Nclex Exam 4

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? 1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells (43%) 2. Client with an ulcerative colitis flare-up has temperature 101 F (38.3 C) and abdominal cramping (17%) 3. Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2 (23%) 4. Client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL (743 µmol/L) (15%)

1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells (43%) The nurse should check on the assigned clients in the following order: Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) - the nurse should: Check the infusion device; flow rate; and IV site, tubing, and filter Collect baseline physical assessment data against which to compare subsequent assessments Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute transfusion reaction; these can occur at any time during the transfusion (Option 1) Client with chronic kidney disease scheduled for dialysis in 30 minutes - the nurse should perform a baseline assessment before dialysis is initiated. The nurse should then prepare the client by making sure the client eats breakfast, administering prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out. Elevated creatinine level (eg, normal 0.6-1.3 mg/dL [53-115 µmol/L]) is an expected finding. (Option 4) Client with ulcerative colitis (UC) with elevated temperature and abdominal pain - UC is an inflammatory bowel disease; fever and lower-quadrant abdominal cramping are expected findings. After assessing the client, the nurse will administer an analgesic and an antipyretic as prescribed. (Option 2) Client with history of atrial fibrillation, prescribed warfarin (Coumadin) - the client is on telemetry; in most facilities, if dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately. The goal INR is 2.0 to 3.0 for atrial fibrillation. An INR of 3.2 is expected when adjusting the warfarin dose. (Option 3) Educational objective:To prioritize client care, the nurse first identifies the type of problem, its associated complications, and the desired outcomes. The nurse then decides which client has the most urgent problems and needs and assesses that client first.

A parent rushes a 4-year-old child to the emergency department after finding the child sitting on the kitchen floor holding an empty bottle of aspirin. The parent has no idea how many tablets were left in the container. The child is sniffling and quietly crying. The nurse anticipates initially implementing which treatment? 1. Activated charcoal (47%) 2. Gastric lavage (25%) 3. Sodium bicarbonate (10%) 4. Syrup of ipecac (16%)

1. Activated charcoal (47%) Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing elimination. (Option 2) Similar to syrup of ipecac, gastric lavage is associated with risk of aspiration. In addition, there is no convincing evidence that it decreases morbidity. It is not routinely recommended but may be performed for the ingestion of a massive or life-threatening amount of drug. If necessary, it should be administered within 1 hour of ingestion and requires a protected airway and possible sedation. (Option 3) IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate. (Option 4) Syrup of ipecac has been shown to have minimal benefit in treating aspirin overdose; in addition, it is not recommended due to the risk of aspiration pneumonia secondary to induced vomiting. Educational objective:Activated charcoal is used as the initial treatment for aspirin overdose in clients with clinical signs of salicylate toxicity as well as in those who are asymptomatic. Activated charcoal binds with salicylate and therefore inhibits absorption by the small intestine. IV sodium bicarbonate is also used for treating aspirin overdose after treatment with activated charcoal has been initiated.

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counterpressure to the client's sacrum during contractions (46%) 2. Encouraging the client to remain in bed during early labor (0%) 3. Positioning the client on the left side with pillows for support (49%) 4. Requesting that the nurse anesthetist administer epidural anesthesia (3%)

1. Applying counterpressure to the client's sacrum during contractions (46%) Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis). The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager) (Option 1). (Option 2) Clients should be encouraged to change positions frequently (every 30-60 minutes) during labor to promote fetal rotation/descent and increase maternal comfort. Remaining in bed during early labor increases the risk for persistent fetal malposition and slows labor progression. (Option 3) Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine positioning when the client is resting in bed. However, it may not alleviate the client's back pain. (Option 4) Although epidural anesthesia can provide effective pain relief, it can limit client mobility and contribute to persistent fetal malposition. This client is also still in early labor and has not requested an epidural at this time. Educational objective:Fetal occiput posterior position may cause intense back pain during labor. Client comfort can be increased by applying counterpressure to the sacrum during contractions.

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply. 1. Assess for bruising 2. Assess for tarry stools 3. Monitor intake and output 4. Monitor liver function tests 5. Monitor platelets

1. Assess for bruising 2. Assess for tarry stools 5. Monitor platelets Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5). (Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients without hepatic impairment. Educational objective:Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is admitting a client at 41 weeks gestation for induction of labor due to oligohydramnios. Considering the client's indication for induction, what should the nurse anticipate? 1. Aterm-2dditional neonatal personnel present for birth (37%) 2. Intermittent fetal monitoring during labor (26%) 3. Need for forceps-assisted vaginal birth (13%) 4. Need for uterotonic drugs for postpartum hemorrhage (21%)

1. Aterm-2dditional neonatal personnel present for birth (37%) Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord compression and promote lung development. Oligohydramnios is a condition characterized by low amniotic fluid volume. This can occur due to fetal kidney anomalies (eg, renal agenesis or urine flow obstruction) or fluid leaking through the vagina (eg, undiagnosed ruptured membranes). Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a fetal outline that is easily palpated through the maternal abdomen should raise suspicion for oligohydramnios. Ultrasound confirms the diagnosis. Major complications of oligohydramnios are: Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated amniotic fluid. Therefore, additional neonatal personnel should attend the birth in anticipation of possible resuscitation (Option 1). Umbilical cord compression - continuous (not intermittent) fetal monitoring should be applied to monitor for variable decelerations (Option 2). (Option 3) Operative vaginal birth (ie, use of forceps or vacuum) may be indicated due to prolonged second-stage labor or fetal distress. Oligohydramnios does not increase the likelihood of operative vaginal birth. (Option 4) Polyhydramnios (excessive amniotic fluid volume) is a risk factor for postpartum hemorrhage due to overdistension of the uterus. Oligohydramnios is not associated with postpartum hemorrhage. Educational objective:Oligohydramnios increases the risk for umbilical cord compression and pulmonary hypoplasia. Additional neonatal personnel should be present for possible resuscitation and/or evaluation of the newborn. The nurse should anticipate continuous fetal monitoring during labor to monitor for signs of cord compression. Additional Information Physiological Adaptation NCSBN Client Need

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply. 1. Bumetanide in the client with heart failure who has hypokalemia 2. Calcium acetate in the client with chronic kidney disease who has hyperphosphatemia 3. Carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level 4. Isoniazid in the client with latent tuberculosis who has elevated liver enzymes 5. Metronidazole in the client with Clostridium difficile infection who has leukocytosis

1. Bumetanide in the client with heart failure who has hypokalemia 4. Isoniazid in the client with latent tuberculosis who has elevated liver enzymes Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance (Option 1). Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4). (Option 2) Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces. (Option 3) Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription. (Option 5) Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection. Educational objective:Loop diuretics (eg, bumetanide, furosemide, torsemide) can cause hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]). Elevated liver enzymes in clients receiving the antitubercular drug isoniazid can indicate development of drug-induced hepatitis.

The nurse is planning care for an 8-year-old client with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate to include in the plan of care? Select all that apply. 1. Consistently assign the same nurse and unlicensed assistive personnel to care for the client 2. Give direct procedural education and explanations to the parent rather than the client 3. Provide appropriate toys based on developmental level rather than chronological age 4. Reinforce parental limit-setting measures for preventing self-injurious behavior 5. Use a picture board to facilitate communication and promote understanding of procedures

1. Consistently assign the same nurse and unlicensed assistive personnel to care for the client 3.Provide appropriate toys based on developmental level rather than chronological age 4. Reinforce parental limit-setting measures for preventing self-injurious behavior 5. Use a picture board to facilitate communication and promote understanding of procedures Clients with cognitive impairment (intellectual disability) are diagnosed prior to adulthood and have limited levels of intellectual functioning and adaptive skills for their chronological age. Manifestations may include a decreased ability to perform abstract or logical reasoning, interpret complex ideas, and learn by experience. Cognitive impairment results in developmental delays of varying levels (eg, mild, moderate) and types (eg, cognitive, physical, social, emotional, behavioral) and requires the nurse to assess the client's skills and abilities and provide individualized care. Appropriate nursing interventions for a client with cognitive impairment include: Promoting the staff's understanding of client behavior/needs and maintaining a familiar environment for the client by consistently assigning the same staff (eg, nurse) for care (Option 1) Fostering playtime by providing toys that are developmentally appropriate, not necessarily age appropriate (Option 3) Preventing self-injury by reinforcing the parents' limit-setting measures (eg, time-outs) and positively reinforcing good behavior (Option 4) Facilitating communication and learning by using visual demonstration (eg, picture board) rather than complex explanations (Option 5) (Option 2) The nurse should involve parents in preprocedural education but avoid excluding the client; explaining procedures using methods appropriate for the client's cognitive ability is encouraged. Educational objective:Appropriate nursing interventions when caring for a pediatric client with cognitive impairment include providing consistency in staff assignments, providing toys appropriate for the client's developmental (not chronological) age, preventing self-injurious behavior (eg, reinforce parental limit setting), and using visual demonstration (eg, picture board) and simple explanations to facilitate communication and learning. Additional Information Health Promotion and Maintenance NCSBN Client Need

A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the registered nurse to intervene? 1. Elevating a client's residual limb on a pillow 1 day after above-the-knee amputation (38%) 2. Placing an abductor pillow between a client's legs after total hip replacement (7%) 3. Positioning a client with Buck traction supine with the foot of the bed raised (41%) 4. Using pillows to raise a client's extremity following cast placement (12%)

1. Elevating a client's residual limb on a pillow 1 day after above-the-knee amputation (38%) To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be elevated, especially after 24 hours. Instead, edema should be managed using a figure eight compression bandage. The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too tightly. Hip flexion contractures can also be avoided by placing the client in prone position with hip in extension for 30 minutes 3 or 4 times a day. (Option 2) Following total hip replacement, hip dislocation is prevented by using an abductor pillow to maintain the hip in a straight and neutral position. The nurse should also teach the client not to bend at the hip more than 90 degrees or cross the legs or ankles. (Option 3) Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a prescribed weight pulls the limb into traction. The client is typically placed in supine position with the foot of the bed raised to maintain countertraction. (Option 4) After a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to increase venous return and decrease edema in the affected extremity. However, the extremity should not be elevated if compartment syndrome develops. Educational objective:Care of the client with above-the-knee amputation includes placement in prone position for 30 minutes 3 or 4 times a day and using a figure eight compression bandage to decrease edema. The client's residual limb should not be elevated as this will promote flexion contractures. Additional Information Reduction of Risk Potential NCSBN Client Need

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply. 1. Helps prevent colorectal cancer 2. Improves glycemic control 3. Promotes weight loss 4. Reduces risk of vascular disease 5. Regulates bowel movements

1. Helps prevent colorectal cancer 2. Improves glycemic control 3. Promotes weight loss 4. Reduces risk of vascular disease 5. Regulates bowel movements Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer (Options 1 and 5). Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss (Options 2 and 3). Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke (Option 4). Educational objective:Dietary fiber increases stool bulk and makes stool softer and easier to pass. A fiber-rich diet helps prevent constipation; decreases risk of colorectal cancer; promotes weight loss; improves blood glucose control; and decreases serum cholesterol levels, which reduces the risk of coronary artery disease and stroke. Additional Information Health Promotion and Maintenance NCSBN Client Need

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? Select all that apply. 1. "A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag." 2. "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." 3. "Only daytime urine should be collected in the container as cortisol levels are higher in the morning." 4. "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." 5. "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

2. "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." 4. "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." 5. "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug." A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows: Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity (Options 1 and 5). Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded (Options 3 and 4). Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation (Option 2). Educational objective:A 24-hour urine is collected to test for increased cortisol levels when evaluating for Cushing syndrome. The client should be taught to collect the urine in a dark jug issued by the lab, start time and then empty the bladder and discard the 1st urine, and collect all the urine for 24 hours; it is kept in the refrigerator or ice chest with a secure lid. Exactly 24 hours after start time, empty bladder once more into the collection container. Additional Information Reduction of Risk Potential NCSBN Client Need

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back? 1. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection (1%) 2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration (79%) 3. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding (14%) 4. 84-year-old man with prostate cancer and spine metastasis is requesting increased pain medication (4%)

2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration (79%) Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department. (Option 1) Urinary tract infections can recur in sexually active women. This client needs antibiotics but is not a priority. (Option 3) This client may have some degree of prostatic hyperplasia given his age. Decongestants (eg, pseudoephedrine) or antihistamines (eg, diphenhydramine) should be used with caution as they can lead to difficulty voiding and acute urinary retention. The client needs to be assessed, but this is not the most emergent call. (Option 4) The client with prostate cancer may need increasing pain medication as clients develop tolerance to opioids. However, this is not a priority. Educational objective:Priapism is a prolonged, painful erection not necessarily related to sexual arousal. It requires urgent treatment in the emergency department as it can lead to erectile tissue ischemia and necrosis. Additional Information Management of Care NCSBN Client Need

A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority? 1. Administer digoxin 0.25 mg (10%) 2. Administer furosemide 40 mg IV push (51%) 3. Initiate dopamine infusion at 5 mcg/kg/min (6%) 4. Obtain blood sample for arterial blood gases (31%)

2. Administer furosemide 40 mg IV push This client is exhibiting signs of pulmonary edema, a life-threatening condition. In the presence of acute left ventricular failure, pulmonary vasculature overload causes increased pulmonary venous pressure that forces fluid out of the vascular space into the pulmonary interstitium and, if untreated, into the alveoli. Clinical manifestations of pulmonary edema include: A history of orthopnea and/or paroxysmal nocturnal dyspnea Anxiety and restlessness Tachypnea (often >30/min), dyspnea, and use of accessory muscles Frothy, blood-tinged sputum Crackles on auscultation The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema (Option 2). Management of acute decompensated heart failure (ADHF) may also include oxygen therapy, vasodilators (eg, nitroglycerin, nesiritide), and positive inotropes (eg, dopamine, dobutamine). Vasodilators decrease preload thus improving cardiac output and decreasing pulmonary congestion. Positive inotropes improve contractility but are only recommended if other medications have failed or in the presence of hypotension. (Option 1) Digoxin is a positive inotropic drug (improves contractility) used in long-term treatment of heart failure. (Option 3) Dopamine, a positive inotropic drug, is used as a short-term treatment for ADHF; however, it does not resolve the fluid overload affecting oxygenation. (Option 4) Drawing arterial blood gases is appropriate in the setting of ADHF, but it is not the priority in this situation. Educational objective:In the presence of acute decompensated heart failure (ADHF) and pulmonary edema, diuretic (eg, furosemide) administration is effective in removing excess fluid to reduce pulmonary congestion and improve oxygenation. Vasodilators (eg, nitroglycerin, nesiritide) and positive inotropes (eg, dopamine, dobutamine) are also used in the treatment of ADHF. Additional Information Physiological Adaptation NCSBN Client Need

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client 1-day post-thoracotomy wedge resection who has subcutaneous emphysema at the chest tube insertion site (21%) 2. Client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago (70%) 3. Client with COPD exacerbation who is receiving bi-level positive airway pressure (BIPAP) therapy and has a pulse oximetry reading of 90% (2%) 4. Client with leg cellulitis following a spider bite who needs the IV restarted to initiate prescribed antibiotics (4%)

2. Client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago (70%) The nurse should first assess the client with asthma who reports shortness of breath 15 minutes after receiving a nebulizer treatment with albuterol. Asthma exacerbations may require repeat nebulization every 20 minutes, or continuous nebulization for 1 hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the inflammation (Option 2). The nurse should assess the client for wheezing, decreased breath sounds, use of accessory muscles to breathe, capillary refill, respiratory rate, and pulse oximeter reading and pulse. (Option 1) Subcutaneous emphysema is air that leaks into the tissue surrounding the chest tube insertion site. The amount is usually small and reabsorbs spontaneously. The nurse should auscultate for lung sounds, assess for a popping sound, and palpate the site for a crackling sensation. However, this client does not have the most urgent need. (Option 3) Clients with an exacerbation of COPD are prescribed noninvasive positive pressure ventilation with a BIPAP device to treat hypercapnia and hypoxemia and improve gas exchange. An oxygen saturation of 88-92% is adequate in clients with COPD. The nurse should perform a thorough pulmonary assessment, but this client does not have the most urgent need. (Option 4) The nurse should follow institution policy and either start the IV or notify the IV team to restart the infusion. Although it is important to initiate antibiotic therapy as soon as possible to treat an existing infection, this client does not have the most urgent need. Educational objective:Nurses should prioritize assessing clients with asthma who report unrelieved shortness of breath within 15 minutes of nebulizer treatment with albuterol as their needs are urgent due to the risk for severe pulmonary complications.

The nurse is making follow-up phone calls to clients who had cataract surgery with intraocular lens implantation the previous day. The nurse receives which client report that requires priority intervention? 1. Blurry vision in the affected eye (13%) 2. Constipation (59%) 3. Itching in the affected eye (14%) 4. Sleeping on 2 pillows at night (11%)

2. Constipation (59 Following cataract surgery, the client will be instructed that for several days (or until approved by the surgeon), activities that may increase intraocular pressure should be avoided to decrease the risk of damage to sutures or surgical site. These include bending (eg, vacuuming floors, playing golf), lifting more than 5 lb, sneezing, coughing, rubbing or placing pressure on the eye, or straining during a bowel movement. The nurse should encourage this client to increase fluids and fiber in the diet as well as consider an over-the-counter stool softener or laxative. (Option 1) It may take 1-2 weeks before visual acuity is improved. (Option 3) It is common for the client to experience itching ("sand" in the eye), photophobia, and mild pain for several days following surgery. Purulent drainage, increased redness, and severe pain should be reported. (Option 4) Sleeping on 2 pillows will elevate the head of the bed and decrease intraocular pressure. Educational objective:Following cataract surgery, the client should be instructed to avoid coughing, sneezing, lifting over 5 lb, bending, rubbing the eye, or straining during bowel movements for several days to prevent increased intraocular pressure. It is common for the client to experience itching ("sand" in the eye), photophobia, and mild pain for several days following surgery.%)

The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs? Select all that apply. 1. Create a strict daily schedule for the client while hospitalized 2. Encourage the client to have peers visit while hospitalized 3. Ensure parental presence during any client procedure 4. Include the client as an active participant when planning care 5. Support the client in discussing concerns about body image changes

2. Encourage the client to have peers visi 4. Include the client as an active participant when planning care 5. Support the client in discussing concerns about body image changes Pediatric clients are at increased risk for impaired psychosocial integrity during stressful experiences (eg, hospitalization, surgical procedures, medical treatment) and require developmentally appropriate care based on their age to assist with managing stress. Unaddressed or ineffectively managed developmental needs may lead to or worsen the client's anxiety, disobedient behavior, and/or social withdrawal. Developmentally appropriate nursing care for an adolescent client includes: Encouraging interaction with peers (eg, hospital visits, internet communication), which supports the developmental need for social connection and support and reduces stress and anxiety (Option 2) Involving the client in care planning to address the developmental needs for control and independence (Option 4) Assisting the client to discuss emotions or fears related to treatment (eg, changes in body image, disability, possibility of death) to improve coping, support the developmental need for understanding, and decrease anxiety (Option 5) (Option 1) Strict scheduling by the nurse reduces the adolescent's perception of control and independence, which may increase stress. Adolescents should be allowed to determine their daily schedule when possible. (Option 3) Loss of privacy (eg, forced parental presence) can increase anxiety in the adolescent client. Adolescents should be asked if they want parents present for procedures and what level of parental involvement they prefer. Educational objective:Nursing care for the hospitalized adolescent client needs to be developmentally appropriate and promote the elimination of stressors. The nurse should encourage adolescent clients to interact with peers, discuss emotions or fears about treatments, and involve the client in decision-making regarding the plan of care. Additional Information Health Promotion and Maintenance NCSBN Client Need

The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs? Select all that apply. 1. Create a strict daily schedule for the client while hospitalized 2. Encourage the client to have peers visit while hospitalized 3. Ensure parental presence during any client procedure 4. Include the client as an active participant when planning care 5. Support the client in discussing concerns about body image changes

2. Encourage the client to have peers visit while hospitalized 4. Include the client as an active participant when planning care 5. Support the client in discussing concerns about body image changes Pediatric clients are at increased risk for impaired psychosocial integrity during stressful experiences (eg, hospitalization, surgical procedures, medical treatment) and require developmentally appropriate care based on their age to assist with managing stress. Unaddressed or ineffectively managed developmental needs may lead to or worsen the client's anxiety, disobedient behavior, and/or social withdrawal. Developmentally appropriate nursing care for an adolescent client includes: Encouraging interaction with peers (eg, hospital visits, internet communication), which supports the developmental need for social connection and support and reduces stress and anxiety (Option 2) Involving the client in care planning to address the developmental needs for control and independence (Option 4) Assisting the client to discuss emotions or fears related to treatment (eg, changes in body image, disability, possibility of death) to improve coping, support the developmental need for understanding, and decrease anxiety (Option 5) (Option 1) Strict scheduling by the nurse reduces the adolescent's perception of control and independence, which may increase stress. Adolescents should be allowed to determine their daily schedule when possible. (Option 3) Loss of privacy (eg, forced parental presence) can increase anxiety in the adolescent client. Adolescents should be asked if they want parents present for procedures and what level of parental involvement they prefer. Educational objective:Nursing care for the hospitalized adolescent client needs to be developmentally appropriate and promote the elimination of stressors. The nurse should encourage adolescent clients to interact with peers, discuss emotions or fears about treatments, and involve the client in decision-making regarding the plan of care.

The nurse is caring for a client with advanced Alzheimer disease. Which techniques are appropriate when speaking with this client? Select all that apply. 1. Ask open-ended questions 2. Face the client while speaking 3. Speak in a loud voice 4. Turn off the television and close the door 5. Use simple statements and questions

2. Face the client while speaking 4. Turn off the television and close the door 5. Use simple statements and questions Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (dementia) in older individuals (most commonly age >60). Conversation becomes progressively more difficult, and the client experiences word-finding difficulty. The best way for the nurse to obtain information and communicate is to use simple statements and questions (Option 5). Facing the client allows the client to visualize the speaker's face and helps reduce distraction (Option 2). Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting stimuli (Option 4). (Option 1) Asking open-ended questions is a valuable communication technique for collecting information from most clients, but it may confuse the client with AD. The nurse should instead ask simple, direct questions. (Option 3) AD results in a reduction in cognitive function. Speaking loudly does not improve comprehension and may increase anxiety and confusion. Educational objective:When speaking with a client with Alzheimer disease, the nurse should face the client and use clear, simple statements and questions. Facing the client allows the client to visualize the speaker's face and helps reduce distraction. The nurse should also maintain a quiet environment to reduce competing or distracting stimuli.

The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today, the health care provider prescribes filgrastim. Which of the following is an expected outcome of this medication? 1. Decrease in serum uric acid (12%) 2. Increase in hemoglobin level (8%) 3. Increase in neutrophil count (63%) 4. Increase in platelet count (15%)

2. Increase in hemoglobin level (8%) Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can result in decreased red blood cells, white blood cells, and platelets, all manufactured in the bone marrow. It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (the nadir) usually at 7-10 days after therapy initiation. Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm3) and neutropenia is a decrease in circulating neutrophils (usually <1500/mm3). Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it (Option 3). (Option 1) Cancer chemotherapy causes cell lysis, which results in tumor lysis syndrome due to massive release of nucleic acid and its metabolic product, uric acid. Uric acid deposition leads to acute kidney injury. Medications such as allopurinol or rasburicase and aggressive IV hydration are used to prevent this complication. (Option 2) Anemia is also common with chemotherapy. Epoetin (Procrit), a form of erythropoietin, stimulates the body to make additional red blood cells. (Option 4) Low platelet count is not considered an urgent need until it is at <50,000/mm3. Usually, platelet transfusions are given. Educational objective:Bone marrow suppression from chemotherapy can cause decreased red blood cells, white blood cells, and platelets. Erythropoietin is used to increase red blood cell production, and filgrastim is administered to stimulate neutrophil production.

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? 1. A sitting position is assumed as the head is bowed slightly forward (37%) 2. The client points the spray tip toward the nasal septum during instillation (39%) 3. The nasal spray tip is inserted into the nostril as the other nostril is occluded (13%) 4. While administering the medication, the client inhales deeply through the nose (9%)

2. The client points the spray tip toward the nasal septum during instillation (39% The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse teaches the client to: Assume a high Fowler's position with head slightly tilted forward (Option 1) Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger (Option 3) Point the nasal spray tip toward the side and away from the center of the nose (Option 2) Spray the medication into the nose while inhaling deeply (Option 4) Remove the nozzle from the nose and breathe through the mouth Repeat the above steps for the other nostril Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation Educational objective:The correct administration of nasal medication includes pointing the nasal spray tip toward the side and away from the center of the nose.

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority? 1. The client reports a headache (14%) 2. The client reports feeling dizzy and lightheaded (45%) 3. The client reports feeling flushed (16%) 4. The client reports feeling nervous (23%)

2. The client reports feeling dizzy and lightheaded (45%) Nitroglycerin is a nitrate that causes vasodilation and relaxation of vascular smooth muscle. In clients with acute coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of the coronary arteries, thereby increasing perfusion and oxygen supply to the cardiac muscle. Due to systemic vasodilation, this client is at risk for significant hypotension. The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension (Option 2). If the client is found to be hypotensive, the nurse may need to decrease or discontinue the infusion. (Option 1) Headache is a common side effect of nitroglycerin therapy and is often a sign that the medication is working properly. It is not a priority, although acetaminophen may be given for pain relief. (Options 3 and 4) Systemic vasodilation and decreased cardiac preload may cause the client to feel flushed and nervous during infusion. However, reports of dizziness and lightheadedness should take priority. Educational objective:Nitroglycerin is a vasodilator that may be administered by IV infusion in the management of acute coronary syndrome. Clients receiving nitroglycerin are at risk for profound hypotension resulting from systemic vasodilation. The nurse should immediately assess a client with signs of hypotension (eg, dizziness, lightheadedness) because the nitroglycerin infusion may need to be decreased or stopped. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury? 1. Decreased body temperature (11%) 2. Toes pointed straight down (41%) 3. Weak and thready pulse (19%) 4. Wheezing on auscultation (26%)

2. Toes pointed straight down (41% Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. (Option 1) Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia will eventually lead to organ failure, making this an urgent finding but not initially life-threatening. (Option 3) A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. Sometimes the client is so cold that a pulse cannot be detected; this is why a client is not dead until warm and dead. Such clients may require prolonged resuscitation. (Option 4) When wheezing is heard on auscultation after a near-drowning, the first observation would be that the client is still moving air and providing oxygen to the body. The wheezing may indicate that the client has bronchospasm. If the client has aspirated fluid, crackles would be heard. Most such clients will develop acute respiratory distress syndrome. Educational objective:Decerebrate posturing (arms and legs straight out, toes pointed down, head/neck arched back) usually indicates severe brain injury.

The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this." How should the nurse respond? 1. "You can cry and get it all out; I will stay with you." (18%) 2. "You have dealt with diabetes; you can conquer dialysis." (2%) 3. "You sound very discouraged and frightened." (78%) 4. "You still have a lot to live for; think about your family." (1%)

3 "You sound very discouraged and frightened." (78%) Clients may feel overwhelmed when managing chronic illnesses. The nurse should assist them in processing difficult news or events through discussion of thoughts and feelings, which also fosters rapport. Reflecting, or referring the statement back to the client, is a therapeutic communication technique that promotes open dialogue and encourages the client to recognize feelings (Option 3). Acknowledging feelings is an important step in successfully navigating difficult circumstances. (Option 1) Encouraging the client to cry if needed conveys concern but does not encourage further discussion of feelings. (Option 2) Giving false reassurance is an example of a nontherapeutic communication technique that may seem supportive; however, it inappropriately offers hope for an outcome that the nurse cannot guarantee. False reassurance also invalidates and hinders discussion of the client's feelings. (Option 4) Making cliché statements or automatic responses (eg, "you have a lot to live for") or shifting the focus to others' feelings (eg, "think about your family") invalidates the client's feelings and impedes open communication. Educational objective:Nurses should assist clients in processing difficult news or events through discussion of thoughts and feelings. Reflecting is an appropriate technique that promotes open communication and encourages the client to recognize feelings.

The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond? 1. "I find it helpful to investigate the options. I will get you a pamphlet about hospice services." (14%) 2. "It's hard to say what the best decision is, but I know hospice provides wonderful care." (3%) 3. "These decisions are challenging. Tell me your spouse's beliefs about end-of-life." (74%) 4. "You seem overwhelmed. I'll contact a chaplain to come and talk with you about the options." (7%)

3. "These decisions are challenging. Tell me your spouse's beliefs about end-of-life." (74%) End-of-life decisions (eg, hospice, code status) often overwhelm clients and medical decision-makers due to the magnitude of the choices and feelings of guilt that may accompany decisions. Clients and their families may lean on hospital staff to guide these decisions. These moral and ethical dilemmas require the nurse to have strong therapeutic communication skills. When discussing decisions related to client care, the nurse should facilitate exploration of the client's emotions, values, and beliefs, rather than offer personal opinions. Nurses can promote self-exploration by using open-ended questions and guiding phrases (Option 3). (Option 1) Providing information is an appropriate response when that is what the client is seeking. However, there is no indication that the spouse seeking advice requires additional information, and this response does not promote further communication. (Option 2) The nurse's opinion and personal biases can influence clients/family members and may even push them toward decisions incongruent with their values and beliefs. Giving advice is not therapeutic and does not promote open communication. (Option 4) It is within the nurse's scope to discuss moral and ethical decisions with clients. Deferring these conversations to another professional (eg, chaplain) instead of talking with the individual inhibits the therapeutic relationship and does not support client self-exploration. Educational objective:When discussing ethical decisions related to client care, it is important for the nurse to use open-ended questions and guiding phrases to facilitate exploration of clients'/family members' emotions, values, and beliefs regarding the topic. Nurses should avoid giving advice and influencing individuals' decisions. Additional Information Psychosocial Integrity NCSBN Client Need

A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? 1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM." (24%) 2. "That's fine. I can come in whenever it is convenient for everyone." (2%) 3. "This is unacceptable. I had my whole day planned out." (66%) 4. "Why are they doing this to me?" (7%)

3. "This is unacceptable. I had my whole day planned out." (66%) Individuals with obsessive-compulsive personality disorder are typically self-willed and obstinate, punctual, pay attention to rules and regulations, and need to control both internal and external experiences. These traits are very extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the client feels emotionally paralyzed. (Option 1) This response is characteristic of a client with narcissistic personality disorder, who may behave in grandiose, demanding, and entitled ways and needs to have his/her own way. (Option 2) This response could be attributed to a client with dependent personality disorder, who tends to be passive and submissive and wants to please others. (Option 4) This response would be more characteristic of an individual with paranoid personality disorder, who may feel slighted or is overly sensitive. Educational objective:An individual with obsessive-compulsive personality disorder is typically rigid and inflexible and has a need to control both internal and external experiences. A change in a schedule that is outside of the client's control could cause significant distress. Additional Information Psychosocial Integrity NCSBN Client Need

In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is most important for the nurse to take which of these actions? 1. Assess the client for intercostal retractions (19%) 2. Assess the client's blood pressure in both arms (1%) 3. Auscultate the client's lung sounds (70%) 4. Observe the color of the client's fingernail beds (7%)

3. Auscultate the client's lung sounds (70 A client experiencing respiratory distress while receiving mechanical ventilation should be assessed for proper ventilation first. The nurse needs to determine if the mechanical ventilation equipment is still properly placed in the trachea. An endotracheal tube (ET) can become displaced with movement. By assessing the client's lung sounds, the nurse can quickly determine if ET placement has been compromised (Option 3). Airway is the priority for this client. By auscultating the client's lung sounds, the nurse can determine if the client has an open airway. (Option 1) This is an assessment of the client's breathing, which is not the priority at this time. (Option 2) This is an assessment of the client's circulation, which is not the priority at this time. (Option 4) This is an assessment of the client's circulation, which is not the priority at this time. Educational objective:Clients with respiratory distress should be assessed for a patent airway first. The nurse should assess the client's airway to determine if it is present or needs to be established. Additional Information Physiological Adaptation NCSBN Client Need

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read-back) communication is most important for the nurse to report to the health care provider? 1. Client has been ill for approximately 4 hours (4%) 2. Client has improved from apparent earlier distress (3%) 3. Client is now lethargic with abnormal vital signs (88%) 4. Does the health care provider want to order a laxative? (3%)

3. Client is now lethargic with abnormal vital signs (88%) SBAR (situation, background, assessment, recommendation/read-back) is an established reporting format used to communicate with the health care provider (HCP). Use of SBAR ensures that the HCP receives the necessary information to make a clinical judgment regarding treatment or need for immediate assessment. In this situation, the client's presentation indicates worsening symptoms that require immediate intervention. The client's lethargy represents a declining level of consciousness. The client also has significantly abnormal vital signs (normal infant pulse rate is 110-160/min, respirations generally around 40/min). These are ominous signs that should be reported immediately (Option 3). (Option 1) Although it is helpful to know that the change is fairly recent, it is most important to report the current concerning change in the client's clinical presentation and vital signs. (Option 2) Abnormal vital signs with a decreased level of consciousness are not improvements; rather, these findings indicate deterioration. (Option 4) It would not be appropriate to assume and treat potential constipation in this client without further assessment and diagnostic procedures. The nurse needs to assess additional aspects, including bowel sounds, abdominal characteristics, and temperature. Vital signs this significantly abnormal would not be caused by constipation. Educational objective:SBAR (situation, background, assessment, recommendation/read-back) is used to transmit complete essential information to the health care provider. Any abnormal vital signs or current deterioration should be communicated immediately. Additional Information Management of Care NCSBN Client Need

The charge nurse is instructing a new graduate nurse on performing postmortem care. Which client situations might cause the nurse to delay or not perform postmortem care? Select all that apply. 1. Client died following a prolonged illness 2. Client's family was not present when death occurred 3. Client's religious background requires special ceremonial treatment of the body 4. Death occurred in the emergency department following a suicide attempt 5. Family requests a priest to perform last rites

3. Client's religious background requires special ceremonial treatment of the body 4. Death occurred in the emergency department following a suicide attempt 5. Family requests a priest to perform last rites Postmortem care typically is performed immediately following the pronouncement of death to allow visitation of the deceased by the family. There are several circumstances in which postmortem care may be delayed or not performed. Certain cultural or religious beliefs require that care be performed by the family or clergy (Option 3). The family also may want religious ceremonies performed or last rites given before the body is cleaned or disturbed in any way (Option 5). Postmortem care can also be delayed, altered, or not performed in accordance with state law and agency policies. These situations include deaths that are considered non-natural, traumatic, or associated with criminal activity (Option 4). (Option 1) Death following a prolonged illness may be expected and would not cause a delay in postmortem care unless the family requests it. (Option 2) Unless family members notify the agency of any religious or cultural needs related to the deceased, they do not have to be present for postmortem care to take place. Educational objective:Postmortem care may be delayed or not performed if the family has certain cultural or religious beliefs or if the death is considered to be non-natural, traumatic, or associated with criminal activity. Additional Information Basic Care and Comfort NCSBN Client Need

The nurse is caring for a client with a pulmonary contusion. Assessment reveals restlessness, chest pain on inspiration, diminished breath sounds, and oxygen saturation of 86%. Which acid-base imbalance does the nurse correctly identify? Click on the exhibit button for more information. 1. Metabolic acidosis (4%) 2. Metabolic alkalosis (1%) 3. Respiratory acidosis (86%) 4. Respiratory alkalosis (7%)

3. Respiratory acidosis (86%) This client's arterial blood gas analysis reveals respiratory acidosis, with a low pH (<7.35), low PaO2, and high PaCO2 (>45 mm Hg [>5.98 kPa]). Any condition that causes a decrease in respiratory rate or tidal volume (eg, chronic obstructive pulmonary disease, chest trauma, over-sedation, sleep apnea) increases the risk of developing respiratory acidosis. This client's breathing is likely shallow due to pain, impairing gas exchange and leading to buildup of acidic carbon dioxide in the blood. (Option 1) In metabolic acidosis, pH would be decreased (<7.35) and HCO3- would be decreased (<22 mEq/L [<22 mmol/L]). (Option 2) In metabolic alkalosis, pH would be increased (>7.45) and HCO3- would be increased (>26 mEq/L [>26 mmol/L]). (Option 4) In respiratory alkalosis, pH would be increased (>7.45) and PaCO2 would be decreased (<35 mm Hg [<4.7 kPa]). Educational objective:Buildup of acidic carbon dioxide from hypoventilation causes a decrease in pH, creating a state of respiratory acidosis. Additional Information Reduction of Risk Potential NCSBN Client Need

A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam. Pulse oximetry shows 87% on room air. Which findings would the nurse expect to assess on an arterial blood gas? 1. Metabolic acidosis and hyperventilation (9%) 2. Metabolic alkalosis and hypoventilation (17%) 3. Respiratory acidosis and hypoventilation (63%) 4. Respiratory alkalosis and hyperventilation (9%)

3. Respiratory acidosis and hypoventilation (63%) The combination of excessive alcohol ingestion and the benzodiazepine alprazolam (Xanax) causes respiratory depression, which leads to alveolar hypoventilation secondary to carbon dioxide retention, and respiratory acidosis. Therefore, clients should be advised not to take multiple substances that increase the risk of respiratory depression (eg, opioids, benzodiazepines, alcohol, sedating antihistamines). (Option 1) Diarrhea, ketoacidosis, lactic acidosis, and renal failure can cause metabolic acidosis due to loss of bicarbonate or retention of acids; the lungs would compensate by hyperventilating. (Option 2) Vomiting, gastrointestinal suction, and administration of alkali (ie, sodium bicarbonate) are common causes of metabolic alkalosis; the lungs would compensate by hypoventilating. (Option 4) Hypoxia, anxiety, and pain are common causes of respiratory alkalosis, which is due to alveolar hyperventilation (rapid breathing). Educational objective:Over-sedation, sleep apnea, anesthesia, drug overdose, progressive neuromuscular disease, and chronic obstructive pulmonary disease depress the respiratory center; this leads to alveolar hypoventilation, secondary to carbon dioxide retention, and respiratory acidosis. Additional Information Physiological Adaptation NCSBN Client Need

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" (18%) 2. "My blood pressure this morning was 158/84 mm Hg." (4%) 3. "Sometimes I feel somewhat dizzy when I stand up." (5%) 4. "Will you look at my tongue? It feels thicker than normal." (72%)

4. "Will you look at my tongue? It feels thicker than normal." (72%) ngioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life-threatening as it progresses to the airways. Angioedema is an adverse effect of ACE inhibitors (eg, enalapril, lisinopril, captopril) and occurs more commonly in African American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client (Option 4). (Option 1) A persistent, dry, hacking cough is a common side effect of ACE inhibitors. It is not life-threatening, but the medication should be discontinued or changed to resolve the cough. (Option 2) The nurse should review the client's blood pressure readings over the past month since starting enalapril. The client may need a dosage change or an additional medication. This should be reported but is not the priority in this situation. (Option 3) Occasional dizziness upon rising (ie, orthostatic hypotension) is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before standing up. Educational objective:Swelling of the tongue can be a sign of angioedema in clients taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this immediately to the health care provider. Angioedema occurs more commonly in African American clients. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? 1. Clamp the chest tube immediately (4%) 2. Increase oxygen to 6 L via nasal cannula (3%) 3. Medicate client for pain and document the findings (22%) 4. Notify the health care provider immediately (69%)

4. Notify the health care provider immediately (69%) Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management. (Option 1) Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. (Option 2) Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option 3) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority. Educational objective:A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. Additional Information Physiological Adaptation NCSBN Client Need

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? 1. Ask the UAP to go back and ask the client what the current needs are (14%) 2. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room (3%) 3. Tell the UAP to inform the client in the next room that the nurse will be there shortly (21%) 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room (60%)

4. Tell the UAP to tell the charge nurse about the needs of the client in the next room (60%) With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door. (Option 1) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. (Option 2) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. (Option 3) The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation. Educational objective:The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure.

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? 1. The nurse has encouraged exploration of the client's situation (3%) 2. The nurse has shown interest in the client's concerns (2%) 3. The response conveys empathy toward the client and promotes self-confidence (27%) 4. The response devalues the client's feelings and gives false reassurance (65%)

4. The response devalues the client's feelings and gives false reassurance (65%) The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued. (Option 1) The nurse has not encouraged exploration of this client's feelings and options. This could have been done by using any one of several therapeutic communication techniques (eg, reflecting, focusing, exploring). An appropriate response by the nurse, such as stating, "Tell me what concerns you have," would have facilitated communication with the client. (Option 2) The nurse has shown no interest in the client's concerns; instead, the nurse should show interest, be available, and have a conversation with the client (eg, "I will stay and listen to your concerns"). (Option 3) The nurse has not conveyed empathy (attempting to understand and share the feelings behind a client's actions and words). An empathetic nurse might say, "This must be hard for you," or, "I understand you are upset." Educational objective:The nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship.

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting (0%) 2. Second-trimester client with dysuria and urinary frequency (6%) 3. Second-trimester client with obesity reporting decrease in fetal movement (47%) 4. Third-trimester client with right upper quadrant pain and nausea (45%)

4. Third-trimester client with right upper quadrant pain and nausea (45%) Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. (Option 1) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. (Option 2) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. (Option 3) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority. Educational objective:HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications including placental abruption, stroke, and death may occur if HELLP syndrome is not treated immediately. Additional Information Management of Care NCSBN Client Need

Which of the following diets would place a client at the highest risk for macrocytic anemia? 1. Lacto-ovo-vegetarian (13%) 2. Lacto-vegetarian (8%) 3. Macrobiotic (15%) 4. Vegan (61%)

4. Vegan (61%) Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate. (Option 1) Lacto-ovo-vegetarian — eggs, milk, and milk products are included, but no meat is consumed. (Option 2) Lacto-vegetarian — milk and milk products are included in the diet; eggs and meats are excluded. (Option 3) Macrobiotic — whole grains, vegetables, fruits, and seaweeds are emphasized; fish and seafood may be included in the diet up to several times a week. Educational objective:Individuals who follow a plant-based diet, especially vegans, are at risk for vitamin B12 deficiency and the resulting macrocytic anemia. Additional Information Health Promotion and Maintenance NCSBN Client Need

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1. Color of sputum (7%) 2. Lung sounds (37%) 3. Saturation level (6%) 4. White blood cell count (WBC) (48%)

4. White blood cell count (WBC) (48%) HAP is a bacterial infection acquired in a health care facility that was not present on admission. Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm3). Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP. If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics. The nurse monitors WBC as the best indicator of treatment effectiveness as antibiotics cause bacterial lysis or hinder bacterial DNA reproduction. The reduced number of bacteria and the resulting decrease in inflammation cause a decrease in the number of white blood cells needed to fight the infection. Other indicators of treatment effectiveness include improvement of infiltrates on chest x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). (Option 1) The color of sputum (eg, clear, yellow, green, grey, rusty, blood-tinged) can vary with different types of pneumonia; it is not the best indicator of treatment effectiveness. (Option 2) Adventitious/abnormal lung sounds (crackles, low-pitched wheeze, bronchial breath sounds) can be present as the pneumonia resolves or can be a sign of further complication (pleural effusion). However, these are not the best indicators of treatment effectiveness. (Option 3) Saturation is an indicator of oxygenation but can be affected by many other factors, such as coexisting disease, peripheral circulation, and drugs. It is not the best indicator of treatment effectiveness. Educational objective:Indicators of treatment effectiveness for HAP include decreased WBC on complete blood count with differential and improvement of infiltrates on chest-x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). Additional Information Physiological Adaptation NCSBN Client Need

A client receiving a first dose of IV cefazolin has developed a diffuse rash, hypotension, and shortness of breath. Place the nurse's subsequent actions in the correct order. All options must be used.

5. Stop the infusion and call for help 2. Assess airway and place client on oxygen 3. Give IM epinephrine and start IV normal saline 1. Administer diphenhydramine IV 4. Monitor vital signs for changes Anaphylactic shock has an acute onset (20-30 minutes) caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs (eg, antibiotics), foods (eg, shellfish, peanuts), diagnostic agents (eg, contrast), biologic agents (eg, blood, vaccines), and venom (eg, bees, snakes) and results in circulatory failure, laryngeal edema, and severe bronchoconstriction. Management of anaphylactic shock includes: Stop the infusion that is causing the reaction and call for help (eg, rapid response team) (Option 5). Ensure patent airway, then administer oxygen via a high-flow nonrebreather mask and prepare for intubation if needed (Option 2). Give epinephrine intramuscularly. Epinephrine counteracts the effect of the histamines released, dilating bronchial smooth muscles and providing vasoconstriction. Most deaths from anaphylaxis are due to delaying epinephrine. Maintain blood pressure with normal saline IV fluid (Option 3). Administer adjunctive therapies: Bronchodilators (eg, albuterol) to dilate the small airways and reverse bronchoconstriction, antihistamines (eg, diphenhydramine) to modify the hypersensitivity reaction, and corticosteroids (eg, methylprednisolone) to decrease airway inflammation and swelling associated with the allergic reaction (Option 1). Continue to reassess vital signs for any changes (Option 4). Educational objective:In a client who is experiencing an anaphylactic reaction to an IV medication, it is imperative to first stop the infusion; ensure airway patency and administer oxygen; give epinephrine and initiate IV fluids; and administer adjunctive therapies (antihistamines, bronchodilators, corticosteroids). Additional Information Physiological Adaptation NCSBN Client Need

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy? 1.Take the blood pressure sitting and standing (10%) Assess how far the client can walk (3%) 2. Check sensation in fingers and toes (73%) 3. Inspect extremities for diabetic ulcers (12%) 4.

Take the blood pressure sitting and standing (10%) Diabetic neuropathy is caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus. Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly. (Options 1, 2 & 3) Sensory or peripheral neuropathy affects the peripheral nervous system and may cause problems with the extremities. Educational objective:Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension and put the client at risk for falls.