; the impression that it gives is one of being lazy and not caring.

What disorder or disease would you suspect? A. Diabetes [3%] B. Iron deficiency anemia [20%] C. Hypoxia [70%] D. A nail fungus [7%]

Explanation Choice C is correct. The picture shows clubbing of the fingernails. Clubbing, which is also referred to as Hippocratic fingers, indicates that the client has a pulmonary or cardiac condition that causes significant hypoxia over time. Choice A is incorrect. You would not suspect diabetes. Diabetes does not lead to the abnormal appearance of the nails that are shown in the picture; however, lost nails may occur with diabetes as the result of impaired microcirculation, which is a complication of diabetes. Choice B is incorrect. You would not suspect iron deficiency anemia, although another nail abnormality called spooning is associated with this disorder. Choice D is incorrect. You would not suspect a nail fungus because a nail fungus is characterized by discoloration, thickening, and brittleness.

An 86-year-old patient presents with an open wound of the right lower extremity, leucocyte count of 12000/ul, body mass index (BMI) 18.8, and a pre-albumin of 12 mg/dL. Which diet would be most appropriate for this patient? A. Low fiber, low residue [3%] B. Total parenteral nutrition (TPN) with iron supplementation [7%] C. High calorie, high protein [85%] D. Low sodium (heart healthy) [5%]

Explanation Choice C is correct. This patient is showing signs in need of increased protein and caloric intake as evidenced by the elevated WBC count (normal WBC range: 4-11), open wound, low albumin level (normal prealbumin range: 15-36mg/dL), and BMI within the normal range, but very close to underweight (normal BMI range: 18.5-24.9). This patient needs increased protein and caloric intake to fight infection and promote wound healing. Choice A is incorrect. A low fiber/residue diet is indicated in GI conditions such as Crohn's disease, IBD, and diverticulitis. No assessment data is suggesting that the patient is experiencing any GI problems. Choice B is incorrect. No assessment data is suggesting that the patient is deficient in iron. TPN is indicated when a patient has an absorption problem or when oral intake is not possible. The patient should be started on an appropriate high-calorie, high protein diet first before any parenteral nutrition is considered. Choice D is incorrect. No assessment data is suggesting that the patient is experiencing any cardiac issues requiring a low sodium/heart-healthy diet. NCSBN Client Need Topic: GI/Nutrition, Subtopic: Nutrition and oral hydration, illness management

The nurse receives a report on four patients at the start of shift change. Which patient should the nurse see first? A. A patient with a right femur fracture who complains of right leg pain. [15%] B. A patient being treated for pneumonia with scheduled IV antibiotics due. [7%] C. A patient with a history of T6 spinal injury 6 months ago, now presents with a headache. [59%] D. A patient that is 1-day postoperative open cholecystectomy with green drainage. [19%]

Explanation Choice C is correct. This patient may be developing autonomic dysreflexia, a medical emergency. One of the first signs/symptoms of autonomic dysreflexia is a severe, throbbing headache following spinal cord injury (most common in T6 and above). Patients usually develop autonomic dysreflexia one month to one year after their injury. However, it has also been described in the first days or weeks after the original trauma. Objectively, an episode is defined as an increase in systolic blood pressure of 25 mmHg. Patients with this condition will develop dangerously high blood pressure that can result in severe, fatal diseases such as seizures, pulmonary edema, and myocardial infarction. Assessing this patient would be the nurse's highest priority. Choice A is incorrect. Right leg pain is expected in a patient with an acute right femur fracture. The nurse needs to address this patient's pain, but expected outcomes would not be the highest priority. Choice B is incorrect. Scheduled medications would not be a higher priority than the patient showing symptoms of a life-threatening complication. Choice D is incorrect. Green drainage is expected in a patient with an open cholecystectomy due to the green color of bile in the common bile duct. The nurse should assess this patient's drainage and progression of healing, but it would not be the highest priority. NCSBN Client Need Topic: Establishing priorities, medical emergencies, Subtopic: Priorities

A 76-year-old woman with dementia lives in an assisted living facility and often asks, "When will my sister come to visit me this afternoon?" The sister passed away last year. Which is the best response from the nurse? A. "This is so sad. I'm sorry to tell you but your sister died last year." [16%] B. "She won't be coming to visit today." [6%] C. "I understand you want her to visit you. Where did you and your sister grow up?" [77%] D. "Wait and see if she comes to visit today." [1%]

Explanation Choice C is correct. This statement shows compassion toward the patient. Asking where the client and her sister grew up allows her to think about her sister and reminisce without triggering anxiety or agitation. When communicating with a patient who has altered mental status, such as those with dementia, it is essential to foster therapeutic communication. Any statement that may trigger agitation or begin the grieving process should be avoided. Choices A and B are incorrect. These statements may trigger agitation or start the grieving process over again, which can be distressing to the patient. Choice D is incorrect. Saying the sister will not visit or that the patient should "wait and see" gives false hope and is deceptive. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Therapeutic Communication

The primary care physician has ordered an enema for a patient with fecal impaction. The nurse would be correct in placing the client in which position before administration? A. Trendelenburg's position [1%] B. Semi-Fowler's position [1%] C. Left Sims' position [93%] D. Right-side with the head of the bed lowered [5%]

Explanation Choice C is correct. When administering an enema for fecal impaction, the nurse should place the patient in the left Sims' position. This allows the medicine to move naturally throughout the colon. Choice A is incorrect. Trendelenburg's position would not allow the fluid from the enema to flow throughout the colon. Choice B is incorrect. Semi-fowler's position works against gravity when giving an enema. Choice D is incorrect. Lowering the head of the bed is not necessary and would not be appropriate during this procedure. NCSBN client need Topic: Pharmacological Therapies, Medication Administration

Which of the following would be an appropriate question to ask when taking a patient's menstrual history? A. How many sexual partners have you had? [2%] B. Do you have a history of any type of cancer in your family? [7%] C. Do you ever skip periods? [88%] D. Do you use condoms during intercourse?

Explanation Choice C is correct. When obtaining a menstrual history, the nurse should ask for information only related to the menstrual function. This includes information about the last menstrual period (LMP, date of the first day of bleeding), cycle length, and frequency (e.g. 4/28, 4 days of bleeding every 28 days), the heaviness of bleeding (number of tampons used per day), history of intermenstrual bleeding, history of postcoital bleeding (PCB), age of menarche/menopause, and presence or absence of postmenopausal bleeding. Choices A and D are incorrect. These questions are a part of the sexual history, not menstrual history. Questions related to sex or sexually transmitted infections are asked later in the history-taking after the nurse has established a trusting relationship with the patient. Choice B is incorrect. History of cancer in relatives is part of the family history. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Reproductive

Total parenteral nutrition (TPN) is being considered for your client. Your client tells you, "My doctor is thinking about hyperalimentation, and I know nothing about it. Can you tell me what it is?". You should respond to this client's statement with: A. "Your doctor is thinking about total parenteral nutrition and not hyperalimentation." [7%] B. "Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube." [19%] C. "Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line." [74%] D. "You should choose to have enteral nutrition and not accept hyperalimentation." [0%]

Explanation Choice C is correct. You should respond to this client's statement with, "Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line." Parenteral nutrition, which is synonymous with hyperalimentation and IV hyperalimentation, provides the client with complete food when it is indicated for a client such as one who is adversely affected Choice A is incorrect. You should not respond to this client's statement with, "Your doctor is thinking about total parenteral nutrition and not hyperalimentation" because parenteral nutrition is hyperalimentation; parenteral nutrition is synonymous with hyperalimentation and IV hyperalimentation. Choice B is incorrect. You should not respond to this client's statement with, "Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube" because hyperalimentation is parenteral nutrition and not enteral nutrition. Choice D is incorrect. You should not respond to this client's statement with, "You should choose to have enteral nutrition and not accept hyperalimentation" because this is coercive and contrary to the client's right to make an informed decision about any or all care that is being considered.

Which of the following clients is the most likely to receive total parenteral nutrition? A. A client who is adversely affected with dysphagia. [57%] B. A client who is adversely affected with aphasia. [5%] C. A client with a dangerous positive nitrogen balance. [13%] D. A client with a dangerous negative nitrogen balance. [24%]

Explanation Choice D is correct. A client with a dangerous negative nitrogen balance is most likely to receive total parenteral nutrition (TPN). For example, a client who has endured a severe burn injury may have a negative nitrogen balance, which requires the administration of total parenteral nutrition. Amino acids are building blocks of proteins and nitrogen is an essential component of amino acids. Therefore, protein metabolism can be determined by measuring nitrogen balance. Nitrogen balance is given by subtracting nitrogen output from nitrogen input. A negative balance means the amount lost is greater than the amount ingested. A negative nitrogen balance is used to assess malnutrition. Clients with severe negative nitrogen balance will benefit from total parenteral nutrition. Other conditions where total parenteral nutrition is indicated include advanced cancer, advanced acquired immunodeficiency disorder, and severe gastrointestinal disease, which requires complete bowel rest. Choice A is incorrect. A client who is adversely affected with dysphagia would not likely receive total parenteral nutrition. A client who is adversely affected by dysphagia would most likely receive enteral nutrition rather than parenteral nutrition to meet their nutritional needs. Enteral nutrition can be given via tube feedings in the setting of dysphagia. Choice B is incorrect. A client who is adversely affected with aphasia would not likely receive parenteral nutrition. A client who is negatively affected by aphasia has a communication disorder, rather than a nutritional disease or nutritional need. Choice C is incorrect. A client with a dangerous positive nitrogen balance would not be likely to receive parenteral nutrition to meet their nutritional needs. Additional protein is not necessary.

Upon entering the room, the nurse finds the patient lying on the floor appearing unresponsive. Which of the following should the nurse do first? A. Initiate a Code Blue [4%] B. Check if the patient is breathing [36%] C. Assess carotid pulse [24%] D. Shout the patient's name and perform a sternal rub [36%]

Explanation Choice D is correct. Although the patient "appears" unresponsive, the "true unresponsiveness" can only be determined upon adequate assessment. Therefore, the first action the nurse should take is to check if the patient is alert/arousable. The nurse can assess this by shouting the patient's name (assessing for a response to verbal stimulation) and tapping the patient/performing a sternal rub (assessing for a response to physical stimulation). If the patient is unresponsive despite these measures, the nurse should proceed to carry out other interventions. Among the focused assessment options provided, assessing responsiveness is the fastest and the priority action. Choice A, B, and C are incorrect. The nurse should first assess the patient before initiating a code blue (Choice A). Following an assessment of the patient for responsiveness, the nurse should assess respiration/breathing (Choice B). If the patient is found to be unresponsive but breathing, the rapid response should be called. If the patient is not breathing, a code blue should be initiated. Pulse must be assessed; however, the nurse's correct sequence of actions is first to assess the patient's responsiveness, then check for breathing, and then assess for the presence of a pulse. NCSBN Client Need: Topic: establishing priorities, medical emergencies, Subtopic: Prioritization

The nurse is educating a client about newly prescribed aspart insulin. The nurse should instruct the client to self-administer this insulin A. 30-45 minutes before a meal. [12%] B. one hour after a meal. [7%] C. 20-30 minutes before a meal. [19%] D. 10-15 minutes before a meal. [61%]

Explanation Choice D is correct. Aspart insulin is a rapid actin insulin that should be administered to the client no greater than 10-15 minutes prior to the meal or while the client is actively eating. Prior to the administration of this insulin, the client's blood glucose should be obtained. Choices A, B, and C are incorrect. These are inappropriate times to administer aspart insulin. Rapid onset insulins (lispro, aspart, glulisine) are given 10-15 minutes before a meal or while the client is actively eating. Additional Info The three rapid-acting insulins are lispro, aspart, and glulisine. The client needs to take this insulin 10-15 minutes before a meal or while actively eating. A rapid-acting insulin is utilized as correctional insulin before meals to prevent post-prandial hyperglycemia. This type of insulin is commonly loaded into an insulin pump.

A pediatric nurse is preparing to insert a nasogastric tube in an 8-month-old infant. Which nursing action is most appropriate when preparing the infant for the procedure? A. Tightly swaddle the infant using a mummy restraint. [9%] B. Offer a sugar-coated pacifier during the feeding. [4%] C. Measure the NG tube length from the bridge of the nose to the earlobe to the xiphoid process. [47%] D. Measure the NG tube length from the bridge of the nose to the earlobe to the halfway point between the umbilicus and the xiphoid process.

Explanation Choice D is correct. For infants ( less than one year of age), the nurse should measure the distance from the bridge of the nose to the earlobe to a point halfway between the xiphoid process and the umbilicus. This measurement ensures that the tube is long enough to enter the stomach. However, for children older than one year, the NG tube measurement should be from the bridge of the nose to the earlobe to the xiphoid process. Choice A is incorrect. The nurse should loosely swaddle the infant in a mummy restraint. Tightly wrapping the infant causes unwarranted pressure on the infant. Choice B is incorrect. The nurse should offer a plain pacifier to initiate non-nutrient suckling from the infant during feeding. A sugar-coated pacifier increases the infant's blood sugar levels higher than necessary. Choice C is incorrect. Measuring the NG tube length from the bridge of the nose to the earlobe to the xiphoid process is indicated for children older than one year, not infants. Using this measurement for an infant less than a year old would mean that it will be too short of reaching the stomach and may end up in the esophagus. Learning Objective Recognize that the NG tube length measurement differs for infants compared to older children.

This nurse is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates A. a reduction in weight. [2%] B. increased mood lability. [40%] C. an appropriate gait pattern. [8%] D. decreased thoughts of persecution. [50%]

Explanation Choice D is correct. Risperidone is an atypical (second generation) antipsychotic indicated in psychotic disorders such as schizophrenia. If the client reported decreasing thoughts of persecution (and was observed to have fewer thoughts of persecution), this would be a therapeutic effect. Choices A, B, and C are incorrect. Risperidone increases prolactin levels and weight. Atypical antipsychotics, unfortunately, carry this consequential effect that may induce metabolic syndrome. Risperidone would assist in providing mood stability - not increased lability. Adversely, risperidone may cause extrapyramidal side effects causing gait disturbances. Additional Info Second-generation antipsychotics (risperidone, olanzapine, quetiapine, clozapine, lurasidone, ziprasidone, aripiprazole, brexpiprazole) are preferred because of the decreased risk of movement disorders. The concern with SGA's is that they may adversely impact the client metabolically by raising glucose and weight. For a client receiving an antipsychotic, the nurse must always monitor for NMS, which could be fatal.

The clinic nurse is assessing a 12-month old infant and notes that the child's anterior fontanel is still slightly open. The child's mother asks about the finding. What is the nurse's most appropriate response? A. "I will need to call the doctor immediately." [5%] B. "I will do more examinations to the child." [5%] C. "We will need to get an MRI for the child." [1%] D. "These are normal findings for a child his age." [88%]

Explanation Choice D is correct. The anterior fontanel typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanel as still being slightly open is a normal finding requiring no further action. Choice A is incorrect. There is no need to notify the physician, as this is a reasonable assessment finding for the child. Choice B is incorrect. Additional assessments are not needed. Choice C is incorrect. An MRI is not necessary.

The nurse is caring for a client recently diagnosed with ovarian cancer. Which of the following statements, if made by the client, would indicate ineffective coping? A. "I joined a local community support group." [4%] B. "I am unsure of my overall prognosis." [26%] C. "The radiation I receive has made intercourse difficult." [9%] D. "I find myself sleeping more and eating less."

Explanation Choice D is correct. The client states that she is sleeping more and eating less, which are two depressive symptoms that signify ineffective coping and warrant follow-up. Choices A, B, and C are incorrect. Joining a local community support group would signify effective coping as the client is engaging in prosocial behavior. The client being unsure of their overall prognosis would indicate a knowledge deficit - not ineffective coping. Radiation to the pelvic area may make intercourse difficult. This is a common side effect associated with radiation and does not indicate that the client is engaging in ineffective coping. NCLEX Category: Psychosocial Integrity Activity Statement: Coping mechanisms Question type: Analysis Additional Info Ineffective coping needs to be addressed by the nurse at every client encounter. Depressive symptoms such as decreased appetite, avolition, suicidal ideations, sleep changes, and lack of interest are suggestive of ineffective coping and need to be addressed.

Which of the following nursing diagnoses is appropriate for a client who has serum albumin of 2.8 g/dL and serum prealbumin of 17? A. At risk for renal calculi related to the albumin and prealbumin levels. [11%] B. At risk for hyperalbuminemia related to the albumin and prealbumin levels. [18%] C. At risk for hypoalbuminemia related to the albumin and prealbumin levels. [47%] D. At risk for the loss of muscle mass related to the albumin and prealbumin levels.

Explanation Choice D is correct. The nursing diagnosis that is appropriate for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 is "at risk for the loss of muscle mass related to the albumin and prealbumin levels." These levels indicate that the client is affected by low albumin levels (hypoalbuminemia). Hypoalbuminemia can lead to the loss of muscle mass, poor wound healing, and other complications. Choice A is incorrect. "At risk for renal calculi related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17. There is no relationship between albumin and prealbumin levels and the formation of renal calculi. Choice B is incorrect. "At risk for hyperalbuminemia related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 because these levels do not indicate high albumin. Choice C is incorrect. "At risk for hypoalbuminemia related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 because these levels indicate the need for an actual nursing diagnosis, rather than a potential "at-risk" nursing diagnosis.

The charge nurse is making room assignments for four new patients being admitted to the unit. There is one private room available. The patient who should be assigned to the private room is the patient with: A. Seizures [5%] B. Diabetes [1%] C. Hyperthyroidism [2%] D. Clostridium difficile [92%]

Explanation Choice D is correct. The patient with Clostridium difficile (C. diff) should be placed in a private room. This infection is a significant health threat that can lead to death in sick or immunocompromised patients. Clostridium difficile symptoms include persistent watery diarrhea, abdominal pain, nausea, fever, and appetite loss. It is spread quickly from one person to another, so exceptional hand hygiene must be practiced by anyone coming into contact with the patient. Also, personnel must use gloves and gowns when caring for these patients. Full contact-enteric precautions must be practiced. Contact enteric precautions include all contact precautions plus washing hands with soap and water when leaving the patient room. Choices A, B, and C are incorrect. Patients with seizures, diabetes, and hyperthyroidism do not require placement in a private room since they do not pose a threat to others. NCSBN Client Need Topic: Safety and Infection Control; Management of Care; Sub-Topic: Standard Precautions/Transmission-Based Precautions

What tool, or graphic display, that is shown in the exhibit can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with the systems theory? See the exhibit. A. Histogram [19%] B. A scatter-gram [14%] C. Genogram [25%] D. Ecomap

Explanation Choice D is correct. The tool, or graphic display that is shown above is an ecomap or an ecogram. Ecomaps can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with the systems theory. Ecomaps show the interrelationships of individuals, families, and communities with their external environment as well as the forces and relationships that impact the individual, family, and community. Choice A is incorrect. Histograms show statistical data. Choice B is incorrect. Scatter grams show statistical data. Choice C is incorrect. Genograms show medical information and risk factors in a realistic manner. NCSBN Client Need: Topic: Psychosocial Integrity; Sub-Topic: Family Dynamics.

The nurse is triaging phone calls at a local obstetrics clinic. Which client situation requires immediate follow-up? A client reporting A. a decrease in fetal movements of ten in the past hour. [19%] B. irregular, painful contractions that are decreased with repositioning. [2%] C. abdominal cramping following her amniocentesis six hours ago. [14%] D. epigastric pain and a frontal headache not relieved with acetaminophen. [65%]

Explanation Choice D is correct. These symptoms are strongly suggestive of severe pre-eclampsia. Severe pre-eclampsia manifests as epigastric to right-upper quadrant pain suggestive of a liver injury. This, combined with a frontal headache, is highly concerning for severe pre-eclampsia. The client needs to be immediately evaluated as these symptoms may worsen to an eclamptic seizure. Choice A, B, and C are incorrect. A decrease in fetal movements is only concerning if the fetal movements are less than ten in two consecutive hours. Irregular, painful contractions that are decreased with repositioning is false labor, also known as Braxton-hick contractions. This does not require follow-up; the client should be instructed to hydrate and rest. Abdominal cramping that occurs less than 24 hours from the amniocentesis is normal and does not require follow-up. Additional Info Preeclampsia is hypertension (systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg) occurring after 20 weeks of pregnancy in women with previously normal blood pressure, usually accompanied by proteinuria. The client with preeclampsia should be instructed to check her blood pressure and report symptoms that suggest worsening preeclampsia, such as visual disturbance, severe headache, or epigastric pain. Symptoms that suggest fetal compromise, such as reduced fetal movement, also should be taught.

Which procedures below require a sterile technique? Select all that apply. A. Administering medication through a PICC line. [25%] B. Inserting a Foley catheter. [38%] C. Inserting a peripheral IV line. [18%] D. Suctioning an endotracheal tube with in-line suction. [19%]

Explanation Choices A and B are correct. Administering medication in a central line requires a sterile technique. Central lines include PICC lines, Broviaks, IJs, EJs, and other lines that terminate in or just above the patient's heart rather than in a peripheral vein (Choice A). Inserting a Foley catheter should be done using a sterile technique (Choice B). Choice C is incorrect. Inserting a peripheral IV requires a clean technique, not a sterile technique. If you work in a nurse role that allows you to add central lines, such as a PICC, then a sterile technique is required. Choice D is incorrect. It is not necessary to use aseptic technique when using in-line suctioning. This is a closed-loop system, so the endotracheal tube should not be contaminated by the nurse touching it. NCSBN Client Need: Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control

The nurse is assessing a client for bacterial meningitis. Which of the following assessments should the nurse perform? Select all that apply. A. Oral temperature [29%] B. Patellar reflexes [21%] C. Weber and Rinne tests [9%] D. Glasgow Coma Scale [27%] E. Orthostatic blood pressure [12%]

Explanation Choices A and D are correct. Bacterial meningitis manifests as a stiff neck, photophobia, fever, altered mental status, and malaise. The nurse would need to perform an oral temperature and the Glasgow Coma Scale to discern the client's current mental status. Choices B, C, and E are incorrect. Patellar reflexes are not significant in the assessment of a client with bacterial meningitis. Patellar reflexes would be pertinent for a client with a severe electrolyte imbalance such as hypermagnesemia. Weber and Rinne testing are utilized to differentiate between the types of hearing loss and is not pertinent to meningitis. A client with meningitis may have low blood pressure due to the dehydration caused by the fever. However, an orthostatic assessment of their blood pressure is not warranted. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Analysis Additional Info Symptoms of meningitis classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias. The nurse's immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions. Close monitoring of the client's neurological status is the priority, along with prompt administration of prescribed antibiotics after the lumbar puncture. The Glasgow Coma Scale is a quick and effective tool that monitors neurological status. The highest score on the GCS is 15 as it measures the client's best eye-opening, verbal, and motor responses.

The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply. A. Unilateral frontotemporal pain [29%] B. Drowsiness [17%] C. Phonophobia [21%] D. Shuffling gait [5%] E. Dysphagia [2%] F. Vomiting [26%]

Explanation Choices A, B, C, and F are correct. An array of symptoms may be reported for a client experiencing a migraine headache (MH). The most common manifestations associated with an acute migraine headache include Unilateral frontotemporal pain that may be described as throbbing or dull Sensitivity to light (photophobia) and sound (phonophobia) Nausea and/or vomiting Altered mentation (drowsiness) Dizziness, numbness, and tingling sensations Choices D and E are incorrect. An acute migraine headache (MH) would not produce symptoms such as a shuffling gait. This clinical feature would be linked to Parkinson's disease. Dysphagia is not a manifestation associated with an MH. Additional Info Migraine headaches have a complex pathophysiology that is not entirely understood. The current thought process regarding this syndrome is that it is caused by a combination of neuronal hyperexcitability and vascular, genetic, hormonal, and environmental factors. During an acute migraine headache, often the client may feel as though they are experiencing a stroke because of transient facial paralysis and/or numbness that may be experienced.

The nurse is assigned to care for a client with a sodium level of 122 mEq/L. Which assessment findings does the nurse anticipate based on this lab result? Select all that apply. A. Confusion [32%] B. Abdominal cramps [22%] C. Tall, peaked t-waves [10%] D. Hypoactive bowel sounds [15%] E. Nausea and vomiting [21%]

Explanation Choices A, B, and E are correct. A is correct. A sodium level of less than 135 mEq/L is indicative of hyponatremia - too little sodium in the blood. When sodium falls below 125 mEq/L, it is considered "severe" hyponatremia. Confusion is a common neurological symptom of acute or severe hyponatremia. Sodium plays a very important role in the brain, so low levels of this electrolyte can be devastating and produce symptoms ranging from confusion, lethargy, and stupor as well as seizures and cerebral edema B is correct. Abdominal cramps are another symptom of hyponatremia. Since water follows sodium, there are decreased levels of sodium in the blood and decreased fluid. This creates a fluid volume deficit, decreased urine output, muscle spasms, and abdominal cramping. E is correct. Nausea and vomiting are common signs of low sodium levels in the blood or hyponatremia. Choice C is incorrect. Arrhythmias such as tall, peaked t-waves are not indicative of hyponatremia. Rather, the nurse would anticipate seeing arrhythmias when the client has an alteration in their potassium level. Tall, peaked t-waves are characteristic of hyperkalemia. Choice D is incorrect. Hypoactive bowel sounds are not a sign of hyponatremia. Hyperactive bowel sounds rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. Sodium plays an important role in muscle cells as well; when levels are too low, this results in cramping, spasms, and hyperactive bowel sounds. NCSBN Client Need: Physiological Adaptation Topic: Fundamentals of care, Subtopic: Fluid and Electrolyte Imbalances

The nurse is caring for a client who has been prescribed a 14-day course of prednisone. Which of the following statements, if made by the nurse, would be correct? Select all that apply. A. "This medication may make you gain weight." [30%] B. "It is best to take this medication in the morning with food." [27%] C. "If you have further pain, it is okay to take naproxen." [5%] D. "Your blood pressure may decrease while taking this medication." [6%] E. "Do not abruptly stop taking this medication." [32%]

Explanation Choices A, B, and E are correct. Prednisone is a corticosteroid and is indicated for various conditions, including exacerbations of rheumatoid arthritis. The medication potentiates aldosterone causing sodium and water retention, thereby allowing the client to gain weight. Steroids are best taken in the morning with food. If the steroid is taken at nighttime, it may cause insomnia. The cessation of this drug should be tapered to avoid adrenal insufficiency. This medication should not be abruptly discontinued. Choices C and D are incorrect. Corticosteroids should not be combined with NSAIDs such as naproxen because that would hasten the risk of peptic ulcer disease. Blood pressure would increase because of fluid retention. Additional information: Corticosteroids may cause an array of adverse effects while they mitigate inflammation. This includes peptic ulcer disease, edema, hypokalemia, hyperglycemia, and hypernatremia. The client should be educated to maintain a low sodium and high potassium diet while taking prednisone. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: F&E Imbalances

The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply. A. At the start of the interview, inquire about the client's preferred pronoun. [28%] B. Utilize binary gender terms on healthcare documentation. [13%] C. Transgender individuals feel a variance between gender and natal sex. [17%] D. Clients who are transgender may be reluctant to seek healthcare. [23%] E. Inquire about any current or future plans for hormone therapy. [19%]

Explanation Choices A, C, D, and E are correct. The start of the interview should begin with the nurse utilizing the client's preferred name or pronoun. This immediately conveys a caring attitude. Transgender individuals experience an incongruence between the gender they identify with and their natal sex. Negative attitudes towards transgender clients often result in the client feeling disrespected, ultimately creating hesitancy in seeking medical care. It is appropriate to inquire about any current or future plans for hormone therapy as the client may pursue surgical and non-surgical options. Choice B is incorrect. Using binary options on healthcare documentation is not recommended (for example - only female or male choices). Instead, it is recommended that healthcare forms include gender-neutral terminology and not limit options to either female or male. Additional Info For a client who is transgender, it is essential that the nurse convey a caring attitude that fosters respect. Clients who identify as transgender often have negative experiences with nurses and healthcare providers, and this may increase the hesitancy to seek care. The nurse should avoid using terms that are pejorative and includes shemale, he-she, or tranny.

Which of the following are true regarding aortic regurgitation in a pediatric client with complex congenital heart disease? Select all that apply. A. Aortic regurgitation increases preload in the left ventricle. [24%] B. Aortic regurgitation leads to a systolic murmur. [23%] C. Aortic regurgitation causes decreased cardiac output. [31%] D. Aortic regurgitation increases left ventricle end diastolic pressure. [22%]

Explanation Choices A, C, and D are correct. With aortic regurgitation, during diastole, there is a backward flow of blood from the aorta into the left ventricle. The blood should be moving forward into the systemic circulation, but when the heart relaxes, there is a small amount of 'regurgitation,' and the blood trickles back to where it came from. With this increased amount of blood flowing back into the left ventricle, there is increased preload in the left ventricle (A is correct), a decrease in cardiac output (C is correct), and an increased left ventricular end-diastolic pressure (D is correct). Choice B is incorrect. Aortic regurgitation does not cause a systolic murmur but rather a diastolic murmur. The blood backflows across the aortic valve when the heart relaxes during diastole, causing a diastolic murmur. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological Adaptation

Select the sensory impairment that is accurately paired with one of its possible causes or a method for assessing it. Select all that apply: A. Impaired gustatory sensation: Using the Grady Scale [16%] B. Impaired tactile sensation: Diabetes [27%] C. Impaired auditory sensation: Using the Braden Scale [11%] D. Impaired Stereognosia: Alzheimer's disease [27%] E. Impaired Proprioception: Morse Scale [19%]

Explanation Choices B and D are correct. Impaired tactile sensation is often caused by peripheral neuropathy secondary to diabetes. Peripheral neuropathy, a long term complication of diabetes, is characterized by the person's inability to feel things like heat, cold, and a painful stimulus like the prick of a needle in their feet. Impaired stereognosis is the lack of the client's ability to identify an everyday object with tactile sensations and without visual cues. Impaired stereognosis is associated with Alzheimer's disease. Choice A is incorrect. The impaired gustatory sensation is assessed by providing the client with small tastes of sweet, sour, salty, and spicy foods to identify their feelings. Grady Scales are used to determine levels of consciousness and not gustatory sensation. Choice C is incorrect. The impaired auditory sensation is assessed by using an audiometer or a tuning fork. The Braden Scale is used to screen clients for their risk of developing a pressure ulcer. The Braden Scale uses scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing a pressure ulcer. Score categories include 19-23 = no risk; 15-18 = mild risk; 13-14 = moderate risk or less than 9 = severe risk Choice E is incorrect. Proprioception is the sense of the relative position of body segments about other body segments. Examples of tests used to assess proprioception include the Finger-Nose test, the Heel-shin test, and the Thumb finding test. Morse scale is used to assess a patient's risk of falling, not proprioception. It consists of six variables that are quick and easy to score: History of falling - immediate or within 3 months; Secondary diagnosis; Ambulatory aids; Intravenous therapy; Gait and Mental status. NCBSN Client Needs Topic: Psychosocial Integrity, Subtopic: Sensory/Perceptual Alterations.

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include? Select all that apply. A. "This procedure will require you to receive general anesthesia." [6%] B. "You will need to report any shortness of breath following the procedure." [37%] C. "You will need to empty your bladder before this procedure." [19%] D. "After the procedure, a follow-up chest x-ray will be done." [32%] E. "You will need to be on a clear liquid diet one day before the procedure." [6%]

Explanation Choices B and D are correct. These two statements should be included in patient education about thoracentesis. A thoracentesis is a procedure indicated for pleural effusions. The client will need to report any dyspnea after the procedure (Choice B). Shortness of breath following the thoracentesis procedure may indicate either iatrogenic pneumothorax or re-expansion pulmonary edema. Pneumothorax is a common complication following thoracentesis (studies report post-thoracentesis pneumothorax rates ranging from 0 to 19%). The nurse should assess the client carefully for any signs of pneumothorax. Symptoms and signs of a pneumothorax include shortness of breath and reduced or absent breath sounds on the affected side. A more severe pneumothorax, such as tension pneumothorax, may present with obstructive shock. A nurse must notify the physician immediately if any of such signs/symptoms were to occur. A chest x-ray (Choice D) must be completed post-procedure to make sure there is no iatrogenic pneumothorax even if the patient did not show any of the above signs or symptoms. Re-expansion pulmonary edema (REPE) is a complication that occurs after rapid re-expansion of a collapsed lung within 1 to 24 hours. It has been reported <1% in most studies are associated with high mortality. The pathophysiologic mechanism of REPE is unknown. Clinical features vary from cough and chest tightness to acute respiratory failure. Treatment is usually supportive and includes continuous non-invasive positive pressure ventilation or mechanical ventilation in severe cases; some patients also require vasopressors, steroids, and diuretics. Choice A is incorrect. Thoracentesis is a bedside procedure and can be completed under local anesthesia. Choice C is incorrect. It would be inappropriate to advise that the client empty their bladder before the procedure. Choice E is incorrect. Finally, a clear liquid diet one day before the procedure would be appropriate for a colonoscopy - not for a Thoracentesis. Additional Info

The nurse is preparing to obtain a prescription for Rho(D) Immune Globulin. The nurse understands that this medication may be administered through which route? Select all that apply. A. Intradermal [5%] B. Intramuscular [43%] C. Subcutaneously [15%] D. Oral [4%] E. Intravenous [33%]

Explanation Choices B and E are correct. Most commonly, Rho(D) Immune Globulin is given intramuscular (IM); however, if the client has a patent peripheral vascular access device and the prescriber agrees, the medication may be given intravenously to minimize the discomfort associated with IM injections. Choices A, C, and D are incorrect. The only route to administer Rho(D) Immune Globulin is IM or IV. Additional Info Rh immune globulin (RhoGAM) prevents the production of anti-Rho(D) antibodies in Rh-negative women who have been exposed to Rh-positive blood by suppressing the immune reaction of the Rh-negative woman to the antigen in Rh-positive blood; preventing antibody response and thereby preventing hemolytic disease of the newborn in future Rh-positive pregnancies. Type and antibody screening of the mother's blood and cord blood type of the newborn should be performed to determine the need for the medication. The mother must be Rh-negative and negative for Rh antibodies. The newborn must be Rh-positive. If the fetal blood type after the termination of pregnancy is uncertain, the medication should be administered. The newborn might have a weakly positive antibody test if the woman received Rho(D) immune globulin during pregnancy. The drug is administered to the mother, not the infant. The deltoid muscle is recommended for intramuscular administration. The medication may be given intravenously if prescribed.

You are caring for a client who is in the burn unit with severe burns. Since this is your first client contact with this person, you introduce yourself and tell the client that they will be taken care of by you for this shift. The client greets you and states, "Why am I getting this stuff that is hanging up here?" as they are pointing to the ordered total parenteral infusion. You should: A. Respond to the client stating, "I don't think you should be getting this. I am going to call your doctor." [1%] B. Respond to the client stating, "This is total parenteral nutrition and you are getting it because your nutritional status is impaired as the result of your burns". [94%] C. Respond to the client stating, "This is total parenteral nutrition and you are getting it because your nutritional status is impaired because you aren't eating enough." [5%] D. Respond to the client stating, "I don't think you should be getting this. I am going to turn it off now." [0%]

xplanation Choice B is correct. You would respond to the client stating, "This is total parenteral nutrition, and you are getting it because your nutritional status is impaired as the result of your burns." Many clients with severe burn injuries get parenteral nutrition to meet the nutritional demands of burn injuries like those associated with a negative nitrogen balance, which indicates a deficiency of protein. Choice A is incorrect. You would not respond to the client stating, "I don't think you should be getting this. I am going to call your doctor." You should know why the client is getting this nutritional treatment, and you should be able to explain the purpose of this dietary treatment to the questioning client. Choice C is incorrect. You would not respond to the client stating, "This is total parenteral nutrition, and you are getting it because your nutritional status is impaired because you aren't eating enough." You should know that the reason for the parenteral nutrition is not related to the client's oral input of food and fluids but, instead, another reason. Choice D is incorrect. You would not respond to the client stating, "I don't think you should be getting this. I am going to turn it off now." You should know the reason for the parenteral nutrition and you should be able to explain the purpose of this nutritional treatment to the questioning client. You would also not discontinue the parenteral nutrition without a doctor's order.

The nurse is caring for a patient who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse? Select all that apply. A. Administer prescribed carbamazepine. [14%] B. Notify the rapid response team (RRT). [21%] C. Obtain a prescription for lorazepam. [18%] D. Loosen any restrictive clothing. [31%] E. Review the client's most recent phenytoin level. [14%]

xplanation Choices B, C, and D are correct. A client experiencing status epilepticus will require aggressive treatment as this is a persistent seizure that continues to recur despite treatment or a seizure that has lasted more than five minutes. The RRT should be notified as this is a medical emergency and requires evaluation by the RRT team. Obtaining a prescription for a parenteral benzodiazepine such as lorazepam is appropriate and should be completed by the nurse. Benzodiazepines are key in terminating a seizure. Central to caring for a client with a seizure is, placing them on their side and loosening any restrictive clothing. Choices A and E are incorrect. The client will likely require antiepileptic drugs to prevent future seizures; however, this is not the priority as carbamazepine is a maintenance drug used for seizure prevention. Additionally, reviewing drug levels that may assist in determining why a seizure may have occurred is not a priority during this medical emergency. The normal phenytoin level is 10-20 mcg/mL. Additional Info Status epilepticus is a medical emergency. This is when a seizure has lasted five or more minutes. Additionally, status epilepticus is defined as repeated seizure activity over the course of thirty minutes. During an acute seizure, the nurse should place the client on their side, loosen restrictive clothing, and anticipate a prescription for a parenteral benzodiazepine such as lorazepam. Status epilepticus requires more aggressive medical treatment, such as high-dose benzodiazepines or barbiturates.

Which type of care environment is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues? A. A milieu environment [84%] B. A locked environment [2%] C. One employing mindfulness therapy [13%] D. One employing universal seclusion [1%]

Explanation Choice A is correct. A milieu environment is the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that the clients with emotional and behavioral problems can concentrate their energies and thoughts on the things impacting them rather than external stressors that have been eliminated from the environment of care. Choice B is incorrect. A locked environment is not the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Clients are placed in a locked environment only when all alternative measures are not possible or practical, and the client is in grave danger to themselves and others, as consistent with the regulations of the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations. Choice C is incorrect. Although mindfulness therapy is used for a large number of clients with different psychiatric mental health disorders in a wide variety of care environments, mindfulness is not the environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Choice D is incorrect. An environment that employs universal seclusion for all clients is not the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Seclusion and restraint are a last resort and, as such, they are not employed unless all other measures to protect the client and others from imminent harm have not been effective, as consistent with the regulations of the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations.

The nurse is assisting a client with their insulin pump. The nurse understands which insulin is loaded into the pump? A. Rapid acting [34%] B. Short acting [31%] C. Intermediate acting [18%] D. Long acting

Explanation Choice A is correct. A rapid-acting insulin is the only insulin used in insulin pumps. A rapid-acting insulin is correctional insulin and should be appropriately dosed 10-15 minutes before a client's meal or while actively eating. Choices B, C, and D are incorrect. The advantage of an insulin pump is that a client may dose themselves with insulin without having to use syringes and needles. Most pumps operate with the client having the ability to input their blood glucose for a preprogrammed amount of insulin. Finally, users may also give themselves appropriate bolus doses if they eat additional carbohydrates. Additional Info The three rapid-acting insulins are lispro, aspart, and glulisine. The client needs to take this insulin 10-15 minutes before a meal or while actively eating. A rapid-acting insulin is utilized as correctional insulin before meals to prevent post-prandial hyperglycemia. This type of insulin is commonly loaded into an insulin pump.

he nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)? A. Alprazolam [37%] B. Rifaximin [25%] C. Lactulose [14%] D. Spironolactone [24%]

Explanation Choice A is correct. Benzodiazepines should be avoided for a client with hepatic encephalopathy. These medications can worsen the sensorium of a client, therefore, making the client at high risk for falls and injury. Choices B, C, and D are incorrect. Rifaximin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is the main staple in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels. Spironolactone is the diuretic of choice for a client's ascites because it removes the fluid but holds on to the potassium. Hypokalemia should be avoided because it contributes to the production of ammonia. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Adverse Effects/Contraindications/Side Effects/Interactions Question type: Knowledge/comprehension Additional Info Safe client care is emphasized when caring for a client with hepatic encephalopathy. This involves aggressive fall precautions, frequent reorientation, and administering prescribed medications. Frequent neurological assessments should be completed to determine the improvement or worsening of the client's mentation and overall function.

The nurse is caring for a 3-year-old boy that is admitted for pneumonia. The nurse notices that the boy is always irritable and anxious. Which action by the nurse is most appropriate? A. Give the child some molding clay. [40%] B. Play cards with the child. [3%] C. Give the child a piece of paper and some crayons. [49%] D. Play "Hangman" with the child. [8%]

Explanation Choice A is correct. Children release their anxiety by pounding, hitting, running, punching, or shouting. Giving the child some molding clay allows the child to pound and hit the clay flat, helping him relieve his anxiety. Choice B is incorrect. Playing cards with the child is inappropriate since cards are not yet suitable for his age. Choice C is incorrect. Paper and crayons are not yet suitable for a preschooler to relieve his anxiety. Choice D is incorrect. Playing "Hangman" with the child is inappropriate and not yet suitable for his age. This play is suitable for school-aged children.

The nurse is caring for a child diagnosed with a coarctation of the aorta who is scheduled for a surgical repair tomorrow morning. When the nurse auscultates the child's lung sounds, the nurse notes diffuse crackles and rales throughout the lung fields. The nurse interprets this assessment as which of the following? A. Pulmonary congestion [75%] B. Foreign body aspiration [1%] C. Pneumonia [17%] D. Systemic congestion

Explanation Choice A is correct. Crackles and rales are indicative of pulmonary congestion. Because this child has coarctation of the aorta, there is too much blood backing up in the lungs. It is impossible for the left side of the heart to move sufficient blood forward working against the coarctation. This causes the back up of blood in the lungs, and therefore the crackles and rales are indicative of pulmonary congestion. Choice B is incorrect. Crackles and rales are not indicative of foreign body aspiration. The child presenting with a foreign body aspiration would be coughing, choking, have difficulty breathing and speaking, and might start to turn cyanotic. When the nurse auscultates that patient's lungs, she would hear wheezing and stridor instead of crackles and rales. Choice C is incorrect. While rales can sometimes be auscultated in pneumonia, crackles are not usually present. Instead the nurse would auscultate rhonchi. Additionally, because of the congenital heart defect coarctation of the aorta, the nurse knows that blood will be backing up in the lungs leading to pulmonary congestion. She does not suspect pneumonia in this patient. Choice D is incorrect. Crackles and rales are not indicative of systemic congestion, rather they are a sign of pulmonary congestion. Signs of systemic congestion would include splenomegaly, JVD, weight gain, edema, and ascites. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic care, comfort, Pediatrics - Cardiac

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury? A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor. [75%] B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor. [8%] C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position. [5%] D. Hold the gait belt, and lower the client to the floor by using a narrow base of support. [12%]

Explanation Choice A is correct. For a client who is ambulating, the nurse should always be slightly behind the client and positioned on the affected (weaker) side. If a client starts to fall, the nurse should hold the gait belt, try to extend one leg, let the client slide against the leg, and gently lower the client to the floor, protecting the head. The nurse can help prevent client injury by maintaining a wide base of support. Choices B, C, and D are incorrect. These actions place the nurse at risk for injury. The nurse should never let go of the gait belt. Additionally, instructing the client to fall to the floor in a side-lying position will not mitigate injury. To prevent injury, whenever the nurse is engaged in physical care with a client, the nurse should maintain a broad base of support and engage their thigh muscles. Additional Info Trying to stop or minimize a fall can cause the nurse injury. An approach that may be used to minimize injury during a fall is where the nurse assumes a wide base of support with one foot in front of the other, thus supporting the client's body weight. Allowing the client to slide down one leg can reduce injury to the client.

The nurse is caring for a client newly diagnosed with mastitis. The nurse anticipates a prescription for which medication? A. Cephalexin [77%] B. Acyclovir [8%] C. Fluconazole [8%] D. Imiquimod [7%]

Explanation Choice A is correct. Mastitis is commonly caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. Thus, antibiotics such as cephalexin are effective in the treatment of mastitis. Choices B, C, and D are incorrect. Mastitis responds to antibiotic therapy. Acyclovir is an antiviral and not indicated in the treatment of mastitis. Fluconazole is an antifungal. Imiquimod is indicated in the treatment of genital warts and certain skin cancers. Additional Info Mastitis is often caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. The bacteria are most often carried on the skin of the mother or in the mouth or the nose of the newborn. The organism enters through an injured area on the nipple, such as a crack or blister. The primary medical treatment is antibiotics and continued emptying of the breast. Comfort measures during mastitis include applying moist heat or ice packs, breast support, bed rest, fluids, and analgesics.

This nurse is caring for a client who is receiving prescribed pregabalin. It will be a therapeutic finding if the client reported less of which of the following? A. Neuropathic pain [73%] B. Cravings for cigarettes [10%] C. Binge eating [6%] D. Depressive symptoms [11%]

Explanation Choice A is correct. Pregabalin is indicated in the treatment of neuropathic pain, certain anxiety disorders, and focal seizures. This controlled substance is five times more potent compared to gabapentin. Choices B, C, and D are incorrect. Pregabalin does not reduce the craving for cigarettes or mitigate binge eating. Pregabalin is an effective agent for social anxiety but not depression. Additional information: Pregabalin is indicated for neuropathic pain and disorders causing neuropathic pain such as fibromyalgia, herpes zoster, and phantom limb pain. This medication's common side effects include dizziness, drowsiness, and respiratory depression when combined with other CNS depressants. Considering the CNS depressant effects of this medication, the nurse should institute fall precautions for the client. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Expected Actions/Outcomes

The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain? A. Respiratory rate [74%] B. Blood Pressure [19%] C. Pulse [5%] D. Temperature [2%]

Explanation Choice A is correct. Respiratory rate is essential to monitor when a cervical spinal cord injury is sustained. The upper cervical spinal nerves innervate the diaphragm to control breathing. Thus, specific injuries to the cervical spinal cord could be catastrophic. Choices B, C, and D are incorrect. These assessments are not a priority to monitor because the cervical spinal cord nerves innervate the diaphragm to control breathing. So these vital signs would not be directly relevant. Additional Info The upper cervical spinal nerves innervate the diaphragm to control breathing. Monitor all individuals with a spinal cord injury for respiratory problems, diaphragmatic breathing, and for diminished or absent reflexes in the airway (cough and gag). Until a cervical spinal cord injury can be excluded, the client should have immobilization via a cervical spinal cord collar.

The nurse has provided medication instruction to a client who has been prescribed metformin. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? A. "This medication may cause me to have bloating or loose stools." [42%] B. "I will need to take my blood glucose prior to taking this medication." [50%] C. "If I eat fewer carbohydrates in a day, I should skip a dose." [2%] D. "The goal of this medication is to increase my hemoglobin A1C." [5%]

Explanation Choice A is correct. The most common side-effect associated with Metformin is gastrointestinal upset. This side-effect typically occurs at the start of the therapy and subsides over time. To minimize these effects, the client should take this medication with meals, or they may be prescribed the extended-release form. Choices B, C, and D are incorrect. Metformin does not cause hypoglycemia, and the client is not required to take their blood glucose before a dose. Other classes of anti-diabetic drugs such as sulfonylureas and insulin cause hypoglycemia. A blood glucose check is recommended before taking bolus doses of insulin. Because Metformin does not cause symptomatic hypoglycemia, clients should not skip the drug based on their carbohydrate intake. The goal of Metformin is to decrease the hemoglobin A1C - not an increase. Learning Objective Recognize that the most common side effect of Metformin is gastrointestinal upset which can be minimized by taking the drug with meals. While hypoglycemia is a frequent side effect with sulfonylureas, Metformin, when taken by itself, does not induce hypoglycemia. Additional Info Metformin is the first-line therapy for type II diabetes mellitus. Metformin is efficacious in having clients lose weight and decrease their hemoglobin A1C. The most common side-effect associated with Metformin initiation is gastrointestinal side effects such as bloating, diarrhea, nausea, or vomiting. The nurse should counsel the client that these side effects are transient and may be lessened by taking the medication with food. Metformin should not be taken within 48 hours of a contrast procedure because should contrast-related nephrotoxicity occur, Metformin metabolites accumulate and cause lactic acidosis.

The nurse is working in a palliative care unit. The client she is taking care of is on a fentanyl patch and is in the late stages of cancer. During her shift, the client dies. Which of the following can be done by the nurse? A. Remove the patch and throw it away in a proper receptacle. [88%] B. Remove the patch and tell a family member to return the patch to the pharmacy. [2%] C. Leave the patch in place and have the morgue staff remove it. [10%] D. Tell the family to take off the patch and throw it away themselves. [0%]

Explanation Choice A is correct. The nurse should remove the patch and dispose of it in a safe manner. Choice B is incorrect. Once a patch is used, it cannot be returned to the pharmacy. Choice C is incorrect. The morgue staff is not trained to remove the fentanyl patch, nor do they have the proper knowledge in handling and disposing of opioid medications. Choice D is incorrect. The patient's family is not trained, nor do they have the proper knowledge in handling and disposing of opioid medications, especially a fentanyl patch.

The nurse is reviewing the client's laboratory data. Which current prescription should the nurse clarify with the primary healthcare provider (PHCP)? See the image below. A. Dextrose 5% in water (D5W) [50%] B. Dexamethasone [16%] C. Digoxin [29%] D. Vitamin D

Explanation Choice A is correct. This client has hyponatremia, and infusing more water into the client (D5W) would drive down the sodium further. D5W is a hypotonic solution (although it goes in isotonic, it then becomes hypotonic) and raises blood glucose while restoring intracellular volume. D5W provides an individual with water and some calories. Prolonged use of this fluid may cause hyperglycemia and hyponatremia. Choices B, C, and D are incorrect. This client has hyponatremia, and the other labs are within normal limits. Dexamethasone would raise sodium levels because of its effect on aldosterone. Digoxin alters the sodium-potassium pump, and the electrolyte concerning this medication is potassium. Vitamin D would be concerning if an alteration in the calcium was evident, which is not the case. Additional Info

The nurse is observing a student perform a physical assessment. It will demonstrate appropriate technique if the student assesses for stereognosis by instructing the client to A. close their eyes, place an object in their hand, and ask them to identify it. [46%] B. close their eyes with feet together, arms at the sides, and observe for loss of balance. [24%] C. walk on their heels and then on their tiptoes for at least ten feet. [5%] D. touch the tip of their nose with the index finger and return the arm to an extended position. [24%]

Explanation Choice A is correct. This is the correct assessment technique for stereognosis. The concept of stereognosis is for the individual to recognize (or perceive) an object without using vision. For example, having a client close their eyes and placing a toothbrush in their hand can accurately state that it is a toothbrush. Choices B, C, and D are incorrect. The Romberg test is demonstrated in Choice B. This test identifies if the client can maintain balance with closed eyes. A loss of balance makes this test positive and would result in the client falling to the side. Normally the client does not break their stance. Having the client walk on their tiptoes and heels for at least ten feet, along with touching the tip of their nose with the right index finger, is an appropriate assessment for cerebellar function. Additional Info Stereognosis is a sense that allows a person to recognize the size, shape, and texture of an object. For an individual with dementia, this is likely to be failed because of the inability to recognize (or use) the object. This would be agnosia.

The nurse is caring for a client involuntarily admitted to the behavioral health unit. The client has been mailed a package. The nurse should perform which action? A. Provide the client with the package [29%] B. Open the package to review its content [40%] C. Provide the package upon discharge [16%] D. Determine if the sender is the client's next of kin

Explanation Choice A is correct. Under the patient bill of rights, the client has a right to confidentiality and privacy. The nurse should not open postal packages prior to giving them to the client. If the nurse is concerned that the client could be mailed something harmful, the nurse should request that they open the package up in front of them. Choices B, C, and D are incorrect. All of these options violate the client's right to privacy and confidentiality. Mail tampering is a crime, and the nurse is obligated to provide the client with dignity, privacy, and respect. This includes timely delivery of their mail. Additional Info The Patient Bill of Rights To courtesy, respect, dignity, and timely, responsive attention to his or her needs. To receive information from their physicians and to have opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing treatment. Patients should be able to expect that their physicians will provide guidance about what they consider the optimal course of action for the patient based on the physician's objective professional judgment. Ask questions about their health status or recommended treatment when they do not fully understand what has been described and have their questions answered. To make decisions about the care the physician recommends and to have those decisions respected. A patient who has decision-making capacity may accept or refuse any recommended medical intervention. To have the physician and other staff respect the patient's privacy and confidentiality. To obtain copies or summaries of their medical records. To obtain a second opinion. To be advised of any conflicts of interest their physician may have in respect to their care. To continuity of care. Patients should be able to expect that their physician will cooperate in coordinating medically indicated care with other health care professionals and that the physician will not discontinue treating them when further treatment is medically indicated without giving them sufficient notice and reasonable assistance in making alternative arrangements for care.

The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important? A. Assess the patient's mental status [46%] B. Provide oral hygiene [0%] C. Keep accurate intake and output measurements [50%] D. Reduce stress and discomfort [3%]

Explanation Choice A is correct. When caring for a patient with SIADH, the nurse should carefully monitor for changes in mental status and level of consciousness. SIADH causes excess free water retention and hyponatremia, which may lead to confusion and behavioral changes. These alterations in the mental state may also lead to seizures. Patients with SIADH may also experience cardiac dysrhythmias. Choice B is incorrect. Nurses should always assist their patients in caring for their oral hygiene, especially when suffering from SIADH. However, providing oral health is not the priority nursing intervention in this situation. Choice C is incorrect. SIADH creates alterations in a patient's fluid and electrolyte balance, and thus nurses must keep accurate accounts of all intakes and outputs. However, monitoring the patient's mental status is more important. Choice D is incorrect. While reducing pain and stress is an essential part of nursing care, monitoring a patient with SIADH for mental status and LOC changes is a higher priority. NCSBN client need Topic: Physiologic Adaptation, Illness management

The health fair nurse is evaluating patients for osteoporosis. Which of the following patients is at the greatest risk of developing this disease? A. A 27-year-old woman who jogs three times a week. [2%] B. A 60-year-old woman who has smoked cigarettes for 40 years. [79%] C. A 70-year-old man who suffers from alcoholism. [17%] D. A 25-year-old man with asthma.

Explanation Choice B is correct. A 60-year-old woman who smokes cigarettes is at risk of developing osteoporosis. Osteoporosis occurs more frequently in women than men and occurs more regularly in patients who smoke, consume alcohol, and are over the age of 50. Genetics also plays a role. Choice A is incorrect. Women's bone density is at its highest at age 30 and begins to deteriorate afterward. Exercise is considered a protective effect against this disease. Choice C is incorrect. While men can be diagnosed with osteoporosis, it is much less common. The 60-year-old woman would be much more likely to develop this illness than her male counterpart. Choice D is incorrect. A 25-year-old male with asthma is not at an increased risk of developed osteoporosis. NCSBN client need Topic: Maintenance and health promotion, health screening

The nurse is caring for a client with an arterial blood gas (ABG) of pH = 7.33; PaO2 = 95 mm Hg; PaCO2 = 53 mm Hg; HCO3- = 24 mEq/L; SaO2 = 96%. Which prescription should the nurse request from the primary healthcare provider (PHCP)? A. Supplemental oxygen [35%] B. Bronchodilator [48%] C. Regular insulin [5%] D. Sodium polystyrene [11%]

Explanation Choice B is correct. A bronchodilator would benefit this client as the arterial blood gas demonstrates respiratory acidosis. The accumulation of CO2 causes respiratory acidosis, and a bronchodilator such as formoterol or albuterol would help with exhaling the excessive CO2. Choices A, C, and D are incorrect. This client is oxygenating just fine, and supplemental oxygen would be inappropriate. The normal PaO2 is 80 - 100 mm Hg, and the normal oxygen saturation is 95% or greater. Regular insulin would be a treatment for metabolic acidosis that is caused by diabetic ketoacidosis, this is not shown in the ABG. Sodium polystyrene is a medication that treats hyperkalemia that would not be found with respiratory acidosis. Additional Info The causes of respiratory acidosis include pulmonary emphysema, atelectasis, and hypoventilation. Treatment is aimed at the underlying cause, including instructing the client to turn, cough, and breathe deeply. An incentive spirometer may also be used to help treat respiratory acidosis.

The nurse is caring for a male patient diagnosed with gout. The medication prescribed for reducing uric acid levels is: A. Colchicine [21%] B. Allopurinol [73%] C. Non-steroidal anti-inflammatory drugs [3%] D. Corticosteroids [3%]

Explanation Choice B is correct. Allopurinol. Gout is a disease that develops when high uric acid levels form crystals that accumulate in joints. Patients with gout are usually obese men with a family history of gout. The patient with gout often complains of intense pain in the feet that occurs at night. The prescriber will usually order medications to lower uric acid levels after the severe attack subsides. Choices A, C, and D are incorrect. Colchicine, NSAIDs, and corticosteroids are medications that the patient will take during the first 24 hours after gout begins to relieve the acute pain. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Expected Actions/Outcomes; Musculoskeletal

The nurse in the recovery room is anticipating the arrival of a client from the OR after a thyroidectomy. The nurse is aware of the potential complications of such an operation and prepares all necessary equipment, except: A. Sphygmomanometer and stethoscope [6%] B. ECG machine [33%] C. Additional pillows and sandbags [48%] D. Oxygen, suction equipment, intubation supplies, and tracheostomy set [13%]

Explanation Choice B is correct. Although an ECG machine may be needed for checking the patient's heart rhythm, it is not necessary as of this moment. Choice A is incorrect. The nurse should keep a sphygmomanometer and stethoscope nearby to assess the patient's blood pressure frequently. The blood pressure cuff can also be used to evaluate for hypocalcemia by checking for a positive Trousseau's sign. Choice C is incorrect. The nurse should keep pillows and sandbags at the bedside to use them as splints for the client's neck. The nurse needs to immobilize the client's neck to prevent damage/strain on his suture line. Choice D is incorrect. The nurse needs to have all of this emergency airway equipment at the bedside in the event of respiratory obstruction caused by edema of the glottis.

The nurse is caring for a child who is immunocompromised and diagnosed with varicella. The nurse should expect a prescription for which medication? A. Amoxicillin-Clavulanate [8%] B. Acyclovir [76%] C. Doxycycline [8%] D. Azithromycin [8%]

Explanation Choice B is correct. Antiviral medications such as acyclovir or valacyclovir are commonly used to treat varicella infections. While these medications are not routinely prescribed for all infections, immunocompromised individuals are at risk for varicella complications, including meningitis. Thus, antiviral medications would be appropriate in this circumstance. Choices A, C, and D are incorrect. These medications are antibiotics and are not clinically indicated in the treatment of varicella. Additional Info Varicella is a highly contagious viral infection spread by aerosolized droplets, contaminated surfaces, and direct contact with the lesions. Treatment is symptomatic with prescribed acetaminophen and therapeutic baths with cool water and uncooked oatmeal or baking soda. If a client is admitted with varicella, they should be isolated using airborne and contact precautions until the lesions have crusted.

The nurse is performing a respiratory assessment of a patient with abnormal breathing patterns. The patient's breathing is rhythmic, yet has periods of apnea. The nurse would be most correct in charting this breathing style as: A. Neurogenic hyperventilation [3%] B. Cheyne-Stokes [71%] C. Apneustic [22%] D. Ataxic

Explanation Choice B is correct. Cheyne-Stokes is rhythmic breathing with periods of apnea usually caused by a metabolic issue or neurological problem. Choice A is incorrect. Neurogenic hyperventilation is regular and fast and indicates an issue in the pons or midbrain. Choice C is incorrect. Apneustic breathing is irregular and presents with apnea at the end and beginning of each breath. Choice D is incorrect. Ataxic breathing is utterly irregular in rate, depth, and rhythm. NCSBN client need Topic: Physiologic Integrity, Reduction of Risk potential Additional Info

The ICU nurse is taking care of a client who sustained a head injury due to a motorcycle accident. In the morning, the client is responsive to pain and assumes a decorticate position. After 4 hours, which assessment would indicate to the nurse that the client needs immediate intervention? A. The client displays purposeful movement when the nurse performs a sternal rub. [5%] B. The client extends his arms and legs when the nurse rubs his sternum. [58%] C. The client flails his arms and legs when a noxious stimulus is applied. [35%] D. The client moves his fingers upon request. [2%]

Explanation Choice B is correct. Extension of the arms and legs indicates decerebrate posturing, an indication of increased intracranial pressure. The nurse should intervene when the client displays this. Choice A is incorrect. Purposeful movement when a painful stimulus is applied indicates an improvement in the client's condition. Choice C is incorrect. Aimless flailing of the client's extremities would mean an improvement in the client's condition and would not need an intervention from the nurse. Choice D is incorrect. This means that the client can follow simple commands. This indicates that the client's condition is improving and would not need any intervention from the nurse.

The nurse is evaluating a patient with symptoms of metabolic acidosis. Which of the following is not a cause of metabolic acidosis? A. Severe diarrhea [12%] B. Hyperventilation [70%] C. Starvation [10%] D. Diabetes mellitus

Explanation Choice B is correct. Hyperventilation due to asthma, anxiety, or high altitude may lead to respiratory alkalosis. Unless it is quickly corrected, acidosis and alkalosis can have severe or fatal consequences. The nurse needs to understand possible causes and identify symptoms as soon as possible. Note: Acidosis and alkalosis are not diseases, but instead signs of an underlying disorder. The primary treatment of acid-base disorders is targeted at correcting the underlying cause. Choices A, C, and D are incorrect. These are all possible causes of metabolic acidosis. Therefore, not the answers to the question. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by A. excessive red blood cell production that requires therapeutic blood donation. [15%] B. hemolysis of fetal erythrocytes resulting from incompatibility between maternal and fetal blood [74%] C. inability to metabolize amino acid phenylalanine, causing high levels of phenylalanine. [3%] D. erythrocytes become shaped like a sickle and sensitive to hypoxia. [8%]

Explanation Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, which is a severe anemia that results in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility. Choices A, C, and D are incorrect. Polycythemia vera is characterized by excessive red blood cell production that requires therapeutic blood donation. The inability to metabolize amino acid phenylalanine, causing high levels of phenylalanine characterizes phenylketonuria. Sickle cell anemia fits the description of erythrocytes becoming shaped like a sickle and sensitive to hypoxia. Additional Info The use of Rho(D) immune globulin (RhoGAM) to prevent the mother from forming antibodies against Rh-positive blood has greatly decreased the incidence of erythroblastosis fetalis.

Your client is experiencing severe, acute anxiety prior to a scheduled endoscopy procedure. Which of the following medications is most likely to be ordered by the physician? A. Oxycodone [3%] B. Midazolam [50%] C. Clonazepam [38%] D. Haloperidol [9%]

Explanation Choice B is correct. Midazolam (Versed) is a benzodiazepine used for acute anxiety attacks. Midazolam is preferred in this setting because of its rapid onset (2 to 5 minutes after IV administration) and short duration of action (3 to 8 hours). It can be administered intravenously or orally. Given these benefits, midazolam would be the most useful for the patient experiencing an acute anxiety attack before or during endoscopic procedures, or before surgery. Additional benefits of midazolam during procedures are sedation and amnesia. Midazolam as continuous IV infusion is also used in sedating mechanically ventilated patients in critical care settings. The nurse should keep flumazenil as an antidote ready in case severe respiratory depression occurs with benzodiazepines. Choice A is incorrect. Oxycodone is an opioid pain medication. This is prescribed for severe pain. It is not indicated for the patient experiencing an acute anxiety attack. Choice C is incorrect. Clonazepam is a long-acting benzodiazepine often used in anxiety attacks after a traumatic event, panic disorders, or generalized anxiety disorder. Your client has pre-procedural anxiety and, therefore, does not need a long-acting anxiolytic. Your client needs an anxiolytic with a rapid onset of action and short duration. Choice D is incorrect. Haloperidol is an antipsychotic and is often used in mental health settings to address acute and severe agitation/aggression associated with psychiatric disorders (schizophrenia, substance intoxication). It would not be useful for a patient experiencing pre-procedural acute anxiety. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological therapies

Where would the nurse expect to assess tympany when performing percussion on a patient with ascites? A. Sides of abdomen [30%] B. Over the top of the abdomen [42%] C. Below the umbilicus [9%] D. Over the umbilicus [18%]

Explanation Choice B is correct. Patients with ascites present with tightly stretched skin over a rounded, distended abdomen due to accumulation of fluid in the peritoneal cavity typically related to liver disease, portal hypertension, tuberculosis, or nephritic syndrome. Upon percussion of the abdomen, the nurse would expect to note tympany over the top of the abdomen where the intestines float, and dullness over the sides where fluid settles (fluid shifts when the patient is turned to the side). Choices A, C, and D are incorrect. Dullness is percussed over the sides of the abdomen where fluid settles (fluid shifts when the patient is turned to the side) Learning objective: Abdominal percussion can help identify ascites. A tympanic note over the top of the abdomen and dullness over the sides is a characteristic finding. When there is a tense ascites, a fluid thrill may also be elicited.

The nurse in the ER is caring for a child that is having an acute asthma attack. The nurse is interviewing the patient's mother to determine activities that precipitate the child's asthma attacks. Which statement by the mother would warrant the nurse to provide further teaching? A. "My son loves playing the trumpet in his grade school band." [14%] B. "My son rakes leaves every Saturday afternoon to help out with the work at home." [67%] C. "My son participates in extracurricular activities." [9%] D. "My son swims 5 laps, twice a week, with his friends" [11%]

Explanation Choice B is correct. Raking leaves exposes the child to allergens from the trees. The nurse should advise the mother to find another activity for her child. Choice A is incorrect. Musical instruments, such as a trumpet, help improve lung function. Choice C is incorrect. Extracurricular activities are encouraged to promote maturity in the child. Choice D is incorrect. Swimming is an excellent exercise for the lungs.

The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Isoniazid [20%] B. Colchicine [36%] C. Allopurinol [15%] D. Warfarin [29%]

Explanation Choice B is correct. The initial treatment for acute pericarditis includes NSAIDs or colchicine. Colchicine may be combined with an NSAID in the treatment of pericarditis. Choices A, C, and D are incorrect. Isoniazid is indicated for pulmonary tuberculosis, allopurinol is indicated for gout, and warfarin is an anticoagulant used to prevent thrombosis. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected Actions/Outcomes Question type: Knowledge/comprehension Additional Info Acute pericarditis can be managed with NSAIDs, colchicine, or glucocorticoids. Major side effects of colchicine include gastrointestinal upset, which may be mitigated by taking this medication with food. Colchicine may be added to NSAID therapy adjunctively to maximize treatment response.

You are the nursing supervisor in a long-term care facility. One of the major considerations that you apply into your practice is strict infection control prevention measures because you are knowledgeable about the fact that the normal aging process is associated with the deterioration of the body's normal defenses. Which theory of aging supports your belief that strict infection control prevention measures are necessary? A. The Programmed Longevity Theory [5%] B. The Immunological Theory of Aging [90%] C. The Endocrine Theory [2%] D. The Rate of Living Theory

Explanation Choice B is correct. The theory of aging that supports your belief that strict infection control prevention measures are necessary is the 'Immunological Theory of Aging'. The 'Immunological Theory of Aging' states that aging leads to the decline of the person's defensive immune system and the decreased ability of the antibodies to protect us against infection. Programmed theories assert that the human body is designed to age and there is a certain biological timeline that bodies follow. All of these theories share the idea that aging is natural and "programmed" into the body. Error theories, such as the 'Rate of Living Theory', assert that aging is caused by environmental damage to the body's systems, which accumulates over time. Choices A, C, and D are incorrect. The 'Programmed Longevity theory of aging' states that genetic instability and changes occur such as some genes turning on and off lead to the aging process; the 'Endocrine Theory of aging' states that aging results from hormonal changes and the biological clock's ticking; and 'Rate of Living Theory' states that one's longevity is the result of one's rate of oxygen basal metabolism. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation

The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse. The nurse should take which priority action based on the tracing? A. Start cardiopulmonary resuscitation (CPR) [51%] B. Perform immediate defibrillation [44%] C. Initiate intravenous (IV) access [2%] D. Review the client's most recent electrolyte levels [2%]

Explanation Choice B is correct. This concerning tracing on the electrocardiogram is ventricular fibrillation. Ventricular fibrillation is electrical chaos in the ventricles that produces no cardiac output. The priority is to defibrillate the client immediately according to ACLS protocol. If a defibrillator is not readily available, high-quality CPR must be initiated and continued until the defibrillator arrives. Choices A, C, and D are incorrect. CPR is a critical intervention in the management of ventricular fibrillation. However, it does not prioritize defibrillation. Defibrillation has been proven to terminate this lethal arrhythmia and is essential to perform. IV access is essential to obtain to deliver medications such as epinephrine, but restoring normal cardiac output will not come through IV access. Ventricular fibrillation may be caused by various conditions, including severe electrolyte disturbances. However, this client is in distress, and assessment is not the priority. Additional Info Ventricular fibrillation causes the ventricles to merely quiver, consuming a tremendous amount of oxygen. There is no cardiac output or pulse and therefore no cerebral, myocardial, or systemic perfusion. This rhythm is rapidly fatal if not successfully ended within 3 to 5 minutes. The essential treatment of ventricular fibrillation is defibrillation, and CPR is merely a life-sustaining measure that should be used until a defibrillator arrives.

The nurse is administering palivizumab to a 3 month old infant being discharged from the Neonatal Intensive Care Unit. Which of the following images correctly demonstrates the appropriate site for the injection?

Explanation Choice B is correct. This image shows an injection being given in the vastus lateralis. This is the preferred injection site for IM injections in infants less than 12 months of age. The injection should be administered into the bulkiest part of the vastus lateralis muscle. Choice A is incorrect. This image shows an injection being given in the dorsogluteal site. This is not recommended in infants less than 12 months of age, but can be used in adult patients. The dorsogluteal site is above an imaginary line between the greater trochanter and the posterior superior iliac crest. The injection is administered laterally and superior to this imaginary line. Choice C is incorrect. This image shows an injection being given in the deltoid. This is not recommended in infants less than 12 months of age, but can be used in adult patients. The injection site is in the middle of the deltoid muscle, about 2.5 to 5 cm (1 to 2 inches) below the acromion process. Choice D is incorrect. This image shows an injection being given in the ventrogluteal site. This is not recommended in infants less than 12 months of age, but can be used in adult patients. To administer an injection in the ventrogluteal muscle, first, find the trochanter and then find the anterior iliac crest. Place the palm of your hand over the trochanter with your fingers extending towards the anterior iliac crest and give the injection between the knuckles on your index and middle fingers. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Pediatric - Respiratory

While performing a cardiovascular assessment on an infant at 2 hours of life, you note the following: Normal sinus rhythm HR = 178 Systolic murmur +1 pedal pulses +3 radial pulses 5 second capillary refill No edema What is the priority nursing action after this assessment? A. Continue to monitor [22%] B. Notify the health care provider [68%] C. Administer PRN acetaminophen [0%] D. Re-evaluate the patient in one hour [9%]

Explanation Choice B is correct. This patient is displaying signs and symptoms of congenital heart disease; specifically coarctation of the aorta. Even if you did not know which congenital heart disease they may have, you would be expected to know that the healthcare provider needs to be notified of these symptoms. Your patient is in normal sinus rhythm and has a normal heart rate for the newborn age group. The systolic murmur, the gradient in peripheral pulses, and 5 second capillary refill are all abnormal. The murmur indicates that there is an opening somewhere in the heart where there should not be. This could be an ASD, VSD, or one of the bypasses in fetal circulation (the ductus arteriosus or foramen ovale) may not have closed on their own. The gradient in pulses indicates that there is more blood flow in the top half of the body than in the lower half - this is what points to coarctation of the aorta. A capillary refill time of 5 seconds is the last abnormal sign for this patient. Capillary refill should be less than 3 seconds in a newborn - delayed capillary refill indicates poor perfusion and must be addressed quickly. It is important to recognize that these are abnormal signs and symptoms and need to be reported to the health care provider for prompt intervention. Choices A, C, and D are incorrect. These are not the priority action. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn

A client has newly prescribed varenicline for smoking cessation. The nurse instructs the client that they should take this medication how many days before their planned quit date? A. 14 days [46%] B. 7 days [34%] C. 2 days [4%] D. 21 days [15%]

Explanation Choice B is correct. Varenicline is a medication intended to assist an individual with smoking cessation. This medication should be started seven days before the planned quit date and gradually increased in dose. The medication may be prescribed for twelve weeks to ensure appropriate abstinence. Choices A, C, and D are incorrect. The client should start the medication seven days before the planned quit date. Additional Info A combination of medications and behavioral therapy works best for smoking cessation rather than either treatment alone. Most smoking cessation medications work by reducing nicotine withdrawal and craving. Medicines for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion. Varenicline is a preferred option for most patients. Varenicline is administered as an oral pill. It works by relieving nicotine withdrawal symptoms and blocking the smoking-related reward feeling. For a patient taking varenicline, starting the medication one week before quitting cigarettes is recommended. The patient may continue the treatment for up to twelve weeks. The most common side effect of varenicline is nausea. Adversely, neuropsychiatric effects such as vivid dreams, depression, and suicidal ideation have been reported. Varenicline should not be used in patients with a history of suicidal ideation or unstable psychiatric illness. Nicotine replacement therapy (NRT) is available in various forms ( patch, lozenge, gum, inhaler, and nasal spray). NRT may be prescribed as a first-line choice based on the client's preference. Adverse effects include insomnia and vivid dreams. Bupropion is less effective compared to NRT or varenicline. However, it's a preferred choice for patients with depression because bupropion can work as an anti-depressant. Additionally, bupropion promotes weight loss and may be preferred for clients wishing to avoid weight gain following smoking cessation. Bupropion reduces the seizure threshold, and consequently, it is contraindicated in patients with a seizure disorder. Ongoing counseling should be pursued to enhance a patient's success at smoking cessation.

The nurse is discussing acute osteomyelitis with staff members. The nurse would be correct to state which of the following? A. "IV antibiotic therapy is typically given for seven to fourteen days." [41%] B. "The most common cause of acute osteomyelitis is a virus." [11%] C. "A significant fever is present with typically greater than 101° F." [35%] D. "Petechiae on the affected extremity is a common finding."

Explanation Choice C is correct. Acute osteomyelitis is manifested by localized bone pain, a fever, and swelling to the affected extremity. Choices A, B, and D are incorrect. Osteomyelitis is a serious infection that requires six to twelve weeks of antibiotic therapy. The most common cause of osteomyelitis is staphylococcal bacteria. Petechiae are small reddish-purplish dots usually found with some conditions, such as a fat embolism. This is not a manifestation associated with osteomyelitis. Additional Info Osteomyelitis may occur post-operatively after any orthopedic surgery. Further, this may happen if the client has an external fixation device. Finally, osteomyelitis may develop in conjunction with severe cellulitis. Magnetic Resonance Imaging (MRI) is often useful in the diagnosis of osteomyelitis along with its symptoms of localized bone pain, fever, and swelling of the extremity.

A hospice nurse is taking care of a client with pancreatic cancer. The client's breathing becomes progressively deeper with periods of apnea. What is this breathing pattern called? A. Kussmaul [21%] B. Ataxic [5%] C. Cheyne-Stokes [71%] D. Biot's

Explanation Choice C is correct. Cheyne-Stokes respirations are characterized by irregular respirations with periods of crescendo and decrescendo, with periods of apnea. It usually indicates brain dysfunction. Choice A is incorrect. Kussmaul respiration is characterized as deep, labored breathing that is associated with diabetic ketoacidosis. Choice B is incorrect. Ataxic breathing is similar to agonal breathing, which is characterized by completely irregular breathing with irregular periods of apnea. There is no pattern with this type of breathing, which is the case with Cheyne-Stokes respiration. Choice D is incorrect. Biot's breathing is similar to Cheyne-Stokes in that it is pattern-like. Biot's breathing can be characterized by short, shallow breaths followed by irregular periods of apnea. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Alterations in Body Systems, Respiratory System Additional Info

The nurse has received the following prescriptions for newly admitted clients. The nurse should first A. irrigate a wound for a client with a stage III pressure ulcer. [2%] B. complete pin care for a client with a halo fixation device. [4%] C. administer diazepam for a client with delirium tremens (DTs). [73%] D. insert an indwelling urinary catheter for a client with retention. [21%]

Explanation Choice C is correct. Delirium tremens (DTs) is a severe form of alcohol withdrawal. This prescription should be implemented immediately as the risk of seizure activity is quite significant. Choices A, B, and D are incorrect. These prescriptions require quite a bit of time and are low priority compared to the client experiencing an acute threat of a seizure. The nurse must prioritize actions based on acuity and time necessary to complete each task. Activities related to discharge are low priority and any dressing changes are also a low priority. Additional Info Delirium tremens (DTs) is the most severe form of alcohol withdrawal. Manifestations of DTs include disorientation, hyperthermia, psychomotor agitation, hypovolemia, hallucinations, hypertension, and seizure activity. To prevent seizure activity and mitigate agitation, benzodiazepines are commonly used. Maintenance dosing of benzodiazepines may be used along with PRN dosing for additional mitigation of symptoms. DTs occur within 48 to 96 hours following the last alcoholic drink.

The home health nurse is talking to a client with iron-deficiency anemia. Which meal plan would indicate to the nurse that the client understood her discharge instructions? A. Roast beef, gelatin salad, green beans, and peach pie [53%] B. Chicken salad, coleslaw, French fries, ice cream [2%] C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisins [42%] D. Pork chops, creamed potatoes, corn, and coconut cake [3%]

Explanation Choice C is correct. Foods that are high in iron are egg yolks, wheat bread, carrots, green leafy vegetables, and raisins. This is an optimal meal for the client to increase his dietary iron intake. Choice A is incorrect. Roast beef is high in iron; however, the other dishes accompanying the meal are low in iron. Choice B is incorrect. Chicken and green leafy vegetables are rich in iron; however, french fries and ice cream have low nutritional value. Choice D is incorrect. Pork chops contain high iron. Potatoes, corn, and coconuts, however, contain low iron.

The nurse is counseling a client with congestive heart failure (CHF) about newly prescribed bumetanide. The nurse determines that the teaching has been effective when the client plans to A. increase their daily intake of protein. [1%] B. record their daily urinary output. [12%] C. weight themselves daily. [70%] D. take their blood pressure and pulse daily. [16%]

Explanation Choice C is correct. For a client with congestive heart failure prescribed bumetanide, a loop diuretic, the client should verbalize the importance of weighing themselves daily. Their daily weight should be obtained in the morning after the first void. Choices A, B, and D are incorrect. Increasing the intake of protein while taking a loop diuretic is not necessary. It is potassium that should be increased because bumetanide is a potassium-wasting diuretic. Recording the client's urinary output is not necessary nor an accurate way to determine the client's fluid status. Intake and output are a crude way of determining a client's fluid status. Blood pressure should be monitored while a client takes this medication - but not daily. Additionally, this medication does not impact the pulse and thus is irrelevant. Additional Info Loop diuretics act primarily along the thick ascending limb of the loop of Henle, blocking chloride and, secondarily, sodium resorption. Loop diuretics are also thought to activate renal prostaglandins, which dilate the blood vessels of the kidneys, the lungs, and the rest of the body (i.e., reduction in renal, pulmonary, and systemic vascular resistance). The hemodynamic effects of loop diuretics are a reduction in both the preload and central venous pressures (which are the filling pressures of the ventricles). These actions make them useful in treating the edema associated with heart failure, hepatic cirrhosis, and renal disease. Examples of loop diuretics include - bumetanide, ethacrynic acid, furosemide, and torsemide.