ASSESSMENT 2 Flashcards
What is shown in the picture below that is labeled 13? <>
A. The anterior horn
B. The dorsal root ganglion
C. The anterior root
D. The posterior root
Explanation
Correct Answer is B
Correct. The dorsal root ganglion is shown in the picture above that is labeled 13. The dorsal root ganglion contains the nerve fibers that sense painful and noxious stimuli that can be chemical, thermal, and chemical.
All the above anatomical structures play a role in pain and pain perception.
Choice A is incorrect. The anterior horn is not shown in the picture above, which is labeled 13. The anterior horn is shown in the image above that is labeled 1.
Choice C is incorrect. The anterior root is not shown in the picture above, which is labeled 13. The anterior origin is shown in the image above that is marked 11.
Choice D is incorrect. The posterior root is not shown in the picture above, which is labeled 13. The dorsal root is shown in the image above that is marked 12.
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.
George, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that George needs to continue taking the salicylates he had received at home?
A. Chorea.
B. Polyarthritis.
C. Subcutaneous nodules.
D. Erythema marginatum.
Explanation
Rheumatic fever is an inflammatory disease that can develop when strep throat or scarlet fever, which are caused by streptococcus bacteria, isn’t adequately treated. It most often affects children who are between 5 and 15 years old, though it can develop in younger children and adults. Although strep throat is frequent, rheumatic fever is rare in the United States and other developed countries. However, rheumatic fever remains common in many developing nations. Rheumatic fever can cause permanent damage to the heart, including damaged heart valves and heart failure. Treatments can reduce cost from inflammation, lessen pain, and other symptoms, and prevent the recurrence of rheumatic fever.
The correct answer is B. Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates.
A is incorrect. Chorea is the restless, sudden aimless and irregular movements of the extremities suddenly seen in persons with rheumatic fever, especially girls.
C is incorrect. Subcutaneous nodules are non-tender swellings over bony prominences sometimes seen in persons with rheumatic fever.
D is incorrect. Erythema marginatum is a skin condition characterized by nonpruritic rash, affecting the trunk and proximal extremities, seen in persons with rheumatic fever.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 22: Drugs for Bacterial Infections
Lesson: Complications of Streptococcus
Core Concepts in Pharmacology (Holland/Adams)
While reviewing congenital heart defects with a senior nurse in the PICU, she asks you which errors have increased pulmonary blood flow. You respond by listing which of the following mistakes? Select all that apply.
A. Atrial septal defect (ASD)
B. Atrioventricular canal defect
C. Ventricular septal defect (VSD)
D. Aortic stenosis
Explanation
Answer: A, B, and C.
A is correct. An ASD is an abnormal opening between the atria. It causes an increased flow of oxygenated blood into the right side of the heart, which therefore increased pulmonary blood flow.
B is correct. An atrioventricular canal defect (AV canal) is the incomplete fusion of the endocardial cushions leading to an open ‘canal’ between both atriums and ventricles. Oxygenated and deoxygenated blood mix in the open canal and cause increased pulmonary blood flow.
C is correct. A VSD is an opening between the two ventricles. Blood shunts from the left ventricle where there is higher pressure to the right ventricle where there is lower pressure, causing the increased pulmonary blood flow.
D is incorrect. Aortic stenosis is the narrowing of the aortic valve. This causes resistance to systemic blood flow and is characterized as an obstructive congenital heart defect. It does not create increased pulmonary blood flow.
NCSBN Client Need
Topic: Physiological Adaptation Subtopic: Alterations in Body Systems
Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 491
Which of the following clients is at the highest risk for complications related to folate deficiency?
A. An 80-year-old man living in a nursing home
B. A 4-year-old boy who is developmentally delayed
C. A 16-year-old girl who just started her menstrual cycle
D. A 25-year-old woman who is attempting to get pregnant
Explanation
Folic acid (vitamin B9) works with vitamin B12 and vitamin C to help the body break down, use, and make new proteins. The vitamin helps form red and white blood cells. It also helps produce DNA, the building block of the human body, which carries genetic information.
Folic acid is a water-soluble type of vitamin B. This means it is not stored in the fat tissues of the body. The remaining amounts of the vitamin leave the body through the urine.
Because folate is not stored in the body in large amounts, your blood levels will get low after only a few weeks of eating a diet low in folate. Folate is found in green leafy vegetables and liver.
Contributors to folate deficiency include:
Diseases in which folic acid is not well absorbed in the digestive system (such as Celiac disease or Crohn disease) Drinking too much alcohol I am eating overcooked fruits and vegetables. Folate can be easily destroyed by heat. Hemolytic anemia Certain medicines (such as phenytoin, sulfasalazine, or trimethoprim-sulfamethoxazole) Eating an unhealthy diet that does not include enough fruits and vegetables Kidney dialysis
Groups of people considered at-risk for folate deficiency include women who are pregnant, women who wish to become pregnant, alcoholics, liver disease and dialysis patients, and breast-feeding mothers.
Answer and Rationale:
The correct answer is D. Evidence shows that adequate intake of folate before conception and in the first trimester of pregnancy reduces the incidence of neural tube defects. The U.S. Public Health Service recommends that all women of childbearing age and capable of pregnancy consume 400 ugs of synthetic folic acid daily from either foods or supplements. A, B, and C are incorrect. At the same time, all individuals can have deficiencies in folate, the client at the highest risk of complications among those listed is the 25-year-old woman who is attempting to conceive.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 7: Nutritional Assessment
Lesson: Vitamin Deficiencies
A client is experiencing spiritual distress after receiving a diagnosis of advanced brain cancer. Which of the following would be appropriate interventions? (Select all that apply).
A. Ask the patient how she is feeling.
B. Provide food compatible with the person’s religious needs.
C. Help the patient identify feelings of guilt.
D. Offer to massage the client’s shoulders.
E. Offer encouragement based on assumptions about the patient’s beliefs.
F. Assess the patient’s needs for reconciliation
Explanation
Answer & Rationale:
The correct answers are A, B, C, D, and F.
o A- It is essential to offer the client an opportunity to express his/her feelings. The best way to do this is to simply ask how she is feeling or what she thinks about a particular situation.
o B- Providing foods that are compatible with the client’s religious belief adds to the feeling of “self.” In some cases, it may be acceptable to encourage family members to bring food from home.
o C- Help the patient identify feelings of guilt. You might ask the following after a patient has voiced a concern: “How do you feel about that?” or “You seem to feel sad about saying/doing that.”
o D- Maximize the patient’s comfort. This is one of the most important spiritual activities a nurse can perform. A patient cannot think about religious issues when plagued with physical pain or discomfort.
o F- Assess the patient’s needs for reconciliation. This may include reconciliation with self, others, and God.
E is not correct. The nurse should not make assumptions about the patient's and family's beliefs.
Resource:
NCSBN Client Need:
Topic: Psychosocial Integrity
Chapter 17: Loss, Grief & Dying
Lesson: Death & Dying
Reference: Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith)
A 14-year-old was taken to the Emergency department for having stepped on a broken piece of glass. The wound is cleansed and a dressing was applied. The nurse asks the adolescent to have a tetanus shot. He responds by saying that all his immunizations are up to date. All the other antibiotics were given and the client is sent home with instructions to return whenever changes in the wound occur. After a few days, the client was admitted to the hospital due to Tetanus. What is the nurse’s legal responsibility in this situation?
A. The nurse displayed adequate judgment and the client was treated accordingly.
B. The nurse performed an incomplete assessment.
C. Tetanus was not foreseen because of the clients’ complete immunization status
D. The nurse should have routinely given the Tetanus shot after such injury.
Explanation
A is incorrect. The nurse’s assessment was inadequate, thus leading to inadequate judgment regarding the situation. The nurse should have asked regarding the date the last tetanus immunization was given.
B is correct. The nurse’s assessment was inadequate and incomplete, thus leading to inadequate judgment regarding the situation. The nurse should have asked regarding the date the last tetanus immunization was given.
C is incorrect. The clients’ wound would have alerted the nurse to ask more regarding tetanus immunizations since a puncture wound is a “tetanus-prone” wound.
D is incorrect. The function of a nurse does not include giving orders of tetanus immunization. The nurse should have assessed further regarding the immunization date of the client so that the doctor was made aware and could have ordered a new tetanus shot.
Reference
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
A 76-year-old woman with dementia lives in an assisted living facility and often asks. “When will my sister come to visit me this afternoon?” The sister passed away last year. Which is the best response from the nurse?
A. This is so sad. I’m sorry to tell you but your sister died last year.”
B. “She won’t be coming to visit today.”
C. “I understand you want her to visit you. Where did you and your sister grow up?”
D. “Wait and see if she comes to visit today.”
Explanation
Important Fact:
When communicating with a patient with altered mental status, such as those with dementia, it is essential to foster therapeutic communication. Any statement that may trigger agitation or begin the grieving process should be avoided.
Answer & Rationale:
C is the correct answer. Stating “I understand,” shows compassion toward the patient. Asking where the client and her sister grew up allows her to think about her sister and reminisce without triggering anxiety or agitation. A and B are incorrect- It may trigger agitation or start the grieving process over again, which can be distressing to the patient. D is incorrect. Saying the sister will not visit or that the patient should “wait and see” gives false hope and is deceptive.
Resource:
NCSBN Client Need
Topic: Psychosocial Integrity
Chapter 26: Communicating
Lesson: Therapeutic Communication
Reference: Kozier and Erb’s Fundamentals of Nursing
A 28-week client is admitted to the gynecology ward for induction of labor due to fetal demise. Does the nurse understand that which substance will be used for the effacement of the client’s cervix?
A. Normal saline solution
B. Oxytocin IV
C. Amniotomy
D. Laminaria
Explanation
A is incorrect. Normal saline is no longer effective in effacing the cervix in mid-trimester abortions.
B is incorrect. Oxytocin induces uterine contractions, not efface and soften the cervix.
C is incorrect. An amniotomy is performed during labor to aid in the descent of the fetal head once work is established. However, in fetal demise, it does help not help in effacing the cervix.
D is correct. Laminaria is dehydrated seaweed. They are inserted into the cervical canal, and once it absorbs the cervical secretions, it expands and aids in the effacement and dilatation of the cervix.
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
A 3-year-old child presents to the ED with a sore throat, large red, edematous epiglottis, drooling, and moderate subcostal retractions. On exam, heart rate 188/min, respiratory rate 72/min, Blood pressure 88/56 mm Hg, Temp 39C. The nurse suspects epiglottitis. She should avoid which of the following actions to maintain the child’s airway? Select all that apply.
A. Taking an oral temperature
B. Obtaining a blood culture
C. Visualizing the posterior pharynx
D. Obtaining a throat culture.
Explanation
Answer: A, C, and D
A is correct. Taking an oral temperature could agitate the child and cause spasm of the epiglottis. This leads to complete airway obstruction.
B is incorrect. It is okay to obtain a blood culture as this should not lead to spasming of the epiglottis.
C is correct. Asking the child to open their mouth and say ‘ah’ so that you may visualize the posterior pharynx can be enough stimulation to cause complete airway obstruction. This should not be performed.
D is correct. Attempting to swab the child’s throat to obtain a throat culture would be very dangerous and could lead to complete airway obstruction. This should be avoided.
NCSBN Client Need:
Topic: Physiological Adaptation; Subtopic: Alterations in Body Systems
Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 475
The nurse is working in a women’s health clinic. Which patient should the nurse see first?
A. A 17 year-old complaining of severe cramping in her lower abdomen.
B. A 25 year-old primigravida with blurred vision.
C. A 50 year-old menopausal client expelling dark red blood clots.
D. A 70 year-old client who states her uterus is going to “fall out.”
Explanation
A is incorrect. The 17-year-old with severe lower abdominal cramping needs to be assessed if she is currently menstruating. It does not, however, hold priority over a client with signs of preeclampsia.
B is correct. Signs and symptoms of preeclampsia include blurred vision, hypertension, generalized edema, and proteinuria. The client is also a primigravida, which predisposes her for preeclampsia. The nurse should prioritize the client to include further assessment and intervention.
C is incorrect. Clients who undergo menopause experience expulsion of dark red blood clots. This should not cause concern to the nurse.
D is incorrect. This may indicate a possible uterine prolapse, but this is not a life-threatening situation. The client may need a hysterectomy to remove the uterus or use a pessary device.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
The RN performs palpation and percussion in a head-to-toe assessment. Over what organ would he/she expect to hear tympany when percussed?
A. Stomach
B. Liver
C. Normal lung tissue
D. Tympany is abnormal finding
Explanation
A is correct. Tympany refers to a high, loud, drum-like tone that can be heard with percussion over air containing organs. The stomach and intestines would produce tympany in a healthy adult.
B is incorrect. Dense organs such as the liver and the spleen produce “dull” tones upon percussion. Dull tones are soft, short, and high and sound like a muffled thud.
C is incorrect. Percussion of healthy lung tissue produces a “resonant” sound that is medium to loud, low, clear, and hollow sounding.
D is incorrect. Tympany is a normal finding over organs with air inside.
Subject: Fundamentals
Lesson: Skills/procedures
Topic: Pathophysiology
Reference: (Jarvis, C, 2012, p. 117)
What is the best time to assess the respiratory rate of a young child?
A. While the child is quietly sitting on the parent’s lap
B. While the child is crying
C. While the child is playing in the playroom
D. Immediately after assessing the child’s blood pressure
Explanation
Answer and Rationale:
The correct answer is A. Respirations are best determined while the child is sleeping or quietly awake. B, C, and D are incorrect. When a child is playing or upset, respirations may increase because of the crying or activity. This could result in the appearance of a false abnormal finding.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 27: Children and Adolescents
Lesson: Comprehensive Physical Assessment
Which of the following images shows a cleft palate?
Explanation
Answer: B
A is incorrect. This image shows a cleft lip. A cleft lip is an opening or split in the upper lip that occurs when developing facial structures in an unborn baby don’t close completely.
B is correct. This image shows a cleft palate. A cleft palate is an opening or split in the roof of the mouth that occurs when the tissue doesn’t fuse together during development in the womb. Cleft palates can be associated with a cleft lip too, but do not have to be.
C is incorrect. This image shows choanal atresia. Choanal atresia is a congenital disorder where the openings that connect the nasal cavity with the nasopharynx are occluded by soft tissue or bone.
D is incorrect. This image shows micrognathia. Micrognathia is a condition in which the lower jaw is undersized. It is a symptom of a variety of craniofacial conditions.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
According to the American Nurse Association Code of Ethics. “liability with the performance of duties in a specific role” is:
A. Accountability
B. Authority
C. Responsibility
D. Delegation
Explanation
Correct Answer: C.
Responsibility. Accountability, authority, and trust are all aspects of the delegation process. Responsibility involves liability with the performance of duties in a specific role. Essentially, this means that when an LPN/LVN accepts an assignment, they also take responsibility for performing the task correctly. Accountability refers to the review of actions to determine if they were performed successfully. This means that the RN verifies that the LPN/LVN accepts responsibility for the task that is delegated to them. Authority in the delegation process means that the RN can legally transfer responsibility to another competent individual on the team. The RN also has the authority to complete assessments, plan and evaluate nursing care, and exercise nursing judgment in the course of care.
NCSBN Client Need
Topic: Management of Care
Sub-topic: Assignment and Delegation
Subject: Leadership and Management
Lesson: Assignment/Delegation
Reference: National Council of State Boards of Nursing. National Guidelines for Nursing Delegation. Journal of Nursing Regulation. Accessed online on February 11, 2020, at https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf.
The client in the delivery room has just delivered her third child. The physician ordered methylergonovine (Methergine) to the client and was promptly administered. Which manifestation would indicate to the nurse that the medication is having its intended effect?
A. The client reports a decrease in pain.
B. The nurse palpates a firm uterus on the client.
C. The client states that she wants to empty her bladder.
D. The client’s blood pressure increases.
Explanation
A is incorrect. Methylergonovine does not control pain. It is an ergot alkaloid that promotes vasoconstriction and uterine muscle constriction.
B is correct. Methylergonovine promotes vasoconstriction and uterine contraction. A firm and contracted uterus is a sign that the medication is having its desired effect.
C is incorrect. Methylergonovine does not promote urine production nor stimulate urination.
D is incorrect. An increase in blood pressure is a side effect of methylergonovine. Its primary indication and effect is uterine contraction and vasoconstriction, which leads to a rise in blood pressure.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
After experiencing a traumatic amputation and related body image disturbance. The nurse documents the nursing diagnosis of body image disturbance related to changes in appearance secondary to:
A. Severe trauma
B. Loss of a body part
C. Chronic disease
D. Loss of body function
Explanation
Answer and Rationale:
The nursing diagnosis is Body Image Disturbance. When referencing a nursing diagnosis that is secondary to a condition/experience, it is essential to be specific.
The correct answer is B. Although the amputation was related to severe trauma, being specific about what type of injury, the loss of a body part, gives precise information to other health care team members who may assume care of this client. A is incorrect. The loss of limb was caused by severe trauma but is not the most appropriate answer to this question. C is incorrect. The amputation is a chronic condition but is not a disease. D is incorrect. While the loss of body function will become evident, it is about the loss of the limb, which is the most appropriate answer.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Chapter 13: Psychosocial Health and Illness
Lesson: Body Image
Reference: Fundamentals of Nursing (Wilkinson and Barnett)
Which of the following is an improper technique for correcting written documentation? Select All That Apply.
A. Draw a line through the error, write the date, time, and reason for the error, and add your initials
B. Use correction tape and write over the error so there is no confusion
C. Write over the error in darker ink
D. Completely black out the error with a black marker
Explanation
Choices B, C, and D are correct. All of these practices are inappropriate methods of correcting written documentation. Using a tape, writing over the sentence using a black ink, and blacking out using black marker are attempts to conceal the original documentation and may be considered illegal in a court. In a court of law, the court needs to see the underlying data that were corrected. No effort should be made to obliterate the error.
Choice A is incorrect. It is not illegal for medical professionals to make the necessary updates to records, as long as they follow proper methods and do not obscure information. Choice A, in fact, is the correct technique for correcting the written documentation.
NCSBN Client Need I Topic: Health Promotion and Maintenance
Reference: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer); Chapter 4: Documentation and Interprofessional Communication; Lesson: Accuracy and Completeness
The nurse is educating a woman with an above-average BMI on her risk factors. Which of the following issues does not correlate with an above-normal BMI pre-pregnancy?
A. Gestational diabetes
B. Preeclampsia
C. Swelling
D. Frequent UTI
Explanation
NCSBN client need | Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care
Rationale:
The correct answer is D. Frequent urinary tract infections are not associated with maternal above average body mass index.
Choices A, B, and C are incorrect. The development of gestational diabetes, preeclampsia, and swelling are positively correlated with maternal above-average BMI. Other issues include increased C-section rates, stillbirth, and poor wound healing.
Reference:
Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014
When providing bowel training education to a 65-year-old woman with chronic constipation. Which of the following indicates that the nurse needs to continue gathering information?
A. The client’s fluid intake is between 2500-3000 ml per day
B. The client’s dietary habits include foods high in bulk.
C. The client engages in moderate exercise each day
D. The client’s states she can use a laxative 4-5 times weekly until bowel regularity is achieved.
Explanation
The reasons for constipation can range from lifestyle habits (e.g., lack of exercise) to severe malignant disorders (e.g., colorectal cancer). The nurse should evaluate any complaints of constipation carefully for each individual. A change in bowel habits over several weeks with or without weight loss, pain, or fever should be referred to a primary care provider for a complete medical evaluation. See Clinical Manifestations for risk factors and symptoms of colorectal cancer.
The correct answer is D. The consistent use of laxatives inhibits natural defecation reflexes and is thought to cause rather than cure constipation. The frequent user of laxatives eventually requires larger or stronger doses because the effect is progressively reduced with continual use. Laxatives may also interfere with the body’s electrolyte balance and decrease the absorption of specific vitamins.
A B and C are all measures that help promote healthy bowel habits and indicate the client understands steps to help reduce constipation. Adequate fluid intake helps prevent dry, hard stools. High bulk in the diet helps promote the absorption of water, which
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Basic Care and Comfort
Fundamentals of Nursing
Chapter 49: Fecal Elimination
Lesson: Fecal Elimination Problems
Which of the following scores for distance visions indicates the patient with the poorest vision?
A. 20/100
B. 200/20
C. 18/20
D. 24/20
Answer and Rationale:
The average refractive index is 20/20. Visual acuity for distance vision is documented in reference to what a person with normal vision can see standing 6 m (20 feet) in front of the test (which is the numerator of the acuity fraction). The numerator is compared to what a person with normal visual acuity could read on that particular line (which is the denominator in the acuity fraction). Someone with a 20.20 vision can read at 20 ft. What a person with normal vision can read at 20 ft.
The correct answer is A. B, C, and D are incorrect.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 13: Eye Assessment for Advanced and Specialty Practice
Lesson: Visual Acuity
The nurse is caring for a hospitalized infant due to dehydration and failure to thrive. The nurse notes that her mother is a drug user. With this knowledge, the nurse would expect to the child to develop:
A. Autonomy
B. Trust
C. Mistrust
D. Shame and doubt
Explanation
A is incorrect. Autonomy develops when toddlers are left to assert their independence.
B is incorrect. Infants develop a sense of trust when their needs are met consistently.
C is correct. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment.
D is incorrect. Preschoolers develop a sense of guilt when their sense of initiative is thwarted.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
A nurse is assigned to care for 4 clients who are 1-day postpartum. The nurse performs an initial assessment. Which assessment finding would prompt the nurse to evaluate further?
A. A client complaining of mild after pains
B. A client with a pulse rate of 65 bpm
C. A client with colostrum discharge from both breasts
D. A client with red, foul-smelling lochia
Explanation
Rationale: For day one postpartum clients, it is reasonable to have mild after pains; therefore, further assessment is not required. A pulse rate of 65 bpm is also standard, as well as colostrum discharges for clients who are day one postpartum. Options A, B, and C are, therefore, incorrect. Lochial discharges are expected to be red, similar to menstrual discharges, and should have a fleshy odor. A foul-smelling lochia may indicate the presence of pus and could be a sign of infection. This should alert the nurse to conduct further evaluation. Option D is, therefore, the correct answer.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014
The nurse is performing medication reconciliation to a patient in the Respiratory clinic recently prescribed with terbutaline. Which medication shall the nurse be concerned about?
A. Atenolol
B. Furosemide
C. Cefuroxime
D. Omeprazole
Explanation
A is correct. Atenolol is a beta-blocker that can interfere with the action of Terbutaline due to its antagonistic effect on the beta receptor cells in the bronchi. The nurse should talk to the prescribing physician regarding shifting the Atenolol to another drug class.
B is incorrect. Furosemide is a loop diuretic. They block the reabsorption of water and sodium in the loop of Henle, leading to diuresis. They do not cause any drug-drug reaction with Terbutaline.
C is incorrect. Cefuroxime is a second-generation cephalosporin that does not produce any reaction with Terbutaline.
D is incorrect. Omeprazole is a proton pump inhibitor. It does not produce any undesirable drug interactions with Terbutaline.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006
The volunteer in the medical ward recognizes one of the clients as her neighbor and asks about the client’s condition. What should the nurse tell the volunteer?
A. Ask the volunteer about how she knows the patient.
B. Inform the volunteer of the client’s condition in simple terms.
C. Ask permission from the client to talk to the volunteer.
D. Educate the volunteer that client information is on a need-to-know basis.
Explanation
A is incorrect. The volunteer being neighbors with the client does not warrant her the right to discuss the client’s condition with the nurse.
B is incorrect. The nurse cannot release any information to anyone without the permission of the client. This is a violation of the Health Insurance Portability and Accountability Act (HIPAA).
C is incorrect. The nurse should not discuss the situation with the client. The would let the client know that there are possible breaches in confidentiality.
D is correct. The volunteer should be reminded of the HIPAA and confidentiality rules that govern any information concerning clients in a healthcare setting.
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.
You are a registered nurse who is performing the role of a case manager in your hospital. You have been asked to present a class to newly employed nurses about your role. your responsibilities and how they can collaborate with you as the case manager. Which of the following is a primary case management responsibility associated with reimbursement that you should you include in this class?
A. The case manager’s role in terms of organization wide performance improvement activities.
B. The case manager’s role in terms of complete. timely and accurate documentation.
C. The case manager’s role in terms of the clients’ being at the appropriate level of care.
D. The case manager’s role in terms of contesting denied reimbursements
Explanation
Important Fact:
RN case managers have a primary case management responsibility associated with reimbursement because they are responsible for ensuring the patient is cared for at the appropriate level, consistent with medical necessity and current patient needs.
Answer & Rationale:
The correct answer is C. A failure to ensure the appropriate level of care jeopardizes reimbursement. For example, care in an acute care facility will not be reimbursed when the client’s current needs can be met in a subacute or long-term care setting. A, B, and D are incorrect. Nurse case managers do not have organization-wide performance improvement activities, the supervision of complete, timely, and accurate documentation or challenging denied reimbursements in their role. These roles and responsibilities are typically assumed by quality assurance/performance improvement, supervisory staff, and medical billers, respectively.
Resource
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Management of Care
Chapter 6: Healthcare Delivery Systems
Lesson: Providers of Healthcare
Reference: Kozier and Erb’s Fundamentals of Nursing
Which term is synonymous with analgesic?
A. Equianalgesic
B. Placebo
C. NSAID
D. Adjuvant
Explanation
Correct Answer is D
Correct. The term that is synonymous with analgesics is adjuvant. Coanalgesic drugs, or adjuvant drugs, are analgesic medications that can be used alone or in combination with other analgesics to relieve pain.
Choice A is incorrect. Equianalgesic is not synonymous with analgesic; equianalgesic is the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine.
Choice B is incorrect. Placebo is not synonymous with analgesic; a placebo is an
oral sugar pill or normal saline that may have an effect that is not related to the properties and composition of the placebo.
Choice C is incorrect. NSAIDs are not synonymous with analgesic; NSAIDs are nonsteroidal anti-inflammatory drugs.
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.
Which procedures necessitate the use of surgical asepsis techniques? Select all that apply.
A. Intramuscular medication administration
B. Central line intravenous medication administration
C. Donning gloves in the operating room
D. Neonatal bathing
E. Foley catheter insertion
F. Emptying a urinary drainage bag
Explanation
Surgical Asepsis, or sterile technique, refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores. Surgical Asepsis is used for all procedures involving the sterile areas of the body.
The correct answers are B, C, E. Surgical asepsis is used when managing central line intravenous medication administration, when donning sterile gloves in the operating room and when inserting an indwelling Foley catheter.
A, D, and F are incorrect. Medical Asepsis is used when administering an intramuscular injection, bathing a neonate, and when emptying a urinary drainage bag.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Chapter 31: Asepsis
Lesson: Surgical Asepsis
Fundamentals of Nursing (Kozier and Erb’s)
The nurse is preparing to sign a patient’s surgical consent form after the physician has explained the procedure to the patient and family. As the patient signs the form, she comments “I really didn’t understand most of what the doctor said, but I have to have this procedure, so I want to sign.” Which is the appropriate nursing action?
A. Witness the document, as the patient states she wants to sign it.
B. Notify the physician or nursing supervisor.
C. Call the OR to cancel the procedure and reschedule at a later date.
D. Explain the information she did not understand.
Explanation
Correct Answer B. The person ( here, the doctor) responsible for performing the procedure has the responsibility to obtain the patient’s consent, providing a clear explanation about the procedure and all associated risks. When witnessing the patient’s signature, the nurse confirms that the patient understands the information about the procedure. If the patient denies understanding, the nurse must contact the physician or the nursing supervisor.
Choice A is incorrect. The nurse has to witness the patient’s signature but even prior to that, she must confirm that the patient understood the information about the procedure.
Choice C is incorrect. The nurse must call the physician or nursing supervisor and inform that the patient did not understand the procedure information. Canceling the procedure is not necessary as something else needs to be done right now.
Choice D is incorrect. It is the responsibility of the person performing the procedure ( here, the doctor) to obtain the patient’s consent, providing a clear explanation about the procedure and all associated risks. The nurse only needs to confirm if the patient understood it.
NCBSN Client Need:
Category: Management of care; Sub-topic: Informed Consent.
Reference:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8th Edition. Elsevier Mosby St Louis 2013.
The clinical nurse educator (CNE) is supervising a newly registered nurse administer packed red blood cells to a client with anemia. Which action by the new RN shall the CNE correct?
A. The RN checks the physician’s orders for blood transfusion and makes sure that it is complete.
B. The RN verifies the client’s name and number and checks blood compatibility and expiration with another RN.
C. Remains with the client during the first 15-20 minutes of the transfusion.
D. The RN prepares 0.9% NaCl with 5% dextrose as flushing for the packed RBCs after they have finished transfusing.
Explanation
A is incorrect. This is the correct action of the nurse. The nurse should ensure that the physician’s order is complete before starting the transfusion.
B is incorrect. This is the correct action of the nurse. The nurse should double-check the order, client number, and identification, blood compatibility, and expiry date with another nurse as the most common cause of ABO incompatibility reactions is human error.
C is incorrect. This is the correct action of the nurse. The nurse should stay with the client during the first 15 – 30 minutes of the transfusion as hemolytic reactions most commonly occur within the first 50 ml of the infusion.
D is correct. This is an incorrect action of the nurse. Only standard saline solution is used in flushing blood products as other IV fluids cause hemolysis.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006
