Archer Review 7b

Select the culture that is accurately paired with an example of its associated cultural practice in terms of nutrition. A. Arabs: Liquids must be available with the meal to aid digestion and the enjoyment of the meal. [20%] B. Navajo: The major protein content for this culture is the consumption of sheep meat. [28%] C. Mexican Americans: All gifts of food should be not rejected, but instead, graciously accepted. [39%] D. African Americans: Foods included in the meal are served in the traditional order. [13%]

Explanation Choice B is correct. The main protein content for the Navajo culture is the consumption of sheep meat. Other cultural Navajo practices include corn and squash as their major vegetable. Food is a significant part of the Navajo native Americans celebrations. Choice A is incorrect. Arabs do not consume liquids with the meal to aid digestion and the enjoyment of the meal. Instead, Arabs do not consume juices or beverages until after the meal is completed. Choice C is incorrect. African American clients, rather than Mexican Americans, graciously accept gifts of food, and they do not reject them. Choice D is incorrect. The Chinese cultures, rather than African Americans, serve foods in a specific order according to their cultural practices.

You are caring for a client who is 5 foot 6 inches tall and has a BMI of 28. This client is now on a regular diet. You would most likely recommend: A. Continuing their diet as it is [12%] B. Weight reduction with diet and exercise [72%] C. A high caloric diet to gain weight [4%] D. Nothing at all, this client is normal [12%]

Explanation Choice B is correct. You would most likely recommend weight reduction with diet and exercise for this client who is 5 foot 6 inches tall and has a body mass index (BMI) of 28 because this client is overweight. The ranges for BMI are as follows: Underweight: Under 18.5 Normal: From 18.5 to 24.9 Overweight: From 25 to 29.5 Obesity: From 30 to 39.9 Extreme obesity: Over 40 Choice A is incorrect. You would not advise the client to continue with their current diet and nutritional intake because a body mass index (BMI) of 28 indicates the need for education about dietary intake. Choice C is incorrect. You would not advise the client to begin a high caloric diet to gain weight because a body mass index (BMI) of 28 indicates the need for education about dietary intake. Choice D is incorrect. A body mass index (BMI) of 28 indicates the need for education about dietary intake and exercise.

The client, who is 24 weeks pregnant, is complaining to the nurse about her "worsening varicosities." The nurse would advise her to: A. Avoid exercise as blood pools in her legs during movement [7%] B. Wear knee-high hose with garters [64%] C. Avoid citrus fruits [3%] D. Sleep in a side-lying position [26%]

Explanation Choice D is correct. Sleeping in a side-lying position ( "SOS," Sleep On Side) moves the fetus away from the inferior vena cava ( IVC). Therefore, the fetus's weight and pressure on the IVC are minimized, promoting venous return. Better venous drainage reduces potential lower extremity swelling, varicose veins, and hemorrhoids in the pregnant woman. Sleeping supine during pregnancy must be avoided because it increases the risk of late stillbirths. Traditionally, the left side-lying position is preferred over the right side because there is a theoretical risk of IVC compression due to the liver being present on the ride side. If the pregnant client is comfortable sleeping on the right side, it should not be discouraged because a 2019 meta-analysis has revealed both left and right-side lying positions are equally safe in pregnancy. Choice A is incorrect. Contrary to the statement, exercise promotes venous return when coupled with frequent rest periods. Pregnant women should be encouraged to exercise regularly. Choice B is incorrect. The client should avoid wearing knee-high stockings with garters. Garters are tight straps present at the top of the stockings to prevent the stockings from slipping down the leg. These garters can cause occlusion of the blood flow and increase the venous pressure in the extremities. The nurse must ensure that the stockings are not causing a garter effect at the knee or thigh level. The nurse should advise the pregnant client to wear graduated compression stockings ( GCS) or thrombo-embolus deterrent stockings ( TEDs). These should be applied up to above the point of varicose enlargement. In pregnancy, GCS or TEDs also serve as mechanical prophylaxis against deep vein thrombosis ( DVT). Choice C is incorrect. The client should increase her intake of vitamin C found in citrus fruits as vitamin C is involved in forming blood vessel collagen and endothelium. Additionally, vitamin C helps increase iron absorption in the gastrointestinal tract. Learning Objective Understand that varicosities are common in pregnancy, and the clients should be advised regarding side-lying sleep positions and graduated compression stockings. Additional Info Varicose veins are a common symptom during pregnancy, affecting about 40% of pregnant women. The gravid uterus puts pressure on the IVC, increasing venous pressure in the pelvis and lower extremities. In addition to the varicose veins in the lower extremities, varicosities in the vulvar region and hemorrhoids are also common in pregnancy. Women should be informed that these do not cause harm. Side-lying position and compression stockings can improve the varicose-related symptoms, but the evidence shows these measures will not prevent varicose veins from actually appearing.

When auscultating a patient's posterior lung sounds, where would the nurse place the stethoscope to assess bronchovesicular sounds? A. Under the lateral ribcage, on the left side [27%] B. Mid-clavicular line [24%] C. Between the scapulae, especially on the right side [41%] D. Lumbar region

Explanation Choice C is correct. Bronchovesicular sounds occur over major bronchi where there are fewer alveoli. They are moderate in pitch and amplitude and are normally equal during inspiration and expiration. Posteriorly, bronchovesicular breath sounds can be auscultated between the scapulae, especially on the right side. Choices A, B, and D are incorrect.

The nurse is caring for a client with an acute migraine headache. The nurse would anticipate a prescription for which medication? Select all that apply. A. Ketorolac [25%] B. Nitroglycerin [4%] C. Topiramate [16%] D. Dexamethasone [9%] E. Hydromorphone [19%] F. Acetaminophen-caffeine [26%]

Explanation Choices A, D, and F are correct. Treatment for an acute migraine headache (MH) involves abortive medications such as ketorolac (NSAID), dexamethasone (corticosteroid), and acetaminophen-caffeine. Depending on the severity of the MH, the provider takes a stepwise or aggressive approach to treatment. Choices B, C, and E are incorrect. Nitroglycerin would intensify the headache and would be unhelpful during an acute MH. Topiramate is an anticonvulsant and is a preventative treatment. Opioids (fentanyl, morphine, hydromorphone) are not recommended in managing an MH because they are likely to cause a paradoxical headache. Additional Info The treatment for an acute migraine headache aims to abort the headache and the associative symptoms such as nausea and vomiting. Commonly, a client may be prescribed an anti-emetic such as metoclopramide to assist with abating the symptoms. The below table reviews the treatment options for a migraine headache.

The primary healthcare provider (PHCP) prescribes 2350 mL of 0.9% saline to a client with severe hypovolemia. The PHCP prescribes the infusion over five hours. How many mL/hr will deliver the prescribed dose? Fill in the blank. 470 mL/hr

Explanation To solve this problem, the formula of volume / by the number of hours will be used 2350 mL / 5 hours = 470 mL/hr

The nurse is caring for a patient with left-sided heart failure. Which of the following signs and symptoms is related more to right-sided heart failure? A. Ascites [72%] B. Tachypnea [9%] C. Cough [3%] D. Crackles and wheezes [16%]

Explanation Choice A is correct. Ascites is a symptom of right-sided heart failure, not left-sided. Right-sided heart failure involves congestion in the systemic circulation. Patients with right-sided heart failure may also experience jugular vein distention, oliguria, weight gain, and peripheral edema. Choice B is incorrect. Tachypnea, or more frequent than normal respirations, is seen in left-sided heart failure as breathing becomes more difficult. In left-sided heart failure, fluid backs up into the lungs and makes breathing more difficult. Choice C is incorrect. A cough, along with other heart failure symptoms, is a sign of left-sided heart failure. As fluid backs up in a patient's lungs, the patient may present with a cough. Choice D is incorrect. Crackles and wheezes upon respiratory auscultation are a sign of left-sided heart failure. As fluid backs up into the lungs because the heart is unable to pump properly, the lungs sound wet, wheezy, and may present with crackles. NCSBN client need Topic: Physiologic integrity, alterations in body systems

The nurse is performing a physical assessment. The nurse should assess the client's visual acuity by obtaining which of the following? A. Snellen chart [42%] B. Tonometer device [10%] C. Penlight [15%] D. Slit lamp [32%]

Explanation Choice A is correct. Having a client stand 20 feet away from a Snellen chart is an appropriate assessment tool to determine a client's visual acuity. Choices B, C, and D are incorrect. A tonometer device is used to determine intraocular pressure, which is normally between 10- and 20-mm Hg. This device is useful in diagnosing ocular problems such as glaucoma. A penlight can be used for various ocular assessments, including if the pupils are reactive to light. A slit lamp is a tool used by an advanced provider that may determine any abnormality in the cornea, lens, or anterior vitreous humor. NCLEX Category: Health Promotion and Maintenance Related Content: Techniques of a Physical Assessment Question type: Knowledge/comprehension Additional Info A Snellen chart is a tool to determine a client's visual acuity. The client is instructed to stand 20 feet away from the chart, remove all glasses and contact lenses, cover each eye, read the line with the smallest letters, and read aloud. The results are expressed as a fraction where 20/20 is considered optimal. For example, if a client has a visual acuity of 20/40, that means an individual with 20/40 vision sees things at 20 feet that most people who don't need vision correction can see at 40 feet.

The nurse is caring for the following assigned clients. The nurse should prioritize a patient with which of the following? A. A patient being evaluated for chest pain and requests an antacid for indigestion. [74%] B. A patient reporting nervousness following the administration of albuterol. [22%] C. A patient requesting pain medication for their chronic knee and back pain. [3%] D. A patient awaiting discharge teaching on their insulin pump and glucometer. [2%]

Explanation Choice A is correct. Reports of indigestion could be a symptom associated with myocardial infarction. This atypical sign is concerning because the patient is already being evaluated for chest pain. Thus, the nurse needs to follow up with this patient. Choices A, B, and D are incorrect. Nervousness following the administration of albuterol is an expected finding because albuterol stimulates beta-adrenergic receptors. Pain medication for chronic pain is a priority but not the initial priority for the nurse because the nurse should always prioritize acute needs over chronic needs. Discharge teaching is a low-priority task for the nurse. Additional information: When prioritizing patient care, the nurse should always see patients who report acute changes, appear unstable or have imminent safety concerns. Unstable patients will have abnormal vital signs or exhibit signs such as restlessness which is a non-reassuring finding in any patient as it could be hypoxia, increased intracranial pressure, etc.

The client is receiving instructions from the nurse in a clinic about interventions that help alleviate symptoms of gastroesophageal reflux disease. Which statement from the client indicates an accurate understanding of the instructions given? A. "It's much better for me to wear loose-fitting clothes right now." [74%] B. "Thank goodness, I can still eat a burger and fries." [3%] C. "A glass of wine before bedtime can help me sleep better." [1%] D. "I need to take my medication, omeprazole, after meals."

Explanation Choice A is correct. The client with GERD is advised to avoid tight clothing and wear loose-fitting clothing. Choice B is incorrect. The client with GERD is encouraged to eat a low-fat, high-fiber diet. Burger and fries have high-fat content and may stimulate excess gastric acid production. Choice C is incorrect. Clients are instructed to avoid eating and drinking 2 hours before bedtime; they also need to avoid alcohol. Choice D is incorrect. Omeprazole is a proton pump inhibitor; it needs to be taken 20 - 30 minutes before meals to achieve its desired effect.

You are administering medications on the pediatric floor and have a patient who needs his scheduled clobazam. The order reads 5 mg PO BID. You remove the drug and the label reads clobazam 2.5 mg/mL suspension. How many milliliters will you administer to your patient? A. 2 mL [94%] B. 1 mL [3%] C. 3 mL [1%] D. 10 mL [2%]

Explanation Choice A is correct. The formula for calculating the correct medication dose is: the desired medication divided by the medication you have timed the vehicle the medication comes in. (D/H) x V. In this case, your desired dose is 5 mg. D = 5. The dose that you have is 2.5 mg, H = 2.5. The vehicle that medication comes in is 1 mL, V = 1. Therefore: (5 mg/2.5 mg) x 1 mL = 2 mL. You will administer 2 mL of clobazam to your patient for a total of 5 mg. Choice B is incorrect. The formula for calculating the correct medication dose is: the desired medication divided by the medication you have timed the vehicle the medication comes in. (D/H) x V. This gives you 2 mL as the proper amount. If you administered 1 mL, it would only be a total of 2.5 mg of clobazam, which is not the prescribed amount. Choice C is incorrect. The formula for calculating the correct medication dose is: the desired medication divided by the medication you have timed the vehicle the medication comes in. (D/H) x V. This gives you 2 mL as the proper amount. If you administered 3 mL, it would be a total of 7.5 mg of clobazam, which is not the prescribed amount. Choice D is incorrect. The formula for calculating the correct medication dose is: the desired medication divided by the medication you have timed the vehicle the medication comes in. (D/H) x V. This gives you 2 mL as the proper amount. If you administered 10 mL, it would be a total of 20.5 mg of clobazam, which is much more than the prescribed amount and would result in an overdose. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Medication Administration

Analyze the following ABG: pH 7.19, CO2 36, HCO3 12 A. Compensated metabolic acidosis [16%] B. Uncompensated metabolic acidosis [73%] C. Compensated respiratory acidosis [8%] D. Uncompensated respiratory alkalosis [3%]

Explanation Choice B is correct. First, determine if the ABG is compensated or uncompensated. Since the pH is not between 7.35 and 7.45, it is uncompensated. Next, decide whether it is acidosis or alkalosis. The pH is less than 7.35, so it is an acidosis. Lastly, determine if it is respiratory or metabolic. Evaluate the CO2 and HCO3 to see which is out of range. The CO2 is average, and the HCO3 is low, so this is a metabolic problem. Putting it all together, you have an uncompensated metabolic acidosis. This patient is not producing a sufficient amount of bicarbonate. Bicarbonate is a base, so without enough of it, the pH will become acidotic. The lungs have not yet started compensating, hence the average CO2 level. The lungs should begin compensating by breathing off more CO2, an acid, to increase the pH to normal levels. Choices A, C, and D are incorrect. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation

The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their A. dairy intake. [2%] B. fiber intake. [74%] C. fat intake. [8%] D. calcium intake.

Explanation Choice B is correct. It is appropriate for the nurse to advise the client to increase their fiber intake. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. The patient should ingest about 30 to 40 g of fiber each day. Choices A, C, and D are incorrect. Dairy may be a trigger for a client with IBS, and while triggers are individualized, dairy is likely a trigger for an IBS flare. Fat and calcium has no bearing on IBS management, and the emphasis should be on the intake of fiber. Additional Info Irritable bowel syndrome (IBS) is a functional GI disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. The client should ingest about 30 to 40 g of fiber each day. Eating regular meals, drinking 8 to 10 glasses of water each day, and chewing food slowly help promote normal bowel function.

The nurse should assess an Alzheimer's patient who has been started on rivastigmine for which of the following side effects? A. Liver toxicity [20%] B. Weight loss [15%] C. Renal failure [10%] D. Extrapyramidal side effects [55%]

Explanation Choice B is correct. The most common side effects of rivastigmine are flu-like symptoms, dizziness, and weight loss. The FDA has approved limited drugs for Alzheimer's Disease. The most effective medications act by intensifying the effect of acetylcholine at the cholinergic receptor. Acetylcholine is naturally degraded in the synapse by the enzyme acetylcholinesterase. When acetylcholinesterase is inhibited, acetylcholine levels increase and significantly affect the receptors. Choice A is incorrect. Liver toxicity is not an anticipated side effect of rivastigmine. Choice C is incorrect. Renal failure is not an anticipated side effect of rivastigmine. Choice D is incorrect. Extrapyramidal symptoms are not an anticipated side effect of rivastigmine. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacologic Intervention, Acetylcholinesterase inhibitors Used for Alzheimer's Disease

The emergency department (ED) nurse triages a client experiencing a panic attack. The client reports nausea, chest discomfort, and a feeling of impending doom. The nurse should plan to take which priority action based on the client's symptoms? A. Assess the client for suicide [13%] B. Obtain a 12-lead electrocardiogram (ECG) [57%] C. Develop a therapeutic rapport with the client [18%] D. Inquire about the precipitating event

Explanation Choice B is correct. When a client is experiencing a panic attack, somatic symptoms such as hyperventilation, perspiration, chest discomfort, and nausea are likely. However, the nurse should always prioritize physical needs/reports such as chest pain. The nurse should obtain a 12-lead electrocardiogram as this is an effective way to rule out acute coronary syndrome (ACS). ACS may cause similar symptoms, such as a feeling of impending doom, and the nurse should intervene and obtain this necessary test. Choices A, C, and D are incorrect. These actions are essential. However, they do not prioritize over physical needs. The nurse should assess the client for suicide; however, the time assessing for suicide should be spent determining the physical stability of the client. Developing a therapeutic rapport would be helpful. Inquiring about the precipitating event would be unhelpful during a panic attack because clients cannot solve problems and effectively reflect. Additional Info Maslow's Hierarchy of Needs can be an effective tool in solving this item. You may recognize that physical needs are at the bottom of the framework that is because it would be ineffective to keep a client safe who is physically unstable. Thus, physical reports and needs should always come first.

A neonate is suspected of having a tracheoesophageal fistula. Which symptom would the nurse observe from the neonate? A. Hypersensitive gag reflex [46%] B. Dry mouth [4%] C. Cyanosis [45%] D. Decreased level of consciousness [5%]

Explanation Choice C is correct. Cyanosis is a significant symptom in the infant with a tracheoesophageal fistula. This may be due to the aspiration of feeding when the infant is fed. Choice A is incorrect. A hypersensitive gag reflex is not related to a tracheoesophageal fistula. Choice B is incorrect. An infant with a tracheoesophageal fistula would display excessive salivation and drooling, not a dry mouth. Choice D is incorrect. A decreased level of consciousness is not related to a tracheoesophageal fistula.

Medications bound to protein have the following effect: A. Enhancement of drug availability. [7%] B. Rapid distribution of the drug to receptor sites. [21%] C. The more the drug is bound to protein, the less it is available for the desired effect. [36%] D. Increased metabolism of the drug by the liver.

Explanation Choice C is correct. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Plasma protein binding refers to the degree to which medications attach to proteins within the blood. A drug's efficiency may be affected by the degree to which it binds. The less bound a drug is, the more efficiently it can traverse cell membranes or diffuse. A drug in blood exists in two forms: bound and unbound. Depending on a specific drug's affinity for plasma protein, a proportion of the drug may become attached to plasma proteins, with the remainder being unbound. Only the unbound fraction of the drug undergoes metabolism in the liver and other tissues. As the drug dissociates from the protein, more and more drug undergoes metabolism. Changes in the levels of the free drug change the volume of distribution because the free drug may distribute into the tissues leading to a decrease in plasma concentration profile. For the medicines which rapidly undergo metabolism, clearance is dependent on hepatic blood flow. For drugs that slowly undergo metabolism, changes in the unbound fraction of the drug directly change the approval of the drug. Choice A is incorrect. Less of the drug is available if it is bound to protein. Choice B is incorrect. Distribution to receptor sites is irrelevant since the drug bound to protein cannot unite with a receptor site. Choice D is incorrect. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological Therapies, What Happens After a Drug Has Been Administered, Drug Metabolism

A client suddenly develops syndrome of inappropriate antidiuretic hormone (SIADH) after undergoing cranial surgery. Which manifestations should the nurse expect to see from the patient? A. Peripheral edema and weight gain [60%] B. Excessive urine production [14%] C. Normal or slightly increased blood pressure [13%] D. A low urine specific gravity [13%]

Explanation Choice C is correct. SIADH is an abnormal release of the antidiuretic hormone (ADH), which causes the client to retain water abnormally. It is a euvolemic condition because only free water is retained, not sodium. Because free water is retained, the urinary output is lower, urine osmolality is higher, and specific gravity is higher. Physical exam findings often reveal normal skin turgor. Blood pressure is mostly normal (normotensive) or slightly increased. Choice A is incorrect. Because of free water retention, one of the most typical manifestations of SIADH is euvolemic hyponatremia. Cerebral edema can be seen as the water moves into brain cells to equalize osmolality. Since the SIADH patients are euvolemic, peripheral edema, pulmonary edema, jugular venous distension, and hypotension are absent. SIADH patients can have weight gain, but peripheral edema is absent. Weight gain without peripheral edema is, therefore, a feature of euvolemic hyponatremia (SIADH). On the contrary, weight gain with peripheral edema, jugular venous distension, and pulmonary edema are features of hypervolemic hyponatremia (examples: congestive heart failure, liver cirrhosis). Decreased skin turgor, weight loss, and decreased blood pressure are seen in hypovolemic hyponatremia (examples: excessive diuretic use, the recovery phase of acute tubular necrosis) Choices B and D are incorrect. These represent Diabetes Insipidus ( DI). DI is characterized by decreased ADH release or decreased sensitivity to ADH. So, free water excretion increases. Therefore, it has opposite effects to that of SIADH. Excessive urine production, low blood pressure, and low urine specific gravity are manifestations of DI.

The nurse is discussing possible causes of sleeping difficulties in an older patient. Which of the following statements. If reported by the client indicates a need for further teaching? A. "I used chewing gum to help me quit smoking." [8%] B. "I take my dog for walks through the park two or three times a week." [2%] C. "Reading before bedtime helps calm me down." [7%] D. "I enjoy a cup of English tea before bed." [83%]

Explanation Choice D is correct. Since this client is experiencing insomnia, they should be advised to cut out stimulating drinks and food from their diet. English tea is a black tea that contains caffeine and may result in a lack of quality sleep. Choices A, B, and C are incorrect. Quitting smoking will help the patient sleep. Exercise and reading are both excellent ways to relax and sleep more effectively. NCSBN client need Topic: Health Promotion and Maintenance: Aging Process

A nurse is talking to a post Billroth I (Partial Gastrectomy and Vagotomy) client that is about to be discharged. Which of the following instructions should the nurse advise to the client? A. The client should stay upright for at least half an hour after eating. [62%] B. The client should drink a glass of water with meals to avoid acid reflux. [4%] C. The client is advised to increase the consumption of cereals and breads. [6%] D. The client should eat in a recumbent or semi-recumbent position. [27%]

Explanation Choice D is correct. The client should be taught ways on how to prevent and manage dumping syndrome. The client should be instructed to have small, frequent meals; maintain a high protein, high fat, low carbohydrate, and dry diet. The client should be notified to eat in a recumbent or semi-recumbent position. Such positioning during eating delays gastric emptying. Choice A is incorrect. The client is instructed to lie down after meals to delay gastric emptying. Choice B is incorrect. The client should not drink any water 1 hour before eating, with food, or 2 hours after eating to prevent dumping syndrome. Choice C is incorrect. The client should limit carbohydrate intake to prevent dumping syndrome.

The occupational health nurse was called to see a construction worker who has sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the worker's eye. Initial nursing intervention should be: A. Attempt to carefully remove the glass from the eye [3%] B. Reassure the worker that everything is okay [2%] C. Administer a sedative for pain relief [13%] D. Advise the worker to rest in a sitting position until expert care arrives [81%]

Explanation Choice D is correct. To prevent intraocular pressure (IOP) from increasing, the client should be advised to stay seated, as the lying position may increase IOP and cause the glass to advance further into the eye. The nurse should also recommend the client rest and avoid unnecessary movement until an ophthalmologist arrives to decrease the possibility of further eye damage. Choice A is incorrect. In cases of penetrating wounds, the nurse should never attempt to remove the object such as the piece of glass from the eye as it could tear or rupture the internal ocular structure, resulting in further and permanent damage. Choice B is incorrect. The nurse should reassure the client that medical help is on the way and stay with the client and his family until expert help arrives. However, false reassurance that "everything is okay" is inappropriate. Choice C is incorrect. The nurse must not administer any sedative unless ordered by a physician.

While orienting a new graduate nurse in the ICU, you take care of a patient scheduled for peritoneal dialysis. Which of the following principles do you explain to the new graduate about peritoneal dialysis functions? Select all that apply. A. Osmosis [32%] B. Diffusion [30%] C. Oncotic pressure [10%] D. Osmotic pressure

Explanation Choices A and B are correct. Osmosis is an essential principle upon which peritoneal dialysis functions. Osmosis is the passive movement of solvents, such as water, across a permeable membrane. The peritoneum is a permeable membrane. (Choice A). Diffusion is an essential principle upon which peritoneal dialysis functions. Distribution is the passive movement of solutes across a membrane. Solutes diffuse from an area of higher concentration to an area of lower concentration, across the peritoneum, until there is an equal amount of each on both sides of the membrane (Choice B). Choice C is incorrect. The oncotic pressure is a form of osmotic stress induced by proteins in a blood vessel's plasma that displaces water molecules. This is not an essential principle upon which peritoneal dialysis is based. Choice D is incorrect. Osmotic pressure is the pressure that would have to be applied to a pure solvent to prevent it from passing into a given solution by osmosis. This is not an essential principle upon which peritoneal dialysis is based. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Renal

While reviewing the client's medication list, the nurse understands which of the following prescribed medication (s) is/are classified as calcium channel blocker (s)? Select all that apply. A. Nifedipine [44%] B. Propranolol [7%] C. Verapamil [37%] D. Hydralazine [12%]

Explanation Choices A and C are correct. Nifedipine and verapamil are calcium channel blockers ( CCBs). Other CCBs include amlodipine, nicardipine, felodipine, and diltiazem. CCBs are broadly classified into dihydropyridine and non-dihydropyridine classes. The dihydropyridine calcium channel blockers ending with the suffix "-dipine" are more selective to the vascular system. They cause systemic vasodilation and are, therefore, used to decrease blood pressure ( treat hypertension). These agents also cause coronary vasodilation and consequently increase the blood flow to the myocardium. Increasing blood flow to the myocardium decreases anginal symptoms, another common reason nifedipine is prescribed (Choice A). However, due to systemic vasodilation, one of the most common side effects of these CCBs with the suffix "-dipine" is "reflex tachycardia." Because of this reflex increase in the heart rate and increased myocardial oxygen demand, the "-dipine" class has limited effectiveness in angina. Using a concomitant β-blocker can overcome this side effect. Verapamil ( Choice C) is a non-dihydropyridine calcium channel blocker that is relatively selective to the myocardium. Verapamil acts by reducing myocardial contractility ( negative inotropy) and is often used to treat angina. Tachycardia is detrimental in angina because increased heart rate increases myocardial oxygen demand. Verapamil is a preferred CCB in treating angina because it does not cause much vasodilation and hence, very minimal reflex tachycardia. Choice B is incorrect. β-blockers can be identified by their suffix ending with "-lol." Propranolol is a non-selective β-blocker. β-blockers block β- adrenergic receptors ( β1 and β2) in various body sites. β-1 receptors are present in the myocardium and kidneys whereas, β-2 are present in bronchial, uterine, vascular, and gastrointestinal smooth muscles. The catecholamines (epinephrine and norepinephrine) function via. β-receptors. Typically, catecholamines ( fight or flight hormones) increase blood pressure, increase pulse, increase contractility, and cause vasoconstriction ( remember - catecholamines increase everything). Therefore, blocking β-receptors decreases them all - reduces blood pressure, heart rate, myocardial contractility, and causes systemic vasodilation. β-blockers are classified into - selective ( atenolol, metoprolol) and non-selective ( propranolol, sotalol, nadolol, labetalol, carvedilol). The selective β-blockers selectively block β-1 receptors while sparing β-2. Therefore, selective β-1 blockers are preferred in treating hypertension, cardiac arrhythmias, angina, and congestive heart failure. The use of β-blockers in congestive heart failure (CHF) warrants further discussion because they have negative inotropic action ( reduces myocardial contractility and thereby reduces ejection fraction). β-blockers should not be used in acute CHF ( decompensated CHF/ CHF exacerbation) because they may worsen the symptoms by acutely reducing the ejection fraction. However, β-blockers are used as adjunctive therapy to ACE inhibitors ( ACEI)/ angiotensin receptor blockers (ARBs) and diuretics ( furosemide) in stable, compensated CHF. Numerous studies have shown β-blockers reduce morbidity and mortality in compensated, stable CHF. In clients with concomitant asthma and chronic obstructive pulmonary disease (COPD), non-selective β-blockers may worsen the respiratory symptoms by blocking β-2 receptors in the airway. Cardio-selective β-blockers like metoprolol and bisoprolol are preferred agents in CHF. However, despite being a non-selective β-blocker, carvedilol is one of the most preferred agents in stable CHF. Carvedilol is thought to help CHF patients by causing remodeling of the heart. Choice D is incorrect. Hydralazine is a direct vasodilator. The "-dipine" calcium channel blockers also cause vasodilation, but they work differently. Calcium channel blockers block the calcium channels in the vascular smooth muscle whereas, vasodilators like hydralazine act directly on the peripheral arterial vessels to cause vasodilation. Both CCBs and direct vasodilators lower blood pressure, but by different mechanisms. Learning objective: Identify CCBs and β-blockers. Understand the mechanism of action and relative selectivity of these agents. Realize that reflex tachycardia is one of the common side effects of CCBs ending with the suffix "-dipine," and this side effect can be overcome by using β-blockers. Recognize that while β-blockers have negative inotropic action, they are very beneficial in reducing mortality/ morbidity in compensated and stable CHF. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Cardiac

Which of the following motor skills does the nurse expect to be developed during the school-age period, ages 6 to 12-years-old? Select all that apply. A. Writing in cursive [27%] B. Increased hand-eye coordination [23%] C. Working a zipper [19%] D. Jumping rope [31%]

Explanation Choices A and D are correct. A is correct. Writing in cursive is a fine motor skill that children develop in the school-age period, between 6 and 12-years-old. During this period of time children should have already mastered holding a pen or pencil and manipulating it so that they are able to color and draw. When they start school, they begin fine-tuning those motor skills to write in cursive, a much more specific skill. Children younger than 6 have not yet developed the fine motor skills necessary to write in cursive. D is correct. Jumping rope is a gross motor skill that should be developed in the school-age period. This period is characterized by rapid learning and development of skills as children start school. Other motor development milestones during the school-age period include: riding a bike, playing games, swimming, and roller skating. Choice B is incorrect. Increased hand-eye coordination is a characteristic of the development of adolescents. During this final stage of childhood development, adolescents are beginning to develop the completed fine and gross motor skills that they will use in adulthood. School-age children have not yet developed the advanced hand-eye coordination skills that will develop through adolescence. Choice C is incorrect. Working a zipper is a fine motor skill that should be developed during the toddler period, from 1 to 3-years-old. This skill should not be developed during the school-age period, rather it should have already been developed before the school-age period. If a child begins school and is still unable to work a zipper, further evaluation is warranted to ensure they are not behind on other milestones.

The nurse is caring for a client receiving a continuous infusion of heparin for a pulmonary embolism. The nurse reviews the client's laboratory data and should take which action? See the image below. Select all that apply. A. Discontinue the heparin infusion [26%] B. Obtain an immediate activated partial thromboplastin time (aPTT) [19%] C. Assess the client's intravenous site for bleeding [22%] D. Prepare to administer a unit of packed red blood cells [5%] E. Notify the primary healthcare provider (PHCP) [27%]

Explanation Choices A and E are correct. Discontinuing the heparin infusion is essential because this is a life-threatening complication. Heparin-induced thrombocytopenia (HIT) is a hypercoagulable condition and promotes clotting. Continuing heparin in a client with HIT and acute pulmonary embolism may cause an extension of thrombus and even death. The physician must be notified; however, the heparin infusion must be held while awaiting the physician's orders. Choices B, C, and D are incorrect. Obtaining an immediate aPTT would be unhelpful because the issue is an autoantibody reaction with the heparin. This reaction would show in the client's platelets. Assessing the client for bleeding would be highly unlikely as thrombosis is likely to occur with this complication. Preparing a unit of packed red blood cells would not be an effective treatment as the client is not bleeding, and the immediate treatment is to cease the client's exposure to heparin. Learning Objective Recognize that Heparin-induced-thrombocytopenia is a hypercoagulable condition, not a bleeding disorder. Immediate discontinuation of heparin is necessary to prevent worsening thrombosis. Additional Info HIT is an adverse response to heparinoids. This autoantibody reaction causes venous ( deeper vein thrombosis, pulmonary embolism) and arterial thrombosis ( thrombotic strokes, myocardial infarction, arterial thromboembolism) The priority of HIT is to recognize it and stop the heparin product. The classic presentation of HIT is a reduction in the platelets by up to 50%, which is likely to occur between days four and five of heparin therapy. The nurse must report this type of platelet reduction immediately to the primary healthcare physician (PHCP). HIT treatment includes using an alternative anticoagulation agent such as fondaparinux, warfarin, rivaroxaban, dabigatran, and argatroban, inhibiting thrombin. Note that anticoagulation must be pursued in HIT despite thrombocytopenia.

Which of the following signs are indicative of heart failure in an infant? Select all that apply. A. Weight loss [12%] B. Tachycardia [29%] C. Diaphoresis [29%] D. Fatigue [31%]

Explanation Choices B, C, and D are correct. Tachycardia is a sign of heart failure. The heart is not pumping effectively and the cardiac output is therefore decreasing. The infant's body notices a decrease in oxygen delivery to the tissues and increases the heart rate to compensate for the decreasing cardiac output. This is why tachycardia is a sign of heart failure (Choice B). Diaphoresis is a sign of heart failure. Infants will become very sweaty when they are in heart failure; you can notice this especially on their scalp, where healthy babies would not usually sweat. They are diaphoretic because their body is working hard to compensate for the decrease in cardiac output due to heart failure (Choice C). Fatigue is common in heart failure (Choice D) due to the decreased cardiac output and thereby, reduced oxygen delivery to the tissues. The infant's body demands more oxygen and heart failure makes it difficult to keep up with the demand, so they get very fatigued. Choice A is incorrect. Weight gain, not loss, is a sign of heart failure in an infant. For infants experiencing heart failure, their hearts will not be pumping blood effectively. This means that fluid is not moving forward and blood is backing up in the body. This backup of blood leads to many complications, one of which is weight gain. When there are sudden weight changes, think fluid, not fat. Fluid changes most often are caused by cardiac problems. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Pediatrics - Cardiac

Select the complication of intravenous therapy that is accurately paired with one of its treatments. Select all that apply. A. Catheter embolus: Place a tourniquet distal to the intravenous site [12%] B. Site ecchymosis: Apply cool moist compresses after 48 hrs [13%] C. Infiltration: Stop the IV and elevate the affected limb [34%] D. Phlebitis: Culture the catheter and site if drainage is present [19%] E. Fluid overload: Assess the client's plasma sodium level [22%]

Explanation Choices C and D are correct. One of the treatment interventions, when an infiltration occurs, is to stop the IV and elevate the affected limb. Other interventions include the application of warm or cold compresses as indicated by the type of intravenous solution that infiltrated and starting another IV in an alternative limb when possible. If not possible, another IV should be started proximal to the infiltrated site. A culture of the intravenous catheter and the intravenous site should be done if drainage is present when phlebitis or thrombosis occurs as a complication of intravenous therapy. Other corrective treatment interventions include the immediate cessation of intravenous therapy, elevation of the affected limb, and the application of warm compresses. Choice A is incorrect. You would not place a tourniquet distal to the intravenous site for a catheter embolus. Instead, you would place a tourniquet as high on the limb as possible and proximal (not distal) to the intravenous site for a catheter embolus. This prevents the migration of the catheter pieces. Choice B is incorrect. Site ecchymosis is treated with the application of warm compresses after 48-72 hours, not cool moist compresses. Ice packs can be used for the first 24-48 hours after the injury. Other interventions for site ecchymosis include elevation of the affected limb and applying pressure to the intravenous therapy insertion site after the IV has been discontinued. Choice E is incorrect. Fluid overload is not treated with an assessment of the client's plasma sodium level. It can, however, be treated with stopping the intravenous therapy or reducing its rate by raising the client's head of the bed and the administration of diuretics to decrease fluid volume, as ordered.

A nurse is preparing to administer vancomycin to a child. The order is for 50 mg/kg/day in three divided doses. The client weighs 13 kg. The medication label indicates vancomycin 500 mg in 100 mL of 0.9% saline. How many mL will the nurse administer per dose? Fill in the blank. Round your answer to the nearest whole number. 43 mL

Explanation First, determine the total daily dose for this child 50 mg x 13 kg = 650 mg Next, determine the individual dose. Divide the daily dose by 3. 650 mg/day / 3 doses/day = 216.66 mg Next, divide the prescribed dose by the dose on hand x volume 216.66 / 500 mg x 100 mL = 43.32 mL Finally, round your answer to the nearest whole number. 43.32 mL = 43 mL Additional Info Vancomycin is a glycopeptide antibiotic that is effective in the treatment of MRSA infections.

Which of the following pharmacological statements is accurate? A. Idiosyncratic side effects to medications are relatively unpredictable and they occur on a highly individual basis. [22%] B. Pharmacokinetics addresses the three phases of medications which are the absorption, distribution, and excretion of medications. [67%] C. It is possible that isoniazid will more rapidly absorb among Scandinavians when compared to Japanese clients. [1%] D. Medications can lead to increased absorption when they have similar metabolic pathways. [10%]

Explanation Choice A is correct. Idiosyncratic side effects of medications are relatively unpredictable and they occur on a highly individual basis. Distinctive side effects of medications are peculiar, rare, and unusual side effects of the drug. Choice B is incorrect. Pharmacokinetics addresses the four phases of medications, which are the absorption, distribution, biotransformation or metabolism, and excretion of drugs; not the three phases of medications. Choice C is incorrect. Isoniazid may more slowly, but not more rapidly, absorb among Scandinavians when compared to Japanese clients. Ethnic differences in terms of medications are referred to as ethnopharmacology. Choice D is incorrect. Medications can lead to decreased, rather than increased absorption when they have similar metabolic pathways. Related metabolic pathways can lead to the accumulation of drugs and toxicity when one or more medications share the same metabolic pathway.

A 28-year-old married woman was just prescribed a pack of oral contraceptive pills. The nurse's initial instruction would be: A. "Once you've taken the pills, you are now safe from pregnancy whenever you have sexual contact." [4%] B. "You need to use another form of contraception for the next 7 days as these pills will not take effect during the first week." [77%] C. "You should take two pills today and take two pills tomorrow." [1%] D. "Expect to have breakthrough bleeding. This is because of the increased estrogen levels in your system brought about by the pills." [18%]

Explanation Choice B is correct. Contraceptive pills do not take effect until seven days after they are started. The nurse should instruct the client to use another form of contraception during the initial seven days that she takes the pills. Choice A is incorrect. The patient can still conceive during the first seven days of taking contraceptive pills. Contraceptive pills do not take effect until seven days after they are started. The nurse should instruct the client to use another form of contraception during the initial seven days she takes the pills. Choice C is incorrect. Taking two pills today and another two pills tomorrow is an instruction given by the nurse to the client who forgot to take her pills for two consecutive days. Choice D is incorrect. While this may happen as a side effect of the contraceptive medication, the most important instruction for the nurse to the patient would be to instruct them to use another form of contraception for the first seven days.

You receive an order to administer 600 mg ibuprofen to your patient PRN every 6 hours. You retrieve the medication which comes in 200 mg tablets. How many pills do you administer to your patient? A. 1 tablet [0%] B. 5 tablets [0%] C. 3 tablets [98%] D. 2 tablets [1%]

Explanation Choice C is correct. 3 tablets x 200 mg = 600 mg of ibuprofen. This is the correct dose. Choice A is incorrect. 1 tablet x 200 mg = 200 mg of ibuprofen. This is not the correct dose. Choice B is incorrect. 5 tablets x 200 mg = 1,000 mg of ibuprofen. This is not the correct dose. Choice D is incorrect. 2 tablets x 200 mg = 400 mg of ibuprofen. This is not the correct dose. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Medication Administration

Which of the following is an expected outcome for a pediatric client who is transitioning from being a toddler to a pre-school child? A. The parents will teach the child ways to perform concrete operations. [20%] B. The parents will teach the child ways to apply abstract thinking. [10%] C. The child will develop new coping strategies to adapt to a maturational crisis. [23%] D. The child will develop industry and a sense of achievement. [46%]

Explanation Choice C is correct. An expected outcome for a pediatric client who is transitioning from being a toddler to a pre-school child is that the child will develop new coping strategies to adapt to a maturational crisis. Maturational crises occur predictably along the life span with expected challenges and tasks that require the person to develop new coping strategies since previously learned coping strategies/mechanisms are no longer useful. Choice A is incorrect. It is not realistic for the parents to teach this child to perform concrete operations because this child is still in the preoperational stage of cognitive development, according to Jean Piaget. Choice B is incorrect. It is not realistic for the parents to teach this child to apply abstract thinking because this child is still in the preoperational stage of cognitive development, according to Jean Piaget. Choice D is incorrect. It is not realistic to expect this child to develop industry and a sense of achievement because instead, it is initiative that is the developmental task for this child, according to Erik Erikson.

The nurse is caring for a patient with suspected bowel perforation. Which of the following would be contraindicated for this patient? A. Administering gastrografin for an upper GI x-ray. [16%] B. An exploratory laparotomy procedure. [22%] C. Administering milk of magnesia following an upper GI study. [59%] D. An abdominal CT scan.

Explanation Choice C is correct. Milk of magnesia is a cathartic agent used to promote the excretion of barium sulfate following an upper GI study. Since barium sulfate would not be appropriate for this patient due to bowel perforation, gastrografin would be used instead. Gastrografin may cause diarrhea, which would be exacerbated by giving this patient milk of magnesia. Choice A is incorrect. Water-soluble gastrografin is an osmotic cathartic and is indicated for patients with bowel perforation who require upper GI x-ray studies. Gastrografin is used instead of barium sulfate. Choice B is incorrect. Surgical intervention (i.e. exploratory laparotomy) is commonly used to diagnose and determine the cause of bowel perforation. This procedure would be indicated for this patient unless other issues are present that would prevent the patient from tolerating surgery, such as severe congestive heart failure or multiorgan failure. Choice D is incorrect. Bowel perforation is not a contraindication for a CT scan. CT imaging may be more useful than x-ray in locating bowel perforation due to more sensitive imaging/results. NCSBN Client Need Topic: Gastrointestinal, Subtopic: Diagnostic tests, the potential for complications of diagnostic tests/treatments/procedures, elimination

The nurse is preparing to remove a central venous catheter. It would be appropriate to place the client in which position for this procedure? A. Reverse Trendelenburg [11%] B. Left lateral [8%] C. Trendelenburg [35%] D. High-Fowler's [46%]

Explanation Choice C is correct. Placing the client supine or Trendelenburg for this procedure would be appropriate. One of these two positions is acceptable to decrease the risk of air embolism. The client should not have their head elevated for this procedure. Choice A, B, and D are incorrect. The positioning of a client is essential to avoiding an air embolism. Thus, having a client high-Fowler's, lateral, or reverse Trendenlenberg would be contraindicated. If a client experiences an air embolism, turning the client to the left-lateral position would be appropriate, but not for the procedure of removing a central line itself. Additional Info During the removal of a central venous catheter, the client should be positioned either supine or in Trendelenburg. The catheter should not be removed while the client is sitting up because this would increase the risk of air embolism because of the rise in atmospheric pressure compared to intrathoracic pressure. To ensure that the intrathoracic pressure is higher than atmospheric pressure, position them either supine or Trendelenburg and have the client hold their breath or perform a Valsalva maneuver during removal.

A nurse educator is shadowing a student nurse taking care of a psychiatric client. The nurse educators should instruct the student that a therapeutic nurse-client relationship starts with: A. A sincere desire to help others [9%] B. Acceptance [18%] C. Understanding and self-awareness [68%] D. Knowledge of psychiatric nursing [5%]

Explanation Choice C is correct. The basis for a robust nurse-client relationship is a strong knowledge and awareness of self. Choices A, B, and D are incorrect. Although all other options are desirable, the nurse should first be self-aware and understand his/her self and personal feelings before he/she can initiate a relationship with a psychiatric client.

Select the age group that is accurately paired with a physiological characteristic that places them at risk for adverse effects, contraindications, side effects, and/or interactions related to medications. A. Neonates: Acidic gastric acids that affect absorption [4%] B. Toddler: Immature hepatic functioning that affects distribution [8%] C. The elderly: Decreased renal perfusion that affects excretion [85%] D. Adolescents: An underdeveloped blood-brain barrier

Explanation Choice C is correct. The elderly population, as the result of the regular changes occurring in the aging process, is at a higher risk for adverse medication effects, contraindications, side effects, and interactions. Among these frequent changes of the aging process include decreased renal perfusion and functioning, decreased hepatic perfusion and functioning, lowered bodily water, reduced gastric acid production, increased adipose tissue, and polypharmacy as the result of multiple chronic diseases and disorders. This also increases the elderly's risk for adverse effects, contraindications, side effects, and/or interactions. Choice A is incorrect. Neonates can be affected by adverse effects, contraindications, side effects, and interactions with medications because their gastric acid is more alkaline (not more acidic). Choice B is incorrect. Neonates and infants less than one year of age have immature hepatic functioning that affects distribution (not toddlers). Choice D is incorrect. Neonates and infants less than one year of age have an underdeveloped blood-brain barrier (not adolescents).

The nurse is caring for an infant with gastroesophageal reflux. At the beginning of the shift, she has been prescribed thickened feedings to help with the reflux. Which sign would indicate the effectiveness of the intervention? A. Increased stools [4%] B. Decreased urine output [0%] C. Absence of vomiting [86%] D. Weight gain [9%]

Explanation Choice C is correct. Thickened feedings are given to the child to stop the reflux of gastric contents back into the esophagus and prevent vomiting. Choice A is incorrect. Thickened feedings do not have any effect on the stools of the infant. Choice B is incorrect. Thickened feedings do not have any effect on the urine output of the infant. Choice D is incorrect. Weight gain is not expected since the intervention was only started during the shift.

When assessing a 2-year-old patient for potential neglect. Which of the following signs should the nurse assess for? Select all that apply. A. Height and weight [33%] B. Bruising [28%] C. Developmental milestones [35%] D. Temperature [4%]

Explanation Choices A and C are correct. The nurse should assess the child's height and weight to evaluate for potential neglect. A child who has been neglected will likely fall behind the growth and development of other children their age. Their height and weight should be plotted on the growth chart specific to their age and sex to determine where they fall. If they are steadily falling behind, it could be a physical sign of their neglect (Choice A). The nurse should assess the child's development to evaluate for potential neglect. A child who has been neglected will likely fall behind in both the growth and development of other children their age. For example, developmental milestones that the average two-year-old should achieve include: knowing the names of body parts, saying 2-4 word sentences, building towers of 4 or more blocks, kicking a ball, running, and walking up/downstairs. A child who has been neglected may be falling behind in these milestones (Choice C). Choice B is incorrect. Bruising is not a sign of neglect. The definition of negligence is to fail to care for properly. The child who is being neglected might be left at home alone unsupervised, not given adequate food and nutrition, not being taken to their pediatrician, behind on their vaccination schedule, and more. The definition of abuse, on the other hand, is to treat a person with cruelty or violence. This could include physical abuse, where a child may show bruising. Choice D is incorrect. The child's temperature will not help the nurse assess for neglect. A fever could indicate an illness, but would not assist in determining negligence. The nurse should assess the child's physical appearance, height, weight, and developmental milestones. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Abuse & Neglect

Which of the following interventions should the nurse anticipate for an infant with omphalocele awaiting surgical repair? Select all that apply. A. Cover the intestines with a sterile gauze soaked in saline [43%] B. Prone positioning [10%] C. Radiant warmer for thermoregulation [30%] D. Trophic feedings [16%]

Explanation Choices A and C are correct. It would be appropriate to cover the intestines with sterile gauze soaked in saline. This will do two things: it will keep the intestines moist and it will prevent infection. It is a priority nursing intervention to prevent infection in these patients because their abdominal contents are exposed to the environment putting them at risk of infection. It is also a priority to keep the intestines from drying out, as this will severely decrease their ability to function after the surgical repair (Choice A). Using a radiant warmer for thermoregulation is appropriate. These infants will struggle to maintain their body temperatures, as their intestines are open to the air. Additionally, they cannot be tightly swaddled as this would put pressure on the exposed intestines. Using a radiant warmer can help with thermoregulation in these infants without compromising the intestines (Choice C). Choice B is incorrect. It is inappropriate to position an infant with an omphalocele in the prone position. This would place their exposed intestines directly onto the bed surface, compressing them and pushing them inside the infant. This must be avoided. Supine positioning is appropriate instead. Choice D is incorrect. Trophic feedings would not be started in an infant with an omphalocele before the surgical repair. The intestines will need to be placed back inside the infant before feeds can start. At first, they will be primarily parenteral, with very gradual increases in the enteral feeds.

The nurse is caring for a patient with Borderline Personality Disorder. Which of the following actions should the nurse take? Select all that apply. A. Assess the patient for suicide [24%] B. Encourage independent decision-making [11%] C. Establish therapeutic boundaries [29%] D. Refer the patient for therapy [20%] E. Encourage social relationships [16%]

Explanation Choices A, C, and D are correct. Individuals with Borderline Personality Disorder (BPD) often engage in self-harm/parasuicide behaviors in which the intent is not death. These gestures may be superficial cutting, etc. All patients should be assessed for suicide regardless of their diagnosis. Therapeutic boundaries should be established as a characteristic of this personality disorder is polarizing individuals and splitting. Referring the patient for therapy is one of the cornerstone treatments for BPD. Choices B and E are incorrect. Independent decision-making is not impaired for an individual with BPD. This would be an intervention for Dependent Personality Disorder. Finally, the patient with BPD can establish social relationships - although they may be unstable, this would be an intervention for Avoidant Personality Disorder. Additional information: Borderline Personality Disorder occurs more in females than males and has features such as self-harm/parasuicidal behavior, splitting, unstable relationships, an unclear self-image, and impulsivity.

The nurse is teaching parents about antepartum testing. Which statements should the nurse include? Select all that apply. A. "Oral glucose tolerance testing will measure fetal activity at certain intervals." [8%] B. "A nonstress test may be used to measure fetal heart rate." [44%] C. "Amniocentesis may be used to assess if you have preeclampsia." [7%] D. "Chorionic villus sampling may be done to assess for neural tube defects." [38%] E. "You may need to fill up your bladder prior to an ultrasound."

Explanation Choices B and E are correct. A nonstress test is performed in the third trimester if the client has indications such as a high-risk pregnancy that may result in a stillbirth or complications such as fetal hypoxia. Ultrasounds typically require a full bladder as the fluid moves the uterus upward and assists with visualization. Choices A, C, and D are incorrect. Oral glucose tolerance testing is completed between 24-28 weeks of gestation. This test is used to determine if the client has gestational diabetes and does not take into account fetal activity. Amniocentesis is an antepartum test that may be used to determine the gender of the fetus, lung maturity, neural tube defects, or chromosomal abnormalities. Chorionic villus sampling is a test that may be performed as early as ten gestational weeks to determine if the fetus has any chromosomal abnormalities. Additional Info Amniocentesis is performed for a variety of indications and at different gestational ages. Common indications for amniocentesis include identifying chromosomal, metabolic, or genetic abnormalities. Amniocentesis can assist in determining fetal lung maturity (FLM) status. After this procedure, women should be instructed to report signs of bleeding, amniotic fluid that continues to leak after 24 hours, severe cramping that lasts several hours, or a temperature greater than 100.4°F

The nurse is performing an assessment on a term newborn four hours after delivery. Which assessment findings require follow-up? Select all that apply. A. Head circumference of 34 cm [13%] B. Chest is 2 cm smaller than the head [10%] C. Vernix caseosa in the skin folds [4%] D. Positive Babinski reflex [4%] E. Asymmetrical gluteal folds [33%] F. Jaundice noted in the head [34%]

Explanation Choices E and F are correct. Jaundice may be classified as pathologic or physiologic. Jaundice with an onset of less than 24-hours is pathologic and concerning as this may indicate hemolysis. Asymmetrical gluteal folds are not an expected finding because this suggests developmental dysplasia of the hip. Choices A, B, C, and D are incorrect. These assessment findings are within normal limits and do not require follow-up. A head circumference of 34 cm is normal. The normal head circumference of a term newborn is 32 to 38 cm. It is expected for the chest to be 2 to 3 cm smaller than the head. Vernix caseosa in the skin folds is a normal finding. This biofilm is usually washed away after birth. A Babinski reflex that is positive is an expected finding. This reflex may be elicited by stroking the lateral sole of the foot from the heel to across the base of the toes. This reflex disappears in eight to nine months. Additional Info When measuring the head circumference of a newborn, the nurse should measure around the fullest part of the head, with the tape placed around the occiput and just above the eyebrows. When measuring the chest circumference of a newborn, the nurse should measure the chest at the level of the nipples. The normal head circumference for a term newborn is 32 to 38 cm. The normal chest circumference for a term newborn is 30 to 36 cm. It is normal for the chest to be 2 to 3 cm smaller than the head. If molding of the head is present, the head and chest measurements may be equal at birth.

A woman comes into the emergency department with multiple bruises on the face and head. The nurse suspects that intimate partner violence (IPV) may be the cause of her injuries. What is the most appropriate action for the nurse to take at this time? A. Ask the person if she is afraid of someone at home who is hurting her. [61%] B. Refer the person to a shelter for battered women. [6%] C. Call a social worker to assess the person for IPV. [32%] D. Document the concern in the chart, but do nothing else.

Explanation Choice A is correct. Asking the patient if he or she is afraid of someone at home or if they are being hurt at home is the first critical step in a comprehensive assessment. Intimate partner violence (IPV) is a serious problem for men and women of all socioeconomic and cultural backgrounds. Age is also not a defining factor for potential victims, either. Nurses should suspect IPV when injuries are not consistent with the history given by the client. Choice B is incorrect. Referring the patient to a shelter before a complete assessment is done may lead to inappropriate care. Choice C is incorrect. While collaboration with other health professionals may be necessary, the first step is a comprehensive assessment by the nurse. Choice D is incorrect. Documentation alone does not address, reduce, or solve the concern. NCSBN Client Need Topic: Safe & Effective Care Management, Subtopic: Safety & Infection Control

Two nurses are taking an apical-radial pulse and note a difference in the pulse rate of 8 bpm. The nurse would document this difference as to which of the following? A. Pulse deficit [71%] B. Pulse amplitude [19%] C. Ventricular rhythm [4%] D. Heart arrhythmia [6%]

Explanation Choice A is correct. Counting of the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical-radial pulse rate. A difference between the apical and radial pulse rates is called the pulse deficit, which indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated. When taking a pulse, the rate, rhythm, and strength or amplitude of the pulse are noted. The average pulse in an adult is between 60 and 100 beats per minute. The rhythm is checked for possible irregularities, which may be an indication of the general condition of the heart and the circulatory system. Choice B is incorrect. Pulse amplitude is defined as the strength of a pulse. It is often described as nonpalpable, weak, thready, secure, or bounding. Choice C is incorrect. Ventricular rhythm relates to the rhythm with which the ventricles contract and relax within a cardiac cycle. Choice D is incorrect. Heart arrhythmia, also known as irregular heartbeat or cardiac dysrhythmia, is a group of conditions where the pulse is intermittent, too slow, or too fast. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Pulse

While working in a pediatric cardiac unit, you are assigned to take care of an infant with tetralogy of Fallot. During report, you are told that the infant is having frequent 'tet spells'. To prepare for your shift, which medication do you ensure is readily available in case of a tet spell? A. Morphine sulfate [38%] B. Dexmedetomidine [21%] C. Fentanyl [7%] D. Atropine sulfate [34%]

Explanation Choice A is correct. Morphine sulfate is the drug of choice for use during tet spells. It helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and therefore the hypercyanotic tet spell. Choice B is incorrect. Dexmedetomidine is a sedative. It is not used for tet spells. Choice C is incorrect. Fentanyl is a narcotic used for pain relief. Although it is similar in some ways to morphine sulfate, it is not used for tet spells. Choice D is incorrect. Atropine sulfate is an anticholinergic. It is used for several different purposes such as treating a slow heart rate or to decrease saliva production prior to surgery, but it is not used for tet spells. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies, Cardiovascular

Which of the following statements, if made by a male cancer patient with hair loss secondary to chemotherapy, indicates the goal for new coping patterns is being met? A. I washed my wig today. [76%] B. I asked my dad to bring me some shampoo. [6%] C. I'm thinking of getting new barrettes for my hair. [13%] D. I'm considering changing my hair color. [5%]

Explanation Choice A is correct. One of the best indicators for adapting to coping mechanisms is when the client is showing a willingness and ability to assume the responsibility of self-care. Setting goals for new coping patterns and monitoring for the development of effective coping mechanisms is crucial for this client. Any indication that the client is accepting the loss of hair and a willingness to participate in self-care activities is a sign that goals are being met. Choices B, C, and D are incorrect. The client is experiencing hair loss due to chemotherapy treatment. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Stress and Coping

A client has been placed on a sodium-restricted diet following a myocardial infarction. Which of the following would be the most appropriate meals to suggest? A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. [81%] B. Broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk. [9%] C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple. [2%] D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice. [8%]

Explanation Choice A is correct. People with heart failure may improve their symptoms by reducing the amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt. Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup. Patients should be encouraged to follow a low-sodium diet to help manage symptoms of hypertension and to reduce edema. One of the most natural things a patient can do at home is to reduce the amount of sodium intake. They can also eat fresh vegetables rather than canned. If canned vegetables are the only option, the patient should rinse the plants with clean water and cook them with unsalted water. Choice B is incorrect. Canned vegetables should be avoided. Choices C and D are incorrect. Canned or processed meats are higher in sodium and should be avoided. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse is caring for a patient with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins including a minimal amount of serous exudate. Which of the following interventions is contraindicated for this patient? A. Apply TED hose to bilateral legs [72%] B. Assess the need for smoking cessation [6%] C. Physical therapy consult [8%] D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler [14%]

Explanation Choice A is correct. The patient is presenting with signs of arterial insufficiency. The application of compression (TED hose) to the extremities is contraindicated in cases of severe arterial problems and should not be applied until cleared by the healthcare provider. The physician may want to make sure that the perfusion is adequate before clearance is given to apply a compression device. Choices B, C, and D are incorrect. These are appropriate and indicated for a patient with peripheral arterial disease (PAD). Smoking is a significant risk factor for developing arterial problems. Patients with PAD should be counseled to stop smoking (Choice B). Exercise improves the PAD symptoms. Most PAD patients do not get enough exercise; nurses should encourage patients to participate in physical therapy and to ambulate frequently throughout the day (Choice C). The ankle-brachial index (ABI) is a non-invasive way to calculate the relative severity of PAD (Choice D). NCSBN Client Need Topic: Cardiovascular, Subtopic: Potential for complications from health alterations, system-specific assessments, pathophysiology

While looking at routine lab draw levels, the nurse notices a patient's potassium is 6.3 mEq/L. The nurse calls the patient to notify them and encourage them to be seen by a provider. What sort of physical changes is the nurse concerned about? A. Headache [8%] B. Peaked T waves on EKG [85%] C. Right lower quadrant pain [2%] D. Shortened QRS interval [5%]

Explanation Choice B is correct. Hyperkalemia will cause EKG changes like peaked T waves, widened QRS complexes, and ST-segment depression. Choice A is incorrect. Having a headache is not directly related to hyperkalemia. Physical changes related to hyperkalemia include chest pain, arrhythmias, and muscle weakness or paralysis. Choice C is incorrect. Abdominal pain has no direct relation to hyperkalemia. RLQ pain might be a possible sign of appendicitis, but it does not relate to hyperkalemia. Choice D is incorrect. The QRS interval is lengthened, not shortened. This is a physical characteristic seen on EKGs in patients with hyperkalemia. NCSBN Client Need Topic: Physiological Adaptation; Sub-topic: Fluid and Electrolyte Imbalances

The nurse is observing a newly hired nurse apply bilateral wrist restraints to a client. Which action by the newly hired nurse requires follow-up? A. Secures the restraint to the frame of the bed. [13%] B. Repositions the client from semi-Fowlers to prone. [73%] C. Provides easy access to the quick release buckle. [6%] D. Assesses the radial pulse every two hours. [8%]

Explanation Choice B is correct This action is not appropriate and requires follow-up. A client in physical restraints should not be positioned prone, which may lead to suffocation. Additionally, a client should not be positioned supine because this makes the client feel vulnerable. Choices A, C and D are incorrect. These actions by the newly hired nurse are appropriate and do not require follow-up. Physical restraints should not be secured to the side rails as this may result in physical injury to the client. Securing the restraint with a knot is no longer acceptable clinical practice and the nurse should engage a quick release buckle that is anchored to the bed frame. Part of the assessment of a client in bilateral wrist restraints includes the client's radial pulses to determine the client's neurovascular status. Additional Info Restraints should be used as a last resort if alternative methods are not effective. A nurse should never threaten a client with restraints. This is considered assault. The nurse may place a client who is violent in restraints without an order from the primary healthcare provider (PHCP). If this was to occur, the nurse has one hour to inform the provider and obtain an order. Restraints are never as needed (PRN). They should be discontinued at the earliest possible time. When restraining a client, the reason for the restraint must be explained to the client and the behavior the client needs to demonstrate for the restraints to be discontinued. The nurse should observe the client at frequent intervals to offer nutrition & toileting, assess their behavioral status, obtain vital signs, and provide range of motion. These intervals are determined by the facility and the type of restraint—the more restrictive the restraint and the younger the client, the more frequent assessment. Restraints must be able to quickly be removed via a quick release buckle (knots are no longer recommended). The nurses' documentation must be comprehensive, describing the reasoning for the restraints, alternatives utilized, the education provided to the client, the type of restraint utilized, how it was secured, and the ongoing behavior necessary to continue the restraint. The nurse should also document the intervals at which the restraints were released.

The nurse is caring for a client experiencing acute mountain sickness (AMS). The nurse anticipates a prescription for which medication? A. Sodium bicarbonate [22%] B. Acetazolamide [42%] C. Tamsulosin [22%] D. Dutasteride [14%]

Explanation Choice B is correct. Acetazolamide, a carbonic anhydrase inhibitor, is commonly prescribed to prevent or treat AMS. It acts by causing a bicarbonate diuresis, which rids the body of excess fluid and induces metabolic acidosis. The acidotic state increases the respiratory rate and decreases the occurrence of periodic respiration during sleep at night. In this way, it helps clients acclimate faster to a high altitude. By increasing the client's respiratory rate, the client can perfuse more oxygen. It is preferred that this medication be taken 24 hours prior to the ascent. Choices A, C, and D are incorrect. Sodium bicarbonate is not indicated for AMS. The goal is to create metabolic acidosis by giving the client prescribed acetazolamide, increasing the client's respiratory rate, and increasing oxygen delivery. Tamsulosin and dutasteride are indicated in benign prostatic hyperplasia (BPH) treatment. Additional Info Acute mountain syndrome (AMS) causes increased sympathetic nervous system activity, increased heart rate, blood pressure, and cardiac output. Pulmonary artery pressure rises as an effect of generalized hypoxia-induced pulmonary vasoconstriction. Cerebral blood flow increases to maintain cerebral oxygen delivery. All of these processes call for an increased need for oxygen. Treatment for AMS includes supplemental oxygen (if available) and getting the client to a lower altitude. The client may also benefit from prescribed acetazolamide.

The nurse is performing a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are A. Heberden's nodes. [18%] B. Janeway lesions. [52%] C. tophi. [11%] D. Bouchard's nodes.

Explanation Choice B is correct. Janeway lesions are common with infective endocarditis (IE). The cause of these findings are the cause of the lesions are septic microemboli from the valvular lesion. These macules are not painful and are typically located on the palms, soles, and plantar surfaces of the toes. Choices A, C, and D are incorrect. Heberden's and Bouchard's nodes are associated with arthritis. Heberden nodes are bony nodules at the distal interphalangeal [DIP] joints. Bouchard's nodes are bony nodules at the proximal interphalangeal [PIP] joints. Tophi are dermal and subcutaneous deposits of urate crystals associated with gout. 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. Manifestations of IE include fever, anorexia, weight loss, cardiac murmur, petechiae, Janeway lesions, and splinter hemorrhages are commonly observed with IE.

An emergency department (ED) nurse establishes continuous cardiac monitoring for a client. The following tracing is observed on the monitor. The nurse should take which initial action? See the image below. A. Establish vascular access and request a prescription for atropine [29%] B. Assess the client's blood pressure and level of consciousness [54%] C. Obtain and review the client's current medications [8%] D. Document the findings and reassess the client in one hour [8%]

Explanation Choice B is correct. The nurse should prioritize assessing the client's vital signs and level of consciousness. This tracing reflects sinus bradycardia. While sinus bradycardia may be benign, if the client should experience unstable blood pressure or have dizziness, the nurse will need to act by establishing vascular access and administering atropine. However, this is predicated on the client's overall stability which can only be discerned by assessment. Choices A, C, and D are correct. These actions are plausible but do not prioritize assessing the client and their overall condition. Reviewing the client's current medications may determine the origin of the bradycardia but will not yield clues as to the client's current level of stability. Documentation should only occur once the nurse has determined that the client is stable. Additional Info Sinus bradycardia is a regular rhythm with a rate of less than sixty. Sinus bradycardia is only concerning if the client is symptomatic. Pathological causes of bradycardia include severe hypothyroidism, hypothermia, anorexia nervosa, and prolonged hypoxia.

A primigravida patient begins labor and is visibly upset that her family is unavailable. Which is the most appropriate approach for the nurse to take to help meet the client's needs at this time? A. Assure her that the nursing triage team will stay with her at all times. [24%] B. Encourage the client regarding her own abilities to cope and maintain a sense of control. [30%] C. Ask the client if there is someone else who wants to be her support person. [41%] D. Tell the client that they will try to locate her family.

Explanation Choice C is correct. Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her. Women and families have different expectations during childbearing. These expectations are shaped by their experiences, knowledge, belief systems, and social as well as family backgrounds. In most cases, a childbirth companion (or social support during birth) has been found to improve the whole birth experience. Research shows that women who receive good social support during labor and childbirth tend on average to have shorter labors, control their pain better, and often have less need for medical intervention. With these things in mind, the nurse should put forth an effort to help find a support person for the laboring mother. Keep in mind, while nursing staff and non-medical staff can offer support, this is a very emotional time for the mother. Asking the mother's preference regarding who an alternate support person should be would give her the ability to feel like she still has some control over the situation and may prevent worsening stress. Choice A is incorrect. The triage team is responsible for the initial assessment of the client. While the nursing staff and ancillary personnel will check on the mother throughout the labor process, it is unlikely that staff will be with her "at all times." Choice B is incorrect. Although the client should be encouraged, this is an emotional time, and having the support of friends/loved ones is important. Choice D is incorrect. It is most appropriate to ask the client if there is someone specific she would like to have contacted on her behalf. It is not up to the nurse to determine who should be contacted. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Emotional Support During Labor

The nurse has provided medication instruction to a client who has been prescribed formoterol. Which of the following statements would indicate a correct understanding of the teaching? A. "I will take this medication if I experience shortness of breath." [30%] B. "I will need to rinse my mouth out after using this medication." [43%] C. "This medication may make it hard for me to fall asleep." [17%] D. "I should take this medication two hours before I go exercise." [10%]

Explanation Choice C is correct. Beta-adrenergic agonists may cause a client to develop insomnia because the medication has the propensity to activate the client and their adrenergic receptors. Drugs in this class (albuterol, salmeterol) share the same effect, insomnia. Choices A, B, and D are incorrect. Formoterol is a long-acting beta-agonist and is indicated in the management of chronic respiratory illnesses. This medication should not be used in acute dyspnea. The client is not required to rinse their mouth out following the use of this medication. This is appropriate instruction for inhaled corticosteroids such as fluticasone. This medication is given on a scheduled basis, and a medication such as montelukast is given two hours prior to exercise to prevent exercise-induced asthma. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Adverse Effects/Contraindications/Side Effects/Interactions Question type: Analysis Additional Info Long-acting beta-agonists (LABAs) are indicated in the maintenance treatment of asthma. The client should be taught that this medication is not indicated for acute exacerbations. Adverse reactions of LABAs include tachycardia, palpitations, and angina.

The nurse is caring for a client prescribed dutasteride. The nurse understands this medication had achieved its therapeutic effect when the client reports decreased symptoms of A. pyrosis. [12%] B. hypothyroidism. [3%] C. urinary retention. [73%] D. anxiety. [11%]

Explanation Choice C is correct. Dutasteride works by inhibiting this enzyme 5-alpha reductase, which normally converts testosterone to 5-alpha dihydrotestosterone (DHT). DHT is a more potent form of testosterone and is the principal androgen responsible for stimulating prostatic growth. The growth of the prostate may cause BPH, therefore, causing overflow incontinence which is manifested as urinary retention. Decreased size of the prostate and less urinary retention is a therapeutic findings of this medication. Choices A, B, and D are incorrect. Dutasteride is not indicated for any of these conditions. Additional Info BPH is often treatable with a 5-alpha reductase inhibitor. There are currently two such drugs: finasteride and dutasteride. Finasteride (Proscar), the prototypical drug for this class, works by inhibiting this enzyme, which normally converts testosterone to 5-alpha dihydrotestosterone (DHT). DHT is a more potent form of testosterone and is the principal androgen responsible for stimulating prostatic growth, as well as the expression of other male primary and secondary sex characteristics. Because these medications suppress DHT, the biggest adverse effect for men is decreased libido and erectile dysfunction. Caution must be taken when handling these medications because they are quite teratogenic, and pregnant women should handle the drug while wearing gloves.

A client who is pregnant and is attending a prenatal class. Which statement, if made by the client, requires further teaching? A. "Since my body mass index is normal, I should be gaining 25-35 pounds." [12%] B. "It will be okay for me to continue using sugar substitutes, such as sucralose." [21%] C. "Since I am pregnant, I will have to abandon my vegan diet." [51%] D. "I will need to keep my caffeine intake less than 200 mg/day." [16%]

Explanation Choice C is correct. This statement is false and requires follow-up. A vegan diet may be continued during pregnancy if the woman is methodical in her food choices. The concern with vegan diets is the consumption of complete proteins. However, evidence has indicated that plant proteins can meet pregnancy needs. Choices A, B, and D are incorrect. These statements are true and do not require follow-up. For a woman with a normal BMI, the average weight during pregnancy should be 25-35 pounds. Sugar substitutes are permitted in moderation. The current recommendation for daily caffeine intake is not to exceed 200 mg/day. Additional Info Individuals who follow a vegan diet avoid all animal products and may have the most difficulty meeting their nutrient needs. Through careful consideration of foods and supplemental vitamins, it is entirely possible for a woman who follows the vegan diet to have a successful pregnancy.

The nurse is going over the list of assigned clients for the shift. The nurse knows which client is most at risk for experiencing a fluid volume deficit? A. A client with cirrhosis [4%] B. A client with an ileostomy and normal amount of output [2%] C. A client with a BUN of 32 and creatinine of 2.7 [22%] D. A client with diabetes insipidus and an NG tube set to low intermittent wall suction [72%]

Explanation Choice D is correct. A client with diabetes insipidus and an NG tube set to low intermittent wall suction is at very high risk for a fluid volume deficit. They have 2 risk factors and are therefore the client at the most risk. In diabetes insipidus, the body puts out huge amounts of dilute urine, depleting the body of fluid. Having an NG tube to suction also removes fluid from the client, by way of their GI secretions, making it another risk factor for fluid volume deficit. Choice A is incorrect. The client with cirrhosis is not at risk for a fluid volume deficit. Clients with liver failure are more likely to experience a fluid volume excess due to portal hypertension. This can be observed in edematous legs and ascites. Choice B is incorrect. A client with an ileostomy can be at risk for fluid volume deficit if there are large volumes of fluid dumping out of their ostomy. Since the question stem indicates that there was a normal amount of output from the ileostomy, this is not the client most at risk for fluid volume deficit out of the choices provided. Look for the client with the highest number of risk factors. Choice C is incorrect. A client with a BUN of 32 and Cr 2.7 is suffering from kidney damage. Decreased kidney function puts clients at risk for fluid volume excess due to their inability to concentrate urine and results in a subsequent build-up of fluid in the body. NCSBN Client Need Topic: Physiological Adaptation, Subtopic: Fluid and Electrolyte Imbalances

An advantage of mutual pretense at the end of life for the client is that it allows the client: A. To fully employ the ego defense mechanism of denial at the end of life. [8%] B. To exercise control over loved ones when they are at the end of life. [5%] C. To fully employ the ego defense mechanism of projection at the end of life. [8%] D. To preserve a degree of dignity and privacy at the end of life. [79%]

Explanation Choice D is correct. An advantage of mutual pretense at the end of life for the client is that it allows the client to preserve a degree of dignity and privacy at the end of life. Mutual pretense is one of the three levels of awareness that occur with a terminal illness and at the end of life. It occurs when the dying client and the loved ones simply do not talk about death with each other even though all are aware of the seriousness of the illness and the fact that the end is near. Choice A is incorrect. Denial is not an advantage of mutual pretense. Denial is the subconscious inability of the client to believe that they are genuinely terminally ill and dying; still, they simply do not talk about it. Choice B is incorrect. The mutual pretense is not used by the client to exercise control over their loved ones at the end of life; in fact, mutual deceit is often used to protect loved ones from sorrow and distress. Choice C is incorrect. Projection is not an advantage of mutual pretense. Screening is defined as redirecting anger toward a more socially acceptable target; mutual deceit is often used to protect loved ones from sorrow and distress, not the redirection of rage.

The nurse is performing a head-to-toe assessment of the patient. During the abdominal evaluation, the correct sequence for this assessment is: A. Auscultation, Inspection, Palpation, Percussion [4%] B. Inspection, Palpation, Auscultation, Percussion [8%] C. Percussion, Auscultation, Palpation, Inspection [1%] D. Inspection, Auscultation, Percussion, Palpation

Explanation Choice D is correct. For the abdominal exam, the exact sequence of actions would be inspection, auscultation, percussion, and palpation. The abdominal assessment is an integral part of the evaluation of any patient, but it is critical when the chief complaint is related to intestinal issues. The abdominal assessment should always progress from least intrusive (inspection) to most invasive. All findings should be related to one or more of the four quadrants of the abdomen. For example, a laceration noted in the right upper quadrant might be a documented finding. During the abdominal assessment, the clinician should look at the stomach first, observing for swelling, lacerations or punctures, asymmetry, or other abnormalities. In the second step, auscultation, the clinician is listening for bowel sounds. It is essential to do this before palpation or percussion since any manipulation of the abdomen can change the bowel sounds. If bowel sounds are not immediately auscultated, the clinician should spend 30-60 seconds listening. Palpation should be gentle to determine the amount of discomfort the patient is having. When percussion is needed, it helps the nurse assess the borders of the major organs (especially the liver and spleen). NCSBN Client Need Topic: Health Promotion and Maintenance;Sub-Topic: Physical Assessment

Which client's right is most closely related to the need for nurses to give complete and unbiased information to the client? A. Veracity [63%] B. Fidelity [20%] C. Freedom from abuse [2%] D. Self determination

Explanation Choice D is correct. Self-determination and autonomy are client rights that require us to give our clients complete and unbiased information without any coercion so that the client can make an independent decision about their care. Choice A is incorrect. Veracity is an ethical aspect of nursing and not a client's right; integrity requires that nurses are honest with their clients. Choice B is incorrect. Fidelity is a moral aspect of nursing and not a client's right; fidelity requires that nurses are faithful to their promises to their clients, including their commitment to delivering high quality and safe care to their clients. Choice C is incorrect. Although freedom from abuse and neglect are clients' rights, violence and neglect do not have a relationship with giving clients complete and unbiased information.

g assignment for this patient would be: A. The charge RN [3%] B. Another RN [19%] C. An LVN/LPN with 5 years of experience in orthopedics [47%] D. An LVN/LPN with 5 years of experience in geriatric care [31%]

Explanation Choice D is correct. The charge RN knows that this patient has been stable following her surgery. The client will require routine post-op care rather than specific orthopedic care. The responsibility for this patient can be handled by an LPN/LVN after the initial evaluation. However, given the client's advanced age, there are additional needs specific to the geriatric age group. Therefore, the most appropriate assignment is the LVN/LPN with five years of experience in geriatric care. Choices A, B, and C are incorrect. Effective use of resources is crucial in healthcare settings. A charge RN ( Choice A) assumes a leadership role and oversees a specific department or unit. Charge nurses are responsible for delegating nursing duties and assignments to other nurses and hence, have more complex duties to attend. An RN ( Choice B) can probably be used more effectively with another patient that requires additional teaching or advanced assessment. Assigning the elderly client to an LVN/LPN ( Choice C) experienced in orthopedic care alone will not address the other needs specific to this geriatric client. NCSBN Client Need, Topic: Management of Care, Sub-topic: Assignment and Delegation

As you are bathing your client and providing foot care, you notice that the client's toenails appear as shown in the exhibit. Which condition should you suspect? A. Onychomycosis [48%] B. Onychomadesis [17%] C. Onychorrhexis [9%] D. Onychia

Explanation Choice D is correct. The exhibit shows inflammation of the nail folds. This disorder is referred to as onychia. Onychia is characterized by inflammation of the nail fold resulting from either injury or infection. Whereas, paronychia refers to infection of the proximal nail folds. Infection of the nail folds can occur by the introduction of bacteria into nail folds through small wounds. The nurse should document and report this condition. Choices A, B, and C are incorrect. Onychomycosis is a fungus infection of the nails that causes the nails to look thick, discolored, and crumbling. Onychomadesis is the falling off and the separation of the nails from the nail bed and not the inflamed appearance of the nail in the exhibit. Onychorrhexis refers to brittle nails that tend to break easily and not the appearance of the affected nail in the exhibit.

A nurse is caring for a woman who will undergo electroconvulsive therapy (ECT) for the first time. Her husband asks the nurse if he could visit his wife on her ECT treatment days and voiced out concerns regarding what he should expect after the initial treatment. The nurse's best response is: A. "Are you sure you'd like that? They are pretty sick after the first treatment, and you'll have to get permission from the physician to visit." [1%] B. "Visitors are prohibited. We will just telephone you to update you of her progress." [1%] C. "She will be asleep for several hours after the treatment. There's really no need to stay there." [1%] D. "Yes, you may visit her. She may have temporary drowsiness, confusion, or memory loss after each session."

Explanation Choice D is correct. The nurse discusses visiting privileges according to hospital policy. For ECT treatments, visitors are allowed and encouraged, particularly family members. ECT treatments do not make clients sick, and they are usually awake an hour after the surgery. As the anesthetic wears off, the client's drowsiness also wanes. "Yes, you may visit her. She may have temporary drowsiness, confusion, or memory loss after each session," is the best response as it allows the nurse to alleviate fears by explaining the temporary side effects of the treatment. Choices A, B, and C are incorrect. These are nontherapeutic responses.

The nurse is caring for a client with an acute exacerbation of Bell's palsy. Which of the following prescriptions would the nurse anticipate? Select all that apply. A. Prednisone [34%] B. Donepezil [12%] C. Pyridostigmine [20%] D. Valacyclovir [17%] E. Topiramate [16%]

Explanation Choices A and D are correct. Bell's palsy classically causes facial nerve paralysis. The herpes simplex virus likely causes this disorder. Exacerbations of Bell's palsy are treated with corticosteroids ( prednisone, Choice A) and antivirals ( valacyclovir, Choice D). Corticosteroids decrease facial nerve inflammation, and antivirals address the underlying viral etiology. Choices B, C, and E are incorrect. Donepezil is an acetylcholinesterase inhibitor utilized to manage dementia in Alzheimer's disease ( Choice B). Although Donepezil does not decrease the progression of Alzheimer's disease, it does help symptoms by improving cognition and behavior. Pyridostigmine is an acetylcholinesterase inhibitor indicated for improving muscle strength in myasthenia gravis ( Choice C). Topiramate is an anticonvulsant indicated for epilepsy and migraine headache prevention ( Choice E). Learning Objective Understand that antivirals and corticosteroid medications are frequently used in managing Bell's palsy Additional Info Exacerbations of Bell's palsy usually occur abruptly with unilateral facial paralysis. This is accompanied by eyebrow sagging, diminished taste, decreased eye tearing, and drooping of the mouth on the affected side. Nursing care is aimed at mitigating symptoms by using artificial tears and ointment. A client may also use an eye patch on the affected eye at night.

Which of the following are appropriate teaching points for a patient with chronic stable angina prescribed sublingual nitroglycerin? Select all that apply. A. Take one tablet and if the pain has not subsided, take another every 5 minutes, maximum of three doses. [40%] B. Swallow the entire pill, do not crush or chew. [7%] C. Call the healthcare provider immediately if a headache develops. [13%] D. Keep the tablets in a dark bottle. [39%]

Explanation Choices A and D are correct. For sublingual nitroglycerin (NTG), the patient should be told to take one tablet at the onset of an acute attack. If the chest pain does not subside within 5 minutes, they should call 911 and take another pill. If the pain has not subsided, these tablets can be taken every 5 minutes and for a total of three doses (Choice A). NTG should be kept in a 9x9 dark glass bottle and stored in a dry, cool location. NTG is photosensitive; if kept in a light-filled place, the medication could become inactivated (Choice D). Choice B is incorrect. Never tell the patient to swallow ANY sublingual medication. These medications are designed to be absorbed in the mucous membrane and could be dangerous if ingested. The proper administration instructions to educate your patient are to place one tablet under the tongue and allow it to dissolve. Some pills will burn or fizz; that is acceptable. Choice C is incorrect. A patient doesn't need to contact their healthcare provider for a headache after taking sublingual nitroglycerin. NTG is a potent vasodilator, causing venous and arterial dilation. NTG dilates the coronary arteries, allowing more blood flow to the myocardium, hopefully stopping the chest pain. Still, it also causes vasodilation of the carotids, which supplies the brain with increased blood. This rush of increased blood causes a headache. Since this is an expected response, the patient does not need to notify the healthcare provider immediately. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Cardiac

You are called to the delivery of an infant that is 41 weeks gestation. And they suspect meconium in the amniotic fluid. After birth, which of the following signs would help you confirm a meconium delivery? Select all that apply. A. Brown-tinged amniotic fluid [48%] B. Thick, white substance coating the newborn [4%] C. Vigorous cry [10%] D. Brown discoloration of the infant's nails [39%]

Explanation Choices A and D are correct. If the amniotic fluid is tinged brown, it is a good indication that the meconium was passed before delivery (Choice A). Brown discoloration of the infant's nails, umbilical cord, or tongue can all indicate a meconium aspiration (Choice D). Choice B is incorrect. A thick, white substance coating the newborn is known as vernix caseosa. This is a potent substance and serves to moisturize the newborn's skin. Choice C is incorrect. A vigorous cry is a good sign in a newborn. This alone is not an indicator of meconium aspiration. If there is meconium in the fluid and then the infant starts to cry vigorously, it can then lead to meconium aspiration. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Newborn

You are assessing a 16-year-old female with anorexia nervosa. Which of the following symptoms and signs would you expect to find? Select all that apply. A. Lanugo [37%] B. Heavy menstrual periods [9%] C. Hypertension [9%] D. Hypothermia [44%]

Explanation Choices A and D are correct. Lanugo (Choice A) is defined as "fine and soft hair that covers the body and limbs of a human fetus/newborn." It is abnormal for a 16-year-old to have lanugo. In a patient who is severely underweight and has lost a large amount of subcutaneous fat, such as in a patient with anorexia nervosa, the body will develop lanugo as a way to insulate itself. Hypothermia (Choice D) is a severe complication of anorexia nervosa. Subcutaneous fat is necessary to insulate the body and regulate the temperature. Clients with anorexia nervosa lose a significant amount of subcutaneous fat due to malnourishment and weight loss. Consequently, they are prone to hypothermia. Choice B is incorrect. Amenorrhea (lack of menstrual period) rather than increased menses is a complication seen in anorexia nervosa—self-inflicted starvation in anorexia nervosa results in malnourishment, hormonal imbalance, and amenorrhea. Choice C is incorrect. Hypotension is seen in anorexia nervosa, not hypertension. Clients with anorexia are prone to malnourishment and dehydration. Dehydration results in fluid-volume deficit and hypotension. Electrolyte imbalance such as hypernatremia is also seen due to free water deficit and concentrated body fluids. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Mental health

When caring for clients in a long-term care facility, which of the following place the client at a higher risk for falls? Select all that apply. A. A patient who is older than 65 years of age [18%] B. A patient who has a history of two previous falls [26%] C. A patient who is taking antibiotics [2%] D. A patient who experiences postural hypotension [25%] E. A patient who is experiencing chemotherapy-related nausea [10%] F. A 70-year-old male patient who is being transferred for long-term care [18%]

Explanation Choices A, B, D, and F are correct. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. Falls among older adults are the most common cause of hospital admissions for trauma. The Joint Commission requires that hospitals implement fall prevention assessments and programs. The Centers for Medicare and Medicaid Services have identified falls as a "never event" because they are preventable and should never occur. Falls and trauma are also on the CMS list of hospital-acquired conditions that result in limited reimbursement, especially those falls that result in injuries. Choice C and E are incorrect. Although medication regimens that include diuretics, tranquilizers, sedatives, hypnotics, and analgesics are a risk factor for falls, chemotherapy and antibiotics are not. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Preventing Falls

The nurse is caring for a client whose latest lab results show a serum calcium level of 13.2 mg/dL. Which medication does the nurse expect to administer based on this lab result? Select all that apply. A. Phosphorus [32%] B. Calcitonin [21%] C. Vitamin D [13%] D. IV calcium gluconate [12%] E. IV Bisphosphonates [22%]

Explanation Choices A, B, and E are correct. A is correct. The normal serum calcium level is 8.4-10.2 mg/dL. This client has a high serum calcium level (hypercalcemia). Phosphorus is a medication the nurse would expect to administer to treat hypercalcemia. Phosphorus and calcium have an inverse relationship, so by increasing the serum level of phosphorus the nurse can decrease the serum level of calcium. Oral phosphate is the preferred method of administering phosphorus. If given IV, calcium phosphate forms and precipitates in the tissues. This precipitation phenomenon reduces serum calcium levels very quickly. B is correct. Calcitonin is a medication the nurse would expect to administer to treat hypercalcemia. Calcitonin is a thyroid hormone that decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration. E is correct. Bisphosphonates are intravenous osteoporosis drugs that can quickly lower calcium levels and are often used to treat hypercalcemia due to cancer. Choice C is incorrect. Vitamin D should be avoided in hypercalcemia. Vitamin D enhances the absorption of calcium and can therefore increase the level of serum calcium, which we do not want to do when the client's level is already high. Choice D is incorrect. IV calcium gluconate is given to patients that are hypocalcemic, not hypercalcemic. It can treat the tetany that occurs when a client is severely hypocalcemic. It can also be given to protect the cardiac muscle if a client has severe hyperkalemia or hypermagnesemia. NCSBN Client Need: Topic: Expected Actions/Outcomes; Pharmacological and Parenteral therapies, Subtopic: Medication administration; Fluids & Electrolytes

A mother states that she refuses to have her children immunized because she believes vaccinations increase a child's odds of developing autism. Which of the following should the nurse point out to her as the consequences of her decision to the community overall? Select all that apply. A. Reduction in herd immunity [20%] B. Increase in teenage pregnancy [1%] C. Increased incidence of diseases once thought to be eradicated [27%] D. Increase in absences from school or workdays [23%] E. Reduction in the incidence of physical or mental impairment [4%] F. Increased costs associated with doctor and hospital visits [24%]

Explanation Choices A, C, D, and F are correct. Failure to comply with immunization schedules can result in a reduction in herd immunity/community-wide protection from contagious diseases that occur when most people in that community are immunized (Choice A). Failure to comply with immunization schedules increases conditions once controlled by immunization (e.g. pertussis [whooping cough], polio, mumps, and smallpox) (Choice C). Failure to comply with immunization schedules results in an increase in absent school days or workdays across the community (Choice D). Failure to comply with immunization schedules results in increased costs associated with doctor and hospital visits (Choice F). Choice B is incorrect. Failure to comply with immunization schedules is not associated with an increase in teenage pregnancy. Choice E is incorrect. Failure to comply with immunization schedules is not associated with a reduction in the incidence of physical or mental impairment across the community. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

The nurse is assisting a client to choose food options appropriate for Celiac disease. Which food items would be appropriate to select? Select all that apply. A. Grilled chicken [33%] B. Wheat pasta [4%] C. Scrambled eggs [31%] D. Oatmeal [7%] E. Beef patties [24%]

Explanation Choices A, C, and E are correct. Celiac disease is characterized by an individual's intolerance to gluten. Grilled chicken, scrambled eggs, and beef patties are all examples of foods that have no gluten Choices B and D are incorrect. A client with Celiac disease should avoid sources of gluten such as barley, rye, oats, and wheat. Wheat pasta and oatmeal would not be appropriate selections for a client with gluten intolerance. Oats are not gluten-free as when they are transported they come into contact with other gluten-containing products. Additional Info Celiac disease, if untreated, may cause an individual abdominal pain, distention, vomiting, anemia, and diarrhea. A client should be thoroughly educated to avoid foods that contain gluten. Foods allowed include beef, chicken, pork, vegetables, fish, and eggs.

The nurse is assessing a client who was just diagnosed with acute pyelonephritis. Which of the following findings should the nurse expect to observe? Select all that apply. A. Costovertebral angle tenderness [18%] B. Jugular venous distention [5%] C. Fever and chills [30%] D. Urinary retention [21%] E. Dysuria [27%]

Explanation Choices A, C, and E are correct. Pyelonephritis is an ascending urinary tract infection that involves the kidney. The client exhibits the classic symptoms of cystitis (urinary frequency, dysuria, malaise) along with constitutional symptoms such as fever, chills, and costovertebral tenderness. Choices B and D are incorrect. Jugular venous distention (JVD) is not an expected finding of pyelonephritis as this is a manifestation associated with fluid volume overload. Clients with pyelonephritis typically present with dehydration from the fever and urinary frequency. Urinary frequency is a classic manifestation. Additional information: Acute pyelonephritis is a complication of cystitis. The infection has spread up the urinary tract and now involves the kidney. Nursing care is like that of cystitis, which includes the administration of prescribed antibiotics, educating the client to stay hydrated, and measures to prevent recurrence. A complication of pyelonephritis is sepsis, thus, signs of sepsis such as tachycardia and hypotension should be reported to the primary healthcare provider. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Alterations in Body Systems

The nurse is informed during shift change report that her client is at risk for developing hypercalcemia. Which signs and symptoms should the nurse assess the client for? Select all that apply. A. Seizures [20%] B. Hypoactive bowel sounds [25%] C. Decreased deep tendon reflexes [32%] D. Shortened PR interval [22%]

Explanation Choices B and C are correct. Hypoactive bowel sounds are a sign of hypercalcemia. Hypercalcemic clients have decreased peristalsis, leading to hypoactive bowel sounds. This decrease in peristalsis may cause abdominal pain, nausea, and constipation (Choice B). The nurse should monitor for decreased deep tendon reflexes in a client with hypercalcemia. Calcium has an inhibitory effect on the neuromuscular system. Therefore, increased calcium decreases the reflexes. Remember the catch sentence to memorize this effect - "in hypercalcemia; everything slows down." The client may experience weakness, flaccidity, and decreased deep tendon reflexes (Choice C). Choice A is incorrect. The signs of neuromuscular irritability include Chvostek's, Trousseau's, paresthesias, tetany, muscle cramps, and seizures. Calcium inhibits the neuromuscular system. Therefore, the signs of neuromuscular irritability are seen with hypocalcemia, not hypercalcemia. The neuromuscular symptoms of hypercalcemia include muscle weakness, flaccidity, and decreased deep tendon reflexes. Choice D is incorrect. A shortened PR interval is not a manifestation of hypercalcemia. In hypercalcemia, everything slows down - the nurse may note a prolonged PR interval, prolonged QRS interval, and shortening the QT interval on the ECG. These changes lead to bradycardia. Heart block can occur. However, hypercalcemia may also cause premature ventricular contractions ( PVCs) and, rarely, ventricular tachycardia. Other cardiovascular changes in hypercalcemia include hypertension. Blood pressure increases because calcium induces contraction of vascular smooth muscle. NCSBN Client Need: Topic: Physiological Adaptation, Subtopic: Fluid & Electrolyte Imbalances

A male patient, one-day post-CVA, is showing signs of left-sided neglect. To begin the rehabilitation process, the nurse caring for this patient should add the following interventions to the patient's plan of care. Select all that apply. A. Sit on the unaffected side when interacting with the patient. [27%] B. Place the phone on the patient's affected side. [13%] C. Encourage the patient to touch the affected hand with the unaffected hand. [37%] D. Place a favorite object into the hand on the affected side. [23%]

Explanation Choices B, C, and D are correct. Rehabilitation should start as early as possible for the stroke victim with unilateral neglect. In this side effect of a stroke, the patient is not aware of one side of the body. In this scenario, the patient would ignore the left side of the body and might be unaware of anything happening to his left. The key to this question is the phrase "to begin the rehabilitation process." In this case, the purpose of rehab is to help the patient become aware of the side he is currently ignoring. These answer choices will all force the patient to acknowledge his left side. Sitting on the unaffected side will allow the patient to continue to ignore the left side; thus, the nurse should encourage visitors to interact with the patient from his left side. This may mean that the visitor will have to turn the patient's head physically to the left. Choice A is incorrect. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-Topic: Therapeutic Procedures, Neurologic