Archer Review 8a

Risk factors for preeclampsia include all of the following, except: A. Chronic hypotension [68%] B. Age [6%] C. Race [19%] D. Family history of preeclampsia [6%]

Explanation Choice A is correct. Chronic hypotension is not a risk factor for preeclampsia; therefore, this is the correct answer to the question. Instead, a history of high blood pressure is a risk factor. This hypertension is defined as a blood pressure reading above 140/90 mmHg. Choices B, C, and D are incorrect. Older and very young pregnant women are at higher risk. African-American women are at higher risk than other races. A personal or family history of preeclampsia increases the risk of preeclampsia for a woman. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Alterations in Body Systems; Antepartum

When a patient presents with complaints of drooping of the eyelid on one side, the finding is documented as: A. Pharyngitis [1%] B. Ptosis [90%] C. Kernig sign [8%] D. Thyroglossal cyst [1%]

Explanation Choice B is correct. Ptosis is drooping of the eyelid. Choice A is incorrect. Pharyngitis is an inflamed and sore throat Choice C is incorrect. Kernig sign is found with meningitis. Choice D is incorrect. A thyroglossal cyst is a birth defect mass that is found in the neck. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Abnormal Findings of the External Eye

An infant is admitted to the medical ward to rule out cystic fibrosis. The nurse assesses his stool and concludes that the stool is symptomatic of cystic fibrosis. Which of the following would describe the stool in this patient? A. Small, hard stools [7%] B. Green, malodorous stool [39%] C. Large, bulky stool [33%] D. Loose, yellow stool [21%]

Explanation Choice C is correct. There is malabsorption in cystic fibrosis; thus, the presence of bulky stools. Stools are also foul-smelling and greasy. Choice A is incorrect. Small, hard stools are not characteristic stools of cystic fibrosis. Choice B is incorrect. Stools in cystic fibrosis are malodorous; however, they are not green. Choice D is incorrect. Loose, yellow stools are not characteristic of cystic fibrosis.

A client is scheduled for hip replacement surgery. She expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most therapeutic? A. "Everyone is nervous before any surgery. What you feel is completely normal." [5%] B. "Here's what's going to happen to you during the procedure. I will explain it to you in detail." [4%] C. "Can you tell me what you have been told about the surgery?" [82%] D. "Let me tell you about the care you will receive and the pain you should anticipate after the surgery." [9%]

Explanation Choice C is correct. This response by the nurse provides the patient with an opportunity to express her thoughts further and would give the nurse a baseline of the patient's knowledge and readiness for the surgery. This way, the nurse can come up with appropriate explanations around what the client already knows and by filling in facts. Open-ended questions that facilitate further discussion are the most therapeutic in this situation. Choices A, B, and D are incorrect. These responses will only increase the patient's level of anxiety and are, therefore, inappropriate.

The nurse is educating a pregnant woman with an above-average BMI about her risk factors. Which of the following issues does not correlate with an above-normal BMI pre-pregnancy? A. Gestational diabetes [6%] B. Preeclampsia [5%] C. Swelling [10%] D. Frequent UTI [79%]

Explanation Choice D is correct. Frequent urinary tract infections are not associated with maternal above-average body mass index. Choices A, B, and C are incorrect. The development of gestational diabetes, preeclampsia, and swelling are positively correlated with maternal above-average BMI. Other issues include increased C-section rates, stillbirth, and poor wound healing. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

The nurse is caring for a teenager who is recovering from a tonsillectomy. The nurse walks into the room and sees the client eating chips and salsa from a Mexican restaurant. Which response by the nurse is most appropriate? A. "I love that restaurant! Their chips are so good." [0%] B. "You cannot eat anything yet, I am sorry." [1%] C. "Chips are not a good choice right now because you need a high protein diet after your surgery." [1%] D. "Those chips are really hard on the back of your throat where you had your surgery. I'm worried they could cause you to bleed if they damage your incision site. Let's get something softer for you to eat right now." [97%]

Explanation Choice D is correct. This is the most appropriate response by the nurse. She correctly explains to the client that the sharp tortilla chips would be really hard on the surgical site after a tonsillectomy. Allowing clients to eat foods like chips or popcorn after surgery in the back of the throat would put them at risk for damage to the incision and subsequent hemorrhage. Offering the client something soft, such as jello or soup, is what is most appropriate. Choice A is incorrect. This is not an appropriate response. The client should not be eating anything hard or sharp like chips after a tonsillectomy. That food could damage the surgical area at the back of the throat and cause postoperative complications such as hemorrhage and sore throat. Choice B is incorrect. This is not an appropriate response. It is fine for the client to eat, but they will need to start with a soft diet in order to protect the surgical site. It is not necessary to keep the client NPO after their surgery has finished and the gag reflex has returned. Choice C is incorrect. This is not an appropriate response. Although the nurse correctly identified that chips are not a good choice after surgery, she gave the client incorrect information about the reason. Clients after a tonsillectomy need a soft diet, not a diet that is high in protein. NCSBN Client Need: Topic: Health promotion and maintenance; Subtopic: Pediatric - HEENT

Which of the following images represents an unstageable pressure ulcer?

Explanation Choice D is correct. This pressure ulcer is considered unstageable because there is full-thickness tissue loss, but the wound bed is covered by eschar. Due to the eschar, real depth and stage cannot be determined. The eschar must be removed to visualize the foundation of the wound before staging. Choice A is incorrect. This is a stage I pressure ulcer. The skin is intact, but the area is red and does not blanch with external pressure. Choice B is incorrect. This is a stage IV pressure ulcer. There is full-thickness skin loss with exposed bone, tendons, or muscles. Choice C is incorrect. This is a stage III pressure ulcer. There is full-thickness loss into the dermis and subcutaneous tissue. There may or may not be slough, visible subcutaneous tissue, or undermining and tunneling. However, the bed of the wound is evident, and there is no exposed bone, tendons, or muscles. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Integumentary

Which of the following nursing interventions are appropriate for a manic patient experiencing delusions of grandeur? Select all that apply. A. Refrain from talking excessively about their delusion [39%] B. Set boundaries [45%] C. Enforce three meals a day [12%] D. Argue that their delusions are not your reality [4%]

Explanation Choices A and B are correct. It is essential to refrain from talking much about the delusions that your manic patient is having. Delusions of grandeur, such as the patient thinking they are god, come from a need for them to feel necessary and proper about themself. You need to support the patient's confidence in a realistic way. By refraining from talking excessively about the delusion, you are not supporting its reality, which is therapeutic for the patient (Choice A). Setting boundaries and limits are incredibly crucial for the manic patient. These patients can be incredibly manipulative and by setting limits, you will be helping them come back down to reality. Consistency is also key to these boundaries. For example, if you make a rule that lights must be off at 10:00 pm each night, this rule should be followed every single night without exception (Choice B). Choice C is incorrect. Enforcing three meals a day will not work for the manic patient. They are too busy to sit down for a large meal and will end up just forgetting to eat. This can lead to severe malnutrition and dehydration. It is essential to provide the patient with finger foods and stay with them while they walk and eat. Keep them calm and try to maximize the calories that they are getting instead of trying to enforce sitting through three meals a day. Choice D is incorrect. It is not therapeutic to argue with a manic patient. These patients are very manipulative and argumentative. They will fight back and their behavior will escalate. It is essential to help guide them towards reality by setting boundaries and letting them know their delusion is not your reality, but you should never argue. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Psychiatric Nursing

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing type II diabetes mellitus? Select all that apply. A. Gestational diabetes [22%] B. Metabolic syndrome [21%] C. Chronic corticosteroid use [23%] D. Gastric bypass surgery [3%] E. Obesity [30%]

Explanation Choices A, B, C, and E are correct. Type two diabetes mellitus is the most common type of diabetes worldwide. Risk factors for diabetes mellitus include gestational diabetes, metabolic syndrome, chronic corticosteroid use, and obesity. Individuals with gestational diabetes should be tested for diabetes mellitus, type II, within one year following their pregnancy. Choice D is incorrect. Gastric bypass surgery would help ameliorate the signs and symptoms of diabetes mellitus (DM). This surgery would not cause DM. This surgery has been associated with B12 deficiency anemia. Additional Info Risk factors for type II diabetes mellitus include - A history of gestational diabetes Metabolic syndrome: abdominal obesity, hyperlipidemia, hypertension, impaired fasting blood glucose, and being overweight Native American, African American, and Hispanic ethnicity Age with the risk increasing after the age of 45 Polycystic ovary syndrome

The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply. A. A client who had rectal surgery and a post-operative abscess [20%] B. A child who has pneumonia [2%] C. An older client who is post-myocardial infarction (MI) [22%] D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia [29%] E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC) [25%]

Explanation Choices A, C, D, and E are correct. (Choice A) Rectal temperature should not be used in clients with a history of rectal surgery. Because of the risk of disruption of surgical anastomosis, it is preferred to refrain from rectal temperature checks in such clients. Additionally, the rectal temperature should not be used in clients with diarrhea and newborns under 12 weeks. Many healthcare providers prefer axillary temperature screening in newborns because of the theoretical risk of rectal perforation. However, if an accurate temperature reading is desired in a newborn, rectal temperature may be performed because the available evidence does not substantiate the fears of rectal perforation using a rectal thermometer. (Choice C) The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve. Therefore, patients who are post-MI should not have a rectal temperature taken. (Choice D) Assessing a rectal temperature is contraindicated in neutropenic patients. A leukemia client with neutropenia and anemia shouldn't be subjected to rectal temperature checks. A normal absolute neutrophil count should be more than 1500/ microfiber ( 1500/ul). A neutrophil count less than 1500/ul is mild neutropenia, whereas a count less than 500/ul is severe. Neutropenia predisposes to infections, and any invasive procedures with the potential to introduce pathogens into the body must be avoided. (Choice E) Assessing rectal temperature is also avoided in those with certain neurologic disorders and patients with thrombocytopenia (low platelet count). Acute pancreatitis can be complicated with DIC in severe cases. Disseminated intravascular coagulation (DIC) causes consumptive thrombocytopenia. Thrombocytopenia increases the bleeding risk when invasive procedures are performed. Therefore, a client with acute pancreatitis and DIC should not get a rectal temperature assessment. Choice B is incorrect. A child with pneumonia can have a rectal temperature taken. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Temperature Learning Objective While rectal thermometry to confirm fever is one of the most accurate methods, recognize that there are conditions where it is contraindicated.

The nurse is assessing her prenatal client for sexually transmitted infections (STIs) by looking for risk factors. Which of the following are risks of acquiring an STI? Select all that apply. A. Low socioeconomic status [19%] B. A monogamous relationship [4%] C. A past history of working in the sex industry [26%] D. Illicit drug use [23%] E. History of cancer [2%] F. Previous history of STIs [27%]

Explanation Choices A, C, D, and F are correct. Low socioeconomic status, a history of being a sex worker, illicit drug use, and a previous history of sexually transmitted infections are all risk factors for contracting STIs. Other factors include numerous sexual partners and being unmarried. Choices B and E are incorrect. A history of cancer and exclusive/monogamous relationships are not examples of risk factors for acquiring an STI.

A patient presents with dizziness upon standing, bilateral hand tremors, inability to sleep, irritability, sweating, and a heart rate of 95. From what substance is the patient most likely experiencing these withdrawal symptoms? A. Alprazolam [28%] B. Nicotine [18%] C. Adderall [9%] D. Cocaine [45%]

Explanation Choice A is correct. Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia. Choice B is incorrect. Typical nicotine withdrawal symptoms include headache, nervousness, poor concentration, anger, hunger, and restlessness. Choice C is incorrect. Adderal is an amphetamine drug. Typical amphetamine withdrawal symptoms include dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation. Choice D is incorrect. Typical withdrawal symptoms of cocaine are similar to amphetamine withdrawal symptoms: dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation. NCSBN Client Need Topic: Psychological medications, Subtopic: Chemical and other dependencies/substance use disorder, high-risk behaviors, lifestyle choices

A patient is rushed to the emergency department after being exposed to radioactive materials in a workplace accident. What should be the initial action of the nurse? A. Strip the patient of all clothing and decontaminate him. [87%] B. Ask the patient what happened during the accident. [8%] C. Decontaminate the room where the patient was staying. [3%] D. Save the clothing for analysis. [2%]

Explanation Choice A is correct. Removing any radioactive material from the patient should be the first priority of the nurse. Choice B is incorrect. The nurse should investigate what happened after all contaminants have been removed from the patient. Choice C is incorrect. The primary responsibility of the nurse is the patient, not the room. The room can be decontaminated once the patient has been stabilized and treated. Choice D is incorrect. The nurse can save the clothing for analysis, but only after the client has been stabilized.

A 32-year-old man is admitted to the neurology floor after being admitted for sepsis. He has paraplegia and is bound to a wheelchair. What is the most probable cause of sepsis? A. Pneumonia [18%] B. Pressure ulcer [48%] C. Urinary tract infection [31%] D. Gonorrhea [2%]

Explanation Choice B is correct. Since this patient uses a wheelchair, a pressure ulcer is the most likely cause of sepsis. If it is uncared for, it can develop into an infection and spread into the bloodstream. Choice A is incorrect. This patient could be suffering from pneumonia, but a pressure ulcer is a more likely diagnosis. Choice C is incorrect. This patient could be suffering from a UTI, especially if he has to self-catheterize himself. However, the correct answer is pressure ulcers due to wheelchair use. Choice D is incorrect. It is unlikely that this patient is suffering from gonorrhea-related sepsis. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Alterations in Body Systems, Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome

Parents bring their 2-year old daughter into the emergency department after picking her up from her aunt's house. They are concerned that she has an upper respiratory infection. The nurse notices bruises on the patient's posterior thigh, wrists, and upper back. They appear to be in different stages of healing. Once the patient is stable after administering a bronchodilator and steroid, what should the nurse do? A. Question the parents [17%] B. Call the department of child and family services (DCFS) [80%] C. Call poison control [0%] D. Obtain an arterial blood gas (ABG) [2%]

Explanation Choice B is correct. This patient has bruises on her thigh, wrists, and upper back that are in different stages of healing, which is a reliable indicator of abuse. Bruising on these parts of the body is not a common area for 2-year olds to injure. Typical areas of injury are the knees elbows and chin. Thigh, wrist, and upper back injuries can be due to grabbing, burning, or pushing. The department of child and family services (DCFS) needs to be contacted by the nurse because nurses are mandated reporters. Recognizing signs of abuse is extremely important. Choice A is incorrect. The parents do not need to be questioned at this point. Once the nurse calls DCFS, they will handle the questioning and investigation. Assessing these bruises is enough assessment findings to call DCFS. Choice C is incorrect. There is no indication to call poison control at this time. Choice D is incorrect. If the patient's respiratory status were unstable, this would be necessary. However, the patient is stable at this time on a bronchodilator and steroids. NCSBN Client Need Topic: Safe and Effective Care Environment, Sub-topic: Care Management, Abuse

The nurse is caring for a patient diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse should anticipate a prescription for which of the following? A. Citalopram [9%] B. Risperidone [18%] C. Methylphenidate [64%] D. Carbamazepine [9%]

Explanation Choice C is correct. ADHD may be treated by psychostimulants such as amphetamines or methylphenidate. These medications work by projecting the dopamine and norepinephrine in the front of the brain to ameliorate the symptoms of inattention, impulsivity, and hyperactivity. Choices A, B, and D are incorrect. Citalopram is a serotonergic drug used in the treatment of depressive and anxiety disorders. Risperidone is indicated for psychotic disorders such as schizophrenia. Carbamazepine is an anticonvulsant indicated for bipolar disorders as it has a mood-stabilizing effect. Additional information: Methylphenidate is a drug commonly indicated for ADHD. Patient education should include the dosing of the medication, which should be earlier in the day. It is important to limit caffeine and chocolate. For pediatric patients, the nurse should monitor the patient's height and weight since this medication is an appetite suppressant.

A couple in a fertility clinic tell the nurse that they are concerned about transmitting a particular disease to their children. The nurse refers them to genetic counseling. All of the following are the purposes of genetic counseling, except: A. Reassure people who are concerned about their children inheriting a particular disorder as well as provide concrete and accurate information. [15%] B. Allow people who are affected by inherited disorders to make informed choices about future reproduction. [12%] C. Educate the couple on how to prevent their child from acquiring inherited disorders. [65%] D. Educate the couple about inherited disorders and the process of inheritance. [8%]

Explanation Choice C is correct. This is an incorrect statement and therefore the correct answer to the question. Genetic counseling aims to let people understand that they have no control over inherited traits. Marriages and relationships can suffer because of this unless they are given adequate support. Choice A is incorrect. This is a correct statement. Genetic counseling results in making individuals feel well or free of guilt, knowing that the disorder they are worried about is not an inherited disorder. Choice B is incorrect. This is a correct statement. Genetic counseling results in individuals acquiring information about having a trait that is responsible for a child's condition. Some people may opt not to have children because of this, but it is essential knowledge for decision-making. Choice D is incorrect. This is a correct statement. Genetic counseling educates people regarding how a particular inherited trait is passed on to the next generation.

Which of these nursing responsibilities is a part of the evaluation aspect of supervision? Select all that apply. A. The ongoing determination of staff's time management skills [23%] B. Ongoing staff competency validation [25%] C. The provision of feedback to staff, including negative feedback [28%] D. The immediate intervention and prevention of unsafe practices [24%]

Explanation Choices A, B, C, and D are correct. The evaluation aspect of supervision includes the ongoing determination of staff's time management skills, the current staff competency validation to ensure that the job is being done correctly and competently, the provision of feedback to the team, including negative feedback when a staff member needs correction and the immediate intervention and prevention of unsafe practices when the supervising nurse objects a lack of adherence to the standards of care and nursing practice.

You are assigned to administer hydromorphone to a patient with post-operative pain. You should be aware of which of the following legal mandates in terms of controlled substances? Select all that apply. A. The signatures of 2 registered nurses but not from practical nurses when a narcotic is wasted. [17%] B. Prohibitions against the use of a placebo for pain management. [12%] C. The signatures of 3 registered nurses or practical nurses when a narcotic is wasted. [2%] D. The verification of the narcotic count at the beginning and the end of the shift. [25%] E. Check the controlled substance at least 3 times prior to its administration. [17%] F. The secure locking of controlled substances to prevent diversion and theft. [26%]

Explanation Choices D and F are correct. The verification of the narcotic count at the beginning and the end of the shift (Choice D) and the secure locking of controlled substances to prevent diversion and theft (Choice F) are legal mandates in terms of narcotics and controlled substances. Nurses are responsible for ensuring that there is adequate documentation in the medical record to support the administration and the wasting of controlled substances. It's legally mandated that controlled substances are securely locked to prevent diversion. Examples of storage systems for controlled substances include locked medication carts, locked cabinets, and automated dispensing systems. When controlled substances are removed from secure storage in quantities more than what needs to be administered, the nurse is responsible for wasting the excess/unused portion in the presence of a witness. The best practices for the spending of controlled substances include: Waste at the time of removal from the storage. Witnessing nurses must watch the administering nurse as the correct dose is drawn. Witnessing nurses must observe as the unneeded portion is wasted in the approved manner. Document the waste electronically or in writing. Witness the wasting of controlled substances then verify product label, the number of wastes matches what is documented, and that the medication is wasted in an irretrievable location. Two nurses, both the administering nurse and the witness, are responsible for documenting the wastage. Either a Registered Nurse or a Licensed Practical Nurse can witness and sign. A nurse should never document seeing controlled substance wastage that was not observed. Choice A is incorrect. Although the signatures of two nurses are legally mandated when a narcotic is wasted, licensed practical nurses can also sign when an opiate is wasted. Choice A claims practical nurses cannot endorse, which is an incorrect statement. Choice B is incorrect. Although there is a prohibition against the use of a placebo for pain management, this is an ethical and not a legal mandate. Choice C is incorrect. Although the signatures of more than one nurse are legally mandated when a narcotic is wasted, the names of 3 registered nurses or practical nurses are not legally required when an opiate is wasted. Two signatures of RNs or LPNs will suffice. Choice E is incorrect. Although checking the controlled substance and all other medications, at least three times before its administration is appropriate, this is a standard of practice and not a legal mandate.

Which of the following are signs of hypocalcemia? Select all that apply. A. Chvostek's sign [48%] B. Grey-Turner's sign [2%] C. Homan's sign [3%] D. Trousseau's sign [47%]

Choices A and D are correct. Chvostek's sign is an indication of hypocalcemia. This sign is positive if the patient's upper lip twitches upon tapping over a branch of the facial nerve on the same side (Choice A). Trousseau's sign is also an indication of hypocalcemia. Trousseau's is positive if a carpopedal spasm is observed upon inflating a blood pressure cuff past the systolic blood pressure ( Choice D). Choice B is incorrect. Grey-Turner's sign indicates abdominal pathology, not hypocalcemia. Grey-Turner's sign refers to ecchymosis/ bruising around the flanks and takes about 24-48 hours to develop after the inciting event. The causes of Grey-Turner's sign include retroperitoneal hemorrhage and severe acute pancreatitis. Choice C is incorrect. Homan's sign indicates a deep vein thrombosis ( DVT), not hypocalcemia. Homan's sign is positive when there is deep calf pain and tenderness while extending the leg straight and dorsiflexing the foot. The sign is obsolete now and not used because it is unreliable in predicting a DVT. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Endocrine

The nurse is caring for a client who has an acute myocardial infarction (AMI). The nurse should anticipate an immediate prescription for which of the following? A. Aspirin [68%] B. Warfarin [7%] C. Propranolol [9%] D. Amiodarone [16%]

Explanation Choice A is correct. 325 mg of chewable aspirin should be prescribed to a client with acute myocardial infarction (AMI). This medication exerts antiplatelet effects and is the standard of care for an AMI. Choices B, C, and D are incorrect. Warfarin is not acutely used in an AMI. This medication is useful in the prevention of venous thrombosis. The client needs immediate antiplatelet medications such as aspirin and clopidogrel. Propranolol is a beta-blocker and while this may be utilized in an AMI, a cardioselective beta-blocker such as atenolol or metoprolol is preferred over propranolol which is non-selective. Amiodarone is an antiarrhythmic and is utilized in life-threatening dysrhythmias. This medication has no utility during an AMI. Additional information: The nurse must recognize typical and atypical manifestations. Typical sign would be substernal chest pain that radiates to the arm or jaw; the client may be pale, diaphoretic, dyspneic, and apprehensive. Atypical signs of an AMI include nausea/vomiting and epigastric pain which may be confused for indigestion. Atypical features emphasize less on the actual chest pain and more on nausea, dyspnea, and significant fatigue. Immediate treatment for an AMI includes a 12-lead electrocardiogram, continuous cardiac monitoring, and stabilizing treatments such as nitroglycerin, oxygen, aspirin, and percutaneous coronary intervention (PCI). NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Indications and Expected Actions

Which of the following is a priority for the nurse to monitor for during the acute management of a patient who has taken an overdose of aspirin? A. Onset of pulmonary edema [24%] B. Metabolic alkalosis [37%] C. Respiratory alkalosis [25%] D. Symptoms that mimics Parkinson's disease [14%]

Explanation Choice A is correct. Aspirin overdose can lead to metabolic acidosis and cause the development of pulmonary edema. Early symptoms of aspirin poisoning include tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs include drowsiness, unsteady gait, bizarre behavior, and coma. Abnormal breathing caused by aspirin overdose is usually deep and rapid. Pulmonary edema may be related to an increase in the permeability within the capillaries of the lung leading to "protein leakage" and transudation of fluid in both renal and pulmonary tissues. The alteration in renal tubule permeability may lead to a change in colloid osmotic pressure, therefore facilitating pulmonary edema. Choice B is incorrect Aspirin overdose may lead to metabolic acidosis, not metabolic alkalosis. Choice C is incorrect. Although initial respiratory alkalosis may occur with acute aspirin or salicylates overdose, metabolic acidosis ensues shortly thereafter. Choice D is incorrect. Aspirin overdose is not associated with Parkinson's-type symptoms. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation - Non-Steroidal Anti-Inflammatory Medications

The nurse is taking care of a patient that was recently rescued from a near-drowning experience. The patient is now having pulmonary edema. The nurse understands that pulmonary edema is the result of which process? A. Water washing out the alveolar surfactant. [38%] B. Water introducing bacteria into the lungs and causing infection. [18%] C. Decreased intrathoracic pressure in the lungs. [40%] D. A sudden change in temperature within the lungs. [3%]

Explanation Choice A is correct. Freshwater and saltwater wash out the alveolar surfactant when they enter the lungs. This leads to alveolar collapse, intrapulmonary shunting, decreased lung compliance, and hypoxemia, which will eventually result in pulmonary edema. Choice B is incorrect. The introduction of bacteria into the lungs leading to infection may be possible; however, the initial result would be pneumonia, not pulmonary edema. Choice C is incorrect. A decreased intrathoracic pressure does not cause fluid to shift into the lungs. Choice D is incorrect. Sudden temperature changes may bring about cardiac dysrhythmias but is unlikely to cause pulmonary edema.

A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as: A. Autocratic [79%] B. Democratic [9%] C. Participative [6%] D. Laissez-faire [6%]

Explanation Choice A is correct. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit. Choice B is incorrect. In a democratic style of management, staff members are encouraged to participate in the decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in this management style. Choice C is incorrect. In a participative style of management, problems are identified by the manager and presented to the staff with several solutions. Staff members are encouraged to provide input however, the manager makes the final decision. Choice D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of management. The manager abdicates responsibility and decision-making whenever possible in this type of management.

The nurse is providing sensitivity training to new members of the health care team about the best ways to manage and care for families after a miscarriage. The nurse explains that when it comes to telling children about a woman's pregnancy or pregnancy loss, it is the health care team's job to: A. Provide available resources and ultimately support the mother's decision. [92%] B. Inform the children of the parents so that they don't have to worry over the task. [2%] C. Encourage the parent's not to inform the children of the status of their mother's pregnancy. [1%] D. Use a hands-off approach and let the family come up with a solution alone. [5%]

Explanation Choice A is correct. It is the health care team's job to provide resources and support to the mother and her family when it comes time to discuss pregnancy and pregnancy loss. Choice B is incorrect. It is not the job of the health care team to inform the children of a woman about her pregnancy or pregnancy loss. Choice C is incorrect. There is no reason that the best option is to withhold information from the children at this point. This is a decision for the parents to make. Choice D is incorrect. A hands-off approach may be tempting, but the health care team should provide resources that are available and provide as much support as possible. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

The registered nurse is on a shift in the emergency department of a pediatric hospital. There are four patients in the ED; which patient would the nurse see first? A. A 1-month-old infant that is crying with retractions during inspiration. [78%] B. A 5-year-old with pneumonia with 95% pulse oxygen saturation. [2%] C. A 10-year-old with diarrhea and vomiting with a potassium level of 3.6 mEq/L. [7%] D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL. [12%]

Explanation Choice A is correct. The child with inspiratory retractions indicates respiratory distress in the child and should be assessed first. Choice B is incorrect. The child with pneumonia is stable. The nurse does not need to assess this patient urgently. Choice C is incorrect. The child still has an average potassium level even though he is having diarrhea and vomiting. The nurse does not need to assess this child first. Choice D is incorrect. A glucose level of 190 mg/dL is not threatening. The nurse does not need to assess this child first.

The nurse is talking to the client who has suffered a stroke which resulted in the difficulty of understanding spoken words. Which action by the nurse is most appropriate when talking to the client? A. Giving simple instructions to the client. [90%] B. Talk to the client in a raised tone of voice. [1%] C. Encourage the client to respond to every statement by the nurse. [8%] D. Consistently shift topics of conversation. [0%]

Explanation Choice A is correct. The client with receptive difficulty should only be given simple instructions when communicating with them. This makes the task of understanding what the nurse said much easier for the client. Choice B is incorrect. The nurse should talk to the client in a soft, audible voice. The client can hear the nurse's words, but he is having difficulty understanding them. Choice C is incorrect. Pressing the client for a response to every statement by the nurse puts undue pressure on the client, leading to frustration. Choice D is incorrect. The nurse should gradually shift topics of conversation and inform the client when there will be a topic change. This decreases confusion on the part of the client.

The nurse is assessing a patient who just returned from surgery. The nurse checks preoperative vital signs at 8:30 AM to compare them with the current vital signs at 10:30 AM. What action should the nurse take? See the exhibit. A. Assess the surgical wound [68%] B. Collect blood cultures [5%] C. Administer oxygen at 2 L/minute [15%] D. Encourage by-mouth (PO) fluids [11%]

Explanation Choice A is correct. The patient's 10:30 AM vital signs show signs of shock. Considering this patient is in the immediate post-operative period, the nurse should assess the surgical wound for signs of hemorrhage. If this is the source of the bleeding, the nurse should reinforce the dressing. The nurse should notify the primary healthcare physician (PHCP) of the patient's change in condition. Choices B, C, and D are incorrect. Collecting blood cultures is not necessary as the likely hood of this being a surgical site infection or sepsis is low. This is because the patient is immediately post-operative, and infections typically begin in the extended postoperative period. Oxygen administration is not indicated as an oxygen saturation of 95% is optimal. The nurse should not encourage by-mouth fluids - rather obtain a prescription for intravenous fluids. Additional information: An early manifestation of shock is tachycardia. The nurse must continually trend a patient's vital signs post-operatively in the event they should develop hypovolemic shock.

The lymph nodes which lie in front of the mastoid bone are called the: A. Preauricular nodes [53%] B. Superficial cervical nodes [13%] C. Occipital nodes [12%] D. Supraclavicular nodes [23%]

Explanation Choice A is correct. The preauricular nodes are, as the name implies, in front of the ear. Choice B is incorrect. Cervical nodes are in the neck. Choice C is incorrect. Occipital nodes are at the base of the skull posteriorly. Choice D is incorrect. Supraclavicular nodes are above the clavicle. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Lymph Nodes

What tool, or graphic display, that is shown below can assist the nurse in understanding the health status of the family unit and its risk factors? A. Genogram [68%] B. Ecomap [9%] C. Histogram [20%] D. Scattergram [3%]

Explanation Choice A is correct. The tool or graphic display that is shown in the image that can assist the nurse in understanding the health status of the family unit and its risk factors is a genogram. Choice B is incorrect. Ecomaps show the interrelationships of individuals, families, and communities with their external environment as well as the forces and relationships that impact the individual, family, and community. Choice C is incorrect. Histograms show statistical data, not the health status of the family unit and its risk factors. Choice D is incorrect. Scatter grams show statistical data, not the health status of the family unit and its risk factors.

You are taking care of a 10-year-old with a gastro-jejunostomy (GJ) tube. Which electrolyte deficit is this patient at risk for? A. Sodium [28%] B. Potassium [52%] C. Chloride [10%] D. Calcium [10%]

Explanation Choice A is correct. There is a large amount of extracellular fluid in the peritoneal cavity, which contains a high amount of sodium. If this fluid is lost through the GJ tube, there will be a sodium deficit. Choice B is incorrect. Patients with GJ tubes are not at risk for a potassium deficit. Choice C is incorrect. Patients with GJ tubes are not at risk for a chloride deficit. Choice D is incorrect. Patients with GJ tubes are not at risk for a calcium deficit. NCSBN Client Need: Topic: Health Promotion Subtopic: Child Health, Renal

While working in the emergency department, you triage a 29-year-old female who states, "I am going to kill myself. They're coming for me!" Which of the following responses utilizes a therapeutic form of communication? A. "You are safe here. Can you tell me what is happening?" [82%] B. "Please don't try to kill yourself. We will sedate you if we have to." [0%] C. "Why would you kill yourself?" [4%] D. "Who is coming for you?" [14%]

Explanation Choice A is correct. This statement uses therapeutic communication by helping the client feel safe and asking open-ended questions to gather more information. Choice B is incorrect. Telling the client not to kill themselves will not work for this patient. Instead, it will increase the likelihood of them trying to do so. Furthermore, it is never therapeutic to threaten to sedate a patient. Choice C is incorrect. Asking 'why' questions are never therapeutic communication. This can seem judgemental and make the client defensive rather than open up to you. Choice D is incorrect. This question endorses the client's thought that someone is coming for them by asking them 'who'. This is also a closed-ended question that will not promote further conversation. In therapeutic communication, you should use open-ended questions. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Adult Health, Mental Health Nursing

Which nursing diagnosis is most appropriate for a caregiver abusing drugs and alcohol to self-medicate to overcome caregiver stress? A. Ineffective coping related to alcohol and abuse [18%] B. Ineffective coping related to responsibilities required in the caregiver's role [76%] C. The client will make better lifestyle choices [1%] D. The client will attend two 12-step recovery programs per week for one month [4%]

Explanation Choice B is correct. "Ineffective coping related to responsibilities required in the caregiver's role" is an appropriate nursing diagnosis for a caregiver who abuses alcohol and drugs to self-medicate to overcome caregiver stress. Choice A is incorrect. "Ineffective coping related to alcohol and abuse" is not an appropriate nursing diagnosis for a caregiver abusing drugs and alcohol. The use of drugs and alcohol signifies the individual is in a self-sabotage or destructive coping stage, both of which are signs and symptoms of ineffective coping. Choice C is incorrect. "The client will make better lifestyle choices" is not an example of a nursing diagnosis. Although this option appears to be an expected outcome, it is important to remember that an expected client outcome must be measurable. Here, "[t]he client will make better lifestyle choices" is not a nursing diagnosis nor an expected client outcome. Choice D is incorrect. "The client will attend two 12-step recovery programs per week for one month" is an example of an appropriate client outcome, not a nursing diagnosis. Learning Objective Utilize the objective information provided to determine the most appropriate nursing diagnosis for the client in question. Additional Info Ineffective coping is the inability to make sound decisions due to the failure to assess a stressful life event. The individual may have difficulty asking for assistance, locating the appropriate resources, or utilizing the appropriate problem-solving skills to manage the situation. An individual who is ineffectively coping may have difficulty meeting their own basic needs, such as food and shelter (i.e., the lower level of Maslow's Hierarchy of Needs), let alone the role of caregiver. Self-sabotage/destructive behavior via alcohol and/or illicit drugs is just one of the many signs of ineffective coping. Additional signs and symptoms may include: Incapability to maintain responsibilities of daily life Neglect in personal care Insufficient skills to problem-solve appropriately Fatigue An expected outcome is a measurable behavior demonstrated by the client responsive to nursing interventions.

Which of the following is the final step that is used during the physical assessment of the abdomen? A. Inspection [2%] B. Deep palpation [61%] C. Percussion [18%] D. None of the above [18%]

Explanation Choice B is correct. Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include their tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the age of the individual, the severity of the illness, the preferences of the nurse, the location of the examination, and the agency's priorities and procedures. Choice A is incorrect. Inspection is typically the first step of an assessment. Choice C is incorrect. Percussion of the abdomen should be done before any palpation, especially deep palpation. Choice D is incorrect. Since choices A and C are incorrect, choice D is also wrong. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: The Health Assessment - Abdomen

Which term is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine? A. Morphine equivalency [19%] B. Equianalgesia [53%] C. Morphine equivalent [20%] D. The morphine factor [9%]

Explanation Choice B is correct. Equianalgesia is the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine. The equianalgesic of an opioid, when compared to parenteral morphine, is mathematically calculated. Choice A is incorrect. Morphine equivalency relates to the equivalency of an opioid analgesic when compared to parenteral morphine. Choice C is incorrect. Morphine equivalent relates to the equivalency of an opioid analgesic when compared to parenteral morphine. Choice D is incorrect. The morphine factor is the term that elements in the power of parenteral morphine.

The nurse is caring for a client admitted to the acute care facility. The nurse takes a phone call from an individual who wants to know where the client is located. The nurse should A. inform the individual that this information cannot be released. [46%] B. provide the caller with the client's current location. [26%] C. not acknowledge the presence of this individual. [5%] D. inquire with the caller as to the reasoning for the information. [23%]

Explanation Choice B is correct. HIPAA allows for directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated. The client may also decide against having this information shared in the directory. If that is the case, the nurse should not acknowledge that an individual by this name is currently in the facility. The item provided does not state that the client has decided against being in the directory. Choices A, C, and D are incorrect. Directory information may be released, and stating that it cannot be divulged would be inappropriate. Unless the client has asked to be removed from the directory, the nurse is permitted to state where the client is located, the health condition in general terms, and their religious affiliation. Not acknowledging the presence of this client would only be appropriate if the client wanted to be removed from the hospital directory. The nurse would simply state, "I do not have a client by that name." The nurse does not need to inquire about the reasoning for the caller's inquiry - that would be inappropriate. Additional Info HIPAA allows for directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated. The client must be informed about the information to be included in the directory, and to whom the information may be released, and must have the opportunity to restrict the information or to whom it is disclosed, or opt out of being included in the directory. The client may be informed and make his or her preferences known, orally or in writing.

Which of the following clients should the nurse attend to first? A. A client who is newly diagnosed with Hepatitis A who is reporting stomach pain and itchy skin. [3%] B. A patient in an arm cast who is 2 days post-op and is reporting feelings of numbness and tingling in his affected arm. [71%] C. A post-op prostatectomy patient complaining of bladder spasms and bloody urine in his foley bag. [9%] D. A patient with a newly placed NG tube who is complaining of pain around the face and a "plugged" nose. [17%]

Explanation Choice B is correct. Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a doctor right away. Choices A, C, and D are incorrect. Each of these features is expected or are typical symptoms related to their diagnosis. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care - Prioritizing Care

A nurse is instructing a client about prescribed risperidone. Which statements, if made by the client, require follow-up? A. "I should report any abnormal movements that I develop." [12%] B. "I will need to have weekly tests to monitor my white blood cells." [57%] C. "If I get muscle stiffness, I should notify my physician." [13%] D. "I will need to chew sugarless gum if I develop a dry mouth." [18%]

Explanation Choice B is correct. Risperidone is a second-generation antipsychotic used in delirium, schizophrenia, and some childhood disorders. Weekly white blood cell tests are not required with risperidone as this is appropriate for an individual receiving clozapine. Choices A, C, and D are incorrect. Risperidone is a second-generation antipsychotic which may adversely cause movement disorders such as dystonia or tardive dyskinesia. The client should report any abnormal movements to the provider. Neuroleptic Malignant Syndrome (NMS) is a potentially fatal adverse reaction manifested by muscle rigidity, fever, and tachycardia. This must be reported promptly. Finally, the client should use special mouthwashes and sugar-free gum for dry mouth because of the anticholinergic properties associated with this drug. Additional Info Second-generation antipsychotics (risperidone, olanzapine, quetiapine, clozapine, lurasidone, ziprasidone, aripiprazole, brexpiprazole) are preferred because of the decreased risk of movement disorders. The concern with SGA's is that they may adversely impact the client metabolically by raising glucose and weight. For a client receiving an antipsychotic, the nurse must always monitor for NMS, which could be fatal.

You are the nurse performing education for a patient with AIDS at the community clinic. Which of the following statements is an example of appropriate teaching? A. "Do not wash your dishes with your roommate's dishes." [9%] B. "Clean all utensils and dishes before reusing them." [73%] C. "Do not use the same shower or toilet as your roommate." [13%] D. "Hand sanitizer is not necessary unless you plan on touching someone else." [5%]

Explanation Choice B is correct. Stagnant water and food particles can be a breeding ground for pathogenic microorganisms. A patient with an AIDS diagnosis is susceptible to contracting illness/infections more quickly due to the deficiency in his/her immune system. The focus of education should include measures to protect the patient from contracting illnesses from others. Choices A and C are incorrect. Washing dishes with someone else's or sharing bathroom facilities does not protect the patient or the roommate from illness or spread of disease. Choice D is incorrect. Using hand sanitizer is recommended for all people to help prevent the spread of germs. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement? A. Steak and a baked potato [2%] B. Brussel sprouts and a whole grain roll [89%] C. White rice with chicken [6%] D. A ham sandwich with tomato soup [3%]

Explanation Choice B is correct. The best option here is to choose vegetables that are rich in fiber and either cooked or raw. Brussel sprouts, as well as cauliflower, broccoli, and leafy greens, are great examples. Whole-grain bread, brown rice, and nuts/seeds are also dense in fiber. Constipated clients should also be encouraged to drink plenty of water. Choice A is incorrect. A steak and a potato do not contain enough fiber to promote a bowel movement in a constipated client. Choice C is incorrect. White rice and chicken do not contain enough fiber to promote a bowel movement. Choice D is incorrect. A ham sandwich with tomato soup is not the best choice because it does not contain enough fiber to promote bowel movements in a constipated client. NCSBN client need Topic: Health Promotion and Maintenance, health promotion

The nurse is preparing to sign a patient's surgical consent form after the physician has explained the procedure to the patient and family. As the patient signs the form, she comments "I really didn't understand most of what the doctor said, but I have to have this procedure, so I want to sign." Which is the appropriate nursing action? A. Witness the document, as the patient states she wants to sign it. [2%] B. Notify the physician or nursing supervisor. [83%] C. Call the OR to cancel the procedure and reschedule at a later date. [1%] D. Explain the information she did not understand. [14%]

Explanation Choice B is correct. The person (in this case, the doctor) responsible for performing the procedure has the responsibility to obtain the patient's consent, providing a clear explanation about the procedure and all associated risks. When witnessing the patient's signature, the nurse should confirm that the patient understands the information about the procedure. If the patient denies understanding, the nurse must then contact the physician or the nursing supervisor. Choice A is incorrect. The nurse has to witness the patient's signature but even prior to that, she must confirm that the patient understood the information about the procedure. Choice C is incorrect. The nurse must call the physician or nursing supervisor and inform them that the patient did not understand the procedure information. Canceling the procedure is not necessary as something else needs to be done first. Choice D is incorrect. It is the responsibility of the person performing the procedure (in this case, the doctor) to obtain the patient's consent, providing a clear explanation about the procedure and all associated risks. The nurse only needs to confirm if the patient understood it.

Your client presents with conjunctivitis, numbness in the extremities, and atrioventricular heart block following a tick bite that occurred two months ago. You suspect Lyme disease. Which stage of Lyme disease does this presentation represent? A. First stage [2%] B. Second stage [29%] C. Third stage [51%] D. Fourth stage [17%]

Explanation Choice B is correct. This reflects the second stage of Lyme disease. Neurological and cardiac involvement are hallmarks. Manifestations may include atrioventricular heart block and neuropathy. Ocular manifestations such as conjunctivitis can be seen in 10% of cases. The second stage occurs typically around seven weeks after the initial tick bite. It is also referred to as "early, disseminated Lyme" disease. Choice A is incorrect. The first stage of Lyme disease usually presents with a red rash the size of a pimple or as a large ring. The patient generally complains of flu-like symptoms. Choice C is incorrect. The third stage of Lyme disease is characterized by sizeable joint involvement and arthritis (chronic Lyme arthritis). Knee joints are often involved. Choice D is incorrect. There is no fourth stage in Lyme disease. NCSBN client need Topic: Infectious disease, Subtopic: Physiologic integrity, physiologic adaptation

There is a new patient in your clinic. Six months ago, he had a kidney transplant and is taking immunosuppressive drugs. Recently, he has been experiencing repeated bacterial infections and was switched to different antibiotics throughout the past six months. The physician suspected kidney infection. He is admitted to the hospital and administered gentamicin 300 mg daily by IV infusion. Which of the following tests should the nurse monitor? A. Input and output ratio [20%] B. Kidney function tests [67%] C. Visual acuity tests [9%] D. Fasting blood glucose levels [4%]

Explanation Choice B is correct. To monitor for signs of nephrotoxicity; the nurse should monitor the results of kidney function tests closely while the patient is taking gentamicin. Gentamicin is an aminoglycoside drug, that is capable of causing severe adverse effects in some patients. The most significant concerns are their effects on the inner ear and the kidneys. Damage to the inner ear, or ototoxicity, may cause hearing impairment, dizziness, persistent headache, or ringing in the ears. Nephrotoxicity is recognized by abnormal kidney function tests, such as elevated serum creatinine or blood urea nitrogen. Choice A is incorrect. Although intake and output (I&O) may be ordered, it is not indicated simply because of the use of gentamicin. Choice C is incorrect. Visual acuity tests are not required when a patient is taking gentamicin therapy. Choice D is incorrect. The primary concerns related to gentamicin therapy are ototoxicity and nephrotoxicity. Blood glucose monitoring is not indicated because of the use of this therapy. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies

The nurse receives her assignment for the day and is caring for each of the following clients. Whom should the nurse assess first? A. A patient in Buck's traction. [0%] B. An unstable patient dependent on mechanical ventilation. [61%] C. A patient who is status-post CABG procedure getting ready for discharge. [1%] D. A new admission diagnosed with a sickle cell pain crisis. [38%]

Explanation Choice B is correct. When deciding which patient is a priority, the nurse must follow the ABCs (Airway, breathing, and circulation should be addressed in that order). An unstable client who is dependent on a mechanical ventilator has an alteration in their airway and therefore is the priority. Choice A is incorrect. The patient in Buck's traction needs to be monitored closely, but there is no immediate need. Choice C is incorrect. A patient who is status-post CABG procedure and ready for discharge should be stable and not need immediate interventions. Choice D is incorrect. A new admission diagnosed with a sickle cell pain crisis will be dealing with extreme pain. This will need to be addressed soon, but the nurse should follow the ABC priorities and first assess the unstable patient with an airway issue. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Infection control and safety; Prioritization, delegation, and leadership

A nurse is doing an assessment on a client who is 6-hours postpartum after delivering a full-term infant. The client verbalized feeling dizzy and faint. Which is the most appropriate nursing action? A. Place the client in Trendelenburg's position [37%] B. Review the pre-delivery hemoglobin and hematocrit [19%] C. Instruct the client to get out of bed slowly and ask for help when ambulating [37%] D. Inform the nursery nurse to delay rooming-in until the client is stable [7%]

Explanation Choice C is correct. In the first 8 hours postpartum, orthostatic hypotension is a regular occurrence that may be manifested by feeling faint or dizzy. The nurse should reassure the client that this is normal and focus on the client's safety. The client should always be instructed to get help when getting out of bed and ambulating until the symptoms subside. Choice A is incorrect. Placing the client in Trendelenburg's position is not the most appropriate intervention. Trendelenburg's position is appropriate when there is evidence of hypovolemic shock. While this patient could have lost blood during delivery, there is no information to suspect hypovolemic shock. The most likely reason for the client's dizziness is orthostatic hypotension, thus choice C is most appropriate. Choice B is incorrect. Reviewing the pre-delivery hemoglobin and hematocrit is incorrect. Hemorrhagic shock may manifest with blood-loss anemia and low blood pressure. However, there's no suggestion in the question that severe intrapartum bleeding has occurred. Even if such intrapartum bleeding has occurred, reviewing pre-delivery hemoglobin is not reliable because examining the values obtained before the hemorrhagic event is of no help. Choice D is incorrect. Informing the nursery nurse to delay rooming-in until the client is stable is not necessary. The symptoms the client is experiencing are a regular occurrence in the first 8 hours postpartum and do not require delayed rooming-in. Keeping mother and baby together by rooming-in is recommended as a healthy birth practice. It promotes early breastfeeding and encourages maternal-infant bonding.

Which of the following meals would be appropriate for a nurse to assign to a client of Orthodox Judaism faith on a kosher diet? A. Pork belly roast, rice, vegetables, mixed fruit, milk [5%] B. Crab salad on a croissant, potato salad, milk, vegetables with dip [12%] C. Sweet and sour chicken with rice and vegetables, juice, mixed fruits [76%] D. Fettuccini Alfredo with shrimp and vegetables, salad, mixed fruit, iced milk tea [7%]

Explanation Choice C is correct. Orthodox Judaism believers adhere to kosher dietary laws, and for this group, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed. Other meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and those that are ritually slaughtered. Choices A, B, and D are incorrect. All these options are prohibited in orthodox Judaism because meat and dairy can not be combined. NCSBN client need | Topic: Fundamentals; SubTopic: Culture and Spirituality

A client is admitted to the ward for exacerbation of his rheumatoid arthritis. The nurse would expect the physician to prescribe which medication to combat the client's inflammation and produce immunosuppression? A. Allopurinol [11%] B. Azathioprine [7%] C. Prednisone [72%] D. Naproxen sodium [10%]

Explanation Choice C is correct. Prednisone is a steroid with anti-inflammatory and immunosuppressive effects to treat rheumatoid arthritis. Choice A is incorrect. Allopurinol is an anti-gout medication. It lowers the patient's uric acid levels by reducing the production of uric acid in the body. Choice B is incorrect. Azathioprine is used for clients with life-threatening rheumatoid arthritis for its immunosuppressive effects. Choice D is incorrect. Naproxen sodium is a COX2 inhibitor that is an anti-inflammatory, reducing pain.

Which activity would best promote the achievement of school-age child development? A. Pull toys [8%] B. Pat-a-cake [16%] C. Simon says [66%] D. Shopping [10%]

Explanation Choice C is correct. The most appropriate action for school-age children is Simon says, as it promotes cooperation with some competition, refines communication skills, and is a group activity. Choices A, B, and D are incorrect. Pull toys are best for developing autonomy and gross motor activities in the toddler. Pat-a-cake promotes imitation and the development of the infant. Shopping is most appropriate for adolescents to promote financial responsibility.

The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate? A. "Stop! You will kill your baby." [0%] B. "That is a nice, tight swaddle. It will help soothe your new baby." [3%] C. "May I help you? We will need to be careful with their intestines since we do not want the swaddle to push them back inside." [90%] D. "Swaddling is not allowed for these babies; please stop." [7%]

Explanation Choice C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very loosely and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It also promotes bonding with the infant, as it encourages the parent to touch and care for their baby. Choice A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to promote the parent bonding with their infant, so phrases like this will scare the parent and make them afraid to touch the baby, which is not therapeutic. Choice B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place pressure on their exposed intestines and push them back inside the baby, which we do not want. Choice D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed intestines, but if it is done loosely and avoids placing pressure on the defect, it can certainly be done. Telling the parent to stop will not promote bonding and decreases their interaction with the baby. The nurse should educate the parent on the necessary precautions when traveling and develop a positive relationship with their new baby. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Gastrointestinal

Case management, as a form of patient care delivery and documentation, is most closely aligned with which of the following? A. The SOAP method of documentation [30%] B. The SOAPIE method of documentation [45%] C. Variances [19%] D. Case mix [6%]

Explanation Choice C is correct. Variances, including patient variances, system variances, and practitioner variances are deviations from the expected plan of care and treatment that is documented on the critical pathway of the case management method of patient care delivery and documentation. Choice A is incorrect. The SOAP method of documentation is part of the problem-oriented medical record documentation system and not the case management method of patient care delivery and documentation. Choice B is incorrect. The SOAPIE method of documentation is part of the problem-oriented medical record documentation system and not the case management method of patient care delivery and documentation. Choice D is incorrect. Case-mix reflects the collective conditions of the clients and it is not part of the case management method of patient care delivery and documentation.

Which of the following statements should the nurse use to best describe a very low-calorie diet? A. "This is a long-term treatment measure that assists obese people who can't lose weight." [37%] B. "A VLCD contains very little protein." [10%] C. "This diet can be used only when there is close medical supervision." [42%] D. "This diet consists of solid food that is pureed to facilitate digestion and absorption." [10%]

Explanation Choice C is correct. Very Low-Calorie Diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. Deficient calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in the treatment of adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death) but became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the deficient calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision. Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3-5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, constipation, and the risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3-4 months. Although rapid weight loss is seen, it is not regularly well maintained with many patients gaining up to 50% of that weight back within the subsequent 12 months and gaining all of the weight back in less than five years. Low-calorie diets (LCDs) are not as extreme and with almost twice as many calories allowed (1200-1500 kcal/day), the weight loss is modest. Choice A is incorrect. The VLCD is not intended to be a long-term treatment measure. Choice B is incorrect. VLCD consists of high levels of quality proteins. Choice D is incorrect. The food on a VLCD is not pureed.

Which of the following clinical manifestations should the nurse document as a positive sign of pregnancy? A. Amenorrhea [3%] B. Uterine soufflé [1%] C. Positive pregnancy test [7%] D. Fetal heartbeat [89%]

Explanation Choice D is correct. A fetal heartbeat can be detected with a doppler as early as 10-12 weeks of pregnancy and is considered a positive or diagnostic sign of fertility. Signs of pregnancy can be possible, probable, or definite. Because likely signs of pregnancy may also occur when other conditions are present, the nurse needs to know what each possible indicator of pregnancy means. Choice A is incorrect. Amenorrhea, the absence of menses, is considered a possible sign of pregnancy. It is a more helpful sign when more than one cycle has been missed. Choice B is incorrect. Uterine soufflé is the sound heard on auscultation over the uterus that is caused by blood flow through the placenta. It is considered a probable sign of pregnancy, but not a definite sign of pregnancy since other conditions like uterine myomas or ovarian tumors can cause it. Choice C is incorrect. A positive pregnancy test is based on the detection of human chorionic gonadotropin. It is present during pregnancy, but other conditions can cause it to be elevated, so it is considered a probable sign of fertility. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Physical and Psychological Changes of Pregnancy

A middle-aged man comes into the clinic for a check-up. His pulse is 49 beats per minute and the client reports that he has gained 20 pounds in the past two months. The nurse also notices that his skin is cool to touch and that he has three layers of clothing. The nurse suspects hypothyroidism. Which nursing diagnosis should be of the highest priority? A. Fatigue [3%] B. Activity intolerance [4%] C. Hypothermia [26%] D. Decreased cardiac output [67%]

Explanation Choice D is correct. Cardiac output is essential to ensure adequate blood flow to all parts of the body. It is affected by the circulating blood volume and heart rate. If left unattended, a decreased pulse can lead to shock. It should take priority over all other nursing diagnoses. Choice B is incorrect. The client may experience activity intolerance due to hormonal changes in hypothyroidism, but this is not a priority nursing diagnosis. Choice A is incorrect. The client may experience fatigue due to hormonal changes in hypothyroidism, but this is not a priority nursing diagnosis. Choice C is incorrect. Due to decreased metabolism, clients with hypothyroidism have reduced tolerance to cold. This, however, should not be prioritized over the problem of decreased cardiac output.

You are the nurse working in the coronary care unit of the hospital. You are assessing the patient who is alert and oriented, respirations 12 and non-labored, and pulse rate 84 and regular. You look up at the monitor and see the rhythm. See the exhibit. Your first intervention is to: A. Start CPR. [14%] B. Connect the patient to the defibrillator. [2%] C. Begin ventilations with a bag-valve-mask device. [1%] D. Check to ensure the monitor leads are connected to the patient. [83%]

Explanation Choice D is correct. Check to ensure the monitor leads are connected to the patient. Although this rhythm looks like asystole, the fact that the patient is awake and talking to you with a palpable pulse of 84 would indicate that he is probably disconnected from the cardiac monitor. If you determined that the patient was pulseless and unresponsive, you would first start CPR since that would be an indication that the patient is in asystole. Ventilations and a defibrillator are not necessary for this stable patient. NCSBN Client Need Topic: Physiological Adaptation, Sub-Topic: Medical Emergencies, Cardiovascular; Prioritization

The nurse in the gynecology clinic is assessing a first-time client who is 8 weeks pregnant. Which assessment finding would alert the nurse of a high-risk pregnancy? A. The client complains of nausea and vomiting [1%] B. The client expresses to the nurse her ambivalence towards the pregnancy [9%] C. The client complains of constipation ever since finding out she was pregnant [2%] D. The client reports of vaginal spotting and cramping [87%]

Explanation Choice D is correct. Danger signs of pregnancy include vaginal bleeding, sudden discharge of clear fluid from the vagina, and abdominal pain. The nurse should be on the lookout for symptoms and signs such as these. Other danger signs of pregnancy would also include fever and chills, severe headaches with blurred vision; generalized swelling of the face and limbs; and absence of fetal movement. Choice A is incorrect. Nausea and vomiting are a result of varying hormones during pregnancy. Unless nausea and vomiting cause severe dehydration and electrolyte loss, the pregnancy is not considered at risk. Choice B is incorrect. Ambivalence is a normal emotional response to pregnancy, where the mother realizes that a separate individual is growing in her. She may have interwoven feelings to want or not want the pregnancy. Choice C is incorrect. Constipation is a normal change in pregnancy due to high levels of progesterone.

A client was accompanied by the nurse for a bronchoscopy. During the insertion of a rigid scope, the nurse would note that the client is experiencing a vasovagal response if she notices which of the following? A. Dilated pupils [7%] B. Bronchodilation [12%] C. Decrease in gastric secretions [5%] D. Noticeable drop in heart rate [76%]

Explanation Choice D is correct. During bronchoscopy, the involvement of the pharynx may cause stimulation of the vagus nerve resulting in a vasovagal response that is manifested by a sudden drop in the client's heart rate leading to syncope. Choices A, B, and C are incorrect. Stimulation of the vagus nerve does not cause dilation of the pupils or bronchodilation. Also, in a vasovagal response, an increase in gastric secretion is noted.

Which of the following is a physiological alteration that can occur with stress? A. Decreased visual acuity [11%] B. Increased peristalsis [30%] C. Decreased glucocorticoids [12%] D. Hyperglycemia [47%]

Explanation Choice D is correct. Hyperglycemia is a physiological alteration that can occur with stress among both diabetic and non-diabetic clients. This hyperglycemia occurred as the result of increased secretion of glucocorticoids and increased gluconeogenesis that is part of the general adaptation syndrome and the "fight or flight" phenomena. Choice A is incorrect. Increased, rather than decreased, visual acuity is the result of the general adaptation syndrome and the "fight or flight" phenomena. Improved visual acuity allows the person to be more vigilant and aware of their environment. Choice B is incorrect. Decreased, rather than increased, gastrointestinal system peristalsis occurs as the result of the general adaptation syndrome and the "fight or flight" phenomena in response to stress. Natural resources are directed to higher priority bodily functions rather than gastrointestinal functioning. Choice C is incorrect. The increased secretion of glucocorticoids, rather than decreased glucocorticoids, in addition to increased gluconeogenesis, are part of the general adaptation syndrome and the "fight or flight" phenomena. These increases raise blood sugar levels.

A G3P3 client in labor tells the nurse, "I would like to breastfeed, but my breasts got so engorged last time. I could not take it. Do I have to go through that again?" Which of the following responses is most appropriate? A. "Keeping your baby on an every 4-hours schedule would help slow the milk production and lessen the engorgement." [17%] B. "You can feed your baby formula milk until your milk comes in. This will reduce stimulation and prevent engorgement." [4%] C. "You can take Bromocriptine to stop your milk production and prevent engorgement." [2%] D. "You need to feed your baby as soon as possible. Also, feeding your baby often would prevent breast engorgement." [76%]

Explanation Choice D is correct. Immediate and frequent breastfeeding is the key to decreasing breast engorgement in breastfeeding women. Also, the first step in treating engorgement is encouraging the mother to immediately breastfeed and continue to do so every 2 hours. The most common causes of engorgement include: A missed session of feeding or breast milk expression. Feeding the baby on a strict schedule. Less feeding by the baby due to illness/sickness. Rapid weaning from breast milk. The mother should be educated to slow down the weaning process if she experiences engorgement during weaning. Choices A and B are incorrect. Feeding and emptying the breasts less often (Choice A) and substituting it with formula (Choice B) increases the risk of engorgement. Having a strict feeding schedule increases the risk of breast engorgement. The amount of milk that can be stored in the breasts without causing engorgement varies from person to person. Therefore, following a fixed schedule of feeding/expression may predispose the mother to breast engorgement and mastitis because of inadequate milk drainage. Choice C is incorrect. Bromocriptine completely stops milk production; it also has serious side effects including stroke, when given to postpartum women.

The nurse is interviewing a client who reports frequent urination and nausea. The client is concerned that she may be pregnant. The nurse understands that these manifestations are A. a possible sign of pregnancy. [14%] B. probable sign of pregnancy. [14%] C. positive sign of pregnancy. [1%] D. presumptive sign of pregnancy. [71%]

Explanation Choice D is correct. Nausea and urinary frequency are manifestations associated with presumptive signs of pregnancy. Choices A, B, and C are incorrect. Positive signs of pregnancy include visualization of the embryo or fetus via ultrasound, fetal movements detected by the examiner or auscultation of fetal heart sounds. Presumptive signs of pregnancy include amenorrhea, nausea and vomiting, and an increase in urinary frequency. Possible signs of pregnancy are not a category utilized. Additional Info Presumptive signs of pregnancy Amenorrhea Nausea and vomiting Fatigue Urinary frequency Quickening (slight fluttering movement usually between 16-20 weeks gestation) Probable signs of pregnancy Goodell's sign (softening of the cervix) Chadwick's sign (bluish appearance of the cervix) Hegar's sign (softening of the isthmus of the cervix) Ballottement (sudden tap on the cervix during the vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position) Braxton hicks contractions Positive pregnancy test Palpation of fetal outline Positive signs of pregnancy Fetal movements detected by an examiner Auscultation of fetal heart sounds Visualization of embryo or fetus

Increased levels of which of the following hormones is related to hyperemesis gravidarum? A. Testosterone [2%] B. Progesterone [48%] C. Aldosterone [9%] D. Estrogen [41%]

Explanation Choice D is correct. The cause of hyperemesis is thought to be related to high levels of estrogen and human chorionic gonadotropin (hCG). Nausea and vomiting, also known as morning sickness, are common during the first trimester of pregnancy for many women. If nausea and vomiting interfere with an adequate intake of fluid and food and persists past 20 weeks of gestation, it is termed hyperemesis gravidarum. The cause is unknown, but elevated hormone levels and the relaxation of smooth muscles, which results in delayed gastric emptying, are believed to contribute to this condition. Hyperemesis can cause problems for the mother and fetus. Severe hyperemesis gravida- darum can result in preterm labor. The dehydration that occurs may lead to reduced placental perfusion and inadequate oxygenation to the fetus. Fetal growth can be compromised, leading to an infant who is small for gestational age. Also, women with hyperemesis gravidarum in the second trimester have an increased risk for preterm labor, pre-eclampsia (i.e. an increase in blood pressure, protein in the urine, and edema), and placental abruption. Choice A is incorrect. Testosterone is the primary male hormone. Choice B is incorrect. Progesterone is a relaxant and does not promote vomiting. Choice C is incorrect. Aldosterone is a steroid hormone. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Care of the Woman with Hyperemesis Gravidarum

The nurse is educating the client regarding oral contraceptives. All of the following statements by the nurse are true, except: A. "Oral contraceptives are drugs containing combined doses of estrogen and progesterone that stop ovulation." [12%] B. "Oral contraceptives increase your risk for thrombophlebitis and hypertension." [9%] C. "They are almost 99% effective when taken consistently." [12%] D. "They prevent sperm from entering the cervical os." [66%]

Explanation Choice D is correct. This nurse's statement is incorrect, therefore the correct answer to the question. Oral contraceptives work by stopping the process of ovulation, preventing implantation, and inhibiting sperm travel. Prevention of sperm from entering the cervical os is the mechanism of action of barrier contraceptive methods (example: Diaphragm). Choice A is incorrect. This nurse's statement is correct. Oral contraceptives contain fixed or altered estrogen and progesterone doses that inhibit the hypothalamus from producing hormones needed for ovulation. Choice B is incorrect. This nurse's statement is correct. Oral contraceptives increase platelets and clotting factors that increase the woman's risk for thrombophlebitis. Choice C is incorrect. This nurse's statement is correct. Oral contraceptives, when taken consistently, are about 99.7% effective. Generally, the efficacy rate is about 92 to 95%, but the efficacy rate approaches 99.7% if taken perfectly. The nurse needs to emphasize that oral contraceptive intake should not be based on the timing of sexual intercourse. Meaning, to ensure utmost efficacy, the client should take them every day at the same time of day, regardless of whether she will have sex.

The nurse in the clinic is caring for a 10-year-old with asthma. The child uses an albuterol multi-dose inhaler before engaging in exercise. The nurse should educate the child and parents that potential side effects of this short-acting beta-2 agonist (SABA) are: Select all that apply. A. Tachycardia [40%] B. Hypotension [18%] C. Headache [35%] D. Hypoglycemia [6%]

Explanation Choices A and C are correct. According to the National Asthma Education and Prevention Program Expert Panel Report 3, potential side effects of all the SABAs include tachycardia, headache, hypertension, hyperglycemia, tremors, hypokalemia, and increased lactic acid accumulation. The inhaled route is relatively safe since there are few systemic effects from the medication. Choices B and D are incorrect. Hypotension and hypoglycemia are not side effects of SABA use. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Adverse Effects/Contraindications/Side Effects/Interactions; Pharmacology; Respiratory

The registered nurse (RN) is observing licensed practical/vocational nurses (LPN/VN) care for assigned patients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply. A. Positions an unconscious patient semi-Fowlers for oral care. [23%] B. Administers a bronchodilator to a patient with chronic asthma. [7%] C. Irrigates an indwelling urinary catheter with 30 ml of sterile saline. [15%] D. Removes and reapplies weight to a patient's skin traction every two hours. [36%] E. Administers intramuscular (IM) ketorolac to a patient with osteoarthritis. [19%]

Explanation Choices A and D are correct. An unconscious patient should not be positioned semi-Fowler's for oral care. The patient should be positioned on their side to prevent aspiration. When a patient has skin traction, the weights should be hanging freely and not removed unless prescribed by the physician. Intermittent removal and reapplication may be harmful to the patient. Choices B, C, and E are incorrect. Administering a bronchodilator to a patient with chronic asthma, irrigating an indwelling urinary catheter, and administering intramuscular anti-inflammatory medications such as ketorolac is all within the scope of an LPN. Additional information: The scope of an LPN is as follows - the LPN may reinforce teaching, data collection, and care for patients with low acuity illnesses. The LPN may perform skills involving sterility such as tracheostomy suctioning and the insertion of an indwelling urinary catheter. Nonsterile skills that an LPN may perform include irrigation of an ostomy, medication administration (except intravenous push), and the insertion of a nasogastric tube.

The nurse is caring for a client with an order to receive a blood transfusion. Which of the following options are considered inappropriate to delegate to a UAP? Select all that apply. A. Assist the nurse to cross-check client's identification with blood bag client identifiers. [32%] B. Monitor for shortness of breath during transfusion. [31%] C. Record the client's vital signs prior to the infusion. [12%] D. Request blood products from the blood bank as directed by the RN. [25%]

Explanation Choices A, B, and D are correct. Choice A is correct. Cross-checking must be done with two nurses, never the UAP. Choice B is correct. Monitoring for adverse reactions of interventions falls under the scope of the nurse, not the UAP. The UAP can check vitals after the nurse has stayed with the client and checked vitals during the first 15 minutes. Choice D is correct. The nurse should request the blood products from the blood bank; it would not be appropriate to delegate this task. The UAP may obtain the blood products when available but would not be able to request them. Choice C is incorrect. It would be appropriate for the UAP to check and record this client's vital signs before the RN administers the blood.

A nurse on the surgical floor is caring for a patient who is three days post-splenectomy. During 0700 vital signs, the CNA obtains a 100.2-degree temperature but forgets to tell the nurse about this finding. At 1500, the nurse takes the patient's temperature, and it is 101.8 degrees. After documenting the findings, the nurse should do which of the following? Select all that apply. A. Administer amoxicillin per the standing order [25%] B. Call the physician immediately [31%] C. Palpate the patient's right upper quadrant [10%] D. Administer acetaminophen [31%] E. Place the patient in the Trendelenburg position [3%]

Explanation Choices A, B, and D are correct. After splenectomy, the patient is at high risk for developing OPSI (overwhelming post-splenectomy infection) and the nurse should recognize signs of an infection early on. Administering antibiotics and antipyretics for a fever is crucial to prevent the disease from worsening. The doctor should be called immediately because further treatment may be necessary. Choices C and E are incorrect. Palpating the patient's RUQ will not tell the nurse any vital information since the spleen would be palpated on the LUQ. The patient should not be placed in the Trendelenburg position because this will have no change in the patient's status. NCSBN Client Need Topic: Physiological Integrity, Sub-Topic: Reducing Risk, Care of the Surgical Patient

You are taking care of a 5-year old that presents with impetigo. Which of the following symptoms would be expected for this disease? Select all that apply. A. Lesions [39%] B. Burning [17%] C. Rhinitis [5%] D. Pruritus [38%]

Explanation Choices A, B, and D are correct. Impetigo is a contagious bacterial infection of the skin. It presents with lesions (most commonly on the face), erythema, pruritus, burning, and sometimes secondary lymph node involvement. Choice C is incorrect. Rhinitis is characterized by a runny nose and 'stuffiness', which is not a symptom of impetigo. NCSBN Client Need: Topic: Physiological Adaptation Subtopic: Alterations in Body Systems

Select the transmission based precaution that is accurately paired with an associated pathogen. Select all that apply: A. Contact precautions with soap and water hand hygiene: Clostridium difficile [30%] B. Enteric precautions: Norovirus [8%] C. Airborne precautions: Measles [26%] D. Droplet precautions: Tuberculosis [8%] E. Droplet precautions: Influenza [28%]

Explanation Choices A, C, and E are correct. Clients with Clostridium difficile and other pathogens such as Norovirus are contained and prevented from spreading infection due to the use of contact precautions. Contact precautions are often used for preventing infections that are spread by touching the patient, items, or stool contaminants. Other examples include MRSA, VRE, diarrheal illnesses, open wounds, and RSV. However, in cases of diarrheal illnesses like C. difficle and Norovirus, an additional requirement of cleaning hands with soap and water upon leaving the patient's room is mandatory. To standardize infection control practices and to specify this additional hand hygiene requirement, many hospitals have adopted special signage, "contact enteric precautions." It is important to know the difference between airborne vs. droplet precautions, along with examples for each. Airborne droplets transmit measles. It is contained and prevented by using airborne precautions. Patients with measles should remain in airborne precautions for 4 days after the onset of rash. Other diseases needing airborne precautions include Severe Acute Respiratory Syndrome (SARS), Varicella (chickenpox), and Mycobacterium tuberculosis. Influenza is transmitted by contact of tiny droplets gaining direct access to the respiratory tract of the individual. Healthcare workers should wear a surgical mask while in the room. This does not need negative air pressure in the room, unlike in airborne isolation. Droplet isolation precautions are used for diseases spread in tiny droplets caused by coughing and sneezing. In contrast, airborne spread occurs by airborne droplets via the air. Examples where droplet precautions are used: Pneumonia, influenza, whooping cough, and bacterial meningitis. Choice B is incorrect. The term "enteric precautions" alone is no longer used. In the past, however, these kinds of precautions were used to prevent the transmission of pathogens in the stool. Contact precautions with special hand hygiene requirements or contact enteric precautions, rather than just enteric precautions, are the correct terms to be used for those precautions to contain and prevent the spread of Norovirus. Choice D is incorrect. Airborne precautions (not droplet precautions) are used to prevent the spread and transmission of Tuberculosis.

The nurse is teaching a group of students on incident reports. The nurse will need to provide further teaching if the student makes which of the following statements? Select all that apply. A. "Incident reports must be completed within an hour after the event." [20%] B. "Witnesses to an incident should be mentioned in the report." [12%] C. "A patient eloping does not require an incident report." [30%] D. "Events such as a slip and fall as well as medication errors should be reported." [6%] E. "Incidents involving visitors do not have to be reported." [32%]

Explanation Choices A, C, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any type of activity deviates from the norm. This could include a fall, medication error, elopement, unplanned transfer of care, patient complaint, or a delay in care. It is highly recommended that the event be reported after it occurs to ensure accuracy; however, event reporting should be completed as soon as possible, which may even include the next day. Incidents involving visitors such as a fall, misconduct, complaint, or injury should be reported. Choices B and D are incorrect. The incident report should be completed with cohesion and based on fact. Supporting statements from witnesses, as well as the identification of witnesses, is appropriate to include in the report. Additional information: Incident (sometimes termed occurrence or event) reporting is a tool to mitigate future risks. Elements of a report should include - A factual account of the incident. Do not assume or make opinions. The date and time of the incident and the duration (if applicable). Patient or visitor statements in quotation marks. Key interventions took after the incident. This includes if contact was made with the primary healthcare provider. Witness quotes and witnesses pertinent to the event. The incident should not be logged in the medical record or nursing notes.

The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)? Select all that apply. A. Furosemide [32%] B. Neomycin [19%] C. Naproxen [6%] D. Lactulose [32%] E. Diazepam [9%]

Explanation Choices B and D are correct. Neomycin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is central in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels. Choices A, C, and E are incorrect. Potassium wasting diuretics such as furosemide should be avoided because it contributes to hypokalemia. Hypokalemia contributes to the production of ammonia. Thus, a highly preferred diuretic in mitigating ascites is potassium-sparing diuretic spironolactone. NSAIDs should be avoided because of their nephrotoxic and anticoagulation effects. Low doses of acetaminophen may be approved for mild to moderate pain. Benzodiazepines, such as diazepam, should be avoided for a client with hepatic encephalopathy. These medications can worsen the sensorium of a client, therefore, making the client at high risk for falls and injury. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected actions/outcomes Question type: Knowledge/comprehension Additional Info Treatment options for hepatic encephalopathy would include prescribed potassium-sparing diuretics, lactulose, and antibiotics such as neomycin or rifaximin. Nursing care aims to assist the client in achieving and maintaining treatment adherence and the avoidance of medication such as NSAIDs and benzodiazepines that could worsen the encephalopathy.

You are teaching a new group of nurses about insulin administration for a client with type I diabetes mellitus. Which of the following points should you include? Select all that apply. A. It is important to wait for the client's food tray to be delivered before administering their glargine. [11%] B. When drawing up different types of insulin together in a syringe, first draw up regular insulin and then NPH. [40%] C. You should teach patients to eat 1-2 hours after taking their regular insulin. [13%] D. Monitoring the HbA1c is very important and patients with diabetes should have a goal of less than 7%. [36%]

Explanation Choices B and D are correct. This is an appropriate teaching point. Regular insulin is the standard insulin given IV. It is active for about 6 to 8 hours and peaks in 2-4 hours. Regular insulin is clear. NPH insulin is considered intermediate-acting insulin. It is active for about 16-18 hours and peaks in 4-10 hours. NPH insulin is cloudy. It is safe to administer regular insulin and NPH insulin together in the same syringe, but they must be drawn up correctly. You should teach the nurses first to draw up regular insulin, and then draw up the NPH insulin (Choice B). Monitoring of the HbA1c is crucial in diabetic patients and you should educate your patient about the need to check this level at their doctor's appointments. Glycosylated Hemoglobin (HbA1c) shows the percentage of red blood cells that have become saturated with hemoglobin. The higher this number is, the higher the patient's blood sugar has been over the past 3-4 months. Anything higher than 6.5% indicates that the patient has diabetes. For patients with diagnosed diabetes, their goal should a HbA1c of less than 7% and they should have it checked every 3-4 months (Choice D). Choice A is incorrect. Glargine, or Lantus, is a long-acting insulin; its duration of action is 24 hours and does not have a peak. Due to this, it is given just once a day and acts as the basal insulin for the client. Glargine can be provided in the morning or evening, as long as the client takes it at the same time every day. Since there is no peak, glargine does not need to be timed with meals, so you would not teach the new nurses to wait for the client's food before administration. Choice C is incorrect. You should teach patients to eat 2-4 hours after taking their regular insulin. The peak of regular insulin is 2-4 hours, so we should teach patients to eat when insulin is at its peak level. When insulin is at its peak, blood sugar is at its lowest. This is the most appropriate timing for regular insulin administration and meals. NCSBN Client Need: Topic: Health promotion and maintenance; Subtopic: Endocrine

Which of the following are concepts or constructs associated with cultural competence? Select all that apply. A. Cultural obedience [10%] B. Cultural skills [18%] C. Cultural encounters [12%] D. Cultural desire [8%] E. Cultural awareness [26%] F. Cultural knowledge [26%]

Explanation Choices B, C, D, E, and F are correct. The five concepts or constructs associated with cultural competence are cultural skills, cultural encounters, cultural desire, cultural awareness, and cultural knowledge. These five concepts put forth by Campinha-Bacote underscore the need for nurses and other healthcare providers to develop the knowledge, skills, and abilities to provide culturally competent care to individuals, families, and the community. Choice A is incorrect. Cultural obedience is NOT one of the concepts or constructs associated with cultural competence.

The nurse is caring for a cancer patient who is receiving chemotherapy. The patient is experiencing weight loss as a result of intermittent nausea. The nurse should implement which of the following nursing interventions to help with the patient's nausea? Select all that apply. A. Suggest using hot sauce and strong herbs for bland foods. [1%] B. Serve small meals every 2-3 hours. [38%] C. Provide meals that are best eaten at room temperature. [31%] D. Encourage the patient to brush their teeth in the afternoon rather than in the morning. [15%] E. Serve high-fat and protein dense foods. [14%]

Explanation Choices B, C, and D are correct. Serving small meals every 2-3 hours may help keep nausea at bay. Food eaten at room temperature and delaying teeth brushing till the afternoon may also improve nausea. Choice A is incorrect. Spicy foods and healthy herbs may heighten nausea in the patient receiving chemotherapy. Choice E is incorrect. High-fat foods are especially nauseating for those experiencing nausea. NCSBN client need Topic: Health Promotion and Maintenance

The nurse is caring for a client at 32 gestational weeks. Which laboratory data should be reported to the primary healthcare provider (PHCP)? Select all that apply. A. Hemoglobin 11.5 g/dL [5%] B. Platelets 90,000 mm3 [28%] C. Fasting blood glucose 254 mg/dL [32%] D. White blood cell 9,500 mm3 [4%] E. Creatinine 3.9 mg/dL [30%]

Explanation Choices B, C, and E are correct. These laboratory values are abnormal and require follow-up. A platelet count of fewer than 150,000 mm3 is concerning for thrombocytopenia and suggests severe preeclampsia. The blood glucose is significantly elevated as the normal fasting blood glucose is 70-100 mg/dL. This client has clinical hyperglycemia and requires follow-up. Finally, the creatinine is quite elevated, suggesting acute kidney injury. This, combined with a low platelet count, is more convincing of severe preeclampsia. Choices A and D are incorrect. These findings are within normal limits. For a client who is pregnant, the normal hemoglobin level may decrease to 11.5 g/dL without any intervention. Finally, this white blood cell count is normal (the normal range is 5000 - 10000 mm3). Additional Info The following are the clinical criteria for severe preeclampsia If one or more of the following criteria are present: 1. Blood pressure of ≥160 mm Hg systolic or ≥110 mm Hg diastolic or higher on two occasions at least 6 hr apart while the patient is on bed rest 2. Oliguria of <500 mL in 24 hr 3. Cerebral or visual disturbances 4. Pulmonary edema or cyanosis 5. Epigastric or right upper quadrant pain 6. Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both 7. Thrombocytopenia 8. Renal insufficiency

Which of the following comments by the patient reflects an understanding of the proper use of a metered-dose inhaler? Select all that apply. A. "I will be careful not to shake the canister before using it." [5%] B. "I will inhale the medication through my nose." [4%] C. "I will continue to inhale when the cold propellant is in my throat." [29%] D. "I will only inhale one spray with one breath." [33%] E. "I will activate the device while continuing to inhale." [29%]

Explanation Choices C, D, and E are correct. Patients need repeated instructions on using inhalers and nebulizers effectively and safely. Overuse may result in serious side effects and eventual ineffectiveness of the medication. Patients must understand that it is essential to keep track of dosing with meter dose inhalers (MDIs) to ensure they are not using an empty canister. While some MDIs have integrated dose counters, not all MDIs do, and it can be challenging to know when the cartridge is empty. Choices A and B are incorrect. Common mistakes patients make when using metered-dose inhalers include failing to shake the canister and inhaling through the nose rather than the mouth.

A 4-year-old presents to your ED with 20% of her body surface area burned. The burns appear to be chemical and the child is covered in an unknown substance. Upon her arrival to your trauma room, place the following priority nursing actions in the order they should be completed. Stop the burning process Remove burned clothing and jewelry Cover the wound with a clean cloth Assess airway, breathing, and circulation

Stop the burning process Assess airway, breathing, and circulation Remove burned clothing and jewelry Cover the wound with a clean cloth Explanation The nurse should first stop the burning process. In this scenario, that would require removing the unknown substance from the child by decontamination. This must be done before any other nursing intervention to prevent the burn from worsening. Next, the nurse should assess the airway, breathing, and circulation. The airway should be assessed because internal burns can occur and may cause airway swelling and compromise. Intravenous fluids should be initiated as necessary. Next, the nurse should remove the burned clothing and jewelry. Metals from silver and on clothes such as buttons and zippers can become very hot and continue cooking the client if not removed. Also, there is significant swelling after a burn, so if the nurse does not remove clothing and jewelry, they can become constrictive and cut off circulation. Next, the nurse should cover the wound with a clean cloth to prevent infection, and lastly, the nurse should keep the child warm. NCSBN Client Need I Topic: Physiological Adaptation Subtopic: Medical Emergencies