ASSESSMENT

Question 1

Your client is receiving an enteral feeding every 4 hours. What is an appropriate expected outcome for this client in terms of the gastrointestinal system?

A. The client will be free of any insertion site infection
B. The nurse will measure residual prior to each feeding
C. The client will be free of dumping syndrome
D. The nurse will administer no more than 200 mL for each feeding

Answer 1

CORRECT ANSWER C

Explanation

Choice C is correct. The appropriate expected goal or expected outcome for this client, in terms of the gastrointestinal system, who is receiving an enteral feeding every 4 hours, is that the client will be free of dumping syndrome, which can further increase the client’s nutritional deficits. Simply stated, dumping syndrome is the very rapid and quick movement of foods and fluids through the stomach and then into the small intestine; the feed is then mostly undigested and eliminated through the gastrointestinal tract. Although dumping syndrome is primarily associated with gastric bypass surgery, it can also occur as a result of enteral bolus feedings.
Because “dumping syndrome” is one of the main complications that accompany enteral feeding,you must ensure to prevent it by implementing appropriate nursing interventions which include giving formula at room temperature and increasing the feeding rate gradually.

Choice A is incorrect. “The client will be free of any insertion site infection” may be an appropriate expected goal or expected outcome for this client who is receiving an enteral feeding every 4 hours. Still, this outcome is not related to the client’s gastrointestinal system.

Choice B is incorrect. “The nurse will measure residual before each feeding” is an appropriate nursing intervention, but it is not an expected goal or expected outcome.

Choice D is incorrect. “The nurse will administer no more than 200 mL for each feeding” is not an expected goal or expected outcome. Moreover, the nurse can administer more than 200 mL for each feeding. The volume of each food is typically from 250 to 400 ml per feeding.

Reference: Knippa, Audrey, Sheryl Sommer, Brenda Ball et al. (2010) Nutrition for Nursing 4.0; ATI Nursing Education.

Question 2

Which of the following is least likely to develop trust in the nurse-client relationship? Select All That Apply.

A. Using consistency in approaching the client
B. Encourage the client to use “testing” behaviors
C. Tell the patient how she should behave
D. Avoid setting limits

Answer 2

CORRECT ANSWER B, C, D

Explanation

B, C, and D are the correct answers. Avoiding limit setting will not instill trust, nor will it encourage testing behaviors or telling the client how he should behave.

One of the essential elements of trust is consistency. The client learns to trust that the nurse will follow through and do what is promised.

NCSBN Client Need

Topic: Psychosocial Integrity

Chapter 26: Communicating

Lesson: The Helping Relationship

Fundamentals of Nursing (Kozier and Erbs)

Question 3

A client is currently experiencing bradycardia, low blood pressure, and dizziness. Which of the following does the nurse expect to be ordered?

A. Defibrillation
B. Digoxin
C. Monitor the client closely
D. Prepare patient for transcutaneous pacing

Answer 3

CORRECT ANSWER D

Explanation

Choice D is correct. The normal heart rate in an average adult is between 60 to 100 beats per minute. A heart rate less than 60 beats per minute is referred to as bradycardia. Bradycardia can be symptomatic or asymptomatic. Some healthy adults and athletes may have a heart rate between 40 and 60 beats per minute and do not experience any symptoms. When symptomatic, bradycardia can lead to shortness of breath, dizziness, and low blood pressure ( hypotension, shock). A patient experiencing symptomatic bradycardia will likely need transcutaneous pacing. In addition, an EKG must be performed to confirm the rhythm. The etiology of bradycardia may vary and include reversible ( medications) and irreversible causes ( heart blocks). Therefore, one should explore causes, but the priority intervention in a patient experiencing symptoms from bradycardia is to restore the heart rate quickly with transcutaneous pacing and maintain circulation.

Choice A is incorrect. Defibrillation is recommended when the patient is experiencing pulseless ventricular tachycardia or ventricular fibrillation.

Choice B is incorrect. Digoxin is a cardiac glycoside that has negative chronotropic action on the sinus node. Therefore, digoxin decreases the heart rate and would be dangerous in this patient with symptomatic bradycardia.

Choice C is incorrect. While this patient should be monitored closely, priority action ( transcutaneous pacing) should quickly restore the heart rate.

NCSBN client need | Topic: Physiological Integrity, Reduction of Risk Potential

Question 4

A 30-year-old male client in the medical ward for admitted for hiatal hernia is being discharged today. The nurse talks to him regarding methods to prevent and reduce pain associated with his condition. Which of the following statements from the client indicate that teaching is successful?

A. “I need to wear loose-fitting clothes.”
B. “After a meal, I must lie down to avoid dumping syndrome.”
C. “I need to eat three large meals a day.”
D. “I can go to my favorite Indian restaurant anytime of the week.”

Answer 4

CORRECT ANSWER A

Explanation

A is correct. The nurse should teach the client measures that reduce gastric acid reflux in the patient. The nurse should instruct the patient to wear loose-fitting clothes to prevent pressure in the stomach that might cause reflux.

B is incorrect. The client should not lie down after a meal. Instead, the client should remain in an upright position for 2 hours after eating. Dumping syndrome in a hiatal hernia does not exist.

C is incorrect. The nurse should instruct the client to have frequent small feedings rather than three large meals to avoid gastric reflux.

D is incorrect. Spicy food and caffeine trigger acid reflux and should be avoided. Indian food is full of spices, and clients should avoid eating tasty food.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 5

Auscultation is one of the most important components of which body systems?

A. Pulmonary. gastrointestinal. neurological
B. Reproductive. neurological. integumentary
C. Cardiovascular. pulmonary. gastrointestinal
D. Gastrointestinal. neurological. and reproductive

Answer 5

CORRECT ANSWER C

Explanation

Answer and Rationale:

The correct answer is C. Auscultation of the heart provides information on rate, rhythm, extra sounds, and murmurs. Auscultation of the lungs includes information on the underlying music and adventitious sounds, which relate to pathology in the alveoli and airways. Gastrointestinal sounds may be absent, hypoactive, or hyperactive.
A, B, and D are incorrect. Auscultation plays a minimal role in the reproductive, neurological, and integumentary systems.

NCSBN Client Need

Topic: Physiological Integrity

Subtopic: Reduction of Risk Potential

Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)

Chapter 30: Head-to-toe Assessment of the Adult

Lesson: Auscultation

Question 6

In an adult, sustained intracranial pressure greater than _______ mmHg can lead to severe neurologic damage.

Answer 6

Explanation

Answer: 20

In adults, normal intracranial pressure is 10 to 15 mmHg. In adults, increased ICP at more than 20 mmHg increase risk for neurologic damage.

Normal Intracranial Pressure (ICP) in young children is 3-7 mmHg.

NCSBN Client Need:

Topic: Physiological Integrity Subtopic: Physiological Adaptation

Reference: Brorsen, A. & Roglet, K. (2011). Pediatric Critical Care. Burlington, MA: Jones & Bartlett Learning.

Question 7

While monitoring your patient’s cardiac telemetry, you notice the following ECG changes: tall peaked T waves, absent P waves, and a widened QRS. You notify the health care provider and anticipate an order for which of the following laboratory studies?

A. BMP
B. CBC
C. Coags
D. Type and screen

Answer 7

CORRECT ANSWER A

Explanation

Answer: A

A is correct. A basic metabolic panel (BMP) is what the nurse anticipates the healthcare provider will order. This laboratory study will examine all the essential electrolytes such as sodium, potassium, chloride, magnesium, and calcium. The nurse is expecting the potassium to be elevated in her patient, given the ECG changes, so she will expect to monitor all electrolytes in her patient.

B is incorrect. A complete blood count will monitor RBCs, RBCs, platelets, and other cell counts in the patient. This is important when tracking for anemia, infection, and much more, but should not have any result that immediately impacts these ECG changes. The electrolyte abnormalities are more likely, and therefore the nurse anticipates an order for a BMP.

C is incorrect. Coagulation studies are essential for showing clotting times in the patient’s blood, but the nurse is not concerned about that right now. Abnormal clotting times should not cause ECG changes.

D is incorrect. A type and screen identify the patient’s blood type. This is very important for surgery and before administering any blood products, but will not help the nurse determine the cause of the ECG changes she noticed.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Pharmacological therapies

Subject: Fundamentals

Lesson: Electrolytes

Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.

Question 8

Many factors impact on the occurrence of diseases and disorders as well as client recovery from these diseases and disorders. Which of the following is the extrinsic factor that most greatly and most frequently can hurt and interfere with our client’s physical and emotional recovery from a disease or disorder?

A. Age
B. Genetic makeup
C. Family dynamics
D. Gender

Answer 8

CORRECT ANSWER C

Explanation

Correct Answer is C

Correct. Family dynamics is the extrinsic factor that most greatly and most frequently hurts and interferes with our clients’ physical and emotional recovery from a disease or disorder; in fact, family dynamics is the only extrinsic risk factor listed above. All of the other factors are intrinsic risk factors that are associated with a possible negative impact on the recovery of a client.

Choice A is incorrect. Age does have a possible negative impact on and interference with our client’s physical and emotional recovery from a disease or disorder; however, age is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients’ physical and emotional recovery from a disease or disorder.

Choice B is incorrect. Genetic makeup does have a possible negative impact on and interference with our clients physical and emotional recovery from a disease or disorder, however, genetic makeup is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients’ physical and/or emotional recovery from a disease or disorder.

Choice D is incorrect. Gender does have a possible negative impact on and interference with our client’s physical and emotional recovery from a disease or disorder; however, gender is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients’ physical and emotional recovery from a disease or disorder.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 9

Total parenteral nutrition is being considered for your client. Your client tells you that “my doctor is thinking about hyperalimentation, and I know nothing about it. Can you tell me what it is? You should respond to this client’s statement with:

A. “Your doctor is thinking about total parenteral nutrition and not hyperalimentation.”
B. “Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube.”
C. “Hyperalimentation is a one kind of parenteral nutrition that gives you feedings with a special IV line.”
D. “You should choose to have enteral nutrition and not accept hyperalimentation.”

Answer 9

CORRECT ANSWER C

Explanation

Correct Answer is C

Correct. You should respond to this client’s statement with “Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line.” Parenteral nutrition, which is synonymous with hyperalimentation and IV hyperalimentation, provides the client with complete food when it is indicated for a client such as one who is adversely affected

Choice A is incorrect. You should not respond to this client’s statement with “Your doctor is thinking about total parenteral nutrition and not hyperalimentation” because parenteral nutrition is hyperalimentation; parenteral nutrition is synonymous with hyperalimentation and IV hyperalimentation.

Choice B is incorrect. You should not respond to this client’s statement with “Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube” because hyperalimentation is parenteral nutrition and not enteral nutrition.

Choice D is incorrect. You should not respond to this client’s statement with “You should choose to have enteral nutrition and not accept hyperalimentation” because this is coercive and it is contrary to the client’s right to make an informed decision about any or all care that is being considered and given.

Reference: McCuistion, Linda E., Joyce LeFever Kee, and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier

Question 10

While reviewing fetal monitoring strips, the labor and delivery nurse notes that the piece is nonreassuring. What features characterize a fetal monitoring strip as nonreassuring? Select all that apply.

A. Fetal heart rate less than 110 beats/minute.
B. Increase in variability.
C. Late decelerations
D. Mild variable decelerations

Answer 10

CORRECT ANSWER A, C

Explanation

Answer: A and C

A is correct. A fetal heart rate less than 110 beats/minute or greater than 160 beats/minute is nonreassuring.

B is incorrect. An increase in variability is a reassuring factor. A decrease in variability would be nonreassuring.

C is correct. Late decelerations are an ominous sign, and immediate interventions should be taken to improve the fetal heart rate. They are characteristic of a nonreassuring heart rate.

D is incorrect. Mild, variable decelerations are okay, only when the variable decelerations are severe are they nonreassuring.

NCSBN Client Need

Topic: Physiological AdaptationSubtopic: Alterations in Body Systems

Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 363

Question 11

You are supervising a nursing assistant and observing their competency in providing personal care and hygiene for a group of clients. As you are reviewing this nursing assistant’s documentation you see that the nursing assistant has documented shaving one of the clients, who is taking warfarin. What should you do? You should:

A. Tell the nursing assistant that shaving clients who are taking warfarin are strictly prohibited in all settings.
B. Complete an incident report because shaving clients are outside the nursing assistant’s scope of practice.
C. Tell the nursing assistant to cross off the documented evidence of having shaved the client.
D. Ask the nursing assistant what kind of razor was used and about the client’s response to the shave.

Answer 11

CORRECT ANSWER D

Explanation

Correct Answer is D

Correct. You would ask the nursing assistant what kind of razor was used and about the client’s response to the shave when you learn that the nursing assistant has documented shaving one of the clients who is taking warfarin.

You would determine what kind of razor was used because an electric or battery operated razor is much safer than a dull razor blade to use for clients who are on an anticoagulant like warfarin. If the nursing assistant used a regular razor blade, instead of an electric or battery operated razor, you would ask the nursing assistant about the client’s response to the shave. For example, you would determine whether or not there was any skin nicking or bleeding. After these things are determined, you would also ask the nursing assistant to document the type of razor that was used in addition to the client’s responses to the shave.

Choice A is incorrect. You would not tell the nursing assistant that shaving clients who are taking warfarin are strictly prohibited in all settings because this is not accurate and true. Clients who are taking warfarin can and should be shaved with an electric or battery operated razor because these razors are much safer than a dull razor blade.

Choice B is incorrect. You would not complete an incident report because shaving clients are outside the nursing assistant’s scope of practice. Shaving, personal care, and hygiene are within the legal reach of unlicensed assistive personnel, including nursing assistants and patient care technicians, provided that they have the training and documented competency to do so.

Choice C is incorrect. You would not tell the nursing assistant to cross off the documented evidence of having shaved the client. If the person cut, this documentation must remain in place.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 12

The nurse is working with a patient who is receiving a new prescription of prednisone. The nurse would be most correct in instructing the client to take this medication at which time every day?

A. In the morning
B. Around noon
C. Before bed
D. Anytime. but the same time everyday

Answer 12

CORRECT ANSWER A

Explanation

NCSBN client need | Topic: Physiological Adaptation, Pharmacological and Parenteral Therapies

Rationale:

The correct answer is A. Corticosteroids should be taken in the morning, preferably before 9 AM. This mimics the natural release of glucocorticoids from the adrenal glands in the morning.

Choice B is incorrect. The best time to take prednisone is not around noon.

Choice C is incorrect. The best time to take prednisone is not before bed. Taking prednisone before bed could cause restlessness or insomnia.

Choice D is incorrect. There is a more specific time to take prednisone.

Reference:

Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011

Question 13

A 15-year-old female comes into the gynecology clinic asking for a prescription of contraceptive pills. Fifteen minutes later, her mother comes in and scolds the teenager about her decision. She tells the doctor not to give her the pills and says that her daughter is still too young and it is her decision that should be followed. What should be the most appropriate action of the nurse?

A. Withdraw the prescription contraceptive pills.
B. Call Child Protective Services.
C. Explain to the mother that in cases of birth control services, her daughter has the right to give consent.
D. Explain to the teenager that her mother still has consenting authority over her decisions.

Answer 13

CORRECT ANSWER C

Explanation

A is incorrect. Parental or guardian consent should be obtained before treatment is initiated for a minor except in an emergency. In situations in which the permission of the minor is sufficient, this includes birth control treatments.

B is incorrect. There is no sign of abuse; the nurse does not need to call child protective services.

C is correct. When the minor is seeking birth control treatments, the minor’s consent is sufficient and does not warrant the permission of her parents.

D is incorrect. The mother no longer has consenting authority over her child when it comes to birth control treatments.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 14

For burns, pain management primarily consists of morphine delivered intravenously. The reason for this is:

A. The IV route delays absorption to provide continuous pain relief
B. The IV route facilitates absorption as muscle absorption is not dependable
C. The IV route allows for discontinuance in the event of respiratory depression
D. The IV route prevents further pain from IM injections

Answer 14

CORRECT ANSWER B

Explanation

Rationale: The I.V. route of administering medications facilitates increased absorption of drugs, not decreased intake. Option A is incorrect. In clients with burns, they are usually hemodynamically unstable, and tissue perfusion is compromised. Medications remain in the subcutaneous tissue with the fluid in the interstitial spaces in the acute phase of the injury. Because of this, the IM route is avoided until stability has been achieved. Option B is, therefore, the correct answer. In the event of respiratory depression, the IV route would hasten the process, making option C incorrect. The goal in I.V. administration is not for the primary reason of avoiding causing the additional client pain. Option D is also wrong.

Reference:

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 15

The nurse is reviewing the results of her patient’s basic metabolic panel and notes a potassium level of 5.7 mEq/L. She knows that which of the following conditions could cause this result? Select all that apply.

A. Cushing’s disease
B. Continuous NG tube suction
C. Severe dehydration
D. Hyperinsulinism

Answer 15

CORRECT ANSWER C

Explanation

The normal level for potassium is 3.5 to 5. This patient has a potassium level of 5.7, indicating hyperkalemia.

A is incorrect. Cushing’s disease is likely to cause hypokalemia, not hyperkalemia. In this disease the adrenal glands produce too much aldosterone. Aldosterone causes the body to excrete potassium, putting patients with Cushing’s disease at risk for excessive potassium losses leading to hypokalemia.

B is incorrect. The patient with an NG tube to continuous suction is likely to experience hypokalemia, not hyperkalemia. NG tube suction removes all of the gastric contents, which are rich in potassium. With those excessive potassium losses, the patient becomes hypokalemic.

C is correct. Severe dehydration is a potential cause of hyperkalemia. When a patient is severely dehydrated (from vomiting, diarrhea, profuse sweating, etc.), potassium is lost and large amounts of fluid are lost. While this patient is experiencing a fluid volume deficit, the concentration of potassium in their blood is elevated, which is why they are hyperkalemic.

D is incorrect. Hyperinsulinism is likely to experience hypokalemia, not hyperkalemia. Insulin is a hormone secreted by the pancreas that facilitates the movement of insulin into cells. With it comes potassium, and therefore when there is too much insulin as there is in hyperinsulinism, too much potassium is moved into the cells and the serum potassium level drops causing hypokalemia.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Physiological adaptation

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Subject: Fundamentals of care

Lesson: Fluids & Electrolytes

Question 16

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
B. azathioprine
C. prednisone
D. naproxen sodium

Answer 16

CORRECT ANSWER C

Explanation

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.

B is incorrect. Azathioprine is used for clients with life-threatening rheumatoid arthritis for its immunosuppressive effects.

C is correct. Prednisone is a steroid with anti-inflammatory and immunosuppressive effects to treat rheumatoid arthritis.

D is incorrect. Naproxen sodium is a COX2 inhibitor that is an anti-inflammatory, reducing pain.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 17

The nurse on duty at the ER just witnessed the father of a client grab another nurse by his throat, threatening to hurt him if he does not come to see his child. Upon separating the two, the nurse knows that they can file which complaints against the father?

A. Libel
B. Slander
C. Assault
D. Battery

Answer 17

CORRECT ANSWER D

Explanation

A is incorrect. Libel is a form of false communication that causes damage to someone’s reputation in writing.

B is incorrect. Slander is a form of false communication that causes damage to someone’s reputation verbally.

C is incorrect. Assault occurs when a person puts another person in fear of harmful or offensive contact. The victim fears and believes that harm will result because of the threat.

D is correct. The battery is an intentional touching of another’s body without the other’s consent. Grabbing the nurse by the throat is a form of battery and is punishable by law.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 18

A patient with kidney injury has a serum potassium level of 6.1 mEq/L. Which of the following actions is a priority action?

A. Encourage exercise
B. Check the patient’s sodium level
C. Place the patient on a cardiac monitor
D. Encourage increased fluid intake

Answer 18

CORRECT ANSWER C

Explanation

NCSBN client need | Topic: Physiological Integrity, Reduction of Risk Potential

Rationale:

The correct answer is C. A serum potassium level of 6.1 mEq/L is high. A normal serum potassium level is between 3.5 and 5.0 mEq/L. Hyperkalemia puts the patient at risk for developing cardiac changes and therefore this patient should be on a cardiac monitor.

Choice A is incorrect. Encouraging exercise will not lower the serum potassium level which is dangerously high at 6.0 mEq/L. The normal serum potassium level is 3.5-5.0 mEq/L.

Choice B is incorrect. Checking this patient’s sodium level delays the necessary treatment of the dangerously high serum potassium level of 6.0 mEq/L. The normal serum potassium level is 3.5-5.0 mEq/L.

Choice D is incorrect. Encouraging an increase in fluids delays the necessary treatment of the dangerously high serum potassium level of 6.0 mEq/L. The normal serum potassium level is 3.5-5.0 mEq/L.

Reference:

Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby

Question 19

Medications bound to protein have the following effect:

A. Enhancement of drug availability.
B. Rapid distribution of the drug to receptor sites.
C. The more the drug is bound to protein, the less it is available for the desired effect.
D. Increased metabolism of the drug by the liver.

Answer 19

CORRECT ANSWER C

Explanation

Plasma protein binding refers to the degree to which medications attach to proteins within the blood. A drug’s efficiency may be affected by the degree to which it binds. The less bound a drug is, the more efficiently it can traverse cell membranes or diffuse. A drug in blood exists in two forms: bound and unbound. Depending on a specific drug’s affinity for plasma protein, a proportion of the drug may become attached to plasma proteins, with the remainder being unbound. Only the unbound fraction of the drug undergoes metabolism in the liver and other tissues. As the drug dissociates from the protein, more and more drug undergoes metabolism. Changes in the levels of the free drug change the volume of distribution because the free drug may distribute into the tissues leading to a decrease in plasma concentration profile. For the medicines which rapidly undergo metabolism, clearance is dependent on hepatic blood flow. For drugs that slowly undergo metabolism, changes in the unbound fraction of the drug directly change the approval of the drug.

The correct answer is C. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect.
A is incorrect. LESS of the drug is available if it is bound to protein.
B is incorrect. Distribution to receptor sites is irrelevant since the drug bound to protein cannot unite with a receptor site.
D is incorrect. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again.

NCSBN Client Need

Topic: Physiological Integrity; Subtopic: Pharmacological Therapies

Chapter 4: What Happens After a Drug Has Been Administered; Lesson: Drug Metabolism

Reference: Core Concepts in Pharmacology (Holland/Adams)

Question 20

The Registered Nurse is preparing a patient for a pneumonectomy. What teaching should the nurse discuss with the patient?

A. Instruct patient to lie on non-operative side following procedure.
B. Expect remaining lung to return to normal function within 2-6 hours.
C. Advise patient to avoid coughing, assure that nurse will use wall suction to clear secretions.
D. Keep head of bed elevated at 30-45 degree angle post-procedure.

Answer 20

CORRECT ANSWER D

Explanation

Correct Answer is D. Keeping the head of the bed between 30-45 degrees will minimize respiratory efforts and facilitate recovery post pneumonectomy. This intervention will also prevent post-pneumonectomy pulmonary edema. The patient should lie on the operative side and should have the head of the bed raised to 45 degrees as soon as awake. These positions minimize the gravitational effect on capillary pressure in the remaining lung.

A is incorrect. Lying on the non-operative slides will increase the risk of pulmonary edema and therefore, should be avoided. The patient would be instructed to lie on the backor operative side only to prevent leaking of fluid into the operative side ( pulmonary edema) and to allow full expansion of the remaining lung.

B is incorrect. The remaining lung will require 2-4 days to adjust to increased blood flow.

C is incorrect. Deep breathing, coughing, and splinting are encouraged during the post-op period to promote the expansion of the lung. Wall suction is contraindicated after pneumonectomy.

NCBSN Client need:
Topic: Reduction of Risk Potential. Sub-Topic: Use precautions to prevent injury and/or complications associated with a procedure or diagnosis
Reference:
Jones & Fix, 2015, p. 127-128

Question 21

The nurse in the Intensive Care Unit notes bleeding from the client’s transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for Sepsis. What should be the nurse’s immediate next action?

A. Assess the client’s hemoglobin and hematocrit level
B. Check the client’s oxygen saturation.
C. Apply pressure to the intravenous site.
D. Call the physician.

Answer 21

CORRECT ANSWER D

Explanation

Choice D is correct. The client is manifesting signs of Disseminated Intravascular Coagulation (DIC). This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as Sepsis. In this condition, the clotting system is activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may fuel the thrombotic process in DIC. Therefore, Platelets, cryoprecipitate, and Fresh Frozen Plasma are not routinely injected in DIC unless there is significant bleeding.

The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors.

Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (Anemia). The nurse should undoubtedly check the client’s Hemoglobin and Hematocrit levels; however, the nurse needs to notify the physician right away since the client is showing bleeding signs of DIC.

Choice B is incorrect. Assessing the client’s oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic patient and the nurse must notify the physician immediately since urgent intervention is needed

Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the bleeding from other websites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion.
NCSBN Client Need:
Topic: Pharmacological and parenteral therapies; Sub-Topic: Blood and Blood Products

Question 22

What is the normal level for creatinine in a healthy adult male?

A. 0.4 to 0.8 mg/dL
B. 0.1-0.4 mg/dL
C. 0.6-1.2 mg/dL
D. 1.5-2.0 mg/dL

Answer 22

CORRECT ANSWER C

Explanation

Answer: C

Choice C is correct. The normal creatinine range is 0.6 to 1.2 mg/dL in a healthy adult male.

Creatinine values reflect both the amount of muscle a person has and their amount of kidney function. Hence, the levels are slightly lower in women due to lesser muscle mass. Most men with normal kidney function have 0.6 to 1.2 milligrams/deciliters (mg/dL) of creatinine. Most women with normal kidney function have between 0.5 to 1.1 mg/dL of creatinine.

A is incorrect. This is not the normal lab value range for creatinine in a healthy adult male.

B is incorrect. This is not the normal lab value range for creatinine in a healthy adult male.

D is incorrect. This is not the normal lab value range for creatinine in a healthy adult male.

NCSBN Client Need:Topic: Health Promotion

Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing.

Question 23

While attending to a client with constipation, the clinic nurse reviews the home medication list. Which of the following drugs would the nurse be correct in identifying as potentially constipation inducing?

A. Baclofen
B. Omeprazole
C. Citalopram
D. Cephalexin

Answer 23

CORRECT ANSWER A

Explanation

NCSBN client need | Topic: Physiological adaptation, reduction of risk potential

Rationale:

The correct answer is A. Baclofen, a medication used to treat muscle spasms may cause constipation. It may also be responsible for urinary retention and dizziness.

Choice B is incorrect. Omeprazole is a Proton-Pump Inhibitor used to treat gastroesophageal reflux, stomach ulcers, and esophagitis.

Choice C is incorrect. Citalopram is a selective serotonin reuptake inhibitor and is used to treat depression.

Choice D is incorrect. Cephalexin is a common antibiotic most frequently used to treat urinary tract infections, upper respiratory tract infections, and skin conditions.

Reference:

Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011

Question 24

The nurse in the ICU is taking care of a client recently diagnosed with Myocardial infarction resulting in massive necrosis in the left ventricular wall. A central catheter is inserted to measure CVP. What CVP reading should the nurse expect?

A. 2 cm of water
B. 7 cm of water
C. 16 cm of water
D. 9 cm of water

Answer 24

CORRECT ANSWER A

Explanation

A is correct. The client is expected to show signs of left ventricular failure due to the damage to his left ventricle. A reading of less than 3 cm of water is indicative of early left ventricular failure.

B is incorrect. A CVP reading of 7 cm of water is a regular CVP reading. The normal CVP reading is 2 – 12 cm of water.

C is incorrect. A CVP reading of 16 cm of water is indicative of right ventricular failure, not LVF.

D is incorrect. A CVP reading of 9 cm of water is a regular CVP reading. The normal CVP reading is 2 – 12 cm of water.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 25

The nurse is proving patient teaching in the clinic. The patient is being prescribed a bisphosphonate to treat osteoporosis. Which information should the nurse be sure to inform this patient? A. Take this medication sitting upright first thing in the morning with a full glass of water. B. Take this medication at night. just before bed. C. This medication should be taken along with a full meal. D. This medication is the best alternative if an esophageal disorder is present.

Answer 25

CORRECT ANSWER A Explanation NCSBN client need | Topic: Physiological Integrity, pharmacological and parenteral therapies Rationale: The correct answer is A. Bisphosphonates should be taken the first thing in the morning with a full glass of water. Patients should also wait 30 minutes to eat any food and should remain sitting or standing during that time. This prevents esophageal damage that may occur when this medication is taken improperly. Choice B is incorrect. This medication should not be taken at night because the patient needs to remain sitting or standing for 30 minutes following medication administration. Choice C is incorrect. This medication should not be taken with a full meal. Choice D is incorrect. Bisphosphonates are contraindicated in patients with esophageal disorders. Reference: Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011

Question 26

``` Which of the following images shows the most appropriate position for an infant who has just had a cleft palate surgery? A. TRENDELENBURG B. RIGHT LATERAL RECUMBENT C. SUPINE D. PRONE ```

Answer 26

CORRECT ANSWER D Explanation Choice D is correct. For a child who is status post cleft palate surgery, it is most appropriate to position them prone. Due to their unique anatomy, they are at an increased likelihood of their tongue falling back into their airway, causing obstruction and respiratory distress. The prone position prevents the tongue from falling backward. A prone position is recommended to facilitate the drainage of excessive secretions post-operatively. Choice A is incorrect. This is Trendelenburg's position. It is not recommended in children with a cleft palate due to their risk for airway obstruction caused by their tongue falling back into the airway. Choice B is incorrect. This is a right lateral recumbent position. Lateral positioning can prevent the tongue from obstructing the airway, and it can be used in infants with cleft palate during feeding and sleep. However, this is not the best position post-surgically. Post-operatively, the goal is to facilitate the drainage of excessive secretions. The prone position is most helpful to serve that purpose. Choice C is incorrect. This is a supine position. It is not recommended in children with an unrepaired cleft palate due to their risk for airway obstruction caused by their tongue falling back into the airway. Reference: Hockenberry, M., Wilson, D. & Rodgers, C. Wong's Essentials of Pediatric Nursing, St. Louis, MO: Elsevier Limited.

Question 27

You are working in a long-term psychiatric rehabilitation center and are assigned to a patient with debilitating agoraphobia. He is going through desensitization therapy. Which of the following interventions is an appropriate part of this treatment? Select all that apply. A. Speak frequently of what causes the fear to start for him. B. Take a short walk in the hallway outside of his room. C. Make promises to support him and keep such promises. D. Encourage him to face his fear outside where he is least comfortable.

Answer 27

CORRECT ANSWERS B, C Explanation Answers: B and C B is correct. Because your patient has agoraphobia, he will be reluctant to leave any place he feels comfortable for somewhere. This is either unfamiliar or hard to escape from. This is why people with agoraphobia have such a hard time leaving the house. Your patient needs to be desensitized to this fear slowly, and a short walk in the hallway outside of his room (where he feels safe) is an appropriate choice. C is correct. This is a fundamental part of building a trusting relationship with your patient, and building a trusting relationship with a patient going through desensitization therapy is essential. You need the patient to be able to trust you so that when you ask them to do little things that are outside of their comfort zone, they will be able to do them. This is the key to slow, gradual progress in desensitization. Making small promises and keeping these promises will help build such a trusting relationship that you can improve your patient. A is incorrect. When treating patients who have a phobia, it is not advisable to talk about hatred frequently. Although you will need to address the phobia over time, focusing on this does not help the patient desensitize. Instead, it keeps them focused on hatred. For some patients, just speaking about their phobia can send them into a panic attack. D is incorrect. The key to desensitization therapy with phobias is a gradual change over time, not a dramatic leap to facing the hatred directly. This advice would likely cause your patient to have a panic attack, which would set him back considerably. Instead of suggesting that he face his phobia and jump right to where he is least comfortable, start with little steps, and work towards those bigger goals gradually. NCSBN Client Need: Topic: Psychosocial Integrity Reference: Halter, M. J. (2018). Manual of Psychiatric Nursing Care Planning: An Interprofessional Approach. Elsevier Health Sciences. Subject: Adult Health Lesson: Psychiatric Nursing

Question 28

You have just received a doctor’s order for amoxicillin and lignocaine. You should: A. Call the ordering doctor because these medications, in combination, cause severe adverse side effects. B. Call the ordering doctor because these medications have an inhibiting effect on each other. C. Refer to a reliable drug compatibility chart or resource to determine their compatibility with each other. D. Ask a more experienced nurse whether or not these two drugs are compatibility with each other.

Answer 28

CORRECT ANSWER C Explanation Correct Answer is C Correct. You should refer to a reliable drug compatibility chart or resource to determine their compatibility with each other. The compatibilities and incompatibilities of medications with each other and the harmonies and incompatibilities of medicines with different intravenous solutions are far too numerous to memorize and remember. Therefore, it is strongly advised that you check a reliable pharmacological chart or resource to determine compatibilities and incompatibilities. Lignocaine and amoxicillin are not compatible. Thus, they cannot be mixed. Choice A is incorrect. You would not call the ordering doctor because these medications, in combination, cause severe adverse side effects because this is not true. However, there is something else that you would want to do. Choice B is incorrect. You would not call the ordering doctor because these medications have an inhibiting effect on each other. After all, this is not accurate; however, there is something else that you would want to do. Choice D is incorrect. You would not ask a more experienced nurse whether or not these two drugs are compatibility with each other because the compatibilities and incompatibilities of medications with each other and the harmonies and incompatibilities of medicines with different intravenous solutions are far too numerous to memorize and remember, therefore, it is strongly advised that you do something else to determine the compatibility of these two medications. Reference: Kee, Joyce LeFever, Evelyn Hays, and Linda McCistion (2011) Pharmacology: A Nursing Process Approach 7th edition. Elsevier Saunders.

Question 29

A 13-year-old girl diagnosed with ALL is worried about the side effects of her new steroid medications. Which of the patient's following statements indicates to the nurse that the adolescent understands steroids' side effects? Select all that apply. A. “I will have more water in my body, so I might look puffier.” B. “It might hurt to go to the bathroom.” C. “I might soon get bruises more easily than before.” D. “This medicine might make me moody.”

Answer 29

CORRECT ANSWERS A, D Explanation Choices A and D are correct.Steroids can cause fluid retention ( Choice A) and often result in “puffiness” from the excess fluid. This is often seen in the face and sometimes described as a “moon face.” The nurse should validate this concern of her adolescent patient and explain why she might experience this. It is essential to be honest with the teenage patient to help them cope with the side effects. Mood swings ( Choice D) are a known side effect of corticosteroids. They can cause irritability, anxiety, and depression. It is essential to educate the adolescent client about this side effect and reinforce that she should ask for help if she feels overwhelmed. The parents should also be educated about this side effect, so they know to expect mood swings and are ready to help their adolescent. Choice B is incorrect. Steroids do not cause constipation, dysuria, or any other pain related to going to the bathroom. The nurse should reinforce education with this adolescent and assure her that she should not experience this. Choice C is incorrect. Steroids do not directly cause bruising. Long term steroids may thin the skin and predispose to easy bruising. However, newly started steroid therapy should not thin the skin immediately. More immediate side effects include fluid retention, steroid acne, hyperglycemia, and mood swings. Steroids do not cause a decrease in platelets or clotting factors that would cause more frequent bruising immediately. However, due to her ALL diagnosis, she may have decreased platelets due to her cancer. This could cause her to bruise more often, so she may misunderstand the cause of this. The nurse should reinforce education with this adolescent about her disease process and what could occur and ensure that the steroid medication itself should not immediately increase bruising. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological therapies Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Question 30

Which of the following statements are true regarding the pathophysiology of beta-blockers? Select all that apply. A. Decrease blood pressure B. Decrease workload of the heart C. Increase contractility D. Increase cardiac output

Answer 30

CORRECT ANSWERS A, B Explanation Answer: A and B Beta-blockers block the beta cells of the body. Beta cells are receptor sites for your catecholamines, such as epinephrine and norepinephrine. When we block the receptor sites for the catecholamines, they cannot do their job. Catecholamines function to increase everything - increase blood pressure, increase pulse, increase contractility, and cause vasoconstriction. This is because they are your fight or flight hormones! They get your body excited and ready to go! So, when beta-blockers block them, everything decreases. Your body vasodilates, the heart slows down, the blood pressure decreases…. A is correct. The vasodilation properties of a beta-blocker mean that they decrease blood pressure. This is because the beta-blockers are blocking the receptor sites for your catecholamine, so they cannot do their job and cause vasoconstriction. B is correct. Beta-blockers decrease the workload of the heart. This is because of the vasodilation, subsequent decrease in blood pressure, and then fall in afterload. Remember, afterload is the pressure against which the left ventricle must pump. With decreased blood pressure, we reduce afterload. And, with reduced afterload, the left ventricle does not have to work as hard to pump blood to the body. So, beta-blockers decrease the workload of the heart. C is incorrect. Beta-blockers decrease contractility, not increase. This is because they are blocking those beta cell receptor sites for catecholamines such as epinephrine and norepinephrine. The catecholamines work to increase contractility, but they are blocked by the beta-blockers. So, beta-blockers decrease contractility. D is incorrect. Beta-blockers decrease cardiac output, not increase. This is because of the decreased contractility we just talked about. While the catecholamine receptor sites blocked, they are unable to cause increased contractility and the contractility of the heart decreased. With decreased contractility comes a lowered stroke volume. And, because CO = HR x SV, a reduced stroke volume means a reduced cardiac output. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Pharmacological therapies Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences. Subject: Adult health Lesson: Cardiac

Question 31

You are learning about Latex Allergies from a senior nurse. Which of the following is not true regarding latex allergies? Select All That Apply. A. They always result in anaphylactic reactions and shock B. They cannot be caused by equipment such as a stethoscope C. They can be reduced by using moisturizing oils after hand-washing D. They are more common in nurses and in frequently hospitalized patients

Answer 31

CORRECT ANSWERS A, B, C Explanation The correct answers are A, B, and C. Latex allergies do not always result in anaphylactic reaction/shock. Most of the reactions are like contact/ irritant dermatitis. Latex allergies can be caused by equipment such as a stethoscope. Moisturizing the hands after washing does NOT help decrease latex allergies. On the contrary, this practice may increase the likelihood of latex allergies. One should avoid oil-based hand creams and moisturizing lotions, which may deteriorate the gloves and accelerate the release of latex allergens. It is recommended to wash hands with a pH-balanced soap and let them dry between glove use. Such practice helps remove latex proteins and prevents skin irritations. Latex allergies usually result from repeated exposure to proteins in natural rubber latex through skin contact or inhalation. Latex can be present in many commonly used medical equipment like Blood pressure cuffs; Stethoscopes, Intravenous tubing; Syringes, Gloves, and surgical masks. Reactions usually begin within minutes of exposure to latex, but they can occur hours later and produce various symptoms. Less commonly, severe symptoms such as Anaphylaxis can occur. Choice D is incorrect. The question is asking to select "not true" statements regarding latex allergy. The report, "Latex allergies are more common in nurses and frequently hospitalized patients," is a true statement and is, therefore, not the answer here. Nurses and other health care workers are more likely to have latex allergy than the general population (Choice D). The U.S. Department of Labor, Occupational Safety and Health Administration (2014) reports that 8-12% of latex allergies are among healthcare workers vs. 1% of the general population. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological Adaptation Reference: Nursing Health Assessment (The Best Approach) Wolters/Klewer; Chapter3: Techniques of Assessment and Safety; Lesson: Latex Allergy

Question 32

The nurse is administering eye drops to a client diagnosed with conjunctivitis. Place the following steps in the correct sequence for the nurse to perform appropriate eye drop administration.. Pull down the lower eyelid Tilt the patients head back Administer the medication in the center of the lower eyelid Ask the patient to close their eyes

Answer 32

Explanation First: tilt the client's head back. Second: pull down the lower eyelid, thus creating a pocket in which to administer the medication. Third: administer the medication in the center of the lower eyelid where the pocket was created by pulling down the lower eyelid. Fourth: ask the client to close their eyes (without squeezing) for 1-3 minutes to allow the eye drops to fully absorb. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Pharmacological therapies Subject: Pediatric Lesson: HEENT

Question 33

The nurse is preparing a client for a thoracentesis. All of the following are appropriate actions by nurse except: A. Obtains an informed consent. B. Places the client on semi-fowler’s position. C. Instructs the client to hold still when the needle is inserted. D. Watch out for tachypnea, dyspnea, and cyanosis.

Answer 33

CORRECT ANSWER B Explanation A is incorrect. This is an appropriate action by the nurse. Informed consent is needed for a Thoracentesis. B is correct. This is an inappropriate action by the nurse. The client should be placed upright, leaning over the tray table. C is incorrect. This is an appropriate action by the nurse. The insertion of the needle is painful. Sudden movement may force the needle through the pleural space and injure the visceral pleura and lung parenchyma. D is incorrect. This is an appropriate action by the nurse. Changes in respiratory rate and character may indicate pneumothorax which is a common complication to Thoracentesis. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 34

The husband of a woman recently diagnosed with SLE is talking to the nurse. The husband suddenly tells the nurse, “My wife and I have been planning to get pregnant. Can my wife tolerate a pregnancy now that she has the disease?” What is the nurse’s most appropriate response? A. “Pregnancies have better outcomes with women diagnosed with SLE.” B. “How long is your wife in remission?” C. “Women with SLE have longer labor times.” D. “You need to get pregnant within six months of being diagnosed with SLE.”

Answer 34

CORRECT ANSWER B Explanation A is incorrect. Pregnancies do not improve with SLE. On the contrary, pregnancies have increased morbidity and mortality with SLE. B is correct. Women diagnosed with SLE need to be in remission for at least five months before getting pregnant. C is incorrect. SLE does not affect labor in pregnancies. D is incorrect. Women should wait two years after being diagnosed before they conceive. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 35

Which of the following is a critical lab value? Select all that apply. A. Sodium: 134 mEq/L B. Potassium: 7.8 mEq/L C. Calcium: 9.2 mg/dl D. Magnesium: 2.0 mEq/L

Answer 35

CORRECT ANSWER B Explanation Answer: B A is incorrect. The average value for sodium is 135-145 mEq/L. 134 is considered slightly low but is not a critical lab value. B is correct. The average value for potassium is 3.5-5.0 mEq/L. 7.8 is a critical value, and the patient is at risk for arrhythmias and death. C is incorrect. The average value for calcium is 9.0 - 10.5 mg/dl. This is a typical lab value. D is incorrect. The average value for magnesium is 1.3-2.1 mEq/L. This is a typical lab value. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk of the potential reduction Subject: Fundamentals Lesson: Laboratory Values Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.V

Question 36

The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first? A. Administer PRN analgesic. B. Obtain STAT EKG. C. Encourage ambulation. D. Discuss pain with patient.

Answer 36

CORRECT ANSWER D Explanation D is correct. Shoulder pain may occur following a cesarean section due to gas or referred pain from the surgery. The nurse should assess the patient’s pain to determine the cause before administering medications or other interventions. A is incorrect. The nurse should first assess the patient’s pain to determine the cause before administering pain medication. B is incorrect. The nurse should first assess the patient’s pain. If assessment data indicates the patient’s pain is cardiac, an EKG may be indicated. C is incorrect. Ambulation may help if the patient’s pain is related to gas/indigestion, but the nurse should first assess the patient’s pain before implementing this intervention. Subject: Leadership/management Lesson: Prioritization Topic: establishing priorities, postpartum care, the potential for complications from surgical procedures Reference: (Colgrove & Hargrove-Huttel, 2011, p. 635)

Question 37

A post gastric bypass client has been advanced from a clear liquid diet to a full liquid diet. The client verbalized that he was happy about the diet change because he has been “bored” with the clear liquid diet. Which item should the nurse offer to the client that belongs to a full liquid diet? A. Gelatin B. Tea C. Custard D. Popsicle

Answer 37

CORRECT ANSWER C Explanation Rationale: A full liquid diet includes food items such as plain ice cream, soups that are strained, sherbet, milk, pudding and custard, breakfast drinks, refined cooked cereals, and strained vegetable juices. A clear liquid diet, on the other hand, consists of relatively transparent foods. The food items in options A, B, and D are clear liquids and are, therefore, the incorrect answer. Custard is under the full liquid diet specification and is the correct answer. Source: Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 38

Which of these is the best example of an ethical principle in nursing? A. Fidelity - the nurse maintained honesty with the patient during any education and care. B. Veracity- the nurse followed through with any promises made to the patient during his or her care. C. Beneficence- the nurse promoted the patient to be respected and involved in his or her care. D. Nonmaleficence- the nurse did not cause harm to the patient.

Answer 38

CORRECT ANSWER D Explanation The ethical principles that nurses must adhere to are the principles of justice, beneficence, nonmaleficence, accountability, fidelity, autonomy, and veracity. Justice is fairness. Nurses must be fair when they distribute care, for example, among the patients in the group of patients that they are taking care of. Care must be fairly, justly, and equitably distributed among a group of patients. Beneficence is doing good and the right thing for the patient. Nonmaleficence is doing no harm, as stated in the historical Hippocratic Oath. Harm can be intentional or unintentional. Accountability is accepting responsibility for one's own actions. Nurses are accountable for their nursing care and other actions. They must accept all of the professional and personal consequences that can occur as a result of their actions. Fidelity is keeping one's promises. The nurse must be faithful and true to their professional promises and responsibilities by providing high quality, safe care in a competent manner. Autonomy and patient self-determination are upheld when the nurse accepts the client as a unique person who has the innate right to have their own opinions, perspectives, values, and beliefs. Nurses encourage patients to make their own decision without any judgments or coercion from the nurse. The patient has the right to reject or accept all treatments. Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress. The correct answer is D. The nurse did not cause harm to the patient, which is known as nonmaleficence. A is incorrect. Fidelity is keeping one’s promise. B is incorrect. Veracity is being truthful with clients. C is incorrect. Beneficence is doing what is good and right for the patient. NCSBN Client Need Topic: Safe and Effective Care Environment Subtopic: Coordinated Care Chapter 5: Values, Ethics and Advocacy Lesson: Nursing Ethics Reference: Fundamentals of Nursing (Kozier and Erb)

Question 39

Which question would you ask to assess the family as the basic unit of society as you are applying a structural-functional theory of family? A. What community health promotion resources do you use? B. Who is the major decision maker in the family? C. What community activities does the family enjoy? D. What support people do you have outside of the home?

Answer 39

Explanation Correct Answer is B Correct. The question would you ask to assess the family as the basic unit of society as you are applying a structural-functional theory of family is “Who is the major decision-maker in the family?” Structural-functional methods of family address issues like decision making, intrafamily relationships, family structures, and patterns of communication in the family. Asking about the community health promotion resources that are used by the family, asking about the community health promotion resources that are used by the family, and asking about the community activities that are enjoyed by the family are applications of the systems theory and not a structural-functional theory of the family. Choice A is incorrect. Asking about the community health promotion resources that are used by the family is an assessment of the family based on systems theory and not a structural-functional approach of the family. A question such as this assesses the family’s interaction outside of the boundaries of the family. Choice C is incorrect. Asking about the community activities that are enjoyed by the family is an assessment of the family based on systems theory and not a structural-functional approach of the family. A question such as this assesses the family’s interaction outside of the boundaries of the family. Choice D is incorrect. Asking about the support people that the family has outside of the home is an assessment of the family based on systems theory and not a structural-functional approach of the family. A question such as this assesses the family’s interaction outside of the boundaries of the family. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 40

The nurse is caring for a client who arrives to the emergency department (ED).complaining of chest pain radiating to the arm. The nurse is correct to take which action? Select all that apply. A. Obtain an electrocardiogram (ECG) B. Prepare the client for prescribed cardioversion C. Establish intravenous (IV) access D. Insert an indwelling urinary catheter. E. Administer prescribed nitroglycerin

Answer 40

CORRECT ANSWERS A, C , E Explanation A client presenting with chest pain radiating to the arm warrants immediate intervention as it could be an acute myocardial infarction. The nurse is correct to obtain an electrocardiogram. Establish intravenous access and administer the prescribed nitroglycerin. Preparing a client for cardioversion is not necessary unless an applicable arrhythmia is present. Finally, inserting a urinary catheter is not required for an individual presenting with angina.

Question 41

Industry vs. _________ is the typical stage of development for school-age children, which are 6 to 11-year-olds.

Answer 41

CORRECT ANSWER: INFERIORITY Explanation Answer: Inferiority In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in inferiority. Examples of tasks done by school-age children in the industry vs. inferiority stage are attending school, completing homework, and taking tests. NCSBN Client Need: Topic: Psychosocial Integrity Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.

Question 42

The nurse observes that an 85-year-old man at an adult daycare center fondly shares stories about traveling on the “orphan trains” and his subsequent adoption, following a behavioral ¬assessment. The nurse should perform which interventions? A. Refer him for a geriatric psychiatric evaluation. B. Listen and ask him questions about his life. C. Distract him and change the conversation. D. Involve him in more social activities.

Answer 42

CORRECT ANSWER: B Explanation Important Fact: Reminiscence about past life events, doing a life review, especially if the experiences were positive, is considered to be a regular psychosocial activity for older adults. It helps them to focus on past accomplishments and contributions to society, thus increasing their self-concept. Answer & Rationale: The correct answer is B. Taking the time to listen and ask the client questions about his life shows that the nurse is interested in the patient. It also helps increase his self-concept. A is incorrect: If behavioral or significant memory problems had been noted, a geriatric psychiatric consult would be appropriate, but that is not so in this situation. C and D- While social activities and conversations should be encouraged, it should not be done to the point of demeaning the importance of his life stories. Resource NCSBN Client Need Topic: Health Promotion and Maintenance Chapter 23: Promoting health in older adults Lesson: Cognitive Agility Reference: Kozier and Erb’s Fundamentals of Nursing

Question 43

Your client has been typed and cross-matched in anticipation of the infusion of pack red cells. This client has B agglutinogens and A agglutinins. Which blood type would you administer to this client? A. Type A packed red cells. B. Type B packed red cells. C. Type AB packed red cells. D. Type O packed red cells.

Answer 43

CORRECT ANSWER B Explanation The correct answer is B. You would administer type B packed red cells to your client who has been cross-matched with B agglutinogens and A agglutinins. Type A packed red cells are delivered to clients who have been cross-matched as with A agglutinogens and B agglutinins: type AB packed red cells are delivered to clients who have been cross-matched as with both A and B agglutinogens and no agglutinins, and type O packed red cells are delivered to clients who have been cross-matched as with no agglutinogens and both A and B agglutinins. Choice A, B, C are incorrect. Type A, AB, O packed red cells are not administered to clients with B agglutinogens and A agglutinins; another blood type is applied to prevent severe and possibly life-threatening ABO incompatibility reactions to the improper blood. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 44

A diabetic client has just given birth to a male neonate. Which assessment finding by the nurse would warrant nursing intervention? A. Crying B. Restlessness C. Twitchiness D. Yawning

Answer 44

CORRECT ANSWER C Explanation A is incorrect. Crying, Restlessness and Yawning are all normal for the newborn. B is incorrect. Crying, Restlessness and Yawning are all normal for the newborn. C is correct. Twitchiness or jitteriness is a sign of seizures in the newborn. The nurse should inform the physician. D is incorrect. Crying, Restlessness and Yawning are all normal for the newborn. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014Explanation A is incorrect. Crying, Restlessness and Yawning are all normal for the newborn. B is incorrect. Crying, Restlessness and Yawning are all normal for the newborn. C is correct. Twitchiness or jitteriness is a sign of seizures in the newborn. The nurse should inform the physician. D is incorrect. Crying, Restlessness and Yawning are all normal for the newborn. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 45

Which assessment data should the nurse recognize as a sign of acute kidney injury (AKI)? A. Hypernatremia B. Metabolic alkalosis C. Oliguria D. Hypokalemia

Answer 45

CORRECT ANSWER C Explanation C is correct. Oliguria (urine output less than 400mL/24 hours) is the most common initial sign of AKI. It is usually seen within the first week of the injury. A is incorrect. When the kidneys are damaged, they are unable to retain sodium. Sodium levels would be decreased (hyponatremia), not increased. B is incorrect. Metabolic acidosis, not alkalosis, is typically seen with AKI. The kidneys are unable to excrete acids from metabolic processes and unable to synthesize ammonia needed to excrete hydrogen ions. Serum bicarbonate decreases, and reabsorption of bicarbonate is ineffective, resulting in acidosis. D is incorrect. Hyperkalemia, not hypokalemia, is seen with acute kidney injury. In AKI, the kidneys cannot excrete excess potassium normally. Metabolic acidosis can also develop, causing increased hydrogen ions into the cell, which forces additional potassium into the extracellular fluid. Subject: Adult health Lesson: Renal/urinary Topic: Fluid/electrolyte imbalance Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1166-1167)

Question 46

There is a massive airline crash near your acute care facility. As the victims of this massive external disaster arrive at your facility, your new graduate nurse preceptor asks you what the black colored triage tags on the incoming victims mean. How should you respond to this new graduate? A. You should tell the new graduate nurse that the black colored triage tags on the incoming victims mean that the victims are the lowest priority for care. B. You should tell the new graduate nurse that the black colored triage tags on the incoming victims mean that the victims with these black tags have life-threatening injuries and are in need of immediate care. C. You should tell the new graduate nurse that the black colored triage tags on the incoming victims mean that the victims are always dead. D. You should tell the new graduate nurse that the black colored triage tags on the incoming victims mean that the victims are in a severe medical crisis, and they have little chance of survival.

Answer 46

CORRECT ANSWER D Explanation Correct Answer is D. You should tell the new graduate nurse that the black colored triage tags on the incoming victims mean that the victims are in a severe medical crisis, and they have little chance of survival. In mass casualty scenarios, an advanced triage system is implemented and involves a color-coding scheme using red, yellow, green, white, and black tags. Remember DIME acronym: Delayed; Immediate, Minor, Expectant. Red tags- IMMEDIATE- highest priority treatment/ transfer. These patients cannot survive without immediate treatment but have a high chance of post-treatment survival. E.g., Tension Pneumothorax, Cardiac tamponade, Massive hemorrhage. Yellow tags- DELAYED- a medium priority. No immediate danger of death, stable but will still need hospital care. Under normal circumstances, these patients will be treated immediately, but in mass casualty scenarios, they are medium priority. E.g., isolated humerus or femur fracture. Green Tags- MINOR- lowest priority - those with minor injuries, ambulating ( "walking" wounded). E.g., abrasions sprain. These are attended to after high and medium priority patients are addressed. Black Tags- EXPECTANT- keep comfortable, pain medications only until death. These are patients with injuries so extensive that they will not be able to survive with the best available care or those dead already. E.g., Massive head injury with fixed pupil, Third-degree burns involving 95% body surface. Walking away from those with black tags can be emotionally and ethically challenging. About "expectant" victims, WHO states, “It is unethical for a physician to persist, at all costs, at maintaining the life of a patient beyond hope, thereby wasting to no avail scarce resources needed elsewhere.” Choice A is incorrect. You should not tell the student nurse that black tags on the incoming victims mean that the victims are the lowest priority for care. Green indicates that the victims are the lowest priority for consideration. Black has no preference for ongoing care, and only comfort care needs to be provided. Choice B is incorrect. You should not tell the new graduate nurse that the black colored triage tags on the incoming victims mean that the victims with these black tags have life-threatening injuries and need immediate care. Red color indicates that the victims have fatal injuries and need urgent attention. Choice C is incorrect. You should not tell the new graduate nurse that the black colored triage tags on the incoming victims always means that the victims are dead because it could also represent critically injured but unsalvageable victims. Reference: Medical Triage: Code Tags and Triage Terminology (2014)

Question 47

The patient experiencing an epidural tumor is exhibiting symptoms of spinal cord compression. The nurse knows that they should initiate care of this patient by: A. Assessing and controlling patient’s pain B. Watching for signs of urinary retention C. Help this patient perform personal and hygiene care D. Uphold strict bed rest until spinal instability is ruled out.

Answer 47

CORRECT ANSWER D Explanation NCSBN client need | Topic: Oncology Rationale: The correct answer is D. If the nurse suspects that his patient is experiencing a spinal cord compression, strict bed rest should be upheld until spinal stability is evaluated. Choices A, B, and C are incorrect. While observing for signs of urinary retention, aiding the patient in performing personal and hygiene care, and controlling pain are essential aspects of caring for a patient with spinal cord compression, these steps need not be completed until bed rest has been executed. Reference: Williams L Hopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co.; 2011.

Question 48

Which of the following is an example of an inspection? A. Skin pink B. Lungs clear C. Heart rate and rhythm are regular D. Abdomen tympanic

Answer 48

CORRECT ANSWER A Explanation Inspection is the first technique of the overall general survey and for each body part. It can provide a wealth of information regarding a patient’s status. A check is performed for every body part and system. The purpose of gathering data during this initial phase is to give an overall impression of the patient and to assess the severity of the situation. Nurses should learn to observe for cues that may indicate a job that requires immediate attention. Answer and Rationale: The correct answer is A. Inspection refers to visual examination. B and C are incorrect. These options are examples of auscultation. D is incorrect. Tyranny is a form of palpation, as vibrations are felt. NCSBN Client Need Topic: Health Promotion and Maintenance Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer) Chapter 3: Techniques of Assessment and Safety Lesson: Objective Data

Question 49

Which of the following educational points are correct when teaching a patient about iron supplementation? Select all that apply. A. Take iron supplement 30 minutes after a meal. B. Drink a glass of orange juice with your iron supplement. C. Report any black stools to your doctor D. Drink suspension with a straw

Answer 49

CORRECT ANSWER B, D Explanation Answer: B and D A is incorrect. Taking an iron supplement on a full stomach will not allow for proper absorption. You must educate the patient to take their iron supplement on an empty stomach. B is correct. Orange juice is high in vitamin C, which will help increase the absorption of iron. Also, this will make taking the supplement easier on the stomach, and many say it helps with the bad taste. C is incorrect. Black stools are an expected side effect of iron supplementation. Patients do not need to report black stools to their doctor if they are taking an iron supplement. The nurse should warn them to expect this side effect so that they are not alarmed. D is correct. If the healthcare provider orders an oral suspension iron supplementation, you should teach your patient to drink it through a straw to avoid staining their teeth. Alternatively, if you are administering the medication to a young child who cannot drink through a straw, you can pull it up in a syringe and squirt it into the back of their mouth behind their teeth. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Pharmacological therapies Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Hematology

Question 50

The nurse is teaching a patient about congestive heart failure (CHF). Which of the following information should the nurse include? Select all that apply. A. “Foods such as canned vegetables and luncheon meat should be avoided.” B. “Weigh yourself daily and notify physician when weight gain is more than ten pounds in a week.” C. “You may continue to take ibuprofen for your aches and pains.” D. “Annual immunizations such as the influenza vaccine are recommended.” E. “If you feel sick, you will need to check your urine for ketones.”

Answer 50

CORRECT ANSWER A, D Explanation Choices A and D are correct.The client will need to maintain a low sodium diet, so processed foods such as luncheon meat should be avoided.Annual immunizations are recommended because of the increased risk of complications from influenza. Complications from influenza are higher in those with co-morbidities such as CHF. Congestive heart failure (CHF) is a chronic condition that causes a decrease in cardiac output. Choice B is incorrect. The client should be taught to weigh themselves daily and to report a weight gain of five pounds or more within one week. The client must not wait until he/ she gains 10lbs/ week. Choice C is inorrect. NSAIDs such as ibuprofen may contribute towards fluid retention and should not be used in clients with CHF. Choice E is incorrect. Assessing the urinary ketones is only done for those with hyperglycemia secondary to diabetes mellitus. This is done to check for potential development of ketoacidosis.

Question 51

Which of the following data would NOT be included in a client's pain history? A. The client’s affective responses to pain B. The client’s past alleviating measures C. The client’s current vital signs D. The client’s meaning of pain

Answer 51

CORRECT ANSWER C Explanation Correct. The client’s current vital signs would NOT be included in a client's pain history. However, these vital signs are part of the initial nursing assessment and ongoing assessments. Choice A is incorrect. The client’s affective responses to pain are an integral part of a client's pain history; some emotional responses to pain include the client's feelings such as depression and anxiety in response to pain. Choice C is incorrect. The client’s past alleviating measures that lessened their pain are an integral part of a client's pain history; therefore, this would be included in the client’s pain history. Choice D is incorrect. The client’s meaning of pain is an integral part of a client's pain history; therefore, this would be included in the client’s pain history. Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 52

While working in the Neonatal Intensive Care Unit (NICU), you are notified that a "small for gestational age" infant is being brought to the unit. Being a NICU nurse, you understand that this means which of the following? A. The infant's weight is less than 2500 grams. B. The infant’s weight is below the 20th percentile. C. The infant’s weight is less than 1500 grams. D. The infant’s weight is below the 10th percentile.

Answer 52

CORRECT ANSWERS: D Explanation Choice D is correct. The term "Small for Gestational Age (SGA)" is used when the infants are smaller than normal for the number of weeks of pregnancy (gestational age). When an infant’s weight is below the 10th percentile for the gestational age, it is considered small for gestational age. By definition, about 10 percent of all newborns are labeled as "SGA." Not all “Low Birth Weight” babies are SGA. Infants may be of low birth weight but may still fall above the 10th percentile for gestational age. It is important to distinguish SGA from other related terms, “Low Birth Weight (LBW)”, “Very Low Birth Weight (VLBW), and “Extremely Low Birth Weight (ELBW).” These definitions are based on the infant’s weight at the time of birth. These are not percentile scores and are defined on the absolute weight limit. An LBW infant is defined as an infant with a weight of less than 2500 grams (5 lb. and 8 ounces), regardless of gestational age at the time of birth. A VLBW infant is defined as the one with a weight less than 1500 grams at the time of birth. An ELBW infant is less than 1000 grams at the time of birth. Choice A is incorrect. When infants are born at less than 2500 grams, they are considered of low birth weight. A classification which considers only the weight and not the gestational age, is LBW, VLBW and ELBW whereas percentiles are used for the small/average/large for gestational age comparison. Choice B is incorrect. The 20th percentile is considered average for gestational age. Infant’s size falling between 10th - 90th percentile is considered average. One that is less than the 10th percentile is “small for gestational age”, and greater than 90th percentile is “large for gestational age”. Choice C is incorrect. When infants are born at less than 1500 grams, they are considered as “very low birth weight”. Percentile scores are used for the small/average/large for gestational age comparison. NCSBN Client Need: Topic: Health Promotion and Maintenance Reference:DeWit, S. C., & Williams, P. A. (2013).Fundamental concepts and skills for nursing. Elsevier Health Sciences.

Question 53

The LPN is assigned to take care of a patient with hemophilia. When she reviews the lab values, does she expect to find which of the following? Select all that apply. A. Normal PT level B. Abnormal PTT level C. Normal Thrombin time D. Abnormal INR

Answer 53

CORRECT ANSWERS A, B, C Explanation Answer: A, B, C A is correct. Patients with hemophilia will have an average PT level, between 11 and 13.5. The Prothrombin time test measures the time necessary to generate fibrin after activation of factor VII. This evaluates the extrinsic pathway. - factors, V, X, prothrombin, and fibrinogen. Because patients with hemophilia have deficiencies in factors XIII, IX, or XI depending on their sub-type, this test result will be reasonable. B is correct. Patients with hemophilia will have an abnormal PTT level. The partial thromboplastin time measures the integrity of the intrinsic clotting cascade, evaluating factors XII, XI, VIII, and IX. Because these are the factors in which a deficiency leads to a type of hemophilia, this level will be abnormal in patients with hemophilia. It is prolonged from the regular 25 to 35 seconds, meaning that it takes the blood longer than usual to clot. C is correct. Patients with hemophilia will have a standard Thrombin time. Thrombin time assesses how long it takes fibrin to form from fibrinogen in plasma. This is not part of the clotting cascade that patients with hemophilia have a deficiency in, so there is no abnormality. Their value will be reasonable, between 12 and 14 seconds. D is incorrect. The INR, otherwise known as the international normalized ratio, is a value calculated from the PT or prothrombin time lab. It is used to give medical professionals a standardized range from which they can compare their patients' costs, regardless of what lab the test was run. It is often used to monitor patients who are taking warfarin or Coumadin. Patients with hemophilia will have a normal INR because they have a regular PT. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Coordinated Care Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Hematology

Question 54

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

Answer 54

CORRECT ANSWER C Explanation C is correct. This patient is showing signs of the need for increased protein and caloric intake as evidenced by elevated WBC count (normal WBC range: 4-11), open wound, low albumin level (normal prealbumin range: 15-36mg/dL), and BMI within the normal range, but very close to underweight (normal BMI range: 18.5-24.9). This patient needs increased protein and caloric intake to fight infection and promote wound healing. A is incorrect. Low fiber/residue diet is indicated in GI conditions such as Crohn’s disease, IBD, and diverticulitis. No assessment data is suggesting the patient is experiencing any GI problems. B is incorrect. No assessment data is suggesting the patient is deficient in iron. TPN is indicated when a patient has an absorption problem or when oral intake is not possible. The patient should be started on an appropriate high calorie, high protein diet first before any parenteral nutrition is considered. D is incorrect. No assessment data is suggesting the patient is experiencing any cardiac issues requiring a low sodium/heart-healthy diet. Subject: Adult health Lesson: GI/Nutrition Topic: nutrition and oral hydration, illness management Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 928-929)

Question 55

In Piaget’s Stages of Cognitive development, the ______________ stage occurs from 0 to 2 years old.

Answer 55

CORRECT ANSWER : SENSORIMOTOR Explanation Answer: sensorimotor. In Piaget’s Stages of Cognitive Development, the sensorimotor stage occurs from 0 to 2 years old. During this stage, the child learns to coordinate their senses with motor responses. They are curious about the world and use their senses to explore. They start to form language and use it for demands. They also develop object permanence. NCSBN Client Need: Topic: Psychosocial Integrity Subject: Pediatrics Lesson: Development Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.

Question 56

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

Answer 56

CORRECT ANSWER B Explanation NCSBN client need | Topic: Maintenance and health promotion, health screening Rationale: The correct answer is B. A 60-year-old woman who smokes cigarettes is at risk of developing osteoporosis. Osteoporosis occurs more frequently in women than men and occurs more regularly in patients who smoke, consume alcohol, and are over the age of 50. Genetics also play a role. Choice A is incorrect. Women’s bone density is at its highest at age 30 and begins to deteriorate afterward. Exercise is considered a protective effect against this disease. Choice C is incorrect. While men can be diagnosed with osteoporosis, it is much less common. The 60-year-old woman would be much more likely to contract this illness than her male counterpart. Choice D is incorrect. A 25-year-old male with asthma is not at an increased risk of developed osteoporosis. Reference: Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby

Question 57

A client is prescribed bed rest by the physician after surgery. The nurse that is taking care of the patient always avoids putting pressure on the back of the client’s knees. The reason for this is to prevent which complication? A. Cerebral embolism B. Pulmonary embolism C. Limb gangrene D. Coronary Vessel occlusion.

Answer 57

CORRECT ANSWER B Explanation A is incorrect. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary bed will be the first small vessels that the embolus will encounter, not the cerebral blood vessels. B is correct. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary bed will be the first small vessels that the embolus will encounter, resulting in pulmonary embolism. C is incorrect. Gangrene occurs when the blood supply to the affected limb is compromised. Putting pressure on the back of the client’s knees, like a pillow, does not impair circulation. D is incorrect. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary bed will be the first small vessels that the embolus will encounter, not the coronary blood vessels. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 58

A client was brought to a psychiatric hospital when police found him walking around the neighborhood at night without shoes in the snow. He looks confused and disoriented. Which should be the priority at this point? A. Assess and stabilize the client medically B. Perform psychologic assessment and stabilize client psychologically C. Locate nearest family members to get client’s history D. arrange for a transfer to the nearest medical facility

Answer 58

CORRECT ANSWER A Explanation Rationale: Since the client walked barefoot in the snow, the possibility of frostbite should be evaluated, among other things. The client’s psychological needs, locating family members, or arranging for transfer may be addressed after the client’s immediate medical needs have been met. Option A is the correct answer, while options B, C, and D are incorrect. Reference: Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009 Kelly, P; Marthaler, M; Nursing Delegation, Setting Priorities, and Making Patient Care Assignments, 2nd Edition; Cengage Learning, 2010

Question 59

Your client at the end of life is experiencing guilt for past transgressions. After a number of independent and dependent nursing functions, as reflected in the plan of care, and expected outcome for this client could be that: A. The client will articulate the nature of humans in terms of fallibility. B. The client will go to confession to ask for forgiveness. C. The client will perform relaxation techniques to dissolve guilt. D. The client will not express any more feelings at the end of life.

Answer 59

CORRECT ANSWER A Explanation Correct Answer is A Correct. An expected outcome for this client could be that the client will articulate the nature of humans in terms of fallibility. The purpose of guilt is to allow the person to know that they have done something wrong, and it also permits the person, at the end of life, to make final amends to those that they have hurt. Only a few religions use confession to ask for forgiveness so, unless the client has expressed a desire to practice this religious ritual, this would not be an expected outcome. Although relaxation techniques may be used by the person to decrease their anxiety related to guilt, relaxation techniques do not dissolve guilt. And, lastly, “The client will not express any more feelings at the end of life” is not an appropriate outcome; all clients should be encouraged to express their feelings freely and without any judgments. Choice B is incorrect. Only a few religions use confession to ask for forgiveness so, unless the client has expressed a desire to practice this religious ritual, this would not be an expected outcome. Choice C is incorrect. Although relaxation techniques may be used by the person to decrease their anxiety related to guilt, relaxation techniques do not dissolve guilt. Choice D is incorrect. The client will not express any more feelings at the end of life is not an appropriate outcome; all clients should be encouraged to express their opinions freely and without any judgments. Reference: Ackley, Betty J., Gail B. Ladwig, and Mary Beth Flynn Magic. (2016). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Elsevier Health Sciences and Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 60

The nurse is caring for a client with Systemic Lupus Erythematosus in the acute phase of exacerbation. The nurses should focus on which aspect of nursing care? A. Prevention of additional infection B. Alleviation of feelings of powerlessness C. Development of positive coping skills D. Providing social support

Answer 60

CORRECT ANSWER A Explanation A is correct. During exacerbations, nursing care should be directed towards assessment and management of acute confusion, prevention of seizures, maintenance of skin integrity, prevention of new infection, evaluation of renal function, and management of impaired gas exchange. B is incorrect. Feelings of powerlessness usually occur during the chronic phase of the illness. C is incorrect. Helping the client develop positive coping skills occur at the later phase of the disease, where the patient is about to be discharged. The nurse helps the patient find support groups and networks to help in coping with SLE. D is incorrect. We are providing the client with social support an essential part of the nurse’s role in the client’s care. However, social support comes after the acute exacerbation phase, where the priority is the physiological aspect of client care. Reference Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 61

A patient recovering from myocardial infarction is presenting with Heart rate 110 beats per minute, Blood Pressure 86/58 mmHG, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority? A. Administer medications to increase stroke volume. B. Provide analgesics. C. Obtain STAT Electrocardiogram and troponins D. Administer fluid replacement to increase blood pressure.

Answer 61

CORRECT ANSWER A Explanation Choice A is correct. Based on the assessment information, the nurse can determine the patient is experiencing cardiogenic shock secondary to myocardial infarction. Since cardiogenic trauma occurs as a result of the heart not pumping effectively, the highest priority is to increase cardiac output to ensure adequate tissue perfusion. Cardiac Output = Stroke volume x Heart Rate. Medications that improve stroke volume will improve cardiac output in cardiogenic shock. The following agents may be used in the pharmacological management of cardiogenic shock. Inotropes: Positive Inotropes strengthen the heart contractility (increase stroke volume). Dobutamine has more beta-adrenergic action than alpha activity. It causes peripheral vasodilation while increasing contractility. But in higher doses, it may increase heart rate and exacerbate myocardial ischemia. Vasopressors: In severe shock, Vasopressors (Dopamine, Norepinephrine) maintain blood pressure but decrease blood flow to organs. They increase afterload and reduce cardiac output. However, they may be needed initially to provide hemodynamic support. Dopamine increases myocardial contractility and maintains blood pressure. If Dopamine fails to support blood pressure, norepinephrine is added. Vasodilators: Vasodilators (Nitroglycerin) decrease venous return (preload) to the heart and decrease peripheral resistance (afterload). Although vasodilators may drop blood pressure, they sustain cardiac output and help achieve hemodynamic stability when combined with vasopressor support in cardiogenic shock. Supplemental oxygen may also be necessary to increase tissue oxygenation. Choice B is incorrect. There is no assessment information in the question that points to chest pain. If a patient in cardiogenic shock is showing signs or complaining of pain, this action would be appropriate, but not the highest priority. Choice C is incorrect. The patient recently experienced MI, so they should already be on a telemetry monitor. ECG will likely be abnormal, and troponins may still be elevated. This action may be appropriate but will not change the immediate treatment of shock, so it would not be the highest priority. Choice D is incorrect. Fluid replacement is not the correct immediate action because the patient is showing signs of pulmonary edema (crackles, shortness of breath, jugular vein distention). Cardiac output needs to be improved before considering the additional fluid volume. This action might be appropriate if the patient was in hypovolemic shock, not cardiogenic. NCSBN Client Need Topic: Establishing priorities, illness management, medical emergencies, pathophysiology, Reference: (Jones & Fix, 2015, p. 234-236), (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1733), (Huether & McCance, 2008, p. 659)

Question 62

You are admitting a new patient to your acute psychiatric facility. And you determine that they have suicidal ideations. Which of the following questions should you as the nurse ask this patient? Select all that apply. A. Do you have a plan? B. Does anyone else know about your plan? C. What is your plan? D. Do you have the items to carry out your plan?

Answer 62

CORRECT ANSWERS A,C,D Explanation Answer: A, C, and D A is correct. Do you have a plan is the first question a nurse should ask any suicidal patients? Patients who have a concrete idea are much more likely actually to attempt suicide than patients who do not have a plan. By discovering your patient's program, you can take active steps to prevent them from carrying out this plan. B is incorrect. This is not a question of vital importance. If others do or do not know about your client’s suicide plan, it will not change any of your interventions. While admitting a suicidal patient, the nursing priority should be safety, safety, safety! Figuring out what the plan is and if they have the items they need to carry it out so that those can be confiscated and the safety of the client maintained are top priority! C is correct. What is your plan should be the second question a nurse asks a suicidal patient after they have answered yes to having a plan to commit suicide. By discovering exactly what your patient's plan is, you can take active steps to prevent them from carrying out this plan. It is essential to be very, very direct with these questions so that you will get straight answers and be able to keep the patient safe. D is correct. This question will depend on what the patient tells you their plan for committing suicide is. For example, if they say you they plan to shoot themselves, the appropriate question would be - “do you have a gun?” This is of the utmost importance for the patient’s safety. If they do have a gun, or whatever item is needed to carry out their suicide plan, the nurse needs to have it confiscated immediately to keep them safe. NCSBN Client Need: Topic: Psychosocial Integrity Reference: Halter, M. J. (2018). Manual of Psychiatric Nursing Care Planning: An Interprofessional Approach. Elsevier Health Sciences. Subject: Adult Health Lesson: Psychiatric Nursing

Question 63

You are providing asthma education to a teen that has just been diagnosed. Which of the following statements indicate a need for further teaching? Select all that apply. A. “When I am having an asthma attack. I should call 911 first.” B. “When I am having an asthma attack. my airway is constricting and it can become dangerous.” C. “I should try to identify what causes me to have an asthma attack. and avoid those activities.” D. “I’ve really been wanting to get a dog. and my asthma will not stop me.”

Answer 63

CORRECT ANSWERS A, D Explanation Answer: A and D A is correct. This statement indicates a need for further education. During an asthma attack, the first action should not be to call 911. The patient will have an asthma action plan that lists the steps she should take in the order she should take them. For most patients, the first step is to make her short-acting inhaler medications. It is not necessary to first call 911 for every asthma attack. B is incorrect. This is an appropriate statement and does not indicate a need for further education. When a patient is having an asthma attack, the physiology is that there are inflammation and constriction in the airways. This can result in obstruction, making it impossible for the patient to breathe. That is why asthma attacks are so dangerous. C is incorrect. This is an appropriate statement and does not indicate a need for further education. One of the most critical educational points for patients newly diagnosed with asthma is identifying their triggers. Triggers are what precipitate an asthma attack for that patient. For example, maybe playing soccer, or dusting the house. Whatever it is that precipitates, the offense should be avoided. D is correct. This statement indicates a need for further education. Although asthma will not stop every child from getting a dog, pets with hair that sheds can be a trigger. It would be inadvisable for a teen newly diagnosed with asthma to get a new dog. It could end up causing more asthma attacks and present a severe problem. If the patient wants a new pet, a fish would be a better recommendation given their new asthma diagnosis. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Subject: Pediatrics Lesson: Respiratory Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.

Question 64

Which of the following drugs is associated with photosensitivity? Select All That Apply. ``` A. Ciprofloxacin (Cipro) B. Sulfonamide C. Norfloxacin (Noroxin) D. Sulfamethoxazole and Trimethoprim (Bactrim) E. Isotretinoin (Accutane) F. Nitro-Dur patch ```

Answer 64

CORRECT ANSWER A, B, C, D , E Explanation Photosensitivity is an extreme sensitivity to ultraviolet rays from the sun and other light sources. A type of photosensitivity called PHototoxic reactions are caused when medications in the body interact with UV rays from the sun. Anti-infectives are the most common cause of this type of response. Answer and Rationale: The correct answers are A, B, C, D, and E. F is incorrect. Nitro-Dur patches are not associated with photosensitivity. NCSBN Client Need Topic: Physiological Integrity Subtopic: Pharmacological Therapies Resource: Core Concepts in Pharmacology Chapter 22: Drugs for Bacterial Infections Lesson: Tetracyclines

Question 65

Which procedures necessitate the use of surgical asepsis techniques? Select all that apply. A. Intramuscular medication administration B. Central line intravenous medication administration C. Donning gloves in the operating room D. Neonatal bathing E. Foley catheter insertion F. Emptying a urinary drainage bag

Answer 65

CORRECT ANSWERS B, C, E Explanation Surgical Asepsis, or sterile technique, refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores. Surgical Asepsis is used for all procedures involving the sterile areas of the body. The correct answers are B, C, E. Surgical asepsis is used when managing central line intravenous medication administration, when donning sterile gloves in the operating room and when inserting an indwelling Foley catheter. A, D, and F are incorrect. Medical Asepsis is used when administering an intramuscular injection, bathing a neonate, and when emptying a urinary drainage bag. NCSBN Client Need Topic: Safe and Effective Care Environment Subtopic: Safety and Infection Control Chapter 31: Asepsis Lesson: Surgical Asepsis Fundamentals of Nursing (Kozier and Erb’s)

Question 66

Select the psychiatric mental health disorder that is accurately paired with its signs and symptoms. A. Borderline personality disorder: Intense irrational fears and the need for orderliness and perfection B. Obsessive compulsive disorder: The need for control, orderliness and perfection C. Bipolar disorder: Fears of abandonment, feelings of emptiness and unstable relationships with others D. Codependency: Fears of abandonment, a need for control, and a need for perfection

Answer 66

CORRECT ANSWER B Explanation Correct Answer is B. Obsessive-compulsive disorder is characterized by the client’s unyielding need for control, orderliness, and perfection, as well as the performance of compulsive behaviors to relieve the stressors of their obsession. Choice A is incorrect. A borderline personality disorder is characterized by unstable relationships, fears of abandonment, feelings of emptiness, weak ego strength, impulsive behaviors, and impaired anger management, and not intense irrational fears or phobias or the need for orderliness and perfection. Choice C is incorrect. The client’s ongoing cycling characterizes bipolar disorder with periods of high activity and mood and periods of low activity and depression and not fears of abandonment, feelings of emptiness, and unstable relationships with others. Choice D is incorrect. Codependency is characterized by the client’s dysfunctional relationship with another that enables another’s dependency or addiction to substances and other things like gambling, for example, and not fears of abandonment, a need for control, and a need for perfection. Reference: Sommer, Sheryl, Janean Johnson, Karin Roberts, Sharon Redding, Lois Churchill, Norma Jean Henry, and Mendy McMichael. (2013) RN Mental Health Nursing 9.0; ATI Nursing Education

Question 67

The nurse is giving instructions to a client about to be discharged with Nitroglycerine as their medication. Which statement by the client would warrant additional teaching by the nurse? A. “I will get a refill of my prescription every six months.” B. “I will take one tablet every 5 minutes if chest pain occurs.” C. “I will place my medication in a clear glass bottle.” D. “I must not chew on the tablet when taking it.”

Answer 67

CORRECT ANSWER C Explanation A is incorrect. This is a correct statement by the client. The prescription and supply for Nitroglycerin are for six months. B is incorrect. This is a correct statement by the client. When chest pain occurs, the client should take one tablet of nitroglycerin sublingually every 5 minutes for 3 consecutive doses. If chest pain still persists, the client should seek medical attention right away. C is correct. This is an incorrect statement by the client. Nitroglycerine is an unstable drug and tends to lose its potency when exposed to air, water, and light. It should be kept in an air-tight, water-tight, and solid light-proof container. D is incorrect. This is a correct statement by the client. Nitroglycerine tablets are not to be swallowed or chewed but kept under the tongue. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 68

The ICU nurse is caring for a patient on positive pressure ventilation. Which would not be an appropriate preventative intervention to reduce this patient’s risk of developing ventilator-associated pneumonia (VAP)? A. Administer proton pump inhibitor. B. Obtain specimen for culture via tracheal suctioning. C. Elevate the head of bed to 45 degrees. D. Perform hand hygiene before and after suctioning.

Answer 68

CORRECT ANSWER B Explanation B is correct. If pneumonia is suspected, cultures may be taken via tracheal suctioning or bronchoscopy. This would not be appropriate for prevention. A is incorrect. Routine peptic ulcer prophylaxis with H2 receptor blockers or proton pump inhibitors is indicated for the prevention of VAP. C is incorrect. Elevating the head of the bed to 30-45 degrees reduces the patient’s risk of developing pneumonia secondary to aspiration. D is incorrect. Hand hygiene should be performed before and after contact with respiratory equipment or secretions. Gloves should be worn for all communication with patients and should be changed between activities. Subject: Critical Care Lesson: Critical Care Concepts (mechanical ventilation) Topic: standard precautions, the potential for complications of treatments/procedures Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1709)

Question 69

You are working in a pediatric unit with acutely and chronically ill pediatric clients. Which of the following pain assessment tools would you most likely use to assess pain and pain intensity among your clients who range in age from 2 years old to 10 years old? A. The NIPS Pain Scale B. The FLACC Scale C. The PAINAD Pain Scale D. The CRIES Scale

Answer 69

Explanation Correct Answer is B Correct. The FLACC Pain Scale is a valid and reliable pain assessment tool for the assessment of pain and pain intensity among your clients who range in age from 2 years old to 10 years old. The FLACC scale consists of pain behavior assessments, such as: F: Face expressions such as grimacing L: Movement of the legs A: Level of activity C: Crying C: Degree to which the child is consolable Choice A is incorrect. You would not use the Neonatal Infant Pain Scale (NIPS). The NIPS scale is only valid and reliable for infants and neonates, and not for the assessment of pain and pain intensity among your clients who range in age from 2 years old to 10 years old. Choice C is incorrect. You would not use the PAINTED Pain Scale. The PAINTED Pain Scale is only valid and reliable for elderly adults who are adversely affected with advanced dementia and not for the assessment of pain and pain intensity among your clients who range in age from 2 years old to 10 years old. Choice D is incorrect. You would not use the CRIES pain scale because this pain assessment tool is valid and reliable only for neonates and not for the assessment of pain and pain intensity among your clients who range in age from 2 years old to 10 years old. Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.

Question 70

Which photo below indicates the appropriate location to auscultate an apical pulse in an infant? A. 5th intercostal space to the left of the sternum at the midclavicular line B. 4th intercostal space to the left of the sternum at the midclavicular line C. 5th intercostal space to the right of the sternum at the midclavicular line. D. 4th intercostal space to the right of the sternum at the midclavicular line

Answer 70

CORRECT ANSWER B Explanation Choice B is correct. This image highlights the 4th intercostal space to the left of the sternum at the midclavicular line. This is the area where you would auscultate the apical pulse of an infant. Choice A is incorrect. This image highlights the 5th intercostal space to the left of the sternum at the midclavicular line. This is the area where you would auscultate the apical pulse of an adult, but it is different for an infant. Choice C is incorrect. This image highlights the 5th intercostal space to the right of the sternum at the midclavicular line. You would not auscultate this area for the apical pulse of anyone, as the apex of the heart is to the left of the sternum, not the right. Choice D is incorrect. This image highlights the 4th intercostal space to the right of the sternum at the midclavicular line. You would not auscultate this area for the apical pulse of anyone, as the apex of the heart is to the left of the sternum, not the right. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care

Question 71

The nurse is taking care of a client that is 24 hours post-angioplasty. The client says, “I don’t feel good today. I don’t feel like eating.” What is the nurses’ best action? A. The nurse asks what the statement means to the client. B. The nurse delegates an LPN to assess the client. C. The nurse notifies the physician D. The nurse encourages the client to eat.

Answer 71

CORRECT ANSWER A Explanation A is correct. The nurse should assess first the client before implementing any intervention. Asking what the client means by his statement explores the client’s feelings and provides information regarding his condition. B is incorrect. The LPN cannot assess the client. It is the RNs responsibility to perform an assessment. C is incorrect. The nurse should assess first the client before implementing any intervention. The nurse will need additional information to convey to the physician regarding the client’s condition. D is incorrect. The nurse should assess first the client before implementing any intervention. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 72

The nurse is providing care to a client with an endotracheal tube that requires suctioning. While suctioning, the client's heart rate and respiratory rate increase. Which priority actions are appropriate for the nurse to take? Select all that apply. ``` A. Check oxygen saturation. B. Call a rapid response. C. Increase suction pressure. D. Stop suctioning. E. Notify the physician. ```

Answer 72

CORRECT ANSWER A, D Explanation Choices A and D are correct. Tracheal suctioning is often needed to clear the secretions and maintain an open airway. It is important for the RN to understand the complications of tracheal suctioning. If the nurse notices a change in vital signs (Tachycardia, Tachypnea) while suctioning a patient, the nurse should stop the suctioning and check the oxygen saturation immediately. When the client becomes tachycardic and tachypneic while suctioning, it is a sign of distress which indicates that the client is not tolerating the suctioning. Hence, suctioning needs to be immediately discontinued to prevent further distress and the cause of distress should be explored. Hypoxemia is an important cause of tachycardia and cardiac arrhythmias during suctioning. If hypoxemia is noted, 100% oxygen should be administered quickly. Other things to monitor for would be bradycardia, changes in the heart rhythm (arrhythmias), desaturations, or cyanosis. Choice B is incorrect. There is no information in the question that indicates that a rapid response needs to be called. By discontinuing the suctioning and further exploring the cause of distress, the nurse has taken the appropriate actions. If the client’s condition were to continue to deteriorate after the suctioning was discontinued, then a rapid response may need to be called. Choice C is incorrect. It is not appropriate for the nurse to increase suction pressure. The client’s vital signs have changed indicating that he/she is not tolerating the suctioning. If the nurse continues to suction or increases pressure further, the client may further deteriorate. Choice E is incorrect. In this scenario, notifying the physician is not immediate nursing action. Independent nursing interventions ( actions in Choices A and D) should be implemented first. By discontinuing the suctioning and further exploring the cause of distress, the nurse has taken the appropriate action. If the client's condition were to continue to deteriorate after the suctioning was discontinued, then the physician needs to be notified. SEE Copyright : ARCHER NCLEX REVIEW https://drive.google.com/file/d/1GZTVDM3NfPona8KIgs1AxEVp-PiamMPR/view?usp=sharing

Question 73

Your adolescent client has been admitted to the adolescent psychiatric mental health unit. The first thing that you should do for this client is to: A. Assess their current psychosocial functioning. B. Generate a nursing diagnosis. C. Establish trust with the client. D. Allow the client to ventilate their feelings.

Answer 73

Explanation Correct Answer is C Correct. The first thing that you should do for this client is to establish trust with the client. Trust is the early stage of the therapeutic nurse-client relationship. After the trust is established, the nurse should encourage, facilitate, and allow the client to ventilate their feelings. This ventilation of feelings is used for and enfolded into the assessment of the client and their current psychosocial functioning, which is then used to generate a nursing diagnosis that is specific to the client’s needs. Choice A is incorrect. Although the nurse will assess the client and their current psychosocial functioning, this cannot be done until other phases of the nursing process, and the therapeutic nurse-client relationship is done. Choice B is incorrect. A nursing diagnosis is not established until other phases of the nursing process, and the therapeutic nurse-client relationship is done. Choice D is incorrect. Although it is necessary to encourage, facilitate, and allow the client to ventilate their feelings, this cannot be done until something else in terms of the therapeutic nurse-client relationship must be done. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson.

Question 74

The nursing student is explaining the cause of Cushing’s disease. Which of the following statements indicate a correct understanding of this illness? A. Cushing’s disease occurs when insulin is over produced. B. Cushing’s disease is the result of the under production of corticotropic hormones C. Cushing’s disease occurs when androgen hormones are under produced. D. Cushing’s disease is the result of an increased production of pituitary hormones.

Answer 74

CORRECT ANSWER D Explanation NCSBN client need | Topic: Physiological Integrity, Physiologic Adaptation Rationale: The correct answer is D. Cushing’s disease occurs when adrenocorticotropic hormones are over secreted by the pituitary gland, increasing cortisol. Choice A is incorrect. The overproduction of insulin does not characterize Cushing’s disease. Choice B is incorrect. The underproduction of corticosteroid hormones is Addison’s disease. Choice C is incorrect. Cushing’s disease is unrelated to the overproduction of androgen. Reference: Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby

Question 75

You are treating a postpartum patient with subinvolution. The nurse receives orders for each of the following medications. Which of these medications should the nurse question the order form? before administering? Select all that apply. A. Oxytocin B. Methylergonovine C. Carboprost Tromethamine D. Magnesium Sulfate

Answer 75

CORRECT ANSWER D Explanation Answer: D A is incorrect. Oxytocin would be an appropriate medication to administer for a patient experiencing subinvolution. The nurse does not need to question this order, so this answer is incorrect. Oxytocin, also known as Pitocin, causes contraction of the uterus. This will help in the case of subinvolution because the uterus is not clamping down as needed to prevent bleeding after the delivery. B is incorrect. Methylergonovine would be an appropriate medication to administer for a patient experiencing subinvolution. The nurse does not need to question this order, so this answer is incorrect. Methylergonovine affects the smooth muscle of the uterus, causing increased muscle tone. This will also help with bleeding due to uterine atony that occurs during subinvolution. C is incorrect. Carboprost Tromethamine would be an appropriate medication to administer for a patient experiencing subinvolution. The nurse does not need to question this order, so this answer is incorrect. Carboprost Tromethamine is a prostaglandin that causes smooth muscle contraction. It, therefore, causes the uterus to contract, clamp down, and stop the bleeding associated with subinvolution. D is correct. Magnesium Sulfate is not an appropriate medication to administer for a patient with subinvolution. The nurse needs to question this order. Magnesium Sulfate is a tocolytic agent that inhibits contractions of myometrial smooth muscle cells. This is given to prevent preterm labor, or relax the uterus during hypertonic contractions. It would be contraindicated in the case of subinvolution. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Subject: Maternal and Newborn Health Lesson: Labor and Delivery Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.