ADULT HEALTH

Question 1

Which of the following images represents the visual field of a patient with macular degeneration?

Answer 1

Explanation

Choice C is correct.This represents what a patient with macular degeneration would see. Their peripheral vision remains intact, while the central idea becomes darker and darker until there is a spot in the center of their visual field through which they cannot see.

Choice A is incorrect.This represents what a patient with end-stage glaucoma would see. End-stage Glaucoma will show a very constricted visual field with the loss of peripheral vision by causing damage to the Optic Nerve.

Choice B is incorrect.This represents what a patient with cataracts would see. It shows a uniformly blurred image. Cataracts affect the visual field reasonably consistently. Cataracts cause visible degradation by three mechanisms: image blur, light scattering, and decreased illumination.

Choice D is incorrect. This represents what a patient would see if they had a detached retina. It is often described as a “curtain coming down over their field of vision.” This is a medical emergency.
NCSBN Client Need:
Topic: Physiological Integrity; Subtopic: Basic Care and Comfort

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

Question 2

The nurse is teaching a group of nursing students infectious diseases that are reportable to the local health department. It would be correct to state which of the following condition (s) should be reported? Select all that apply.

A. Bacterial vaginosis

B. Herpes simplex virus

C. Human immunodeficiency virus

D. Hepatitis A

E. Syphilis

F. Human Papilloma Virus infection

Answer 2

Explanation

Correct Answers are C, D, and E.

Infectious Conditions that are reportable to the local health department include Human immunodeficiency virus (Choice C), Hepatitis-A (Choice D) and Syphilis (Choice E).

Also, other reportable conditions include chlamydia, pulmonary tuberculosis, rabies, chickenpox, influenza, and gonorrhea. Healthcare providers have the responsibility to report these to the state/ local health departments.
Mnemonic for Mandatory reportable diseases in most states and to CDC:
HEP-HEP-HEP-HooRay-SSSMMMARTT Great CHICk: Hepatitis-A, Hepatitis-B, Hepatitis-C, HIV, Rabies, Syphilis, Shigella, Salmonella, Mumps, Measles, Meningococci, AIDS, Rubella Tuberculosis, Tetanus, Gonorrhea, Giardiasis, Chlamydia, H, Influenza, Chickenpox.

Choice A is incorrect. Bacterial vaginosis is a common infection that does not require reporting.

Choice B is incorrect. Herpes simplex virus (HSV) is spread by multiple methods and thus is not reportable. Genital herpes need not be reported.

Choice F is incorrect. Human Papillomavirus (HPV) is not a reportable disease. Human Papillomavirus (HPV) infection and other HPV-associated clinical conditions are not nationally notifiable or required by CDC. Some states and jurisdictions require specific HPV associated conditions reported ( cervical cancer, cervical pre-cancer) but not infection itself.
NCSBN Client Need:
Topic Health promotion and maintenance; Sub-Topic: Health promotion and disease prevention

Question 3

he nurse is discussing breast self-examination with a patient who has a strong family history of breast cancer. The nurse suggests that the patient lies flat and examines her right breast placing a pillow ________________.

A. Under the left shoulder

B. Under the right scapula

C. Under the right shoulder

D. Under the lower back

Answer 3

Explanation

The correct answer is C

When performing a self-breast exam, the patient should be instructed to place a pillow under the shoulder of the ipsilateral breast.

The breasts are best examined while lying down. “Lying down” position spreads the breast tissue uniformly over the chest. The client should be instructed to perform Breast Self-Examination (BSE) while lying flat on the back, with one arm over the head and a pillow under the same side shoulder. The purpose of this position is to flatten the breast and make it easier to check for any lumps/ masses. The client should use her finger pads (not the fingertips) of the middle fingers of her left hand to press firmly on her right breast. The procedure is repeated in the same way for the left breast.

Choices A, B, and D are all incorrect. When performing a self-breast exam, the patient should be instructed to place a pillow under the shoulder of the ipsilateral breast.

NCSBN client need |Topic: Reduction of risk potential, Potential for alterations in body systems
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby

Question 4

You are teaching a student nurse regarding various types of pain. The student nurse should realize which of the following types of pain are accurately paired with one of their signs or symptoms? Select all that apply.

A. Chronic pain: The vital signs are normal

B. Chronic pain: The sympathetic nervous system is activated.

C. Acute pain: The pulse, blood pressure and respiratory rate are increased.

D. Acute pain: The parasympathetic nervous system is activated.

E. Somatic pain: A type of neuropathic pain.

F. Somatic pain: Pain sensation originates from the bones, the skin, and the muscles.

G. Visceral pain: A type of neuropathic pain.

H. Visceral pain: The vital signs are normal

Answer 4

Explanation

Choices A, C, and F are correct.

Chronic Pain is characterized by typical vital signs (Choice A), whereas acute pain is characterized by increased pulse, blood pressure, and respiratory rate (Choice C).

In chronic pain, pupils can be healthy or dilated, and the client can be withdrawn and depressed. In chronic pain, the parasympathetic nervous system is activated.

In acute pain, the sympathetic nervous system is activated. Therefore, the presentation includes the features of sympathetic activation. Pulse, blood pressure, and respiratory rate are increased. The pupils are dilated; the client can be restless and show pain behaviors such as guarding the painful area and crying.

Somatic pain originates from the bones, the skin, and the muscles (Choice F) and somatic pain is a type of nociceptive pain, rather than neuropathic pain.

It is essential to understand the terminology of pain based on:

Onset and duration (Acute Pain vs. Chronic Pain).
Origin (Somatic pain vs. Visceral Pain) – The fully functional nervous system transmits messages that a part of the body is damaged. Somatic pain occurs when the damage involves the bones, the skin, and the muscles. Visceral Pain occurs when the injury involves the internal organs in the central cavities of the body (also called the viscera). Physical pain may be described as sickening, deep, or dull in quality. In visceral pain, vital signs are increased.
Cause of the pain (Nociceptive vs. Neuropathic)
    Nociceptors are pain receptors present on many parts of the body, including internal organs. Nociceptive pain arises secondary to a damage/ injury caused to the body part by an external stimulus or condition. This is often acute but may also be chronic. Examples include burns, bee stings, stab wounds, tumors, inflammatory arthritis, etc. Both Somatic and Visceral pain are types of Nociceptive pain.
    Neuropathic pain is mediated by the nerves and is from damage to the nervous system itself. It may be because of injury secondary to the central or peripheral nervous system from different causes. Examples: Multiple sclerosis, peripheral neuropathy, etc. It may be stabbing, shooting, or aching in nature. This type of pain is often chronic.

Choice B is incorrect. In chronic pain, the parasympathetic nervous system, rather than the sympathetic nervous system, is activated.

Choice D is incorrect. In acute pain, the sympathetic nervous system, rather than the parasympathetic nervous system, is activated.

Choice E is incorrect. Somatic pain is a type of nociceptive pain, not neuropathic pain.

Choice G is incorrect. Visceral pain is a type of nociceptive pain, not neuropathic pain.

Choice H is incorrect. The vital signs are not normal with visceral pain. They are often increased.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016).

Question 5

The nurse is assessing a client with a chest tube for crepitus. Which assessment technique is most appropriate for the nurse to perform?

A. Pressing down on the client’s abdomen, releasing, and assessing for pain.

B. Palpating the skin around the chest tube and observing for a crackling sensation

C. Auscultating the bowel sounds in each quadrant

D. Inspecting the client’s chest for even rise and fall

Answer 5

Explanation

Answer: B

A is incorrect. When the nurse presses down on a client’s abdomen and then releases, the nurse is assessing for rebound tenderness. This occurs when pain is present upon letting go of the client’s abdomen, not pressing inward. It is a sign of peritonitis.

B is correct. The nurse may assess for crepitus by palpating the skin around the chest tube and observing for a crackling sensation. Crepitus is defined as infiltration of air in the subcutaneous layer of skin, also known as subcutaneous emphysema. It is caused by air leaking into the subcutaneous space.

C is incorrect. Auscultating the bowel sounds in each quadrant is not an appropriate way to assess for crepitus.

D is incorrect. Inspecting the client’s chest for even rise and fall will not allow the nurse to monitor for crepitus; rather this will help the nurse to assess for a symmetrical chest and unlabored breathing.

NCSBN Client Need:

Topic: Reduction of Risk Potential

Subtopic: System Specific Assessments

Subject: Adult Health

Lesson: Respiratory

Question 6

Which advice is most appropriate for a patient who is on neutropenic precautions to prevent infection?

A. Brush teeth once a day or every other day

B. Avoid the use of tampons for menstrual periods

C. Do not let visitors within 10 feet

D. Wash hands after cleaning up after pets

Answer 6

Explanation

The correct answer is B. Tampons may cause vaginal mucosal tears that could lead to infection. Therefore, patients on neutropenic precautions should avoid using them.

A is incorrect. Teeth should be brushed twice daily with a soft toothbrush to help prevent infection.
C is incorrect. Healthy visitors are usually acceptable. However, in some circumstances, it may be best for them to wear a mask, gown, or gloves when in close contact.
D is incorrect. People with low neutrophil count should avoid cleaning up after pets and should have some else take on this task. Pets are often a source of infection.

NCSBN Client Need
Topic: Safe and Effective Care Environment;Subtopic: Safety and Infection Control

Resource: Fundamentals of Nursing (Taylor/Linnis/Lynn);Chapter 23: Asepsis and Infection control;Lesson: Providing Care in Special Situations

Question 7

The nurse is providing in-service regarding tick bites. Which information should be included in the presentation? (Select all that apply)

A. Use forceps or tweezers to grab the tick as close to the skin as possible, then pull upwards with firm motion.

B. After the removal of the tick, clean skin with soap and water.

C. If tick’s mouth remains in the skin, use petroleum jelly or hydrogen peroxide to loosen and remove with tweezers.

D. Monitor for flu-like symptoms and bulls-eye rash for several days following tick bite.

Answer 7

Explanation

Choices A, B, and D are correct. Tweezers or forceps should be used to remove the embedded tick as close to the head as possible. A smooth, steady pull upwards should be applied, ensuring not to twist the tick while lifting. After the tick is removed, the area should be cleaned well with soap and water. If the tick has transmitted the pathogen, Lyme disease’s classic symptoms usually appear within days of the bite and include flu-like symptoms and a bulls-eye rash at the site.

C is incorrect. If the tick’s mouth is too deep to be removed and remains in the skin, it should be left alone. No heat or topical products should be used in an attempt to extract it. Once the mouth is no longer attached to the body, the tick can no longer transmit bacteria and disease.

NCSBN Client need:
Topic: Illness management, medical emergencies, pathophysiology

Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1778)

Question 8

A nurse is assigned to care for a client with an internal radiation implant. Which of the following should not be included in the plan of care?

A. Wearing gloves when handling the client’s bedpan

B. Keeping all of the client’s linens in the room until the implant is removed

C. Wearing a lead apron when direct care is provided to the client

D. Placing the client in a semiprivate room at the end of the hallway

Answer 8

Explanation

Rationale: A client with an internal radiation implant must be placed in a private room with a private bath to prevent accidental exposure of other clients to radiation. Option D is, therefore, the correct answer.

Options A, B, and C are the right interventions for a client with a radiation implant and should be included in the plan of care. These options are, therefore, incorrect.

Reference

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

Question 9

Explanation

Rationale: A client with an internal radiation implant must be placed in a private room with a private bath to prevent accidental exposure of other clients to radiation. Option D is, therefore, the correct answer.

Options A, B, and C are the right interventions for a client with a radiation implant and should be included in the plan of care. These options are, therefore, incorrect.

Reference

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

Answer 9

Explanation

Correct Answer is D.Thispressure ulcer is considered unstageable because there is full-thickness tissue loss, but the wound bed is covered by eschar. Because of the eschar, real depth and stage cannot be determined. The eschar must be removed to visualize the foundation of the wound before staging.

Choice A is incorrect.This is a stage I pressure ulcer. The skin is intact, but the area is red and does not blanch with external pressure.

Choice B is incorrect.This is a stage IV pressure ulcer. There is full-thickness skin loss with exposed bone, tendons, or muscles.

Choice C is incorrect.This is a stage III pressure ulcer. There is full-thickness loss into the dermis and subcutaneous tissue. There may or may not be slough, visible subcutaneous tissue, or undermining and tunneling. However, the bed of the wound is evident, and there is no exposed bone, tendons, or muscles.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological Adaptation

Reference: Ignatavicius D, Workman ML: Medical-surgical nursing: Patient-centered collaborative care, ed 7, Philadelphia, 2013, Saunders

Question 10

The nurse is caring for a client who presents with hyperglycemia. Which of the following finding(s) is/are expected? Select all that apply.

A. Sweating

B. Increased urinary output

C. Cool and clammy skin

D. Tachycardia

E. Orthostatic hypotension

Answer 10

Explanation

Correct Answers are B, D and E. Increased urinary output ( Polyuria) (Choice B), Tachycardia (Choice D), and Orthostatic hypotension (Choice E) are expected findings with hyperglycemia.

Polyuria: Increased urine output
Tachycardia: Increased heart rate
Orthostatic Hypotension: Postural (orthostatic) hypotension is defined as a drop in systolic blood pressure of at least 20 mm Hg or more and a drop in diastolic blood pressure of at least 10mm Hg or more within two to five minutes of quiet standing after five minutes of supine rest.

Symptoms of hyperglycemia include increased thirst ( Polydipsia), Polyuria, Polyphagia, weight loss, blurry vision, and slow wound healing. Long-standing hyperglycemia can lead to nerve damage resulting in Neuropathy ( tingling, numbness, neuropathic pain) when random blood glucose is ≥200 mg/dL, many patients with Type 1 diabetes, and some patients with Type 2 diabetes present with symptomatic hyperglycemia.

Hyperglycemia leads to osmotic diuresis when glucose levels are so high that glucose is excreted in the urine. Water follows the glucose concentration passively, leading to abnormally high urine output. In turn, this leads to dehydration. Dehydration manifests with Tachycardia ( Choice D) because the body responds to maintain perfusion by increasing cardiac output. Dehydration results in hypovolemia, which can display with Orthostatic Hypotension as well ( Choice E).

Choice A is incorrect. Sweating is a manifestation of Hypoglycemia, not hyperglycemia.

Choice C is incorrect. Cold and clammy skin are expected findings with hypoglycemia, not hyperglycemia.
NCSBN Client Need:
Topic Physiological adaptation; Sub-Topic: Alteration in body systems.

Question 11

The nurse is preparing morning medications for a client with a nasogastric tube connected to low-intermittent wall suction. Which of the following actions does the nurse take to ensure proper administration of this client’s medications? Select all that apply.

A. Position the client in Trendelenburg position

B. Verify correct placement of the tube before medication administration

C. Turn off the suction during medication administration

D. Return the NG tube to low-intermittent wall suction after administering the medication.

Answer 11

Explanation

Answer: B and C

A is incorrect. It would be highly inappropriate to place a client in the Trendelenburg position before administering medications through a nasogastric tube. To prevent aspiration, the nurse should sit the patient up as much as tolerated, raising the head of the bed at least 30 degrees. This will allow gravity to help the medication flow into the stomach for absorption.

B is correct. It is very important to always verify correct placement of the tube before medication administration. 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 nurse can assess that the tube has not moved and remains in the stomach prior to each feed.

C is correct. It is appropriate to turn off the suction during medication administration. If the client remained on low-intermittent wall suction, the medication would be evacuated from the stomach via suction before it had the chance to be absorbed. The nurse should stop the suction and clamp the nasogastric tube for 30 minutes after administering the medications to allow them to fully absorb.

D is incorrect. It is not appropriate to return the NG tube to low-intermittent wall suction after administering the medication. This would prevent the medications from fully absorbing. In general, clamping the nasogastric tube for 30 minutes after medication administration will be enough to allow for medication absorption. Then the nurse may return the NG tube to low-intermittent wall suction.

NCSBN Client Need: Reduction of Risk Potential

Topic: Potential for Complications of Diagnostic Tests/Treatments/Procedures

Subject: Fundamentals

Lesson: Safety

Question 12

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 12

Explanation

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 13

he nurse is talking to a client that is being evaluated for possible acute leukemia. Which question by the nurse is most relevant?

A. How is your sleep recently?

B. Did you have a respiratory infection recently?

C. Did you lose weight the last couple of months?

D. Have you noticed any changes in your bowels lately?”

Answer 13

Explanation

A is incorrect. Leukemia may be associated with insomnolence. However, it is not one of the primary clinical manifestations of the disease.

B is correct. The client with leukemia is at risk for bleeding tendencies and infection. Therefore, the nurse should ask about recurrent infections and an abnormal bleeding tendency, which are the primary clinical manifestations of leukemia.

C is incorrect. Weight loss may be associated with leukemia, but it is not a primary clinical manifestation of the disease.

D is incorrect. A change in bowel habits is one warning sign of cancer. However, it is associated more with colon cancer rather than leukemia.

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 14

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include? Select all that apply.

A. “This procedure will require you to receive general anesthesia.”

B. “You will need to report any shortness of breath following the procedure.”

C. “You will need to empty your bladder before this procedure.”

D. “After the procedure. a follow-up chest x-ray will be done.”

E. “You will need to be on a clear liquid diet one day before the procedure.”

Answer 14

Explanation

Correct Answers are B and D. These two statements should be included in patient education about Thoracentesis. A thoracentesis is a procedure indicated for pleural effusions.

The client will need to report any dyspnea after the procedure (Choice B). Shortness of breath following the thoracentesis procedure may indicate either iatrogenic pneumothorax or re-expansion pulmonary edema. Pneumothorax is a common complication following Thoracentesis (studies report post-thoracentesis pneumothorax rates ranging from 0 to 19%). The nurse should assess the client carefully for any signs of pneumothorax. Symptoms and signs of a pneumothorax include shortness of breath, reduced or absent breath sounds on the affected side. A more severe pneumothorax, such as tension pneumothorax, may present with obstructive shock. A nurse must notify the physician immediately if any of such signs/ symptoms were to occur. A Chest x-ray (Choice D) must be completed post-procedure to make sure there is no iatrogenic pneumothorax even if the patient did not show any of the above signs or symptoms.

Re-expansion pulmonary edema (REPE) is a complication that occurs after rapid re-expansion of a collapsed lung within 1 to 24 h. It has been reported <1% in most studies and associated with high mortality. The pathophysiologic mechanism of REPE is unknown. Clinical features vary from cough and chest tightness to acute respiratory failure. Treatment is usually supportive and includes continuous non-invasive positive pressure ventilation or mechanical ventilation in severe cases; some patients also require vasopressors, steroids, and diuretics.

Choice A is incorrect. Thoracentesis is a bed-side procedure and can be completed under local anesthesia.

Choice C is incorrect. It would be inappropriate to advise that the client empty their bladder before the procedure.

Choice E is incorrect. Finally, a clear liquid diet one day before the procedure would be appropriate for a colonoscopy – not for a thoracentesis.
NCSBN Client Need:
Topic Reduction of risk potential; Sub-Topic: Diagnostic tests

Question 15

The nurse is planning to assist a respiratory therapist in performing a chest physiotherapy procedure. Which of the following is the initial action by the nurse before the process?

A. Place a gown or fabric between the hands or percussion device and the client’s skin

B. Walk with the patient for a few laps around the unit to aid in percussion

C. Administer a prescribed bronchodilator

D. Call the physician to confirm x-ray results

Answer 15

Explanation

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

Rationale:

Choice C is correct. The nurse should make sure that the patient receives a prescribed bronchodilator about 15 minutes before their chest physiotherapy procedure. Chest physiotherapy is used to loosen secretions trapped in the lungs. When administered before this procedure, a bronchodilator helps to dilate the bronchioles and liquify secretions.

Choice A is incorrect. A gown or piece of fabric should be placed between the hands or percussion device right before the procedure. However, this should be done just before the process. Another option ( administering bronchodilator 15 minutes prior) exists in the choices and is the initial action.

Choice B is incorrect. I was walking with the patient before the procedure is not necessary before chest physiotherapy.

Choice D is incorrect. Calling the physician to confirm the x-ray results is not necessary at this time and does not alter the plan for chest physiotherapy.

Reference:

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

Question 16

While working in the ICU, you are caring for a client receiving Total Parenteral Nutrition (TPN). Does the nurse know to monitor for which of the following complications while patients are receiving TPN? Select All That Apply

A. Pneumothorax

B. Infection

C. Air embolism

D. Tamponade

Answer 16

Explanation

The correct answers are A, B, and C.

A is correct. Pneumothorax is a possible complication of TPN administration. This is usually caused by incorrect catheter placement and is a medical emergency that requires the nurse to notify the health care provider immediately.

B is correct. Infection is a possible complication of TPN administration due to poor aseptic technique, contamination of the catheter, or contamination of the TPN solution itself. To prevent disease, the nurse should use careful aseptic technique when dealing with the catheter, monitor the patient’s temperature, and frequently assess the IV site for signs of infection.

C is correct. Air embolism is a possible complication of TPN administration if the catheter system is opened or disconnected, allowing air to enter the IV tubing instead of the TPN solution. It is a nursing responsibility to ensure air never enters the catheter system by clamping all connections, and providing the pipe is connected correctly.

D is incorrect. Tamponade is not a complication of TPN administration. Tamponade occurs when there is bleeding into the pericardial sac and, therefore, an abrupt increase in the central venous pressure with a decrease in the systemic blood pressure. No complications of TPN administration would cause tamponade.

NCSBN Client Need:

Topic: Pharmacological and Parenteral Therapies Subtopic: Parenteral/Intravenous Therapies

Reference:

Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 142

Question 17

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. What foods should the nurse include in dietary teaching with the client that are good sources of phosphorus? Select all that apply.

A. Leafy greens

B. Garlic

C. Nuts

D. Whole milk

E. Turkey

Answer 17

Explanation

Answer: B, C, and E

A is incorrect. While leafy greens are good choices for many vitamins and minerals, they do not contain a lot of phosphorus. Therefore, this would not be a good choice to recommend to a client that needs a diet rich in phosphorus.

B is correct. Garlic is a food rich in phosphorus and would be an appropriate recommendation for the client needed to incorporate more phosphorus in their diet.

C is correct. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of this important mineral. Cashews, almonds, and brazil nuts all are very high in phosphorus.

D is incorrect. Whole milk is rich in calcium, but does not have a lot of phosphorus. This would not be an appropriate recommendation.

E is correct. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, which is more than 40% of the recommended daily intake (RDI).

NCSBN Client Need: Health Promotion and Maintenance

Topic: Health Promotion/Disease Prevention

Subject: Fundamentals of care/Diet teaching

Lesson: Fluids & Electrolytes

Question 18

The nurse is caring for a client with uterine cancer post-hysterectomy. The client has severe nausea, looks emaciated, and has not eaten for several days. To improve her nutrition status, Total Parenteral Nutrition (TPN) and nutritionist consult are initiated. After 3 to 5 days, which of the following is the best parameter the nurse should focus on to assess if the client’s nutritional status has improved?

A. The client’s Serum Albumin

B. The client’s Pre-Albumin level

C. The client’s weight gain of 2lbs since starting TPN

D. The client’s Blood Urea Nitrogen (BUN)

Answer 18

Explanation

Correct Answer is B. Serum Pre-Albumin ( also known as Transthyretin) is an earlier indicator of improvement in the nutritional status, compared to Albumin. It is produced in the liver so, acute phase events causing inflammation may decrease Pre-Albumin. Still, it correlates well with the previous five days of nutrition in an otherwise stable patient. Its half-life is 3-5 days. If the patient receives stable feeding for up to 1-2 weeks, pre-albumin should normalize. Please note that the question is asking for a proper assessment parameter at 3 to 5 days since initiating TPN.

Total Parenteral Nutrition (TPN)is a type of nutritional support indicated for clients who can not tolerate oral or enteral feeding ( nasogastric/ orogastric feeding). The client in the vignette is unable to eat or tolerate enteral nutrition because of uncontrolled nausea. TPN is intended to provide full nutritional support. In most cases, it takes about seven days of TPN to see an improvement in patient outcomes. While on TPN, lab tests and assessments are done to monitor the client for:

⦁ Therapeutic effectiveness of TPN ( improvement in nutritional status).

⦁ Complications related to TPN ( Electrolyte imbalances, Dehydration, elevated Blood Urea Nitrogen due to pre-renal azotemia, calorie overfeeding, hyper/hypoglycemia, elevated triglycerides, fluid overload).

To assess the improvement in nutritional status, specific laboratory, and physical assessment parameters can be used. Still, their sensitivity in determining the dietary outcomes depends on how much time has elapsed since the initiation of TPN. ( For example, Albumin and Pre-Albumin can provide insights into nutritional status within a few days. However, bodyweight measurement (Choice C) as an indicator to assess whether calorie input is meeting the needs is not valid until at least 3 to 5 weeks. Any significant changes in weight sooner than that may be from fluid imbalance - for example, fluid overload can increase pressure). Also, these parameters are not always specific to nutritional status as many confounding variables can be present (e.g., Fluid overload falsely increases weight, dehydration incorrectly increases serum albumin).

Choice A is incorrect. Serum albumin level is also a good indicator of a client’s nutritional status while on TPN. However, pre-albumin is an even better indicator than Albumin. Albumin has a half-life of 14 -20 days. In the acute phase situation, it’s levels can significantly decrease from reduced liver production and doe snot always re. At 3-5 days since initiation of TPN, Pre-albumin serves as a good indicator for improvement than the albumin. However, albumin can be a useful screening parameter of long- term nutritional status in healthy clients.

Choice C is incorrect. They are gaining 2lbs weight since TPN initiation may be secondary to nutritional improvement but can also be from other causes such as fluid retention. Weight is not an accurate indicator to monitor the client’s nutritional status outcomes in the first couple of weeks of initiating TPN. Weight is still measured at baseline and then daily. This is to monitor whether fluid inputs are meeting the needs.

Choice D is incorrect. The client’s Blood Urea Nitrogen (BUN) is not an accurate measure of the client’s nutritional status. It is used to monitor for complications related toTPN. BUN is monitored every 1-2 days in patients on TPN. This is to watch for pre-renal azotemia ( increased BUN from pre-renal causes) rather than to assess nutritional outcomes. Such elevation of BUN can happen with dehydration, high protein intake, and gastrointestinal bleeding. BUN can be decreased if there is reduced muscle turnovers, such as small muscle mass and low protein intake.
Reference:
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 19

The nurse is assessing her prenatal client for sexually transmitted infections (STIs) by looking for risk factors. Which of the following are risks of acquiring an STI? Select all that apply.

A. Low socioeconomic status

B. A monogamous relationship

C. A past history of working in the sex industry

D. Illicit drug use

E. History of cancer

F. Previous history of STIs

Answer 19

Explanation

Correct Answers are A, C, D, and F.

Low socioeconomic status, a history of being a sex worker, illicit drug use, and a previous history of sexually transmitted infections are all risk factors for contracting STIs. Other factors include numerous sexual partners and being unmarried.

A history of cancer and exclusive relationships are not examples of risk factors for acquiring an STI.
NCSBN Client Need
Topic: Health Promotion and Maintenance; Sub-Topic: High-Risk Behaviors

Question 20

Which statement about dentition is accurate?

A. Caucasians tend to have less tooth decay than African Americans.

B. Tooth size can normally vary among some different ethnicities.

C. African Americans lose more teeth than Caucasians.

D. Neonatal teeth are more present at birth among African Americans than others.

Answer 20

Explanation

Choice B is correct.

Tooth size can usually vary among some different ethnicities. For example, Caucasians have the smallest tooth size and then, in ascending order of increasing tooth size, are African Americans, people with an Asian ethnicity, and then North American Native Americans with the largest tooth size.

Choice A and C are incorrect. African Americans tend to have less tooth decay/ tooth loss than Caucasians and not more. This difference is most likely related to the fact that African Americans have more dense tooth enamel to protect the teeth against corrosion than Caucasians do.

Choice D is incorrect. Neonatal teeth are not more prevalent at birth among African Americans than others. The presence of teeth at birth is more prevalent among members of some Canadian Eskimos and some native Alaskan Indians.

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

Question 21

A 24-year old woman presents to the emergency department and appears as shown (See Exibit).What type of injury does this assessment finding suggest?

A. CSF leak

B. Basilar skull fracture

C. Brown-sequard syndrome

D. Subarachnoid hemorrhage

Answer 21

Explanation

Choice B is correct. This picture represents a clinical assessment symptom called Raccoon’s eyes (retroorbital ecchymosis). Pooling of blood surrounding the eyes is most often associated with fractures of the anterior cranial fossa or basilar skull fracture. This assessment finding may be delayed by 1 to 3 days following initial injury. If bilateral, this sign is highly suggestive of a basilar skull fracture. Other signs of basilar skull fractures include hemotympanum (pooling of blood behind the tympanic membrane) and Battle sign (retro auricular or mastoid ecchymosis).

Choice A is incorrect. Although Cerebrospinal fluid (CSF) leak could be a later complication of this injury, the initial injury that this patient is suffering from is a basilar skull fracture. A CSF leak occurs in about 20% of patients following a basilar skull fracture. When meningeal structures are damaged by the fractured bones, CSF can leak through the subarachnoid space, and manifests as “clear fluid” draining from nostrils (CSF rhinorrhea) or ears (CSF otorrhea). To confirm that the fluid is indeed CSF, physician may order testing the fluid for beta-transferrin.

Choice C is incorrect. The Brown-Sequard syndrome (BSS) is a hemi-section of the spinal cord and does not cause Raccoon’s eyes. Symptoms of the BSS include weakness and loss of proprioception on one side of the body (ipsilateral side of injury) and loss of temperature sensation on the opposite side. Causes for the BSS include a spinal cord tumor, trauma, ischemia, or infectious or inflammatory diseases (tuberculosis, or multiple sclerosis).

Choice D is incorrect. Signs of a subarachnoid hemorrhage (SAH) include severe headache (often stated by the patients as “worst headache of their life”), photophobia, nausea and vomiting, and vision changes. Causes of SAH include aneurysmal rupture, or trauma.
NCSBN Client Needs
Topic: Physiological Integrity

Reference: Lewis, Dirksen, Heitkemper, Bucher.

Question 22

The nurse is caring for a client who had a fenestrated tracheostomy tube placed one week ago. Which statements are true regarding fenestrated tracheostomies? Select all that apply.

A. This type of tracheostomy does not require trach care

B. The client with a fenestrated tracheostomy can speak

C. This is the only type of tracheostomy used with mechanical ventilation

D. A fenestrated tracheostomy can be capped if the cuff is deflated

Answer 22

Explanation

Answer: B and D

A is incorrect. A client with a fenestrated tracheostomy will require the same amount of trach care as other types of tracheostomies. It is very important to keep the tracheostomy site clean to prevent skin breakdown, infections of the stoma, tracheitis, and respiratory infections.

B is correct. It is true that clients with a fenestrated tracheostomy can speak. Fenestrated tracheostomy tubes have a small opening in the outer cannula. This allows some air to escape through the larynx, which means that the client will be able to speak with this type of tube.

C is incorrect. Fenestrated tracheostomy tubes are not the only type of tracheostomy used with mechanical ventilation, there are also non-fenestrated tracheostomy tubes. A fenestrated tube would be used as a client progresses and is being weaned from breathing only through the tracheostomy to starting some breathing through the nose and mouth. Fenestrated tracheostomy can also be used with mechanical ventilation, but the cuff must be inflated.

D is correct. A fenestrated tracheostomy can be capped if the cuff is deflated. It is very important to remember to deflate the cuff if capping a fenestrated tracheostomy tube, because if the tube is capped and the cuff is still inflated the client will not be able to breathe at all.

NCSBN Client Need: Physiological adaptation

Topic: Alterations in Body Systems

Subject: Adult Health

Lesson: Respiratory

Question 23

As you are bathing your client and providing foot care, you notice that the client’s toenails appear as shown in the exhibit. Which condition should you suspect?

A. Onychomycosis

B. Onychomadesis

C. Onychorrhexis

D. Onycia

Answer 23

Explanation

Choice D is correct. The exhibit shows inflammation of the nail folds. This disorder is referred to as Onychia. Onychia is characterized by inflammation of the nail fold resulting from either injury or infection. Paronychia refers to infection of proximal nail folds. Infection of the nail folds can occur by introduction of bacteria into nail folds through small wounds. The nurse should document and report this condition.

Choices A, B, and C are incorrect. Onychomycosis is a fungus infection of the nails that causes the nails to look thick, discolored, and crumbling. Onychomadesis is the falling off and the separation of the nails from the nail bed and not the inflamed appearance of the nail in the exhibit. Onychorrhexis refers to brittle nails that tend to break easily and not the appearance of the affected nail in the picture above.

Question 24

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor(s) for developing colorectal cancer? Select all that apply.

A. Ulcerative colitis

B. Body Mass Index (BMI) = 21

C. Human Immunodeficiency Virus (HIV) infection

D. Low-fiber diet

E. Excessive alcohol consumption

F. African-American ethnicity

Answer 24

Explanation

Choices A, D, E, and F are correct. Risk factors for colorectal cancer are divided into modifiable and non-modifiable types. Modifiable risk factors are usually behavioral factors that can increase a person’s risk of cancer. In theory, these risk factors can be modified with interventions. Non-modifiable risk factors are those that can not be changed. Awareness of the client’s risk factors will help the health care provider prescribe personalized lifestyle and cancer screening recommendations. The gold standard of colorectal cancer prevention is a colonoscopy that should begin as early as age 45 ( USPTF new guidelines, 2021).

(Choice A) Inflammatory bowel disease ( especially ulcerative colitis) is a non-modifiable risk factor that may cause cellular damage and hastens the risk of colorectal cancer. 
(Choice D) A diet low in fiber is a modifiable risk factor for colon cancer. Encourage the client to increase fiber intake and decrease red meat.
(Choice E) Excessive alcohol intake is a modifiable risk factor for colorectal cancer.
(Choice F) African American ethnicity is a non-modifiable risk factor for colorectal cancer. 

(Choice B) Incorrect. A BMI of 21 is optimal ( Choice B) and is not a risk factor. Obesity is a modifiable risk factor for colorectal cancer. Obesity is defined as a Body Mass Index ( BMI) ≥ of 30 kg/m2.

(Choice C) Incorrect. HIV is a risk factor for many malignancies such as testicular cancer but not colorectal cancers. Since rates of colorectal cancer are similar between people with and without HIV, existing screening guidelines are sufficient for people with HIV. Another virus called human papillomavirus (HPV) has been implicated in colorectal cancers.

Learning Objective: Recognize that the risk factors for colorectal cancer include age, African American ethnicity, family history of colon cancer, certain genetic conditions, a diet low in fiber, a diet rich in red meat, obesity, smoking, and inflammatory bowel conditions (ulcerative colitis).

NCSBN client need - Topic: Health Promotion and Maintenance; Sub-topic: Perform targeted assessments; Bloom’s Taxonomy: Knowledge/comprehension

Question 25

The nurse is taking vital signs for a client who has a chest tube in place. While counting the client’s respirations, the nurse notes that the water in the water-seal-chamber is fluctuating. Which action by the nurse is most appropriate based on this finding?

A. Finish counting the client’s respirations

B. Empty the water-seal chamber

C. Assist the client with incentive spirometry

D. Notify the charge nurse

Answer 25

Explanation

Answer: A

A is correct. It is appropriate for the nurse to simply finish counting the client’s respirations and continuing to monitor them as normal. Fluctuations of the water in the water-seal-chamber with inspiration and expiration is a sign that the drainage system is patent. Normally, the water level will increase when the client breathes in, and decrease when they breathe out. This is due to changes in intrathoracic pressures.

B is incorrect. The nurse should not empty the water-seal chamber. This would cause a break in the closed drainage system and could result in injury to the client.

C is incorrect. It is not necessary for the nurse to help the client with incentive spirometry based on this finding. The nurse has noted an expected finding of the chest-tube system and can continue to assess the client as normal.

D is incorrect. It is not necessary for the nurse to notify the charge nurse based on this finding. The nurse has noted an expected finding of the chest-tube system and can continue to monitor the client as normal.

NCSBN Client Need:

Topic: Reduction of Risk Potential

Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures

Subject: Adult Health

Lesson: Respiratory

Question 26

The nurse receives a call from a post-abdominal surgery client. He reports some numbness in his right leg and a funny feeling in his toes. What should the nurse do next?

A. Elevate the client’s legs by placing a pillow and tell him to drink more water.

B. Tell the client to stay in bed and call the physician.

C. Instruct the client to rub or massage his legs to stimulate the blood flow.

D. Encourage the client to ambulate and educate regarding the dangers of prolonged bed rest.

Answer 26

Explanation

Choice B is correct. These signs and symptoms may indicate nerve injury or impaired circulation or thrombophlebitis/ venous thrombosis. These conditions may be related to injury during surgery or post-surgical complications. The nurse should let the patient lie down and limit the activity and call the physician.

Choice A is incorrect. While elevating the client’s leg on a pillow may be beneficial to reduce swelling and discomfort by increasing venous return, fluids should be withheld until the physician is notified. In this post-surgical patient, if any injury is suspected, procedures may be required, and it may be necessary that the client refrains from oral intake before some methods.

Choice C is incorrect. If the diagnosis is acute venous thrombosis, rubbing or massaging the leg is contraindicated since it may dislodge the thrombus. If an alternative diagnosis such as nerve-related discomfort is proven, rubbing/ massaging may ease the pain. However, until the physician is notified, and deep vein thrombosis is excluded, such measures should be withheld.

Choice D is incorrect. This option can be a distractor since early ambulation is often encouraged in post-operative patients. However, this patient has symptoms, and the diagnosis needs to be established. Acute Deep vein thrombosis (DVT) is included in the differential diagnosis of the symptoms reported by this post-operative patient. In acute DVT, most clinicians historically preferred recommending bed rest to avoid dislodgement of the possible thrombus. Recent studies have shown that early ambulation can be recommended even for those with new DVT since there was no increased incidence of pulmonary embolism in patients with DVT who were ambulatory and because early ambulation decreased the duration and severity of the symptoms. Irrespective of this debate, the first step for the nurse is to tell the client to say in bed and call the physician because the diagnosis is not established yet, and other diagnoses such as nerve injury and circulatory injury have not yet been excluded.

NCSBN Client need
Topic: Reduction of Risk Potential; Subtopic: Potential for complications from Surgical Procedures
Reference
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination.20thEdition

Question 27

Which of the following patients would be the best candidates for total parenteral nutrition (TPN)? Select All That Apply.

A. A patient with inflammatory bowel disease who has intractable diarrhea.

B. A patient with celiac disease who is not absorbing nutrients.

C. A patient who is underweight and needs short-term nutritional support.

D. A patient who is comatose and needs long-term nutritional support.

E. A patient who has anorexia and refuses to take foods via the oral route.

F. A patient with burns who has not been able to eat adequately for 6 days.

Answer 27

Explanation

Choices A, B, and F are correct.The assessment criteria used to determine the need for Total Parenteral Nutrition (TPN) include an inability to achieve or maintain enteral access.

Examples include motility disorders, intractable diarrhea ( Choice A), impaired absorption of nutrients from the gastrointestinal tract ( Choice B), and when oral intake has been inadequate for a period over seven days. TPN promotes tissue healing and is an excellent choice for a patient with burns who has an improper diet.

Please note that oral intake is the best feeding method; the second best method is via the enteral route. Total parenteral nutrition (TPN) is indicated only in specific cases. TPN provides calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. TPN can also promote tissue and wound healing and healthy metabolic function. TPN may be used to improve a patient’s response to surgery.

TPN is a highly concentrated, hypertonic nutrient solution. Hence, it is given intravenously through a central venous access device, such as a multi-lumen, a tunneled catheter into the subclavian vein, or a peripherally inserted central catheter (PICC). Strict surgical asepsis should be followed due to the risk of infections.

Choice C is incorrect. For short-term use (less than four weeks), a nasogastric or gastrointestinal route is usually selected.

Choice D is incorrect. A gastrostomy is a preferred route to deliver enteral nutrition in a comatose patient because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings.

Choice E is incorrect. Patients who refuse to take food should not be force-fed nutrients against their will.

NCSBN Client Need - Topic: Physiological Integrity; Subtopic: Physiological Adaptation

Reference: The Art and Science of Person-Centered Nursing Care (Wolters/Klewer); Chapter 35: Nutrition; Lesson: Providing Parenteral Nutrition

Question 28

You are assigned to take care of a client who just underwent cholecystectomy. Which of the following would decrease the risk of developing atelectasis in this client? (Select all that apply)

A. Deep inspiration.

B. Supine position with head end of the bed elevated.

C. Change position every 2 hours.

D. Encourage patient to cough at-least 10 times/hr.

Answer 28

Explanation

Correct Answers are A, B, C, and D. Atelectasis is defined as the total or partial collapse of the alveoli. This is a common complication in the immediate postoperative period, especially after abdominal surgeries. If atelectasis is not addressed, it may progress to pneumonia. Since alveoli are responsible for gas exchange, alveolar collapse can lead to impaired gas exchange/ impaired oxygenation.

Post-operatively, the client may not be able to take deep inspiration due to pain from the movement of abdominal muscles. This impaired expansion of alveoli leads to the accumulation of secretions/ mucus plug, decreased surfactant and eventually, obstruction of airway and collapse of alveoli. Additional factors that predispose to this may include hypoventilation, sedation, and reduced mobility. When such factors are identified, the nurse should encourage the client to adopt interventions to mitigate those factors and prevent atelectasis. Such interventions include:

Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry. An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expansion of the alveoli.
Keeping the client in the supine position with the head end of the bed elevated (Choice B) or semi-recumbent area (head of the bed raised 30 to 45 degrees). This allows for maximum thoracic expansion by lowering the abdominal pressure on the diaphragm.
Encouraging the client to change position at least every 2 hours (Choice C). This increases mobility and allows full chest expansion and increases perfusion to both lungs.
Encouraging the client to cough at least ten times per hour (Choice D) when awake. This helps promote alveolar expansion. 

The above interventions are aimed at preventing Atelectasis. However, the nurse should be aware of detecting atelectasis if it did end up happening. Physical exam findings assist in the diagnosis and include fever and decreased breath sounds on the side of atelectasis. In the case of complete atelectasis/ collapse, the trachea/ mediastinum may be shifted to the same side due to the pull by a collapsed lung. Atelectasis in the postoperative period is referred to as “resorption atelectasis” but the nurse should also be aware of other types in different client scenarios.

Once the nurse detects atelectasis, treatment interventions from a nurse’s perspective include: -

Use of Incentive Spirometry (IS) - IS mimics the natural process of sighing or yawning. It encourages the patient to take slow and deep breaths. The result of this process is decreased pleural pressure, increased lung expansion, and improved gas exchange. Regular repetition of IS can prevent or even reverse the atelectasis.
Supportive devices to assist with deep coughing.
Chest physiotherapy which includes tapping on the chest to loosen mucus
Mobilizing the patient early including encouraging sitting up in bed, sitting over the edge of the bed, standing, or assisted ambulation.
Postural drainage - to achieve this, the body is positioned with the head lower than the chest to promote gravitational drainage of the mucus from the bottom of the lungs. (Note this position is for treatment of atelectasis and is different from the semi-recumbent area used to prevent atelectasis)
Bronchoscopy may be ordered in certain cases by the physician to remove the mucus plug if the patient is not showing improvement despite the above non-invasive measures.

Question 29

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.

Answer 29

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 30

The nurse is preparing to administer a tube feeding to a client. The order reads:

Nutren 1.2 kcal
¾ strength
Continuous @ 50 mL/hr

The formula comes in cans of 237 mL. How much water does the nurse add per can to correctly administer the tube feeding as prescribed?
175
mLs

Answer 30

Explanation

Answer: 79 mLs

This is a simple question where the stem contains much more information that you actually need to solve the problem. You must identify what exactly the question is asking, and use only the information needed to solve the problem. Don’t overthink it! The question asks how much water the nurse will add to the can of formula. The order reads ¾ strength, and the can of formula is 237 mLs. The nurse must add 79 mLs of water to dilute the formula to ¾ strength. To find this answer, divide 237 by 3. This will give you 3 parts formula, 1 part water - or ¾ strength.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Pharmacological therapies

Question 31

Which of the following statements should the nurse use to best describe a very low-calorie diet?

A. “This is a long-term treatment measure that assists obese peoples who can’t lose weight.”

B. “A VLCD contains very little protein.”

C. “This diet can be used only when there is close medical supervision.”

D. “This diet consists of solid food that is pureed to facilitate digestion and absorption.”

Answer 31

Explanation

Deficient calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in the treatment of adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death) but became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the deficient calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision.

Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3–5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, and constipation, and risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3–4 months [68]. Although rapid weight loss is seen, it is not regularly well maintained with many patients gaining up to 50% of that weight back within the subsequent 12 months; and gaining all of the importance back in less than five years [69]. LCDs are not as extreme, and with almost twice as many calories allowed (1200–1500 kcal/day), the weight loss is modest.

The correct answer is C. Very Low-Calorie Diets are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis.
A is incorrect. The VLCD is not intended to be a long-term treatment measure.
B is incorrect. VLCD consists of high levels of quality proteins.
D is incorrect. The food on a VLCD is not pureed.

NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Physiological Adaptation

Question 32

Select the hazard of immobility and complete bed rest that is accurately paired with one of its preventive measures?

A. Renal calculi: Treatment to increase urinary alkalinity

B. Hypocalcemia: Calcium supplementation

C. Venous dilation: The application of heat

D. Hypercalcemia: A tilt table

Answer 32

xplanation

Correct Answer is D

Correct. Hypercalcemia, a hazard of immobility and complete bed rest, can be prevented with the use of a tilt table to provide weight-bearing and the prevention of the demineralization of the bones as occurs during periods of immobility and complete bed rest. As the bones demineralize, the calcium leaves the bones and enters the blood to create hypercalcemia.

Choice A is incorrect. Renal calculi formation, a hazard of immobility and complete bed rest, cannot be prevented with measures to increase urinary alkalinity because it is alkaline urine that leads to renal calculi formation.

Choice B is incorrect. Hypocalcemia can be prevented by calcium supplements. But the question is asking about Hazard of immobility. Hypocalcemia is not a hazard of immobility and complete bed rest; however, hypercalcemia is.

Choice C is incorrect. Venous dilation, a hazard of immobility and complete bed rest, cannot be prevented with the application of heat; heat is a vasodilator and, as such, would only add to the venous dilation.

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

Question 33

An oncology nurse is reviewing lab values for her patients in the morning. She has a 45-year-old patient diagnosed with cancer of the bone marrow, which has caused his platelet count to be persistently low. The nurse would expect that his platelet count will be less than ___________k cells/mm3.

Answer 33

Explanation

Answer: 150

( 150k = 150,000)

The normal range for a platelet count is 150,000 to 400,000 cells/mm3. Platelets are produced by the bone marrow, though, so in a patient with cancer of the bone marrow, the nurse would expect a low platelet count. This patient will be on bleeding precautions and need careful monitoring.

NCSBN Client Need

Topic: Reduction of Potential Risk Subtopic: Laboratory Values

Reference:

Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 117

Question 34

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

A. The client will be free of any insertion site infection

B. The nurse will measure residual prior to each feeding

C. The client will be free of dumping syndrome

D. The nurse will administer no more than 200 mL for each feeding

Answer 34

Explanation

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

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

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

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

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

Question 35

Which of the following statements are true regarding COVID-19? Select all that apply.

A. COVID-19 is caused by the Staphylococcus aureus bacteria.

B. COVID-19 is spread through droplet transmission.

C. Immunocompromised patients are most at risk of severe COVID-19.

D. Headaches, malaise, and loss of appetite are the most common symptoms of COVID-19.

E. N95 masks are preferred while attending COVID-19 patient.

Answer 35

Explanation

The correct answers are B, C, and E.

COVID-19 is indeed spread through droplet transmission(Choice B). This means that when someone coughs or sneezes, the secretions have the virus and can then infect another person. The droplets can also live on a surface and then be transmitted to another person. Percurrent CDC guidelines, Droplet precautions should be used by healthcare personnel to prevent the spread of the infection. But if a patient will be undergoing aerosolizing procedures like intubation, nebulizations, etc; airborne precautions with negative pressure isolation rooms are used.

The patients that are most likely to suffer significantly from COVID-19 are those who are immunocompromised (Choice C)and have a weak immune system. This includes the geriatric population, the chronically ill, patients going through chemotherapy or other cancer treatments, and patients with other pre-existing conditions like Diabetes/Cardiac issues. These patients have a high risk of complications and a high risk of dying from COVID-19.

When available, N95 masks (Choice E) are preferred while attending to COVID-19 patients. The ‘N95’ designation means that when subjected to careful testing, the respirator blocks at least 95 percent of tiny (0.3 microns) test particles. These masks are typically used in Airborne precautions, but in dealing with confirmed COVID-19 patient, N95 is preferred over face mask as per current CDC guidelines. However, due to a shortage of N95, CDC is currently allowing Surgical masks (Face masks) as well if N95 is not available. However, when specific aerosolizing procedures are being done (nebulization, intubation) on a COVID19 patient, N95 masks MUST ALWAYS BE used.

Choice A is incorrect. The COVID-19 disease is NOT caused by the Staphylococcus aureus bacteria. COVID-19 is the name of the disease caused by the SARS-COV2 virus. This stands for sudden acute respiratory syndrome coronavirus 2. Because this is a viral illness, antibiotics will not be effective in treating the disease. The Staphylococcus aureus bacteria is a dangerous, gram-positive bacteria that often cause skin infections.

Choice D is incorrect. These are not the most common symptoms of COVID-19. Instead, fever, cough, and shortness of breath are the most common symptoms concerning for COVID-19. This is a respiratory illness, so monitor for respiratory symptoms such as cough, shortness of breath, sneezing, dyspnea, etc.

The following video describes COVID-19 in detail:

NCSBN Client Need:
Topic: Effective, safe care environment Subtopic: Infection control and safety.

Reference: 2019 Novel Coronavirus (2019-nCoV) Situation Summary. (2020, March 9). Retrieved from https://www.cdc.gov/coronavirus/2019-nCoV/summary.html

Question 36

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 36

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 37

Your client asks you which foods he can eat so he gets recommended daily allowance of vitamins. Select the vitamin(s) that is (are)accurately paired with major food sources. Select all that apply.

A. Niacin (B3): Corn and other grains.

B. Riboflavin (B2): Citrus and milk

C. Folate: Liver and legumes

D. Vitamin K: Liver and leafy green vegetables

E. Vitamin D: Fish and fortified milk

F. Pantothenic acid (B5): Grains and legumes

Answer 37

Explanation

Correct Answer is C, D, E, and F

Folate is found in liver, legumes, and leafy green vegetables. Vitamin K is found in leafy green vegetables and liver.

Vitamin D is found in fortified milk and fish.

Pantothenic acid B5is found in whole grains, avocado, beans, legumes (lentils), lean chicken, beef, pork, and broccoli. Pantothenic acid is ubiquitous and hence, a deficiency is very rare except in severe malnutrition.

Choice A is incorrect. Niacin B3 is found primarily inmeats, liver, fish, legumes, peanuts, coffee, and tea. It is deficient in corn and refined grains.

Choice B is incorrect. Riboflavin B2 is found in leafy green vegetables and milk, but not in citrus.

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

Question 38

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 38

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 39

Your client is a male patient who presents with knee joint pain, conjunctivitis, numbness in extremities, and atrioventricular heart block following a tick bite that occurred two months ago. You suspect Lyme’s disease. Which stage of the Lyme’s disease does his presentation represent?

A. First stage

B. Second stage

C. Third stage

D. Fourth stage

Answer 39

Explanation

Choice B is correct. This reflects the second stage of Lyme’s disease. Neurological and cardiac involvement are hallmarks. Manifestations may include atrioventricular heart block and neuropathy. Ocular manifestations such as Conjunctivitis is seen in 10% cases. Joint pain may be present. The second stage occurs typically around seven weeks after the initial tick bite. It is also referred to as “early, disseminated Lyme’s” disease.

Choice A is incorrect. The first stage of Lyme’s disease usually presents with a red rash the size of a pimple or as a large ring. The patient generally complains of flu-like symptoms.

Choice C is incorrect. The third stage of Lyme’s disease is characterized by sizeable joint involvement and arthritis ( chronic Lyme arthritis). Knee joints are often involved.

Choice D is incorrect. There is no fourth stage in Lyme’s disease.

NCSBN client need |Topic: Physiologic integrity, physiologic adaptation
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby