Archer Review 6b

The school nurse is assessing a 12-year old boy who came into her office for a nose bleed. She notices several bruises on his back and forearms that are in various stages of healing. When she asks the boy about them, he is very deceptive. The nurse notifies child protective services of her suspicion. The next day, the boy's mother comes to the nurse's office and yells at her for calling child protective services. Which of the following responses is most appropriate? A. "I am required by law to report any suspected violence." [98%] B. "You should have thought about this before you abused your son." [1%] C. "I'm so sorry. Please don't take this out on me." [1%] D. "Don't talk to me about this. I don't want to see you." [0%]

Explanation Choice A is correct. The nurse is a mandatory reporter of any suspected violence and is required by law to report her suspicions. Parents may become upset and confront the nurse when these allegations come to light, but that should not stop the nurse from saying what she has seen. The nurse should remain calm when the parent confronts her and she should state that she is required to report any suspected violence. Choice B is incorrect. This statement is an accusation and could further aggravate the mother. The nurse does not know that she abused her son and should not make statements such as this one. The nurse needs to remain calm and stick to the fact that she is required to report any suspected violence. Choice C is incorrect. This statement is based on emotion, not fact. The nurse should not apologize to the mother. Instead, she should remain calm and inform her that she is required to report any suspected violence. Choice D is incorrect. This is not an appropriate statement. By telling the mother, she doesn't want to see her; she could further aggravate the mother and place herself in a dangerous situation. The nurse needs to remain calm and stick to the facts. If she feels like she is not safe with the mother, she should move to an open area where others are nearby. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Abuse & Neglect

The nurse is talking to a patient that just had an ileostomy created a month ago. He states that he is a bit embarrassed by the odor that the ostomy is producing. The nurse investigates the food that the client consumes and initiates further health teaching when the client mentions the following menu: A. Spinach [19%] B. Parsley [6%] C. Yogurt and buttermilk [25%] D. Eggs

Explanation Choice D is correct. Eggs, fish, onions, cabbage, and some greens produce foul-smelling stools. Clients are advised to avoid these foods to eliminate foul odors in their ileostomy. Choice A is incorrect. Spinach is a deodorizing food for clients with an ileostomy. Choice B is incorrect. Parsley is a deodorizing food for clients with an ileostomy. Choice C is incorrect. Yogurt and buttermilk are deodorizing food for clients with an ileostomy.

The nurse is assessing a patient with suspected neurological issues. The patient's speech is delivered with normal rhythm but filled with words that do not form any meaningful statements. The patient is also unable to write or repeat back words and does not appear to understand the nurse's instructions or questions. The nurse would recognize these symptoms as: A. Broca's aphasia [24%] B. Global aphasia [20%] C. Expressive aphasia [23%] D. Wernicke's aphasia

Explanation Choice D is correct. This patient is showing symptoms consistent with Wernicke's aphasia, which refers to a lesion in the left posterior superior temporal lobe/language area of the brain. It is characterized by the ability to produce verbal language but mix similar sounding words so that speech is often incomprehensible. Reading, writing, oral comprehension, and repetition are affected. Choice A is incorrect. Broca's aphasia refers to a lesion in the anterior language area of the brain (motor speech cortex). Verbal comprehension remains intact, but the patient is usually unable to form words at all and has difficulty with writing and repetition. Choice B is incorrect. Global aphasia is the most common and severe type of aphasia due to a large lesion that damages both the anterior and posterior language areas of the brain. Speech, comprehension, repetition, reading, and writing are absent or severely impaired in global aphasia. Choice C is incorrect. Expressive aphasia describes the same deficits as noted above for Broca's aphasia. NCSBN Client Need Topic: Adult health - Neurological, Subtopic: Illness management, pathophysiology

You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice that the nursing assistant on the unit is escorting this client to the telephone. After you talk to the client about the telephone privileges, the nursing assistant tells you that, "It is unfair for this client to not be able to use the telephone when other clients are free to do so." What should you determine about this nursing assistant's comment? A. This comment clearly shows that the nursing assistant is favoring this client. [5%] B. This comment indicates that the nursing assistant is ensuring equal rights. [24%] C. This comment indicates that the nursing assistant is preventing discrimination. [5%] D. This comment indicates a learning need relating to the therapeutic milieu.

Explanation Choice D is correct. This comment indicates a learning need relating to the therapeutic milieu for this nursing assistant. A therapeutic milieu has consistent boundaries that are adhered to by all members of the healthcare team. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors, such as changing and inconsistent rules and boundaries that have been eliminated from the environment of care. Choice A is incorrect. This comment indicates something else, although, at first glance, it may appear that the nursing assistant is favoring this client by not adhering to the client's established boundaries. Choice B is incorrect. Although at first glance, it may appear that the nursing assistant is ensuring the equal rights of all clients, this action indicates that this nursing assistant is not adhering to the client's established boundaries. Choice C is incorrect. Although at first glance, it may appear that the nursing assistant is preventing discrimination and ensuring the equal rights of all clients, this action indicates that this nursing assistant is not adhering to the client's established boundaries.

You are a nurse in the emergency department of a local hospital. You are caring for a 60-year-old man with a sudden-onset headache that he describes as, "The worst headache of my life." You know that red flags for this problem include: Select all that apply. A. Confusion [34%] B. Nuchal rigidity [31%] C. Hypotension [16%] D. Age greater than 50 years [19%]

Explanation Choices A, B, and D are correct. Red flags for headaches include confusion, nuchal rigidity, age greater than 50 years (or less than five years). Other signs and symptoms that should trigger a warning about the severity of headaches include fever, weight loss, papilledema, disordered motor function, onset with exertion, and change in frequency, severity, or other features. Any combination of these symptoms may indicate increased intracranial pressure and/or brain hemorrhage. Choice C is incorrect. Hypertension, rather than hypotension, is another red flag. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Medical Emergencies, Neurologic

Which of the following foods can the nurse recommend to parents of toddlers who have constipation? Select all that apply. A. Mac and cheese [6%] B. Whole grains [44%] C. Whole milk [16%] D. Black beans [35%]

Explanation Choices B and D are correct. Whole grains are rich in fiber and an excellent choice for toddlers who have constipation (Choice B). Black beans are high in fiber and are an excellent choice for toddlers who have constipation (Choice D). Choice A is incorrect. For toddlers with constipation, the nurse needs to recommend foods that are high in fiber. Mac and cheese are not high in fiber. In general, dairy is not a food group that is recommended for constipation. Choice C is incorrect. Whole milk is not high in fiber and therefore is not a good recommendation. In general, dairy is not a food group that is recommended for constipation. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Pediatrics - Gastrointestinal

The primary healthcare provider (PHCP) prescribes 1 mg/kg of enoxaparin for a client weighing 132 pounds. How many mL should the nurse give to the client when the prefilled syringe reads 60mg/0.6mL. Fill in the blank. 0.6 mL

Explanation The dose ordered / dose on hand formula x volume = will be used to solve this problem. First, convert the weight from pounds to kilograms. 132 pounds / 2.2 = 60 kilograms Next, determine the prescribed amount 1 mg x 60 kilograms = 60 mg Finally, take the dose ordered / dose on hand x volume 60 mg / 60 mg x 0.6 mL = 0.6 mL Additional Info Enoxaparin is available in prefilled syringes in a range of dosage forms and strengths, for example 40 mg in 0.4 mL. The air bubble should not be expelled from prefilled syringes, as this is designed to remain next to the plunger to ensure that the whole dose is administered.

The nurse is preparing ephedrine nasal spray for a client in the medical ward. The nurse understands that ephedrine is contraindicated in which of the following patients? A. A client with pheochromocytoma [35%] B. A client with bronchial asthma [26%] C. A client with allergic rhinitis [15%] D. A client with hypotension due to sepsis [24%]

Explanation Choice A is correct. A pheochromocytoma is a small vascular tumor of the adrenal medulla, causing irregular secretion of epinephrine and norepinephrine. Clinical manifestations of pheochromocytoma include paroxysmal hypertension, episodic headache, sweating, and palpitations. Ephedrine is an adrenergic agonist and is often, used as a nasal decongestant. It is also used to prevent low blood pressure during spinal anesthesia. In pheochromocytoma, there is a systemic overload of catecholamines. Ephedrine is contraindicated in clients with pheochromocytoma because it may lead to further exacerbation of adrenergic activity which could be fatal. Choice B is incorrect. Ephedrine is indicated in bronchial asthma as it stimulates the dilation of the bronchial muscles by activating the beta receptors found in the bronchus. Choice C is incorrect. Ephedrine is used in allergic rhinitis because it may serve as a nasal decongestant due to its vasoconstrictive effects. Choice D is incorrect. Adrenergic agonists such as ephedrine are used in hypotension due to their sympathomimetic effects on the body leading to increased blood pressure. Ephedrine is often used to prevent low blood pressure during spinal anesthesia.

The nurse is assessing her prenatal client for sexually transmitted infections by looking for risk factors. Which of the following are risks of acquiring an STI? Select all that apply. A. Low socioeconomic status [19%] B. A monogamous relationship [3%] C. A past history of working in the sex industry [26%] D. Illicit drug use [23%] E. History of cancer [2%] F. Previous history of STIs [27%]

Explanation Choices A, C, D, and F are correct. Low socioeconomic status, a history of being a sex worker, illicit drug use, and a previous history of sexually transmitted infections (STIs) are all risk factors for contracting STIs. Other factors include numerous sexual partners and being unmarried. Choices B and E are incorrect. A history of cancer and exclusive relationships are not examples of risk factors for acquiring an STI. NCSBN client need Topic: Health Promotion and Maintenance, High-Risk Behaviors

Which actions are recommended guidelines when providing foot care for residents in a long-term care facility? Select all that apply. A. Bathe the feet thoroughly in a mild soap and tepid water solution. [27%] B. Soak the feet in warm water and bath oil. [6%] C. Dry the feet thoroughly, paying close attention to the area between the toes. [30%] D. Use an alcohol rub if the feet are dry. [0%] E. Use an antifungal foot powder if necessary to prevent fungal infections. [24%] F. Cut the toenails at the lateral corners when trimming the nails.

Explanation Choices A, C, and E are correct. The following are recommended guidelines for foot care: Bathe the feet thoroughly in mild soap and a lukewarm water solution Dry the feet thoroughly, including the area between the toes Use antifungal foot powder, if necessary, to prevent fungal infections Choice B is incorrect. The nurse should avoid soaking the feet. Choice D is incorrect. Moisturizer should be used, not alcohol if the feet are dry. Choice F is incorrect. The nurse should avoid digging into or cutting the toenails at the lateral corners when trimming the nails. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort; Foot Care

Which of the following examples of documenting care for a patient with appendicitis and order for 10 mg morphine IV every 3-4 hours follows the recommended guidelines? Select all that apply. A. 3/13/20 0945 Morphine 10mg administered IV. The patient's response to pain appears to be exaggerated. M. Dean. RN [4%] B. 3/13/20 0945 Morphine 10 mg administered IV. The patient seems to be comfortable. M. Dean. RN [9%] C. 3/13/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Dean. RN [32%] D. 3/13/20 0945 Patient reports 7 out of 10 pain in the right lower quadrant. Morphine 10 mg administered IV. M. Dean. RN [23%] E. 3/13/20 0945 Morphine IV 10 mg will be administered to the patient every 3 to 4 hours. M. Dean. RN [11%] F. 3/13/20 0945 Patient states she doesn't want pain medication despite the return of pain. MD notified. M. Dean. RN [21%]

Explanation Choices C, D, and F are correct. The nurse should enter information in a complete, accurate, concise, current, and factual manner for each entry. The medication record is a legal document. Recording each dose of medication as soon as possible after it is given provides a documented history that can be consulted if there are any questions about whether the patient received the drug. Nurses should never record medication before it is given. The name of the medication, dosage, route of administration, time administered, and the name of the person giving the medication is noted in the record. If a patient refuses to take a drug that is considered essential to the therapeutic regimen, this should be reported promptly. It is necessary to determine the reason for the refusal and to help the patient accept the needed drugs. If the patient refuses the drugs after a reasonable effort has been made to administer the medication, it is unwise to continue urging the patient. Patients have a legal right to refuse therapy, so nurses must recognize and respect that right. Describe the refusal to take the prescribed medication and how the situation was managed in the patient's record, and report the refusal according to the facility's policy. Choices A, B, and E are incorrect. These answer choices do not reflect how documentation of the refusal of medication should be done correctly. Choice A: The RN documents that "The patient's response to pain appears to be exaggerated." This is subjective and a reflection of the nurse's opinion. The best practice is to only document objective, clear, direct information. The nurse should not chart their opinion about the client's response to pain. Choice B: The RN documents that "The patient seems to be comfortable." This is another example of the nurse documenting their opinion. The best practice is to only document objective, clear, direct information. The nurse should not chart their opinion about the client's response to pain. A more appropriate example would be: "The client reports that their pain was reduced to a score of 2 out of 10 after administration of the morphine." Choice E: In this example, the nurse is documenting actions they plan to take in the future by saying, "Morphine IV 10 mg will be administered to the patient every 3 to 4 hours. M. Dean. RN." Documentation should never take place before the intervention is completed.

The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina. Place the priority actions in the correct order. Stay with the client and call for help Apply pressure to lift the presenting fetal part Place the client in Trendelenburg position Administer oxygen Prepare for delivery

Stay with the client and call for help Apply pressure to lift the presenting fetal part Place the client in Trendelenburg position Administer oxygen Prepare for delivery Explanation The priority nursing action is to stay with the client and call for help. This is a medical emergency, and the nurse must remain with the client to ensure safety. Next, the nurse needs to quickly wear gloves and apply pressure to the presenting fetal part. This will lift the fetus off the prolapsed umbilical cord and restore blood flow to the fetus. The nurse cannot let go until the health care provider arrives to deliver the fetus. Next, the nurse needs someone to place the client in Trendelenburg's position. This will assist with keeping the presenting fetal part off of the umbilical cord, so that blood flow to the fetus continues. Next, the nurse needs someone to administer oxygen to the mother via a simple face mask at 8-10 L/min. This will optimize oxygenation to the fetus. Lastly, the nurse needs to prepare for the immediate delivery of the fetus. This is the only way to resolve this medical emergency. Additional Info Variable decelerations suggest an interruption of oxygenation at the level of the umbilical cord, where cord vessels may be compressed. Physiologically, the thin-walled umbilical vein is occluded during umbilical cord compression in umbilical cord prolapse or oligohydramnios. The nurse should execute actions immediately, such as summoning help and relieving pressure off the umbilical cord. Having the client reposition is essential; the nurse may have the client assume positions such as knee-chest position, Trendelenburg position and hips elevated with pillows, with side-lying position maintained.

Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating? A. A toddler playing with his 9-year-old brother's construction set. [73%] B. A 5-year-old eating yogurt for a snack. [1%] C. An infant asleep in her crib without a blanket. [22%] D. A 3-year-old drinking a glass of juice. [4%]

Explanation Choice A is correct. A young child may place small or loose parts of toys in his mouth. A toy that is safe for a 10-year-old child could be deadly for a toddler. Choice B is incorrect. 5-year-old eating yogurt is not a safety concern. Choice C is incorrect. An infant sleeping in an empty crib is not a safety concern. According to the American Academy of Pediatrics, blankets and pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Several infants die each year while sleeping, and the cause is attributed to SIDS, suffocation, entrapment, or strangulation. Blankets increase the risk of all these four reasons. Choice D is incorrect. A 3-year-old drinking a glass of juice is not a safety concern. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Choking Hazards

The nurse is caring for a patient who intentionally overdosed on amitriptyline. What action should the nurse prioritize? A. Obtain a 12-lead electrocardiogram [73%] B. Request a prescription to consult psychiatry [3%] C. Determine the reasoning for the overdose [8%] D. Establish a therapeutic relationship [15%]

Explanation Choice A is correct. Amitriptyline is a tricyclic antidepressant (TCA) and, when taken in excess, may cause cardiac dysrhythmias. The most severe cardiac effects seen with TCA toxicity include QT interval prolongation, torsade de pointes, and sudden cardiac death. The essential action is to address the patient's physiological needs by assessing if the patient is having catastrophic dysrhythmias. Choices B, C, and D are incorrect. A consultation with psychiatry is highly likely considering the intentionality of the overdose. However, the priority is the patient's physiological needs. Determining the reasoning for the overdose and establishing a therapeutic relationship is not a priority over the patient's physical needs. Additional information: TCAs are indicated for depressive and obsessive disorders. Considering they are profoundly anticholinergic; the toxicity of these medications may be fatal. Drugs in this class include amitriptyline, nortriptyline, imipramine. Clinical features of an overdose include dysrhythmias, hypotension, confusion, and hyperthermia. The nurse should immediately determine hemodynamic stability through continuous cardiac and blood pressure monitoring. Test taking strategy: While answering such priority questions, one should apply Maslow's hierarchy and address the client's physiological needs first.

You are working in a community clinic. You are giving instructions to a 72-year-old man who was diagnosed today with early bilateral senile cataracts. You know that the man understood your instructions when he says: A. "I may have to quit driving until I get the cataracts treated." [80%] B. "I am going to miss being able to read the morning newspaper." [9%] C. "My wife will have to pick out my clothes since I won't be able to see the colors." [6%] D. "I will have to be careful since my eyes won't move together." [5%]

Explanation Choice A is correct. As individuals age, they are at increased risk for senile cataracts. During the early stages of this condition, diminishing distance vision is the highest risk for older adults. The nurse must caution the patient that the ability to see signs when driving will present a significant risk. Choice B is incorrect. Usually, near vision is not affected by these cataracts. Choice C is incorrect. In the early stages, color vision is not usually affected, although there may be changes as the condition progresses. Choice D is incorrect. Extraocular movements are not affected by senile cataracts. The cranial nerves that control eye movements are not affected by cataracts. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Developmental Stages and Transitions, Visual/Auditory; Growth & Development

This nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following findings would indicate a therapeutic response? A. Decreased abdominal cramping [39%] B. Absence of nausea and vomiting [20%] C. Decreased urinary retention [19%] D. Less burning with urination [21%]

Explanation Choice A is correct. Dicyclomine is an antispasmodic agent used in the treatment of irritable bowel syndrome (IBS). This may provide the client with relief from the spasms and cramping associated with IBS. Choices B, C, and D are incorrect. Dicyclomine is not indicated for the treatment of nausea, vomiting, urinary retention, or dysuria. This medication has anticholinergic properties and may cause dizziness, xerostomia, nausea, and/or blurred vision. Additional Info Dicyclomine is typically dosed on a PRN basis for a client experiencing abdominal cramping. This medication is antispasmodic and is often utilized for irritable bowel syndrome (IBS). The client should be educated on the common adverse effect of dizziness which may increase a client's risk for falls.

The nurse has just finished receiving the shift report from the night nurse. Which patient should the nurse see first? A. A 90-year-old patient with pneumonitis who is getting restless but is currently afebrile. [63%] B. A 20-year-old patient with influenza who is febrile and complaining of a headache. [13%] C. A 40-year-old patient with hemothorax in the right lung who is attached to a chest drainage system that is tidaling. [16%] D. A 27-year-old with sinusitis having green drainage from his nose.

Explanation Choice A is correct. Elderly clients do not show "typical" symptoms of pneumonia, such as fever. The nurse should watch for altered levels of consciousness or behavioral changes as these may indicate decreased oxygenation to the brain from sepsis. Therefore, the nurse should see this client first. Choice B is incorrect. The client is showing the expected signs and symptoms of influenza. This patient does not require the nurse's immediate attention. Choice C is incorrect. Tidaling in a water-seal system is expected; therefore, the nurse would not need to see this client first. Choice D is incorrect. Drainage from the nose in a patient with a sinus infection is expected. Additional Info

The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following? A. Prepares to administer intravenous valproate. [56%] B. Places the client in a lateral position. [16%] C. Activates the rapid response team (RRT). [23%] D. Loosens any restrictive clothing.

Explanation Choice A is correct. Intravenous benzodiazepines such as lorazepam, diazepam, or midazolam should be promptly administered to this client. These medications help terminate the seizure. IV antiepileptics such as valproate, topiramate, phenytoin should be used secondary only after the acute seizure has terminated. Thus, a medication used to prevent seizure reoccurrence rather than medication used to terminate a seizure is not the priority. Choices B, C, and D are incorrect. Status epilepticus is a medical emergency and notifying the RRT is appropriate considering the severity of this situation. Loosening restrictive clothing and placing the client on their side will help decrease the risk for aspiration and injury. Additional information: Status epilepticus is a medical emergency. This is when a seizure has lasted five or more minutes. Additionally, status epilepticus is defined as two or more continuous seizures without complete recovery. 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 diazepam. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Medical Emergencies

Which of the following medications does the obstetrics nurse expect to be ordered for the patient who is experiencing hypotonic labor? A. Oxytocin [78%] B. Fentanyl [2%] C. Magnesium sulfate [14%] D. Betamethasone [6%]

Explanation Choice A is correct. Since this patient is in hypotonic labor, meaning she is not having contractions that are strong and coordinated enough for her labor to progress, she needs intervention. Oxytocin, or Pitocin, is the medication that will strengthen contractions by stimulating the muscles of the uterus. The nurse expects this medication to be ordered for her patient in hypotonic labor. Choice B is incorrect. Fentanyl is an opioid used for severe pain. This medication may be used in an epidural for a laboring patient, but it would not be indicated for hypotonic labor. Choice C is incorrect. Magnesium sulfate is a medication used in preterm labor to help stop contractions. It would be contraindicated in the patient experiencing hypotonic labor. Choice D is incorrect. Betamethasone is a steroid administered to mothers in preterm labor to help the development of the fetus's lungs in anticipation of preterm delivery. It would not be indicated for hypotonic labor. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care

You are in the emergency department of the hospital. A man is brought back to a treatment bed. His wife states that he has been having chest pain for the last hour. As you move him onto the stretcher, his eyes roll back into his head, and he is gasping. You determine that he has no pulse. You place him on the cardiac monitor and see the rhythm. See the exhibit. Your first intervention is to: A. Start CPR. [55%] B. Connect the patient to the defibrillator. [33%] C. Begin ventilations with a bag-valve-mask device. [4%] D. Check to ensure the monitor leads are connected to the patient. [8%]

Explanation Choice A is correct. Start high-quality CPR. The nurse should recognize this rhythm as ventricular fibrillation. You have already determined that the patient does not have a pulse and has only agonal respirations. As you begin CPR, you should call for help to assemble the code team. At this point, if the patient is already connected to a defibrillator, you would shock the patient. However, you should never delay CPR to connect the patient to a defibrillator or begin ventilations. As the code team assembles, other team members will begin further interventions. Since you have already determined that the patient has no pulse, there is no need to check the monitor leads. NCSBN Client Need Topic: Physiological Adaptation, Sub-Topic: Medical Emergencies, Critical Care

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Based on the vital signs, what action should the nurse take? See the image below. A. Administer acetaminophen (APAP) [45%] B. Provide the patient with warm blankets [2%] C. Apply oxygen at 2 liters via nasal cannula [47%] D. Obtain an arterial blood gas (ABG) [6%]

Explanation Choice A is correct. The client has a fever, and the treatment for a fever includes fluids and antipyretics such as acetaminophen or ibuprofen. Choices B, C, and D are incorrect. The client's temperature is increased, and providing warm blankets would be detrimental, considering the patient has pyrexia. Tepid water baths may be used to promote comfort. Oxygen is not indicated as the oxygen saturation is above 88%, which is the norm for individuals with COPD. There is no indication in the question that the patient requires an ABG. The patient has tachypnea and hypoxia, a cardinal manifestation associated with COPD. Additional Info COPD is a combination of chronic bronchitis and pulmonary emphysema. Manifestations associated with COPD include tachypnea, hypoxia, hyperinflation of the lungs, and respiratory acidosis.

A client is admitted to the behavioral health unit and diagnosed with acute mania. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. Valproic acid [26%] B. Haloperidol [53%] C. Bupropion [10%] D. Fluoxetine [10%]

Explanation Choice A is correct. The gold standard for treating bipolar mania is mood stabilizers. Valproic acid (VPA) is a mood stabilizer and is efficacious in treating mania because it has a fast onset. Choices B, C, and D are incorrect. Haloperidol is a first-generation (typical) antipsychotic. The goal for acute mania (or bipolar depression) is mood stabilization. First-generation antipsychotics are not the mainstay of treatment for bipolar disorder. Antidepressants such as fluoxetine and bupropion would be detrimental for a client who is manic. This could exacerbate the mania. Additional Info

The nurse is caring for a client with a 27% total body surface area burn. The burns are a combination of second and third-degree. Prior to the prescribed dressing change, the nurse should administer which medication? A. Hydromorphone 1 mg intravenous (IV) push [71%] B. Oxycodone extended-release (ER) 10 mg by mouth (PO) [10%] C. Ketorolac 15 mg intravenous (IV) push [18%] D. Fentanyl transdermal patch 12 mcg/hr

Explanation Choice A is correct. The nurse should provide appropriate pain management during procedures that can be painful. For the client with extensive burns, it is highly appropriate to administer a prescribed opioid by a route that will provide expedient pain control. Hydromorphone is a potent opioid indicated for severe pain. Choices B, C, and D are incorrect. Oxycodone ER would not provide immediate pain relief for the scheduled dressing change as the medication is extended release intended to provide pain control over a set number of hours. Ketorolac is an antiinflammatory and indicated for mild to moderate pain. This would not be an appropriate choice. Fentanyl transdermal patch takes 24 hours to peak and is left in place for 72 hours. This also would not be an appropriate choice. Additional Info Hydromorphone is an opioid pain reliever. The nurse should assess the client's respiratory rate, oxygen saturation, and blood pressure prior to administration. Hydromorphone is six to seven times more potent than morphine. Caution must be taken when this medication is administered.

You are the permanently assigned nurse on an adult medical-surgical floor. You hear a "Code Pink" over the public announcement system. You know that a "Code Pink" means an infant abduction. Your hospital has fire drills and infant abduction drills every two months. Since you are working in the adult medical-surgical area without infants, you should do which of the following? A. Must respond and perform your role in this code. [93%] B. Ask the unit secretary to go to the code for you. [2%] C. Ignore the code because you are caring for clients. [2%] D. Ignore the code because you are not in the nursery.

Explanation Choice A is correct. You would immediately respond and perform your role in this code regardless of whether or not you are caring for clients in the nursery, or busy caring for adult clients. You CANNOT ever assume code is a practice drill; you must respond to all emergencies as if it were a real emergency. Choice B is incorrect. You would not ask the unit secretary to go to the code for you because YOU have a role and responsibility in this "Code Pink." Choice C is incorrect. You would not ignore the code. You are caring for clients however, YOU have a role and responsibility in this "Code Pink." Choice D is incorrect. You would not ignore the code because YOU have a role and responsibility in this "Code Pink."

You have just heard that a gunman is in your facility and is shooting at walls. What should you do before you get further instructions? A. Close all the windows in the clients' rooms. [7%] B. Close all the clients' doors to their rooms. [64%] C. Do a horizontal evacuation of the clients to avoid this gunman. [17%] D. Do a vertical evacuation of the clients to avoid this gunman. [12%]

Explanation Choice B is correct. Active shooter ("Code Silver") events are becoming increasingly common. The nurse should be aware of the best steps for survival when faced with an active shooter situation. Coordination of response with appropriate multi-disciplinary response partners is essential for succeeding in an active shooter situation. The key objectives are to protect the patients, visitors, and staff. Among the options listed, the most appropriate action is to close all the client's doors to their rooms until you get further instructions from the security officers or the security department. Closing doors and hiding keeps clients out of the view of the gunman. If it's safe to do so, evacuation can be carried out, but it's important to have some idea regarding the gunman's location before evacuating and coordinate with security personnel. The "4As" refers to a 4-step process to prevent or reduce loss of life in an active shooter event: Accept that an emergency is occurring. Assess what to do next depending on the location to save as many lives as possible Act: Lockdown (lock and barricade the doors, turn off the lights, have patients get on the floor and hide) or evacuate if safe or when instructed by security personnel or fight back (last resort). Alert law enforcement and security. Choice A is incorrect. The entry doors must be closed first, and the clients must be kept out of the view of the gunman. Closing all the windows may take longer, so the nurse should prioritize a more pertinent action. Choices C and D are incorrect. Horizontal and Vertical evacuations are used during fire incidents. Horizontal evacuation refers to moving patients out of the area to another unit or section on the same floor, safely passing through the fire door. Vertical evacuation refers to moving patients downward away from a threat in the upper floors (example: 5th floor to the 4th floor). Evacuation will be different during an active shooter situation than it would be for the fire. You would not do a horizontal or vertical evacuation of the clients to avoid this gunman when there is no clarity regarding the gunman's location.

The nurse is caring for a post-cesarean section client in the maternity ward. Which finding by the nurse is most indicative of a common complication post-cesarean delivery? A. A distended bladder [22%] B. Soaked perineal pads and a soft fundus [52%] C. Shivering [9%] D. An elevated temperature [16%]

Explanation Choice B is correct. Although some vaginal bleeding is anticipated, soaked perineal pads and a soft fundus are cause for concern. Typically, if a client is utilizing a new perineal pad every 15 minutes, persistent, significant bleeding should become the primary concern. Following a quick assessment for restlessness, increased pulse, decreased blood pressure, skin coolness, clamminess, and color, the nurse should immediately notify the health care provider. Choice A is incorrect. Although a full bladder interferes with the ability of the uterus to contract and, if not corrected, eventually leads to uterine atony, a distended bladder is not the finding most indicative of a common complication post-cesarean delivery. Choice C is incorrect. Following birth, many mothers often experience tremors that resemble shivering, although they deny feeling cold. These tremors are thought to be due to a vasomotor response involving epinephrine during the birthing process. This shivering should spontaneously resolve within 20 minutes. Choice D is incorrect. An elevated temperature following a caesarian section is highly unlikely. Hypothermia occurs more commonly immediately following. Learning Objective Identify the symptom most indicative of a common complication post-cesarean delivery. Additional Info Although a woman can have any medical complication following the birth of a child, most complications related to childbirth fall into one of the six following categories: Hemorrhage Mood Disorders Puerperal Infections Shock Subinvolution of the Uterus Thromboembolic Disorders Hemorrhage and shock may occur early, during the initial 24 hours post-delivery, or even later. The most significant risk is within the four hours post-delivery. A distended bladder pushes the uterus upward, usually to one side of the abdomen. The fundus may be boggy or firm. If not empty, a distended bladder can result in uterine atony and hemorrhage as it interferes with the normal contraction of the uterus. In the immediate post-operative phase, a urinary catheter is attached to the client to drain urine continuously. The chance of developing a distended bladder is minimal. Although many women often experience shivering after birth, this typically resolves spontaneously within 20 minutes. If chills with an accompanying fever are present after the initial 24 hours following delivery, notify the health care provider immediately, as this may be indicative of an infection. Postpartum fever is defined as a temperature of 100.4°F (39°C) or higher after the initial 24 hours following the birth or during two of the initial ten days following the birth. If a post-cesarean client presents with complaints of fevers, the nurse should assess for signs and symptoms of infection regardless of the time since delivery.

The nurse is performing an initial assessment on a patient being admitted for acute pancreatitis. Which assessment data would support this diagnosis? A. Homan's sign [9%] B. Cullen's sign [69%] C. Hyperactive bowel sounds [12%] D. Kernig's sign [10%]

Explanation Choice B is correct. Cullen's sign refers to the bluish periumbilical discoloration/ecchymosis that is common in acute pancreatitis. The discoloration occurs due to blood-stained exudates seeping from the pancreas. Choice A is incorrect. A positive Homan's sign (pain in the calf with foot dorsiflexion) would indicate the presence of a DVT, not pancreatitis. Choice C is incorrect. A patient with acute pancreatitis would present with hypoactive (decreased) bowel sounds, not hyperactive. Choice D is incorrect. A positive Kernig's sign indicates possible subarachnoid hemorrhage or meningitis. It would not support the patient's acute pancreatitis diagnosis. NCSBN Client Need Topic: Adult health - Endocrine, Subtopic: techniques of physical assessment, pathophysiology

The nurse is caring for a client in labor who just received epidural analgesia. The nurse should monitor the client for which adverse effects? A. Hypertension [25%] B. Bladder distention [38%] C. Hypothermia [19%] D. Precipitous labor [17%]

Explanation Choice B is correct. Epidural analgesia may cause bladder distention. Bladder distention may cause pain that remains after initiation of the block and may interfere with fetal descent in labor. Choices A, C, and D are incorrect. Epidural analgesia is known to cause hypotension; thus, it is routine for a client to receive a preprocedural fluid bolus of isotonic lactated ringers. Hypothermia is unlikely with epidural placement. The fever associated with epidural analgesia is usually not caused by infection but may result from reduced hyperventilation and decreased heat dissipation. Epidural analgesia commonly slows the progression of the second stage of labor because it relaxes pelvic muscles. Additional Info The epidural space is entered at the L3-L4 interspace (below the end of the spinal cord), and a catheter is passed through the needle into the epidural space. The catheter allows continuous infusion or intermittent injection of medication to maintain pain relief during labor and vaginal or cesarean birth. The infusion of epidural medication also may be regulated by a patient-controlled epidural analgesia (PCEA) pump

The nurse is teaching a client about diabetes mellitus type I and exercise. Which statement, if made by the nurse, would be appropriate? A. Increasing exercise would increase insulin requirement [23%] B. Increasing exercise would decrease insulin requirement [64%] C. Insulin needs don't change with exercise [12%] D. Decreasing exercise would decrease insulin requirement [1%

Explanation Choice B is correct. Exercise causes blood sugar to decrease by promoting the uptake of glucose by the muscles. Less insulin is therefore needed to metabolize ingested carbohydrates. The client may require extra food. Choices A, C, and D are incorrect. Increasing insulin when the activity level is increased would result in hypoglycemia. When exercise is decreased, there is no need to alter the insulin dosage unless the client's blood sugar becomes unstable. Additional Info Exercise is an effective treatment for both types of diabetes. Exercise can be safely done for a client with diabetes if the client plans for adverse hypoglycemia by carrying a quick-acting carbohydrate. The client should not exercise during periods of hypoglycemia and hyperglycemia. When a client exercises, the blood glucose will initially increase because of the release of epinephrine; as the exercise is sustained and the muscles are consuming the glucose, the blood glucose will begin to fall.

The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN) for three days. After reviewing the client's laboratory data, the nurse should take which action? See the image below. A. Reduce the infusion rate of the TPN. [16%] B. Obtain a prescription for sliding scale insulin. [36%] C. Assess for signs and symptoms of hyperglycemia. [40%] D. Pause the infusion for two hours and then reassess blood glucose. [8%]

Explanation Choice B is correct. Hyperglycemia is common with both pancreatitis and the infusion of TPN. The client's blood glucose shows an elevation pattern, but it is not hyperglycemic. The nurse needs to act to maintain normoglycemia. The blood glucose target for a client receiving TPN is less than 180 mg/dL. It is the trend over the course of the three days that causes the nurse to be concerned about this problem. A sliding scale of insulin combined with insulin added to the TPN Choices A, C, and D are incorrect. Reducing the rate of the TPN could be detrimental to the client's nutritional status. TPN is prescribed at a fixed rate that is detailed on the bag. The only time the nurse should reduce the rate of the TPN is when the TPN is prescribed to be discontinued. In this case, the nurse should taper in a stepwise fashion. Assessing for signs and symptoms of hyperglycemia is not necessary because the client does not meet the clinical threshold of hyperglycemia (250 mg/dL or greater). Pausing the infusion for two hours should not happen because this could allow the client to develop hypoglycemia. Additional Info TPN is a risk factor for infection as the high glucose content makes the client more likely to develop a bacterial or fungal infection. During an infusion of TPN, the nurse should monitor the client's vital signs and blood glucose. Hyperglycemia may delay healing and should be managed with a prescribed insulin protocol.

A client with thrombocytopenia is currently having epistaxis. The most appropriate nursing intervention should be: A. Instruct the client to lie flat with his neck suspended [3%] B. Ask client to sit upright, leaning slightly forward [64%] C. Ask client to blow his nose, then put lateral pressure on his nose [4%] D. Ask client to hold his nose while bending forward from the waist

Explanation Choice B is correct. In the event of epistaxis, the client should be instructed to assume an upright position, leaning slightly forward to help prevent an increase of vascular pressure in the nose and helps prevent aspiration of blood. Choices A, C, and D are incorrect. Lying in the supine position would predispose the client to aspiration. Blowing the nose would risk dislodging any clotting that has occurred and promote further bleeding. Bending at the waist increases the vascular pressure in the nose that would lead to further bleeding instead of stopping it.

The nurse is preparing to administer the prescribed mannitol. The nurse plans to administer the infusion using A. microdrip intravenous tubing. [39%] B. filtered intravenous tubing. [38%] C. vented intravenous tubing. [14%] D. non-vented intravenous tubing. [8%]

Explanation Choice B is correct. Mannitol is an osmotic diuretic indicated for cerebral edema. Mannitol may crystallize when exposed to low temperatures. Because of this, mannitol is always administered intravenously through intravenous tubing with a filter. Choices A, C, and D are incorrect. These tubing choices are incorrect and should not be used for mannitol administration. Micro drip tubing is utilized when precise amounts of fluid need to be administered. For this tubing, 60/gtts = 1 mL of fluid. Vented tubing is helpful to progress the infusion of fluids (or medication). The vent allows air to enter the container and displace the medication or solution as it's infused. Non-vented tubing creates a vacuum that allows the container to shrink or collapse as the fluid drains from the container. Additional Info Mannitol is used in the treatment of patients in the early oliguric phase of acute renal failure. For it to be effective in this setting, however, enough renal blood flow and glomerular filtration must still remain to enable the drug to reach the renal tubules. Mannitol can also be used to promote the excretion of toxic substances, reduce intracranial pressure, and treat cerebral edema.

The nurse is caring for a prenatal client who is in labor and may need a blood transfusion. The nurse knows that which of the following spiritual groups prohibit the use of blood transfusions? A. Catholicism [3%] B. Jehovah's witnesses [94%] C. Islam [2%] D. Christian reform [1%]

Explanation Choice B is correct. Most Jehovah's witnesses do not condone the use of blood products and often refuse blood transfusions. This nurse should verify this information in the chart and with the patient. Most Jehovah's Witnesses believe that a human must not sustain his life with another creature's blood. They believe that Jehovah will turn their back on anyone who receives blood products. Choice A is incorrect: Members of the Catholic faith have no set doctrines that prohibit the administration of blood products. Choice C is incorrect: With regard to the Islamic faith, Muslims are allowed to participate in blood and organ donation in cases of necessity and/or if the donation will save another person's life. This mean's that in life or death situations a blood transfusion is allowable for members of the Islamic faith. Choice D is incorrect: The Christian Reformed Church believes that their salvation is a gift from God and that good works are the Christian response to the gift. None of their doctrines prohibit the use of blood transfusion or blood product donation. Learning Objective Learning Objective: Differentiate major spiritual differences as they related to patient centered care Additional Info Source : Archer Image Library Any blood component may be removed from a donor and transfused into a recipient. Blood products may be transfused individually or collectively. This means that a client receiving a transfusion may receive blood products from one person or multiple people. Nursing responsibilities related to blood product transfusion focus on prevention of blood transfusion reactions and early recognization of transfusion reactions. A nurse will receie orders to transfuse blood. The nurse needs to ensure the patient has been informed of the risks and benefits to a blood transfusion and has signed a consent form. The nurse must also ensure the correct orders are in the patients medical record. The nurse will also need to ensure a blood type and screen has been submitted on their client within the last 72 hours. At any time and for whatever reason the client retains the right to refuse a blood transfusion. In this example, the nurses client that is a Jehovah's Witness retains the right to refuse a blood transfusion as it goes against the guidelines in her religion.

The client is admitted to the gastrology ward with a diagnosis of acute pancreatitis. The nurse should expect which type of pain from the client? A. Burning, aching pain in the left lower quadrant radiating to the hip. [7%] B. Severe pain in the mid-epigastric area radiating to the back. [58%] C. Burning, aching pain in the epigastric area radiating to the umbilicus. [25%] D. Severe pain in the left lower quadrant radiating to the groin. [10%]

Explanation Choice B is correct. Pain in pancreatitis is described as severe and maximal in intensity. It begins mid-epigastrium and radiates to the back; sometimes, it radiates to the chest, flanks, and lower abdomen. Choice A is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice C is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice D is incorrect. Pain in pancreatitis starts in the mid-epigastric area and radiates to the back, chest, and lower abdomen. It does not radiate to the groin.

A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the A. Two-point gait [10%] B. Three-point gait [55%] C. Four-point gait [9%] D. Swing-through gait [25%]

Explanation Choice B is correct. The three-point gait is most appropriate because the client is of non-weight bearing status on the affected leg. In a three-point gait, the client bears weight on both crutches and then the unaffected leg. This gait is also appropriate because it is slower than the swing-through gait, which requires more balance and is faster. Choices A, C, and D are incorrect. The two-point gait requires at least partial weight bearing on each foot. This gait would be inappropriate because the client is instructed to have non-weight bearing status on the affected leg. The four-point, gait gives stability to the client but requires weight-bearing on both legs. This gait would be inappropriate because the client has non-weight bearing status ordered to the affected extremity. If the client has complete paralysis of the hips and legs, the swing-to gait or swing-through gait is utilized. While a swing-to gait may be utilized if the client has a non-weight bearing status of an extremity, this would not be recommended because the client has a history of vertigo. The swing-through gait requires the client to swing forward as a pendulum, which may increase their risk of falling. Additional Info The basic crutch stance is the tripod position, formed when the crutches are placed 6 inches in front of and 6 inches to the side of each foot. This position maintains a client's balance by providing a wider support base.

Which type of transmission precautions utilize the wearing of a HEPA particulate mask? A. Contact precautions [3%] B. Airborne precautions [78%] C. Enteric precautions [7%] D. Droplet precautions

Explanation Choice B is correct. The use of a HEPA particulate, respirator mask, as well as a negative pressure room for the client, is indicated with airborne transmission precautions (for example, when the client has infectious tuberculosis). Choice A is incorrect. Contact precautions require the use of gowns and gloves, but not the use of a HEPA respirator mask. Choice C is incorrect. Enteric transmission precautions are no longer used as a type of transmission precaution. Choice D is incorrect. Droplet transmission precautions require a regular mask and not a HEPA respirator mask. Additional Info

Auscultation is one of the most important components of which body systems? A. Pulmonary, gastrointestinal, and neurological [3%] B. Reproductive, neurological, and integumentary [0%] C. Cardiovascular, pulmonary, and gastrointestinal [95%] D. Gastrointestinal, neurological, and reproductive [1%]

Explanation Choice C is correct. Auscultation of the heart provides information on rate, rhythm, extra sounds, and murmurs. Auscultation of the lungs includes information on the underlying music and adventitious sounds, which relate to pathology in the alveoli and airways. Gastrointestinal sounds may be absent, hypoactive, or hyperactive. Choices A, B, and D are incorrect. Auscultation plays a minimal role in the reproductive, neurological, and integumentary systems. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Auscultation

When providing care for a patient with known IV drug use, which statement would be appropriate for the nurse to discuss to highlight the risk factors of this behavior? A. The use of these drugs can increase the risk of contracting diseases due to immunosuppression. [5%] B. IV drug use can lead to skin infections at the injection sites and poor health. [7%] C. The risk of contracting and spreading bloodborne pathogens such as HIV, which can progress to AIDS, is a considerable risk factor for this activity. [82%] D. Drug use can lead to unsafe sex practices, increasing the risk of transmission of sexually transmitted diseases/infections. [6%]

Explanation Choice C is correct. HIV is a blood-borne pathogen, therefore sharing needles with IV drug abusers exponentially increases the risk of contracting the disease. Choices A, B, and D are incorrect. Although all of these answer choices are true, the most appropriate statement for the nurse to discuss is reflected in choice C. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; The Use of Alcohol and Illicit Drugs

The nurse is caring for a client with acute myocardial infarction (AMI). Which diagnostic intervention should the nurse anticipate? A. Exercise electrocardiography [10%] B. Computed tomography (CT) of the chest with contrast [29%] C. Percutaneous coronary intervention (PCI) [34%] D. Echocardiogram [27%]

Explanation Choice C is correct. Percutaneous coronary intervention (PCI) involves the insertion of a large catheter into the femoral or radial artery to access the coronary arteries. A stent may be placed to keep the lumen of the artery open. This test can diagnose narrowing in the coronary arteries and intervene with angioplasty and stenting, if necessary. Choice A, B, D is incorrect. Exercise electrocardiography is commonly known as a stress test. This is a planned procedure that examines exercise tolerance and its cardiovascular effects. The client is having an acute infarction, and this test would be inappropriate. A chest CT may assist in diagnosing an occlusion in the coronary artery, but this test does not allow for intervention. An echocardiogram is performed to examine the heart's structures and its output. This is not appropriate during an acute myocardial infarction. Additional Information - Percutaneous coronary intervention is performed in the cardiac catheterization laboratory and combines clot retrieval, coronary angioplasty, and stent placement. Under fluoroscopic guidance, the cardiologist performs initial coronary angiography, inserting an arterial sheath and advancing a catheter retrograde through the aorta. Here the physician may determine which arteries are narrowed and require intervention. Intervention may come in the form of angioplasty with or without stenting.

The nurse is supervising an LPN in the psychiatric ward. Which statement by the LPN would warrant attention by the nurse? A. "I bathed the client already this morning" [3%] B. "I will be attending a team meeting in the next hour." [3%] C. "I already gave the client his intravenous Olanzapine." [91%] D. "I will be joining the clients with their games today in the day room." [3%]

Explanation Choice C is correct. The LPN cannot give intravenous medications. LPNs can administer oral medications under RN supervision or under the guidance of the RN. Here, the LPN needs to be reminded that he/she cannot deliver any medication (except saline and heparin flushes) by direct IV push technique. Choice A is incorrect. The LPN can assist the clients in their activities of daily living. Choice B is incorrect. The LPN needs to be included in the team meeting; he/she is a vital part of the team. Choice D is incorrect. The LPN can join activities with the clients to ensure their safety.

A woman is brought to the ER crying and shocked. She tells the nurse that she has just been raped. What should be the nurse's initial action? A. Notify the police [8%] B. Call the sexual assault nurse examiner to see the client [21%] C. Assess her for injuries [69%] D. Assist the client in completing the admission form [2%]

Explanation Choice C is correct. The nurse should address the client's physiological needs first and then facilitate the necessary processes to deal with the rape. Choice A is incorrect. The client may want to notify the police, but the nurse should prioritize her physiological needs first then report the incident. Choice B is incorrect. The sexual assault nurse examiner (SANE) is a nurse specialized in caring for clients that have been raped. They are knowledgeable in dealing with clients who have been raped and are familiar with the legal proceedings. Before notifying the SANE, the nurse should first address the client's physiological needs. Choice D is incorrect. The nurse should prioritize care for the client over admission forms. The client can accomplish the admission forms after being treated.

The nurse is discussing information about advanced directives with a patient who expresses concerns, asking, "What if I change my mind about what I want?" What approach would you use to respond to the patient's care? A. Explain that the patient would have to file a new witnessed document in order to make any changes. [12%] B. Discuss the need to be very sure about his preferences, as the living will is a binding legal document. [9%] C. Assure the patient that he can change or revoke his advanced directives at any time. [79%] D. Advise the patient that changes could not be made during this hospital stay. [0%]

Explanation Choice C is correct. The patient may revoke either a living will or durable power of attorney at any time, and this can be done either verbally or in writing. Choice A is incorrect. The patient can revoke an advanced directive verbally; a newly written document is not required. Choices B and D are incorrect. While the 'living will' is a legal document, advanced directives can be easily changed at any time, just by saying so verbally, or with a newly written report. Blooms Taxonomy - Applying

Which finding is normal in the assessment of cardiac status in pre-school children? A. Noting a big discrepancy in arm and leg blood pressures. [8%] B. The point of maximal impulse (PMI) is at the fifth intercostal space (ICS), about 7-9 cm from the mid-sternum. [50%] C. Pulses are elevated when breathing in and decrease when breathing out. [30%] D. A systolic click can be appreciated at the sternal border.

Explanation Choice C is correct. This indicates a sinus arrhythmia, which is a regular occurrence in children and can be differentiated from a truly abnormal arrhythmia by having the child hold his breath. Choices A, B, and D are incorrect. A large discrepancy in arm and leg blood pressures indicate congenital heart defects like coarctation of the aorta or other obstructive disorders. It is not a normal finding in pre-school children. Choice A is, therefore, incorrect. Choice B is also wrong because the PMI in children is between the fourth and fifth intercostal spaces at the midclavicular line. Choice D describes mitral insufficiency and is not normal in children.

The nurse is performing community health screenings. A client tells the nurse that they smoke two packs a day of cigarettes and have smoked for six years. The nurse should document this finding as how many pack years? A. 3.5 pack years [2%] B. 3 pack years [5%] C. 12 pack years [76%] D. 6 pack years [16%]

Explanation Choice C is correct. This is the correct amount of pack-years for this client. The client has smoked two packs of cigarettes for six years (two x six = twelve). Choices A, B, and D are incorrect. None of these calculations are accurate when two is multiplied by six. Additional Info The smoking history should include the number of cigarettes smoked daily, the duration of the smoking habit, and the age of the patient when smoking started, even for patients who are not current smokers. Record the smoking history in pack-years, which is the number of packs smoked per day multiplied by the number of years the patient has smoked.

The nurse in the family clinic is checking the vital signs of clients. Which client should the nurse prioritize? A. A 9-month-old baby with a pulse rate of 148 [7%] B. A 2-year-old with a respiratory rate of 30 [9%] C. A 24-week pregnant woman with a blood pressure of 148/96 mmHg [79%] D. A 40-year-old man with a temperature of 37.8 °C [4%]

Explanation Choice C is correct. This woman's blood pressure is higher than that of the average systolic BP (90-140 mmHg) and diastolic BP (60-85 mmHg). She may have pregnancy-induced hypertension (PIH) which would warrant further assessment and attention from the nurse. Choice A is incorrect. This client's vital sign is within normal limits. The average pulse rate for a 1- to 11-month-old is 100 to 150. This client does not need further attention. Choice B is incorrect. Toddlers have a normal respiratory rate of 20-30. This client does not need further intervention. Choice D is incorrect. The client may have an infection because of the elevated temperature, but it is not a life-threatening condition.

When a nursing assessment is not done in a timely manner, according to the established policy and procedure, this is referred to as a: A. Nursing fault [14%] B. Medical error [11%] C. Variance [45%] D. Deviance [30%]

Explanation Choice C is correct. When a nursing assessment is not done promptly, according to the established policy and procedure, this is referred to as a variance or an irregular occurrence because this assessment was not done in the time frame that was expected. Choice A is incorrect. When a nursing assessment is not done in a timely manner, according to the established policy and procedure, it is not a nursing fault. This could have occurred for a number of reasons relating to the client or other variables. Additionally, finding fault is not the way to address variances, errors, irregular occurrences incidents, and accidents. Correcting faulty processes is the focus of a blame-free environment. Choice B is incorrect. It is not called a medical error. Medical errors include things like wrong-site surgery, wrong patient surgery, and medication errors. Choice D is incorrect. The term deviance is not used to describe a nursing assessment not done promptly, according to the established policy and procedure.

Your pediatric client has just begun oral penicillin for a throat infection. The mother of this child calls you 12 hours after you saw the client, and she states, "He has taken one dose of the medication, and he has a rash. I think something is wrong with him in addition to the throat infection." You should respond to this mother's comment by: A. Stating, "Many young children get a rash from the slight fever when they have a respiratory infection." [4%] B. Stating, "I don't think it is anything important or serious. I suggest you use calamine lotion if he is itchy." [1%] C. Asking, "Has your son ever taken any penicillin in the past? He may be allergic to it." [94%] D. Asking, "Have you recently changed your laundry soap? It could be contact dermatitis."

Explanation Choice C is correct. You should respond to this mother's comment by asking, "Has your son ever taken any penicillin in the past? He may be allergic to it." This data is essential because an allergy to penicillin can be characterized by a diffuse rash with the first dose, which is called the sensitizing dose, after which a second dose can lead to anaphylaxis which is a potentially life-threatening complication of penicillin when a person is allergic to it. Choice A is incorrect. You would not state, "Many young children get a rash from the slight fever when they have a respiratory infection" because this rash could indicate a severe problem. Choice B is incorrect. You would not state, "I don't think it is anything important or serious. I suggest you use calamine lotion if he is itchy" because this rash could indicate a severe problem. Choice D is incorrect. You would not respond to this mother by asking, "Have you recently changed your laundry soap? It could be contact dermatitis" because this rash could indicate a serious problem.

The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside? A. One liter of 0.9% saline [17%] B. Sterile gloves [3%] C. Portable ultrasound [21%] D. Suction equipment [59%]

Explanation Choice D is correct. A client with severe pre-eclampsia should be monitored closely for seizures which is the hallmark manifestation in eclampsia. The nurse should plan care involving seizure precautions at the bedside, including suction equipment, padded side rails, and oxygen. Choices A, B, and C are incorrect. Sterile gloves, portable ultrasound, and a liter of 0.9% saline would not be necessary to manage a client having a seizure directly related to pre-eclampsia. These tools would be helpful for other obstetric procedures, but not for a client who is severely pre-eclamptic and at risk of having a seizure. Additional information: Severe pre-eclampsia may require intensive care monitoring depending on other factors. Nursing care for a client with severe pre-eclampsia includes: Appropriate safety equipment at the bedside, which includes seizure precautions. Frequent vital sign monitoring, blood pressure needs to be closely monitored as a hypertensive emergency may develop. Prescribed medication administration such as magnesium sulfate. Frequent fetal well-being assessment that includes continuous fetal heart rate monitoring. NCSBN Client need: Topic: Reduction of Risk Potential; Subtopic: Potential for Complications from Health Alterations

When compared to younger adults, the nurse recognizes that the older clients have variations in pulse with: A. Food intake [7%] B. Heat [14%] C. Respirations [22%] D. Exercise [57%]

Explanation Choice D is correct. Exercise increases the heart rate because of increased metabolic demands. Aging adults have a normal pulse range of 60-100 beats/minute. However, the maximum heart rate in older adults is much lesser with exercise. In older adults, the radial artery may stiffen from peripheral vascular disease. With exercise, a variation in the pulse is noted in older adults compared to younger adults. The pulse rate of older adults takes longer to rise to meet sudden increases in demand, takes longer to return to resting state, and tends to be lower than that of younger adults. Choices A and B are incorrect. Certain types of food may cause changes within the body (such as salty foods can increase blood pressure and affect heart rate). Also, internal temperature changes may cause an increase in heart rate. However, overall food intake and heat are not causes for variations in pulse. Choice C is incorrect. Sinus arrhythmia, a variation in pulse with respiration, is common among children, not older adults. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Pulse

The primary objective in identifying similarities and differences among cultural beliefs of a patient is to: A. Communicate with the family [20%] B. Make sure the proper diet is ordered [6%] C. Perform a spiritual consult [4%] D. Avoid making assumptions [70%]

Explanation Choice D is correct. Making assumptions or generalizations about a patient's spiritual needs based on ethnic or religious affiliation is almost sure to be an oversimplification. The nurse should be able to identify similarities and differences among the cultural beliefs of the patients. Just because a patient belongs to a certain culture or ethnicity, it is incorrect to generalize their spiritual needs. Choices A, B, and C are incorrect. Ordering a specific diet as per the patient's specific cultural or religious preference is certainly warranted. However, generalizations cannot be made here either, and knowing the patient's specific preference will help the nurse cater to the patient's dietary or spiritual needs. Communicating with the family and performing a spiritual consult should also be done at the patient's request. While identification of cultural similarities and differences among the patients can help guide these processes, these are not the primary objectives. The primary objective is to avoid making assumptions. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Characteristics of Culture

Select the fact about non-steroidal anti-inflammatory drugs (NSAIDs) that is accurate. Which of the following is true about NSAIDs? A. Vary significantly and greatly in terms of their analgesic effects among the different medications in this classification of medications. [25%] B. Vary little in terms of their anti-inflammatory effects among the different medications in this classification of medications. [15%] C. Cannot be given with an antacid medication because it will interact with the NSAID in terms of its effectiveness. [38%] D. Mortality was lesser among patients receiving NSAIDs compared to opioids.

Explanation Choice D is correct. The World Health Organization ( WHO) recommends using NSAIDS and acetaminophen to treat pain before considering opioids. Long term use of NSAIDS can lead to life-threatening complications, such as gastrointestinal system bleeding and renal dysfunction, with long-term use. However, available evidence indicates that the all-cause mortality was higher in patients receiving opioids than other pain medications. Choice A is incorrect. There is little difference between the various NSAID medications in terms of their analgesic effects. Choice B is incorrect. There are significant differences among the various NSAID medications in terms of their anti-inflammatory effects. Choice C is incorrect. It is recommended that an antacid medication is given when the client is taking non-steroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal bleeding.

The nurse is planning a staff development conference on the prevention of contractures. Which of the following information should the nurse include? Select all that apply. A. Range-of-motion exercises of the extremities help prevent contractures. [31%] B. Splinting the extremities may increase the risk of contractures. [10%] C. Too many pillows under the head may cause a neck flexion contracture. [23%] D. Using multiple staff members to reposition a client may prevent a contracture. [13%] E. Contractures after a hip arthroplasty can be prevented with an abduction pillow. [23%]

Explanation Choices A and C are correct. Range of motion exercises are essential in preventing contractures. Having a client engage in ROM exercises inhibits disuse and atrophy, which drives a contracture. Too many pillows under the neck cause neck flexion, which may cause a contracture. Choices B, D, and E are incorrect. Splints are quite helpful in the prevention of a contracture by providing support, stability, and alignment. These splints are often applied to the hands and the foot. Using multiple staff members to reposition a client may decrease injury to the client and staff during moving, but it would not decrease the risk of contracture. An abduction pillow may be used after a hip arthroplasty to prevent dislocation of the joint - not a contracture. NCLEX Category: Basic Care and Comfort Related Content: Mobility/immobility Question type: Knowledge/comprehension Additional Info Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. Immobility can be a significant risk factor for joint contractures. Nursing Interventions to Prevention Joint Contracture Recognize those who are at risk. These would be individuals recovering from a burn, stroke, or any neurological impairment inhibiting range of motion. Collaborate with other disciplines such as physical and occupational therapy. Apply splints to the hands and feet. Reposition the client frequently Avoid positioning the client that has extremities in extreme flexion. Perform range of motion exercises of all extremities

The nurse is caring for a client receiving intermittent bolus tube feedings. The nurse prepares to begin the next feed but first aspirates 85 mL of residual from the nasogastric tube. Following the aspiration, which of the following actions by the nurse are correct? Select all that apply. A. Document the color, odor, consistency, and amount of the residual. [39%] B. Hold the next feeding. [6%] C. Send the residual to the lab. [3%] D. Administer the residual back to the patient. [34%] E. Administer the feeding, but subtract the quantity of the residual from the feed. [19%]

Explanation Choices A and D are correct. A is correct. This is the appropriate documentation for any fluids the nurse observes from her patient. You can remember this documentation from the mnemonic COCA: color, odor, consistency, and amount. For example, in this situation, it may be tan, formula-like residual, non-odorous, thick, 85 mL. This documentation will help identify what is normal for the client and when there are any issues. D is correct. The nurse should administer the residual back to the client. This is incredibly important for the prevention of electrolyte imbalances. The stomach contents are rich in many electrolytes, such as potassium and chloride. Removing the stomach contents and not returning them to the client could create dangerous electrolyte abnormalities. Choice B is incorrect. When less than 500 mL of residual is aspirated, and if there are no signs of feeding intolerance, it is not necessary to hold the next feeding. If the aspirate is less than 250 mL, the aspirate should even be returned to the client. Choice C is incorrect. It is not necessary to send the residual to the lab. The residual should be returned to the client. Choice E is incorrect. The nurse should not subtract the quantity of the residual from the feed. When less than 500 mL of residual is aspirated, the total feeding amount continues as scheduled unless there are any signs of feeding intolerance. Additional Info Refer to ASPEN guidelines recommending a GRV cut off of 500 mL to hold feedings - click here for link to guidelines Refer to guidelines recommending up to 250 mL GRV be returned to the client - click here

You are putting together a community health presentation about the signs and symptoms of depression to promote awareness of the disease and educate the public. Which of the following signs and symptoms would be essential to include? Select all that apply. A. Anhedonia [33%] B. Flight of ideas [7%] C. Looseness of associations [17%] D. Sleep disturbances [42%]

Explanation Choices A and D are correct. Anhedonia is a common symptom of depression. It is defined as the loss of pleasure in usually pleasurable things. For example, a mother who usually loves going to see her children in their dance recitals says she no longer wants to go. The things that once brought someone joy do not do that anymore due to depression. This can be difficult for families to understand and can cause a lot of frustration. You should educate your community that this is not the patient's fault, but a part of the disease process of depression (Choice A). Sleep disturbances are an incredibly common symptom of depression and should undoubtedly be a point of education. In patients suffering from depression, their sleep disturbances usually occur when they wake up in the middle of the night and are unable to go back to sleep. In patients suffering from anxiety, there are also significant sleep disturbances, but the trouble is usually falling asleep rather than staying asleep (Choice D). Choice B is incorrect. Flight of ideas is not a typical symptom of depression, but rather mania. Flight of ideas is defined as "a rapid shifting of ideas with only superficial associative connections between them that is expressed as a disconnected rambling from subject to subject." It is tough to have a coherent conversation with someone who is experiencing a flight of ideas because they jump from topic to topic so quickly. It is common that this symptom of mania presents in the manic phases of bipolar disorder, but not in depression alone. Choice C is incorrect. Looseness of associations is a common symptom of schizophrenia, but not of depression. Looseness of associations is defined as "speech that is disconnected and fragmented, with the individual jumping from one idea to another unrelated or indirectly related idea." People who have schizophrenia often have disorganized thoughts and are unable to communicate those thoughts to others in a coherent manner. This is not usually the case with a patient experiencing depression. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing

You are reinforcing education to a group of parents after an outbreak of pediculosis capitis at the local elementary school. Which of the following points should you include? Select all that apply. A. Teach your children not to share hats or combs to prevent the spread of lice. [36%] B. It is important to apply the permethrin cream once as soon as you can. [14%] C. Parents will need to manually remove the lice with a fine-tooth comb 2-3 times/day until there are no visible lice. [23%] D. Anyone can get lice, it is not indicative of a dirty house. [27%]

Explanation Choices A and D are correct. You must educate parents to teach their children not to share hats or combs to prevent the spread of lice. Pediculosis capitis, or mites, is transmitted from person to person either through direct contact with the scalp or through personal items. Children may not understand why sharing hats or combs is terrible, so parents must talk with them about it (Choice A). Anyone can get lice; it is not indicative of a dirty house or child. Parents and children often feel embarrassed over having insects in their home and fear the reaction of their peers, friends, and family. The nurse should educate the community that anyone can contract lice and that it is not a reflection of how clean their home environment is (Choice D). Choice B is incorrect. While it is essential to apply permethrin cream to the scalp to kill the lice, it will be necessary to apply twice, not once. The first application will be immediately and then the second will be in 7-10 days. This is to prevent the recurrence of any lice. Choice C is incorrect. It is essential to teach the parents to remove the lice and mites with a fine-tooth comb manually, but only once per day is necessary, not 2-3 times/day. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Infection control and safety; Integumentary

The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply. A. Fever [26%] B. Night sweats [17%] C. Osler nodes [10%] D. Cardiac murmur [20%] E. Syncope [15%] F. Weight loss [12%]

Explanation Choices A, B, C, D, and F are correct. Infective endocarditis (IE) is a serious condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other physical manifestations that may be assessed with IE include a cardiac murmur, Janeway lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of feet). Choice E is incorrect. Syncope is not a clinical feature of IE. Additional Info Infective endocarditis occurs primarily in patients with injection drug use (IDU) and those who have had valve replacements, have experienced systemic alterations in immunity, or have structural cardiac defects. This is a condition caused by the invasion of bacteria which enter the client through contaminated needles, oral cavity following dental procedures, and/or skin abscesses. Classic manifestations of IE include • Fever associated with chills, night sweats, malaise, and fatigue • Anorexia and weight loss • Cardiac murmur (newly developed or change in existing) • Development of heart failure • Evidence of systemic embolization • Petechiae • Splinter hemorrhages • Osler nodes (on palms of hands and soles of feet) • Janeway lesions (flat, reddened maculae on hands and feet) • Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina) Positive blood cultures Treatment of IE is antibiotic therapy for several weeks.

The nurse is preparing for the first interaction with a client recently admitted to the hospital. Which of the following would help establish trust during this encounter? Select all that apply. A. Make sure the client's bed is set up properly ahead of time. [21%] B. Review the client's name, diagnosis, and anticipated length of stay before he or she arrives. [23%] C. Speak confidently and do not tell the patient that one of the nurses providing care is a student nurse. [3%] D. Show the client how to use the bed and call light. [26%] E. Avoid spending too much time talking with the client. [2%] F. Ask about the client's expectations and concerns when taking the health history. [25%]

Explanation Choices A, B, D, and F are correct. Preparing the room and gathering necessary information ahead of time, such as name, diagnosis, and anticipated length of stay allows for more efficient greeting and admission and are appropriate ways to help establish trust with the client. The nurse should also orient the client to the room by making sure the client understands how to use the bed controls, call light, and any necessary equipment. Showing an interest in the client's expectations and concerns shows the client that their feelings are cared about, which helps to establish trust. Choices C and E are incorrect. Many clients are open to being cared for by nursing students, and aware that students have more time to spend with them; being forthcoming regarding the level of experience is likely to establish an atmosphere of trust. Taking the time to get to know the client also helps to establish a trusting relationship. Additional Information: When clients are admitted to a hospital or other care facility, they need support in their transition to wellness, in dealing with the unknown, and in adjusting to a new environment. The relationship and trust established in the first interaction with clients can go a long way toward relieving anxiety and preserving the energy needed for healing. The nurse should take time to get to know the client and try to set a tone of caring, respect, empathy, and understanding. NCLEX Category: Psychosocial Integrity Related Content: Therapeutic Communication Question Type: Application

You are reinforcing the education provided to your 8-year-old patient diagnosed with sickle cell anemia. He had three sickle crises events this year. Which of the following points do you enforce with him and his parents to help prevent more sickle cell crises? Select all that apply. A. Drink lots of water [37%] B. Perform vigorous exercise for 60 minutes a day [1%] C. Take proper precautions if flying on airplanes [30%] D. Call the PCP if he becomes febrile [32%]

Explanation Choices A, C, and D are correct. A is correct. Hydration is an essential component of preventing a sickle cell crisis, so this is a critical education. By drinking lots of water, the boy will increase the volume in his vascular space with fluid, substantially "thinning out" the sickled cells. In other words, they will not be as concentrated anymore. This will help to prevent the sickled cavities from snagging on vessels, creating occlusions, and causing a crisis. C is correct. If patients with sickle cell disease fly on airplanes, they need to take proper precautions. In planes, you are at a very high altitude where there is much less oxygen. This can be a trigger for a sickle cell crisis because it leads to a high oxygen demand state. Precautions to take if they do so include staying very well hydrated, and possibly having an oxygen mask available. Patients with many crisis events may need to avoid flying on airplanes. D is correct. The parents need to know to call the child's primary care doctor if he is ill with a fever. Since the body demands more oxygen when it is febrile, temperatures are a trigger for sickle cell crises and must be treated promptly. Choice B is incorrect. While promoting a healthy lifestyle is always essential, vigorous exercise is a specific trigger for a sickle cell crisis. During strenuous exercise, the tissues have a high oxygen demand and the sickled cells are unable to deliver a sufficient amount of O2, which results in a crisis. So for this patient, 60 minutes of vigorous exercise every day would not be a good recommendation. NCSBN Client Need:Topic: Physiological Integrity, Subtopic: Risk of the potential reduction; Hematology

When performing skin assessments on patients, nurses must pay attention to cleanliness, color, temperature, texture, moisture, sensation, vascularity, and lesions. Which guidelines should the nurse follow when performing these assessments? Select all that apply. A. Compare bilateral body parts for symmetry. [25%] B. Proceed in a toe-to-head systematic manner. [10%] C. Use standard terminology to report and record findings. [24%] D. Do not allow data from the nursing history to direct the assessment. [10%] E. Document only skin abnormalities on the patient record. [5%] F. Perform the appropriate skin assessment when risk factors are identified. [25%]

Explanation Choices A, C, and F are correct. When performing a skin assessment; the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. Choice B is incorrect. The nurse should proceed in a head-to-toe systematic manner, not toe-to-head. Choice D is incorrect. Data from the nursing history should be allowed to direct the assessment. Choice E is incorrect. When documenting the physical assessment of the skin, the nurse should describe precisely what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort; Skin Care

Which of the following signs and symptoms are characteristic of pyloric stenosis? Select all that apply. A. Weight gain [2%] B. Projectile vomiting [42%] C. Olive-shaped mass [32%] D. Anorexia [24%]

Explanation Choices B and C are correct. B is correct. Projectile vomiting, especially right after a feeding, is the characteristic sign of pyloric stenosis. Since the pylorus, the opening from the stomach into the duodenum, is hardened and stiffened, it does not allow food to pass from the stomach into the duodenum. This means that after a feeding, the food cannot pass down, so it comes up in the form of projectile vomiting. C is correct. An olive-shaped mass, specifically in the epigastric region near the umbilicus is a tell-tale sign of pyloric stenosis. This is the enlarged stiffened pylorus. Choice A is incorrect. The client experiencing pyloric stenosis would present with weight loss, not weight gain. Pyloric stenosis is the enlargement and stiffening of the pylorus, the opening from the stomach into the duodenum. This prevents the passage of food into the duodenum and results in projectile vomiting. The inability to keep food and fluids down will lead to weight loss. Choice D is incorrect. Anorexia, or lack of appetite, is not a characteristic of pyloric stenosis. These patients are always hungry, because they cannot keep anything down. They are constantly trying to eat, and vomit back up due to the enlarged and stiffened pylorus not allowing food to advance to the duodenum. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Gastrointestinal

Which of the following signs and symptoms would you expect to see in an infant withdrawing from heroin? Select all that apply. A. Temperature 36.5 degrees Celsius [11%] B. Respiratory rate 88 [36%] C. Diaphoretic [42%] D. Constipation [11%]

Explanation Choices B and C are correct. A respiratory rate of 88 is tachypneic, which is what we would expect for an infant experiencing neonatal abstinence syndrome (NAS). Tachypnea is a common sign of NAS, as is respiratory distress. It is not uncommon to appreciate an increased work of breathing, including things such as nasal flaring, head bobbing, and retractions in these infants (Choice B). Diaphoresis or excessive sweating is a common symptom of infants in neonatal abstinence syndrome. Most of these infants are incredibly irritable, hot, and sweaty. It is similar to the withdrawal you would expect in an adult that goes cold turkey on a drug (Choice C). Choice A is incorrect. A temperature of 36.5 degrees Celsius is an average temperature, whereas an infant withdrawing from heroin would likely present with a fever. For NAS scoring, an illness is higher than 37.8 degrees Celsius. Most of these infants are incredibly irritable, hot, and sweaty. It is similar to the withdrawal you would expect in an adult that goes cold turkey on a drug. Choice D is incorrect. In an infant experiencing neonatal abstinence syndrome, you would expect to see very loose frequent stools, not constipation. These loose stools are so prevalent that many of these infants end up with horrible skin breakdown due to sitting in diapers filled with loose stool. It is essential to know that diarrhea is a common sign of NAS, so that you may monitor for these complications. NCSBN Client Need: Topic: Health Promotion and Maintenance; Subtopic: Newborn

The nurse is caring for a client experiencing an acute episode of severe anxiety. The nurse should plan to take which appropriate action? Select all that apply. A. Discuss previous coping skills [14%] B. Stay and observe the client [24%] C. Maintain an environment with low stimuli [25%] D. Plan to ambulate with the client in the hallway [4%] E. Instruct the client to identify what triggered the event [15%] F. Assess the client for possible hypoventilation [11%] G. Obtain a prescription for haloperidol [6%]

Explanation Choices B and C are correct. Severe anxiety causes an individual to experience a narrow perceptual field, an inability to problem-solve, and somatic symptoms such as dizziness, palpitations, diaphoresis, and a feeling of impending doom. Staying with the client provides the client with assurance and enables the nurse to give the client simple and short directions, if necessary. Choices A, D, E, and F are incorrect. Discussing previous coping skills is not an intervention appropriate for a client experiencing severe anxiety. This level of anxiety prevents a client from appropriately reflecting and conversing about what triggered the anxiety and previous coping skills. The environment should be a low stimulus and ambulating the client in the hallway would exacerbate the anxiety because of the sounds and stimuli. If a client is experiencing this level of anxiety, hyperventilation is more likely to occur, which could cause the client to develop dizziness. Finally, if prescriptive interventions are necessary, haloperidol would be inappropriate because it is an antipsychotic. Antipsychotics have no utility in the management of anxiety. For an acute episode of anxiety, medications such as benzodiazepines (alprazolam) or antihistamines (hydroxyzine) may be indicated. Additional Info Severe anxiety is marked by - Greatly reduced and distorted perceptual field Focuses on details or one specific detail Attention is scattered Inability to problem solve A feeling of impending doom Interventions include staying with the client because their behavior may become unpredictable, coaching breathing if the client develops hyperventilation, giving the client short and simple cues, and obtaining prescriptive medication (if necessary). The nurse should ensure that the environment is tranquil and does not have excessive stimuli.

The nurse is reviewing the arterial blood gas (ABG) results of assigned patients. Which ABG requires immediate follow-up? A. pH = 7.46; PaO2 = 90 mm Hg; PaCO2 = 33 mm Hg; HCO3- = 22 mEq/L; SaO2 = 94% [2%] B. pH = 7.27; PaO2 = 73 mm Hg; PaCO2 = 50 mm Hg; HCO3- = 25 mEq/L; SaO2 = 85% [94%] C. pH = 7.45; PaO2 = 95 mm Hg; PaCO2 = 38 mm Hg; HCO3- = 26 mEq/L; SaO2 = 96% [1%] D. pH = 7.32; PaO2 = 93 mm Hg; PaCO2 = 42 mm Hg; HCO3- = 20 mEq/L; SaO2 = 94%

Explanation Choices B is correct. This ABG depicts respiratory acidosis (low pH; high PaCO2) and is concerning because the patient is hypoxic (PaO2 73; SaO2 85%). This patient requires immediate intervention because of hypoxia. Choices A, C, and D are incorrect. Choice A is respiratory alkalosis which may be caused by hyperventilation. Choice C is a normal ABG and requires no intervention. Choice D is concerning because of its metabolic acidosis, but no hypoxia is evident. Additional Info Additional information: When analyzing an arterial blood gas, evaluate the pH first to determine if the patient is in acidosis or alkalosis. Then, move to the CO2 to determine if there is a disturbance that suggests a respiratory problem. Next, the bicarbonate will reveal if the patient has a metabolic abnormality. Finally, the patient's oxygenation needs to be evaluated for hypoxia (any value less than 80).

The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications that can increase the risk for falls? Select all that apply. A. Naproxen [8%] B. Alprazolam [30%] C. Bumetanide [20%] D. Verapamil [26%] E. Allopurinol [10%] F. Thiamine [4%]

Explanation Choices B, C, and D are correct. Medications that may hasten the risk for falls and included benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic, and this medication may cause a client to experience orthostatic hypotension along with the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly. Choices A, E, and F are incorrect. Naproxen is an anti-inflammatory medication and is not implicated in raising the risk for falls. Allopurinol is indicated to lower uric acid levels and would not increase the risk for falls. Thiamine is a water-soluble vitamin indicated for alcoholism. Additional information: Medications that may raise the risk for falls include any agents that may cause drowsiness (benzodiazepines, opioids), shifts in blood pressure (diuretics, beta-blockers), or alterations to the sensorium (melatonin). The nurse should diligently work to ensure a safe environment for the client and assess their risk for falls.

The nurse is caring for a client with Human Immunodeficiency Virus ( HIV). Which of the following conditions, if present in the client, should make the nurse concerned about Acquired Immunodeficiency Syndrome ( AIDS)? Select all that apply. A. Chronic, progressive visual loss [6%] B. Kaposi's sarcoma [25%] C. Wilms sarcoma [9%] D. Tuberculosis [27%] E. Peripheral neuropathy [8%] F. Toxoplasma gondii [24%]

Explanation Choices B, D, and F are correct. Acquired Immunodeficiency Syndrome is the final stage of untreated chronic HIV infection. AIDS ensues due to progressive depletion of CD4 T-lymphocytes. AIDS is defined by the presence of any AIDS-defining condition or a CD4 cell count < 200cells/microliter. Kaposi's sarcoma, mycobacterium tuberculosis, toxoplasma gondii, mycobacterium avium complex, herpes simplex, histoplasmosis, cryptococcosis, cytomegalovirus retinitis, and salmonella septicemia are some of the AIDS-defining opportunistic illnesses. Opportunistic illnesses are often opportunistic infections (OIs) but may also include malignancies such as invasive cervical cancer and Kaposi sarcoma. OIs are infections that occur more often or are more severe in people with weakened immune systems than in people with healthy immune systems. OIs are caused by a variety of pathogens (viruses, bacteria, fungi, and parasites). HIV associated Kaposi's sarcoma is one of the AIDS defining opportunistic condition and is caused by Kaposi Sarcoma Associated Herpes Virus, also known as human herpesvirus 8 (HHV8). For people with HIV, the best protection against progressing to AIDS and OIs is to adhere to HIV medications. HIV medicines prevent HIV from damaging the immune system. Because HIV medicines are now widely used in the United States, fewer people with HIV get OIs. Choices A and E are incorrect. Although many HIV-infected patients can experience blindness and peripheral neuropathy, these disorders result from nervous system damage rather than an opportunistic infections. Visual losses can occur with CMV retinitis and Cryptococcosis, however, they are acute rather than chronically progressive. Choice C is incorrect. Wilm's tumor is a pediatric form of kidney cancer and is not a condition that typically affects the patient with HIV/AIDS. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control

The nurse is developing a plan of care for a patient with large amounts of insensible fluid losses. Which of the following patients does the nurse know is at risk for this? Select all that apply. A. A patient who is vomiting multiple times per day. [23%] B. A patient who is having a large amount of diarrhea. [24%] C. A patient who is hyperthermic and sweating excessively. [36%] D. A patient with tachypnea.

Explanation Choices C and D are correct. Excessive sweating is an example of insensible fluid loss. Insensible fluid loss occurs to every patient through the skin and the lungs. Examples are sweating and moisture exhaled with each breath from the lungs (Choice C). A patient with tachypnea is at risk for increased insensible fluid loss. With each breath exhaled, a small amount of fluid is lost in the air. They are unaware of this fluid loss, thus it is insensible. A patient who is tachypneic, breathing more rapidly than normal, is at risk for an increase in fluid loss through this mechanism (Choice D). Choice A is incorrect. Vomiting is a sensible fluid loss. Sensible fluid loss is a loss that the patient is aware of. They can occur through vomiting, diarrhea, urination, wound drainage, and more. This patient is not having an insensible fluid loss. Choice B is incorrect. Large amounts of diarrhea is another example of a sensible fluid loss. Because the patient is aware that they are having diarrhea, this is not an example of an insensible fluid loss. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk potential reduction; Fluids & Electrolytes

The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply. A. Limiting visitation to 30 minutes per day. [9%] B. Keeping the door to the client's room closed. [19%] C. Wearing a surgical mask when providing care. [34%] D. Placing the client in a room at the end of the hall. [12%] E. Cleaning common surfaces with 70% isopropyl alcohol. [26%]

Explanation Choices C and E are correct. Wearing a surgical mask when providing care is essential. Additionally, the nurse should wear gloves and a gown when providing client care. The primary mode of transmission for influenza is contact and droplet. Finally, cleaning common surfaces is important as the influenza virus may survive on these surfaces. Choices A, B, and D are incorrect. Visitor restriction up to 30 minutes per day, keeping the client's door closed, and placing the client at the end of the hall are all inappropriate for an individual with influenza. The door should be kept closed for airborne precautions - not droplet. Additional information: Influenza is a highly contagious respiratory infection. Hand hygiene should be reinforced, including the use of alcohol-based hand sanitizers before and after client care. Thorough and frequent hand hygiene is probably the most effective prevention method. NCSBN Client need: Topic: Safety and Infection Control; Subtopic: Transmission Based Precautions

When assessing the new stoma of a client diagnosed with Crohn's disease. Which of these will alert the healthcare provider that the stoma has retracted? A. Narrowed and flattened [29%] B. Concave and bowl-shaped [39%] C. Dry and reddish-purple [26%] D. Pinkish-red and moist

Explanation Choice B is correct. A stoma that has retracted will appear concave and bowl-shaped. A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. Monitoring for signs of proper healing and educating the client/caregivers on signs of complicated healing is important. Complications that could arise from retracted stoma include difficulty maintaining appliance placement, which could lead to leakage and irritated skin. Choice A is incorrect. A narrow, flattened, or constricted stoma indicates stenosis. Choice C is incorrect. A dry, dusky, or reddish-purple stoma indicates ischemia. Choice D is incorrect. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. It should appear pinkish-red and moist. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort, Fecal Elimination

Which of the following information would NOT be included in a client's pain history? A. The client's affective responses to pain [7%] B. The client's past alleviating measures [14%] C. The client's current vital signs [41%] D. The client's meaning of pain [38%]

Explanation Choice C is correct. The client's current vital signs would NOT be included in a client's pain history. However, these vital signs are part of the initial nursing assessment and ongoing assessments. Choice A is incorrect. The client's affective responses to pain are an integral part of a client's pain history; some emotional responses to pain include the client's feelings such as depression and anxiety in response to pain. Choice B is incorrect. The client's past alleviating measures that lessened their pain are an integral part of a client's pain history; therefore, this would be included in the client's pain history. Choice D is incorrect. The client's meaning of pain is an integral part of a client's pain history; therefore, this would be included in the client's pain history

After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the: A. Abdomen [9%] B. Arms [8%] C. Legs [78%] D. Chest [5%]

Explanation Choice C is correct. The level of injury in the spinal cord correlates with innervation on the skin according to the level of the dermatome. Choice A is incorrect. Innervation of the abdomen corresponds to T9 to T12 injury. Choice B is incorrect. Innervation of the arm correlates with C5 to T1. Choice D is incorrect. Injury to T1-T8 correlates with chest innervation. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Spinal Cord Injuries

You are working in a Family Practice office. A patient comes into the office with right facial drooping. The physician makes a diagnosis of Bell's palsy. You know that the primary treatment for this disease is likely to include: Select all that apply. A. Surgery [8%] B. Prednisone [49%] C. Antibiotic [14%] D. Antivirals [28%]

Explanation Choices B and D are correct. Prednisone or another corticosteroid is likely to be prescribed. The anti-inflammatory action of these medications may help to reduce the swelling of the facial nerve and lessen the impingement that is causing the facial drooping. Antivirals are controversial, but some studies show that the combination of antivirals with corticosteroids may be helpful in patients with severe facial drooping. Both of these medications should be given as soon as possible after the symptoms start. Physical therapy to massage facial muscles can help to minimize permanent damage. Choice A is incorrect. Although surgery was once a treatment for Bell's palsy, it is no longer recommended due to the risk of permanent nerve injury and hearing loss. Choice C is incorrect. Antibiotics provide no relief for this condition since it is not caused by a bacteria that will respond to medicine. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Expected Actions/Outcomes, Neurologic

The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include? A. Ask the client to wear a surgical mask during the visit. [4%] B. Obtain vital signs with a disposable blood pressure cuff. [78%] C. Interview the client while maintaining 3 feet distance. [6%] D. Use sterile gloves when performing venipuncture. [13%]

Explanation Choice B is correct. C. diff is a spore-producing bacterium that allows it to be transmitted between clients, environmental surfaces, and contaminated hands. Obtaining vital signs with disposable equipment is recommended to prevent the transmission of this pathogen. Choices A, C, and D are incorrect. The client transmits this pathogen by contact means, not droplets; thus, a mask is unnecessary. Interviewing the client at a spatial distance is not necessary as the pathogen is spread via contact with infected surfaces - not respiratory droplets. Venipuncture requires the use of clean gloves and handwashing. Sterile gloves are not necessary. Additional Info According to the Centers for Disease Control, the transmission of C. diff can be disrupted through: Meticulous hand hygiene with soap and water. Avoid using alcohol-based hand sanitizers. Using disposable healthcare equipment, such as blood pressure cuffs and stethoscopes. Disinfect surfaces with a bleach solution. Discontinuing unnecessary antibiotics.

The ABCDEs of melanoma identification include which of the following? Select all that apply. A. Asymmetry: one half does not match the other half [24%] B. Birthmark: cafe au lait spot that does not fade [6%] C. Color: pigmentation is not uniform [23%] D. Diameter: greater than 6 mm [22%] E. Evolving: any change in size, shape, color, elevation, or any new symptom such as bleeding, itching, or crusting [25%]

Explanation Choices A, C, D, and E are correct. ABCDE stands for: asymmetry, border, color, diameter, and evolution. Choice B is incorrect. The B in ABCDE stands for the irregular border of the lesion. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Melanoma

Which of the following skin lesions may be papular? Select all that apply. A. Acne [32%] B. Herpes zoster [30%] C. Nevi [14%] D. Warts [24%]

Explanation Choices A, C, and D are correct. Acne lesions may include papules as well as pustules. Warts and nevi (or moles) are benign papules. Choice B is incorrect. The lesions of herpes zoster are vesicular. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Skin Lesions

The nurse is caring for a 1-day old newborn client diagnosed with jaundice. Which of the following statements is true regarding jaundice in newborns? Select all that apply. A. Jaundice within the first 24 hours of life is physiologic. [17%] B. Unconjugated bilirubin is excreted in the stool. [14%] C. Assessing a newborn for jaundice involves inspection of the skin, sclera, and mucous membranes. [34%] D. When treating a jaundiced infant with phototherapy, an important nursing consideration is to ensure their eyes and genitals are covered. [35%]

Explanation Choices C and D are correct. When assessing an infant suspected to have jaundice, the most important thing to do will be to evaluate the skin, sclera, and mucous membranes (Choice C). When bilirubin levels are high, there will be a yellow tinge to these areas due to the high levels of the bilirubin pigment in the blood. Jaundice usually starts in the face and forehead area, so the nurse should begin her assessment looking there. The sclera and mucous membranes are a common location to appreciate the yellow discoloration, especially in a patient with darker skin. When treating a jaundiced infant with phototherapy, important nursing considerations are to ensure their eyes and genitals are covered (Choice D). Phototherapy helps reduce serum bilirubin levels by converting bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver. Phototherapy light can be harmful to the infant's eyes and genitals. Nurses should ensure these areas are covered with an eye mask and a diaper. Choice A is incorrect. Jaundice, within the first 24 hours of life, is pathologic. This means that there is some other disease process or condition, causing jaundice that needs to be investigated. Often, etiology includes ABO incompatibility leading to hemolysis, or liver pathology. Physiologic jaundice is noted 2-3 days after birth and is simply due to the normal process of the infant's liver taking over the processing of bilirubin. Since the liver is not mature enough to conjugate and excrete the bilirubin in the bile, predominantly unconjugated physiological jaundice appears. This type of disease should not be of any concern. Choice B is incorrect. It is the conjugated bilirubin that gets excreted in the stool, not unconjugated. Unconjugated bilirubin is the waste product that is released when the heme is released from hemoglobin in the process of red blood cell breakdown. It is transported to the liver to be converted into conjugated bilirubin. When converted to the conjugated form, it can be excreted in bile and reaches the small intestine. Small bowel bacteria convert this conjugated form to stercobilinogen and urobilinogen. Stercobilinogen gives the yellow color to feces. Urobilinogen is water-soluble and is detected in the urine. In obstructive jaundice, conjugated bilirubin does not reach the intestine, which results in pale stools. In newborns with hemolysis or liver pathology, the unconjugated form overwhelms the immature liver's capacity to conjugate. Hence, pathological jaundice ensues within 24 hours in such circumstances. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic care, comfort