NCSBN PRACTICE QUESTIONS 121-131

NCSBN PRACTICE QUESTIONS 121-131 It is the start of the shift and the nurse has just finished listening to a report on four clients. Which client should the nurse assess first? A. A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of 88/58 B. A client with a diagnosis of a concussion and who doesn't remember the motor vehicle accident C. A client diagnosed with viral meningitis and has signs of meningeal irritation D. A client diagnosed with generalized seizures who complains of a headache following an observed seizure - correct answer -A Hypotension adversely affects cerebral perfusion following a traumatic brain injury. Both hypotension and hypoxia are the greatest threats to functional outcomes in brain injury and must be corrected early, taking priority over other interventions for brain injury. Headache after a seizure is expected, amnesia is common with a concussion, and meningeal irritation is an expected finding with viral meningitis, making these clients a lower priority at this point. The nurse discovers that a chest tube has become disconnected from the main connection site of a closed chest drainage unit (CDU). What immediate action should be taken by the nurse? A. Cover the insertion site with a sterile petroleum gauze pad B. Submerge the distal end of the tube in 2 - 4 centimeters of sterile water C. Reconnect the drainage tube to the chest tube D. Clamp the chest tube nearest to the client with a rubber-tipped hemostat - correct answer -B If the tube becomes disconnected from the main connection site of a CDU, the nurse should place the end of the chest tube in a bottle of sterile water (or saline solution) while someone else prepares a new CDU setup. The health care provider should be called (the nurse should expect an order for a chest X-ray.) To prevent the chest tube from coming apart, it's important to spiral-tape the main connection site and not to let loops of tubing hang down the side of the bed. If there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity, potentially leading to a collapsed lung or tension pneumothorax. Only if the chest tube becomes dislodged from the client does the nurse need to cover the insertion site with a sterile gauze dressing. The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate?A. Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time B. Encourage the client to discuss this decision with the health care provider and family C. Tell the family members that the client's preference is to go home to die D. No action is needed at this time unless the client repeats the statement to another caregiver - correct answer -B The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill. A client who is newly diagnosed with hypertension is prescribed benazepril. What is the most important point to make when teaching the client about this medication? A. "Notify the health care provider if there is a change in your voice." B. "Monitor your blood pressure and pulse regularly." C. "Take medication as directed at the same time each day, even if you feel well." D. "Call your health care provider if you develop a dry cough." - correct answer -A Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of the side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to require discontinuation of the drug. But the most important point to make is that if the client's voice changes or "sounds funny" or there is any swelling of the lips, tongue or throat, the client should contact the health care provider because this could indicate angioedema, a potentially fatal condition. A client's admission urinalysis shows the specific gravity value of 1.039. Which of these findings would the nurse expect to find during the physical assessment of this client? A. Above normal heart rate B. Moist mucous membranes C. Poor skin turgor D. Increased blood pressure - correct answer -CThe specific gravity value is high, which would indicate dehydration. Specific gravity measures urine density and an average urine specific gravity value is around 1.020. Poor skin turgor, as seen with tenting of the skin, is consistent with this problem. A male client is preparing for discharge after an acute myocardial infarction. The client asks the nurse about sexual activity once the client is home. What should be the nurse's initial approach? A. Answer the questions accurately in a private environment B. Schedule a private, uninterrupted teaching session with both the client and the partner C. Assess the client's knowledge about the current health problems D. Give the client written material from the American Heart Association about sexual activity with heart disease - correct answer -C The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse should perform a focused assessment to gather additional data prior to planning and implementing nursing interventions. A nurse is caring for a 2 year-old child who is being treated for lead poisoning by chelation therapy. The nurse should be alert for which side effect of chelation therapy? A. Hepatomegaly B. Ototoxicity C. Neurotoxicity D. Hypocalcemia - correct answer -D Injections of ethylenediaminetetraacetic acid (EDTA) or other chemicals bind, or chelate, to iron (and some other metals), which are then eliminated from the body. Since chelation therapy removes minerals from the body, there is a risk of developing low calcium levels (hypocalcemia) and bone damage. After four electroconvulsive treatments over two weeks, a client is very upset and states, "I am so confused. I lose my money. I just can't remember telephone numbers." The most therapeutic response for the nurse to make is which of these statements? A. "Don't get upset. The confusion will clear up in a day or two." B. "You were seriously ill and needed the treatments." C. "I can hear your concern and that your confusion is upsetting to you."D. "It is to be expected since most clients have the same results." - correct answer -C Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed with a movement to the problem-solving stage. A 10 year-old child is recovering from a splenectomy after a traumatic injury. The child's laboratory results show a hemoglobin of 8.8 g/dL and a hematocrit of 26%. What is a priority approach that the nurse should include in the plan of care? A. Promote a diet rich in iron and lean red meats B. Restrict the consumption of carbonated beverages C. Plan for regularly scheduled rest periods D. Encourage bed activities and games for the next five days - correct answer -C The initial priority for this client is rest due to the lack of sufficient red blood cells to carry oxygen. The normal hemoglobin is between 10.0 and 15.0 g/dL, and the normal hematocrit is 35% to 45% for a child this age. Note that all of the options are correct actions that may be used for various reasons. A client is NPO and receiving total parenteral nutrition (TPN). The nurse recognizes which of the following laboratory values is important to monitor regularly while the client is receiving the TPN? A. Cholesterol level B. White blood cell count C. Glucose D. Hemoglobin - correct answer -C The nurse recognizes that the glucose level should be monitored regularly while the client is on TPN because it is common to develop hyperglycemia. The white blood count, cholesterol and hemoglobin don't directly relate to the TPN infusion. A child presents in the emergency department with a documented acetaminophen poisoning event. In order to provide counseling and education for the parents, what information should the nurse understand? A. Hepatic problems may occur and may be life-threatening B. Full and rapid recovery can be expected in most children C. This poisoning is usually fatal because no antidote is availableD. The problem occurs in stages with recovery within 12 to 24 hours - correct answer -A Clinical manifestations associated with acetaminophen poisoning occur in four stages. The third stage is hepatic involvement, which may last up to seven days and be permanent. Clients who do not die in the hepatic stage gradually recover. The antidote for acetaminophen overdose is Nacetylcysteine (NAC). It is most effective when given within eight hours of the event and can prevent liver failure if given early enough. The nurse is administering a vesicant intravenous chemotherapeutic agent to a client. Which assessment should alert the nurse to take immediate action? A. Complaints of pain at the site of the infusion B. A rash on the client's extremities C. Stomatitis lesion in the mouth D. Severe nausea and vomiting - correct answer -A A vesicant agent is one that is capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants that cause pain along the vein wall, with or without inflammation. The client was admitted 2 days ago after a CT scan of the head revealed a basilar skull fracture (BSF). What assessment findings does the nurse anticipate with a BSF? (Select all that apply). A. Bruising behind the ear (Battle's sign) B. Bruising around both eyes (Raccoon eyes) C. Hearing loss D. Purulent drainage from the ear E. Unilateral redness and swelling over the mastoid bone F. Facial numbness - correct answer -A,B,C,F Basilar skull fractures often result from automobile accidents (including auto/bike accidents) or abuse. Clinical findings of a BSF include Raccoon's eyes and Battle's sign, but these don't show up until several hours or even days after the injury. Battle's sign is bruising seen behind the ear. Raccoon's eyes result from fracture of the base of the sphenoid sinus. Other findings may include vision changes, hearing loss and facial numbness or paralysis. Purulent drainage is associated with infection. Redness, swelling or tenderness over the mastoid bone indicates mastoiditis, which is usually caused by a middle ear infection.A 78 year-old client is admitted with a diagnosis of pneumonia with an oral temperature of 100.8 F (38.2 C). When auscultating the client's lungs, the nurse hears inspiratory crackles in the right lower lobe. What other finding would the nurse expect during the assessment? A. Bradycardia B. Hypotension C. Mental confusion D. Flushed skin - correct answer -C Mental confusion is often the first sign of an infection, such as pneumonia, in an older adult. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and lipids. What is the priority nursing action on every eight-hour shift? A. Monitor blood pressure, temperature and weight B. Change the tubing under sterile conditions C. Check serum glucose level D. Adjust the infusion rate to provide for total volume - correct answer -C Because of the high dextrose (about 4 to 5 mg/kg/day) content in parenteral nutrition, plasma glucose should be monitored every six to eight hours. Fluid intake and output should also be monitored continuously. Plasma proteins (serum albumin, for example) and prothrombin time, plasma and urine osmolality, and calcium magnesium and phosphate levels should be measured about twice a week. The nurse is teaching a group of parents about poisoning risks in the home and how to report information in the event of an accidental poisoning. The nurse should instruct the parents to first state the ingested substance and then to state which of these points of information? A. The currency of the immunization and allergy history of the child B. The parent's name and telephone number C. The estimated time of the accidental poisoning with a confirmation to bring the ingested substance containers D. The affected child's current age and most recent weight - correct answer -D All of the points are important. However, after the substance is given, the current age and the most recent weight are the priorities. This gives the health care providers an opportunity to calculate and prepare the needed dosage for an antidote in preparation for when the child arrives. After this information, the time of the accidental poisoning would be next in importance with the history of immunizations as a last item of concern. The nurse caring for a client with chronic heart failure instructs the client to contact a health care provider if which finding occurs? A. Appearance of nonpitting ankle edema B. A significant decrease in appetite C. Weight gain of three pounds or more in a 48-hour period D. Urinating four to five times each day - correct answer -C It is critical for clients to report and be treated for rapid weight gain, decreased urinary output, worsening nocturnal orthopnea, pitting ankle edema, and other findings of chronic heart failure. Hospitalization may be avoided with early intervention. A 34 year-old female, who has been experiencing widespread muscle pain and fatigue, is diagnosed with fibromyalgia (FM). Which statement by the client indicates she does not understand the treatment options and needs further instruction? A. "I should take duloxetine (Cymbalta) once a day, every day." B. "I will avoid caffeine, sugar, and alcohol before bedtime." C. "If I forget to take the pregabalin (Lyrica) in the morning, I can take it with my evening dose." D. "I will take an exercise class - maybe I'll sign up for a yoga class." - correct answer -C Treatment of fibromyalgia is multifaceted and individualized. Both conventional and alternatives treatments must be considered. Pain management includes medications such as pregabalin (Lyrica) and duloxetine (Cymbalta). Pregabalin, which is an anticonvulsant, is usually prescribed twice a day; if a client forgets to take a dose, she can take it as soon as she remembers but should never take 2 or more at the same time. Duloxetine, a SNRI, is the only antidepressant approved by the FDA to treat fibromyalgia pain and is taken once a day. The nurse is working with parents to plan home care for a 2 year-old child with a heart problem. A priority nursing intervention should be to take which action? A. Instruct the parents to avoid contact with persons who have an infection B. Encourage the parents to take a cardiopulmonary resuscitation (CPR) class C. Assist the parents to plan quiet play activities at homeD. Stress to the parents that they may need some respite from caregiving - correct answer -B While all suggestions are appropriate, the education of the parents/caregivers for CPR is a priority and should include techniques of child cardiopulmonary resuscitation so that the parents can to provide emergency care for their child if necessary. A nurse is preparing to take a toddler's blood pressure for the first time. Which action should the nurse perform first? A. Show a cartoon character with a blood pressure cuff on the arm B. Explain that the blood pressure checks the heart pump C. Permit handling of the equipment before putting the cuff in place on the arm D. Tell that the procedure will help the toddler to get well - correct answer -C The best approach to gain a toddler's cooperation is to encourage the handling of the equipment. Detailed explanations are not helpful because the attention span of a toddler is from one to three minutes at the most. The client, who survived an out-of-hospital sudden cardiac arrest, has induced hypothermia protocol started in the emergency department. What is the most compelling reason for actively cooling a client after sudden cardiac arrest? A. Protects the skin from breakdown B. Decreases urinary output and fluid needs C. Decreases the risk of systemic infection D. Improves survival without brain damage - correct answer -D Inducing therapeutic hypothermia counteracts many of the destructive mechanisms of cardiac arrest in the brain, which means that the client may survive without long-term neurological impairment. There are a number of risks associated with this treatment. For example, it suppresses the inflammatory response, increasing the risk of infection. Also, it causes mild diuresis and increased urine output, which is why the nurse needs to carefully monitor fluid balance. Peripheral vasoconstriction places the client at a high risk for skin breakdown; this risk is increased if cooling blankets are used. The child diagnosed with central diabetes insipidus (DI) is being treated with desmopressin nasal. What information is important to reinforce with the family? (Select all that apply.) A. The child should wear MedicAlert® identificationB. It is important to decrease intake of water and other fluids while taking this medication C. Using the nasal preparation may cause a stuffy nose D. A parent or other responsible adult should supervise and help the child use the medication E. Muscle weakness, spasms or cramps are expected and harmless effects of the medication F. The medication increases urine production - correct answer -A,B,C,D DI results from reduced secretion of the antidiuretic hormone, vasopressin. Desmopressin (DDAVP) is a synthetic analogue of the natural pituitary hormone vasopressin that will help prevent the loss of water from the body by reducing urine output and helping the kidneys reabsorb water. All clients taking desmopressin must limit drinking of water and other fluids; drinking too much water can result in hyponatremia, which can cause muscle weakness, spasms or cramping as well as loss of appetite, severe headaches, confusion, loss of consciousness and seizures. Anyone with central DI should wear a MedicAlert® ID and carry an emergency medical information card. The nurse monitors a client after intravenous atropine sulfate was used to treat bradycardia. Which finding should immediately be reported to the health care provider? A. Urinary hesitancy B. Blurred vision C. Dry mouth D. Transient arrhythmias - correct answer -D Atropine sulfate inhibits acetylcholine's muscarinic action at the neuroeffector junctions of smooth muscles, cardiac muscles, exocrine glands, SA and AV nodes, and the urinary bladder. It is used to treat symptomatic sinus bradycardia and bradyarrhythmias. Adverse reactions - such as transient arrhythmias and paradoxical bradycardia - should be reported to the health care provider. Most common adverse effects - including dry mouth, blurred vision and urinary hesitancy - are usually reversible when therapy is discontinued. A 62 year-old arrives in the emergency department reporting chest pain. Following protocol, the client is given nitroglycerin and aspirin. The initial ECG indicates nondiagnostic changes in ST segment or T waves. What does the nurse anticipate will happen next? A. Obtain initial cardiac marker levels and other labs B. Prep the client for percutaneous coronary intervention (PCI) C. Begin oxygen at 4L/min per nasal cannula D. Administer IV morphine - correct answer -ANormal or nondiagnostic changes in the ECG (ST or T wave) represent a low risk of a MI, but serial cardiac markers (including troponin) and other labs should still be drawn. All clients with a suspected MI will have continuous ECG monitoring. Other noninvasive diagnostic tests may be ordered for this client (such as a stress echocardiogram); there's no need for PCI without confirmation of a MI. Supplemental oxygen can have harmful effects, unless the client's O2 saturation is less than 95% (and there is no information in the question about the client's O2 sats.) There's also no indication that the client's pain is not being controlled by the nitroglycerin. A client is receiving sodium nitroprusside intravenously to treat a hypertensive emergency. Which ongoing assessment is the priority during the administration of this medication? A. Serum thiocyanate levels B. Arterial blood gasses C. Blood pressure D. Urine output - correct answer -C Sodium nitroprusside has a rapid onset of action (2 minutes) and can induce unlimited blood pressure reduction. Use of this drug requires continuous invasive hemodynamic monitoring of blood pressure (using an arterial line.) This medication can also cause cyanide and thiocyanate toxicity, which is why serum levels should be measured daily during treatment. Because cyanide toxicity inhibits O2 utilization (resulting in lactic acidosis, mental status changes and hypotension), arterial blood gases must also be monitored during treatment. Urine output should also be monitored frequently. There is an order for a oral potassium chloride (KCl) replacement with the dosage based on the client's serum potassium lab results. If the client's current serum potassium is 3.3 mEq/L, what is the correct dosage to administer?Refer to the Potassium Replacement Protocol-Oral to determine the correct response. Potassium Replacement Protocol - Oral Current Serum Potassium Level 3.7 - 3.9 mEq/L Total Potassium Replacement Administer 1 tablet KCl 20 mEq by mouth Current Serum Potassium Level 3.5 - 3.6 mEq/L Total Potassium Replacement Administer 2 tablets KCl 20 mEq by mouthCurrent Serum Potassium Level 3.3 - 3.4 mEq/L Total Potassium Replacement Administer 3 tablets KCl 20 mEq by mouth Current Serum Potassium Level 3.1 - 3.2 mEq/L Total Potassium Replacement Administer 4 tablets KCl 20 mEq by mouth - correct answer -3 Using the current serum potassium level, the nurse will administer three 20 mEq KCl tablets. The client was treated with IV amiodarone for life-threatening ventricular arrhythmias. The client will be discharged with the oral form of the medication. Which of the following findings will the nurse emphasize as the most serious and requiring immediate notification of the health care provider (HCP)? A. Dyspnea and cough B. Malaise, fatigue and dizziness C. Skin deposits and photosensitivity D. Gastrointestinal disturbances - correct answer -A Amiodarone is a potent (and highly toxic) class III antidysrhythmic. A serious side effect of this medication is pulmonary toxicity, which is why a baseline chest x-ray and pulmonary function tests are needed prior to treatment. The client should contact the HCP to report any dyspnea, cough, or any other type of breathing problem while using the medication. Taking the medication in divided doses with meals can help with GI disturbances. The client should not drive until the effects of the drug stabilize and the body adjusts to it. The client should use suncreen and protective clothing when outdoors; skin deposits are common but benign. On the second postoperative day, a 79 year-old female (who was previously cognitively intact) becomes agitated when she begins having auditory and visual hallucinations. The client later demands to leave the hospital. What action does the nurse take next? (Select all that apply.) A. Contact the primary physician to evaluate the client B. Inform the client that insurance will deny payment for leaving against medical advice (AMA)C. Discuss the situation with the durable power of attorney for healthcare (DPOAHC) D. Review the release from liability form with the client and witness her signature E. Describe the risks and benefits of leaving the hospital to the client - correct answer -A,C,E A client has the right to leave AMA. As long as the client is competent and understands the risk of leaving, the client can sign a release from liability form and leave. The nurse cannot coerce the client into staying; it is not true that insurance will deny payment when someone leaves AMA. When there is reason to believe the client does not have the capacity to make decisions (which is the case for this client), the nurse should contact the primary physician, who will then evaluate the client. If the physician determines the client is not functionally competent and the client cannot explain the risks of leaving the hospital AMA, the client can be detained. The nurse should also contact the DPOAHC. The health care provider orders nafcillin 900 mg IVPB. The nafcillin label states: dilute powder in the vial with 3.4 mL sterile water to produce 1 gram in 4 mL. How many milliliters should the nurse administer? (Report to the nearest tenth and write only the number.) - correct answer -3.6 4mL/1g X 1g/1000mg X 900mg = (4 X 900)/ 1000 = 3.6mL (D/H) X Q = 900mg/1000mg X 4mL = 3.6mL The client arrives at the emergency department accompanied by a family member. The client reportedly has not been sleeping and has gone on shopping sprees. The client is irritable, easily distracted and becomes physically agitated. Which intervention is the priority for this client? A. Place the client in a quiet and secure area and inform staff of what is happening B. Provide factual, scientific, and relevant information to the client about treatment options C. Restrain the client and administer prescribed antipsychotic medication D. Assess the client's understanding of the reasons for the behaviors - correct answer -A The symptoms suggest a manic episode. Emergency assessment needs to determine if the mania is primary or secondary to a medical condition or to a substance disorder. Due to the physical agitation, the priority intervention is to place the client in a quiet and secure area and to inform staff of what is happening. The nurse will use short and concise statements and explanations, as well as a calm but firm approach. Restraints, seclusion, and administration of medication are measures that should be used only when clients present a clear and present danger to themselves or others. During recovery, the client will work with a counselor to gain an understanding of the reasons for his or her behavior.The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? (Select all that apply.) A. Craving and inability to abstain from alcohol B. Prone to act impulsively C. Able to identify problem behaviors D. Insecurity in relationships E. Internally motivated to change F. Inability to suppress memories - correct answer -A,B,D SUD is a chronic disease where a person persistently uses alcohol or drugs. Individuals with SUD have a craving for the addictive substance and are unable to abstain from it. Despite the negative consequences of abusing drugs or alcohol, they typically are not internally motivated to change. They often demonstrate an inability to identify problem behaviors. They are anxious, insecure and often have family and work problems. They may experience blackouts and cannot remember what happened when they were drinking, but the inability to suppress memories is not an issue with SUD. The staff nurse prepares an 88 year-old female for discharge and confirms that follow up care for a home health nurse is scheduled. During the medication reconciliation process, the client's husband states he hopes that his wife has "learned her lesson" and will take her medications as ordered. What action by the staff nurse is indicated? (Select all that apply.) A. Notify the home health agency nurse about the husband's statement B. Notify the health care provider of the need to delay discharge C. Ask the husband to manage his wife's medication at home D. Write a schedule with days and times for the client to take her medication E. Ask the husband why he thinks his wife is not taking her medications properly - correct answer - A,D,E The staff nurse should first determine what the husband meant and directly ask why he thinks his wife is not taking her medications properly. The staff nurse should help the client understand her medications - why she's taking them, when and how to take them, as well as side effects - because assisting older adults in managing their medications can help prevent hospital readmissions. Since medication management requires a multidisciplinary approach, the staff nurse should also alert the home health nurse about potential problems.The nurse will be participating in a quality improvement (QI) project that's intended to reduce falls at the health care facility. Identify the first step that's required for this project. A. Conduct a literature review to find the best practices to reduce falls in similar facilities B. Review the data about the types of falls and precipitating factors at the facility C. Implement fall reduction efforts according to current fall-prevention protocol D. Work with staff to revise fall-prevention policy and procedures - correct answer -B The first step in quality improvement is to review and evaluate the existing data about falls and precipitating factors at the facility. The next step is to conduct a literature review to determine appropriate best practices and effective interventions. Current policy and procedures are then reviewed, updated and, finally, implemented. The client is preparing for discharge after inpatient treatment for substance use disorder (SUD). During a counseling session with the client's mother, which behavior is recognized as having the highest potential to interfere with the client's recovery after discharge to home? A. Neglecting her needs to care for the client B. Offering advice and opinions to the client C. Setting limits for client behavior at home D. Ignoring requests for money - correct answer -A Codependence has the potential to interfere with an addict's recovery. Codependent behavior includes denial, self-neglect, manipulation, avoidance of feelings, hyper-vigilance and many other negative behaviors. A codependent family member gains feelings of personal worth by meeting the needs of the addicted family member and placing the needs of the addict above her own. Offering advice or refusing to discuss money may not be effective, but these probably won't directly affect the client's recovery. Setting limits is usually helpful for people struggling with SUD. The nurse manager is preparing for an inservice about efficiency and cost-effective care. Identify a strategy the nurse manager should include in the presentation that's aimed at increasing efficiency and reducing costs on the nursing unit. A. Eliminate reimbursement for continuing education seminars B. Increase the number of unlicensed staff providing care C. Limit dressings packages and other supplies on the nursing unit D. Label the cost of each item in the supply closet - correct answer -DWhen the cost of each item is displayed, staff becomes more aware of costs and may use supplies more wisely. Increasing the number of staff will not affect efficiency. Limiting the amount of supplies will decrease efficiency because of the time factor involved in obtaining needed supplies. Eliminating staff education reimbursement will not increase efficiency and may even decrease efficiency. The client is admitted to a rehabilitation unit following an ischemic stroke with right hemiplegia. The nurse observes the client having difficulty performing personal hygiene and other activities of daily living (ADLs). What will the nurse include in the plan of care? A. Instruct unlicensed assistive persons to provide total care B. Consult with the physical therapist about upper arm strength training and improving fine motor skills C. Review the occupational therapist's recommendations for the client D. Contact the case manager to determine the appropriate level of care - correct answer -C Even though the client may initially need assistance, s/he must be encouraged to participate in his or her care. The rehabilitation plan will include physical therapy for mobility issues and occupational therapy for ADLs, which is why the nurse should review the occupational therapist's recommendations for care. The nurse will consult with the case manager for discharge planning and coordination of care. The 75 year-old client has an appointment for a DXA scan to screen for osteoporosis. The nurse understands that which finding is a risk factor for osteoporosis? A. Walks two miles every other day B. Has used corticosteroids for arthritis for more than two years C. Drinks two ounces of red wine daily D. Reports late menarche and menopause - correct answer -B A dual energy x-ray absorptiometry (DXA) scan is used to screen for osteoporosis. While there are many causes of osteoporosis, the use of steroids over time increases the risk for osteoporosis. Other risk factors include low bone mass, poor calcium absorption, lack of weight-bearing exercise, and moderate to high alcohol ingestion. A late menopause would have increased the client's supply of estrogen, which would help prevent osteoporosis. The nurse manager is conducting a staff development program about improving client care outcomes. Which of the following processes will best contribute to improved outcomes? A. Clients with a diagnosis of heart failure will have an indwelling urinary catheter insertedB. Clients with a history of pressure ulcers will have an air mattress in place within 6 hours of admission C. Clients will be screened upon admission for methicillin-resistant staphylococcus aureus (MRSA) D. Clients with peripheral edema will have blood drawn for a daily chemistry panel - correct answer - B Providing clients with a history of pressure ulcers with an air mattress is a specific example of quality nursing and preventative care. Screening clients for MRSA or blood draws are not interventions. Although it may be medically-indicated for a client with heart failure, inserting an indwelling urinary catheter will not necessarily improve care or outcomes of care. During family counseling, the parents display the dysfunctional phenomenon called triangulation. Which of the following behaviors demonstrates triangulation? A. One parent accuses the other of spending all her free time and giving special favors to the child B. One parent admits to being disappointed about not having another child and is now volunteering at a children's center C. Both parents and the child seems to be vying for the family leadership position D. The parents state that the grandparents and several other relatives will need to be consulted before any decisions are made - correct answer -A Triangulation is a dysfunctional phenomenon where tension between a dyad (two people who have a relationship) is displaced onto a third person (child, friend, etc.). This behavior serves to lower the tension or resolve the crisis in a short term, but often creates new problems in the long term. Sublimation is a mature defense mechanism where the individual transforms losses or socially unacceptable urges into acceptable behaviors (such as volunteering). Boundary blurring is the loss of distinction among individuals in a family. Enmeshment is where family boundaries are blurred; enmeshed families depend on each other excessively and have little autonomy. Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management? A. Physicians are responsible and accountable for client outcomes. B. The interdisciplinary team makes all the decisions for the client and family. C. Case management strategies focus mainly on the client's needs after discharge. D. Case management is a collaborative process designed to meet complex client needs. - correct answer -DCase management is a collaborative process of organizing and coordinating resources and services within and across multiple settings. The focus is on cost-savings as well as quality and continuity of care. Case management nurses work closely with physicians, nurses, social workers to meet the complex health needs of the client. Case management is "client-centric" and all members of the team, including the client, work together to achieve desired outcomes. Cases that involve high-risk diagnoses (such as HIV/AIDS, cancer or people with cognitive deficits) or high-volume cases (such as total hip or total knee replacements) are often selected for case management. It's mealtime at the long term care facility. The nurse observes an unlicensed assistive person (UAP) returning an uneaten food tray to the food cart, where other trays are waiting to be served. What is the priority action of the nurse? A. Reinforce infection control information after all trays are passed B. Observe the UAP during the next meal to see if the action is repeated C. Immediately reinforce information about infection control D. Report the incident to the director of nursing - correct answer -C Returning a food tray (that had previously been delivered to a client) to the cart will crosscontaminate the other undelivered, "clean" trays, even if the contents of the tray are uneaten. The priority action is to immediately reinforce information regarding infection control. Waiting until all the trays have been delivered or for another meal increases the risk of cross-contamination and illness. There's no need to involve the director of nursing unless the behavior continues unchanged. A Cambodian client witnessed a murder three days prior to admission to an inpatient psychiatric unit. The client now reports that a "wind has entered my chest and I know I am dying." Which nursing intervention is a priority? A. Establish a therapeutic relationship B. Challenge the delusion with reality statment C. Encourage the client to suppress the traumatic memories D. Discourage visits from the client's family until the medication takes effect - correct answer -A Khyâl is a panic attack among Cambodians that can occur with acute stress disorder (ASD) following a traumatic event. Symptoms include the belief that a wind enters the body in the diaphragm causing shortness of breath, tinnitus, dizziness, neck soreness and feelings of impending death. Establishing a therapeutic relationship is necessary to understand the cultural aspects of the client's symptoms and is a priority in ASD. Challenging delusions assumes psychosis rather than examining cultural indications of ASD. Voluntary memory suppression is not practical nor therapeutic in ASD. Family visits can assist the client via cultural understanding of symptoms and event interpretations.A client is newly admitted with acute diarrhea and is wearing an adult incontinence pad. What action should the nurse take before visitors arrive and enter the client's room? A. Ask each visitor to dress in a gown and wear gloves before entering the client's room B. Call the health care provider to request an order for a private room C. Verify that each visitor is wearing a mask if less than 3 feet (0.9 meters) from the client D. Remind all visitors to wash their hands before entering, and when exiting, the room - correct answer -A According to the Centers for Disease Control and Prevention, diarrhea in an incontinent patient requires contact precautions. The nurse can implement precautions for a known or suspected infection; the nurse must then obtain an order (usually within 24 hours) from the health care provider (HCP.) Contact precautions also include standard precautions, such as placing the client in a private room or cohorting; an order is not required for this. Washing hands is very important, but not enough to protect against potential enteric pathogens. Droplet precautions, not contact precautions, involve wearing a mask when within 3 feet (0.9 meters) of the client. While caring for a client in the 2nd stage of labor, the health care provider requests 1% lidocaine, a 10 mL syringe and a 23 gauge 1.5 inch needle. What does the nurse anticipate that the health care provider is preparing to do? A. Perform an episiotomy B. Administer an epidural C. Initiate oxytocin infusion D. Correct a prolapsed cord - correct answer -A During the 2nd stage of labor, a health care provider would use lidocaine, a 10 mL syringe and a 23 g 1.5" needle to administer local infiltration anesthesia for an episiotomy. Epidurals are typically administered by anesthesia personnel during the 1st stage of labor. Using a local anesthetic prior to IV catheterization can reduce pain, but requires only an intradermal injection using a tuberculin syringe. Correcting a prolapsed cord does not require lidocaine. The client is diagnosed with an anxiety disorder. During a psychiatric interview, the client asks the nurse whether religious practices would decrease the symptoms of anxiety. Which response is the most therapeutic? A. "Studies have shown that spiritual practices and religious beliefs help people cope with stress and anxiety." B. "We are not allowed to discuss religion with clients in this facility."C. "Perhaps you can try out some different churches when you are discharged." D. "We have a wonderful chaplain and I will ask him to speak with you today." - correct answer -A Scientific studies have demonstrated that religious and spiritual practices enhance the immune system and increase a sense of well-being in people; they are also associated with decreased mental and physical illness. Nurses should respond honestly to client's questions and provide them with evidence-based information, rather than refuse to discuss the subject. Suggesting church attendance or assuming that the client wants to speak with the chaplain deflects the client request for information from the nurse. During a well-child clinic visit, the nurse assesses a 2 year-old child who is in the 50th percentile for both height and weight. The child still breastfeeds twice a day and the parents report that the child eats a variety of foods that are allowed within the vegetarian practices of their religion. Which of the following is the priority nursing response? A. "Let's take a look at what your child has eaten in the past day or two and then discuss how to decrease the risk of dietary deficiencies." B. "You will need to contact a licensed nutritionist for information about how best to feed your child." C. "Since your child is underweight, I am required to report you and request a home visit from child protective services." D. "Your religion may be harming your child, so I am required to refer your case to social services." - correct answer -A A cultural or spiritual belief system can have negative consequences for a growing child. A vegetarian diet that excludes animal products may result in deficiencies in vitamins B12 and D, as well as calcium, iron, and zinc. Further assessment that is sensitive to the family's culture, as well as information regarding how to compensate for missing nutrients, is needed. It's a nursing responsibility to first assess the child's diet before referring the case to a nutritionist. It's nontherapeutic and judgmental to say that this case must be reported to child protective services, without further assessment. The child is not underweight; s/he is reported to be in the 50th percentile for weight. The nurse evaluates the ECG strip. What type of rhythm is depicted? Picture shows a 6 second strip with 4 QRS complexes. A. Sinus bradycardia B. Normal sinus rhythm C. Ventricular tachycardiaD. First degree heart block - correct answer -A This is sinus bradycardia - the rhythm is regular and less than 60 beats a minute. The P wave, PR interval and QRS wave are all normal. One method to determine the rate is to count the number of small boxes in a typical R-R interval and divide this number into 1500. Although it's difficult to see on this strip, there are about 33 small boxes for the R-R interval; 1500/33 = 45 beats a minute. Alternatively, you can count the number of R waves and multiply by 10. In this example, 4 R waves x 10 = heart rate of about 40. The nurse evaluates the ECG strip for heart rate. What is the client's heart rate? Picture shows a 6 second strip with 7 QRS complexes. A. 60 B. 70 C. 80 D. 90 - correct answer -B This ECG represents normal sinus rhythm. There are several methods for determining heart rate. The easiest method is to simply count the number of QRS complexes over a 6 second interval (note that the black marks at the top indicate 3 second intervals) and multiply that number by 10. There are 7 QRS complexes in 6 seconds on this strip; the client's heart rate is approximately 70. A client at 29 weeks gestation has been admitted to the antepartum unit. Assessment findings include blood pressure 124/82 and uterine contractions are 8 to 10 minutes apart. The medication administration record includes an order for nifedipine. What action by the nurse is appropriate for this situation? A. Administer the medication as ordered B. Hold the medication until the blood pressure is 140/90 C. Request a substitute medication, such as magnesium sulfate D. Administer the nifedipine with an oxytocin drip - correct answer -A Nifedipine is used for preterm labor because it reduces contractility in the smooth muscles of the uterus, causing tocolysis. While it is also an antihypertensive, there are no indications that this client is having issues with her blood pressure. Magnesium sulfate is sometimes used with preterm labor, however, nifedipine has fewer side effects associated with it. Oxytocin, a contraction-inducing or oxytocic medication, would not be appropriate for this client.The client is diagnosed with Clostridium difficile (C. difficile.) The nurse, who does not apply personal protective equipment (PPE), enters the room to administer a medication. The client requests assistance to sit up in bed before taking the medication. What is the next action by the nurse? A. Perform hand hygiene with soap and water B. Assist the client to move up in bed C. Leave the room to apply PPE D. Reposition the client and then apply alcohol-based hand rub - correct answer -A C. difficile is an anaerobic gram-positive bacterium that produces spores resistant to heat, drying and many antiseptic solutions. The spores are transmitted from client to client via improperly sanitized hands. Meticulous hand hygiene, using soap and water, and strict adherence to isolation protocols will help prevent the transmission of C. difficile. In this scenario, the nurse needs to first wash his or her hands with soap and water and then apply PPE (gown and gloves) before providing any care. Alcohol-based hand rubs are ineffective against C. difficile. The nurse cares for a client diagnosed with pneumonia. During the admission interview, the client explains that her husband died a few months ago and states, "I don't seem to be able to sleep or eat now. I'm not sure I have anything to live for." Which of the following reflects an appropriate nursing response? (Select all that apply.) A. "Are you thinking of ending your life?" B. "Your loss is devastating and each person experiences grief differently." C. "You are grieving and if you don't feel better in another month, you should seek help for depression." D. "I'd like to know more about how you are doing and what you have used for support after your husband's death." E. "I need to pass medications, but I will call your daughter to come and talk to you." - correct answer -A,B,D A client who has experienced the recent death of a spouse will express symptoms of grief that are similar to symptoms of depression. The nurse may not have the expertise or time to differentiate between grief and depression but, based on the client's statement, the nurse should recognize there's a potential for suicide; the nurse should directly ask the client if she is contemplating suicide. Using therapeutic communication and offering of self, the nurse should acknowledge the client's feelings. Offering to call a social worker or family member may be a part of a conversation (and plan of care) after the nurse has engaged in a therapeutic exchange with the client.The client has been hospitalized 48 hours for multiple injuries sustained in a motor vehicle accident. An elevated blood alcohol level was present at the time of the accident. Which finding(s) should be a priority in the plan of care? A. Hallucinations B. Loss of appetite and nausea C. Diaphoresis D. Fine tremors - correct answer -A The symptoms of alcohol withdrawal usually begin about 5-10 hours following the last drink and peak around 24-72 hours. The severity of symptoms experienced during detoxification varies with each client. Individuals who have been abusing alcohol for many years are at risk of developing delirium tremens (DTs). Symptoms of DTs include hallucinations, extreme confusion, extreme agitation, and tachycardia; DTs is a medical emergency. Loss of appetite, nausea, diaphoresis and fine tremors are symptomatic of the earlier stages of withdrawal. There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next? A. Use another client's nitroglycerin paste until pharmacy sends a tube for this client B. Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart C. Call the pharmacy to send up a tube of nitroglycerin paste D. Call the prescriber and ask to substitute a different formulation of nitroglycerin - correct answer - C The nurse must call the pharmacy and ask to have the medication sent to the floor. It is never acceptable to borrow another client's medication; this is an example of at-risk behavior, commonly referred to as a "workaround." The nurse can never substitute one formulation of a medication for another, without a specific order to do so. Giving a medication without an order would be considered a medication error and is an example of working outside the nurse's scope of practice. The emergency department nurse cares for a client who has a fractured humerus and multiple bruises to the upper body. The nurse performs a risk assessment screening for abuse. Which question is the priority? A. Have you even been emotionally or physically abused? B. Does your partner hit or kick you when angry? C. Do you feel your life is in danger from abuse or suicide?D. Is your partner extremely and constantly jealous of you? - correct answer -C Less than 12% of battering survivors who present to an emergency department are screened for abuse. After establishing a nurse-client relationship, it is most important to conduct a lethality assessment to determine whether the survivor is in danger of homicide or suicide. The correct option asks the client about a life threat. The other options are all part of abuse assessment screening after the risk of lethality has been established. During a routine office visit, the nurse compares the client's laboratory results with a report from six months ago. Despite medical treatment, the client's total cholesterol remains high. The nurse plans to discuss information with the client about changing behaviors that contribute to cerebrovascular disease. What intervention is the first step towards health promotion? A. Schedule an appointment to review dietary modifications B. Identify programs in the community to increase physical activity C. Discuss risk factors on a stroke risk assessment tool D. Review options for smoking cessation programs - correct answer -C The nurse will first assist the client to identify lifestyle factors they are willing to change, such as changes in diet and activity. If the client recognizes the potential areas for change, the nurse can work with the client to create a collaborative treatment plan that's focused on preventing cerebrovascular disease. The nurse can identify support groups and/or programs in the community based on the client's needs and willingness to change. A client-centered approach helps adherence to treatment, which improves health outcomes. The nurse reviews the client's plan of care after an exacerbation of chronic obstructive pulmonary disease (COPD). Which primary prevention strategies are recommended to reduce the risk of further complications? (Select all that apply.) A. Teach the client about the proper use of prescribed salmeterol inhaler B. Arrange for portable oxygen therapy for home care C. Educate the client about washing hands and avoiding crowds D. Make a referral to a pulmonary rehabilitation program in the community E. Discuss with the client about scheduling an annual influenza vaccination - correct answer -C,E Primary prevention includes a wide range of strategies or interventions that will prevent disease or injury before it occurs. This is accomplished by preventing exposure to pathogens, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury. Salmeterol and oxygen therapy are secondary prevention interventions for the treatment of COPD. They are intended to reduce the impact of the disease that has already occurred. Pulmonary rehabilitation is an example of tertiary prevention. Tertiary interventions are intended to help clients manage long-term, often complex health problems or injuries. The nurse is caring for a 3 year-old child who is hospitalized for a cardiac procedure. Which of the following nursing actions will help reduce anxiety in the child? A. Keep the daily routine close to the usual home routine B. Ask the parents to leave at night to allow for better sleep C. Have the child explain why he is in the hospital D. Discuss the expected outcomes of the hospitalization - correct answer -A Hospitalization for a child induces stress responses and anxiety. The early childhood developmental stage is most comforted by daily routines that more closely mimic the home routine. During the middle and adolescent stages of development, children benefit from sharing their feelings about being hospitalized and procedures they will undergo. Parents should be encouraged to stay overnight since this helps reduce anxiety in the 3 year-old. A 2-month-old is admitted with a fever of undetermined origin. The infant received acetaminophen two hours ago and is now sleeping. The parents are refusing to allow the unlicensed assistive person (UAP) to attempt to measure the baby's temperature because the infant is asleep. What action by the nurse is indicated in this situation? A. Recognize that the parents have a right to refuse treatment B. Insist that the temperature must be taken now C. Ask the parents to step outside of the room to discuss the situation D. Send a different UAP to measure the client's temperature - correct answer -A A client or the client's advocate has the right to accept or refuse routine assessments, especially when it will not alter the outcome. The nurse can make other assessments (for example, count respirations, observe color of skin) and document these findings along with information that the client is sleeping. The client's temperature can be re-evaluated later, when the client is awake. The nurse is making rounds, checking oxygen equipment and assessing clients receiving oxygen therapy. Which of the following situations require intervention by the nurse? (Select all that apply.) A. Humidified oxygen delivery system contains water from condensation in the tubing B. Valves and flaps in the nonrebreather mask will not open C. Oxygen tubing that will allow ambulation to the bathroom is 25 feet (7.6 meters) in lengthD. Humidifier is documented as having been changed 12 hours ago E. The reservoir bag on a nonrebreather mask is inflated F. Nasal cannula tubing is documented as having been changed eight days ago - correct answer - A,B,F Clients receiving humidified oxygen need equipment monitored for condensation in the tubing so that water does not empty into the client mask. Frequent emptying of the tubing away from the client is necessary. Valves and flaps in nonrebreather masks must be patent and able to open during expiration and close during inhalation to maintain FiO2. A mask with valves that do not open must be replaced. In a nonrebreather mask, the reservoir bag should be inflated; if it deflates the client will breathe in exhaled carbon dioxide. Nasal cannula tubing must be changed at least every seven days and humidifiers changed every 24 hours. Oxygen tubing extensions that allow clients to ambulate to bathroom should not exceed 50 feet. The nurse cares for a hospitalized client recovering from pneumonia. The client has been homeless for several years. Which of the following is a priority in discharge planning? A. Arrange for transportation to transitional housing B. Give detailed instructions for follow-up appointments C. Refer to a community day program for social activities D. Provide information about local religious services - correct answer -A Using Maslow's hierarchy of needs, the nurse first ensures access to basic needs such as food, clothing and shelter. Providing transportation to housing relates directly to a basic need. Giving detailed instructions for follow-up appointments is necessary, but secondary to the need for shelter. Referrals to community social or religious programs may be included in the discharge plan depending upon the desires of the client. A client's blood pressure reading has been trending in the 160/90 range. The client's current blood pressure reading is 120/70. Which could be a possible reason for this change? A. The cuff used to measure blood pressure was too large B. The client has been refusing his beta blocker medication for 2 days C. The client was arguing on the phone just prior to the assessment D. The blood pressure measurement was taken on the client's leg - correct answer -A A cuff that is too large will give a false low reading. Lower blood pressure readings would not indicate a client is refusing blood pressure medication. In fact, if the client was not taking medication to lower blood pressure, the expectation is that the blood pressure would increase. Activities such as talking, or even arguing, would contribute to higher, not lower than expected readings. A blood pressure reading from the leg may give systolic values at 20 to 30 mm Hg higher than readings from an upper extremity. The emergency department nurse assesses a client who was involved in a motor vehicle accident. The client has a laceration on his cheeks and nose and bruising over the upper chest. The client says, "I felt lightheaded and my feet were numb, but I got out of the car and walked." What nursing assessment is contraindicated? A. Use a temporal artery thermometer to assess the client's temperature B. Obtain an orthostatic blood pressure measurement C. Ask the client to take a deep breath while assessing lung sounds D. Compare movement of feet bilaterally - correct answer -B A potential spinal cord injury may be indicated with altered sensations in the lower legs. Asking the client to change positions (to sit or stand) is not appropriate for measuring blood pressure without confirmation that the client does not have a spinal cord injury. The temporal artery thermometer can be used if the facial injury is below the eyes. Assessing the lungs accurately is important after a chest injury. Additional neurological assessment of the extremities is also indicated. A 17 year-old male seeking treatment at a clinic reports having fever and chills for several days. The client states that every time he gets sick, his mother sends him to the clinic because she thinks he has human immunodeficiency virus (HIV). What is an appropriate response by the nurse? A. "Are you concerned that you may have HIV?" B. "She's just worried about you." C. "Have you ever given her a reason to think that way?" D. "Are you sure that's what your mother says?" - correct answer -A All the nurse knows is what the client is reporting. The nurse does not know if, in fact, the client's mother is actually concerned about HIV. The most therapeutic response is to ask the client if he is concerned about HIV. Asking an open-ended question should encourage the client to express his feelings and concerns. The nurse should also reassure him that even though he is a minor, any information he discloses is confidential and will not be shared without his consent or without legal justification. Should the client disclose that he is concerned that he has HIV, the nurse will need to determine more information about the client's sexual relationship(s) and if they might involve abuse. The nurse is planning care for a client with a T6 level spinal injury. In conjunction with physical therapy, what types of assistive devices would be included in the plan of care to help with mobility?A. Motorized wheelchair with breath control B. Crutches and bilateral knee-ankle-foot orthoses C. Bilateral leg braces and a quad cane D. Torso brace and steerable knee walker - correct answer -B A client with a T6 level injury will have good torso control but a loss of function below the waist. The client could use knee-ankle-foot orthoses (KAFOs) and crutches or a walker. A lightweight wheelchair can also be used and will enable independent mobility in all environments; a motorized wheelchair can be used but breath control is not necessary with a T6 injury. A quad cane will not provide enough stability for transfers or walking. A steerable knee walker is used after lower leg or foot surgeries. The client is a 74-year-old male client who is recovering on a medical unit after a suicide attempt that involved carbon monoxide poisoning. The client states that his wife died one year ago and he lives alone. Which of the following questions will best assess available client support systems? (Select all that apply.) A. "Have you thought about joining a Christian church?" B. "Who are you closest to in your family?" C. "What kinds of support has been helpful to you in the past?" D. "Why haven't you attended a grief support group?" E. "Let's discuss the resources available to you after you are discharged." F. "I informed your neighbor how best to support you after discharge." - correct answer -B,C,E Many resources and studies identify social support systems as an essential part of suicide assessment (SAD PERSONS scale). Since nurses are res