ASSESSMENT Flashcards
While working in the resuscitation area of the emergency department, EMS notifies you that a 7-year-old male with an avulsion fracture to the left tibia is 20 minutes out. You know to expect which of the following?
A. A fracture that pulls a part of the bone from the tendon or ligament
B. A fracture with which the whole cross section of the bone is fractured
C. A fracture that results from an underlying disease or disorder, not physical trauma or stressors.
D. A fracture that affects only one side of the bone.
Explanation
Correct Answer is A.An avulsion fracture pulls a part of the bone from the tendon or ligament.
Fractures are a common occurrence, and patients often present to the Emergency Room. A nurse should be able to recognize different types of bone fractures and plan for appropriate nursing intervention.
B is incorrect. A fracture with which the whole cross-section of the bone is fractured is referred to as “complete fracture.”
C is incorrect. A fracture that results from an underlying disease or disorder, not physical trauma or stressors, is referred to as “pathological fracture.” Such fractures are common with metastatic cancer, multiple myeloma, and osteoporosis.
D is incorrect. A fracture that affects only one side of the bone is referred to as “greenstick fracture.”
NCSBN Client Need:
Topic: Physiological Integrity; Subtopic: Physiological Adaptation
Reference: DeWit, S. C., & Williams, P. A. (2013).Fundamental concepts and skills for nursing. Elsevier Health Sciences.
An 8-year-old child was brought to the physician’s office with complaints of swelling and pain in the knees. His mother informs the nurse that “The swelling came out of nowhere, and it just keeps getting worse.” The impression is Lyme disease. Which questions should be included during the interview of both mother and child when taking initial history?
A. “Have you noted any flank pain and a decrease in the volume of urine?”
B. “Has there been a fever of over 103F over the last 2-3 weeks?”
C. “Did you notice rashes on the palms and soles?”
D. “Do you have headaches, malaise, or sore throat?”
Explanation
Rationale: The classic symptoms of Lyme disease include flu-like symptoms such as headache, body malaise, and unexplained fatigue. Other symptoms are a stiff neck, anorexia, lymphadenopathy, conjunctivitis, sore throat, splenomegaly, abdominal pain, and cough. The rash that is associated with Lyme disease is Erythema Migrans or the “bulls-eye” rash. The rashes do not appear on the palms and soles. Urinary tract infections are not commonly associated with Lyme Disease, nor is a fever of 103F. The correct answer is option D, while options A, B, and C are incorrect.
Reference:
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
The nurse is caring for a client with a magnesium level of 1.1 mg/dL. Which signs and symptoms does the nurse closely monitor for? Select all that apply.
A. Diarrhea
B. Psychosis
C. Tetany
D. Decreased deep tendon reflexes
E. Cardiac arrhythmias
Explanation
Answer: B, C, and E
A is incorrect. While diarrhea can be an initial cause of hypomagnesemia, it is not an assessment finding indicative of magnesium levels already low. Once the client has low magnesium levels, they have decreased GI motility leading to constipation, not diarrhea.
B is correct. Psychosis is an assessment finding consistent with hypomagnesemia. This client’s magnesium level is below normal, 1.6-2.6 mg/dL, therefore the nurse will need to monitor for potential signs and symptoms of hypomagnesemia. From a neurological perspective this can range from confusion to psychosis.
C is correct. Tetany is another assessment finding consistent with hypomagnesemia for which the nurse should monitor. Other neuromuscular assessment findings consistent with hypomagnesemia, include numbness, tingling, seizures, and increased deep tendon reflexes.
D is incorrect. Decreased deep tendon reflexes is not an assessment finding consistent with hypomagnesemia, rather increased deep tendon reflexes would be. Remember, Magnesium calms the body, so when there are low levels of it the patient will be excitable - seizures, increased reflexes, and psychosis can occur.
E is correct. Cardiac arrhythmias can occur with hypomagnesemia due to alterations in the conductivity of heart muscle.
NCSBN Client Need: Reduction of Risk Potential
Topic: Potential for Alterations in Body Systems
Subject: Fundamentals of care
Lesson: Fluids & Electrolytes
Calculate the equianalgesic of oral hydromorphone below. The equianalgesic chart on the wall of the medication room states that 10 mg of IV morphine is equivalent in terms of potency to 7.5 mg of oral hydromorphone and the client has been effectively treated with 60 mg of IV morphine. Fill in the blank.
______ mg of Oral Hydromorphone.
45
Explanation
The Correct Answer is 45 mg of oral hydromorphone.
The calculation of the equianalgesic of oral hydromorphone when compared to IV morphine, which is always used to calculate equianalgesic, is as shown below when 10 mg of IV morphine is equivalent in terms of potency to 7.5 mg of oral hydromorphone.
10 mg IV Morphine = 7.5 mg Oral Hydromorphone.
1 mg of IV Morphine then equals 0.75mg of Hydromorphone ( 7.5/10) so Equi-analgesic factor = 0.75. Multiply IV morphine dose with Equi-analgesic factor to arrive at oral hydromorphone dose.
60 mg IV Morphine = 60 x 0.75mg oral Hydromorphone= 45 mg of oral hydromorphone.
NCSBN Client Need:
Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management; Dosage Calculation.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
You are educating an adult patient about the injectable influenza immunization. Your teaching should include: (Select all that apply)
A. The influenza injection is 70-80% effective in preventing influenza or decreasing the severity of the disease.
B. Pregnant women can receive the influenza vaccine.
C. The patient can receive the vaccination if they are on antibiotics for a mild illness.
D. The vaccine contains a live virus.
Explanation
Correct answer: Responses A, B, and C are correct. Although the influenza vaccine will not prevent 100% of the cases, it will help to prevent or decrease symptoms in 70 to 80% of the cases. The influenza vaccine is recommended for all pregnant women and is safe for this population. Individuals who are on antibiotics for a mild or moderate illness can receive the influenza vaccine. These individuals can receive any immunization. Response D is not correct. The influenza vaccination does not contain live virus and does not shed; therefore, influenza is not transmitted to others through the immunization.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Sub-Topic: Health Promotion/Disease Prevention
Subject: Adult Health
Lesson: Safety/Infection Control
Reference: Centers for Disease Control and Prevention. Vaccines & Immunizations. https://www.cdc.gov/vaccines/index.html. Accessed online October 1, 2019.
A child with Pulmonary tuberculosis is to be admitted to the pediatric unit. The charge nurse finds out that there are no more private rooms available in the unit, and there are no patients with tuberculosis admitted as well. What is the most appropriate action by the charge nurse?
A. Inform the infection control nurse
B. Room the client with another uninfected child 6 feet apart
C. Room the client with another infected child 6 feet apart
D. Refuse to admit the child
Explanation
A is correct. The nurse should consult the infection control nurse for alternatives for patient placement.
B is incorrect. The disease is transmittable through airborne droplets. The uninfected child can acquire the infection through the airborne droplets.
C is incorrect. The infected child can be infected by the TB through the airborne droplets.
D is incorrect. The staff should consult someone first before refusing to accept the child for admission.
A postpartum client is noted to have changed 3 perineal pads in 3 hours after delivery. The nurse notes a soft fundus. The initial action for the nurse would be
A. Insert vaginal packing
B. Massage the client’s fundus
C. Apply an ice pack over the client’s perineal area
D. Administer packed red blood cells
Explanation
A is incorrect. Inserting a vaginal pack does not address the cause of the bleeding. Only the physician can add a vaginal box.
B is correct. The bleeding of the client is most likely because of uterine atony. The nurse should massage the client’s uterus to stimulate it to contract.
C is incorrect. Applying an ice pack over the perineum does not help improve the uterine tone. This does not help in preventing bleeding due to uterine atony.
D is incorrect. Administration of blood products such as Packed RBC’s is done on a physician’s order.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014
The client’s nephew walks up to the nurse’s station and asks if he can see his uncle’s file. The nephew states, “It’s okay, I’m a nurse as well. I just want to take a quick look and see how my uncle is doing.” What is the nurse’s most appropriate response?
A. “You can take a look for only 5 minutes.”
B. “Let me get an approval from the attending physician.”
C. “I will need permission from your uncle first.”
D. “Non-hospital employees can not view the patient’s file.”
Explanation
The correct answer is C. According to the Health Insurance Portability and Accountability Act (HIPAA), the relative must first obtain consent from the client to view his file.
Choice A is incorrect. According to the Health Insurance Portability and Accountability Act, the relative must first obtain consent from the client to view his file. In the absence of the client’s permission, allowing the nephew to view the data even for 5 minutes is not legal.
Choice B is incorrect. The physician is not the one that decides who can view the client’s file. The client’s consent is necessary under HIPAA provisions.
Choice D is incorrect. Non-employees can view the client’s file once the client has given consent for them to see his data.
Reference
Potter, PA, Perry. AG, Stockert, PA, Hall, AM. Fundamentals of Nursing, 8th ed. St. Louis, MO: Elsevier Mosby;2013
A 10-year-old boy was diagnosed with hemophilia. Which blood study is characteristically abnormal in this condition?
A. PTT (Partial Thromboplastin Time)
B. Thrombocyte count
C. Full blood count
D. Bleeding time
Explanation
Rationale: PTT measures the activity of thromboplastin, which is dependent on the intrinsic clotting factors children with hemophilia are deficient of. Thrombocyte count remains normal in hemophilia. The full blood count does is not affected by hemophilia. Bleeding times are also standard in hemophilia. The correct answer is option A. Options B, C, and D are incorrect.
Reference:
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
The nurse in the medical ward just administered 6 units of regular insulin on a client subcutaneously. The nurse understands that after 3 hours, the nurse should monitor the client for which sign?
A. Rapid, deep, labored breathing with cold sweats
B. Confusion and lack of appetite
C. Cold sweats and trembling
D. Headache and increased urination
Explanation
A is incorrect. Kussmaul respirations indicate hyperglycemia, not hypoglycemia.
B is incorrect. These symptoms are not associated with hypoglycemia.
C is correct. Regular insulin peaks at about 2 – 4 hours after administration. At this time, the nurse should be alert for signs and symptoms of hypoglycemia, the initial signs of which are cool clammy skin, along with cold sweats and trembling.
D is incorrect. Headache and polyuria do not indicate hypoglycemia; although Polyuria may indicate hyperglycemia.
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
The nurse is educating the client regarding oral contraceptives. All of the following statements by the nurse are true except:
A. “Oral contraceptives are drugs containing combined doses of estrogen and progesterone that stop ovulation.”
B. “Oral contraceptives increase your risk for thrombophlebitis and hypertension.”
C. “They are almost 99% effective when taken consistently.”
D. “They prevent sperm from entering the cervical os.”
Explanation
Choice D is correct. Oral contraceptives work by stopping the process of ovulation, preventing implantation, and inhibiting sperm travel. Therefore, the nurse’s statement here is incorrect. Prevention of sperm from entering the cervical os is the mechanism of action of barrier contraceptive methods (example: Diaphragm).
Choice A is incorrect. The nurse’s statement is correct. Oral contraceptives contain fixed or altered estrogen and progesterone doses that inhibit the hypothalamus from producing hormones needed for ovulation.
Choice B is incorrect. The nurse’s statement is correct. Oral contraceptives increase platelets and clotting factors that increase the woman’s risk for thrombophlebitis.
Choice C is incorrect. The nurse’s statement is correct. Oral contraceptives, when taken consistently, are about 99.7% effective. Generally, the efficacy rate is about 92 to 95%, but the efficacy rate approaches 99.7% if taken perfectly. The nurse needs to emphasize that oral contraceptive intake should not be based on the timing of sexual intercourse. Meaning, to ensure utmost efficacy, the client should take them every day at the same time of day, regardless of whether she will have sex.
Reference
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier
Which of the following clients should the nurse assess first when preparing to do initial rounds?
A. The client with Diabetes who is being discharged today
B. A 32-year-old female with a tracheostomy experiencing copious secretions
C. A 16-year-old scheduled for physical therapy this morning
D. An 80-year-old male with a decubitus ulcer that needs a dressing change
Incorrect Correct Answer(s): B 97% of peers have answered correctly. 26 s Time Spent
Explanation
Answer and Rationale:
The correct answer is B. The patient with airway compromise should always be given the highest priority. Remember ABC (Airway, Breathing, Circulation) A, C, and D are incorrect. None of the patients in these answer options indicate a priority for the initial assessment.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Topic: Coordinated Care
Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn)
Chapter 9: Care Coordination
Lesson: Prioritizing Patient Care
While emptying the foley catheter bag for her patient, the nurse sees the following. Which urine specific gravity level does the nurse expect to see when she reviews his labs, based on this assessment of his urine? (Check Exhibit - urine is very dark, and therefore very concentrated)
A. 0.990
B. 1.000
C. 1.020
D. 1.060
Explanation
Answer: D
A is incorrect. The normal urine specific gravity is 1.005 to 1.030, so a value of 0.990 would be slightly low, indicating dilute urine. Based on the observation of this patient’s urine, it is dark and concentrated. The nurse anticipates a high urine specific gravity, so 0.990 is incorrect.
B is incorrect. The normal urine specific gravity is 1.005 to 1.030, so a value of 1.000 would be slightly low, indicating dilute urine. Based on the observation of this patient’s urine, it is dark and concentrated. The nurse anticipates a high urine specific gravity, so 1.000 is incorrect.
C is incorrect. The normal urine specific gravity is 1.005 to 1.030, so a value of 1.020 would be reasonable. Based on the observation of this patient’s urine, it is dark and concentrated. The nurse anticipates a high urine specific gravity, so 1.020 is incorrect.
D is correct. Urine Specific Gravity measures the concentration of urine. The nurse notes that this urine is very dark, and therefore very concentrated. She suspects that the patient is dehydrated based on this assessment of his urine color. In dehydrated patients, there are more particles in the urine, creating a higher urine specific gravity. Normal urine specific gravity is 1.005 to 1.030, so the nurse expects his lab value to be higher than 1.030. This is the only lab value showing an increased urine specific gravity.
NCSBN Client Need:
Topic: Effective, safe care environment
Subtopic: Coordinated care
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Adult Health
Lesson: Genitourinary
The nurse notes that her patient arriving from the emergency department has increased intracranial pressure and is planning to adjust the bed to accommodate them. At what angle should the nurse elevate the head of the bed?
A. 25 degrees
B. 30-40 degrees
C. 10-20 degrees
D. 5-10 degrees
Explanation
NCSBN client need | Topic: Physiologic integrity, alterations in body systems
Rationale:
The correct answer is B. A patient with an increased intracranial pressure should have the head of the bed elevated to 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient’s neck from flexing. A standard ICP is about 5 to 15 mmHg.
Choice A is incorrect. A patient with an increased intracranial pressure should have the head of the bed elevated to 30 or 40 degrees. Twenty-five degrees is too low and could increase intracranial pressure.
Choice C is incorrect. A patient with increased intracranial pressure should have their bed elevated to 30 or 40 degrees. 10 to 20 degrees is too low and could increase intracranial pressure.
Choice D is incorrect. A patient with an increased intracranial pressure should have the head of the bed elevated to 30 or 40 degrees. 5 to 10 degrees is too low and could increase intracranial pressure.
Reference:
Sole M, Klein D, Moseley M. Introduction To Critical Care Nursing. 1st ed. St. Louis, Mo.: Saunders; 2009.
The nurse is caring for a client who claims to have frequent anxiety attacks. While performing the nursing assessment, it becomes evident that some of the client’s responses were due to fear rather than anxiety. Which of the following are true of stress? (Select all that apply).
A. Anxiety is a cognitive response.
B. Anxiety is related to a future or anticipated event.
C. The source of anxiety is often not identifiable.
D. Anxiety results from physical threat.
E. Anxiety initiates the release of epinephrine.
F. If it is mild or moderate, anxiety can be beneficial.
Explanation
Important Fact:
Fear is an emotion or feeling of apprehension or dread. It stems from an identified danger, threat, or pain. The danger may be real or perceived. NANDA International defines anxiety as a” vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a sense of apprehension caused by anticipation of danger.”
Answer & Rationale:
The correct answers are B, C, E, and F.
o B. Anxiety is related to an anticipated event. Fear is associated with a present fact.
o C. The source of anxiety may not be easily identifiable. However, the source of concern can be identified.
o E. Both anxiety and fear initiate the release of epinephrine, which stimulates the sympathetic nervous system in preparation for the “fight or flight” response.
o F. Mild to moderate anxiety can be a sign of adaptation, as it mobilizes and motivates a person to action.
A is incorrect. Anxiety is an emotional response, not cognitive. D is incorrect. Anxiety results from psychological conflict rather than a physical threat.
Resource:
NCSBN Client Need:
Topic: Psychosocial Integrity
Chapter 12: Stress & Adaptation
Lesson: Types of Stressors
Reference: Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith)
Which of the following are included in the Hierarchy of Importance of Pain Measures that is used when a client is unable to self-report pain? Select all that apply.
A. The identification of underlying conditions that are associated with pain
B. The use of a qualitative pain scale for pain measurement
C. The physiological indicators of pain
D. The interview of a significant other about the client’s pain
E. The behavioral indicators of pain
F. The use of a FACES pain scale for pain measurement
G. Attempts to get self reports of pain
H. A self appraised quality of life scale
I. An analgesic trial to confirm pain
Explanation
Correct Answers are A, C, E, G and I
The following are included in the Hierarchy of Importance of Pain Measures that is used when a client is unable to self report pain:
The identification of underlying conditions that are associated with pain
The physiological indicators of pain
The behavioral indicators of pain
Attempts to get self-reports of pain
An analgesic trial to confirm pain
When the client is not able to use a pain scale, a self-report and the communication of the significant other is not a valid assessment criterion.The following are NOT included in the Hierarchy of Importance of Pain Measures that is used when a client is unable to self report pain:
The use of a qualitative pain scale for pain measurement The interview of a significant other about the client’s pain The use of a FACES pain scale for pain measurement A self appraised quality of life scale
Choice B is incorrect. The clients who are unable to self-report pain are not able to use a qualitative pain scale for pain measurement.
Choice D is incorrect. When a client is unable to self-report pain, the significant other’s opinions about the client’s pain is not a valid measurement of pain.
Choice F is incorrect. Clients who are unable to self-report pain are not able to use a FACES pain scale for pain measurement.
Choice H is incorrect. Clients who are unable to self-report pain are not able to use a person assessed quality of life scale.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition)
A nurse is assigned to care for several clients with eating disorders. How would the nurse differentiate bulimic clients from anorectic clients, based on physical appearance?
A. By observing their teeth
B. By body size and weight
C. Mallory-Weiss tears
D. It is impossible to distinguish the clients based on physical exam only
Explanation
Rationale: Both bulimic and anorectic clients have the propensity to impose weight loss rituals, but bulimic clients tend to eat much more, as they have binge episodes, and are expected to be near-normal weight. Not all bulimic clients have enamel-loss on their teeth, especially if the disorder has developed only recently. Mallory-Weiss tears are small tears in the esophageal mucosa brought about by forceful vomiting but aren’t always present in bulimic clients.
Reference:
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
You are working in the Emergency Department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), all of these tasks should be done for this patient:
1) Determine if the patient is a candidate for fibrinolytic therapy
2) Neurologic assessment by the stroke team
3) General assessment and stabilization
4) Administer rtPA
The correct sequence for these tasks is: Neurologic assessment by the stroke team Determine if the patient is a candidate for fibrinolytic therapy Administer rtPA General assessment and stabilization
Correct Answer is: General assessment and stabilization Neurologic assessment by the stroke team Determine if the patient is a candidate for fibrinolytic therapy Administer rtPA
Explanation
Correct sequence:
According to the AHA Suspected Stroke Algorithm, the correct course for the treatment of the stroke patient is:
General assessment and stabilization within 10 minutes of arrival to the ED Neurologic evaluation by the stroke team within 25 minutes of entry to the ED CT scan and determination if there is intracranial hemorrhage within 45 minutes of entry to the ED If ischemic stroke, determine if the patient is a candidate for fibrinolytic therapy using the fibrinolytic checklist Administer rtPA within 60 minutes of entry to the ED Admit to the stroke unit within 3 hours of entry to the ED
NCSBN Client Need
Topic: Management of Care
Sub-Topic: Establishing Priorities
Subject: Critical Care
Lesson: Prioritization; Neurologic
Reference: American Heart Association. Advanced Cardiovascular Life Support: Provider Manual. Adult Suspected Stroke Algorithm. March 2016 eBook edition.
You are a nurse working in a medical unit with a trained aide. You have admitted a new patient and have received the following orders:
Amoxicillin 250 mg by mouth every 6 hours Insulin 2u Humulin Subcutaneous now CBC, Electrolytes, Urinalysis, and two sets of Blood Cultures Vital Signs every 4 hours
The task you can safely delegate to the aide working with you is:
A. Amoxicillin 250 mg by mouth every 6 hours
B. Insulin 2u Humulin Subcutaneous now
C. Collect lab work
D. Vital signs every 4 hours
Explanation
Correct Answer: D.
The performance of vital signs is a task that you can safely and legally delegate to an unlicensed, trained team member. The question stipulates that she is trained, so it is safe to assume that she can do vital signs accurately. Collecting blood and giving medications are usually tasks that cannot be delegated to an unlicensed person. The nurse needs to understand the limits of unauthorized personnel as defined by facility policy, state regulations, and the scope of practice of the team member. When in doubt about the appropriate delegation of a task, the nurse should never delegate the responsibility. Any time the nurse delegates a job, it is critical that the nurse follow up to ensure that the task was completed accurately. The nurse should also be aware of the five rights of delegation: right job, right circumstance, right person, proper direction/communication, and correct supervision.
NCSBN Client Need
Topic: Management of Care
Sub-Topic: Delegation
Subject: Leadership and Management
Lesson: Delegation
Reference: National Council of State Boards of Nursing. National Guidelines for Nursing Delegation. https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf. Accessed online on October 12, 2019.
What is the term that is used to describe a human’s innate biological clock relating to daytime and nighttime wakefulness and activity?
A. REM sleep
B. Circadian rhythm
C. Diurnal activity
D. Nocturnal activity
Explanation
Correct Answer B
Correct. Circadian rhythm is defined as our 24-hour biological clock that, in humans, is primarily one that functions best with daytime wakefulness and activity and nighttime sleep. When clients, and all other human beings, are in synchrony with their biological clock, humans function optimally because many of our essential rational physiological and mental functions like blood pressure, body temperature and levels of alertness and performance are at their optimal levels.
Choice A is incorrect. REM sleep is a phase of the sleep cycle and not the term that is used to describe a human’s innate biological clock relating to daytime and nighttime wakefulness and activity.
Choice C is incorrect. Diurnal activity is daytime activity and not the term that is used to describe a human’s innate biological clock relating to daytime and nighttime wakefulness and activity.
Choice D is incorrect. Nocturnal activity is nighttime activity and not the term that is used to describe a human’s innate biological clock relating to daytime and nighttime wakefulness and activity.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
A client with streptococcal pharyngitis (tonsillitis) has been placed on droplet precautions. Which of the following statements indicates the best understanding of this type of isolation?
A. The client can be placed in a room with another client with measles (rubeola).
B. A special mask (N95) should be worn when working with the client.
C. Must maintain a spatial distance of 3 feet.
D. Gloves should be worn only when giving direct care.
Explanation
The most common forms of transmission of an organism in a client with tonsillitis are coughing, sneezing, and talking. Droplets can travel no more than 3ft, so precautions should be maintained when there is a possibility of entering this distance.
The correct answer is C. A spatial distance of at least 3 feet is recommended.
A is incorrect. This client requires a private room.
B is incorrect. An N95 mask is not required for this client. A face mask instead can be used when dealing with the client.
D is incorrect. Gloves, gowns, face masks, and eye protection should be worn in giving direct care.
NCSBN Client Need
Topic: Safe and Effective Care Management
Subtopic: Safety and Infection Control
Chapter 31: Asepsis
Lesson: Isolation Precautions
Fundamentals of Nursing (Kozier and Erbs)
The nurse is caring for a client post-angiography using a contrast medium via the femoral approach. Which intervention should the nurse include in the patient’s plan of care?
A. Keep the hips bent for 6-8 hours after the procedure.
B. Discontinuation of IV fluids immediately after the procedure.
C. Assessment of kidney function tests the next day.
D. Keep the client on NPO 4 hours after the procedure.
Explanation
A is incorrect. The nurse should keep the punctured extremity in straight alignment, not bent.
B is incorrect. IV fluids should be continuously infused for 6 – 8 hours to hydrate the client to aid in the excretion of the contrast media.
C is correct. The contrast media is a substance that is excreted in the kidneys. Aside from hydration, the nurse should check the clients’ kidney function tests to determine whether there has been any damage to his kidneys during the trial.
D is incorrect. The client can immediately resume his regular diet after the test.
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
Your client is receiving TPN (total parenteral nutrition) because of extensive and serious thermal burns. What is an appropriate expected goal or expected outcome for this client?
A. The client will maintain a serum albumin of 1.5 to 2.0 g/dL.
B. The client will maintain a serum albumin of 2.0 to 2.5 g/dL.
C. The client will gain 0.5 kg bodily weight each day.
D. The client will gain 1 kg of bodily weight each day.
Explanation
Correct Answer is D
Correct. “The client will gain 1 kg of body weight each day” is an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and severe thermal burns.
Choice A is incorrect. “The client will maintain serum albumin of 1.5 to 2.0 g/dL” is not an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and severe thermal burns. TPN (complete parenteral nutrition) is being administered to this client because the caloric demands of the body significantly increase as a result of severe injuries and other disorders like cancer.
Choice B is incorrect. “The client will maintain serum albumin of 2.0 to 2.5 g/dL” is not an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and severe thermal burns. Although TPN (complete parenteral nutrition) is being administered to this client, the serum albumin should not be maintained at 2.0 to 2.5 g/dL because the normal albumin, which is higher than this, is necessary for the wound healing of this client.
Choice C is incorrect. “The client will gain 0.5 kg bodily weight each day” is not an appropriate expected goal or expected outcome for this client who is receiving TPN (total parenteral nutrition) because of extensive and serious thermal burns because this client should be gaining more weight than this to meet the significantly increased demands of the body as a result of severe burns and other disorders like cancer.
Reference: Knippa, Audrey, Sheryl Sommer, Brenda Ball et al. (2010) Nutrition for Nursing 4.0; ATI Nursing Education.
While preparing to administer a newly ordered medication, the nurse notices that the dosage prescribed is higher than the usual recommended dosage. Despite trying multiple times, the nurse is unable to locate the ordering physician. The medication is due to be administered. Which action should the nurse undertake first?
A. Contact the unit’s nursing supervisor
B. Administer the dose as prescribed since the nurse is protected by a written order
C. Hold the medication until the physician can be contacted and the order is clarified
D. Administer what the nurse knows as the recommended dose until the physician can be located
Explanation
Choice A is correct. The nurse must contact the nursing supervisor. If the physician writes a prescription that is questionable or requires clarification, the nurse’s responsibility is to contact the physician. But a resolution regarding the order may not be immediately reached because the physician may not be located or the physician may insists on keeping the medicine as it was written. In such cases, the nurse should contact the nurse manager or nursing supervisor for further clarification. The nursing supervisor can determine the appropriate steps that should be taken.
Choice B, C, and D are incorrect. Once the nurse is aware that the prescription is inappropriate, the nurse should never proceed to carry out the prescription as it is ( Choice B). Nurses have legal and ethical obligations to protect the client. Simply holding the medication until physician can be contacted ( Choice C) is inappropriate since the medication is due to be administered. The nurse should inform the supervisor so appropriate steps can be determined. Administering what the nurse knows ( Choice D) and taking independent treatment decisions regarding the medication dosage is an inappropriate nursing practice.
Your client has had two intravenous infusions that had to be discontinued because of phlebitis, which is a commonly occurring complication of intravenous therapy. Before and as you are preparing to start another intravenous line, you would:
A. Apply a cold compress to the intravenous site that developed phlebitis.
B. Consider the use of a larger sized catheter to prevent further phlebitis.
C. Use the most proximal site as possible for the next in intravenous site.
D. Consider the use of a inline intravenous fluid filter for unmedicated intravenous fluids.
Explanation
Correct Answer is D
Correct. You would consider the use of inline intravenous fluid filter because the inline intravenous fluid filter can prevent the entry of air and particles, the latter of which can lead to mechanical phlebitis. Although many believe that intravenous fluid filters are only used for blood transfusions, they are also highly useful and used for intravenous fluid administration.
Choice A is incorrect. You would apply a warm and not a cold compress to the intravenous site that has developed phlebitis.
Choice B is incorrect. You would consider the use of a smaller, and not a more extensive, sized catheter to prevent further phlebitis.
Choice C is incorrect. You would not consider using the most proximal site as possible for the next in the intravenous section; however, you would use the most distal sites possible so you can preserve more proximal intravenous sites for future use, if necessary.
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition); and Sommer, Johnson, Roberts, Redding, Churchill et al. (2013) Fundamentals for Nursing Edition 8.0; ATI Nursing Education.
A nurse in the surgical ICU is taking care of a young man that was involved in a four-wheeling accident four hours ago. He was diagnosed with a grade two renal laceration, multiple rib fractures, and a concussion upon arrival. While performing the last head-to-toe assessment before the transfer, the nurse notices a small amount of bruising around the patient’s umbilicus. What should the nurse do?
A. Administer pain medication for rib fractures
B. Notify trauma surgeon of bruising immediately
C. Perform serial abdominal exams and keep monitoring umbilicus
D. Assess pupillary reaction
Explanation
B is the correct answer. Bruising around the umbilicus is called Cullen’s sign. This is important to identify after trauma because it indicates bleeding into the abdomen. The nurse needs to notify the surgeon immediately so the patient can be further assessed. The surgeon may monitor the patient medically or take him back into surgery.
A is incorrect. The patient may need pain medication, but the most important intervention at this time is to notify the trauma surgeon of the Cullen’s sign that was noted.
C is incorrect. The trauma surgeon may order serial abdominal exams after assessing the patient, but he needs to be called to evaluate the patient first.
D is incorrect. This assessment is not warranted at this time.
NCSBN Client Need
Topic: Reduction of Risk Potential
Sub-topic: System-specific Assessments
Subject: Adult Health
Lesson: Critical Care
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013
In Piaget’s Stages of Cognitive development, the ______________ stage occurs from 2 to 7 years old. (Enter letters only in the blank).
Explanation
In Piaget’s Stages of Cognitive Development, the preoperational stage occurs from 2 to 7 years old. In this stage, the child is a symbolic thinker. They can use language with proper grammar to express their thoughts. Their imagination and intuition are developing rapidly. They are not yet ready to think complex abstract thoughts.
NCSBN Client Need:
Topic: Psychosocial Integrity
Reference: Ricci, S. S., & Kyle. Maternity and pediatric nursing. Lippincott Williams & Wilkins.
An 86-year-old patient presents with an open wound to RLE. WBC 12. BMI 18.8. and prealbumin 12mg/dL. Which diet would be most appropriate for this patient?
A. Low fiber. low residue
B. TPN with iron supplementation
C. High calorie. high protein
D. Low sodium (heart healthy)
Explanation
C is correct. This patient is showing signs of the need for increased protein and caloric intake as evidenced by elevated WBC count (normal WBC range: 4-11), open wound, low albumin level (normal prealbumin range: 15-36mg/dL), and BMI within the normal range, but very close to underweight (normal BMI range: 18.5-24.9). This patient needs increased protein and caloric intake to fight infection and promote wound healing.
A is incorrect. Low fiber/residue diet is indicated in GI conditions such as Crohn’s disease, IBD, and diverticulitis. No assessment data is suggesting the patient is experiencing any GI problems.
B is incorrect. No assessment data is suggesting the patient is deficient in iron. TPN is indicated when a patient has an absorption problem or when oral intake is not possible. The patient should be started on an appropriate high calorie, high protein diet first before any parenteral nutrition is considered.
D is incorrect. No assessment data is suggesting the patient is experiencing any cardiac issues requiring a low sodium/heart-healthy diet.
Subject: Adult health
Lesson: GI/Nutrition
Topic: nutrition and oral hydration, illness management
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 928-929)
Which of the following images demonstrates the rash typical of varicella?
A . The outbreak clearly shows macules, papules as well as vesicles. The lesions evolve from red macules to form small papules, and then a clear blister develops on this base.
B. the outbreak is on the face, and there are no blisters. Rubella manifests with sudden onset of a maculopapular rash consisting of pinpoint, pink maculopapular
C. the face is spared, but the trunk is involved—Roseola Infantum (exanthem subitum or sixth disease or three-day fever)
D. the lesions of the outbreak are coalescing. It is a highly contagious viral illness. It begins with fever and 3Cs ( conjunctivitis, coryza, and cough). Following this, 1 to 3 mm white/grayish or blue raised spots to appear on the buccal mucosa as well as the hard and soft palate
Explanation
Correct Answer is A. This rash is typical of Varicella. Varicella (Chickenpox) is caused by the varicella-Zoster virus of the herpes group. The outbreak clearly shows macules, papules as well as vesicles. The lesions evolve from red macules to form small papules, and then a clear blister develops on this base. Such evolution of rash has been described as a “dewdrop (vesicle) on a rose petal ( erythematous base).” Over the next several days, these blisters rupture and then crust. The rash begins on the chest and back and spreads centrifugally to involve the face, scalp, and extremities. These blisters and the fact that patient with varicella typically has lesions in different stages of development on the front, trunk, and extremities helps differentiate it from other common viral disease rashes.
Isolation precautions for Varicella: A nurse needs to be able to recognize this rash because this disease is highly contagious, and appropriate isolation precautions should be started. Varicella transmission occurs via contact with aerosolized droplets from nasopharyngeal secretions or by direct cutaneous contact with the vesicular fluid. The nurse should place the varicella patient on airborne infection isolation(i.e., unfavorable air-flow rooms) and contact precautions until all lesions have crusted. A person with varicella is contagious beginning 1 to 2 days before rash onset until all the chickenpox lesions have crusted.
Choice B is incorrect. This is the rash typical of Rubella. In the image, you can notice the outbreak is on the face, and there are no blisters. Rubella manifests with sudden onset of a maculopapular rash consisting of pinpoint, pink maculopapular,and concomitant low-grade fever. It appears on the face first and then spreads to trunk and extremities. On average, the rash lasts three days. Although the outbreak may be similar to Rubeola (measles), rubella rash spreads more rapidly and not darken or coalesce. Rubella does not have vesicles and lacks different stages of lesions, unlike Varicella (Chickenpox).
Isolation precautions for Rubella: Droplet precautions and exclusion from school or child care for seven days after the onset of the rash.
Choice C is incorrect. This is the rash typical of Roseola. In the image, you may notice that the face is spared, but the trunk is involved—Roseola Infantum (exanthem subitum or sixth disease or three-day fever). Human Herpes Virus-8 causes it. The rash is maculopapular and blanching. Very high temperature ( as high as 104F) starts first and lasts about 3 to 5 days. Once fever abates, the rash develops. The outbreak is similar to Rubella and often referred to as pseudo-rubella.
However, there are some differences:
Rubella: Low-grade fever occurs concomitant with a rash. The rash starts on the face and spreads to extremities.
Roseola: Fever starts first, and then comes the rash. The rash begins on trunk and neck and later spreads to the face and extremities.
Isolation precautions for Roseola: Roseola spreads by contact and self-limiting. Simple hygienic measures such as “handwashing” are recommended after contact.
Choice D is incorrect. This is the rash typical of Measles ( Rubeola). In the image, you may notice that the lesions of the outbreak are coalescing. It is a highly contagious viral illness. It begins with fever and 3Cs ( conjunctivitis, coryza, and cough). Following this, 1 to 3 mm white/grayish or blue raised spots to appear on the buccal mucosa as well as the hard and soft palate. These are called “Koplik spots” and are very helpful in accurately diagnosing Measles. Two to four days after onset of fever, the rash appears – it is erythematous, maculopapular, blanching rash beginson the face and spreads centrifugally to involve the neck, trunk, and extremities. The cranial to the caudal progression of the rash is characteristic of measles. Still, a similar pattern of progress is also seen with Measles– however, the lesions coalesce in Measles, but they do not blend in Rubella.
Isolation precautions for Measles: In the healthcare settings, airborne transmission precautions are indicated for four days after the onset of rash in Measles.
NCSBN Client Need:
Topic: Health Promotion and Maintenance
Reference:
Hockenberry M, Wilson D: Nursing care of infants and children, ed 9, St. Louis, 2011.
A rescue dose of IV Ativan is ordered for your actively seizing patient. The treatment is 2mg. And the vial reads: “Ativan 2mg/1mL”. The nurse brings you a syringe with 2mL of medication in it. What should you do?
A. Administer the medication, this is the correct amount.
B. Throw the syringe away, it is an incorrect amount of ativan.
C. Administer the medication even though the amount is incorrect. Your patient is having a seizure!
D. Ask the nurse to draw up a new syringe of ativan with you and check the volume together.
Explanation
Answer: D
The correct amount of medication is 1 mL. (2mg / 2mg) x 1 mL = 1 mL.
A is incorrect. You should not administer the medication; it is the wrong dose.
B is incorrect. While it’s true that this is an ungodly amount of Ativan, it is not appropriate to just throw the syringe away. Your patient is having a seizure and needs the medication. You should correct the dose and then administer the medication properly.
C is incorrect. You should never administer the wrong amount of medication to your patient. This is double the amount of Ativan prescribed and could cause an overdose.
D is correct. You are responsible for recognizing that this is an incorrect amount of medication. It is an easy mistake to make; your order is for 2 mg of Ativan, and instead of 2 mg, the nurse brought you 2 mL. They did not read the label and see that the concentration is 2mg/mL. You should draw up a new syringe of the appropriate amount of Ativan with the nurse and then administer it to your patient.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Subject: Fundamentals
Lesson: Medication Administration
Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing. Elsevier Health Sciences.
