ASSESSMENT Flashcards
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
CORRECT ANSWER C
Explanation
Choice C is correct. The appropriate expected goal or expected outcome for this client, in terms of the gastrointestinal system, who is receiving an enteral feeding every 4 hours, is that the client will be free of dumping syndrome, which can further increase the client’s nutritional deficits. Simply stated, dumping syndrome is the very rapid and quick movement of foods and fluids through the stomach and then into the small intestine; the feed is then mostly undigested and eliminated through the gastrointestinal tract. Although dumping syndrome is primarily associated with gastric bypass surgery, it can also occur as a result of enteral bolus feedings.
Because “dumping syndrome” is one of the main complications that accompany enteral feeding,you must ensure to prevent it by implementing appropriate nursing interventions which include giving formula at room temperature and increasing the feeding rate gradually.
Choice A is incorrect. “The client will be free of any insertion site infection” may be an appropriate expected goal or expected outcome for this client who is receiving an enteral feeding every 4 hours. Still, this outcome is not related to the client’s gastrointestinal system.
Choice B is incorrect. “The nurse will measure residual before each feeding” is an appropriate nursing intervention, but it is not an expected goal or expected outcome.
Choice D is incorrect. “The nurse will administer no more than 200 mL for each feeding” is not an expected goal or expected outcome. Moreover, the nurse can administer more than 200 mL for each feeding. The volume of each food is typically from 250 to 400 ml per feeding.
Reference: Knippa, Audrey, Sheryl Sommer, Brenda Ball et al. (2010) Nutrition for Nursing 4.0; ATI Nursing Education.
Which of the following is least likely to develop trust in the nurse-client relationship? Select All That Apply.
A. Using consistency in approaching the client
B. Encourage the client to use “testing” behaviors
C. Tell the patient how she should behave
D. Avoid setting limits
CORRECT ANSWER B, C, D
Explanation
B, C, and D are the correct answers. Avoiding limit setting will not instill trust, nor will it encourage testing behaviors or telling the client how he should behave.
One of the essential elements of trust is consistency. The client learns to trust that the nurse will follow through and do what is promised.
NCSBN Client Need
Topic: Psychosocial Integrity
Chapter 26: Communicating
Lesson: The Helping Relationship
Fundamentals of Nursing (Kozier and Erbs)
A client is currently experiencing bradycardia, low blood pressure, and dizziness. Which of the following does the nurse expect to be ordered?
A. Defibrillation
B. Digoxin
C. Monitor the client closely
D. Prepare patient for transcutaneous pacing
CORRECT ANSWER D
Explanation
Choice D is correct. The normal heart rate in an average adult is between 60 to 100 beats per minute. A heart rate less than 60 beats per minute is referred to as bradycardia. Bradycardia can be symptomatic or asymptomatic. Some healthy adults and athletes may have a heart rate between 40 and 60 beats per minute and do not experience any symptoms. When symptomatic, bradycardia can lead to shortness of breath, dizziness, and low blood pressure ( hypotension, shock). A patient experiencing symptomatic bradycardia will likely need transcutaneous pacing. In addition, an EKG must be performed to confirm the rhythm. The etiology of bradycardia may vary and include reversible ( medications) and irreversible causes ( heart blocks). Therefore, one should explore causes, but the priority intervention in a patient experiencing symptoms from bradycardia is to restore the heart rate quickly with transcutaneous pacing and maintain circulation.
Choice A is incorrect. Defibrillation is recommended when the patient is experiencing pulseless ventricular tachycardia or ventricular fibrillation.
Choice B is incorrect. Digoxin is a cardiac glycoside that has negative chronotropic action on the sinus node. Therefore, digoxin decreases the heart rate and would be dangerous in this patient with symptomatic bradycardia.
Choice C is incorrect. While this patient should be monitored closely, priority action ( transcutaneous pacing) should quickly restore the heart rate.
NCSBN client need | Topic: Physiological Integrity, Reduction of Risk Potential
A 30-year-old male client in the medical ward for admitted for hiatal hernia is being discharged today. The nurse talks to him regarding methods to prevent and reduce pain associated with his condition. Which of the following statements from the client indicate that teaching is successful?
A. “I need to wear loose-fitting clothes.”
B. “After a meal, I must lie down to avoid dumping syndrome.”
C. “I need to eat three large meals a day.”
D. “I can go to my favorite Indian restaurant anytime of the week.”
CORRECT ANSWER A
Explanation
A is correct. The nurse should teach the client measures that reduce gastric acid reflux in the patient. The nurse should instruct the patient to wear loose-fitting clothes to prevent pressure in the stomach that might cause reflux.
B is incorrect. The client should not lie down after a meal. Instead, the client should remain in an upright position for 2 hours after eating. Dumping syndrome in a hiatal hernia does not exist.
C is incorrect. The nurse should instruct the client to have frequent small feedings rather than three large meals to avoid gastric reflux.
D is incorrect. Spicy food and caffeine trigger acid reflux and should be avoided. Indian food is full of spices, and clients should avoid eating tasty food.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
Auscultation is one of the most important components of which body systems?
A. Pulmonary. gastrointestinal. neurological
B. Reproductive. neurological. integumentary
C. Cardiovascular. pulmonary. gastrointestinal
D. Gastrointestinal. neurological. and reproductive
CORRECT ANSWER C
Explanation
Answer and Rationale:
The correct answer is C. Auscultation of the heart provides information on rate, rhythm, extra sounds, and murmurs. Auscultation of the lungs includes information on the underlying music and adventitious sounds, which relate to pathology in the alveoli and airways. Gastrointestinal sounds may be absent, hypoactive, or hyperactive. A, B, and D are incorrect. Auscultation plays a minimal role in the reproductive, neurological, and integumentary systems.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 30: Head-to-toe Assessment of the Adult
Lesson: Auscultation
In an adult, sustained intracranial pressure greater than _______ mmHg can lead to severe neurologic damage.
Explanation
Answer: 20
In adults, normal intracranial pressure is 10 to 15 mmHg. In adults, increased ICP at more than 20 mmHg increase risk for neurologic damage.
Normal Intracranial Pressure (ICP) in young children is 3-7 mmHg.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological Adaptation
Reference: Brorsen, A. & Roglet, K. (2011). Pediatric Critical Care. Burlington, MA: Jones & Bartlett Learning.
While monitoring your patient’s cardiac telemetry, you notice the following ECG changes: tall peaked T waves, absent P waves, and a widened QRS. You notify the health care provider and anticipate an order for which of the following laboratory studies?
A. BMP
B. CBC
C. Coags
D. Type and screen
CORRECT ANSWER A
Explanation
Answer: A
A is correct. A basic metabolic panel (BMP) is what the nurse anticipates the healthcare provider will order. This laboratory study will examine all the essential electrolytes such as sodium, potassium, chloride, magnesium, and calcium. The nurse is expecting the potassium to be elevated in her patient, given the ECG changes, so she will expect to monitor all electrolytes in her patient.
B is incorrect. A complete blood count will monitor RBCs, RBCs, platelets, and other cell counts in the patient. This is important when tracking for anemia, infection, and much more, but should not have any result that immediately impacts these ECG changes. The electrolyte abnormalities are more likely, and therefore the nurse anticipates an order for a BMP.
C is incorrect. Coagulation studies are essential for showing clotting times in the patient’s blood, but the nurse is not concerned about that right now. Abnormal clotting times should not cause ECG changes.
D is incorrect. A type and screen identify the patient’s blood type. This is very important for surgery and before administering any blood products, but will not help the nurse determine the cause of the ECG changes she noticed.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Pharmacological therapies
Subject: Fundamentals
Lesson: Electrolytes
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
Many factors impact on the occurrence of diseases and disorders as well as client recovery from these diseases and disorders. Which of the following is the extrinsic factor that most greatly and most frequently can hurt and interfere with our client’s physical and emotional recovery from a disease or disorder?
A. Age
B. Genetic makeup
C. Family dynamics
D. Gender
CORRECT ANSWER C
Explanation
Correct Answer is C
Correct. Family dynamics is the extrinsic factor that most greatly and most frequently hurts and interferes with our clients’ physical and emotional recovery from a disease or disorder; in fact, family dynamics is the only extrinsic risk factor listed above. All of the other factors are intrinsic risk factors that are associated with a possible negative impact on the recovery of a client.
Choice A is incorrect. Age does have a possible negative impact on and interference with our client’s physical and emotional recovery from a disease or disorder; however, age is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients’ physical and emotional recovery from a disease or disorder.
Choice B is incorrect. Genetic makeup does have a possible negative impact on and interference with our clients physical and emotional recovery from a disease or disorder, however, genetic makeup is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients’ physical and/or emotional recovery from a disease or disorder.
Choice D is incorrect. Gender does have a possible negative impact on and interference with our client’s physical and emotional recovery from a disease or disorder; however, gender is an intrinsic and not an extrinsic factor that could hurt and interfere with our clients’ physical and emotional recovery from a disease or disorder.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
Total parenteral nutrition is being considered for your client. Your client tells you that “my doctor is thinking about hyperalimentation, and I know nothing about it. Can you tell me what it is? You should respond to this client’s statement with:
A. “Your doctor is thinking about total parenteral nutrition and not hyperalimentation.”
B. “Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube.”
C. “Hyperalimentation is a one kind of parenteral nutrition that gives you feedings with a special IV line.”
D. “You should choose to have enteral nutrition and not accept hyperalimentation.”
CORRECT ANSWER C
Explanation
Correct Answer is C
Correct. You should respond to this client’s statement with “Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line.” Parenteral nutrition, which is synonymous with hyperalimentation and IV hyperalimentation, provides the client with complete food when it is indicated for a client such as one who is adversely affected
Choice A is incorrect. You should not respond to this client’s statement with “Your doctor is thinking about total parenteral nutrition and not hyperalimentation” because parenteral nutrition is hyperalimentation; parenteral nutrition is synonymous with hyperalimentation and IV hyperalimentation.
Choice B is incorrect. You should not respond to this client’s statement with “Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube” because hyperalimentation is parenteral nutrition and not enteral nutrition.
Choice D is incorrect. You should not respond to this client’s statement with “You should choose to have enteral nutrition and not accept hyperalimentation” because this is coercive and it is contrary to the client’s right to make an informed decision about any or all care that is being considered and given.
Reference: McCuistion, Linda E., Joyce LeFever Kee, and Evelyn R. Hayes (2015). Pharmacology: A Patient-Centered Nursing Process Approach, 8th Edition. Saunders: Elsevier
While reviewing fetal monitoring strips, the labor and delivery nurse notes that the piece is nonreassuring. What features characterize a fetal monitoring strip as nonreassuring? Select all that apply.
A. Fetal heart rate less than 110 beats/minute.
B. Increase in variability.
C. Late decelerations
D. Mild variable decelerations
CORRECT ANSWER A, C
Explanation
Answer: A and C
A is correct. A fetal heart rate less than 110 beats/minute or greater than 160 beats/minute is nonreassuring.
B is incorrect. An increase in variability is a reassuring factor. A decrease in variability would be nonreassuring.
C is correct. Late decelerations are an ominous sign, and immediate interventions should be taken to improve the fetal heart rate. They are characteristic of a nonreassuring heart rate.
D is incorrect. Mild, variable decelerations are okay, only when the variable decelerations are severe are they nonreassuring.
NCSBN Client Need
Topic: Physiological AdaptationSubtopic: Alterations in Body Systems
Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 363
You are supervising a nursing assistant and observing their competency in providing personal care and hygiene for a group of clients. As you are reviewing this nursing assistant’s documentation you see that the nursing assistant has documented shaving one of the clients, who is taking warfarin. What should you do? You should:
A. Tell the nursing assistant that shaving clients who are taking warfarin are strictly prohibited in all settings.
B. Complete an incident report because shaving clients are outside the nursing assistant’s scope of practice.
C. Tell the nursing assistant to cross off the documented evidence of having shaved the client.
D. Ask the nursing assistant what kind of razor was used and about the client’s response to the shave.
CORRECT ANSWER D
Explanation
Correct Answer is D
Correct. You would ask the nursing assistant what kind of razor was used and about the client’s response to the shave when you learn that the nursing assistant has documented shaving one of the clients who is taking warfarin.
You would determine what kind of razor was used because an electric or battery operated razor is much safer than a dull razor blade to use for clients who are on an anticoagulant like warfarin. If the nursing assistant used a regular razor blade, instead of an electric or battery operated razor, you would ask the nursing assistant about the client’s response to the shave. For example, you would determine whether or not there was any skin nicking or bleeding. After these things are determined, you would also ask the nursing assistant to document the type of razor that was used in addition to the client’s responses to the shave.
Choice A is incorrect. You would not tell the nursing assistant that shaving clients who are taking warfarin are strictly prohibited in all settings because this is not accurate and true. Clients who are taking warfarin can and should be shaved with an electric or battery operated razor because these razors are much safer than a dull razor blade.
Choice B is incorrect. You would not complete an incident report because shaving clients are outside the nursing assistant’s scope of practice. Shaving, personal care, and hygiene are within the legal reach of unlicensed assistive personnel, including nursing assistants and patient care technicians, provided that they have the training and documented competency to do so.
Choice C is incorrect. You would not tell the nursing assistant to cross off the documented evidence of having shaved the client. If the person cut, this documentation must remain in place.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
The nurse is working with a patient who is receiving a new prescription of prednisone. The nurse would be most correct in instructing the client to take this medication at which time every day?
A. In the morning
B. Around noon
C. Before bed
D. Anytime. but the same time everyday
CORRECT ANSWER A
Explanation
NCSBN client need | Topic: Physiological Adaptation, Pharmacological and Parenteral Therapies
Rationale:
The correct answer is A. Corticosteroids should be taken in the morning, preferably before 9 AM. This mimics the natural release of glucocorticoids from the adrenal glands in the morning.
Choice B is incorrect. The best time to take prednisone is not around noon.
Choice C is incorrect. The best time to take prednisone is not before bed. Taking prednisone before bed could cause restlessness or insomnia.
Choice D is incorrect. There is a more specific time to take prednisone.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
A 15-year-old female comes into the gynecology clinic asking for a prescription of contraceptive pills. Fifteen minutes later, her mother comes in and scolds the teenager about her decision. She tells the doctor not to give her the pills and says that her daughter is still too young and it is her decision that should be followed. What should be the most appropriate action of the nurse?
A. Withdraw the prescription contraceptive pills.
B. Call Child Protective Services.
C. Explain to the mother that in cases of birth control services, her daughter has the right to give consent.
D. Explain to the teenager that her mother still has consenting authority over her decisions.
CORRECT ANSWER C
Explanation
A is incorrect. Parental or guardian consent should be obtained before treatment is initiated for a minor except in an emergency. In situations in which the permission of the minor is sufficient, this includes birth control treatments.
B is incorrect. There is no sign of abuse; the nurse does not need to call child protective services.
C is correct. When the minor is seeking birth control treatments, the minor’s consent is sufficient and does not warrant the permission of her parents.
D is incorrect. The mother no longer has consenting authority over her child when it comes to birth control treatments.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
For burns, pain management primarily consists of morphine delivered intravenously. The reason for this is:
A. The IV route delays absorption to provide continuous pain relief
B. The IV route facilitates absorption as muscle absorption is not dependable
C. The IV route allows for discontinuance in the event of respiratory depression
D. The IV route prevents further pain from IM injections
CORRECT ANSWER B
Explanation
Rationale: The I.V. route of administering medications facilitates increased absorption of drugs, not decreased intake. Option A is incorrect. In clients with burns, they are usually hemodynamically unstable, and tissue perfusion is compromised. Medications remain in the subcutaneous tissue with the fluid in the interstitial spaces in the acute phase of the injury. Because of this, the IM route is avoided until stability has been achieved. Option B is, therefore, the correct answer. In the event of respiratory depression, the IV route would hasten the process, making option C incorrect. The goal in I.V. administration is not for the primary reason of avoiding causing the additional client pain. Option D is also wrong.
Reference:
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
The nurse is reviewing the results of her patient’s basic metabolic panel and notes a potassium level of 5.7 mEq/L. She knows that which of the following conditions could cause this result? Select all that apply.
A. Cushing’s disease
B. Continuous NG tube suction
C. Severe dehydration
D. Hyperinsulinism
CORRECT ANSWER C
Explanation
The normal level for potassium is 3.5 to 5. This patient has a potassium level of 5.7, indicating hyperkalemia.
A is incorrect. Cushing’s disease is likely to cause hypokalemia, not hyperkalemia. In this disease the adrenal glands produce too much aldosterone. Aldosterone causes the body to excrete potassium, putting patients with Cushing’s disease at risk for excessive potassium losses leading to hypokalemia.
B is incorrect. The patient with an NG tube to continuous suction is likely to experience hypokalemia, not hyperkalemia. NG tube suction removes all of the gastric contents, which are rich in potassium. With those excessive potassium losses, the patient becomes hypokalemic.
C is correct. Severe dehydration is a potential cause of hyperkalemia. When a patient is severely dehydrated (from vomiting, diarrhea, profuse sweating, etc.), potassium is lost and large amounts of fluid are lost. While this patient is experiencing a fluid volume deficit, the concentration of potassium in their blood is elevated, which is why they are hyperkalemic.
D is incorrect. Hyperinsulinism is likely to experience hypokalemia, not hyperkalemia. Insulin is a hormone secreted by the pancreas that facilitates the movement of insulin into cells. With it comes potassium, and therefore when there is too much insulin as there is in hyperinsulinism, too much potassium is moved into the cells and the serum potassium level drops causing hypokalemia.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological adaptation
Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
Subject: Fundamentals of care
Lesson: Fluids & Electrolytes
A client is admitted to the ward for exacerbation of his rheumatoid arthritis. The nurse would expect the physician to prescribe which medication to combat the client’s inflammation and produce immunosuppression?
A. allopurinol
B. azathioprine
C. prednisone
D. naproxen sodium
CORRECT ANSWER C
Explanation
A is incorrect. Allopurinol is an anti-gout medication. It lowers the patient’s uric acid levels by reducing the production of uric acid in the body.
B is incorrect. Azathioprine is used for clients with life-threatening rheumatoid arthritis for its immunosuppressive effects.
C is correct. Prednisone is a steroid with anti-inflammatory and immunosuppressive effects to treat rheumatoid arthritis.
D is incorrect. Naproxen sodium is a COX2 inhibitor that is an anti-inflammatory, reducing pain.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013
The nurse on duty at the ER just witnessed the father of a client grab another nurse by his throat, threatening to hurt him if he does not come to see his child. Upon separating the two, the nurse knows that they can file which complaints against the father?
A. Libel
B. Slander
C. Assault
D. Battery
CORRECT ANSWER D
Explanation
A is incorrect. Libel is a form of false communication that causes damage to someone’s reputation in writing.
B is incorrect. Slander is a form of false communication that causes damage to someone’s reputation verbally.
C is incorrect. Assault occurs when a person puts another person in fear of harmful or offensive contact. The victim fears and believes that harm will result because of the threat.
D is correct. The battery is an intentional touching of another’s body without the other’s consent. Grabbing the nurse by the throat is a form of battery and is punishable by law.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
A patient with kidney injury has a serum potassium level of 6.1 mEq/L. Which of the following actions is a priority action?
A. Encourage exercise
B. Check the patient’s sodium level
C. Place the patient on a cardiac monitor
D. Encourage increased fluid intake
CORRECT ANSWER C
Explanation
NCSBN client need | Topic: Physiological Integrity, Reduction of Risk Potential
Rationale:
The correct answer is C. A serum potassium level of 6.1 mEq/L is high. A normal serum potassium level is between 3.5 and 5.0 mEq/L. Hyperkalemia puts the patient at risk for developing cardiac changes and therefore this patient should be on a cardiac monitor.
Choice A is incorrect. Encouraging exercise will not lower the serum potassium level which is dangerously high at 6.0 mEq/L. The normal serum potassium level is 3.5-5.0 mEq/L.
Choice B is incorrect. Checking this patient’s sodium level delays the necessary treatment of the dangerously high serum potassium level of 6.0 mEq/L. The normal serum potassium level is 3.5-5.0 mEq/L.
Choice D is incorrect. Encouraging an increase in fluids delays the necessary treatment of the dangerously high serum potassium level of 6.0 mEq/L. The normal serum potassium level is 3.5-5.0 mEq/L.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
Medications bound to protein have the following effect:
A. Enhancement of drug availability.
B. Rapid distribution of the drug to receptor sites.
C. The more the drug is bound to protein, the less it is available for the desired effect.
D. Increased metabolism of the drug by the liver.
CORRECT ANSWER C
Explanation
Plasma protein binding refers to the degree to which medications attach to proteins within the blood. A drug’s efficiency may be affected by the degree to which it binds. The less bound a drug is, the more efficiently it can traverse cell membranes or diffuse. A drug in blood exists in two forms: bound and unbound. Depending on a specific drug’s affinity for plasma protein, a proportion of the drug may become attached to plasma proteins, with the remainder being unbound. Only the unbound fraction of the drug undergoes metabolism in the liver and other tissues. As the drug dissociates from the protein, more and more drug undergoes metabolism. Changes in the levels of the free drug change the volume of distribution because the free drug may distribute into the tissues leading to a decrease in plasma concentration profile. For the medicines which rapidly undergo metabolism, clearance is dependent on hepatic blood flow. For drugs that slowly undergo metabolism, changes in the unbound fraction of the drug directly change the approval of the drug.
The correct answer is C. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. A is incorrect. LESS of the drug is available if it is bound to protein. B is incorrect. Distribution to receptor sites is irrelevant since the drug bound to protein cannot unite with a receptor site. D is incorrect. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Pharmacological Therapies
Chapter 4: What Happens After a Drug Has Been Administered; Lesson: Drug Metabolism
Reference: Core Concepts in Pharmacology (Holland/Adams)
The Registered Nurse is preparing a patient for a pneumonectomy. What teaching should the nurse discuss with the patient?
A. Instruct patient to lie on non-operative side following procedure.
B. Expect remaining lung to return to normal function within 2-6 hours.
C. Advise patient to avoid coughing, assure that nurse will use wall suction to clear secretions.
D. Keep head of bed elevated at 30-45 degree angle post-procedure.
CORRECT ANSWER D
Explanation
Correct Answer is D. Keeping the head of the bed between 30-45 degrees will minimize respiratory efforts and facilitate recovery post pneumonectomy. This intervention will also prevent post-pneumonectomy pulmonary edema. The patient should lie on the operative side and should have the head of the bed raised to 45 degrees as soon as awake. These positions minimize the gravitational effect on capillary pressure in the remaining lung.
A is incorrect. Lying on the non-operative slides will increase the risk of pulmonary edema and therefore, should be avoided. The patient would be instructed to lie on the backor operative side only to prevent leaking of fluid into the operative side ( pulmonary edema) and to allow full expansion of the remaining lung.
B is incorrect. The remaining lung will require 2-4 days to adjust to increased blood flow.
C is incorrect. Deep breathing, coughing, and splinting are encouraged during the post-op period to promote the expansion of the lung. Wall suction is contraindicated after pneumonectomy.
NCBSN Client need:
Topic: Reduction of Risk Potential. Sub-Topic: Use precautions to prevent injury and/or complications associated with a procedure or diagnosis
Reference:
Jones & Fix, 2015, p. 127-128
The nurse in the Intensive Care Unit notes bleeding from the client’s transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for Sepsis. What should be the nurse’s immediate next action?
A. Assess the client’s hemoglobin and hematocrit level
B. Check the client’s oxygen saturation.
C. Apply pressure to the intravenous site.
D. Call the physician.
CORRECT ANSWER D
Explanation
Choice D is correct. The client is manifesting signs of Disseminated Intravascular Coagulation (DIC). This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as Sepsis. In this condition, the clotting system is activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may fuel the thrombotic process in DIC. Therefore, Platelets, cryoprecipitate, and Fresh Frozen Plasma are not routinely injected in DIC unless there is significant bleeding.
The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors.
Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (Anemia). The nurse should undoubtedly check the client’s Hemoglobin and Hematocrit levels; however, the nurse needs to notify the physician right away since the client is showing bleeding signs of DIC.
Choice B is incorrect. Assessing the client’s oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic patient and the nurse must notify the physician immediately since urgent intervention is needed
Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the bleeding from other websites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion.
NCSBN Client Need:
Topic: Pharmacological and parenteral therapies; Sub-Topic: Blood and Blood Products
What is the normal level for creatinine in a healthy adult male?
A. 0.4 to 0.8 mg/dL
B. 0.1-0.4 mg/dL
C. 0.6-1.2 mg/dL
D. 1.5-2.0 mg/dL
CORRECT ANSWER C
Explanation
Answer: C
Choice C is correct. The normal creatinine range is 0.6 to 1.2 mg/dL in a healthy adult male.
Creatinine values reflect both the amount of muscle a person has and their amount of kidney function. Hence, the levels are slightly lower in women due to lesser muscle mass. Most men with normal kidney function have 0.6 to 1.2 milligrams/deciliters (mg/dL) of creatinine. Most women with normal kidney function have between 0.5 to 1.1 mg/dL of creatinine.
A is incorrect. This is not the normal lab value range for creatinine in a healthy adult male.
B is incorrect. This is not the normal lab value range for creatinine in a healthy adult male.
D is incorrect. This is not the normal lab value range for creatinine in a healthy adult male.
NCSBN Client Need:Topic: Health Promotion
Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing.
While attending to a client with constipation, the clinic nurse reviews the home medication list. Which of the following drugs would the nurse be correct in identifying as potentially constipation inducing?
A. Baclofen
B. Omeprazole
C. Citalopram
D. Cephalexin
CORRECT ANSWER A
Explanation
NCSBN client need | Topic: Physiological adaptation, reduction of risk potential
Rationale:
The correct answer is A. Baclofen, a medication used to treat muscle spasms may cause constipation. It may also be responsible for urinary retention and dizziness.
Choice B is incorrect. Omeprazole is a Proton-Pump Inhibitor used to treat gastroesophageal reflux, stomach ulcers, and esophagitis.
Choice C is incorrect. Citalopram is a selective serotonin reuptake inhibitor and is used to treat depression.
Choice D is incorrect. Cephalexin is a common antibiotic most frequently used to treat urinary tract infections, upper respiratory tract infections, and skin conditions.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
The nurse in the ICU is taking care of a client recently diagnosed with Myocardial infarction resulting in massive necrosis in the left ventricular wall. A central catheter is inserted to measure CVP. What CVP reading should the nurse expect?
A. 2 cm of water
B. 7 cm of water
C. 16 cm of water
D. 9 cm of water
CORRECT ANSWER A
Explanation
A is correct. The client is expected to show signs of left ventricular failure due to the damage to his left ventricle. A reading of less than 3 cm of water is indicative of early left ventricular failure.
B is incorrect. A CVP reading of 7 cm of water is a regular CVP reading. The normal CVP reading is 2 – 12 cm of water.
C is incorrect. A CVP reading of 16 cm of water is indicative of right ventricular failure, not LVF.
D is incorrect. A CVP reading of 9 cm of water is a regular CVP reading. The normal CVP reading is 2 – 12 cm of water.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
The nurse is proving patient teaching in the clinic. The patient is being prescribed a bisphosphonate to treat osteoporosis. Which information should the nurse be sure to inform this patient?
A. Take this medication sitting upright first thing in the morning with a full glass of water.
B. Take this medication at night. just before bed.
C. This medication should be taken along with a full meal.
D. This medication is the best alternative if an esophageal disorder is present.
CORRECT ANSWER A
Explanation
NCSBN client need | Topic: Physiological Integrity, pharmacological and parenteral therapies
Rationale:
The correct answer is A. Bisphosphonates should be taken the first thing in the morning with a full glass of water. Patients should also wait 30 minutes to eat any food and should remain sitting or standing during that time. This prevents esophageal damage that may occur when this medication is taken improperly.
Choice B is incorrect. This medication should not be taken at night because the patient needs to remain sitting or standing for 30 minutes following medication administration.
Choice C is incorrect. This medication should not be taken with a full meal.
Choice D is incorrect. Bisphosphonates are contraindicated in patients with esophageal disorders.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
Which of the following images shows the most appropriate position for an infant who has just had a cleft palate surgery? A. TRENDELENBURG B. RIGHT LATERAL RECUMBENT C. SUPINE D. PRONE
CORRECT ANSWER D
Explanation
Choice D is correct. For a child who is status post cleft palate surgery, it is most appropriate to position them prone. Due to their unique anatomy, they are at an increased likelihood of their tongue falling back into their airway, causing obstruction and respiratory distress. The prone position prevents the tongue from falling backward. A prone position is recommended to facilitate the drainage of excessive secretions post-operatively.
Choice A is incorrect. This is Trendelenburg’s position. It is not recommended in children with a cleft palate due to their risk for airway obstruction caused by their tongue falling back into the airway.
Choice B is incorrect. This is a right lateral recumbent position. Lateral positioning can prevent the tongue from obstructing the airway, and it can be used in infants with cleft palate during feeding and sleep. However, this is not the best position post-surgically. Post-operatively, the goal is to facilitate the drainage of excessive secretions. The prone position is most helpful to serve that purpose.
Choice C is incorrect. This is a supine position. It is not recommended in children with an unrepaired cleft palate due to their risk for airway obstruction caused by their tongue falling back into the airway.
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. Wong’s Essentials of Pediatric Nursing, St. Louis, MO: Elsevier Limited.
You are working in a long-term psychiatric rehabilitation center and are assigned to a patient with debilitating agoraphobia. He is going through desensitization therapy. Which of the following interventions is an appropriate part of this treatment? Select all that apply.
A. Speak frequently of what causes the fear to start for him.
B. Take a short walk in the hallway outside of his room.
C. Make promises to support him and keep such promises.
D. Encourage him to face his fear outside where he is least comfortable.
CORRECT ANSWERS B, C
Explanation
Answers: B and C
B is correct. Because your patient has agoraphobia, he will be reluctant to leave any place he feels comfortable for somewhere. This is either unfamiliar or hard to escape from. This is why people with agoraphobia have such a hard time leaving the house. Your patient needs to be desensitized to this fear slowly, and a short walk in the hallway outside of his room (where he feels safe) is an appropriate choice.
C is correct. This is a fundamental part of building a trusting relationship with your patient, and building a trusting relationship with a patient going through desensitization therapy is essential. You need the patient to be able to trust you so that when you ask them to do little things that are outside of their comfort zone, they will be able to do them. This is the key to slow, gradual progress in desensitization. Making small promises and keeping these promises will help build such a trusting relationship that you can improve your patient.
A is incorrect. When treating patients who have a phobia, it is not advisable to talk about hatred frequently. Although you will need to address the phobia over time, focusing on this does not help the patient desensitize. Instead, it keeps them focused on hatred. For some patients, just speaking about their phobia can send them into a panic attack.
D is incorrect. The key to desensitization therapy with phobias is a gradual change over time, not a dramatic leap to facing the hatred directly. This advice would likely cause your patient to have a panic attack, which would set him back considerably. Instead of suggesting that he face his phobia and jump right to where he is least comfortable, start with little steps, and work towards those bigger goals gradually.
NCSBN Client Need:
Topic: Psychosocial Integrity
Reference: Halter, M. J. (2018). Manual of Psychiatric Nursing Care Planning: An Interprofessional Approach. Elsevier Health Sciences.
Subject: Adult Health
Lesson: Psychiatric Nursing
You have just received a doctor’s order for amoxicillin and lignocaine. You should:
A. Call the ordering doctor because these medications, in combination, cause severe adverse side effects.
B. Call the ordering doctor because these medications have an inhibiting effect on each other.
C. Refer to a reliable drug compatibility chart or resource to determine their compatibility with each other.
D. Ask a more experienced nurse whether or not these two drugs are compatibility with each other.
CORRECT ANSWER C
Explanation
Correct Answer is C
Correct. You should refer to a reliable drug compatibility chart or resource to determine their compatibility with each other. The compatibilities and incompatibilities of medications with each other and the harmonies and incompatibilities of medicines with different intravenous solutions are far too numerous to memorize and remember. Therefore, it is strongly advised that you check a reliable pharmacological chart or resource to determine compatibilities and incompatibilities. Lignocaine and amoxicillin are not compatible. Thus, they cannot be mixed.
Choice A is incorrect. You would not call the ordering doctor because these medications, in combination, cause severe adverse side effects because this is not true. However, there is something else that you would want to do.
Choice B is incorrect. You would not call the ordering doctor because these medications have an inhibiting effect on each other. After all, this is not accurate; however, there is something else that you would want to do.
Choice D is incorrect. You would not ask a more experienced nurse whether or not these two drugs are compatibility with each other because the compatibilities and incompatibilities of medications with each other and the harmonies and incompatibilities of medicines with different intravenous solutions are far too numerous to memorize and remember, therefore, it is strongly advised that you do something else to determine the compatibility of these two medications.
Reference: Kee, Joyce LeFever, Evelyn Hays, and Linda McCistion (2011) Pharmacology: A Nursing Process Approach 7th edition. Elsevier Saunders.
A 13-year-old girl diagnosed with ALL is worried about the side effects of her new steroid medications. Which of the patient’s following statements indicates to the nurse that the adolescent understands steroids’ side effects? Select all that apply.
A. “I will have more water in my body, so I might look puffier.”
B. “It might hurt to go to the bathroom.”
C. “I might soon get bruises more easily than before.”
D. “This medicine might make me moody.”
CORRECT ANSWERS A, D
Explanation
Choices A and D are correct.Steroids can cause fluid retention ( Choice A) and often result in “puffiness” from the excess fluid. This is often seen in the face and sometimes described as a “moon face.” The nurse should validate this concern of her adolescent patient and explain why she might experience this. It is essential to be honest with the teenage patient to help them cope with the side effects.
Mood swings ( Choice D) are a known side effect of corticosteroids. They can cause irritability, anxiety, and depression. It is essential to educate the adolescent client about this side effect and reinforce that she should ask for help if she feels overwhelmed. The parents should also be educated about this side effect, so they know to expect mood swings and are ready to help their adolescent.
Choice B is incorrect. Steroids do not cause constipation, dysuria, or any other pain related to going to the bathroom. The nurse should reinforce education with this adolescent and assure her that she should not experience this.
Choice C is incorrect. Steroids do not directly cause bruising. Long term steroids may thin the skin and predispose to easy bruising. However, newly started steroid therapy should not thin the skin immediately. More immediate side effects include fluid retention, steroid acne, hyperglycemia, and mood swings.
Steroids do not cause a decrease in platelets or clotting factors that would cause more frequent bruising immediately. However, due to her ALL diagnosis, she may have decreased platelets due to her cancer. This could cause her to bruise more often, so she may misunderstand the cause of this. The nurse should reinforce education with this adolescent about her disease process and what could occur and ensure that the steroid medication itself should not immediately increase bruising.
NCSBN Client Need:
Topic: Physiological Integrity; Subtopic: Pharmacological therapies
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Which of the following statements are true regarding the pathophysiology of beta-blockers? Select all that apply.
A. Decrease blood pressure
B. Decrease workload of the heart
C. Increase contractility
D. Increase cardiac output
CORRECT ANSWERS A, B
Explanation
Answer: A and B
Beta-blockers block the beta cells of the body. Beta cells are receptor sites for your catecholamines, such as epinephrine and norepinephrine. When we block the receptor sites for the catecholamines, they cannot do their job. Catecholamines function to increase everything - increase blood pressure, increase pulse, increase contractility, and cause vasoconstriction. This is because they are your fight or flight hormones! They get your body excited and ready to go! So, when beta-blockers block them, everything decreases. Your body vasodilates, the heart slows down, the blood pressure decreases….
A is correct. The vasodilation properties of a beta-blocker mean that they decrease blood pressure. This is because the beta-blockers are blocking the receptor sites for your catecholamine, so they cannot do their job and cause vasoconstriction.
B is correct. Beta-blockers decrease the workload of the heart. This is because of the vasodilation, subsequent decrease in blood pressure, and then fall in afterload. Remember, afterload is the pressure against which the left ventricle must pump. With decreased blood pressure, we reduce afterload. And, with reduced afterload, the left ventricle does not have to work as hard to pump blood to the body. So, beta-blockers decrease the workload of the heart.
C is incorrect. Beta-blockers decrease contractility, not increase. This is because they are blocking those beta cell receptor sites for catecholamines such as epinephrine and norepinephrine. The catecholamines work to increase contractility, but they are blocked by the beta-blockers. So, beta-blockers decrease contractility.
D is incorrect. Beta-blockers decrease cardiac output, not increase. This is because of the decreased contractility we just talked about. While the catecholamine receptor sites blocked, they are unable to cause increased contractility and the contractility of the heart decreased. With decreased contractility comes a lowered stroke volume. And, because CO = HR x SV, a reduced stroke volume means a reduced cardiac output.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Pharmacological therapies
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
Subject: Adult health
Lesson: Cardiac
