CAT

Question 1

You are educating a new nurse regarding Sentinel Events. Which of the following are examples of Sentinel events? Select all that apply.

A. An untimely assessment of the client.

B. An incomplete assessment of the client.

C. A client falls from the chair to the floor and sustains a humerus fracture.

D. An incorrect client is almost sent to the operating room.

E. A client undergoes colectomy instead of appendectomy.

Answer 1

Explanation

Choice C and E are correct. A sentinel event is defined as an event that has reached the patient and caused harm ( death, permanent harm, or severe temporary harm). A sentinel event is unrelated to patient’s illness or underlying condition. Such events are called “sentinel” because they signal a need for immediate investigation and response. All sentinel events must be reviewed by the hospital and are subject to review by The Joint Commission. A sentinel event may occur due to medical errors like wrong-site, wrong-procedure, wrong patient surgery. Please note that the terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.

Choice C (“client falls from the chair to the floor and sustained humerus fracture”) is an actual event that has occurred and caused harm. This event ( fall causing injury) is not a medical error, but constitutes a sentinel event. Choice E ( a client undergoing colectomy instead of appendectomy) is a sentinel event due to a medical error. Other examples of sentinel events include : patient committing suicide while receiving care in the hospital or within 72 hours of discharge, hemolytic transfusion reaction, unanticipated death of a full term infant, rape, assault, sexual abuse, invasive procedure on the wrong site/wrong person/ wrong procedure, discharge of infant to wrong family, any intrapartum maternal death, and so on.

Patient safety events occur commonly in health systems worldwide. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. Safety events can be categorized into sentinel events, adverse events, near misses, and no harm events. Sentinel events are just one category of patient safety events. Others include:

An adverse event: a patient safety event that resulted in harm to a patient. ( eg; an adverse event could include side effects to medications/ vaccines, medical procedures. They may or may not be from negligence. For example, a patient sustaining embolic stroke after a coronary angiography is an adverse event, but not due to medical negligence.)
A no-harm event is a patient safety event that reaches the patient but does not cause harm.
A close call (or a "near miss" or a "good catch") is a patient safety event that did not reach the patient.
A hazardous (or unsafe) condition(s) is a circumstance (other than a patient's own disease process or condition) that increases the probability of an adverse event.

Choice D is incorrect. The event ( when an incorrect client is almost sent to the operating room) did not occur here and did not cause patient harm. This event is referred to as “near-miss”, not a sentinel event. WHO defines “near-miss” as the one with the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is prevented According to the Institute of Medicine, a near miss is an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation.” An error caught before reaching the patient is another definition. It is also referred to as “close call or “potential adverse event.” Near misses also must be reported so root cause analysis can be completed. The root causes of near misses and adverse/sentinel events are similar. Detecting root causes of near misses, therefore, can help us to correct these causes and prevent future adverse events.

Choices A and B are incorrect. Although an untimely assessment of the client and an incomplete assessment of the client can be contributory factors that led to a sentinel event, these are considered deviations from a standard of care and not sentinel events.

References: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice

Question 2

The nurse is researching evidence-based practice and needs related literature. The nurse understands that the best source of reliable writing is:

A. Systematic review and meta-analysis studies

B. Expert opinions

C. Qualitative studies

D. Case studies

Answer 2

Explanation

A is correct. A systematic review and meta-analysis studies provide current, recently summarized evidence, making them the most reliable form of evidence for studies.

B is incorrect. Expert opinions may involve bias on the subject, making them unreliable sources of data.

C is incorrect. Qualitative studies involve interpretation of the database on the author’s understanding of the subject, making these types of literature unreliable sources of data.

D is incorrect. Case studies may also involve bias from the author/s, making them unreliable sources of data as well.

Reference

Potter, PA, Perry. AG, Stockert, PA, Hall, AM. Fundamentals of Nursing, 8th ed. St. Louis, MO: Elsevier Mosby;2013

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

Question 3

In addition to the name of the client, the date and time of the medication order, the name, dosage, route, and frequency of the medication, and the signature of the ordering person, what other information in a medication order would be the most useful, although not required, to you, as the nurse administering the medication?

A. The client’s ethnicity

B. The form of the medication

C. The client’s allergies

D. The time(s) of administration

Answer 3

Explanation

Correct Answer is B

Correct. Other information in a medication order that would be the most useful to you, as the nurse administering the medication, would be the form of the drug. The type of medicine becomes particularly relevant, for example, when oral medication is ordered for a client with a swallowing disorder. Should the medication be given in a pill form or a liquid form?

Choice A is incorrect. The client’s ethnicity is not as relevant and as useful as another piece of information, and the client’s ethnicity should be found in the client’s history and physical.

Choice C is incorrect. The client’s allergies should be found on the client’s medication record and in other places, including on the client’s identification band and their history and physical, so this would not be as important and as useful as another piece of information.

Choice D is incorrect. The time(s) of administration is in the medication order when the frequency of administration is written.

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

Question 4

The nurse is caring for a client with the tracing on the electrocardiogram shown in the Exhibit. The nurse should perform which priority action?

A. Discontinue the prescribed diltiazem infusion.

B. Notify the primary healthcare physician (PHCP).

C. Assess the client’s oxygen saturation and respiratory rate (RR).

D. Prepare a prescription of intravenous (IV) atropine.

Answer 4

Explanation

The tracing shows sinus bradycardia (SB).

The priority action would be to discontinue the diltiazem as it is a calcium channel blocker that lowers heart rate.

The physician should be notified, and oxygen saturation should be assessed. However, the priority action is to discontinue the offending agent.
NCSBN Client Need
Topic: Physiological adaptation; Sub-Topic: Medical Emergencies

Question 5

As you are taking the “staff only” elevator, you see a nurse who is now taking care of a client, Mr. B, who you cared for the week before. You ask the nurse how Mr. B is doing and the nurse tells you how significantly his condition has deteriorated over the last week. You have:

A. Violated the confidentiality of client information.

B. Asked an inappropriate question in the elevator.

C. Shown compassion for Mr. B.

D. Shown your caring about Mr. B.

Answer 5

Explanation

Correct Answer is B. You have asked an inappropriate question in the elevator. You have primarily set the other nurse up for a violation of the need for confidential client information because client information can only be shared, orally, and in writing, with others who are providing direct or indirect care to the client, and they have a need to know this information. As based on the information in this question, you are no longer taking care of Mr. B. Therefore; you should never have asked these questions.

The nurse who gave you the information violated Mr. B’s right to confidentiality. Although you asked this question because you are a compassionate and caring nurse, it was not an appropriate question.

Choice A is incorrect. You have not violated the confidentiality of client information because you did not share any client information with anyone.

Choices C and D are incorrect. Although you may have asked this question because you are a compassionate and caring nurse, this is not an appropriate question since you are no longer involved in the client’s care.

References: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice and Sommer, Johnson, Roberts, Redding, Churchill et al.

Question 6

You are caring for a 14-month-old diagnosed with severe iron deficiency anemia. She is admitted for a blood transfusion and is started on oral iron supplementation. When you change her diaper. You note a dark black stool. What are the appropriate nursing actions? Select all that apply.

A. Notify the healthcare provider.

B. Document the finding

C. Continue with your assessment

D. Administer the oral iron supplement as prescribed

Answer 6

Explanation

Answer: B, C, and D

A is incorrect. Black stools are an expected response to iron supplementation. The nurse doesn’t need to notify the healthcare provider of this.

B is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to document this finding in the chart, but no further action is needed.

C is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to simply continue with your assessment. Because the finding is expected, no other steps are necessary.

D is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to administer the oral iron supplement as prescribed.

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 7

While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case? Select all that apply.

A. Intrauterine growth restriction

B. Hemolytic disease of the newborn

C. Hydrocephaly

D. Large for gestational age infant

E. Stillbirth

Answer 7

Explanation

Rationale:

The correct answers are A, C, and E. Women infected with rubella are at an increased risk of having a miscarriage or a stillbirth. Their infants are more likely to suffer from Intrauterine growth restriction and hydrocephaly.

Choice B is incorrect. Hemolytic disease of the newborn is an alloimmune condition that occurs when the mother is Rh-negative and is pregnant with an Rh-positive baby.

Choice D is incorrect. Women infected with rubella while pregnant are not at an increased risk for delivering an infant who in large for gestational age.

Reference:

Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014

Question 8

The nurse has just finished assisting the physician in applying a fiberglass cast to a patient with a severe ankle sprain. The patient asks the nurse how long he will have to wait until he can walk on the cast. The nurse replies that he can walk on the cast:

A. after 8 hours

B. after half an hour

C. after 24 hours

D. after 48 hours

Answer 8

Explanation

A is incorrect. The client may bear weight (if permitted by a doctor) on his cast once it is fully dry. A synthetic (Fiberglass) cast fully dries after 30 minutes. A plaster cast takes 2-3 days to completely dry, usually after 48 hours.

B is correct. A Fiberglass cast fully dries within 30 minutes (half an hour) of application. The patient can now walk (bear weight) on it if allowed by the physician.

C is incorrect. The client may bear weight (if permitted by a doctor) on his cast once it is fully dry. A synthetic (Fiberglass) cast fully dries after 30 minutes. A plaster cast takes 2-3 days to completely dry, usually after 48 hours.

D is incorrect. The client may bear weight (if permitted by a doctor) on his cast once it is fully dry. A synthetic (Fiberglass) cast fully dries after 30 minutes. A plaster cast takes 2-3 days to completely dry, usually after 48 hours.

Reference:

Daniels, R., et al. Contemporary Medical-Surgical Nursing; Delmar Learning 2007

Question 9

Which of the following is (are) a type of social support? Select all that apply.

A. An emotional social support

B. An informational social support

C. A physical help social support

D. A sensory social support

E. An instrumental social support

F. An appraisal social support

Answer 9

Explanation

Correct Answers are A, B, E and F

Correct Answer A. An emotional, social support is one type of social support. Passionate social support people and networks provide clients with the emotional and psychological that is often needed for decreased client stress and enhanced client coping.

Correct Answer B. An informational social support is one type of social support. Informational social support people and networks provide clients with the knowledge and skills needed to adapt to and cope with a stressor.

Correct Answer E. An instrumental social support is one type of social support. Helpful social support people and networks provide clients with tangible help with things like transportation and household help.

Correct Answer F., An appraisal of social support, is one type of social support. Appraisal social support people and networks provide clients with the opportunity to gain insight and to self evaluate their strengths and limitations.

Choice C is incorrect. A physical help social support is not existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems.

Choice D is incorrect. Sensory, social support is nonexistent. The four types of social support are informational, emotional, instrumental, and appraisal support systems.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition) and Glanz, Karen, Barbara K. Rimer, and K Viswanath. Health Behavior and Health Education: Theory, Research, and Practice. Social Supports. http://www.med.upenn.edu/hbhe4/part3-ch9-key-constructs-social-support.shtml

Question 10

A nurse is taking care of a 60-year-old lady who is on her first postoperative day after a right total hip replacement. The nurse knows that one complication from this procedure is dislocation. To prevent this, the nurse includes which nursing action in the plan of care?

A. Avoid positioning the client with the right leg externally rotated

B. Avoid placing the client in the left lateral decubitus position at all times

C. Ensure that adduction of the legs is avoided

D. Do not allow client to be in semi-Fowler’s position

Answer 10

Explanation

Rationale: Following a total hip replacement, the goal is to prevent dislocation. Leg adduction should be avoided. The legs should be abducted. They may also be externally rotated, and the client may assume a sitting position at a 45-degree angle. The correct answer is, therefore, option C, while options A, B, and D are incorrect.

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 11

You are administering a transfusion of 1 unit of PRBCs to a 63-year-old client with hemoglobin of 8.9gm%. Listed in the Exhibit are his vital signs pre-transfusion, 5 minutes into the transfusion, and 10 minutes into the transfusion. What should the nurse do after 10 minutes of administering the transfusion? Select all that apply.

A. Continue to monitor the patient’s response to the transfusion

B. Notify the health care provider

C. Stop the transfusion

D. Take another set of vital signs at the next 10 minute interval

Answer 11

Explanation

The correct answers are B and C.

As shown in the exhibit, there is an increase in temperature and a drop in the blood pressure following the blood transfusion. Based on the vital signs the nurse has obtained, she expects that the patient is having a transfusion reaction.

Transfusion reactions are adverse reactions that happen as a result of receiving a blood transfusion. Signs and symptoms of a transfusion reaction include fever, chills, diaphoresis, muscle aches, back pain, rashes, dyspnea, pallor, headache, nausea, apprehension, tachycardia, and hypotension. (Most common symptoms ca be remembered by a Mnemonic – REACTION – Rash, Elevated temperature, Aching, Chills, Tachycardia, Increased pulse, Oliguria – low urine output and Nausea).

Most transfusion reactions occur during the first 15 minutes. While initiating blood transfusion, it should be started slowly at a rate of 2 mL/min (120 mL/hr) for the first 15 minutes – the idea here is to minimize the volume of the blood infused if the patient were to develop a reaction. The nurse should use 18 gauge or larger cannula to infuse because a smaller cannula may lead to mechanical lysis of red cells. The nurse should remain at the patient’s bedside for the first 15 minutes and if the blood is tolerated for 15 minutes without a reaction, the infusion rate can be increased. Blood transfusion units are usually at 250 ccs to 300 cc in volume. Transfusion must be completed within 4 hours.

As per blood transfusion protocol used in most centers, vitals must be obtained at 5 minutes, 15 minutes, 30 minutes from the start of the infusion, 1 hourly until the infusion is completed, and then at 1 hour after the transfusion.

Even if the patient is not complaining of the typical signs and symptoms, if their vital signs indicate a possible transfusion reaction, the transfusion should be stopped. In this client, the heart rate is trending up, blood pressure is trending down, and the temperature is trending up. At 10 minutes, he is tachycardic, hypotensive, and febrile. The patient is having a transfusion reaction. This requires immediate intervention. Therefore, the nurse should immediately stop the transfusion (Choice C); disconnect blood tubing from the intravenous site and notify the health care provider (Choice B).

Choice A is incorrect. It is inappropriate to continue monitoring the patient’s response to the transfusion. Their vital signs are out of normal limits and an intervention is required.

Choice D is incorrect. The nurse will begin continuously monitoring vital signs now that she suspects a transfusion reaction. It would be inappropriate for her to wait 10 minutes to take another set of vitals.
NCSBN Client Need:
Topic: Pharmacological and Parenteral Therapies Subtopic: Blood and Blood Products.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby, p. 912

Question 12

Following treatment for a fracture, a client is now undergoing rehabilitation. His regimen involves performing isometric exercises. Which action is evidence that the client has fully understood the proper technique?

A. The patient exercises both extremities simultaneously

B. The client knows that his heart rate should be monitored while exercising

C. The patient practices forced resistance against stable objects

D. The patient swings his limbs through their full range of motion

Answer 12

Explanation

Rationale: Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall. It does not include the simultaneous use of the extremities; neither does swinging of limbs. Heart rate monitoring is done with aerobic exercises. The correct answer is option C. Options A, B, and D are incorrect.

Reference:

gnatavicius 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 13

Beliefs and conceptions about pain and pain management are often not based in fact and scientific evidence. Which of the following is a commonly held misconception about pain and pain management? Select all that apply.

A. Infants do not have developed pain sensors.

B. The lack of physiological and behavioral signs of pain do not negate pain.

C. The amount of pain has a positive correlation with the extent of tissue damage.

D. The amount of pain has a negative correlation with the extent of tissue damage

Answer 13

Explanation

Choices A and C are correct.

The two commonly held misconceptions about pain and pain management are that infants do not have developed pain sensors and that the amount of pain has a positive correlation with the extent of tissue damage. These beliefs are contrary to facts and scientific evidence.

These false beliefs continue to be held by some healthcare providers who believe that infants do not experience pain and that the amount and intensity of grief are increased with significant tissue damage.

Choice B is incorrect. The lack of physiological and behavioral signs of pain does NOT negate the anxiety and pain. People are uninformed when they believe that the lack of physiological and behavioral symptoms of pain indicates the absence of pain.

Choice D is incorrect. The amount of pain has a negative correlation with the extent of tissue damage is not accurate, but this is not a commonly held misconception about pain and pain management. The widely held misconception about pain and pain management is that the amount of pain has a positive and not a negative correlation with the extent of tissue damage.

Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016).

Question 14

The nurse is caring for a 1 year old client diagnosed with acute otitis media. The client is experiencing otalgia, has been febrile for 24 hours, and is pulling at his left ear. Which intervention is the priority nursing action?

A. Position the child on his left side

B. Administer antibiotic ear drops

C. Administer acetaminophen as prescribed

D. Apply a heat pack to the left ear

Answer 14

Explanation

Answer: C

A is incorrect. Positioning the child on his left side is not the priority. This position is appropriate however, because the child is pulling at his left ear indicating that is the affected side, so positioning on the left side will promote drainage of fluids from that ear. With that being said, there is another option with a higher priority, and the question asks for the priority nursing action.

B is incorrect. Antibiotic ear drops are not used to treat acute otitis media. Systemic antibiotics are used to treat acute otitis media infections with a bacterial cause. Amoxicillin, erythromycin, and Cefixime are all systemic antibiotics that may be utilized, but antibiotic ear drops are not effective.

C is correct. Administering acetaminophen is the priority nursing action in this scenario. The question states that the patient has been febrile for 24 hours. It is the priority to address this concern, and the nurse can do so through administration of the antipyretic acetaminophen.

D is incorrect. Applying a heat pack to the left ear is not the priority nursing action. Heat or cold packs can be used for pain relief when the child with acute otitis media is experiencing otalgia, but the stem of the questions states that this child has been febrile for 24 hours. It is not appropriate to place a heat pack on a patient who is febrile. The priority is addressing the fever.

NCSBN Client Need:

Topic: Effective, safe care environment

Subtopic: Coordinated care

Subject: Pediatric

Lesson: HEENT

Question 15

Which of the following signs does the nurse know to expect for her 1-year-old patient in heart failure? Select all that apply.

A. Diaphoresis

B. Weight loss

C. Insomnia

D. Poor feeding

Answer 15

Explanation

Correct answers are A, and D. Diaphoresis, or increased sweating (Choice A), is an expected clinical manifestation of heart failure. As the heart works harder and harder to maintain cardiac output, the body starts to tire, and this is manifested in signs such as diaphoresis. Diaphoresis is possibly related to a catecholamine surge and can mainly display during feeding when the infant/ child attempts to eat while in respiratory distress. Poor nutrition (Choice D) is another expected clinical manifestation of heart failure in infants and children. As the left side of the heart begins to fail, there is fluid backing up in the lungs (Pulmonary edema). This causes dyspnea and makes eating increasingly tricky for patients.

Choice B is incorrect. Weight gain, rather than loss, is an expected clinical manifestation of heart failure. Weight gain is secondary to fluid retention. In heart failure (especially with right heart failure), the heart struggles to move fluid forward in the body, and therefore liquid begins to back up, causing venous congestion and weight gain. Venous congestion in Right-sided heart failure manifest with liver enlargement (hepatomegaly), ascites, pleural effusion, peripheral edema, and jugular venous distension. Venous congestion in Left-sided heart failure manifests with tachypnea, intercostal retractions, nasal flaring or grunting, rales, and pulmonary edema.

Primary mechanisms of fluid retention in heart failure include reduced renal perfusion and, thereby, activation of the Renin-aldosterone pathway. Increased aldosterone production leads to sodium and water retention. Congestion in patients with chronic heart failure usually develops over weeks or even months. In the case of exacerbations of Congestive Heart Failure (CHF), patients may present ‘acutely’ having gained several liters of excess fluid, and hence several pounds of excess weight. Therefore, management in these acute CHF exacerbation patients involves removing that excess fluid (acutely retained fluid) and transitioning them back to a diagnosis of Chronic Heart Failure. In managing clients with acute CHF exacerbation, daily weight monitoring is a crucial measure to monitor outcomes and achieve desired weight-loss (removal of excess fluid). Loop diuretics are the principal agents to attain that target.

Choice C is incorrect. Insomnia is not an expected clinical manifestation of heart failure in children. These patients are often very fatigued but do not typically experience insomnia. Although Paroxysmal Nocturnal Dyspnea and Orthopnea in left heart failure may cause some sleep disturbances, Insomnia is not a commonly reported direct symptom of heart failure.

NCSBN Client Need
Topic: Physiological Integrity Subtopic: Physiological adaptation.
Reference
Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited

Question 16

Which percussion sound would indicate further assessment is needed?

A. Dull tone over spleen

B. Hyperressonance over adult lung tissue

C. Flat tone over bone

D. Hyperressonance over child’s lung tissue

Answer 16

Explanation

B is correct. Hyperressonance is an abnormal finding over adult lung tissue. It indicates an abnormal increase in the amount of air present, such as with emphysema.

A is incorrect. Soft, short, muffled “dull” sounds are normal over dense organs such as the liver and spleen.

C is incorrect. Bones produce a “flat” percussion sound in normal healthy adults.

D is incorrect. Adult lung tissue should create a “resonant” sound during percussion, but hyper resonance is a normal finding in child lung tissue.

Subject: Fundamentals

Lesson: Skills/procedures

Topic: Pathophysiology

Reference: (Jarvis, C, 2012, p. 116-117)

Question 17

You are caring for a client with a terminal disease and this person has asked for a curandero. What should you do?

A. Refer the family to a religious shop with Bibles and other holy books.

B. Refer the family and the client to a member of the clergy who may be able to help.

C. Give the client a candle and close all of the shades and blinds to darken the room.

D. Arrange for the client to go to a religious service to get this special blessing.

Answer 17

Explanation

Correct Answer is B

Correct. You would refer the family and the client to a member of the clergy who may be able to help. A curandero is a healer who is believed to supernatural powers that can cure the sick. These powers are derived from the fact that many believe that illnesses and diseases occur as the result of evil spirits and a curse from God.

You would not give the client a candle and close all of the shades and blinds to darken the room because this is not consistent with the person’s desire to have a curandero; a curandero is not a particular religious blessing, and it is not a holy book.

Choice A is incorrect. A curandero is not a holy book.

Choice C is incorrect. A curandero is not a religious or spiritual practice that uses a candle and a darkened room.

Choice D is incorrect. A curandero is not a particular religious blessing.

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

Question 18

Your client is expressing feelings of dread and impending danger. As you are allowing the client to freely express these feelings, you are attempting to determine the source of these feelings; it then becomes apparent that the source of these feelings is not identifiable. What is the most likely nursing diagnosis for this client?

A. Fear related to an unidentifiable source

B. Anxiety related to an unidentifiable source

C. Ineffective coping related to a source that is not based in reality

D. Maladaptive coping related to a source that is based in reality

Answer 18

Explanation

Correct Answer is B

Correct. The most likely nursing diagnosis for this client is “Anxiety related to an unidentifiable source”. Unlike fear, which is highly similar to anxiety in terms of client responses to it, anxiety can result from an unidentifiable source as well as one that is identifiable.

Fear is related to an identifiable source. The nursing diagnoses of “Ineffective coping related to a source that is not based in reality” and “Maladaptive coping related to a source that is based in reality” are not accurate because this client’s feelings may or may not be based in reality.

Choice A is incorrect. Fear is related to an identifiable source and not an unidentifiable source.

Choice C is incorrect. The nursing diagnosis of “Ineffective coping related to a source that is not based in reality” is not accurate because this client’s feelings may or may not be based in reality.

Choice D is incorrect. The nursing diagnosis of “Maladaptive coping related to a source that is based in reality” is not accurate because this client’s feelings may or may not be based in reality.

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 19

The nurse is preparing to administer Dopamine (Intropin) to a client intravenously. All of the following are precautions are to be taken when administering the medication, except:

A. Use caution in calculating and preparing doses of the drug.

B. Monitor patient response slowly (blood pressure, ECG, urine output, cardiac output).

C. Dilute the drug before use if it is not prediluted.

D. Have Phenylephrine on standby in case extravasation occurs.

Answer 19

Explanation

Choice D is correct. This is not the precaution a nurse needs to take because it represents an erroneous statement. Phentolamine should be on standby to save the vein in case of infiltration, not Phenylephrine.

Phentolamine is an antidote that counteracts the effects of Dopamine, Vasopressin, Norepinephrine, and Phenylephrine by causing vasoconstriction by alpha-receptor stimulation. Dopamine-induced extravasation can cause tissue injury with blanching and hematoma. Subcutaneous injection of phentolamine has been proven to be clinically effective in preventing tissue injury in the case of Dopamine or Vasopressin extravasation.

Choice A is incorrect. This is the precaution that the nurse should take. The nurse should use extreme caution when calculating and preparing doses of the drug because even small errors could have serious effects.

Choice B is incorrect. This is the precaution that the nurse should take. Monitoring the patient’s response to the medication ensures that the most benefit is achieved with the least amount of toxicity to the client.

Choice C is incorrect. This is the precaution that the nurse should take. Diluting the drug prevents tissue irritation on injection.
Reference:
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 20

Which of the following statements accurately describes behaviors that place juveniles at increased risk for injury? Select All That Apply.

A. Approximately 5.000 individuals under the age of 21 die from alcohol-related accidents annually.

B. 1 in 3 high school students reports using some type of tobacco product.

C. The CDC lists motor vehicle accidents as the number one cause of death among adolescents

D. The use of OTC and prescription drugs among teens is at an all-time high.

E. Homicide rates for adolescents are high.

F. As many as 30% of school-aged children are bullied.

Answer 20

Answer and Rationale:

The correct answers are A, C, and D. Each year, underage drinking claims the lives of approximately 5,000 people under the age of 21. The CDC lists motor vehicle accidents as the number one cause of death for adolescents. Marijuana use among teenagers has been on the increase, and the abuse of prescription medication and OTC drugs has remained at a high level.
B is incorrect. Approximately one in five high school students reported using a type of tobacco product.
E is incorrect. Homicide rates for youths using firearms are higher than any other age group, and the most recent statistics indicate that children aged 10-19 years committed almost 1,500 suicides using guns.
F is incorrect. According to the American Academy of Child and Adolescent Psychology, as many as 50% of children are bullied during their school years. Some experts believe that cyberbullying is more dangerous and damaging to children than bullying in the schoolyard.

NCSBN Client Need

Topic: Safe and Effective Care Environment

Subtopic: Safety and Infection Control

Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn)

Chapter 26: Safety, Security, and Emergency Preparedness

Lesson: Promoting Safety at Varying Developmental Stages

Question 21

The nurse in the psychiatric unit is administering fluoxetine (Prozac) together with Tranylcypromine (Parnate). The nurse should watch out for which symptoms signify an expected adverse reaction from the combination of both drugs?

A. low blood pressure and urinary retention

B. muscle rigidity and hyperthermia

C. shortness of breath and pink frothy sputum

D. weakness and diaphoresis

Answer 21

Explanation

A is incorrect. These symptoms are not associated with serotonin syndrome.

B is correct. Serotonin syndrome is a result of too much serotonin in the body due to the use of SSRI’s and MAOI’s. Serotonin syndrome is characterized by high body temperature, agitation, muscle rigidity, tremor, sweating, dilated pupils, and diarrhea. Upon noticing these symptoms, the nurse must report this to the physician to initiate medical intervention.

C is incorrect. These symptoms are related to pulmonary edema, not serotonin syndrome.

D is incorrect. Weakness and diaphoresis are symptoms associated with hypoglycemia, not serotonin syndrome.

Reference

Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

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

Question 22

A nurse is assigned to care for a 2-year-old who is newly diagnosed with acute lymphocytic leukemia. Which action should be included in the client’s plan of care that is directed to facilitate growth and development in the acutely ill toddler?

A. Focus on educating parents to minimize anxiety over parenting of the child

B. Make sure that the toddler is informed in advance of what is to take place in a procedure

C. Isolate child from parents, especially if there are temper tantrums.

D. Encourage regression to a previous developmental level for familiarity and comfort.

Answer 22

xplanation

Rationale: When a toddler is acutely ill, it is best to have parents who are not overly anxious and can work well with hospital personnel. It is, therefore, best to exert effort in educating the parents in this case. Option A is, therefore, the correct answer. Option B is not an appropriate action because a toddler’s thinking is concrete and tangible, and the toddler cannot think beyond the observable. Preparation should be done immediately before the procedure. Temper tantrums are a standard developmental characteristic of a 2-year-old, and the parents must hold her to alleviate fear. Isolating the toddler from her parents is not a therapeutic approach. Option C is, therefore, incorrect. A toddler may regress during hospitalization but will not facilitate comfort. Option D is an inappropriate action.

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 23

Which of the following are independent sleep hygiene nursing functions used to induce and maintain sleep. Select all that apply.

A. The administration of an over-the-counter medication like Benadryl to induce and maintain sleep.

B. The administration of an ordered hypnotic medication like Benadryl to induce and maintain sleep.

C. The provision of a therapeutic soothing back massage and giving the client a warm beverage without caffeine.

D. The encouragement of moderate physical exercise one hour before the client’s scheduled sleep time.

Answer 23

Explanation

The correct answer is C. The provision of a therapeutic soothing back massage and giving the client a warm beverage without caffeine are independent sleep hygiene nursing functions used to induce and maintain sleep. These interventions are separate rather than dependent responses because they do not require a doctor’s order.

Choice A is incorrect. The administration of an over-the-counter medication like Benadryl to induce and maintain sleep is a dependent rather than an independent nursing function because the administration of drugs, even over-the-counter drugs, cannot be done without a doctor’s order.

Choice B is incorrect. The administration of an ordered medication like Benadryl to induce and maintain sleep to produce and maintain sleep is a dependent rather than an independent nursing function. The administration of all medications, even over-the-counter drugs, cannot be done without a doctor’s order. Additionally, Benadryl is not a hypnotic medication; but instead is an antihistamine that has the side effect of drowsiness.

Choice D is incorrect. Moderate physical exercise one hour before the client’s scheduled sleep time is not encouraged. A quiet, peaceful environment is provided; reasonable use should be discouraged several hours before the client’s scheduled sleep time because it impairs sleep.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 24

Which of the following clients, who is receiving normal saline via IV infusion, is at the highest risk for bloodstream infections?

A. A client who has a midline IV catheter in the left antecubital fossa.

B. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.

C. A client with an implanted port in the right subclavian vein.

D. A client who has a non-tunneled central line in the left internal jugular vein.

Answer 24

Explanation

Choice D is correct. Several factors increase the risk of infection for this client. Central lines are associated with a higher risk of infection because the neck and chest skin harbor a high number of microorganisms. Additionally, because the line is non-tunneled, the risk for infection is higher. Non-tunneled catheters are mostly used for short-term access in indications requiring rapid resuscitation or pressure monitoring. Such non-tunneled catheters are good for about 5 to 7 days. They carry a higher risk of infection and are inappropriate for patients who require central venous access for longer than 2 weeks.

Choices A and B are incorrect. Peripherally inserted IV lines such as midline catheters and PICC (peripherally inserted central catheter) lines are associated with a lower infection incidence.

Choice C is incorrect. Implanted ports are placed under the skin and are less likely to be associated with catheter infection than a non-tunneled central IV line.
NCSBN Client Need
Topic: Safe and Effective Care Management; Subtopic: Safety and Infection Control
Reference:
Fundamentals of Nursing (Kozier and Erbs); Chapter 31: Asepsis; Lesson: Nosocomial and Healthcare-Related Infections

Question 25

The client is admitted to the surgical ward after being treated initially in the ER for a femur fracture due to a motor vehicle accident. The client is being interviewed by the nurse for his surgery whenhe suddenlyreports a sharp pain in his chest, displays the difficulty of breathing, and becomes restless. The nurse suspects fat embolism; which action of the nurse should take priority? A. Prepare for intubation and mechanical ventilation B. Administer IV fluids C. Check vital signs and respiratory status D. Notify the physician

Answer 25

Explanation Choice D is correct. The nurse suspects fat embolism. The question provides enough information regarding the client’s distress and sudden change in his clinical status. The mortality rate with fat embolism is about 10%. Early recognition and treatment are crucial. The nurse should immediately inform the physician to initiate medical interventions. Fat embolism is a potentially life-threatening complication that occurs from long bone fractures due to fat emboli being dislodged and traveling into the bloodstream and up into the pulmonary circulation. Symptoms mimic that of pulmonary embolism. The client may report chest pain, respiratory distress (dyspnea), and may have mental status changes (confusion). Other signs include tachypnea, low oxygen saturation, fever, tachycardia, and low blood pressure. Petechiae (axillary or subconjunctival petechiae) are characteristic of fat embolism and help differentiate it from other etiologies. Treatment includes intravenous hydration, oxygenation, and immobilization, and fixation of the fractured limb. In severe cases of hypoxia and neurological deterioration, intubation and ventilation may be required. Choice A is incorrect. The client may eventually need intubation and mechanical ventilation, depending on the respiratory and neurological condition. However, this is not the initial action of the nurse. Choice B is incorrect. IV fluids may be necessary to prevent hypovolemic shock in the client, but this should be done after informing the physician. Choice C is incorrect. There is sufficient information in the question to indicate the client’s distress. The client may need his vital signs checked and monitored; however, this does not take priority over informing the physician and starting emergency interventions. Reference Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 26

A client is scheduled for electroconvulsive therapy. The nurse caring for him notes that there is no signed consent form. Upon further assessment, the nurse finds out that the client is admitted to the unit involuntarily. The nurse understands that in this case: A. informed consent needs to be obtained from the wife B. informed consent needs to be obtained from the client C. informed consent is not necessary D. informed consent needs to be obtained from court

Answer 26

Explanation A is incorrect. Unless declared legally incompetent, the client’s wife does not have the authority to give consent on behalf of the client. B is correct. Even though the client is involuntarily admitted, the client does not lose the right to informed consent. Informed consent must be obtained from the client. C is incorrect. Electroconvulsive therapy needs informed consent from the client to proceed. D is incorrect. Unless deemed legally incompetent, informed consent must be obtained from the client. Reference Halter, MJ.Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 7th Ed. St. Louis, MO: Mosby Elsevier; 2014 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 27

A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most consistent with the nurse’s role of patient advocate. A. Remind the patient of why breast feeding is the best method of infant feeding. B. Request a referral to the lactation consultant. C. Determine the patient’s knowledge base related to infant feeding options. D. Accept the patient’s decision without further discussion

Answer 27

Explanation Correct Answer C. A central concept of patient advocacy is ensuring that the patient’s decisions are based on sufficient information and understanding, supporting the patient’s right to exercise autonomy. Choice A is incorrect. This answer does not serve to support the patient’s right to autonomy. Choice B is incorrect. A referral to the lactation consultant is not necessarily indicated. Choice D is incorrect. While the nurse should support the patient’s choice, it is essential to confirm that the patient’s decision-making process is based on adequate information. Bloom's Taxonomy – Analyzing. Reference: Hyland, D., 2002. An Exploration of the Relationship Between Patient Autonomy and Patient Advocacy: Implications for Nursing Practice. Nursing Ethics 9(5)

Question 28

The client is upset because she just found out that she has syphilis. She tells the nurse, “This is so upsetting. Does everyone need to know?” What would be the nurse’s best response? A. “We need to report this case to the Public Health Department and they will call your past partners.” B. “According to the Health Insurance Portability and Accountability Act (HIPAA), I can’t tell anyone without your permission.” C. “You really should contact your sexual partners, so they can be treated too.” D. “I understand you’re upset. Would you like to talk about it?”

Answer 28

Explanation A is incorrect. The Public Health Department will attempt to notify any sexual partners of the client reports. B is incorrect. This is a false statement. HIPAA does not apply to this situation. C is incorrect. The client should contact all her sexual partners so that they could get treated. The response, however, is not therapeutic. D is correct. This response provides facts but still encourages verbalization of feelings to the client. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 29

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 29

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 30

The home health nurse is visiting an elderly client for the first time in his home. Upon assessment of the client, the nurse notices that the client has been taking 12 prescription medications and five over the counter medications. What is the nurse’s most appropriate action? A. Check for drug interactions. B. Check for side effects to the client from the medications. C. Check for any medication duplication. D. Ask the client if there are family members helping him with his medications.

Answer 30

Explanation A is incorrect. Checking for drug interactions should be done after determining the duplication of medications. B is incorrect. The identification of side effects of medications can be made after the duplication of drugs is determined. C is correct. Checking for any duplication in medication should be the first action of the nurse to eliminate the risk of adverse effects on the client. D is incorrect. Asking about family members helping with his medications is irrelevant to the problem of polypharmacy as of the moment. 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 31

While working in the emergency department. A patient has a cardiac arrest. The nurse caring for the patient quickly defines the necessary tasks and assigns them to each member of the team responding. This nurse demonstrated which of the following leadership styles? A. Autocratic B. Situational C. Democratic D. Laissez-faire

Answer 31

Explanation Answer: A A is correct. This nurse has demonstrated an autocratic leadership approach. She retained all authority and delegated tasks to be accomplished. This approach is useful in emergencies or crises. B is incorrect. Situational leadership is a comprehensive approach that combines the style of the leader with the maturity of the group they are working with and what the current situation is. In this situation, autocratic leadership was demonstrated. C is incorrect. Democratic leadership is a person-centered leadership style focused on the relationships between the team who is working together. Democratic leadership is a good strategy for team development and encouraging the growth of the participating team members. In this situation, autocratic leadership was demonstrated. D is incorrect. Laissez-faire leadership is very lax in style. The leader does not retain control and instead delegates the decision-making to other team members. In this situation, autocratic leadership was demonstrated. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk of the potential reduction Subject: Fundamentals Lesson: Prioritization, delegation, and leadership Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Question 32

Which of the following foods should the nurse reinforce to avoid while the patient is taking Coumadin? Select all that apply. A. Peanut butter B. Spinach C. Kale D. Almonds

Answer 32

Explanation Answer: B and C A is incorrect. Peanut butter does not need to be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Peanut butter only has about 0.05 mcg of vitamin K per 1 tbsp, so it does not need to be avoided. B is correct. Spinach should be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Spinach has 444 mcg per half cup, making it incredibly high in vitamin K! C is correct. Kale should be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Kale has 565 mcg per half cup, making it incredibly high in vitamin K! D is incorrect. Almonds do not need to be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Almonds have virtually no vitamin K, so they do not need to be avoided. 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: Fundamentals Lesson: Medication Administration

Question 33

Which of the following situations represents an appropriate time to place your patient in restraints? Select all that apply. A. When they are trying to pull at their lines. tubes. and drains. B. When their family member asks you to. C. When you feel it is necessary. D. When they are a danger to themselves.

Answer 33

Explanation Answer: A and D A is correct. It is appropriate to place your patient in restraints, with an order from your healthcare provider, if the patient is trying to pull out their lines, tubes, and drains. This makes them a danger to themselves and can cause harm, so restraints may be appropriate. B is incorrect. A family member may request restraints, but this is not an appropriate reason to initiate controls. You should explain to the family member other options and what you are trying to do for their loved one before launching restraints. C is incorrect. Just because you feel that restraints are necessary does not mean you may initiate them. You must speak with your healthcare provider and explain why you think controls are required to obtain an order. D is correct. If your patient is a danger to themselves and other interventions are not keeping them safe, it is appropriate to request an order for restraints from your healthcare provider. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Coordinated care Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences. Subject: Fundamentals Lesson: Safety

Question 34

Select the client care supply or piece of equipment that is accurately paired with the correct type of asepsis. A. Medical asepsis: An autoclave B. Medical asepsis: Sterile gloves C. Surgical asepsis: A single use blood pressure cuff D. Surgical asepsis: An autoclave

Answer 34

Explanation Correct Answer is D. An autoclave is used to sterilize client care supplies and equipment; therefore, an autoclave is accurately paired with surgical asepsis. Choice A is incorrect. An autoclave is used to sterilize; therefore, it is not used for medical asepsis. Choice B is incorrect. Sterile gloves are sterilized and used for sterile procedures, and not for medical asepsis procedures. Choice C is incorrect. Single-use blood pressure cuffs are medically aseptic and not sterilized. Therefore, it is not an example of surgical asepsis. References: 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 35

You are taking care of a client who is taking warfarin and lovastatin. Which statement about the interaction warfarin and lovastatin should you incorporate into your critical thinking and your plan of care? A. Lovastatin decreases the effects of the warfarin. B. Lovastatin increases the effects of the warfarin. C. Lovastatin has no known effects on the warfarin. D. Combining lovastatin and warfarin causes respiratory depression.

Answer 35

Explanation Correct Answer is B Correct. Lovastatin increases the effects of the warfarin, so you, as the nurse, should incorporate this knowledge related to an increased influence of the anticoagulant, warfarin, into your critical thinking and your plan of care. Choice A is incorrect although lovastatin affects the actions of warfarin, lovastatin increases, rather than decreases, the effects of the warfarin. Choice C is incorrect. Lovastatin has known effects on warfarin, an anticoagulant medication, so you, as the nurse, should incorporate this knowledge into your critical thinking and your plan of care. . Choice D is incorrect. Combining lovastatin and warfarin does not cause respiratory depression; however, these medications, in combination, can have another effect. Reference: Kee, Joyce LeFever, Evelyn Hays, and Linda McCistion (2011) Pharmacology: A Nursing Process Approach 7th edition. Elsevier Saunders.

Question 36

The community health nurse is evaluating an individual’s risks of developing Hepatitis A. The nurse knows which age group is at the highest risk of acquiring Hepatitis A? A. Newborns B. The elderly, ages 60 to 90 C. Teenagers older than age 15 D. Children older than 1 year but younger than 15 years

Answer 36

Explanation Choice D is correct. Children who are preschool and elementary school age and those younger than 15 are at the highest risk of developing Hepatitis A virus ( HAV). Hepatitis A is usually contracted by ingesting stool containing the virus. Since it's transmitted through fecal-oral contact, children are more prone as they may not practice proper hand hygiene. Often, children contract infection by eating/ drinking food/ water ( fruits, vegetables, ice, water) contaminated by stools containing HAV, being carried by the infected person that does not wash their hands after using the restroom or traveling to a developing country without being vaccinated for hepatitis A. Outbreaks may occur in child care centers. CDC recommends Hepatitis A vaccine to the following groups: All children aged 12–23 months Unvaccinated children and adolescents aged 2–18 years International travelers Homeless people Men who have sex with men Those engaged in recreational drug use Those with HIV Those with chronic liver disease Those at risk for exposure during their work. Pregnant women at risk for Hepatitis A Hepatitis A vaccine is administered in a two-dose schedule. It is recommended to all children at one year of age (i.e., 12 to 23 months) and as a catch-up vaccine for all unvaccinated children and adolescents 2 to 18 years. Choice A is incorrect. Newborns are not the group most likely to develop Hepatitis A. Newborns and those less than age 12 months tend to harbor passively acquired maternal antibodies ( passively transferred via the placenta). Routine Hepatitis A vaccination is not recommended to children younger than 12 months because their immune systems are not mature. Vaccines before 12 months of age might result in a suboptimal immune response. However, those children at 6-11 months who travel internationally should be given the vaccine. Choice B is incorrect. These elderly age groups do not have more occurrences of Hepatitis A than the children under 15. However, the elderly tend to have more severe symptoms if they do develop Hepatitis A. Choice C is incorrect. Teenagers older than 15 years of age are not at the highest risk of developing Hepatitis A. Preschool to elementary school-aged, and those younger than 15 are at the highest risk. NCSBN client need | Topic: Health Promotion and Maintenance, Health Screening

Question 37

In the ICU, the low-pressure ventilator alarm goes off. The nurse attends the patient, checks the ventilator, and attempts to determine the cause of the signal. She is unable to identify the cause. Which action would the nurse initiate next? A. Give oxygen to the patient. B. Assess the client’s vital signs. C. Ventilate the client manually. D. Start CPR immediately.

Answer 37

planation Choice B is Correct. Checking the client’s vital signs is the priority action among the options given. If the patient is unstable and struggling for air and if no problem has been found with a ventilator, the nurse needs to disconnect the patient from the ventilator and manually ventilate until the problem can be identified. While the question indicates that the Nurse attended the patient, it does not mention if the nurse evaluated the vitals and if the patient is stable. In the absence of such information in the question, it is crucial to assess the vitals and determine if they are durable. Whenever an alarm activates on a ventilator, the nurse first should make sure the patient is adequately ventilated and oxygenated. The nurse should assess the patient's level of consciousness, use of accessory muscles, and chest wall movements; determine whether bilateral breath sounds are present and evaluate the heart rate and SpO2. If the ventilator is intact, the client should never breathe at a rate less than that set on the ventilator. Causes of Low-Pressure ventilator alarm: A leak or disconnect most often causes low-pressure alarmsin the ventilator tubing. Causes include: The patient self-extubates or gets disconnected from the ventilator. Inadequate inflation of the tracheostomy tube cuff Poorly fitting noninvasive masks or nasal pillows/prongs Loose circuit and tubing connections The patient demands higher levels of air than the ventilator is putting out. Responding to Low-Pressure Alarms: While responding to this alarm, please follow this sequence: Always evaluate the patient before checking the ventilator, i.e., always start at the patient and then work your way towards the ventilator checking for loose connections. Assess the patient’s vitals, assess consciousness, chest wall movements, accessory muscles, and oxygen saturation. Look for leaks at the site where the tracheostomy tube enters the neck. Look for loose connections in the rest of the ventilator tubing. If the cause of alarm still cannot be identified, disconnect the circuit from the patient and manually ventilate with a resuscitation bag (Ambu bag) and then call for help. Choice A is incorrect. Oxygen may be helpful, but it may not be enough to address the cause of low-pressure alarm. Choice C is incorrect. After checking the patient's vitals and if no immediate cause for the ventilator alarm can be identified, the nurse needs to disconnect the patient from the ventilator and administer manual ventilation until the problem can be identified and solved. While this option can be a distractor here, please note that it does not take priority over “assessing the patient” unless such information is clearly presented in the question. Choice D is incorrect. There is no indication for CPR at this moment. It is essential to assess the vitals first. High-Yield Tip: Know the causes of low pressure and high-pressure ventilator alarms thoroughly as these are often tested on NCLEX. Know the sequence of responses to such signals. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 38

The nurse is evaluating a patient three days post-operative for signs and symptoms of infection. Which of the following is not a sign of infection of a surgical wound? A. Pus and clear drainage from the site B. Some redness along the edges of the site C. Increasing warmth from the wound D. Red streaks from the site

Answer 38

Explanation NCSBN client need | Topic: Physiological Integrity, Reduction of risk potential Rationale: The correct answer is B. Some redness at the surgical site is a normal finding three days after surgery. Signs of infection include pus, excess wound drainage, increasing warmth from the wound, and red streaks from the site. Choice A is incorrect. While light, clear drainage is an expected finding three days post-operatively, pus drainage is not. Pus indicates a developing infection. Choice C is incorrect. While some heat is normal, an increase in temperature produced by the wound indicates infection at the site. Choice D is incorrect. Red streaks indicate a potentially dangerous infection at the wound and could mean the development of a disease and even sepsis. Reference: Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby

Question 39

While rounding in the mental health unit, you are learning about specific phobias. You should be aware that Ailurophobia is an unreasonable fear of: A. Social interactions B. Clowns C. Crowds D. Cats

Answer 39

Explanation Correct Answer is D. Ailurophobia is best described as an unreasonable fear of cats. The psychiatric mental health treatment interventions for phobias are based on the specific type of phobia. For example, Ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear. Choice A is incorrect. A fear of social interactions is referred to as a Social phobia. Social interaction phobias are typically treated with exposure therapy, antidepressants, or beta-blockers. Choice B is incorrect. The fear of clowns, which is referred to as Coulrophobia, is typically treated with exposure therapy. Choice C is incorrect. The fear of crowds, which is referred to as Enochlophobia, is also typically treated with exposure therapy. 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 40

The nurse is administering digoxin to an infant when she notes that her pulse is 85 beats per minute. What should be the nurse’s most appropriate action? A. Administer the medication. B. Extract blood for serum digoxin levels. C. Withhold the medication and check again after an hour. D. Administer the medication intramuscularly.

Answer 40

Explanation A is incorrect. The nurse should not give the medication if signs of bradycardia are present. The nurse should withhold the medicine and recheck the pulse in an hour. B is incorrect. The initial action of the nurse is to withhold the medication and reassess the patient after an hour. If the pulse remains low, the nurse should inform the physician, and the nurse might extract serum for determination of the client’s digoxin level. C is correct. If the pulse is less than 90 beats/min in an infant, the nurse should withhold the medication and check again in an hour. A consistently low pulse rate may indicate digoxin toxicity. D is incorrect. Digoxin is not administered intramuscularly as it can be excruciating. 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. Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 41

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 41

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 42

A Post Coronary Artery Bypass Graft patient had developed a fever of 38.8° C. The nurse notifies the physician of the elevated temperature because: A. The elevated temperature may lead to profuse sweating B. It may increase cardiac output. C. It is a sign of Cerebral edema. D. It is indicative of hemorrhage.

Answer 42

Explanation A is incorrect. Although there can be diaphoresis during an increase in temperature, it is not going to be a reason to call the physician. B is correct. An increase in temperature leads to increased metabolism and cardiac workload. C is incorrect. Fever is not an early sign of cerebral edema. D is incorrect. When there is significant blood loss, there is no increase in temperature. Instead, there will be a decrease in temperature. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 43

A toddler is brought to the family clinic by her parents due to poor sleep within the past two weeks and intense perianal itching and scratching. The nurse in the clinic would suspect which condition? A. Anal fissure B. Enterobiasis C. Giardiasis D. Celiac disease

Answer 43

Explanation A is incorrect. An anal fissure is a tear in the lining of the lower rectum (anal canal) that causes pain during bowel movements. B is correct. Enterobiasis is an intestinal infestation with the nematode Enterobius vermicularis, or the common pinworm. It is manifested by intense perianal itching and perianal dermatitis and excoriation secondary to scratching due to the presence of eggs in the anal area. C is incorrect. Giardiasis is an inflammatory intestinal infestation with the protozoan Giardia lamblia. It manifests itself as diarrhea, anorexia, vomiting, and failure to thrive in infants and young children. D is incorrect. Celiac disease is a malabsorption disease characterized by hypersensitivity to gluten. Signs and symptoms include failure to thrive, muscle wasting, diarrhea, and vomiting with bulky, foul-smelling stool. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 44

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

Answer 44

Explanation Important Fact: When patients are admitted to a hospital or ambulatory care facility, you will need to support them in their transition from wellness to illness, in dealing with the unknown, and in adjusting to a new environment. The relationship and trust you establish in your first contact with patients can go a long way toward relieving their anxiety and preserving the energy needed for healing. Take time to get to know your client. Try to set a tone of caring, respect, and understanding. Answer & Rationale: The correct answers are A, B, D, and F. o A- Preparing the room, such as making sure the bed is made correctly, is a way to help establish trust with the patient. o B- Gathering necessary information ahead of time, such as name, diagnosis, and anticipated length of stay, allows you to greet the patient more effectively. o D- Orient the patient to the room by making sure the patient knows how to use the bed, the call light, and any equipment as needed. Remember, one of the disruptions associated with illness is anxiety about the unknown. o F- Showing an interest in what the client’s expectations and concerns are told the client that you care about what he is feeling, which helps to establish trust. C is not the correct answer. When introducing yourself, don't be afraid to tell a client that you are a nursing student. Many clients are aware that students have more time to spend with them, and you are more likely to establish an atmosphere of trust by being forthcoming regarding your level of experience. E is incorrect. Taking the time to get to know your client helps to establish a trusting relationship. Try to set a tone of caring, respect, and understanding. NCSBN Client Need Topic: Physiological Integrity Subtopic: Basic Care & Comfort Chapter 11: Experiencing Health and Illness Lesson: Nurse-Patient Relationships Reference: Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith)

Question 45

You ask your 32-year-old female client about her hobbies. The client tells you that they thoroughly enjoy reading, making pottery, hiking, and rock climbing in the mountains. Which of these interests would you primarily focus on and encourage? A. Making pottery because this avocation is relaxing and not hazardous. B. Hiking because this avocation is a good and low-impact exercise. C. Reading because this avocation is relaxing and not hazardous. D. Rock climbing because this avocation is good and low impact exercise.

Answer 45

Explanation The correct answer is B. You would primarily focus on and encourage hiking because hiking is not only a hobby and interest for the client, but it is an excellent form of exercise that is low impact and relatively safe in comparison to other hazardous hobbies like rock climbing. Choice A is incorrect. Making pottery is not the activity or hobby that you would focus on and encourage because pottery making is a sedentary and solitary activity and not one that provides enjoyable outdoor exercise and social interactions with others. However, it can be relaxing and with minimal hazards. Choice C is incorrect. Reading is not the activity or hobby that you would focus on and encourage because the text is a sedentary and solitary activity and not one that provides any exercise and social interactions with others, although it can be relaxing. Choice D is incorrect. Rock climbing is not the activity or hobby you would focus on and encourage because rocking climbing is exceptionally hazardous, although it is an excellent and low-impact exercise. NCSBN Client Need Topic: Health Promotion and Maintenance; Sub-Topic: Education to prevent High-Risk Behaviors. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 46

You are in a client's room and are suddenly interrupted with a fire alarm as you are documenting client care in the client’s electronic medical record. What should you do? A. Follow the RACE procedure to address this internal disaster. B. Rescue all clients and visitors from immediate danger. C. Log off the computer. D. Determine whether or not it is a fire drill.

Answer 46

Explanation Correct Answer is C.You must immediately and rapidly log off the computer to maintain information security and clients’ medical records and information privacy. You would then shortly follow the RACE procedure. It would only take a few seconds to log off the computer. It is essential to protect client privacy under the HealthInsurance Portability and Accountability Act (HIPAA). Patients may take advantage of an open computer terminal to look at their records, leading to a HIPAA violation if they access another patient’s health information. Although most computers are programmed to automatically log off after a specific time, this should not be relied upon as a backup. It is important to log off when the RN leaves the area, even if she is going for a minute or two. Some common HIPAA violations that nurses make: You forget to log out of the computer terminal. They were throwing out handwritten notes that have protected patient information in an insecure fashion. We were discussing patient cases with uninvolved coworkers. I am speaking with unauthorized patient's family members or friends. Taking selfies with patients and posting on social media We are using unsecured channels outside medical software to communicate with the care team (e.g., texting patient information via. personal cell text message). Failure to report HIPAA violations promptly. Failure to take required HIPAA training. Choice A is incorrect. Following the RACE procedure for this internal disaster is not the first step here. You can immediately log off and then move to follow the RACE procedure. Choice B is incorrect. You would not immediately rescue all clients and others because something else must be done first. Choice D is incorrect. You would not determine whether or not this is a fire drill because something else must be done first. Additionally, you must respond to all fire alarms as if it is an actual fire. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 47

Which of the following neurological assessments would be considered abnormal in a newborn? Select all that apply. A. High pitched cry B. Pupils are 2mm. equal. round. and react briskly to light. C. Lethargic D. Sleeping between each feeding.

Answer 47

Explanation Answer: A and C A is correct. A high, pitched cry is an irregular finding in a newborn. It can be a sign of withdrawal in neonatal abstinence syndrome, or a sign of increased ICP if there is birth trauma. B is incorrect. This is the usual pupil assessment. 2-3mm, equal in size, round in shape, and briskly reactive to light, is the expected finding for a pupil assessment in a newborn. C is correct. For the level of consciousness, lazy is not a normal finding. We expect the newborn to be alert. Lethargic, obtunded, stuporous, or comatose are all abnormal findings. D is incorrect. For behavior, an infant is expected to be sleeping between their feedings. This is considered appropriate for the age and is a reasonable assessment finding. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Subject: Maternal and Newborn Health Lesson: Newborn Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Question 48

A patient has been marked as “confidential” due to safety concerns. Which of these actions would be inappropriate for the nurse? A. Keep the patient’s name/information out of public areas such as the nurse’s station B. Tell the patient’s mother he is okay when she calls to ask if he is still on the unit C. Deny that the patient is on the unit when visitors come or call D. Remove the patient from confidential status when he asks to be removed

Answer 48

Explanation Answer and Rationale: The correct answer is B. When a patient has asked to be flagged as confidential, no medical personnel can give out any information, including verifying the patient’s presence in the hospital. NCSBN Client Need Topic: Safe and Effective Care Environment Subtopic: Safety and Infection Control Chapter 26: Safety, Security, and Emergency Preparedness Lesson: Legal Factors Related to Patient Safety

Question 49

Which of the following components should the nurse know to include in her handoff after her shift? Select all that apply. A. PRN medications administered B. Normal assessment findings for the shift C. A complete history of lab results and interventions since admission D. All scheduled medications the client receives.

Answer 49

Explanation Answer: A A is correct. Medications administered as needed should be included in the nursing handoff. Nursing handoff should review the client's condition during the past shift accurately, but quickly. Important information about the client and what has occurred over the recent change is essential to include, and PRN medications would be included in this. B is incorrect. Normal assessment findings for the shift are not a necessary component of the nursing handoff. Nursing handoff should review the client's condition during the past shift accurately, but quickly. Reviewing all normal assessment findings would not only take too long but is not necessary information. Any changes in assessment findings, abnormal findings, and current problems should be included, but normal assessment findings are not required to cover. C is incorrect. A complete history of lab results and interventions since admission is not a necessary component of the nursing handoff. Nursing handoff should review the client's condition during the past shift accurately, but quickly. I was going over a complete history of lab results and interventions since admission would not only take too long but would not be pertinent. D is incorrect. All scheduled medications the client receives is not a necessary component of the nursing handoff. Nursing handoff should review the client's condition during the past shift accurately, but quickly. As needed medications, changes in the client's situation, interventions, and the client’s response to such interventions are part of the nursing handoff. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Coordinated care Subject: Fundamentals Lesson: Prioritization, delegation, and leadership Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Question 50

An experienced nurse is caring for a 24-hour old newborn in the nursery. She suspects asphyxia in utero. All of the following assessment findings would indicate asphyxia in utero except: A. There is a present palmar-grasp reflex. B. The nurse strokes the sole of the newborn’s feet but there is no response. C. The neonate is unresponsive when the nurse claps her hands above him. D. The neonate has weakand ineffective sucking.

Answer 50

Explanation A is correct. A present palmar-grasp reflex indicates that there is an intact neurologic response from the neonate. B is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence in Babinski reflex indicates asphyxia in utero. C is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence in the Startle reflex indicates asphyxia in utero. D is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence or depression in the sucking reflex indicates asphyxia in utero. 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 51

Which of the following nursing diagnoses is appropriate for your client when your client is not coping with a progressive disease in an adaptive manner? A. Ineffective coping related to fear secondary to a progressive disease B. Ineffective coping related to role ambiguity secondary to a progressive disease C. Ineffective coping related to role changes secondary to a progressive disease D. Ineffective coping related to role conflict secondary to a progressive disease

Answer 51

Explanation Correct Answer is C Correct. “Ineffective coping related to role changes secondary to a progressive disease” is the nursing diagnosis that is appropriate for your client when your client is not coping with a progressive disease adaptively. “Ineffective coping related to fear secondary to a progressive disease” is not correct because there is no indication that this client is affected with fear; “Ineffective coping related to role ambiguity secondary to a progressive disease” can occur when the client with a progressive disease is not sure about what is expected in their sick role, there is no indication that this client is affected with this uncertainty. Lastly, “Ineffective coping related to role conflict secondary to a progressive disease” is also not appropriate because there is no data in this question that indicates that the client has a role conflict. Choice A is incorrect. “Ineffective coping related to fear secondary to a progressive disease” is not correct because there is no indication that this client is affected by fear. Choice B is incorrect. “Ineffective coping related to role ambiguity secondary to a progressive disease” can occur when the client with a progressive disease is not sure about what is expected in their sick role. Still, there is no indication that this client is affected by this uncertainty. Choice D is incorrect. “Ineffective coping related to role conflict secondary to a progressive disease” is also not appropriate because there is no data in this question that indicates that the client has a role conflict. 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 52

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

Answer 52

Explanation D is correct. The client should be taught ways on how to prevent and manage dumping syndrome. The client should be instructed to have small, frequent meals; maintain a high protein, high fat, low carbohydrate, and dry diet. The client should be notified to eat in a recumbent or semi-recumbent position. Such positioning during eating delays gastric emptying. A is incorrect. The client is instructed to lie down after meals to delay gastric emptying. B is incorrect. The client should not drink any water 1 hour before eating, with food, or 2 hours after eating to prevent dumping syndrome. C is incorrect. The client should limit carbohydrate intake to prevent dumping syndrome. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 53

You are providing care and leading a therapeutic group for widows and widowers who have recently lost a loved one. Many of these clients express their belief that the loved one was saintly and highly virtuous. Which stage of grief and loss is demonstrated with these beliefs? A. The Beatification stage. B. The Idealization stage. C. The Disbelief stage. D. The Restitution stage.

Answer 53

Explanation The correct answer is B. According to Engel’s theory of grief and loss, these beliefs demonstrate the Idealization stage of grief and loss. The other steps of Engel’s approach are the: * Shock and disbelief stage * Developing awareness stage * Restitution stage * Resolving the loss stage * Outcome stage Choice A is incorrect. Beatification is the process of making something, like a city street, more visually attractive; beatification is not the process of believing that the lost loved one was saintly and highly virtuous. Choice C is incorrect. The Disbelief stage is characterized by shock and denial. Choice D is incorrect. The Restitution stage is characterized by accepting the loss. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 54

A 16-year old male has an appointment with his psychiatrist. He is currently taking haloperidol regularly. The patient complains of dry mouth, weight gain, and muscle stiffness. What adverse effects is this patient experiencing, and what medication will the psychiatrist give? A. Extrapyramidal symptoms. mannitol B. Extratriangular symptoms. ibuprofen C. Extratriangular symptoms. tylenol D. Extrapyramidal symptoms. benadryl

Answer 54

Explanation D is the correct answer. This patient is experiencing side effects that are classified as extrapyramidal symptoms. Administering Benadryl, along with other medications like Cogentin and Artane, is known to help these symptoms improve rapidly. A is incorrect. Mannitol does not indicate this scenario. Mannitol is used to decrease swelling in the brain. B and C are incorrect. Extratriangular symptoms are the wrong term for the adverse effects that the patient is experiencing. Ibuprofen and Tylenol are not likely to help this patient. NCSBN Client Need Topic: Pharmacologic and Parental Therapies Sub-topic: Adverse Effects/Contraindications/Side Effects/Interactions Subject: Psychiatric Health Lesson: Adverse Effects of Medications Reference: Townsend, 2015

Question 55

The nurse is assisting in the monitoring of a client with a chest tube. The nurse documents each of the following assessments. Which of these assessments are expected findings? Select all that apply. A. Drainage system at a level below the patient’s chest B. Vigorous bubbling in the water-seal chamber C. Stable water in the tube of the water-seal chamber during inhalation and exhalation. D. Occlusive dressing over the chest-tube

Answer 55

xplanation Answer: A and D A is correct. It is expected that the drainage system will be at a level below the client’s chest. This is what allows gravity to help drain fluid from the pleural space. If the drainage system was above the client’s chest, the chest tube would not work properly. B is incorrect. Gentle bubbling in the water chamber is an appropriate finding, but the bubbling should not be vigorous. Gentle bubbling indicates that air is draining from the client, but if vigorous or excessive bubbling is noted, there may be an air leak, which will need to be addressed quickly C is incorrect. It is not expected for the water in the tube of the water-seal chamber to be stable during inhalation and exhalation. The water in the tube of the water-seal chamber should fluctuate during inhalation and exhalation. If it does not, the chest tube could be occluded, the lung could have re-expanded, or there could be air leaking into the pleural space. The nurse will need to notify the physician of this finding to investigate the cause and take appropriate action. D is correct. An occlusive dressing placed over the chest-tube is appropriate. This is important to ensure that air does not enter the pleural space causing a pneumothorax. The nurse should check the dressing to ensure that it is airtight. NCSBN Client Need: Reduction of Risk Potential Topic: Potential for Complications of Diagnostic Test/Treatments/Procedures Subtopic: Chest tubes Subject: Adult Health Lesson: Respiratory

Question 56

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 56

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 57

The home health nurse is talking to a client with iron-deficiency anemia. Which meal plan would indicate to the nurse that the client understood her discharge instructions? A. Roast beef, gelatin salad, green beans, and peach pie B. Chicken salad, coleslaw, French fries, ice cream C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisins D. Pork chop, creamed potatoes, corn, and coconut cake

Answer 57

Explanation A is incorrect. Roast beef is high in iron; however, the other dishes accompanying the meal are low in iron. B is incorrect. Chicken and green leafy vegetables are rich in iron; however, french fries and ice cream have low nutritional value. C is correct. Foods that are high in iron are egg yolks, wheat bread, carrots, green leafy vegetables, and raisins. This is an optimal meal for the client to increase his dietary iron intake. D is incorrect. Pork chops contain high iron. Potatoes, corn, and coconuts, however, contain low iron. 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 58

The nurse in the pediatric clinic is talking to a mother of an 18-month-old toddler. The mother asks about her child’s protruding abdomen. The most appropriate response by the nurse is: A. “Your baby ate too much; that’s why he has a large abdomen today.” B. “Your toddler has not yet developed his abdominal muscles.” C. “Your toddler has a bow legged posture. This accounts to your child’s protruding abdomen.” D. “Maybe your child has too much gas in his stomach.”

Answer 58

Explanation A is incorrect. During toddlerhood, food intake decreases, not increases. B is correct. Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. C is incorrect. The toddler’s bow-legged structure does not influence the abdominal circumference of the toddler. D is incorrect. The toddler having too much gas in his abdomen would mean that he is colicky. However, the toddler is not displaying any symptoms of colic. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 59

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 59

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 60

The patient is presenting with a fever, nausea, and dysuria. Which action would the nurse take first? A. Administer as needed antipyretic. B. Call physician to obtain an antibiotic order for a suspected UTI C. Collect midstream, clean-catch urine specimen D. Collect STAT blood cultures

Answer 60

Explanation C is correct. The nurse should recognize that this patient is presenting with symptoms of urinary tract infection (UTI) or pyelonephritis. The most appropriate first action would be to assess the patient and check the urine for infection. A is incorrect. In a patient who is not in distress or severe pain, the nurse should not administer medication until the assessment is complete. B is incorrect. The nurse should finish assessment prior to calling physicians since there is no data to support a medical emergency scenario to immediately notify physician without a complete assessment. Besides, urine specimen should be collected before administering an antibiotic in a suspected UTI. D is incorrect. The patient’s symptoms are consistent with urinary tract infection and would not necessarily warrant blood cultures. A complicated UTI may evolve in to sepsis. If signs of sepsis are present, blood cultures would be appropriate. NCSBN Client need: Topic: Establishing priorities, system-specific assessment Reference: (DiGiulio & Keogh, 2014, p. 368);Subject:Adult health;Lesson:Renal/urinary

Question 61

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? A. Prepare to irrigate the colostomy. B. After assessing the stoma and surrounding skin, notify the surgeon. C. Assess bowel sounds and administer antiemetic. D. Administer a bulk-forming laxative, and encourage increased fluids and exercise.

Answer 61

Explanation Important Fact: Educating patients regarding measures to promote fecal elimination to include: increase daily fluid intake and instruct the client to drink hot liquids, warm water with a squirt of fresh lemon, and fruit juices, especially prune juice. Include fiber in the diet, that is, foods such as raw fruit, bran products, and whole-grain cereals and bread. Answer & Rationale: The correct answer is B. The client has assessment findings consistent with complications of surgery. Answer A is incorrect. Irrigating the stoma is an independent nursing action. It is also an intervention without proper assessment. Answer C is incorrect. Assessing the peristomal skin is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Answer D is incorrect. Administering a bulk-forming laxative to a nauseated patient is contraindicated. Resource NCSBN Client Need Topic: Physiological Integrity Subtopic: Physiological Adaptation Chapter 49: Fecal Elimination Lesson: Bowel Diversion Ostomies Reference: Kozier &Erb’s Fundamentals of Nursing

Question 62

Your newly assigned client has a history of chronic obstructive pulmonary disease (COPD). When you enter his room, you find his oxygen is running at 6 L/min. his color is flushed. And his respirations are 8/min. What should you do, FIRST? A. Place client in high Fowler’s position B. Lower the oxygen rate C. Take baseline vital signs D. Obtain an EKG

Answer 62

Explanation Answer and Rationale: Individuals with COPD experience lowered oxygen tension and increased carbon dioxide retention during sleep, especially during REM sleep, when neuromuscular control usually is depressed. This can result in pulmonary spasm and transient pulmonary hypertension. The correct answer is B. Low oxygen level stimulates respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe. This can lead to increased hypoventilation and, possibly, the development of or worsening of respiratory acidosis can occur. Left untreated, this can result in a patient’s death. A is incorrect. Although High-Fowler’s position is recommended, it is not the FIRST action that should be taken. C is incorrect. Baseline vitals are taken on admission to the unit. D is incorrect. While an EKG may be ordered if symptoms do not resolve, the FIRST nursing action should be to lower the O2 rate and see if there is an improvement in the patient’s status. NCSBN Client Need Topic: Physiological Integrity Subtopic: Reduction of Risk Potential Chapter 12: Stress and Adaptation Lesson: Respiratory System Disorders Resource: Fundamentals of Nursing (Wilkinson/Barnett)

Question 63

Upon your arrival in the Labor and Delivery (L & D) department, the off-going nurse informs you that your patient is a G1P0, 18-year-old, and the fetus is in the ROA position. As an L&D nurse, you know that when you palpate your patient's abdomen, you will find the embryo in which of the following areas? Please choose the correct image.

Answer 63

Explanation The Correct Answer is A. The image is showing the fetus in the ROA (Right Occiput Anterior) position. The presenting part (Occiput, back of the head) is directed rightwards and anterior to the mother’s pelvis. Fetal “Position” represents the orientation of the fetus in the mother’s womb, defined by the location of the presenting part of the embryo relative to the pelvis of the mother. When dealing with the presentation of the fetus, the fetal position is indicated with three letters. The first letter will be either R or L, indicating right or left orientation. The second letter will be either O, M, or S. This indicates the presenting part of the fetus: O for Occiput (head/ vertex presentation), M for Mentum (chin/ face presentation), or S for Sacrum (bottom/ breech presentation) or Scapula (Shoulder presentation). The last letter will be either A or P. This indicates if the presenting part of the fetus is oriented anterior or posterior or transverse to the mother’s pelvis. Choice B shows the fetus in the LOT (Left Occiput Transverse) position. The Occiput is facing felt and is transversely positioned about the mother’s pelvis. Choice C shows the fetus in the ROP (Right Occiput Posterior) position. Choice D shows the fetus in the LOA (Left Occiput Anterior) position.LOA is the most common fetal position. The Occiput-Anteriorposition is the most ideal for birth. NCSBN Client Need Topic: Health Promotion and Maintenance Subtopic: Ante/Intra/Postpartum and Newborn Care

Question 64

The LPN is caring for a 3-year-old newly diagnosed with ALL. While talking to the family. Does she know to reinforce which of the following educational points based on the child’s diagnosis? Select all that apply. A. Bleeding precautions B. Contact precautions C. Neutropenic precautions D. Sternal precautions

Answer 64

Explanation Answer: A and C A is correct. Bleeding precautions are an essential educational point for a patient with ALL. Because of the excess of blast cells, their platelet count will drop. With decreased platelets, it will take the patient longer than usual to clot, leading to an increased bleeding risk. B is incorrect. Contact precautions are not necessary for a patient with ALL. Contact precautions would be used for a disease that is spread from person to person via contact with the infectious agent, such as MRSA. ALL is not a contagious disease that can be transmitted from person to person, so contact precautions are unnecessary. C is correct. Neutropenic precautions are essential to discuss with the family of a child with ALL. Because the child has a low absolute neutrophil count and a high blast percentage, their ability to fight infections will be severely impaired. This means that special precautions need to be in place to protect the child from disease. These neutropenic precautions include no fresh flowers or plants in the room; all visitors should wash their hands before entering the room and wear a mask, no sick visitors, and keeping the door closed. D is incorrect. Sternal precautions are not necessary for the patient with ALL. Sternal precautions are put in place after an incision is made on the sternum during cardiothoracic surgery. It is to prevent excessive pulling and tension on these sutures while the sternum heals. The patient with ALL does not need sternal precautions. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Infection control and safety Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Oncology

Question 65

A nurse is caring for a woman that just had a Normal delivery in the Delivery room an hour ago. The nurse understands that the patient is still at risk for Uterine atony at this stage. All of the following interventions should be included in the care plan of the patient for detection of uterine atony except: A. Checking for saturated perinel pads every shift B. Palpating the fundus at frequent intervals C. Weighing perineal pads once they are changed, noting the time it was changed and the saturation D. Checking vital signs frequently for signs of shock

Answer 65

Explanation A is correct. Checking perineal pads every shift is an incorrect practice. The nurse should assess the perineal pad of the immediate post-partum woman every 30-minutes, not every turn. Perineal pads getting soaked with blood within 30 minutes should be a cause of concern for the nurse for these is a sign of continuous bleeding through the uterus due to Uterine Atony. B is incorrect. Palpating the fundus frequently is correct practice. The nurse should palpate the patient’s fundus frequently to make sure that it is firm and contracted. A firm and contracted uterus prevent blood loss. C is incorrect. Weighing used perineal pads once they are changed is correct practice. The nurse should consider the perineal pads after they are adapted to accurately assess the amount of blood lost by the patient through the perineum. One gram in weight is equivalent to 1 ml in plasma. Taking note of the time, the pads were changed would signify the frequency of pad changes, which is also essential in the assessment. D is incorrect. Checking vital signs for signs of shock is correct nursing practice. The nurse should assess the patient frequently for signs of trauma. These include low blood pressure, weak, thready pulses, increased heart rate, and increased respiratory rate. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003

Question 66

The lymph nodes which lie in front of the mastoid bone are called the: A. Preauricular nodes B. Superficial cervical nodes C. Occipital nodes D. Supraclavicular nodes

Answer 66

Answer and Rationale: The correct answer is A. The preauricular nodes are, as the name implies, in front of the ear. B is incorrect. Cervical nodes are in the neck. C is incorrect. Occipital nodes are at the base of the skull posteriorly. D is incorrect. Supraclavicular nodes are above the clavicle. NCSBN Client Need Topic: Physiological Integrity Subtopic: Physiological Adaptation Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer) Chapter 12: Head and Neck, with Vision and Hearing Basics Lesson: Lymph Nodes

Question 67

Which of the following conditions are considered a risk factor for women to experience postpartum hemorrhage? Select all that apply. A. Microcephaly B. Dystocia C. Placenta previa D. Singleton pregnancy

Answer 67

Explanation Answer: B and C A is incorrect. Microcephaly is a newborn complication where the newborn is born with a head smaller than average. This is not a risk factor for a woman to experience postpartum hemorrhage. If you selected this answer, you might have gotten it confused with macrosomia, a condition where the infant is more significant than average, specifically higher than 4,000g. This is a risk factor for postpartum hemorrhage. B is correct. Dystocia, prolonged, and painful labor, is a risk factor for postpartum hemorrhage. Prolonged labor, specifically, can dramatically increase the risk of postpartum hemorrhage. C is correct. Placenta previa is a risk factor for postpartum hemorrhage. In placenta previa, the placenta is covering the cervix of the mother rather than sitting in the fundus of the uterus as it should be. This puts the mother at risk for postpartum hemorrhage. D is incorrect. A singleton pregnancy or a pregnancy with only one fetus does not pose a risk for postpartum hemorrhage. The risk factor for postpartum hemorrhage is with multiples, such as twins or triplets. 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.

Question 68

An 82-year old man presents to the emergency department after a ground-level fall. The paramedics tell you that the left pupil was fixed and dilated. Upon arrival, the patient's elbows, wrists, and fingers are flexed, and legs extended and rotated inward. What is the most important intervention for this patient? A. Obtain IV access immediately B. Turn patient on his side C. Obtain accurate history from family D. Take him straight to the CT scan

Answer 68

Explanation Choice D is correct. This patient's left pupil is fixed and dilated, which means it is not reactive to light and stays the same size. When this happens, it can be clinically inferred that there is a lesion or hemorrhage on the opposite (contralateral) side of the brain. The patient also exhibits decorticate (flexor) posturing, with elbows, wrists, and fingers flexed, and legs extended and rotated inward. Often, such abnormal posturing indicates severe brain damage. The patient sustained a fall, and these symptoms likely represent raised intracranial pressure due to intracranial hemorrhage. This patient needs to be taken straight to the CT department to obtain a CT scan of the brain. This will allow the physician to diagnose the patient and initiate early treatment. Choice A is incorrect. Even though obtaining IV access is an important intervention, it is not the priority at this time. A non-contrast CT scan is usually the first intervention to detect a hemorrhage. Intravenous contrast is not necessary. The nurse can obtain IV access after the urgent CT scan is performed. Early diagnosis and appropriate treatment is critical in these settings. Choice B is incorrect. If the patient started having a seizure, then he would need to be turned onto his side. However, he is posturing, which is not a seizure. There are two different types of posturing; decorticate and decerebrate. Decorticate looks as if the patient is turning his or her arms into the core of the body. Decerebrate looks like the patient’s arms are facing outwards, away from the body. Choice C is incorrect. This intervention is important, especially to understand any events before arriving at the hospital, medications he is taking, and recent procedures he has had. NCSBN Client Need I Topic: Physiological Adaptation; Sub-topic: Alterations in Body Systems Reference: Lewis, Dirksen, Heitkemper, Bucher,

Question 69

A high school boy was involved in a head-on motor vehicle collision. He suffered a concussion, a femur fracture, and rib fractures. Three days after ORIF surgery, his heart rate increases from 72 to 110 bpm and his respirations from 18 to 24. What complication does the nurse suspect this patient is experiencing? A. Sepsis B. Fat emboli C. Pulmonary embolism D. Deep vein thrombosis

Answer 69

Explanation B is the correct answer. After suffering from a femur fracture, a patient is at high risk for developing fat emboli syndrome that can cause occlusions in the bloodstream. Fat embolism syndrome is characterized by hypoxia, pulmonary issues, shortness of breath, and confusion. A is incorrect. Sepsis may be likely due to the new surgical procedure, but a fat embolus is more likely due to the femur fracture. C is incorrect. A pulmonary embolism is possible, but a fat embolus is more likely. D is incorrect. This is likely due to a new surgical procedure, but a fat embolus is more likely due to the femur fracture. NCSBN Client Need Topic: Physiological Adaptation Sub-topic: Potential for Alterations in Body Systems Subject: Adult Health Lesson: Musculoskeletal Trauma and Orthopedic Surgery Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013

Question 70

Which of the following statements is true regarding growth during the infancy period? Select all that apply. A. Birth weight doubles by 4 months of age. B. The posterior fontanelle should be soft and flat at 3 months of age. C. The anterior fontanelle closes between 1 and 2 months of age. D. Birth weight triples by 12 months of age.

Answer 70

Explanation Answer: D A is incorrect. This statement is incorrect. Birth weight should double by 6 months of age in the normal infant. Infancy is a period of rapid growth and development, and monitoring weight gain is very important. The infant should be weighed at each check-up with their pediatrician, so that their growth may be plotted on the growth chart to ensure they are meeting goals. By 6 months of age, birth weight should have doubled. B is incorrect. This statement is incorrect. The posterior fontanelle should close between 1 and 2 months of age. The assessment finding of a soft, flat fontanelle is a normal assessment finding if the fontanelle is still open, but it is not normal for a 3-month-old infant to still have an open posterior fontanelle. The anterior fontanelle should still be open at 3 months of age, as it does not close until 9 to 18 months. C is incorrect. This statement is incorrect. The anterior fontanelle closes between 9 and 18 months of age. If you selected this answer, you were probably thinking of the posterior fontanelle, which does close between 1 and 2 months of age. Until the anterior fontanelle closes, it should be assessed to ensure it is soft and flat. D is correct. This is the only correct statement - birth weight should in fact triple by the infant's first birthday. For example, if the infant was born to weigh 7 pounds, he or she should be 21 pounds by the time they are 12 months old. This is an important milestone in the growth that occurs during infancy. NCSBN Client Need: Topic: Psychosocial Integrity Subject: Pediatrics Lesson: Development Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Question 71

You are caring for a substance-abusing client who is chemically dependent and in severe pain. Which of the following medications would be the drug of choice for this client? A. Methadone B. Amitriptlyine C. Nalbuphine D. Talwin

Answer 71

Explanation Correct Answer is C Correct. Nalbuphine, an opioid agonist-antagonist, is used for severe pain and it should be used with caution among clients with a history of drug or substance abuse, however, of all the choices above nalbuphine is the only medication that is appropriate for severe pain and not one, like Talwin, is contraindicated for a substance-abusing client who is chemically dependent at the current time. Choice A is incorrect. Methadone is not used for the management of pain, methadone is used for the treatment of opioid addiction to prevent withdrawal and withdrawal syndrome. Choice B is incorrect. Amitriptyline, which is a tricyclic antidepressant medication, is used for pain management, however, amitriptyline is not used alone to manage severe pain; amitriptyline is an adjuvant medication used in combination with an opioid analgesic to potentiate the effects of the opioid analgesic. Choice D is incorrect. Talwin would be the drug of choice for a substance-abusing client who is chemically dependent and in severe pain. Talwin must be avoided for clients who are chemically dependent because it could lead to withdrawal and withdrawal syndrome. Reference: McCuistion, Linda E., Joyce LeFever Kee , and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier

Question 72

The leading and single MOST important indicator of the intensity and presence of pain is: A. A quantitative assessment and measurement of pain and the intensity of pain with a pain intensity scale. B. The client’s reports of pain to the nurse and other heawlthcare providers. C. A qualitative assessment and measurement of pain with a pain and intensity scale. D. The nurse’s observation and assessment of pain behaviors such as guarding and moaning.

Answer 72

Explanation Correct Answer is B Correct. The leading and single MOST crucial indicator of the intensity and presence of pain is the client’s reports of pain to the nurse and other healthcare providers. Too often, pain is undertreated because we fail to listen to the client and their self-reports of pain; instead, we regularly assess and evaluate client vital signs and pain behaviors, which are less accurate and reliable than the client’s reports of illness. Choice A is incorrect. Although a quantitative assessment and measurement of pain and the intensity of pain with a pain intensity scale can and should be used, this is only one way to obtain the subjective client’s reports of pain. Choice C is incorrect. Although a qualitative assessment can and should be used, this is only one way to obtain the subjective client’s reports of pain, its description, and its characteristics. Choice D is incorrect. Although the nurse will observe and assess pain behaviors such as guarding and moaning, this is not the leading and single MOST important indicator of the intensity and presence of pain. 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 73

When making patient care assignments, the nurse delegates care activities to nursing assistive personnel [NAP]. What factors must the nurse consider? Select all that apply. A. Patient gender and ethnicity B. Complexity of the tasks C. Knowledge and skills of the NAP D. Scope of practice for the NAP

Answer 73

Explanation Correct Answers are B, C, and D. When delegating patient care activities to nurse assistive personnel; the RN must be aware of patient needs, the complexity of the tasks to be assigned, the knowledge and skills of the individual NAP, and which jobs are appropriate to delegate according to the scope of practice for NAPs. Choice A is incorrect. Patient gender and ethnicity are not primary concerns. Bloom's Taxonomy: Applying Reference: Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8th Edition. Elsevier Mosby St Louis 2013.v

Question 74

A 35-year-old patient presents to the ER complaining of fever. Chills. And headaches for the past two days. Pink. Macular rash on palms. Wrists. And soles of feet. Which statement by the patient would indicate to the nurse a potential medical emergency? A. “I am allergic to amoxicillin.” B. “There have been cases of hand-foot-mouth in child’s daycare recently.” C. “I went hiking 2 weeks ago.” D. “I switched my laundry detergent last week because of my sensitive skin.”

Answer 74

Explanation C is correct. The patient is experiencing symptoms of Rocky Mountain Spotted Fever: fever, chills, headache, and a macular rash that appears on palms of hands, wrists, soles of feet, and ankles within ten days of exposure. RMSF occurs due to Rickettsia rickettsii bacteria that can be transmitted to humans via the Ixodid tick. The patient has been hiking, which puts them at risk for coming into contact with ticks. RMSF is hard to diagnose in the early stages, and without treatment can be fatal. A is incorrect. An amoxicillin allergy is vital for the nurse to be aware of, but does not indicate an emergency. The nurse should ask about the patient’s reaction to amoxicillin and document in the patient’s chart. The patient has been experiencing symptoms for several days, and there is no information provided that suggests the patient received any antibiotics recently. B is incorrect. Hand-foot-mouth disease is a common childhood virus that may be transmitted to adults but typically results in a blistering rash, not macular. It is not a medical emergency and usually resolves on its own with only supportive treatment. D is incorrect. Allergic contact dermatitis is a hypersensitivity reaction of the skin that can result from changing laundry detergents. The area of rash is usually limited to the skin that is exposed to allergens, so the patient would have a more widespread outbreak if this were the cause. It is not often accompanied by the patient’s other symptoms of fever, chills, or headache, and would not be a medical emergency. Subject: Adult health Lesson: Infectious diseases Topic: high-risk behaviors, pathophysiology, medical emergencies Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 221, 1778)

Question 75

Select the parenting style that is accurately paired with one of its advantages. A. The democratic style of parenting: It is relatively quick and easy to solve problems. B. The autocratic style of parenting: It gives the impression that the family is strong. C. The permissive style of parenting: It facilitates satisfaction among the members of the family. D. The laissez faire style of parenting: It gives the impression that the family is loving.

Answer 75

Explanation Correct Answer is C Correct. The permissive style of parenting, like other parenting styles, has its advantages and its disadvantages. The permissive style of parenting facilitates satisfaction among the members of the family, however, it is disadvantageous because it can lead to undesirable behaviors because young children of the family may need more structure and clearer boundaries to develop appropriate behaviors. The democratic style of parenting is not a quick and easy way to solve problems; the democratic style of parenting is time-consuming but it also allows all members of the family to all have input and a voice that is heard. The autocratic style of parenting does not give the impression that the family is strong; the impression that it gives is one that the family is rigid and highly structured. The laissez-faire style of parenting does not give the impression that the family is loving; the impression that it gives is one of being lazy and not caring. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 76

Calculate the total number of calories that a client will consume with a snack that contains the following: Carbohydrates: 16 grams Protein: 12 grams Fats: 5 grams A. 47 calories B. 57 calories C. 107 calories D. 157 calories

Answer 76

Explanation The Correct Answer is D.The total number of calories that a client will consume with this snack is 157 calories. The number of calories for each gram of carbohydrates, protein, and fat is as shown below: Carbohydrates: 4 calories per gram Protein: 4 calories per gram Fat: 9 calories per gram Using these calorie counts, the calculation of the calories consumed by the client is as follows: Carbohydrates = 16 grams x 4 calories per gram = 64 calories consumed Protein = 12 grams x 4 calories per gram = 48 calories consumed Fats = 5 grams x 9 calories per gram = 45 calories consumed 64 + 48 + 45 = 157 total calories consumed. Choices A, B, and C are incorrect. NCSBN Client Need: Topic: Basic care and comfort; Sub-topic: Nutrition and oral hydration

Question 77

The patient is receiving instructions from the clinic nurse regarding dietary modifications to help in the treatment of her Cystitis. The nurse is giving her a list of foods to avoid because they irritate her bladder. All of the following are foods that she needs to prevent, except: A. Coffee B. Spaghetti C. Alcohol D. Cranberry juice

Answer 77

Explanation A is incorrect. Coffee/Caffeine is an irritant to the bladder and should be avoided by patients with Cystitis. B is incorrect. Spaghetti sauce contains tomatoes which are an irritant to the bladder and should be avoided by patients with Cystitis. C is incorrect. Alcohol is an irritant to the bladder and should be avoided by patients with Cystitis. D is correct. Cranberry juice is used to acidify the urine of the patient with Cystitis and should be included in her dietary regimen. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 78

Due to a flood, staffs that were able to make it to work are two nursing assistants and one licensed practical nurse with the nurse manager. Knowing the different nursing delivery systems, which system shall the nurse manager implement to care for the 20 clients admitted in their ward? A. Primary nursing B. Team nursing C. Functional nursing D. Case management

Answer 78

Explanation A is incorrect. A registered nurse plans and organizes care for a group of clients and cares for this group during their entire hospitalization. This type of care delivery cannot be useful in this situation. B is incorrect. An RN leads nursing staff who work together to provide care for a specific number of clients. The team typically consists of RNs, LPNs, and client care attendants. The team leader assesses client needs, plans client care, and revises the care plan based on changes in the client’s condition. The leader assigns tasks to team members as needed. This cannot be done in this situation, as this involves too many staff required. C is correct. In functional nursing, each caregiver on a specific nursing unit is given specific tasks that fall into their scope of practice. In this situation, the nurse manager may administer medications to the entire group, while a licensed practical nurse performs treatments, and the client care attendants provide physical care. D is incorrect. Case management is a form of primary nursing that involves a registered nurse who manages the care of an assigned group of clients. This nurse coordinates care with the entire health care team. There is only one RN in the situation. Therefore, it cannot be used. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 79

You are caring for a 12-year-old patient with a history of seizures. During her stay, you notice that she begins staring blankly. During this period, you are unable to get her attention, and she does not speak. You suspect that this is a: A. Petit mal seizure B. Simple partial seizure C. Grand mal seizure D. Myoclonic seizure

Answer 79

Explanation Correct Answer: A. The petit mal (or absence) seizure is characterized by blank staring and impaired level of consciousness. This type of seizure usually begins between the ages of 3 and 15 years. In the simple partial (or Jacksonian) seizure, the patient will be in an awake state but will exhibit abnormal motor or autonomic behaviors that can affect any part of the body. The grand mal (or tonic-clonic) seizure is the type of seizure in which there is a rapid extension of the arms and legs with sudden jerking and eventual loss of consciousness of the patient. It is often accompanied by incontinence and post-ictal confusion. During the myoclonic seizure, the patient may be awake or with short periods of loss of consciousness. During this seizure, the patient will have abnormal motor behavior in one or more muscle groups that lasts a few seconds to a few minutes. NCSBN Client Need Topic: Physiological Adaptation Sub-Topic: Pathophysiology Subject: Child Health Lesson: Neurologic Reference: Centers for Disease Control and Prevention. Epilepsy: Types of Seizures. https://www.cdc.gov/epilepsy/about/types-of-seizures.htm. Accessed online October 2, 2019.

Question 80

Which of the following would the nurse consider to be a warning sign of the presence of physical abuse? Select All That Apply. A. Upper respiratory infections B. Bruises and broken bones C. Unintended pregnancies D. Repetitive strain injuries E. Alcoholism F. Depression

Answer 80

Explanation Domestic violence, including physical, emotional, and sexual abuse, occurs throughout society. It is present among all racial, social, and economic groups. Health issues related to domestic violence include physical injury from the assault, as well as chronic health problems that may emerge, either as a complication of traumatic injury or as a physical response to ongoing stress from violence or neglect. Answer & Rationale: The correct answers are B, C, E, and F. B: Health issues related to domestic violence include physical injury from the assault itself, such as bruises and broken bones. C: Families experiencing domestic violence have more unintended pregnancies, miscarriages, abortions, and low-birth-weight babies. E & F: Families experiencing domestic violence have higher rates of substance abuse and depression. A is incorrect. Upper respiratory infections are not particularly associated with physical abuse. D is incorrect. Repetitive strain injuries are not particularly associated with physical abuse, but with repetitive tasks performed over long periods, such as typing and using a mouse or assembling parts in a factory line. NCSBN Client Need Topic: Psychosocial Integrity Resource: Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith) Chapter 14: The Family Lesson: Challenges Related to Family Health

Question 81

A newly registered nurse is tasked by the nurse educator to do a wet-to-dry dressing change on a stage 3 pressure ulcer. Which of the following actions would indicate to the nurse that the LPN is observing proper technique? A. The new RN cleans the ulcer from the outside, rotating into the inside of the ulcer B. The new RN packs the incision with sterile gauze, then pours sterile NSS over the dressing. C. The new RN packs wet gauze into the ulcer without overlapping it onto the skin. D. The new RN saturates the old dressing with sterile saline before it is removed.

Answer 81

Explanation A is incorrect. The RN should clean from the inside going outside. B is incorrect. Dressings need to be soaked before being applied to the tissue. C is correct. The wet dressing should not touch the intact skin as it will cause skin breakdown. D is incorrect. The old dressing should be removed dry so that debris and necrotic tissue are removed together with the dressing. 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 82

A patient who is taking Lasix knows that he should increase the intake of what food? A. Cantaloupe B. Iceberg lettuce C. Plums D. Apples

Answer 82

Explanation Lasix is the most frequently prescribed loop diuretic. It can increase urine output, even when blood flow to the kidneys is diminished. The rapid excretion of large amounts of water caused by loop diuretics may produce adverse effects, such as dehydration and electrolyte imbalances. Potassium loss may result in dysrhythmias. Therefore, potassium supplements and foods high in potassium are encouraged. The correct answer is A. Cantaloupe has high levels of potassium in it, which tends to be lower in a patient taking Lasix. B, C, and D are incorrect. Each of these options offers little no value of potassium to the diet. NCSBN Client Need Topic: Physiological Integrity Subtopic: Pharmacological Therapies Chapter 28: Drugs for Fluid, Acid-Base and Electrolyte Disorders Core Concepts in Pharmacology (Holland/Adams)

Question 83

The nurse is educating a patient who is taking phenytoin. To make sure phenytoin does not fail, which Over-The-Counter (OTC) medication should the nurse advise the patient not to take at the same time? A. Acetaminophen B. Ibuprofen C. Calcium Carbonate D. Ranitidine

Answer 83

Explanation Correct Answer is C. Calcium Carbonate (Tums) should not be taken at the same time as Phenytoin because taking them together can decrease the effects of phenytoin. Antacids containing calcium carbonate reduce the bioavailability of phenytoin by reducing both the rate of absorption and the amount of intake. Phenytoin is an anticonvulsant, and not getting it at therapeutic dose may result in the client having a recurrent seizure. Clients should be cautioned against concomitant use of antacids/ tums and phenytoin. If the client needs calcium carbonate, he should be instructed to separate the times of intake of calcium carbonate and phenytoin by at least two to three hours. Choice A is incorrect. Acetaminophen and Phenytoin can be taken together without any concern for therapeutic failure. Choice B is incorrect. Ibuprofen and Phenytoin can be taken together and do not cause the therapeutic failure of Phenytoin. Choice D is incorrect. Ranitidine and Phenytoin can be taken together and do not cause the therapeutic failure of Phenytoin. Ranitidine may, however, increase the effects of Phenytoin, and the patient should be monitored for any phenytoin related adverse effects. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological Therapies Reference: Core Concepts in Pharmacology (Holland/Adams)

Question 84

A client in acute exacerbation of ulcerative colitis underwent diagnostic tests and was found to have elevated serum osmolality and urine specific gravity. Which condition could have caused this? A. renal insufficiency B. diabetes insipidus C. hypoaldosteronism D. deficient fluid volume

Answer 84

Explanation Rationale: A characteristic of ulcerative colitis is watery diarrhea. The client loses large volumes of fluid causing hemoconcentration and elevation in the serum osmolality and urine specific gravity. Hypoaldosteronism, renal insufficiency, and diabetes insipidus are not associated with ulcerative colitis. The correct answer is option D, while options A, B, and C are incorrect. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009 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 85

A nurse caring for an HIV positive client is preparing to administer an IV gamma globulin to the client. The client asks the nurse, “What is that you are giving me?” The nurse’s most appropriate response would be: A. “This medication will help stimulate production of red blood cells in your body.” B. “This is intravenous gamma globulin. This will increase the proteins circulating in your blood, helping to increase your blood pressure. C. “This medication will slow down the replication of the virus.” D. “This is gamma globulin. This will help you against infection.”

Answer 85

Explanation A is incorrect. Drugs that stimulate RBC production in the body include erythropoietin. IV gamma globulins do not increase RBC production. B is incorrect. The nurse may be referring to albumin. Albumin is used to elevate the blood pressure in cases of shock and can be used to treat hypoalbuminemia in clients with liver failure. C is incorrect. The nurse is referring to antiretroviral drugs. Antiretrovirals stop HIV from multiplying inside the body. D is correct. Gamma globulins or immunoglobulins are given to boost the clients’ immunity, protecting him from infection. 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 86

A 52-year older man is admitted to the burn unit after surviving a house fire. Both of his arms, anterior and posterior, are burned along with his face and chest. According to the rule of 9’s, what percentage of his body was burned? A. 9% B. 18% C. 31.5% D. 35.5%

Answer 86

Explanation C is correct. According to the rule of 9’s, 27% of this patient’s body is burned. Each arm is 9% because the front and back of each arm is 4.5%. The face is 4.5% and the chest is 9% because the entire torso is 18%. 9 (arm) + 9 (arm) + 4.5 (face) + 9 (chest) = 31.5%. NCSBN Client Need Topic: Safe and Effective Care Environment;Sub-topic: Care Management Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013;Subject:Adult Health;Lesson:Burns

Question 87

A client at 32 weeks gestation comes into the maternity unit complaining that she has not felt her baby move for nearly 6 hours. An external fetal monitor is attached for an NST. The nurse reassures her by telling her that she has a reactive NST which is characterized by A. Decelerations of 10-20 seconds in duration decreasing the baseline HR by 20bpm B. FHR of 120 – 160 bpm C. Three accelerations in 10 minutes with 15 second duration at 10 beats above the baseline HR D. One acceleration in 10 minutes lasting 14 seconds at 8 beats above baseline HR

Answer 87

Explanation A is incorrect. Variable decelerations occur commonly in an NST. They do not provide any reassurance regarding fetal condition. B is incorrect. The fetal heart rate does not provide any data regarding fetal tolerance to stress or its neurological integrity. C is correct. A reactive NST must have at least three accelerations in a specified time-frame and must have at least ten beats above baseline lasting 10-15 seconds. D is incorrect. A reactive NST must have at least three accelerations in a specified time-frame and must have at least ten beats above baseline lasting 10-15 seconds. Less than three accelerations do not make an NST positive. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 88

A female client in her mid-40s comes into the clinic complaining of abdominal pain. She states that the pain is colicky in the epigastric area and is always triggered after she eats French fries and burgers. The nurse notes that the client is also overweight. The nurse should suspect which condition? A. Gastric ulcer B. Appendicitis C. Cholecystitis D. Liver cirrhosis

Answer 88

Explanation A is incorrect. Gastric ulcer is an ulceration of the mucosal lining that extends to the submucosal layer of the stomach. Its manifestations include a gnawing, sharp pain at the left mid-epigastric region 30-60 minutes after a meal. B is incorrect. Appendicitis is the inflammation of the appendix. It is manifested by pain in the periumbilical area that descends to the right lower quadrant. C is correct. Cholecystitis occurs most commonly in overweight women older than age 40 who haven’t gone through menopause. Its manifestations include episodic colicky pain in the epigastric area that radiates to the back and shoulder. Pain in cholecystitis resembles indigestion or chest pain after eating fatty or fried foods. D is incorrect. Cirrhosis is a chronic hepatic disease characterized by diffuse destruction of hepatic cells, which are replaced by fibrous cells. The symptoms presented by the patient does not indicate liver cirrhosis. 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 89

When discussing the Denver II test with the parents of a preschooler, which of these statements would indicate that they correctly understood the teaching? A. This test will tell me whether or not my child’s Intelligence Quotient (IQ) is normal. B. This test will tell me about motor developmental tasks my child can do today. C. This test will measure my child’s development D. This test will let me know if my child’s development is normal or not.

Answer 89

Explanation Choice C is correct. The Denver Developmental Screening Test (DDST) was devised to provide a simple method of screening for evidence of slow development in infants and preschool children. The test covers four functions: gross motor, beautiful motor adaptive, language, and personal-social. It has been standardized on 1,036 presumably healthy children (two weeks to six years of age) whose families reflect the occupational and ethnic characteristics of the population of Denver. Choice A is incorrect. The Denver Test does not measure a child’s Intelligence Quotient (IQ). Wechsler Intelligence Scale for Children is one of the methods used to assess IQ. Choice B is incorrect. The Denver Test does not give information just on the “motor” developmental tasks that the child can perform “today.” Instead, it is an instrument comprising of several tasks, which covers four functions: gross motor, fine motor adaptive, language, and personal-social. Choice D is incorrect. The Denver II is not used to define “normal” vs. “abnormal.” Instead, it is used to provide evidence of slow or delayed development. The preschooler in the question is expected to attain the following milestones. Development milestones of a preschooler NCSBN Client Need Topic: Psychosocial Integrity; Sub-Topic: Growth and Development Reference: Safe Maternity and Pediatric Nursing (Holland/Adams)

Question 90

What is the priority nursing intervention for a newly admitted client with the possible nursing diagnosis of Self-care deficit: Bathing and hygiene? A. Helping the client with their self care needs in terms of bathing and hygiene B. Asking a family member to assist the client with their bathing and hygiene self care needs C. A thorough assessment of the client in terms of their self care strengths and weaknesses D. A thorough assessment of the client in terms of their bathing and hygiene preferences

Answer 90

Explanation Correct Answer is C Correct. The priority nursing intervention for a newly admitted client with the possible nursing diagnosis of “Self-care deficit: Bathing and hygiene” is to perform the priority first phase of the nursing process. Your priority nursing intervention is to perform a thorough assessment of the client in terms of their bathing and hygiene self-care strengths and weaknesses so that you can determine if the client has or does not have a possible self-care deficit in terms of bathing and hygiene. Choice A is incorrect. Helping the client with their self-care needs in terms of bathing and hygiene may be an appropriate nursing intervention for this client. However, you do not know this yet. There is something else that you would do first and as the priority. Choice B is incorrect. Asking a family member to assist the client with their bathing and hygiene self-care needs may be an appropriate nursing intervention for this client. However, you do not know this yet. There is something else that you would do first and as the priority. Choice D is incorrect. Although you would perform a thorough assessment of the client in terms of their bathing and hygiene preferences, this is not the priority. There is something else that you would do first and as the priority. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 91

The nurse is caring for a client who has generalized urticaria. The nurse should isolate the client using A. airborne precautions. B. droplet precautions. C. contact precautions. D. standard precautions.

Answer 91

Explanation Generalized urticaria typically manifests when the client is experiencing an allergic reaction. This skin condition does not require isolation. The nurse should plan to care for this client using standard precautions.

Question 92

Which of the following statements correctly outlines the proper flow of blood through the heart? A. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → pulmonary valve → pulmonary artery → lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation. B. Superior and Inferior vena cavas → Right atrium → mitral valve → Right ventricle → pulmonary valve → pulmonary artery → lungs → pulmonary veins → left atrium → tricuspid valve → left ventricle → aortic valve → aorta → systemic circulation. C. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → pulmonary valve → pulmonary veins→ lungs → pulmonary artery → left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation. D. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → aortic valve → pulmonary veins→ lungs → pulmonary artery → left atrium → mitral valve → left ventricle → pulmonary valve → aorta → systemic circulation.

Answer 92

Explanation Answer: A A is correct. This is the proper flow of blood through a healthy heart with normal anatomy. The superior and inferior vena cavas are the large veins that bring back deoxygenated blood from the body to the right atrium of the heart. The blood enters the right atrium, passes through the tricuspid valve into the right ventricle, and is then pumped into the lungs through the pulmonary artery. Here, in pulmonary circulation, the deoxygenated blood drops off its carbon dioxide and waste products and picks up fresh oxygen to deliver to the body. It is now oxygenated. The blood returns to the left atrium through the pulmonary veins passes through the mitral valve to enter the left ventricle and is then pumped out to the body through the aorta. Oxygenated blood is now in the systemic circulation, where it can deliver oxygen to all the tissues of the body. B is incorrect. In this sequence, the mitral and tricuspid valve locations are switched. Remember, the mitral valve is between the left atrium and ventricle, and the tricuspid valve is between the right atrium and ventricle. C is incorrect. In this sequence, the pulmonary artery is switched with the pulmonary vein. The pulmonary carries deoxygenated blood away from the heart and to the lungs. It is the only artery in the body that carries deoxygenated blood! The pulmonary vein brings oxygenated blood back from the lungs to the left atrium. D is incorrect. In this sequence, the pulmonary and aortic valves are switched. This should be easy to remember, as the pipes are named after which vessel they open into. The pulmonary valve is located at the opening of the pulmonary artery, and the aortic valve is located at the opening of the aorta. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk of the potential reduction Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences. Subject: Adult health Lesson: Cardiac

Question 93

The nurse is working in the newborn nursery. Which assessment finding in a newborn would lead the nurse to suspect cystic fibrosis and notify the healthcare provider of the finding? A. Steatorrhea B. Hyperhidrosis C. Meconium Ileus D. Barrel chest

Answer 93

Explanation Choice C is correct. Meconium Ileus is very frequently the first sign of cystic fibrosis in a newborn. Meconium ileus refers to a small bowel obstruction that occurs when the infant's first stool is thicker and stickier than usual, causing a blockage in the ileum. Often, it presents within few hours of birth with bilious vomiting as soon as feedings are initiated. Abdominal distension may be present. Some infants may manifest with just delayed passage of meconium rather than acute symptoms of obstruction. Meconium peritonitis may occur if there is perforation and may manifest with abdominal tenderness, fever, and shock. Choice A is incorrect. Steatorrhea is described as stools that are bulk, frothy, and foul-smelling. Steatorrhea is caused by the excretion of abnormal quantities of fat in the stool. This does occur in cystic fibrosis, but would not be present yet in a newborn. Choice B is incorrect. Hyperhidrosis is a medical condition in which a person sweats excessively and unpredictably. This is not a sign of cystic fibrosis in the newborn. Newborns with cystic fibrosis will have elevated levels of chloride in their sweat, causing it to taste salty, but they will not sweat excessively. Choice D is incorrect. Barrel chest is a long-term complication of cystic fibrosis, but not a sign that would be present at birth in the newborn. A barrel chest refers to a broad, deep chest that is large and cylindrical. It occurs when the patient has been suffering from hypoxemia due to cystic fibrosis for a prolonged period of time. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care

Question 94

The sense of hearing is assessed using which standardized test? A. Taylor test B. Rinne test C. Babinski test D. APGAR test

Answer 94

Explanation Answer and Rationale: The correct answer is B. The sense of hearing is assessed using the Rinne test and the Weber test and a tuning fork. A is incorrect. A Taylor hammer, not a Taylor test, is used to check reflexes like the biceps and triceps reflexes. C is incorrect. The Babinski sign occurs when the foot goes into dorsiflexion, and the great toe curls up; this sign is an abnormal response to this stimulation, and it can indicate the presence of neurological lesions. D is incorrect. The APGAR test is used to assess the neonate immediately after birth in terms of the infant’s appearance, grimace and reflexes, appearance in terms of skin color, and respiratory rate and effort. NCSBN Client Need Topic: Health Promotion and Maintenance Chapter 30: sensation, Perception & Cognition Lesson: Sensory Deficit, Hearing Reference: Fundamentals of Nursing (Wilkinson and Barnett)

Question 95

When evaluating the heart rate of a 2-year-old awake patient, the nurse documents which of the following heart rates as "tachycardia"? Select all that apply. A. 60 beats per minute B. 130 beats per minute C. 150 beats per minute D. 180 beats per minute

Answer 95

Explanation Correct answers are C and D. The average heart rate for a 2-year-old when awake is 100 to 140. So, the nurse would document heart rates of 150 (Choice C) and 180 (Choice D) as "tachycardia." Tachycardia in an infant/ toddler may indicate fever, illness, pain, dehydration, anxiety, or stress. Since pediatric vitals differ from adult vitals, it is essential for the nurse to be aware of the normal vitals in children so the nurse can plan appropriate interventions should the vitals turn out abnormal. Choice A is incorrect. The average heart rate for a 2-year-old is 100 to 140. The nurse would document a heart rate of 60 as bradycardia, not tachycardia. Choice B is incorrect. The average heart rate for a 2-year-old is 100 to 140. The nurse would document a heart rate of 130 as usual, not tachycardia.

Question 96

The nurse is assisting with the care of a client with a chest tube. The nurse knows which of the following interventions would be appropriate when caring for this client? Select all that apply. A. Periodically check that all connections are secure B. Tape the tubing to the bed C. Check the tubing frequently for kinks and dependent loops D. Refill the water-seal chamber once a shift.

Answer 96

Explanation Answer: A and C A is correct. It is appropriate for the nurse to periodically check that all connections are secure when assisting with the care of a client with a chest tube. The chest tube drainage system will only function if it is a closed system, and in order for that to be true all the connections must be secure and air tight. B is incorrect. It is not acceptable for the nurse to tape the tubing of the chest tube system to the bed. This would be a safety concern, because if the client moved and the tubing remained taped to the bed the chest tube could become dislodged. C is correct. It is appropriate for the nurse to check the tubing frequently for kinks and dependent loops when assisting with the care of a client with a chest tube. If there are kinks or dependent loops in the tubing the chest tube drainage system will be obstructed and not draining fluid from the client. Ensuring that this does not occur helps the chest tube drainage system remain patent so that the client’s lung may expand to a normal state. D is incorrect. It is not appropriate for the nurse to refill the water-seal chamber once a shift. The chest tube drainage system should never be opened, because this breaks the closed system. If there are breaks in the closed system air can leak into the patient and cause a pneumothorax collapsing the client's lung. NCSBN Client Need: Physiological Adaptation Topic: Alterations in Body Systems Subtopic: Infection control and safety Subject: Adult Health Lesson: Respiratory

Question 97

Which of the following is a priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting? A. The external healthcare setting’s or service’s cultural values and beliefs. B. The external healthcare setting’s or service’s admission criteria. C. The current healthcare facility’s actual and potential census. D. The current healthcare facility’s actual and potential case mix.

Answer 97

Explanation The correct answer is B. The external healthcare setting’s or service’s admission criteria is the priority that must be considered and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice A is incorrect. Although the external healthcare setting’s or service’s cultural values and beliefs should be considered, it is not the priority that must be found and critically thought about by the nurse before referring a client to a healthcare setting or service external to their current healthcare setting. Choice C and D are incorrect. The current healthcare facility’s actual and potential census is not a consideration that the nurse should think about before referring a client to a healthcare setting or service external to their current healthcare setting; it is the client’s needs that must be considered. Reference: Sommer, Johnson, Roberts, Redding, and Churchill. Nursing Leadership and Management: Review Module Edition 6.0; ATI Nursing Education.

Question 98

The nurse is preparing to admit a newborn diagnosed with Tetralogy of Fallot to neonatal intensive care. The nurse knows that to maintain a patent ductus arteriosus the provider will order __________. A. Alprostadil B. Indomethacin C. Propranolol D. Morphine

Answer 98

Explanation Answer: A A is correct. Alprostadil will be administered to keep the ductus arteriosus open, or patent. This will allow more pulmonary blood flow to the child with low oxygen saturations waiting for surgery. B is incorrect. Indomethacin is used to close the PDA, not to keep it open. C is incorrect. Propranolol is a beta blocker sometimes used in the management of a tetralogy of fallot spell. It will not help keep the PDA open. D is incorrect. Morphine is used to decrease pulmonary vascular resistance and calm the child during a tetralogy of fallot spell, but does not keep the PDA open. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Pharmacological therapies Subject: Pediatrics Lesson: Cardiac

Question 99

A client with lung cancer has recently had a left lower lobe removal. Which priority will the postoperative intervention be performed in the care of this patient? A. A tracheostomy B. A mediastinal tube C. Incentive spirometer D. Closed chest drainage system

Answer 99

Explanation NCSBN client need | Topic: Reduction of Risk Potential / Potential for Complications of Diagnostics Tests, Treatments or Procedures Rationale: The correct answer is D Correct. A patient with a recent lower lobe lung removal will have a chest tube drainage system to collect the blood and drainage and to prevent it from accumulating in the chest. Choice A is incorrect. The patient will likely not have a tracheostomy. Choice B is incorrect. A mediastinal tube is unlikely to be prescribed for this client. Choice C is incorrect. The patient may use an incentive spirometer during their recovery; it is not a priority nursing action. Reference: Lewis S, Dirksen S, Heitkemper M, Bucher L, Harding M. Medical-Surgical Nursing.

Question 100

The nurse is caring for a client who is severely hypernatremic. Based on the complications from this electrolyte imbalance, the nurse knows that the priority assessment is which of the following? A. Cardiovascular status B. Genitourinary status C. Neurological status D. Gastrointestinal status

Answer 100

Explanation Answer: C A is incorrect. Monitoring cardiovascular status is always important, but it is not the priority in a client with severe hypernatremia. Sodium plays a large role in the brain and nervous system, and therefore the nurse should be careful to monitor the client's neurological status very closely when there is any imbalance. B is incorrect. Monitoring genitourinary status is important, but it is not the priority in a client with severe hypernatremia. There are not major GU symptoms with hypernatremia, but the nurse knows that very serious neurological complications can occur in the hypernatremic client. C is correct. When a client is suffering from severe hypernatremia, monitoring neurological status is the nurse's priority. Neurological complication of hypernatremia range from a restless, agitated client, to a comatose state. Sodium plays a major role in the brain and nervous system, and any imbalances can cause serious neurological symptoms. D is incorrect. Monitoring gastrointestinal status is important, but it is not the priority in a client with severe hypernatremia. There are not major GI symptoms with hypernatremia, but the nurse knows that very serious neurological complications can occur in the hypernatremic client. NCSBN Client Need: Topic: Physiological Adaptation Subtopic: Fluid and electrolyte imbalances Subject: Fundamentals of care Lesson: Fluids & Electrolytes

Question 101

Your client is experiencing severe, acute anxiety prior to a scheduled endoscopy procedure. Which of the following medications is most likely to be ordered by the physician? A. Oxycodone B. Midazolam C. Clonazepam D. Haloperidol

Answer 101

Explanation The correct answer is B. Midazolam (Versed) is a benzodiazepine used for acute anxiety attacks. Midazolam is preferred in this setting because of “Rapid Onset” (2 to 5 minutes after IV administration) and “Short Duration” of action (3 to 8 hours). It can be administered intravenously or orally. Given these benefits, Midazolam would be the most useful for the patient experiencing an acute anxiety attack before or during endoscopic procedures, or before surgery. Additional benefits of Midazolam during procedures are sedation and amnesia. Midazolam as continuous IV infusion is also used in sedating mechanically ventilated patients in critical care settings. The nurse should keep Flumazenil as an antidote ready in case severe respiratory depression occurs with benzodiazepines. Choice A is incorrect. Oxycodone is an opioid pain medication. This is prescribed for severe pain. It is not indicated for the patient experiencing an acute anxiety attack. Choice C is incorrect. Clonazepam is a long-acting benzodiazepine often used in anxiety attacks after a traumatic event, panic disorders, or generalized anxiety disorder. Your client has pre-procedural anxiety and, therefore, does not need a long-acting anxiolytic. Your client needs an anxiolytic with a rapid onset of action and short duration. Midazolam fits that criteria among the above list. Choice D is incorrect. Haloperidol is an antipsychotic and is often used in mental health settings to address acute and severe agitation/ aggression associated with psychiatric disorders (Schizophrenia, Substance intoxication). It would not be useful for a patient experiencing pre-procedural acute anxiety. 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 102

A mother in a pediatric clinic asks the nurse about the soft spots on her baby’s head, and when they are going to harden. The nurse’s most appropriate response would be: A. These soft spots are called fontanels. The one on the front closes at 12-18 months, and the one on the back closes at 2 months. B. These soft spots are called fontanels. The one on the front closes at 2 months, and the one on the back closes at 12-18 months. C. These soft spots are called fontanels. The one on the front closes at 12-18 months, and the one on the back closes at 6 months D. These soft spots are called fontanels. The one on the front closes at 9 months, and the one on the back closes at 2 months

Answer 102

Explanation A is correct. Fontanels are soft Anterior fontanels close at 12 – 18 months and posterior fontanels close at two months. Fontanels facilitate the bony plates of the baby’s skull to flex and allow the baby’s head through the birth canal. B is incorrect. This is an inaccurate statement by the nurse. C is incorrect. This is an inaccurate statement by the nurse. D is incorrect. This is an inaccurate statement by the nurse. 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 103

A patient who has recently been brought to the emergency room after experiencing a very traumatic event appears calm and in total control. The nurse assesses this behavior as which of the following defense mechanisms? A. Projection B. Denial C. Rationalization D. Regression

Answer 103

Explanation NCSBN client need | Topic: Psychosocial integrity, coping mechanisms Rationale: The correct answer is B. Denial is a coping mechanism used to protect a patient from a traumatic experience. A patient in denial will behave as though the trauma never occurred. Choice A is incorrect. Projection is a defense mechanism where the patient takes their personal feelings and places them onto someone else, believing the other person is experiencing the undesired feelings. Choice C is incorrect. Rationalization involves working to find a good reason for something negative occurring. Choice D is incorrect. Regression is a coping mechanism where a patient behaves in a manner reminiscent of an earlier, safe time in their life. Reference: Wilson S. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. Journal of Clinical Nursing. 2008;17(8):1120-1120. DOI:10.1111/j.1365-2702.2006.01939.x.

Question 104

A nurse at the Emergency Department attends to a 9-year-old male patient, accompanied by mother, with chief complaints of fatigue. History reveals that the child has a congenital heart defect and has been on the chronic use of digoxin. Which finding would cause the nurse to suspect digoxin toxicity? A. Bradycardia B. Confusion C. Weight loss D. Dyspnea

Answer 104

Explanation Rationale: The classic symptom of digitalis toxicity is bradycardia. A neurologic effect of digitalis toxicity would be lethargy, rather than confusion. Anorexia is another symptom of digitalis toxicity. Children with underlying heart conditions usually have poor weight gain. Dyspnea is usually not related to digitalis toxicity. Option A is therefore the correct answer. Options B, C, and D are incorrect. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 105

After taking the health history of a client who admits to binge eating, which health concern should the nurse delve further with this client? A. Disorganized behavior B. Emotional hunger C. Adolescent turmoil D. Extreme restlessness

Answer 105

Explanation Rationale When a client continues to eat when already feeling full, he/she is into binge eating. This is a way to cope with emotions that aren’t being handled effectively or met. Adolescent turmoil isn’t necessarily associated with binge eating, while disorganized behavior and extreme restlessness are associated with bipolar disorder, not binge eating. 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 106

Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain? A. A 36 year old female client with abdominal pain B. A 56 year old male client with a leg amputation C. A 76 year old female client with terminal cancer D. An 84 year old male client with severe arthritis

Answer 106

Explanation Correct Answer is B Correct. The 56-year-old male client with a leg amputation would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain. Contralateral massage, or stimulation, unlike other cutaneous nonpharmacological comfort interventions, entails the stimulation of the opposite part of the body rather than the direct stimulation of the painful, affected area. For this reason, contralateral stimulation of the intact opposite leg will promote comfort and the decrease phantom pain that has occurred as a result of the amputation. Choice A is incorrect. A 36-year-old female client with abdominal pain would not benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain; alternative comfort measures and pain management interventions may be indicated. Choice C is incorrect. A 76-year-old female client with terminal cancer would not benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain; alternative comfort measures and pain management interventions may be indicated. Choice D is incorrect. An 84-year-old male client with severe arthritis would not benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain; alternative comfort measures and pain management interventions may be indicated. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 107

The nurse on a medical floor receives a report on four patients. Which patient should the nurse see first? A. A client with pulmonary embolism on anticoagulation, dyspnea, and pCO2 of 30mmHg B. A client with atrial fibrillation on Warfarin, history of prior rectal bleeding and an INR of 6.0 C. A client Congestive Heart Failure and Brain Natriuretic Peptide of 640 pg/mL D. A client with Acute pancreatitis and serum calcium of 8.9 mg/dL

Answer 107

Explanation Choice B is correct. While answering prioritization questions, it is essential to determine which findings are unexpected and which pose an immediate risk of complications to the client. The target International Normalized Ratio (INR) for atrial fibrillation is 2.0-3.0. A supra-therapeutic INR of 6.0 is too high for this patient and puts the patient at high risk for bleeding. Additionally, given his prior history of gastrointestinal bleeding, he is more prone to recurrent bleeding in the setting of coagulopathy. The nurse should hold warfarin, assess the patient for signs of bleeding and notify the physician of abnormal results to determine if vitamin K should be administered to counter the effects of warfarin. Choice A is incorrect. The client has an established diagnosis of Pulmonary Embolism (PE) and is on therapeutic anticoagulation. Dyspnea and elevated D-dimer are expected results in patients with known PE. D-dimer reflects thrombin and plasmin activity and is usually positive in hospitalized patients with thrombotic events. Low pO2 (Hypoxia) and low pCO2 (Respiratory alkalosis) are expected findings in patients with PE. Normal PCO2 is 35-45 mmHg, so 30 mmHg is small but not critical (<20 mmHg). Choice C is incorrect. Brain Natriuretic Peptide is a marker for Congestive Heart Failure (CHF) because it correlates with left ventricular pressure. High Left ventricular pressures and high BNP levels are expected findings in patients with heart failure. A BNP more top than 100 pg/mL is abnormal. The client has an established diagnosis of CHF, and a report of BNP at 640 pg/mL does not require immediate action. Choice D is incorrect. Acute pancreatitis can cause decreased calcium levels (hypocalcemia). Severe hypocalcemia may be seen in acute pancreatitis and can present with neurological as well as cardiovascular manifestations. However, since the normal range for serum calcium level is 8.6-10.2 mg/dL, this patient’s result of 8.9 mg/dL is within normal range and would not warrant any intervention. NCSBN Client Need: Subject: Leadership/management; Lesson: Prioritization Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 578-579)

Question 108

In nursing and healthcare, we often use guidelines to aid in our understanding of a particular phenomenon. For example, we use Erik Erikson’s levels of development to understand growth and development along with the lifespan, and we also learn about some commonly used practices and beliefs that are shared among members of a culture, religion, or ethnic group. Which of the following is a pitfall associated with these guidelines? A. These guidelines are generally ignored and not applied appropriately. B. Guidelines are not as useful as they were thought to be in the past. C. These guidelines can often lead us to erroneously stereotype clients. D. Guidelines hamper critical thinking and evidence practices in nursing.

Answer 108

Explanation Correct Answer is C Correct. These guidelines can often lead us to stereotype clients erroneously. Guidelines provide us with some guidance, but they should never be viewed as absolute fact, and we must always be mindful of individual differences among all of our unique clients. Guidelines are not generally ignored, but they can be applied inappropriately when individual differences are not considered; they are still highly useful, and they do not hamper or interfere with critical thinking and evidence practice; they can aid and enhance our critical thinking and professional judgment. Choice A is incorrect. Guidelines are not generally ignored, but they can be applied inappropriately. Choice B is incorrect. Guidelines remain highly useful when they are applied inappropriately. Choice D is incorrect. Guidelines do not hamper or interfere with critical thinking and evidence practice; they can aid and enhance our critical thinking and professional judgment. References: 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 109

In a staff meeting, the nurses were asked by the nurse manager what their thoughts are on the solutions presented to them regarding medication errors. They were also asked to vote whether to apply the changes proposed or to veto it. Which management style is the unit practicing? A. Autocratic B. Democratic C. Participative D. Laissez-faire

Answer 109

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

Question 110

Which of the following medications would the nurse expect to administer to her patient presenting with an intussusception? Select all that apply. A. Cefazolin B. Lactated Ringers C. Metoprolol D. Ranitidine

Answer 110

Explanation Choices A and B are correct. A is correct. Cefazolin is a broad-spectrum antibiotic commonly used before or after surgeries as a prophylactic antibiotic. It is a cephalosporin antibiotic. It is used when a surgical repair of intussusception is performed to prevent infection. If intussusception is complicated by infection or peritonitis, antibiotics are used for treatment purposes. B is correct. Lactated Ringers is an isotonic crystalloid solution used for maintenance IV hydration in a patient with intussusception. Intussusception is often accompanied by vomiting and severe dehydration. Aggressive hydration is therefore needed to prevent dehydration and shock. C is incorrect. Metoprolol is a beta-blocker used for blood pressure, chest pain, and heart failure. It is not used in intussusception. D is incorrect. Ranitidine is an antacid used to treat and prevent heartburn. It is not used in an intussusception. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Pharmacological therapies Subject: Pediatrics Lesson: Gastrointestinal Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong's Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Question 111

The nurse is caring for a client who presents with blood glucose level 45mg/dL. Which of the following finding(s) is/are expected?Select all that apply. A. Blurred vision B. Increased urinary output C. Cool and clammy skin D. Palpitations E. Orthostatic Hypotension F. Paresthesias

Answer 111

Explanation Correct Answers are A, C, D, and F. Blurred vision (Choice A), Cool and clammy skin (Choice C), Palpitations (Choice D), and Paresthesias (Choice F) are expected findings with hypoglycemia. Hypoglycemia is a blood sugar less than 70 mg/dl. Symptoms of hypoglycemia can be divided into two broad categories: Neurogenic ( autonomic): adrenergic and cholinergic symptoms. Adrenergic symptoms include those of catecholamine releases such as tremor, palpitations (Choice D) and anxiety (catecholamine-mediated, adrenergic) and sweating, hunger, and paresthesias (Choice F) (acetylcholine-mediated, cholinergic). Neuroglycopenic: Neuroglycopenia refers to a deficiency of glucose in the brain and neurons secondary to hypoglycemia. Symptoms of moderate Neuroglycopenia include blurred vision (Choice A), slurred speech, drowsiness, dizziness, and extreme fatigue. Severe Neuroglycopenia can cause delirium, confusion, and eventually, seizure and coma. Choice B is incorrect. Increased urinary output is a manifestation of Osmotic diuresis from Hyperglycemia, not hypoglycemia. Choice E is incorrect. Orthostatic Hypotension is an expected finding due to dehydration from osmotic diuresis related to hyperglycemia,not hypoglycemia. NCSBN Client Need: Topic Physiological adaptation; Sub-Topic: Alteration in body systems

Question 112

Which of the following responses should the nurse avoid when communicating with a patient who has just been given a diagnosis with a poor prognosis? Select All That Apply. A. “My mother has the same thing.” B. “I’ll sit with you a while.” C. “I think you should try having surgery.” D. “Don’t cry. Everything is going to be OK.”

Answer 112

Explanation The correct answers are A, C, and D. The nurse should avoid all these actions except Choice B. Choice A (“My mother has the same thing”) is too personal and does not do anything to comfort the patient. Choice C (“I think you should try having surgery”) amounts to giving unwanted advice. It is not appropriate, and it is not a nurse's job to recommend an interventional treatment. Choice D (“Don’t cry. Everything is going to be OK.”) gives "false hope" and is inappropriate. Therapeutic communication is a basic tool used in a caring relationship with patients. In therapeutic communication, the interaction focuses on the patient and the patient’s concerns. Nurses must assist patients as they work through their feelings and explore options related to the situation, outcomes, and treatments. This skill takes practice but can be learned with awareness and close attention. Therapeutic communication means taking the time to listen for messages that may otherwise be unheard. Nurses who learn to practice therapeutic communication with patients find it easier to develop good nurse-patient relationships. Being present and using silence are useful tools in such circumstances (Choice B) and is an appropriate action. NCSBN Client Need Topic: Psychosocial Integrity. Reference: Nursing Health Assessment: A Best Practice Approach (Wolters/Kluwer); Chapter 2: The Health History and Interview; Lesson: Therapeutic Communication

Question 113

Which action would be the most appropriate for a nurse to use as an alternative to restraints for an elderly client who is disoriented and tends to wander the halls of his long-term care facility? A. Sit the patient in a geriatric chair near the nurse’s station B. Use bed sheets to secure the patient snuggly in bed C. Keep the patient’s bed in the high position so he doesn’t get out D. Put the patient’s picture and a balloon on his door so he knows which room is his.

Answer 113

Explanation If safety is not an issue, the resident should be allowed to move about. Measures to help clients who experience confusion or disorientation should be initiated. Many nursing homes and assisted living facilities to enable residents and family members to personalize the client’s door in much the same way that a private person would decorate his/her front door of their home. Answer and Rationale: The correct answer is D. Identifying the patient’s door with his picture, and a balloon may be a helpful alternative to restraints. A and B are incorrect. Using a geriatric chair or sheets are forms of physical restraint. C is incorrect. Leaving the bed in a high position is a safety risk that could result in a fall and injury. NCSBN Client Need Topic: Safe and Effective Care Environment Subtopic: Safety and Infection Control Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn) Chapter 26: Safety, security, and Emergency Preparedness Lesson: Using Alternatives to Restraints

Question 114

he client using over-the-counter nasal decongestant drops reports unrelieved and worsening nasal congestion. What is the appropriate instruction for this client? A. Discontinue the medication for several days. B. Use a combination of oral medications and drops for better results C. Switch to a stronger dose of the decongestant drops D. Increase the frequency of the nasal decongestant drops

Answer 114

Explanation Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alpha-adrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5days, instead of the nasal membranes constricting, vasodilation occurs, causing an increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus. The correct answer is A. Because of their local action; intranasal sympathomimetics produce few systemic effects. However, one side effect associated with their use is rebound congestion. Prolonged use causes hypersecretion of mucus and worsened nasal congestion once the drug effects wear off. This rebound effect sometimes leads to a cycle of increased drug use as the condition worsens. Because of the risk of rebound congestion, intranasal sympathomimetics should be used for no longer than 3-5 days. B is incorrect. The nurse should instruct the patient to discontinue the nose drops. Additionally, the nurse should not tell a client which medications to take. Instead, this responsibility is the doctor’s call. C and D are incorrect. C- A more potent decongestant is not needed. Instead, the patient should stop using the drops. D- The frequency should not be increased. NCSBN Client Need Topic: Physiological Integrity Subtopic: Pharmacological & Parenteral Therapies Chapter 21: Drugs for Inflammation, Allergies, and Immune Disorders Lesson: Allergies Reference: Core Concepts in Pharmacology (Holland/Adams)

Question 115

What is the process with which members of another culture adopt the culture of the host, predominant culture? A. Immigration B. Emigration C. Acculturation D. Assimilation

Answer 115

Explanation Correct Answer is C Correct. Acculturation is the process with which members of another culture adopt the culture of the host, predominant religion. This adaptation allows the members of the non-dominant culture to survive and thrive in the new environment. Although acculturation and assimilation are similar, adaptation is the process with which a person develops a new cultural identity, rather than assimilating and adopting a new culture while retaining their own. Immigration is the process with which citizens of one country enter another country, and emigration is the process with which individuals of a nation leave it. Both immigration and migration can lead to cultural dissonance. Choice A is incorrect. Immigration is the process with which citizens of one country enter another country rather than the method with which members of another culture adopt the culture of the host, predominant religion. Choice B is incorrect. Emigration is the process with which individuals of a country leave it rather than the method with which members of another culture adopt the culture of the host, predominant religion. Choice D is incorrect. Assimilation is the process with which a person develops a new cultural identity process rather than the method with which members of another culture adopt the culture of the host, predominant religion. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 116

The pathological process causing esophageal varices is: A. Systemic hypertension B. Portal hypertension C. Ascites and edema D. Dilated veins and varicosities

Answer 116

Explanation Pathology refers to the science of cause and effects of the disease. Among the above Answer Options, more than once, refers to a symptom that is seen with esophageal varices. However, the cause of the varices is what the Answer is looking for. It’s essential to look for clue words in NCLEX questions, such as “pathology” or “symptom.” The Correct Answer is B. Esophageal varices are enlarged veins in the esophagus. They're often due to obstructed blood flow through the portal vein, which carries blood from the intestine, pancreas, and spleen to the liver. A is incorrect. Systemic Hypertension is high blood pressure in the systemic arteries - the vessels that carry blood from the heart to the body's tissues (other than the lungs). C is incorrect. Ascites is the accumulation of protein-containing (ascitic) fluid within the abdomen. Edema is swelling caused by excess fluid trapped in your body's tissues. Although edema can affect any part of your body, you may notice it more in your hands, arms, feet, ankles, and legs. D is incorrect. Esophageal varices are enlarged veins of the esophagus; the enlarged veins are a result of the pathology, which is portal hypertension. NCSBN Client Need Topic: Physiological Integrity Subtopic: Physiological Adaptation Fundamentals of Nursing (Wilkinson and Barnett) Chapter 37: Circulation Lesson: Complications of Hypertension

Question 117

The nurse is caring for a patient who is admitted to the hospital in acute renal failure. She notices a U wave on the ECG. The nurse should check for which of the following conditions in her laboratory values? A. Hyperkalemia B. Hypokalemia C. Hypernatremia D. Hyponatremia

Answer 117

Explanation A is incorrect. Peaked T waves are a characteristic of Hyperkalemia. Severe and prolonged hyperkalemia will increasingly prolong the PR and QRS intervals with the potential for cardiac arrest. Hyperkalemia should be considered as a medical emergency. B is correct. U waves on the ECG is associated with Hypokalemia. Other ECG manifestations would also include large, flat T waves, ST depression, or prolonged QT intervals. C is incorrect. There are no ECG manifestations brought about by Hypernatremia alone. Muscle weakness, restlessness, lethargy, or coma is a manifestation of hypernatremia. D is incorrect. Hyponatremia is characterized by disorientation, apathy, depression, depressed deep tendon reflexes, and agitation. By itself, hyponatremia does not manifest in the ECG. Reference: Daniels, R., et al. Contemporary Medical-Surgical Nursing; Delmar Learning 2007 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6thEdition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7thed. St. Louis, MO: Elsevier; 2013.

Question 118

While assessing a newborn infant in the nursery, you observe bounding +3 radial pulses and faint +1 pedal pulses. You also notice that the feet are cold and pale, while the hands are warm and pink. Which cardiac defect do you suspect this infant has? A. Tetralogy of fallot B. Hypoplastic left heart syndrome C. Coarctation of the aorta D. Transposition of the great arteries

Answer 118

Answer: C A is incorrect. In Tetralogy of Fallot there is a combination of four defects - an overriding aorta, pulmonary stenosis, hypertrophy of the right ventricle, and a VSD. At birth the nurse would appreciate a murmur and mild to severe cyanosis depending on the case. The described symptoms do not fit the tetralogy of Fallot. B is incorrect. In hypoplastic left heart syndrome there is the underdevelopment of the left side of the heart. The nurse would note cyanosis and murmur at birth, but he described symptoms that do not fit hypoplastic left heart syndrome. C is correct. Coarctation of the aorta is a narrowing of the aorta near the ductus arteriosus. Because of this narrowing, there is increased blood flow to the upper extremities and decreased blood flow to the lower extremities. That is what causes the symptoms described in the question: bounding upper pulses, faint lower pulses, and overall better perfusion to the upper extremities. D is incorrect. In transposition of the great arteries the pulmonary artery leaves the left ventricle and the aorta leaves the right ventricle. These infants are severely cyanotic at birth and need surgery early in life, but the described symptoms do not fit the transposition of the great arteries. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological Adaptation Reference: Hockenberry M, Wilson D: Wong’s nursing care of infants and children, ed 9, St. Louis, 2011, Saunders Subject: Child Health Lesson: Cardiovascular

Question 119

As you are bathing your client and providing nail care, you notice that the client’s nails look abnormal ( Exhibit). You would document this nail abnormality as: A. Onychomycosis B. Onychomadesis C. Onychorrhexis D. Onychia

Answer 119

Explanation Choice A is Correct. You would document this nail abnormality as Onychomycosis. Onychomycosis is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque, and crumbling. Since Onychomycosis is the most common cause of nail dystrophy presenting to the outpatient department, a nurse plays a crucial role in the diagnosis, management, and education of the clients. Dermatophytes (Trichophyton) cause 90% of these toenail infections. Remaining 10% are caused by non-dermatophytes (Saprophytes), and yeast (Candida). The prevalence of Onychomycosis in patients between 20 to 60 years of age is 20%, whereas prevalence in older adults > 70 years of age is about 50%. The nurse should be aware of the risk factors and educate at-risk clients regarding foot care. Some common risk factors for Onychomycosis include immunosuppression, diabetes mellitus, age greater than 70, persistently wet feet, repetitive nail trauma, tight-fitting footwear, HIV infection, prolonged steroid use, peripheral vascular disease, and genetics. Often, patients are asymptomatic. But the quality of life can be substantially decreased by Onychomycosis. Clients may have low self-esteem and feel embarrassed about having thick, discolored nails. Also, they may report mild pain and discomfort. Diagnosis is based on history and clinical exam. Diagnosis can be confirmed by demonstrating dermatophytes in KOH preparation of nail scrapings. The condition is often challenging to treat. Recurrence and failures may be in the range of 20 to 50% (i.e., the cure rate is approximately 50%). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails. Most antifungal treatments may have liver toxicity, and liver function tests may have to be monitored. Terbinafine is contraindicated in clients with baseline liver disease. Choice B is incorrect. Onychomadesis is the falling off, and the separation of the nails from the nail bed and is not the appearance of the affected nail in the Exhibit. The cause of Onychomadesis is often idiopathic (unknown). However, in children, it may occur as a rare complication 4 to 6 weeks following Hand, Foot, and Mouth disease. Choice C is incorrect. Onychorrhexis is the formation of vertical ridges on the nails or brittle nails that tend to break easily. The pins are not thick and discolored, as shown in the Exhibit. Onychorrhexis occurs due to disordered keratinization in the nail matrix. Causes include the normal aging process, recurrent nail trauma, anemia, hypothyroidism, and eating disorders. Choice D is incorrect. Onychia, which is an inflammation of the nail folds, does not appear like the Exhibit above. Onychia is not the infection of the nail itself but rather a disease of surrounding tissue of the nail plate. NCSBN Client Need: Topic: Physiological Adaptation; Sub-Topic: Alteration in body systems. Reference Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 120

You are taking care of a 45-year-old female who is being treated with electroconvulsive treatment (ECT) for severe depression. After her treatment today. which of the following nursing interventions are appropriate? Select all that apply. A. Position her supine with the head of bead at 30 degrees B. Reorient the patient frequently. C. Remain with the patient at all times D. Promote bedrest for 12-24 hours

Answer 120

Explanation Answer: B and C A is incorrect. Supine with the head of the bead at 30 degrees is not the best position for a patient who has just had electroconvulsive therapy. This patient is at risk for aspiration, so the appropriate positioning is on her side. This will prevent anything from entering her airway and causing an aspiration event. Supine with the head of the bead at 30 degrees would be the appropriate positioning for a patient post-op from neurosurgery or at risk for increased ICP. B is correct. It will be a very important nursing intervention to frequently reorient the patient who has just received electroconvulsive therapy. This is because temporary memory loss is associated with this procedure, so they will likely be very confused and disoriented. Due to this disorientation, they will likely be scared, and to make them feel safe and secure the nurse will need to frequently reorient them to their place and situation. C is correct. It will be a very important nursing intervention to remain with the patient who has just received electroconvulsive therapy. A side effect of electroconvulsive therapy is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them at all times to keep them safe. D is incorrect. It is not necessary or appropriate to promote bedrest for 12-24 hours in the patient who has just received electroconvulsive therapy. After they are awake and re-oriented, it is best to promote activity and get them back to their normal routine. Staying active is an important part of treating depression, so bed rest is not appropriate for this patient. 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 121

The nurse in the Emergency Department is caring for a patient with chest pain. He is on a cardiac monitor and oxygen at 2 liters/minute. Suddenly, the patient becomes unresponsive, and the nurse sees this rhythm on the monitor: (See Exhibit) The correct sequence for the nurse to follow in this scenario is: A. Start CPR, Administer epinephrine, Continue CPR B. Start CPR, Attach defibrillator, Shock, Resume CPR, Shock, Resume CPR, Administer epinephrine, Continue CPR C. Attach defibrillator, Shock, Start CPR, Shock, Administer epinephrine, Continue CPR D. Monitor the patient until the code team arrives

Answer 121

Explanation Correct Answer: B. The patient is in ventricular tachycardia. The nurse should recognize this rhythm and should immediately start CPR and call for help. When the team arrives with the defibrillator, a team member should attach the pads to the patient and perform immediate defibrillation (shock). Following the collapse, the team should resume CPR for another 2 minutes. After two minutes, evaluate the rhythm if the rhythm is still shockable (ventricular tachycardia or ventricular fibrillation, deliver another shock. Immediately resume CPR while another team member prepares to administer epinephrine. After 2 minutes of CPR, stop CPR for evaluation of the rhythm. Provide another shock if the rhythm is still shockable, then resume CPR and consider the administration of amiodarone. Option A would be correct for asystole or PEA, but not for pulseless ventricular tachycardia. A cardiac arrest rhythm should always be treated first with high-quality CPR, so Options C and D are not correct. NCSBN Client Need Topic: Management of Care Sub-Topic: Establishing Priorities Subject: Critical Care Lesson: Prioritization; Cardiovascular Reference: American Heart Association. Advanced Cardiovascular Life Support: Provider Manual. March 2016 eBook edition.

Question 122

The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside? A. Trach kit B. Scissors C. Obturator D. Yaunker

Answer 122

Explanation Answer: B A is incorrect. An extra trach kit does not need to be at the bedside of a client with a Sengstaken-Blakemore tube, rather this is a priority item for a client with a tracheostomy. B is correct. Scissors must be kept at the bedside of any client with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of the shift to ensure safety of the client. Scissors are necessary for this client, because if the Sengstaken-Blakemore tube were to rupture, the tube would move upward and could obstruct the airway. This is an emergency, and the nurse would need to act immediately so that the balloon can be cut. C is incorrect. An obturator does not need to be at the bedside of a client with a Sengstaken-Blakemore tube, rather this is a priority item for a client with a tracheostomy. D is incorrect. A Yaunker suction catheter is kept at the bedside of most clients in the event that they need oral suctioning. While this is an appropriate item to keep at the bedside, it is not the priority for this client. NCSBN Client Need: Topic: Reduction of Risk Potential Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures Subject: Medical/Surgical Lesson: Safety

Question 123

The patient is recovering from chest tube insertion. Which interventions are appropriate for the nurse to include in this patient’s care plan? (Select all that apply) A. Change dressing every 48-72 hours as needed B. Maintain drainage container at heart level at all times C. Observe and document drainage color, volume, and consistency D. Clamp chest tubes during transport

Answer 123

Explanation A and C are correct. Chest tube dressings should be changed every 48-72 hours as needed to visualize and assess the site and to protect from pathogens. The patient is at risk for infection, so the color, amount, and consistency of drainage should be monitored and documented to detect any signs of infection. B is incorrect. The drainage container should be kept below the heart level to reduce the risk of pneumothorax. D is incorrect. Chest tubes should only be clamped when checking for leaks or assessing the patient’s readiness to have tubes removed. Clamping during accidental disconnection or transport is not appropriate due to the risk of tension pneumothorax. Subject: Adult health Lesson: Respiratory -or- Subject: Fundamentals Lesson: Safety/infection control Topic: illness management, pathophysiology, the potential for complications from surgical procedures and health alterations Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 571, 574)

Question 124

A panicked mother brings her 8-year old son into the clinic after noticing that he will not eat. The patient only wants to drink water and is continuously urinating. After seeing that the patient’s blood sugar level of 657 mg/dL, the nurse prepares to insert an IV. Which of the following critical assessment findings should concern the nurse? A. Listlessness B. Headache C. Dry mouth D. Frequent urination

Answer 124

Explanation A is the correct answer. This patient is experiencing diabetic ketoacidosis. "Listlessness" refers to decreased level of alertness, lassitude, or lethargy. If this patient is not entirely responsive or responding at all, he may be headed towards a diabetic coma. In that case, further assessments should be performed, such as airway, breathing, and circulation, along with hyperglycemia precautions. B is incorrect. Hyperglycemia may cause the patient to have a headache, but this is not the most concerning symptom. C is incorrect. Hyperglycemia can cause dry mouth, frequent urination, fruity breath, abdominal pain, nausea/vomiting, weakness, confusion, and shortness of breath. Dry mouth is not the most concerning symptom. D is incorrect. Frequent urination is one of the symptoms of hyperglycemia and can be an excellent indicator to lead to a diagnosis. However, confusion and listlessness should be the most concerning symptom at this time. NCSBN Client Need Topic: Reduction of Risk Potential;Sub-topic: System-specific Assessments Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013

Question 125

The nurse prepares to administer a cycled tube feeding to a client through their NG tube. Before initiating the feeding, which actions would be appropriate for the nurse to take? Select all that apply. A. Flush the nasogastric tube with saline B. Verify placement of the nasogastric tube C. Elevate the head of the bed D. Ask the client to remain in bed during the tube feeding.

Answer 125

Explanation Answer: A, B, and C A is correct. Before beginning a cycled tube feeding, it is appropriate for the nurse to flush the nasogastric tube with saline. This allows for verification that the tube is patent, and that the formula will freely flow into the client’s stomach during the feeding. B is correct. It is extremely important to always verify the placement of the nasogastric tube before putting anything in it. If the tube has moved and the tip of it is no longer in the stomach, the feeding could be aspirated causing serious problems such as pneumonia. The gold-standard to verification of tube placement is visualization on an x-ray. After the placement has been initially verified, the nurse may mark where the tube is located at the nare of the client so that the nursing staff can check that the tube has not moved and remains in the stomach prior to each feeding. C is correct. It is appropriate to elevate the head of the bed prior to any tube feeding. This allows gravity to help the tube feeding flow into the stomach and prevent reflux. For clients receiving a bolus feeding, a high-Fowler's position is preferred, and for clients receiving a cycled or continuous feeding, a semi-Fowler’s position is preferred. D is incorrect. It is not necessary for the nurse to instruct the client to remain in bed for the duration of their tube feeding. Some clients may prefer to, but it is up to them. They may like to get up to the chair or sit up, and can get up to ambulate to the restroom etc. if appropriate. NCSBN Client Need: Reduction of Risk Potential Topic: Potential for Complications of Diagnostic Tests/Treatments/procedures Subtopic: Coordinated care Subject: Fundamentals Lesson: Safety

Question 126

After suffering an injury on the ski slope, a 16-year old boy is picked up by the paramedics. Bystanders say that he hit his head after going off of a jump and was not wearing a helmet. He opens his eyes and grabs at the paramedic's hand when pinched, but isn’t making coherent sentences. What is this patient’s Glasgow Coma Score? A. 9 B. 10 C. 11 D. 12

Answer 126

Explanation A is the correct answer. This patient scores a 2 for eye-opening, 2 for a verbal response, and 5 for motor response. B is incorrect. This is not the right score. C is incorrect. This is not the right score. D is incorrect. This is not the right score. NCSBN Client Need Topic: Reduction of Risk Potential Sub-topic: System-specific Assessments Subject: Adult Health Lesson: Acute Intracranial Problems Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013

Question 127

Informed consent mostly upholds the client’s right to: A. Beneficence B. Self determination C. Nonmaleficence D. Confidentiality

Answer 127

Explanation Correct Answer is B.An informed consent mostly upholds the client’s right to self-determination and autonomy. Self-determination, or independence, simply described, is the right of a person to make their own decisions without the undue influences of others. Choice A is incorrect. Although we fulfill or ethical responsibility of beneficence when we facilitate informed consent, this is not the client's right that we are primarily upholding. Choice C is incorrect. Although we fulfill or ethical responsibility of nonmaleficence when we facilitate informed consent, this is not the client's right that we are primarily upholding. Choice D is incorrect. Although we maintain the confidentiality of informed consent in addition to all other medical information, this is not the client's right that we are upholding. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 128

The nurse notes that the physician has entered a do not resuscitate [DNR] order. However, there is no advanced directive by the patient present on the patient’s chart. Which is the appropriate nursing action? A. Notify the physician about the need for a living will to validate this order. B. Verify that the physician consulted with the patient and/or family. C. Accept the order as written, no other documentation is needed. D. Notify the nurse supervisor and risk management about the DNR order.

Answer 128

Explanation The correct answer is B. Documentation that the physician has consulted with the patient and family is required before a do not resuscitate order is entered on the patient’s chart. Choice A is incorrect. It is not necessary to have a living will on the patient’s chart, but there must be documentation that the issue was discussed with the patient/family. Choice C is incorrect. There must be documentation noting that the DNR order was discussed with the patient and family. Choice D is incorrect. It is not necessary to notify the nursing supervisor and risk management about this order. Bloom’s Taxonomy – Applying Reference: Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8thEdition. Elsevier Mosby St Louis 2013

Question 129

The nurse is assessing a patient’s lower extremities for clonus. What would the nurse recognize as a positive result? A. Unilateral redness and swelling that is warm to the touch. B. Rapid. rhythmic muscle contractions. C. Popping or clicking of knee joint with movement. D. Audible cracking and palpable grating with movement of joints.

Answer 129

Explanation B is correct. Clonus is an abnormal response to deep tendon reflexes stimulation that is characterized by rapid, rhythmic muscle contractions. A is incorrect. Unilateral inflammation would be a possible sign of cellulitis, a skin condition caused by infection of the soft tissue. C is incorrect. Popping or clicking of the knee would indicate damage to fibrocartilage in the knee or meniscal injury. D is incorrect. Audible cracking and palpable grating with the movement of joints describe crepitation (crepitus). This finding would indicate fracture, dislocation, or osteoarthritis. Subject: Adult health Lesson: Musculoskeletal Topic: system-specific assessments, pathophysiology Reference: (Jarvis, C, 2012, p. 649)

Question 130

Which of the following special considerations should the nurse make when caring for a Hindu patient based on her religion? (Select all that apply). A. Provide all vegetarian meals. B. Handle the client's temple garments with care. C. Be sure the bathroom is equipped with a shower and not just a tub. D. Be aware that the patient will likely refuse blood transfusions. E. Arrange for female nursing staff to provide care for the client as much as possible. F. Be aware that the patient will likely refuse pain medication.

Answer 130

Explanation Choices C and E are correct. Hindus prefer to wash in free-flowing water (e.g., a shower instead of a tub bath) ( Choice A). If a shower is not available, provide a jug of water for the person to use in the tub. Hindus practice ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Most Hindus are lactovegetarians. Most will not eat beef and avoid bovine-derived medications because they believe in the reincarnation of certain gods. Fasting usually means eating only “pure” foods, such as fruit or yogurt, but it is not expected of the sick. Hindu women are modest and usually prefer to be treated by female medical staff ( Choice E). Choice A is incorrect. Although some Hindus will eat eggs and even chicken, most are lactovegetarians, consuming milk but no eggs. Choice B is incorrect. Hindus may wear a “sacred thread” or religious jewelry around their body or wrist. Mormons, not Hindus, wear “temple garments.” Choice D is incorrect. Jehovah's Witnesses—not Hindus—refuse to accept blood transfusions or blood products, which they view as morally wrong. Choice F is incorrect. Christian Scientists—not Hindus—would be likely to refuse pain medication. NCSBN Client Need:Topic: Psychosocial Integrity Reference: Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith)

Question 131

There have been reports circulating about an impending terrorist attack involving Anthrax in the local news. The nurse manager in the ER understands that Anthrax can be countered by which of the following medications? A. Acyclovir B. Zidovudine (Retrovir) C. Ciprofloxacin D. Oseltamivir

Answer 131

Explanation Choice C is correct. Anthrax is a bacterial infection treated with antibiotics such as penicillin, doxycycline, and ciprofloxacin. Inhaled anthrax is most effectively treated with a combination of Ciprofloxacin and another antibiotic ( penicillin, clindamycin, chloramphenicol). Antibiotics are usually given for 60 days because it takes that long for spores to germinate. Choice A is incorrect. Acyclovir is an antiviral used to treat herpes. Antiviral medications do not affect Anthrax, which is a bacterial infection. Choice B is incorrect. Zidovudine (Retrovir) is an anti-retroviral medication that is used for the treatment of HIV. Antiviral drugs do not affect Anthrax, which is a bacterial infection. Choice D is incorrect. Oseltamivir is an antiviral drug used to treat influenza. Antiviral medications do not affect Anthrax, which is a bacterial infection. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 132

Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington’s disease, which has developed contractures? A. The patient will monitor for signs of skin breakdown as a result of the contractures B. The patient will learn to reposition himself in bed and in his chair without assistance C. The patient will participate in range of motion exercises to reduce the effects of contractures D. The patient will verbalize the effects of contractures on activities of daily living

Answer 132

Explanation Huntington’s disease is a progressive condition that can lead to muscle atrophy and potential contractures. The patient in this situation should be given a program of range of motion exercises in which he may need assistance. The nurse can help the patient to increase his range of motion and to prevent worsening of contractures by improving flexibility and reducing rigidity. Answer & Rationale: The correct answer is C. Performing range of motion exercises will help decrease the risk of further atrophy and should be encouraged. A is incorrect. Contractures and lack of mobility put a client at risk of compromised skin integrity. However, the nurse is responsible for monitoring for signs of breakdown. B is incorrect. The client has developed contractures and muscle atrophy. He may be unable to reposition himself without assistance. NCSBN Client Need Topic: Physiological Integrity Subtopic: Basic Care and Comfort Chapter 30: Health Assessment Lesson: Musculoskeletal System Reference: Kozier and Erb’s Fundamentals of Nursing

Question 133

You are taking care of a 12-year-old boy in the PICU admitted after a suicide attempt. He received multiple pills from his mother’s medicine cabinet. Some of which were oxycodone. He was found down and successfully resuscitated after 10 minutes of CPR. When doing your admission assessment. You notice several scars as well as open cuts on his wrists. What are the appropriate ways to respond to this finding? Select all that apply. A. Talk with his parents and inform them this is not acceptable. B. Ask him directly how he got these cuts. C. Tell him that he should never harm himself again. D. Speak with the patient in a nonjudgmental manner to understand what he feels has happened.

Answer 133

Explanation Answer: B and D. A is incorrect. Telling his parents is not the appropriate nursing action. This does not deal with the issue directly and may cause the patient not to trust the nurse with their true feelings. B is correct. It is essential to address the issue directly. If the nurse does not bring up the problem, the patient will likely try to avoid it. C is incorrect. Telling the patient not to harm himself again is not therapeutic communication. This negates the patient’s feelings and does not help him in any way. D is correct. It is essential to speak to this patient in a non-judgmental way. This allows the patient to open up and discuss their feelings. They may tell you why they have participated in self-harm activities, allowing you to begin to help them. NCSBN Client Need: Topic: Psychosocial adaptation Subtopic: N/A Reference: Brorsen, A. & Roglet, K. (2011). Pediatric Critical Care. Burlington, MA: Jones & Bartlett Learning.: Subject: Psychiatric Health Lesson: Psychiatric

Question 134

The nurse educator is giving a lecture on the different types of arthritis. Does the nurse educator emphasize which findings that distinguish rheumatoid arthritis from gouty arthritis and osteoarthritis? A. Crepitus with range of motion B. Symmetry of joint involvement C. Elevated serum uric acid levels D. Dominance in weight bearing joints

Answer 134

Explanation Rationale: The distinguishing factor in all three types of arthritis is the symmetry of joint involvement. Rheumatoid arthritis is symmetrical and bilateral, while osteoarthritis and gout are unilateral. Osteoarthritis is characterized by crepitus. Gout is manifested by elevated serum uric acid levels, while Osteoarthritis is characterized by the involvement of dominant weight-bearing joints. 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 135

A 45-year older man on the neurology floor can understand instructions but is unable to express himself through talking. Which lobe of the brain controls the expression of speech? A. Frontal lobe B. Parietal lobe C. Temporal lobe D. Occipital lobe

Answer 135

Explanation A is the correct answer. The expression of speech is controlled by Broca’s area in the frontal lobe. Broca’s area is in the left hemisphere near the motor strip. B is incorrect. The parietal lobe controls the sensory interpretation area for the opposite side of the body. It also controls the ability to interpret spoken words, the ability to read and write, and the ability to see body image. C is incorrect. The temporal lobe controls primary auditory functions. It also controls Wernicke’s area, which is the ability to organize language and understand what someone is saying. It also controls the limbic system and the hippocampus, which control emotions and memory, respectively. D is incorrect. The occipital lobe controls visual processing and visual association. NCSBN Client Need Topic: Physiological Adaptation Sub-topic: Pathophysiology Subject: Adult Health Lesson: Nervous System Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013

Question 136

Which of the following practices does the nurse recognize as typical in the Amish community? Select all that apply. A. Health is viewed as a gift from God. B. They commonly use alternative healthcare. C. Women and men are equal and can both make healthcare decisions. D. Most of the Amish community choose to have health insurance.

Answer 136

754442 (Timed)Explanation Answer: A and B A is correct. The belief that health is a gift from God is prevalent in Amish society. While they believe that their health is a gift, they also believe that clean living and a healthy diet are essential to maintain their health. B is correct. Members of the Amish society commonly use alternative healthcare in addition to traditional healthcare. Healers, herbs, and massage are all widely used in their alternative medicine practices. C is incorrect. Women and men do not have equal authority in the Amish community. Their society is patriarchal, and men typically have power when making healthcare decisions. D is incorrect. Most of the Amish community chooses not to have health insurance. Instead, they may want to save the money they would have spent on health insurance to maintain a mutual aid fund amongst the community for members who need help with medical costs. NCSBN Client Need: Topic: Psychosocial Integrity Subject: Fundamentals of care Lesson: Culture/Spirituality Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Question 137

The nurse is caring for a client with tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit. A. Initiate a code blue B. Establish intravenous (IV) access C. Notify the primary healthcare physician (PHCP) D. Assess the client’s airway, breathing, and circulation.

Answer 137

Explanation Choice D is correct. The tracing indicated that the client is experiencing ventricular fibrillation (Vfib). This is a fatal rhythm. However, the priority action of the nurse is to immediately establish the validity of this fatal arrhythmia tracing by assessing the client’s airway, breathing, and circulation. Ventricular fibrillation is characterized by a complete lack of coordinated contraction, resulting in chaotic electrical activity on the rhythm strip. Due to rapid ventricular contractions, the ventricular filling decreases markedly, leading to a significant decrease in cardiac output. Consequently, a pulse is absent. Clinically, at the time of the event, the patient should be pulseless, unconscious, and unresponsive. Please note that the same question may be presented differently with assessment findings disclosed within the question ( e.g.: information such as patient is unresponsive and pulse is absent within the question stem), the answer would then be Choice A. (Proceed with CPR and defibrillation because assessment has already been completed). Choices A, B, and C are incorrect. None of these options can be implemented until the validity of the rhythm is established. The nurse should clinically validate the rhythm before proceeding to call code blue. Once the client’s vitals validate this fatal rhythm, cardiopulmonary resuscitation (CPR), according to Advanced Cardiac Life Support (ACLS) guidelines, should be initiated immediately and the physician must be notified.

Question 138

Which of the following are appropriate tertiary prevention strategies to teach your patient for cancer prevention? Select all that apply. A. Yearly fecal occult blood testing B. Testicular self exams C. Digital rectal exams D. Rehabilitation programs

Answer 138

Explanation Answer: D Tertiary prevention strategies are aimed at preventing a recurrence of cancer, or stopping the progression of current cancer, in a long term patient. These patients already have cancer, so the prevention is focused on giving them the best outcome given their disease. A is incorrect. Yearly fecal occult blood testing is a screening. Therefore it is a secondary prevention strategy. B is incorrect. Testicular self-exams are a screening. Therefore it is a secondary prevention strategy. C is incorrect. Digital rectal exams are screening. Therefore it is a secondary prevention strategy. D is correct. Rehabilitation programs for cancer patients are considered tertiary prevention strategies. NCSBN Client Need: Topic: Health promotion and maintenance Subject: Adult Health Lesson: Oncology Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.

Question 139

The nurse is caring for a post caesarian section client in the maternity ward. The nurse must assess for which assessment finding which indicates a common complication after delivery? A. A distended bladder B. Soaked perineal pads and a soft fundus C. Shivering D. An elevated temperature

Answer 139

Explanation A is incorrect. In the immediate post-operative phase, a urinary catheter is attached to the client to drain urine continuously. The chance of developing a distended bladder is highly unlikely. Bis correct. Bleeding due to uterine atony is likely to occur in a client post caesarian section. Signs that indicate postpartum hemorrhage include frequently soaked dressing and perineal pads, a soft fundus, tachycardia, and low blood pressure. C is incorrect. Shivering is due to the withdrawal of the client from the anesthetic. It is not a common complication of cesarean section. D is incorrect. An elevated temperature following caesarian section is highly unlikely. Hypothermia occurs more commonly immediately following. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 140

When making patient care assignments, the nurse recognizes that the following tasks are within the scope of practice for nursing assistive personnel [NAP], with which exception? A. Providing catheter care. B. Performing range of motion exercises. C. Changing the colostomy skin barrier. D. Encouraging the use of self-help devices.

Answer 140

Explanation Correct Answer is C. The NAP scope of practice allows the NAP to empty ostomy bags or change bags that do not adhere to the skin; the NAP could apply a new pack to a two-piece system, but not the adhesive skin barrier component. Choices A, B, and D are incorrect. Providing catheter care, performing a range of motion exercises, and encouraging the patient to use self-help devices are within the NAP scope of practice. Bloom's Taxonomy: Analyzing Reference: McMullen, Tara L. et al. Certified Nurse Aide Scope of Practice: State-by-State Differences in Allowable Delegated Activities Journal of the American Medical Directors Association, 2015; 16(1) 20 - 24

Question 141

Parts of a pain assessment entail the subjective comments of the client in terms of their sensory and affective, emotional comments that can indicate the quality and intensity of their pain. Select the type of pain that can be shown with the client's emotions of “nagging and tender”? A. Hurting pain B. Pain C. Somatic pain D. Aching pain

Answer 141

Explanation Correct Answer is D Correct. Aching pain in terms of affective, emotional descriptors can include the client’s subjective comments that include “nagging and tender.” Other personal affective descriptors can consist of “troublesome,” “annoying,” and “tiring.” Affective, emotional, and sensory pain descriptors and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense. Choice A is incorrect. “Nagging and tender” are affective, emotional descriptors of another type of pain. Hurting the client can describe pain with affective, emotional descriptors such as “robbing” and not “nagging and tender.” Sensory and affective, emotional pain descriptors, and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense. Choice B is incorrect. “Nagging and tender” are affective, emotional descriptors of another type of pain in terms of its quality and intensity. Pain, in contrast to other intensity pain, is the highest level possible, and its affective, emotional descriptors include comments such as “agonizing,” suffocating” and “unbearable” and not “nagging and tender.” Sensory and affective, emotional pain descriptors, and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense. Choice C is incorrect. “Nagging and tender” are not sufficient, emotional descriptors of bodily pain. “Nagging and tender” indicates another type of pain in terms of its quality and intensity. Sensory and affective, emotional pain descriptors, and their neural correlates range from ache, which is the least intense, pain which is the most intense and hurt, which is the second most intense. 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 142

An independent nursing intervention relating to the oral administration of opioid narcotic analgesics is to: A. Collect comparative pain assessment data just before the administration of the opioid narcotic analgesic. B. Collect comparative pain assessment data ½ hour after the administration of the opioid narcotic analgesic. C. Collect comparative pain assessment data just before and 1 hour after the administration of the opioid narcotic analgesic. D. Collect comparative pain assessment data just before and ½ hour after the administration of the opioid narcotic analgesic.

Answer 142

Explanation Choice C is correct. The independent nursing intervention relating to administering oral opioid narcotic analgesics is to collect comparative pain assessment data just before and 1 hour after administering the oral opioid. In the case of intravenous opioids, pain assessment must be performed 30 minutes after the opioid administration. This helps determine the effectiveness of these opioid narcotic analgesics in terms of pain reduction. Choice A, B, and D are incorrect. Although the nurse is expected to collect pain assessment data before and after administering the opioid narcotic analgesic, there are specific guidelines concerning the timing of pain assessments, and these must be adhered to. Pain assessment must be made 30 minutes after opioid if given by intravenous route whereas 1 hour after administration if given by oral route. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.

Question 143

Which of the following should the nurse include in the teaching plan for older clients with altered immune responses? Select All That Apply. A. It is normal to run a low grade temperature B. If arthritis pain begins to bother you. the doctor can prescribe something for pain C. I’d like to talk to you about ways to manage stress D. It is very important to eat a well-balanced diet.

Answer 143

xplanation The Correct Answers are B, C, and D. A is incorrect. The elderly often experienced masked signs of infection and inflammation. These masked signs mean that the client may not present with elevated temperature or increased white blood count that is as noticeable as a middle-aged client. It’s essential for the nurse to observe for masked signs of infection and to encourage patients to contact their physician, even if their temperature is “low-grade.” NCSBN Client Need Health Promotion and Maintenance Chapter 213: Promoting Asepsis And Preventing Infection Lesson: Factors Increasing Host Susceptibility Fundamentals of Nursing (Wilkinson/Barnett)

Question 144

What is the medical device shown below used for? A. Automated back massage B. At home ECGs C. Pain management D. Vibratory massage

Answer 144

Explanation Correct Answer is C Correct. The medical device above is a transcutaneous electrical nerve stimulation device or TENS, which is used for nonpharmacological pain management. Choice A is incorrect. The medical device above is not used for automated back massage; this device is used for something else. Choice B is incorrect. The medical device above is not used for ECGs; this device is used for something else. Choice D is incorrect. The medical device above is not used for vibratory massage; this device is used for something else. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)