CAT Flashcards
You are educating a new nurse regarding Sentinel Events. Which of the following are examples of Sentinel events? Select all that apply.
A. An untimely assessment of the client.
B. An incomplete assessment of the client.
C. A client falls from the chair to the floor and sustains a humerus fracture.
D. An incorrect client is almost sent to the operating room.
E. A client undergoes colectomy instead of appendectomy.
Explanation
Choice C and E are correct. A sentinel event is defined as an event that has reached the patient and caused harm ( death, permanent harm, or severe temporary harm). A sentinel event is unrelated to patient’s illness or underlying condition. Such events are called “sentinel” because they signal a need for immediate investigation and response. All sentinel events must be reviewed by the hospital and are subject to review by The Joint Commission. A sentinel event may occur due to medical errors like wrong-site, wrong-procedure, wrong patient surgery. Please note that the terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.
Choice C (“client falls from the chair to the floor and sustained humerus fracture”) is an actual event that has occurred and caused harm. This event ( fall causing injury) is not a medical error, but constitutes a sentinel event. Choice E ( a client undergoing colectomy instead of appendectomy) is a sentinel event due to a medical error. Other examples of sentinel events include : patient committing suicide while receiving care in the hospital or within 72 hours of discharge, hemolytic transfusion reaction, unanticipated death of a full term infant, rape, assault, sexual abuse, invasive procedure on the wrong site/wrong person/ wrong procedure, discharge of infant to wrong family, any intrapartum maternal death, and so on.
Patient safety events occur commonly in health systems worldwide. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. Safety events can be categorized into sentinel events, adverse events, near misses, and no harm events. Sentinel events are just one category of patient safety events. Others include:
An adverse event: a patient safety event that resulted in harm to a patient. ( eg; an adverse event could include side effects to medications/ vaccines, medical procedures. They may or may not be from negligence. For example, a patient sustaining embolic stroke after a coronary angiography is an adverse event, but not due to medical negligence.) A no-harm event is a patient safety event that reaches the patient but does not cause harm. A close call (or a "near miss" or a "good catch") is a patient safety event that did not reach the patient. A hazardous (or unsafe) condition(s) is a circumstance (other than a patient's own disease process or condition) that increases the probability of an adverse event.
Choice D is incorrect. The event ( when an incorrect client is almost sent to the operating room) did not occur here and did not cause patient harm. This event is referred to as “near-miss”, not a sentinel event. WHO defines “near-miss” as the one with the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is prevented According to the Institute of Medicine, a near miss is an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation.” An error caught before reaching the patient is another definition. It is also referred to as “close call or “potential adverse event.” Near misses also must be reported so root cause analysis can be completed. The root causes of near misses and adverse/sentinel events are similar. Detecting root causes of near misses, therefore, can help us to correct these causes and prevent future adverse events.
Choices A and B are incorrect. Although an untimely assessment of the client and an incomplete assessment of the client can be contributory factors that led to a sentinel event, these are considered deviations from a standard of care and not sentinel events.
References: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice
The nurse is researching evidence-based practice and needs related literature. The nurse understands that the best source of reliable writing is:
A. Systematic review and meta-analysis studies
B. Expert opinions
C. Qualitative studies
D. Case studies
Explanation
A is correct. A systematic review and meta-analysis studies provide current, recently summarized evidence, making them the most reliable form of evidence for studies.
B is incorrect. Expert opinions may involve bias on the subject, making them unreliable sources of data.
C is incorrect. Qualitative studies involve interpretation of the database on the author’s understanding of the subject, making these types of literature unreliable sources of data.
D is incorrect. Case studies may also involve bias from the author/s, making them unreliable sources of data as well.
Reference
Potter, PA, Perry. AG, Stockert, PA, Hall, AM. Fundamentals of Nursing, 8th ed. St. Louis, MO: Elsevier Mosby;2013
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
In addition to the name of the client, the date and time of the medication order, the name, dosage, route, and frequency of the medication, and the signature of the ordering person, what other information in a medication order would be the most useful, although not required, to you, as the nurse administering the medication?
A. The client’s ethnicity
B. The form of the medication
C. The client’s allergies
D. The time(s) of administration
Explanation
Correct Answer is B
Correct. Other information in a medication order that would be the most useful to you, as the nurse administering the medication, would be the form of the drug. The type of medicine becomes particularly relevant, for example, when oral medication is ordered for a client with a swallowing disorder. Should the medication be given in a pill form or a liquid form?
Choice A is incorrect. The client’s ethnicity is not as relevant and as useful as another piece of information, and the client’s ethnicity should be found in the client’s history and physical.
Choice C is incorrect. The client’s allergies should be found on the client’s medication record and in other places, including on the client’s identification band and their history and physical, so this would not be as important and as useful as another piece of information.
Choice D is incorrect. The time(s) of administration is in the medication order when the frequency of administration is written.
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 caring for a client with the tracing on the electrocardiogram shown in the Exhibit. The nurse should perform which priority action?
A. Discontinue the prescribed diltiazem infusion.
B. Notify the primary healthcare physician (PHCP).
C. Assess the client’s oxygen saturation and respiratory rate (RR).
D. Prepare a prescription of intravenous (IV) atropine.
Explanation
The tracing shows sinus bradycardia (SB).
The priority action would be to discontinue the diltiazem as it is a calcium channel blocker that lowers heart rate.
The physician should be notified, and oxygen saturation should be assessed. However, the priority action is to discontinue the offending agent.
NCSBN Client Need
Topic: Physiological adaptation; Sub-Topic: Medical Emergencies
As you are taking the “staff only” elevator, you see a nurse who is now taking care of a client, Mr. B, who you cared for the week before. You ask the nurse how Mr. B is doing and the nurse tells you how significantly his condition has deteriorated over the last week. You have:
A. Violated the confidentiality of client information.
B. Asked an inappropriate question in the elevator.
C. Shown compassion for Mr. B.
D. Shown your caring about Mr. B.
Explanation
Correct Answer is B. You have asked an inappropriate question in the elevator. You have primarily set the other nurse up for a violation of the need for confidential client information because client information can only be shared, orally, and in writing, with others who are providing direct or indirect care to the client, and they have a need to know this information. As based on the information in this question, you are no longer taking care of Mr. B. Therefore; you should never have asked these questions.
The nurse who gave you the information violated Mr. B’s right to confidentiality. Although you asked this question because you are a compassionate and caring nurse, it was not an appropriate question.
Choice A is incorrect. You have not violated the confidentiality of client information because you did not share any client information with anyone.
Choices C and D are incorrect. Although you may have asked this question because you are a compassionate and caring nurse, this is not an appropriate question since you are no longer involved in the client’s care.
References: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice and Sommer, Johnson, Roberts, Redding, Churchill et al.
You are caring for a 14-month-old diagnosed with severe iron deficiency anemia. She is admitted for a blood transfusion and is started on oral iron supplementation. When you change her diaper. You note a dark black stool. What are the appropriate nursing actions? Select all that apply.
A. Notify the healthcare provider.
B. Document the finding
C. Continue with your assessment
D. Administer the oral iron supplement as prescribed
Explanation
Answer: B, C, and D
A is incorrect. Black stools are an expected response to iron supplementation. The nurse doesn’t need to notify the healthcare provider of this.
B is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to document this finding in the chart, but no further action is needed.
C is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to simply continue with your assessment. Because the finding is expected, no other steps are necessary.
D is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to administer the oral iron supplement as prescribed.
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.
Subject: Pediatrics
Lesson: Hematology
While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case? Select all that apply.
A. Intrauterine growth restriction
B. Hemolytic disease of the newborn
C. Hydrocephaly
D. Large for gestational age infant
E. Stillbirth
Explanation
Rationale:
The correct answers are A, C, and E. Women infected with rubella are at an increased risk of having a miscarriage or a stillbirth. Their infants are more likely to suffer from Intrauterine growth restriction and hydrocephaly.
Choice B is incorrect. Hemolytic disease of the newborn is an alloimmune condition that occurs when the mother is Rh-negative and is pregnant with an Rh-positive baby.
Choice D is incorrect. Women infected with rubella while pregnant are not at an increased risk for delivering an infant who in large for gestational age.
Reference:
Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014
The nurse has just finished assisting the physician in applying a fiberglass cast to a patient with a severe ankle sprain. The patient asks the nurse how long he will have to wait until he can walk on the cast. The nurse replies that he can walk on the cast:
A. after 8 hours
B. after half an hour
C. after 24 hours
D. after 48 hours
Explanation
A is incorrect. The client may bear weight (if permitted by a doctor) on his cast once it is fully dry. A synthetic (Fiberglass) cast fully dries after 30 minutes. A plaster cast takes 2-3 days to completely dry, usually after 48 hours.
B is correct. A Fiberglass cast fully dries within 30 minutes (half an hour) of application. The patient can now walk (bear weight) on it if allowed by the physician.
C is incorrect. The client may bear weight (if permitted by a doctor) on his cast once it is fully dry. A synthetic (Fiberglass) cast fully dries after 30 minutes. A plaster cast takes 2-3 days to completely dry, usually after 48 hours.
D is incorrect. The client may bear weight (if permitted by a doctor) on his cast once it is fully dry. A synthetic (Fiberglass) cast fully dries after 30 minutes. A plaster cast takes 2-3 days to completely dry, usually after 48 hours.
Reference:
Daniels, R., et al. Contemporary Medical-Surgical Nursing; Delmar Learning 2007
Which of the following is (are) a type of social support? Select all that apply.
A. An emotional social support
B. An informational social support
C. A physical help social support
D. A sensory social support
E. An instrumental social support
F. An appraisal social support
Explanation
Correct Answers are A, B, E and F
Correct Answer A. An emotional, social support is one type of social support. Passionate social support people and networks provide clients with the emotional and psychological that is often needed for decreased client stress and enhanced client coping.
Correct Answer B. An informational social support is one type of social support. Informational social support people and networks provide clients with the knowledge and skills needed to adapt to and cope with a stressor.
Correct Answer E. An instrumental social support is one type of social support. Helpful social support people and networks provide clients with tangible help with things like transportation and household help.
Correct Answer F., An appraisal of social support, is one type of social support. Appraisal social support people and networks provide clients with the opportunity to gain insight and to self evaluate their strengths and limitations.
Choice C is incorrect. A physical help social support is not existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems.
Choice D is incorrect. Sensory, social support is nonexistent. The four types of social support are informational, emotional, instrumental, and appraisal support systems.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition) and Glanz, Karen, Barbara K. Rimer, and K Viswanath. Health Behavior and Health Education: Theory, Research, and Practice. Social Supports. http://www.med.upenn.edu/hbhe4/part3-ch9-key-constructs-social-support.shtml
A nurse is taking care of a 60-year-old lady who is on her first postoperative day after a right total hip replacement. The nurse knows that one complication from this procedure is dislocation. To prevent this, the nurse includes which nursing action in the plan of care?
A. Avoid positioning the client with the right leg externally rotated
B. Avoid placing the client in the left lateral decubitus position at all times
C. Ensure that adduction of the legs is avoided
D. Do not allow client to be in semi-Fowler’s position
Explanation
Rationale: Following a total hip replacement, the goal is to prevent dislocation. Leg adduction should be avoided. The legs should be abducted. They may also be externally rotated, and the client may assume a sitting position at a 45-degree angle. The correct answer is, therefore, option C, while options A, B, and D are incorrect.
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
You are administering a transfusion of 1 unit of PRBCs to a 63-year-old client with hemoglobin of 8.9gm%. Listed in the Exhibit are his vital signs pre-transfusion, 5 minutes into the transfusion, and 10 minutes into the transfusion. What should the nurse do after 10 minutes of administering the transfusion? Select all that apply.
A. Continue to monitor the patient’s response to the transfusion
B. Notify the health care provider
C. Stop the transfusion
D. Take another set of vital signs at the next 10 minute interval
Explanation
The correct answers are B and C.
As shown in the exhibit, there is an increase in temperature and a drop in the blood pressure following the blood transfusion. Based on the vital signs the nurse has obtained, she expects that the patient is having a transfusion reaction.
Transfusion reactions are adverse reactions that happen as a result of receiving a blood transfusion. Signs and symptoms of a transfusion reaction include fever, chills, diaphoresis, muscle aches, back pain, rashes, dyspnea, pallor, headache, nausea, apprehension, tachycardia, and hypotension. (Most common symptoms ca be remembered by a Mnemonic – REACTION – Rash, Elevated temperature, Aching, Chills, Tachycardia, Increased pulse, Oliguria – low urine output and Nausea).
Most transfusion reactions occur during the first 15 minutes. While initiating blood transfusion, it should be started slowly at a rate of 2 mL/min (120 mL/hr) for the first 15 minutes – the idea here is to minimize the volume of the blood infused if the patient were to develop a reaction. The nurse should use 18 gauge or larger cannula to infuse because a smaller cannula may lead to mechanical lysis of red cells. The nurse should remain at the patient’s bedside for the first 15 minutes and if the blood is tolerated for 15 minutes without a reaction, the infusion rate can be increased. Blood transfusion units are usually at 250 ccs to 300 cc in volume. Transfusion must be completed within 4 hours.
As per blood transfusion protocol used in most centers, vitals must be obtained at 5 minutes, 15 minutes, 30 minutes from the start of the infusion, 1 hourly until the infusion is completed, and then at 1 hour after the transfusion.
Even if the patient is not complaining of the typical signs and symptoms, if their vital signs indicate a possible transfusion reaction, the transfusion should be stopped. In this client, the heart rate is trending up, blood pressure is trending down, and the temperature is trending up. At 10 minutes, he is tachycardic, hypotensive, and febrile. The patient is having a transfusion reaction. This requires immediate intervention. Therefore, the nurse should immediately stop the transfusion (Choice C); disconnect blood tubing from the intravenous site and notify the health care provider (Choice B).
Choice A is incorrect. It is inappropriate to continue monitoring the patient’s response to the transfusion. Their vital signs are out of normal limits and an intervention is required.
Choice D is incorrect. The nurse will begin continuously monitoring vital signs now that she suspects a transfusion reaction. It would be inappropriate for her to wait 10 minutes to take another set of vitals.
NCSBN Client Need:
Topic: Pharmacological and Parenteral Therapies Subtopic: Blood and Blood Products.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby, p. 912
Following treatment for a fracture, a client is now undergoing rehabilitation. His regimen involves performing isometric exercises. Which action is evidence that the client has fully understood the proper technique?
A. The patient exercises both extremities simultaneously
B. The client knows that his heart rate should be monitored while exercising
C. The patient practices forced resistance against stable objects
D. The patient swings his limbs through their full range of motion
Explanation
Rationale: Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall. It does not include the simultaneous use of the extremities; neither does swinging of limbs. Heart rate monitoring is done with aerobic exercises. The correct answer is option C. Options A, B, and D are incorrect.
Reference:
gnatavicius 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
Beliefs and conceptions about pain and pain management are often not based in fact and scientific evidence. Which of the following is a commonly held misconception about pain and pain management? Select all that apply.
A. Infants do not have developed pain sensors.
B. The lack of physiological and behavioral signs of pain do not negate pain.
C. The amount of pain has a positive correlation with the extent of tissue damage.
D. The amount of pain has a negative correlation with the extent of tissue damage
Explanation
Choices A and C are correct.
The two commonly held misconceptions about pain and pain management are that infants do not have developed pain sensors and that the amount of pain has a positive correlation with the extent of tissue damage. These beliefs are contrary to facts and scientific evidence.
These false beliefs continue to be held by some healthcare providers who believe that infants do not experience pain and that the amount and intensity of grief are increased with significant tissue damage.
Choice B is incorrect. The lack of physiological and behavioral signs of pain does NOT negate the anxiety and pain. People are uninformed when they believe that the lack of physiological and behavioral symptoms of pain indicates the absence of pain.
Choice D is incorrect. The amount of pain has a negative correlation with the extent of tissue damage is not accurate, but this is not a commonly held misconception about pain and pain management. The widely held misconception about pain and pain management is that the amount of pain has a positive and not a negative correlation with the extent of tissue damage.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016).
The nurse is caring for a 1 year old client diagnosed with acute otitis media. The client is experiencing otalgia, has been febrile for 24 hours, and is pulling at his left ear. Which intervention is the priority nursing action?
A. Position the child on his left side
B. Administer antibiotic ear drops
C. Administer acetaminophen as prescribed
D. Apply a heat pack to the left ear
Explanation
Answer: C
A is incorrect. Positioning the child on his left side is not the priority. This position is appropriate however, because the child is pulling at his left ear indicating that is the affected side, so positioning on the left side will promote drainage of fluids from that ear. With that being said, there is another option with a higher priority, and the question asks for the priority nursing action.
B is incorrect. Antibiotic ear drops are not used to treat acute otitis media. Systemic antibiotics are used to treat acute otitis media infections with a bacterial cause. Amoxicillin, erythromycin, and Cefixime are all systemic antibiotics that may be utilized, but antibiotic ear drops are not effective.
C is correct. Administering acetaminophen is the priority nursing action in this scenario. The question states that the patient has been febrile for 24 hours. It is the priority to address this concern, and the nurse can do so through administration of the antipyretic acetaminophen.
D is incorrect. Applying a heat pack to the left ear is not the priority nursing action. Heat or cold packs can be used for pain relief when the child with acute otitis media is experiencing otalgia, but the stem of the questions states that this child has been febrile for 24 hours. It is not appropriate to place a heat pack on a patient who is febrile. The priority is addressing the fever.
NCSBN Client Need:
Topic: Effective, safe care environment
Subtopic: Coordinated care
Subject: Pediatric
Lesson: HEENT
Which of the following signs does the nurse know to expect for her 1-year-old patient in heart failure? Select all that apply.
A. Diaphoresis
B. Weight loss
C. Insomnia
D. Poor feeding
Explanation
Correct answers are A, and D. Diaphoresis, or increased sweating (Choice A), is an expected clinical manifestation of heart failure. As the heart works harder and harder to maintain cardiac output, the body starts to tire, and this is manifested in signs such as diaphoresis. Diaphoresis is possibly related to a catecholamine surge and can mainly display during feeding when the infant/ child attempts to eat while in respiratory distress. Poor nutrition (Choice D) is another expected clinical manifestation of heart failure in infants and children. As the left side of the heart begins to fail, there is fluid backing up in the lungs (Pulmonary edema). This causes dyspnea and makes eating increasingly tricky for patients.
Choice B is incorrect. Weight gain, rather than loss, is an expected clinical manifestation of heart failure. Weight gain is secondary to fluid retention. In heart failure (especially with right heart failure), the heart struggles to move fluid forward in the body, and therefore liquid begins to back up, causing venous congestion and weight gain. Venous congestion in Right-sided heart failure manifest with liver enlargement (hepatomegaly), ascites, pleural effusion, peripheral edema, and jugular venous distension. Venous congestion in Left-sided heart failure manifests with tachypnea, intercostal retractions, nasal flaring or grunting, rales, and pulmonary edema.
Primary mechanisms of fluid retention in heart failure include reduced renal perfusion and, thereby, activation of the Renin-aldosterone pathway. Increased aldosterone production leads to sodium and water retention. Congestion in patients with chronic heart failure usually develops over weeks or even months. In the case of exacerbations of Congestive Heart Failure (CHF), patients may present ‘acutely’ having gained several liters of excess fluid, and hence several pounds of excess weight. Therefore, management in these acute CHF exacerbation patients involves removing that excess fluid (acutely retained fluid) and transitioning them back to a diagnosis of Chronic Heart Failure. In managing clients with acute CHF exacerbation, daily weight monitoring is a crucial measure to monitor outcomes and achieve desired weight-loss (removal of excess fluid). Loop diuretics are the principal agents to attain that target.
Choice C is incorrect. Insomnia is not an expected clinical manifestation of heart failure in children. These patients are often very fatigued but do not typically experience insomnia. Although Paroxysmal Nocturnal Dyspnea and Orthopnea in left heart failure may cause some sleep disturbances, Insomnia is not a commonly reported direct symptom of heart failure.
NCSBN Client Need
Topic: Physiological Integrity Subtopic: Physiological adaptation.
Reference
Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited
Which percussion sound would indicate further assessment is needed?
A. Dull tone over spleen
B. Hyperressonance over adult lung tissue
C. Flat tone over bone
D. Hyperressonance over child’s lung tissue
Explanation
B is correct. Hyperressonance is an abnormal finding over adult lung tissue. It indicates an abnormal increase in the amount of air present, such as with emphysema.
A is incorrect. Soft, short, muffled “dull” sounds are normal over dense organs such as the liver and spleen.
C is incorrect. Bones produce a “flat” percussion sound in normal healthy adults.
D is incorrect. Adult lung tissue should create a “resonant” sound during percussion, but hyper resonance is a normal finding in child lung tissue.
Subject: Fundamentals
Lesson: Skills/procedures
Topic: Pathophysiology
Reference: (Jarvis, C, 2012, p. 116-117)
You are caring for a client with a terminal disease and this person has asked for a curandero. What should you do?
A. Refer the family to a religious shop with Bibles and other holy books.
B. Refer the family and the client to a member of the clergy who may be able to help.
C. Give the client a candle and close all of the shades and blinds to darken the room.
D. Arrange for the client to go to a religious service to get this special blessing.
Explanation
Correct Answer is B
Correct. You would refer the family and the client to a member of the clergy who may be able to help. A curandero is a healer who is believed to supernatural powers that can cure the sick. These powers are derived from the fact that many believe that illnesses and diseases occur as the result of evil spirits and a curse from God.
You would not give the client a candle and close all of the shades and blinds to darken the room because this is not consistent with the person’s desire to have a curandero; a curandero is not a particular religious blessing, and it is not a holy book.
Choice A is incorrect. A curandero is not a holy book.
Choice C is incorrect. A curandero is not a religious or spiritual practice that uses a candle and a darkened room.
Choice D is incorrect. A curandero is not a particular religious blessing.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).
Your client is expressing feelings of dread and impending danger. As you are allowing the client to freely express these feelings, you are attempting to determine the source of these feelings; it then becomes apparent that the source of these feelings is not identifiable. What is the most likely nursing diagnosis for this client?
A. Fear related to an unidentifiable source
B. Anxiety related to an unidentifiable source
C. Ineffective coping related to a source that is not based in reality
D. Maladaptive coping related to a source that is based in reality
Explanation
Correct Answer is B
Correct. The most likely nursing diagnosis for this client is “Anxiety related to an unidentifiable source”. Unlike fear, which is highly similar to anxiety in terms of client responses to it, anxiety can result from an unidentifiable source as well as one that is identifiable.
Fear is related to an identifiable source. The nursing diagnoses of “Ineffective coping related to a source that is not based in reality” and “Maladaptive coping related to a source that is based in reality” are not accurate because this client’s feelings may or may not be based in reality.
Choice A is incorrect. Fear is related to an identifiable source and not an unidentifiable source.
Choice C is incorrect. The nursing diagnosis of “Ineffective coping related to a source that is not based in reality” is not accurate because this client’s feelings may or may not be based in reality.
Choice D is incorrect. The nursing diagnosis of “Maladaptive coping related to a source that is based in reality” is not accurate because this client’s feelings may or may not be based in reality.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson
The nurse is preparing to administer Dopamine (Intropin) to a client intravenously. All of the following are precautions are to be taken when administering the medication, except:
A. Use caution in calculating and preparing doses of the drug.
B. Monitor patient response slowly (blood pressure, ECG, urine output, cardiac output).
C. Dilute the drug before use if it is not prediluted.
D. Have Phenylephrine on standby in case extravasation occurs.
Explanation
Choice D is correct. This is not the precaution a nurse needs to take because it represents an erroneous statement. Phentolamine should be on standby to save the vein in case of infiltration, not Phenylephrine.
Phentolamine is an antidote that counteracts the effects of Dopamine, Vasopressin, Norepinephrine, and Phenylephrine by causing vasoconstriction by alpha-receptor stimulation. Dopamine-induced extravasation can cause tissue injury with blanching and hematoma. Subcutaneous injection of phentolamine has been proven to be clinically effective in preventing tissue injury in the case of Dopamine or Vasopressin extravasation.
Choice A is incorrect. This is the precaution that the nurse should take. The nurse should use extreme caution when calculating and preparing doses of the drug because even small errors could have serious effects.
Choice B is incorrect. This is the precaution that the nurse should take. Monitoring the patient’s response to the medication ensures that the most benefit is achieved with the least amount of toxicity to the client.
Choice C is incorrect. This is the precaution that the nurse should take. Diluting the drug prevents tissue irritation on injection.
Reference:
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006
Which of the following statements accurately describes behaviors that place juveniles at increased risk for injury? Select All That Apply.
A. Approximately 5.000 individuals under the age of 21 die from alcohol-related accidents annually.
B. 1 in 3 high school students reports using some type of tobacco product.
C. The CDC lists motor vehicle accidents as the number one cause of death among adolescents
D. The use of OTC and prescription drugs among teens is at an all-time high.
E. Homicide rates for adolescents are high.
F. As many as 30% of school-aged children are bullied.
Answer and Rationale:
The correct answers are A, C, and D. Each year, underage drinking claims the lives of approximately 5,000 people under the age of 21. The CDC lists motor vehicle accidents as the number one cause of death for adolescents. Marijuana use among teenagers has been on the increase, and the abuse of prescription medication and OTC drugs has remained at a high level. B is incorrect. Approximately one in five high school students reported using a type of tobacco product. E is incorrect. Homicide rates for youths using firearms are higher than any other age group, and the most recent statistics indicate that children aged 10-19 years committed almost 1,500 suicides using guns. F is incorrect. According to the American Academy of Child and Adolescent Psychology, as many as 50% of children are bullied during their school years. Some experts believe that cyberbullying is more dangerous and damaging to children than bullying in the schoolyard.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn)
Chapter 26: Safety, Security, and Emergency Preparedness
Lesson: Promoting Safety at Varying Developmental Stages
The nurse in the psychiatric unit is administering fluoxetine (Prozac) together with Tranylcypromine (Parnate). The nurse should watch out for which symptoms signify an expected adverse reaction from the combination of both drugs?
A. low blood pressure and urinary retention
B. muscle rigidity and hyperthermia
C. shortness of breath and pink frothy sputum
D. weakness and diaphoresis
Explanation
A is incorrect. These symptoms are not associated with serotonin syndrome.
B is correct. Serotonin syndrome is a result of too much serotonin in the body due to the use of SSRI’s and MAOI’s. Serotonin syndrome is characterized by high body temperature, agitation, muscle rigidity, tremor, sweating, dilated pupils, and diarrhea. Upon noticing these symptoms, the nurse must report this to the physician to initiate medical intervention.
C is incorrect. These symptoms are related to pulmonary edema, not serotonin syndrome.
D is incorrect. Weakness and diaphoresis are symptoms associated with hypoglycemia, not serotonin syndrome.
Reference
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
A nurse is assigned to care for a 2-year-old who is newly diagnosed with acute lymphocytic leukemia. Which action should be included in the client’s plan of care that is directed to facilitate growth and development in the acutely ill toddler?
A. Focus on educating parents to minimize anxiety over parenting of the child
B. Make sure that the toddler is informed in advance of what is to take place in a procedure
C. Isolate child from parents, especially if there are temper tantrums.
D. Encourage regression to a previous developmental level for familiarity and comfort.
xplanation
Rationale: When a toddler is acutely ill, it is best to have parents who are not overly anxious and can work well with hospital personnel. It is, therefore, best to exert effort in educating the parents in this case. Option A is, therefore, the correct answer. Option B is not an appropriate action because a toddler’s thinking is concrete and tangible, and the toddler cannot think beyond the observable. Preparation should be done immediately before the procedure. Temper tantrums are a standard developmental characteristic of a 2-year-old, and the parents must hold her to alleviate fear. Isolating the toddler from her parents is not a therapeutic approach. Option C is, therefore, incorrect. A toddler may regress during hospitalization but will not facilitate comfort. Option D is an inappropriate action.
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
Which of the following are independent sleep hygiene nursing functions used to induce and maintain sleep. Select all that apply.
A. The administration of an over-the-counter medication like Benadryl to induce and maintain sleep.
B. The administration of an ordered hypnotic medication like Benadryl to induce and maintain sleep.
C. The provision of a therapeutic soothing back massage and giving the client a warm beverage without caffeine.
D. The encouragement of moderate physical exercise one hour before the client’s scheduled sleep time.
Explanation
The correct answer is C. The provision of a therapeutic soothing back massage and giving the client a warm beverage without caffeine are independent sleep hygiene nursing functions used to induce and maintain sleep. These interventions are separate rather than dependent responses because they do not require a doctor’s order.
Choice A is incorrect. The administration of an over-the-counter medication like Benadryl to induce and maintain sleep is a dependent rather than an independent nursing function because the administration of drugs, even over-the-counter drugs, cannot be done without a doctor’s order.
Choice B is incorrect. The administration of an ordered medication like Benadryl to induce and maintain sleep to produce and maintain sleep is a dependent rather than an independent nursing function. The administration of all medications, even over-the-counter drugs, cannot be done without a doctor’s order. Additionally, Benadryl is not a hypnotic medication; but instead is an antihistamine that has the side effect of drowsiness.
Choice D is incorrect. Moderate physical exercise one hour before the client’s scheduled sleep time is not encouraged. A quiet, peaceful environment is provided; reasonable use should be discouraged several hours before the client’s scheduled sleep time because it impairs sleep.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
Which of the following clients, who is receiving normal saline via IV infusion, is at the highest risk for bloodstream infections?
A. A client who has a midline IV catheter in the left antecubital fossa.
B. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.
C. A client with an implanted port in the right subclavian vein.
D. A client who has a non-tunneled central line in the left internal jugular vein.
Explanation
Choice D is correct. Several factors increase the risk of infection for this client. Central lines are associated with a higher risk of infection because the neck and chest skin harbor a high number of microorganisms. Additionally, because the line is non-tunneled, the risk for infection is higher. Non-tunneled catheters are mostly used for short-term access in indications requiring rapid resuscitation or pressure monitoring. Such non-tunneled catheters are good for about 5 to 7 days. They carry a higher risk of infection and are inappropriate for patients who require central venous access for longer than 2 weeks.
Choices A and B are incorrect. Peripherally inserted IV lines such as midline catheters and PICC (peripherally inserted central catheter) lines are associated with a lower infection incidence.
Choice C is incorrect. Implanted ports are placed under the skin and are less likely to be associated with catheter infection than a non-tunneled central IV line.
NCSBN Client Need
Topic: Safe and Effective Care Management; Subtopic: Safety and Infection Control
Reference:
Fundamentals of Nursing (Kozier and Erbs); Chapter 31: Asepsis; Lesson: Nosocomial and Healthcare-Related Infections
The client is admitted to the surgical ward after being treated initially in the ER for a femur fracture due to a motor vehicle accident. The client is being interviewed by the nurse for his surgery whenhe suddenlyreports a sharp pain in his chest, displays the difficulty of breathing, and becomes restless. The nurse suspects fat embolism; which action of the nurse should take priority?
A. Prepare for intubation and mechanical ventilation
B. Administer IV fluids
C. Check vital signs and respiratory status
D. Notify the physician
Explanation
Choice D is correct. The nurse suspects fat embolism. The question provides enough information regarding the client’s distress and sudden change in his clinical status. The mortality rate with fat embolism is about 10%. Early recognition and treatment are crucial. The nurse should immediately inform the physician to initiate medical interventions.
Fat embolism is a potentially life-threatening complication that occurs from long bone fractures due to fat emboli being dislodged and traveling into the bloodstream and up into the pulmonary circulation. Symptoms mimic that of pulmonary embolism. The client may report chest pain, respiratory distress (dyspnea), and may have mental status changes (confusion). Other signs include tachypnea, low oxygen saturation, fever, tachycardia, and low blood pressure. Petechiae (axillary or subconjunctival petechiae) are characteristic of fat embolism and help differentiate it from other etiologies.
Treatment includes intravenous hydration, oxygenation, and immobilization, and fixation of the fractured limb. In severe cases of hypoxia and neurological deterioration, intubation and ventilation may be required.
Choice A is incorrect. The client may eventually need intubation and mechanical ventilation, depending on the respiratory and neurological condition. However, this is not the initial action of the nurse.
Choice B is incorrect. IV fluids may be necessary to prevent hypovolemic shock in the client, but this should be done after informing the physician.
Choice C is incorrect. There is sufficient information in the question to indicate the client’s distress. The client may need his vital signs checked and monitored; however, this does not take priority over informing the physician and starting emergency interventions.
Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
A client is scheduled for electroconvulsive therapy. The nurse caring for him notes that there is no signed consent form. Upon further assessment, the nurse finds out that the client is admitted to the unit involuntarily. The nurse understands that in this case:
A. informed consent needs to be obtained from the wife
B. informed consent needs to be obtained from the client
C. informed consent is not necessary
D. informed consent needs to be obtained from court
Explanation
A is incorrect. Unless declared legally incompetent, the client’s wife does not have the authority to give consent on behalf of the client.
B is correct. Even though the client is involuntarily admitted, the client does not lose the right to informed consent. Informed consent must be obtained from the client.
C is incorrect. Electroconvulsive therapy needs informed consent from the client to proceed.
D is incorrect. Unless deemed legally incompetent, informed consent must be obtained from the client.
Reference
Halter, MJ.Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 7th Ed. St. Louis, MO: Mosby Elsevier; 2014
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most consistent with the nurse’s role of patient advocate.
A. Remind the patient of why breast feeding is the best method of infant feeding.
B. Request a referral to the lactation consultant.
C. Determine the patient’s knowledge base related to infant feeding options.
D. Accept the patient’s decision without further discussion
Explanation
Correct Answer C. A central concept of patient advocacy is ensuring that the patient’s decisions are based on sufficient information and understanding, supporting the patient’s right to exercise autonomy.
Choice A is incorrect. This answer does not serve to support the patient’s right to autonomy.
Choice B is incorrect. A referral to the lactation consultant is not necessarily indicated.
Choice D is incorrect. While the nurse should support the patient’s choice, it is essential to confirm that the patient’s decision-making process is based on adequate information.
Bloom’s Taxonomy – Analyzing.
Reference:
Hyland, D., 2002. An Exploration of the Relationship Between Patient Autonomy and Patient Advocacy: Implications for Nursing Practice. Nursing Ethics 9(5)
The client is upset because she just found out that she has syphilis. She tells the nurse, “This is so upsetting. Does everyone need to know?” What would be the nurse’s best response?
A. “We need to report this case to the Public Health Department and they will call your past partners.”
B. “According to the Health Insurance Portability and Accountability Act (HIPAA), I can’t tell anyone without your permission.”
C. “You really should contact your sexual partners, so they can be treated too.”
D. “I understand you’re upset. Would you like to talk about it?”
Explanation
A is incorrect. The Public Health Department will attempt to notify any sexual partners of the client reports.
B is incorrect. This is a false statement. HIPAA does not apply to this situation.
C is incorrect. The client should contact all her sexual partners so that they could get treated. The response, however, is not therapeutic.
D is correct. This response provides facts but still encourages verbalization of feelings to the client.
Reference
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
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.
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
The home health nurse is visiting an elderly client for the first time in his home. Upon assessment of the client, the nurse notices that the client has been taking 12 prescription medications and five over the counter medications. What is the nurse’s most appropriate action?
A. Check for drug interactions.
B. Check for side effects to the client from the medications.
C. Check for any medication duplication.
D. Ask the client if there are family members helping him with his medications.
Explanation
A is incorrect. Checking for drug interactions should be done after determining the duplication of medications.
B is incorrect. The identification of side effects of medications can be made after the duplication of drugs is determined.
C is correct. Checking for any duplication in medication should be the first action of the nurse to eliminate the risk of adverse effects on the client.
D is incorrect. Asking about family members helping with his medications is irrelevant to the problem of polypharmacy as of the moment.
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
While working in the emergency department. A patient has a cardiac arrest. The nurse caring for the patient quickly defines the necessary tasks and assigns them to each member of the team responding. This nurse demonstrated which of the following leadership styles?
A. Autocratic
B. Situational
C. Democratic
D. Laissez-faire
Explanation
Answer: A
A is correct. This nurse has demonstrated an autocratic leadership approach. She retained all authority and delegated tasks to be accomplished. This approach is useful in emergencies or crises.
B is incorrect. Situational leadership is a comprehensive approach that combines the style of the leader with the maturity of the group they are working with and what the current situation is. In this situation, autocratic leadership was demonstrated.
C is incorrect. Democratic leadership is a person-centered leadership style focused on the relationships between the team who is working together. Democratic leadership is a good strategy for team development and encouraging the growth of the participating team members. In this situation, autocratic leadership was demonstrated.
D is incorrect. Laissez-faire leadership is very lax in style. The leader does not retain control and instead delegates the decision-making to other team members. In this situation, autocratic leadership was demonstrated.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Risk of the potential reduction
Subject: Fundamentals
Lesson: Prioritization, delegation, and leadership
Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
Which of the following foods should the nurse reinforce to avoid while the patient is taking Coumadin? Select all that apply.
A. Peanut butter
B. Spinach
C. Kale
D. Almonds
Explanation
Answer: B and C
A is incorrect. Peanut butter does not need to be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Peanut butter only has about 0.05 mcg of vitamin K per 1 tbsp, so it does not need to be avoided.
B is correct. Spinach should be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Spinach has 444 mcg per half cup, making it incredibly high in vitamin K!
C is correct. Kale should be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Kale has 565 mcg per half cup, making it incredibly high in vitamin K!
D is incorrect. Almonds do not need to be avoided while taking Coumadin. Vitamin K is a natural antagonist to Coumadin as it helps the body form clots. So the amount of Vitamin K will need to be controlled while taking Coumadin. Almonds have virtually no vitamin K, so they do not need to be avoided.
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.
Subject: Fundamentals
Lesson: Medication Administration
Which of the following situations represents an appropriate time to place your patient in restraints? Select all that apply.
A. When they are trying to pull at their lines. tubes. and drains.
B. When their family member asks you to.
C. When you feel it is necessary.
D. When they are a danger to themselves.
Explanation
Answer: A and D
A is correct. It is appropriate to place your patient in restraints, with an order from your healthcare provider, if the patient is trying to pull out their lines, tubes, and drains. This makes them a danger to themselves and can cause harm, so restraints may be appropriate.
B is incorrect. A family member may request restraints, but this is not an appropriate reason to initiate controls. You should explain to the family member other options and what you are trying to do for their loved one before launching restraints.
C is incorrect. Just because you feel that restraints are necessary does not mean you may initiate them. You must speak with your healthcare provider and explain why you think controls are required to obtain an order.
D is correct. If your patient is a danger to themselves and other interventions are not keeping them safe, it is appropriate to request an order for restraints from your healthcare provider.
NCSBN Client Need:
Topic: Effective, safe care environment
Subtopic: Coordinated care
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
Subject: Fundamentals
Lesson: Safety
Select the client care supply or piece of equipment that is accurately paired with the correct type of asepsis.
A. Medical asepsis: An autoclave
B. Medical asepsis: Sterile gloves
C. Surgical asepsis: A single use blood pressure cuff
D. Surgical asepsis: An autoclave
Explanation
Correct Answer is D. An autoclave is used to sterilize client care supplies and equipment; therefore, an autoclave is accurately paired with surgical asepsis.
Choice A is incorrect. An autoclave is used to sterilize; therefore, it is not used for medical asepsis.
Choice B is incorrect. Sterile gloves are sterilized and used for sterile procedures, and not for medical asepsis procedures.
Choice C is incorrect. Single-use blood pressure cuffs are medically aseptic and not sterilized. Therefore, it is not an example of surgical asepsis.
References: 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.
You are taking care of a client who is taking warfarin and lovastatin. Which statement about the interaction warfarin and lovastatin should you incorporate into your critical thinking and your plan of care?
A. Lovastatin decreases the effects of the warfarin.
B. Lovastatin increases the effects of the warfarin.
C. Lovastatin has no known effects on the warfarin.
D. Combining lovastatin and warfarin causes respiratory depression.
Explanation
Correct Answer is B
Correct. Lovastatin increases the effects of the warfarin, so you, as the nurse, should incorporate this knowledge related to an increased influence of the anticoagulant, warfarin, into your critical thinking and your plan of care.
Choice A is incorrect although lovastatin affects the actions of warfarin, lovastatin increases, rather than decreases, the effects of the warfarin.
Choice C is incorrect. Lovastatin has known effects on warfarin, an anticoagulant medication, so you, as the nurse, should incorporate this knowledge into your critical thinking and your plan of care.
.
Choice D is incorrect. Combining lovastatin and warfarin does not cause respiratory depression; however, these medications, in combination, can have another effect.
Reference: Kee, Joyce LeFever, Evelyn Hays, and Linda McCistion (2011) Pharmacology: A Nursing Process Approach 7th edition. Elsevier Saunders.
The community health nurse is evaluating an individual’s risks of developing Hepatitis A. The nurse knows which age group is at the highest risk of acquiring Hepatitis A?
A. Newborns
B. The elderly, ages 60 to 90
C. Teenagers older than age 15
D. Children older than 1 year but younger than 15 years
Explanation
Choice D is correct. Children who are preschool and elementary school age and those younger than 15 are at the highest risk of developing Hepatitis A virus ( HAV). Hepatitis A is usually contracted by ingesting stool containing the virus. Since it’s transmitted through fecal-oral contact, children are more prone as they may not practice proper hand hygiene. Often, children contract infection by eating/ drinking food/ water ( fruits, vegetables, ice, water) contaminated by stools containing HAV, being carried by the infected person that does not wash their hands after using the restroom or traveling to a developing country without being vaccinated for hepatitis A. Outbreaks may occur in child care centers.
CDC recommends Hepatitis A vaccine to the following groups:
All children aged 12–23 months Unvaccinated children and adolescents aged 2–18 years International travelers Homeless people Men who have sex with men Those engaged in recreational drug use Those with HIV Those with chronic liver disease Those at risk for exposure during their work. Pregnant women at risk for Hepatitis A
Hepatitis A vaccine is administered in a two-dose schedule. It is recommended to all children at one year of age (i.e., 12 to 23 months) and as a catch-up vaccine for all unvaccinated children and adolescents 2 to 18 years.
Choice A is incorrect. Newborns are not the group most likely to develop Hepatitis A. Newborns and those less than age 12 months tend to harbor passively acquired maternal antibodies ( passively transferred via the placenta). Routine Hepatitis A vaccination is not recommended to children younger than 12 months because their immune systems are not mature. Vaccines before 12 months of age might result in a suboptimal immune response. However, those children at 6-11 months who travel internationally should be given the vaccine.
Choice B is incorrect. These elderly age groups do not have more occurrences of Hepatitis A than the children under 15. However, the elderly tend to have more severe symptoms if they do develop Hepatitis A.
Choice C is incorrect. Teenagers older than 15 years of age are not at the highest risk of developing Hepatitis A. Preschool to elementary school-aged, and those younger than 15 are at the highest risk.
NCSBN client need | Topic: Health Promotion and Maintenance, Health Screening
In the ICU, the low-pressure ventilator alarm goes off. The nurse attends the patient, checks the ventilator, and attempts to determine the cause of the signal. She is unable to identify the cause. Which action would the nurse initiate next?
A. Give oxygen to the patient.
B. Assess the client’s vital signs.
C. Ventilate the client manually.
D. Start CPR immediately.
planation
Choice B is Correct. Checking the client’s vital signs is the priority action among the options given. If the patient is unstable and struggling for air and if no problem has been found with a ventilator, the nurse needs to disconnect the patient from the ventilator and manually ventilate until the problem can be identified. While the question indicates that the Nurse attended the patient, it does not mention if the nurse evaluated the vitals and if the patient is stable. In the absence of such information in the question, it is crucial to assess the vitals and determine if they are durable. Whenever an alarm activates on a ventilator, the nurse first should make sure the patient is adequately ventilated and oxygenated. The nurse should assess the patient’s level of consciousness, use of accessory muscles, and chest wall movements; determine whether bilateral breath sounds are present and evaluate the heart rate and SpO2. If the ventilator is intact, the client should never breathe at a rate less than that set on the ventilator.
Causes of Low-Pressure ventilator alarm: A leak or disconnect most often causes low-pressure alarmsin the ventilator tubing. Causes include:
The patient self-extubates or gets disconnected from the ventilator. Inadequate inflation of the tracheostomy tube cuff Poorly fitting noninvasive masks or nasal pillows/prongs Loose circuit and tubing connections The patient demands higher levels of air than the ventilator is putting out.
Responding to Low-Pressure Alarms: While responding to this alarm, please follow this sequence:
Always evaluate the patient before checking the ventilator, i.e., always start at the patient and then work your way towards the ventilator checking for loose connections. Assess the patient’s vitals, assess consciousness, chest wall movements, accessory muscles, and oxygen saturation. Look for leaks at the site where the tracheostomy tube enters the neck. Look for loose connections in the rest of the ventilator tubing. If the cause of alarm still cannot be identified, disconnect the circuit from the patient and manually ventilate with a resuscitation bag (Ambu bag) and then call for help.
Choice A is incorrect. Oxygen may be helpful, but it may not be enough to address the cause of low-pressure alarm.
Choice C is incorrect. After checking the patient’s vitals and if no immediate cause for the ventilator alarm can be identified, the nurse needs to disconnect the patient from the ventilator and administer manual ventilation until the problem can be identified and solved. While this option can be a distractor here, please note that it does not take priority over “assessing the patient” unless such information is clearly presented in the question.
Choice D is incorrect. There is no indication for CPR at this moment. It is essential to assess the vitals first.
High-Yield Tip: Know the causes of low pressure and high-pressure ventilator alarms thoroughly as these are often tested on NCLEX. Know the sequence of responses to such signals.
Reference:
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
The nurse is evaluating a patient three days post-operative for signs and symptoms of infection. Which of the following is not a sign of infection of a surgical wound?
A. Pus and clear drainage from the site
B. Some redness along the edges of the site
C. Increasing warmth from the wound
D. Red streaks from the site
Explanation
NCSBN client need | Topic: Physiological Integrity, Reduction of risk potential
Rationale:
The correct answer is B. Some redness at the surgical site is a normal finding three days after surgery. Signs of infection include pus, excess wound drainage, increasing warmth from the wound, and red streaks from the site.
Choice A is incorrect. While light, clear drainage is an expected finding three days post-operatively, pus drainage is not. Pus indicates a developing infection.
Choice C is incorrect. While some heat is normal, an increase in temperature produced by the wound indicates infection at the site.
Choice D is incorrect. Red streaks indicate a potentially dangerous infection at the wound and could mean the development of a disease and even sepsis.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
While rounding in the mental health unit, you are learning about specific phobias. You should be aware that Ailurophobia is an unreasonable fear of:
A. Social interactions
B. Clowns
C. Crowds
D. Cats
Explanation
Correct Answer is D. Ailurophobia is best described as an unreasonable fear of cats. The psychiatric mental health treatment interventions for phobias are based on the specific type of phobia. For example, Ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear.
Choice A is incorrect. A fear of social interactions is referred to as a Social phobia. Social interaction phobias are typically treated with exposure therapy, antidepressants, or beta-blockers.
Choice B is incorrect. The fear of clowns, which is referred to as Coulrophobia, is typically treated with exposure therapy.
Choice C is incorrect. The fear of crowds, which is referred to as Enochlophobia, is also typically treated with exposure therapy.
Reference: Sommer, Sheryl, Janean Johnson, Karin Roberts, Sharon Redding, Lois Churchill, Norma Jean Henry, and Mendy McMichael. (2013) RN Mental Health Nursing 9.0; ATI Nursing Education
The nurse is administering digoxin to an infant when she notes that her pulse is 85 beats per minute. What should be the nurse’s most appropriate action?
A. Administer the medication.
B. Extract blood for serum digoxin levels.
C. Withhold the medication and check again after an hour.
D. Administer the medication intramuscularly.
Explanation
A is incorrect. The nurse should not give the medication if signs of bradycardia are present. The nurse should withhold the medicine and recheck the pulse in an hour.
B is incorrect. The initial action of the nurse is to withhold the medication and reassess the patient after an hour. If the pulse remains low, the nurse should inform the physician, and the nurse might extract serum for determination of the client’s digoxin level.
C is correct. If the pulse is less than 90 beats/min in an infant, the nurse should withhold the medication and check again in an hour. A consistently low pulse rate may indicate digoxin toxicity.
D is incorrect. Digoxin is not administered intramuscularly as it can be excruciating.
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
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.
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 Post Coronary Artery Bypass Graft patient had developed a fever of 38.8° C. The nurse notifies the physician of the elevated temperature because:
A. The elevated temperature may lead to profuse sweating
B. It may increase cardiac output.
C. It is a sign of Cerebral edema.
D. It is indicative of hemorrhage.
Explanation
A is incorrect. Although there can be diaphoresis during an increase in temperature, it is not going to be a reason to call the physician.
B is correct. An increase in temperature leads to increased metabolism and cardiac workload.
C is incorrect. Fever is not an early sign of cerebral edema.
D is incorrect. When there is significant blood loss, there is no increase in temperature. Instead, there will be a decrease in temperature.
Reference
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
A toddler is brought to the family clinic by her parents due to poor sleep within the past two weeks and intense perianal itching and scratching. The nurse in the clinic would suspect which condition?
A. Anal fissure
B. Enterobiasis
C. Giardiasis
D. Celiac disease
Explanation
A is incorrect. An anal fissure is a tear in the lining of the lower rectum (anal canal) that causes pain during bowel movements.
B is correct. Enterobiasis is an intestinal infestation with the nematode Enterobius vermicularis, or the common pinworm. It is manifested by intense perianal itching and perianal dermatitis and excoriation secondary to scratching due to the presence of eggs in the anal area.
C is incorrect. Giardiasis is an inflammatory intestinal infestation with the protozoan Giardia lamblia. It manifests itself as diarrhea, anorexia, vomiting, and failure to thrive in infants and young children.
D is incorrect. Celiac disease is a malabsorption disease characterized by hypersensitivity to gluten. Signs and symptoms include failure to thrive, muscle wasting, diarrhea, and vomiting with bulky, foul-smelling stool.
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 nurse is preparing for the first contact with a patient recently admitted to the hospital. Which of the following would help establish trust during this encounter? (Select all that apply).
A. Make sure the patient’s bed is made properly ahead of time.
B. Review the patient’s name. diagnosis. and anticipated length of stay before he or she arrives.
C. Speak confidently and do not tell the patient that one of the nurses providing care is a student nurse.
D. Show the client how to use the bed and call light.
E. Avoid spending too much time talking with the client.
F. Ask about the client’s expectations and concerns when taking the health history.
Explanation
Important Fact:
When patients are admitted to a hospital or ambulatory care facility, you will need to support them in their transition from wellness to illness, in dealing with the unknown, and in adjusting to a new environment. The relationship and trust you establish in your first contact with patients can go a long way toward relieving their anxiety and preserving the energy needed for healing. Take time to get to know your client. Try to set a tone of caring, respect, and understanding.
Answer & Rationale:
The correct answers are A, B, D, and F.
o A- Preparing the room, such as making sure the bed is made correctly, is a way to help establish trust with the patient.
o B- Gathering necessary information ahead of time, such as name, diagnosis, and anticipated length of stay, allows you to greet the patient more effectively.
o D- Orient the patient to the room by making sure the patient knows how to use the bed, the call light, and any equipment as needed. Remember, one of the disruptions associated with illness is anxiety about the unknown.
o F- Showing an interest in what the client’s expectations and concerns are told the client that you care about what he is feeling, which helps to establish trust.
C is not the correct answer. When introducing yourself, don't be afraid to tell a client that you are a nursing student. Many clients are aware that students have more time to spend with them, and you are more likely to establish an atmosphere of trust by being forthcoming regarding your level of experience. E is incorrect. Taking the time to get to know your client helps to establish a trusting relationship. Try to set a tone of caring, respect, and understanding.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Basic Care & Comfort
Chapter 11: Experiencing Health and Illness
Lesson: Nurse-Patient Relationships
Reference: Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith)
You ask your 32-year-old female client about her hobbies. The client tells you that they thoroughly enjoy reading, making pottery, hiking, and rock climbing in the mountains. Which of these interests would you primarily focus on and encourage?
A. Making pottery because this avocation is relaxing and not hazardous.
B. Hiking because this avocation is a good and low-impact exercise.
C. Reading because this avocation is relaxing and not hazardous.
D. Rock climbing because this avocation is good and low impact exercise.
Explanation
The correct answer is B. You would primarily focus on and encourage hiking because hiking is not only a hobby and interest for the client, but it is an excellent form of exercise that is low impact and relatively safe in comparison to other hazardous hobbies like rock climbing.
Choice A is incorrect. Making pottery is not the activity or hobby that you would focus on and encourage because pottery making is a sedentary and solitary activity and not one that provides enjoyable outdoor exercise and social interactions with others. However, it can be relaxing and with minimal hazards.
Choice C is incorrect. Reading is not the activity or hobby that you would focus on and encourage because the text is a sedentary and solitary activity and not one that provides any exercise and social interactions with others, although it can be relaxing.
Choice D is incorrect. Rock climbing is not the activity or hobby you would focus on and encourage because rocking climbing is exceptionally hazardous, although it is an excellent and low-impact exercise.
NCSBN Client Need
Topic: Health Promotion and Maintenance; Sub-Topic: Education to prevent High-Risk Behaviors.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
You are in a client’s room and are suddenly interrupted with a fire alarm as you are documenting client care in the client’s electronic medical record. What should you do?
A. Follow the RACE procedure to address this internal disaster.
B. Rescue all clients and visitors from immediate danger.
C. Log off the computer.
D. Determine whether or not it is a fire drill.
Explanation
Correct Answer is C.You must immediately and rapidly log off the computer to maintain information security and clients’ medical records and information privacy. You would then shortly follow the RACE procedure. It would only take a few seconds to log off the computer. It is essential to protect client privacy under the HealthInsurance Portability and Accountability Act (HIPAA). Patients may take advantage of an open computer terminal to look at their records, leading to a HIPAA violation if they access another patient’s health information. Although most computers are programmed to automatically log off after a specific time, this should not be relied upon as a backup. It is important to log off when the RN leaves the area, even if she is going for a minute or two.
Some common HIPAA violations that nurses make:
You forget to log out of the computer terminal. They were throwing out handwritten notes that have protected patient information in an insecure fashion. We were discussing patient cases with uninvolved coworkers. I am speaking with unauthorized patient's family members or friends. Taking selfies with patients and posting on social media We are using unsecured channels outside medical software to communicate with the care team (e.g., texting patient information via. personal cell text message). Failure to report HIPAA violations promptly. Failure to take required HIPAA training.
Choice A is incorrect. Following the RACE procedure for this internal disaster is not the first step here. You can immediately log off and then move to follow the RACE procedure.
Choice B is incorrect. You would not immediately rescue all clients and others because something else must be done first.
Choice D is incorrect. You would not determine whether or not this is a fire drill because something else must be done first. Additionally, you must respond to all fire alarms as if it is an actual fire.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
Which of the following neurological assessments would be considered abnormal in a newborn? Select all that apply.
A. High pitched cry
B. Pupils are 2mm. equal. round. and react briskly to light.
C. Lethargic
D. Sleeping between each feeding.
Explanation
Answer: A and C
A is correct. A high, pitched cry is an irregular finding in a newborn. It can be a sign of withdrawal in neonatal abstinence syndrome, or a sign of increased ICP if there is birth trauma.
B is incorrect. This is the usual pupil assessment. 2-3mm, equal in size, round in shape, and briskly reactive to light, is the expected finding for a pupil assessment in a newborn.
C is correct. For the level of consciousness, lazy is not a normal finding. We expect the newborn to be alert. Lethargic, obtunded, stuporous, or comatose are all abnormal findings.
D is incorrect. For behavior, an infant is expected to be sleeping between their feedings. This is considered appropriate for the age and is a reasonable assessment finding.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological adaptation
Subject: Maternal and Newborn Health
Lesson: Newborn
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
A patient has been marked as “confidential” due to safety concerns. Which of these actions would be inappropriate for the nurse?
A. Keep the patient’s name/information out of public areas such as the nurse’s station
B. Tell the patient’s mother he is okay when she calls to ask if he is still on the unit
C. Deny that the patient is on the unit when visitors come or call
D. Remove the patient from confidential status when he asks to be removed
Explanation
Answer and Rationale:
The correct answer is B. When a patient has asked to be flagged as confidential, no medical personnel can give out any information, including verifying the patient’s presence in the hospital.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Chapter 26: Safety, Security, and Emergency Preparedness
Lesson: Legal Factors Related to Patient Safety
Which of the following components should the nurse know to include in her handoff after her shift? Select all that apply.
A. PRN medications administered
B. Normal assessment findings for the shift
C. A complete history of lab results and interventions since admission
D. All scheduled medications the client receives.
Explanation
Answer: A
A is correct. Medications administered as needed should be included in the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. Important information about the client and what has occurred over the recent change is essential to include, and PRN medications would be included in this.
B is incorrect. Normal assessment findings for the shift are not a necessary component of the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. Reviewing all normal assessment findings would not only take too long but is not necessary information. Any changes in assessment findings, abnormal findings, and current problems should be included, but normal assessment findings are not required to cover.
C is incorrect. A complete history of lab results and interventions since admission is not a necessary component of the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. I was going over a complete history of lab results and interventions since admission would not only take too long but would not be pertinent.
D is incorrect. All scheduled medications the client receives is not a necessary component of the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. As needed medications, changes in the client’s situation, interventions, and the client’s response to such interventions are part of the nursing handoff.
NCSBN Client Need:
Topic: Effective, safe care environment
Subtopic: Coordinated care
Subject: Fundamentals
Lesson: Prioritization, delegation, and leadership
Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
An experienced nurse is caring for a 24-hour old newborn in the nursery. She suspects asphyxia in utero. All of the following assessment findings would indicate asphyxia in utero except:
A. There is a present palmar-grasp reflex.
B. The nurse strokes the sole of the newborn’s feet but there is no response.
C. The neonate is unresponsive when the nurse claps her hands above him.
D. The neonate has weakand ineffective sucking.
Explanation
A is correct. A present palmar-grasp reflex indicates that there is an intact neurologic response from the neonate.
B is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence in Babinski reflex indicates asphyxia in utero.
C is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence in the Startle reflex indicates asphyxia in utero.
D is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence or depression in the sucking reflex indicates asphyxia in utero.
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
Which of the following nursing diagnoses is appropriate for your client when your client is not coping with a progressive disease in an adaptive manner?
A. Ineffective coping related to fear secondary to a progressive disease
B. Ineffective coping related to role ambiguity secondary to a progressive disease
C. Ineffective coping related to role changes secondary to a progressive disease
D. Ineffective coping related to role conflict secondary to a progressive disease
Explanation
Correct Answer is C
Correct. “Ineffective coping related to role changes secondary to a progressive disease” is the nursing diagnosis that is appropriate for your client when your client is not coping with a progressive disease adaptively.
“Ineffective coping related to fear secondary to a progressive disease” is not correct because there is no indication that this client is affected with fear; “Ineffective coping related to role ambiguity secondary to a progressive disease” can occur when the client with a progressive disease is not sure about what is expected in their sick role, there is no indication that this client is affected with this uncertainty. Lastly, “Ineffective coping related to role conflict secondary to a progressive disease” is also not appropriate because there is no data in this question that indicates that the client has a role conflict.
Choice A is incorrect. “Ineffective coping related to fear secondary to a progressive disease” is not correct because there is no indication that this client is affected by fear.
Choice B is incorrect. “Ineffective coping related to role ambiguity secondary to a progressive disease” can occur when the client with a progressive disease is not sure about what is expected in their sick role. Still, there is no indication that this client is affected by this uncertainty.
Choice D is incorrect. “Ineffective coping related to role conflict secondary to a progressive disease” is also not appropriate because there is no data in this question that indicates that the client has a role conflict.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition). Upper Saddle River, New Jersey: Pearson.
A nurse is talking to a post Billroth I (Partial Gastrectomy and Vagotomy) client that is about to be discharged. Which of the following instructions should the nurse advise to the client?
A. The client should stay upright for at least half an hour after eating
B. The client should drink a glass of water with meals to avoid acid reflux
C. The client is advised to increase consumption of cereals, and breads.
D. The client should eat in a recumbent or semi-recumbent position.
Correct
Answer
Explanation
D is correct. The client should be taught ways on how to prevent and manage dumping syndrome. The client should be instructed to have small, frequent meals; maintain a high protein, high fat, low carbohydrate, and dry diet. The client should be notified to eat in a recumbent or semi-recumbent position. Such positioning during eating delays gastric emptying.
A is incorrect. The client is instructed to lie down after meals to delay gastric emptying.
B is incorrect. The client should not drink any water 1 hour before eating, with food, or 2 hours after eating to prevent dumping syndrome.
C is incorrect. The client should limit carbohydrate intake to prevent dumping syndrome.
Reference
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013
You are providing care and leading a therapeutic group for widows and widowers who have recently lost a loved one. Many of these clients express their belief that the loved one was saintly and highly virtuous. Which stage of grief and loss is demonstrated with these beliefs?
A. The Beatification stage.
B. The Idealization stage.
C. The Disbelief stage.
D. The Restitution stage.
Explanation
The correct answer is B. According to Engel’s theory of grief and loss, these beliefs demonstrate the Idealization stage of grief and loss. The other steps of Engel’s approach are the:
- Shock and disbelief stage
- Developing awareness stage
- Restitution stage
- Resolving the loss stage
- Outcome stage
Choice A is incorrect. Beatification is the process of making something, like a city street, more visually attractive; beatification is not the process of believing that the lost loved one was saintly and highly virtuous.
Choice C is incorrect. The Disbelief stage is characterized by shock and denial.
Choice D is incorrect. The Restitution stage is characterized by accepting the loss.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
A 16-year old male has an appointment with his psychiatrist. He is currently taking haloperidol regularly. The patient complains of dry mouth, weight gain, and muscle stiffness. What adverse effects is this patient experiencing, and what medication will the psychiatrist give?
A. Extrapyramidal symptoms. mannitol
B. Extratriangular symptoms. ibuprofen
C. Extratriangular symptoms. tylenol
D. Extrapyramidal symptoms. benadryl
Explanation
D is the correct answer. This patient is experiencing side effects that are classified as extrapyramidal symptoms. Administering Benadryl, along with other medications like Cogentin and Artane, is known to help these symptoms improve rapidly.
A is incorrect. Mannitol does not indicate this scenario. Mannitol is used to decrease swelling in the brain.
B and C are incorrect. Extratriangular symptoms are the wrong term for the adverse effects that the patient is experiencing. Ibuprofen and Tylenol are not likely to help this patient.
NCSBN Client Need
Topic: Pharmacologic and Parental Therapies
Sub-topic: Adverse Effects/Contraindications/Side Effects/Interactions
Subject: Psychiatric Health
Lesson: Adverse Effects of Medications
Reference: Townsend, 2015
The nurse is assisting in the monitoring of a client with a chest tube. The nurse documents each of the following assessments. Which of these assessments are expected findings? Select all that apply.
A. Drainage system at a level below the patient’s chest
B. Vigorous bubbling in the water-seal chamber
C. Stable water in the tube of the water-seal chamber during inhalation and exhalation.
D. Occlusive dressing over the chest-tube
xplanation
Answer: A and D
A is correct. It is expected that the drainage system will be at a level below the client’s chest. This is what allows gravity to help drain fluid from the pleural space. If the drainage system was above the client’s chest, the chest tube would not work properly.
B is incorrect. Gentle bubbling in the water chamber is an appropriate finding, but the bubbling should not be vigorous. Gentle bubbling indicates that air is draining from the client, but if vigorous or excessive bubbling is noted, there may be an air leak, which will need to be addressed quickly
C is incorrect. It is not expected for the water in the tube of the water-seal chamber to be stable during inhalation and exhalation. The water in the tube of the water-seal chamber should fluctuate during inhalation and exhalation. If it does not, the chest tube could be occluded, the lung could have re-expanded, or there could be air leaking into the pleural space. The nurse will need to notify the physician of this finding to investigate the cause and take appropriate action.
D is correct. An occlusive dressing placed over the chest-tube is appropriate. This is important to ensure that air does not enter the pleural space causing a pneumothorax. The nurse should check the dressing to ensure that it is airtight.
NCSBN Client Need: Reduction of Risk Potential
Topic: Potential for Complications of Diagnostic Test/Treatments/Procedures
Subtopic: Chest tubes
Subject: Adult Health
Lesson: Respiratory
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
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)
The home health nurse is talking to a client with iron-deficiency anemia. Which meal plan would indicate to the nurse that the client understood her discharge instructions?
A. Roast beef, gelatin salad, green beans, and peach pie
B. Chicken salad, coleslaw, French fries, ice cream
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisins
D. Pork chop, creamed potatoes, corn, and coconut cake
Explanation
A is incorrect. Roast beef is high in iron; however, the other dishes accompanying the meal are low in iron.
B is incorrect. Chicken and green leafy vegetables are rich in iron; however, french fries and ice cream have low nutritional value.
C is correct. Foods that are high in iron are egg yolks, wheat bread, carrots, green leafy vegetables, and raisins. This is an optimal meal for the client to increase his dietary iron intake.
D is incorrect. Pork chops contain high iron. Potatoes, corn, and coconuts, however, contain low iron.
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
