CAT 2 Flashcards
Which of the following are the steps of blood glucose level monitoring? Select all that apply.
A. Hold the finger downward so the blood will drop by gravity
B. Use sterile gauze to wipe off the first drop of blood before testing
C. Collect the second blood drop on the test strip.
D. Use a lancet to prick the pad of the finger
Explanation
The correct answers are A, B, and C.
The procedure for checking the client’s blood glucose levels in a correct sequential order is as follows:
Verify and confirm that the code strip corresponds to the meter code. Disinfect the client’s finger with an alcohol swab. Prick the side of the finger using the lancet. Turn the finger down so the blood will drop with gravity. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client’s finger after the specimen has been obtained. Read the client’s blood glucose level on the monitor.
Choice D is incorrect. The side of the finger should be pricked with the lancet, not the pad. Finger pads are not recommended for pricking because they are the thickest part of the finger, so one will have to prick deeper to get the required amount of blood
NCSBN Client Need
Topic: Physiological Integrity;Subtopic: Reduction of Risk Potential
Explanation
The correct answers are A, B, and C.
The procedure for checking the client’s blood glucose levels in a correct sequential order is as follows:
Verify and confirm that the code strip corresponds to the meter code. Disinfect the client’s finger with an alcohol swab. Prick the side of the finger using the lancet. Turn the finger down so the blood will drop with gravity. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client’s finger after the specimen has been obtained. Read the client’s blood glucose level on the monitor.
Choice D is incorrect. The side of the finger should be pricked with the lancet, not the pad. Finger pads are not recommended for pricking because they are the thickest part of the finger, so one will have to prick deeper to get the required amount of blood
NCSBN Client Need
Topic: Physiological Integrity;Subtopic: Reduction of Risk Potential
Explanation
Answer: troponin
Troponins are regulatory proteins found in skeletal and myocardial muscles. When there is decreased blood flow and subsequent infarction to the heart muscle, troponin levels increase. This is one of the most basic lab tests the providers will order to help evaluate a patient for an MI.
NCSBN Client Need
Topic: Reduction of Potential Risk Subtopic: Laboratory Values
Reference:
Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 119
Which of the following would not be included when documenting objective data regarding the patient’s general appearance and behavior? Select All That Apply.
A. “Thoughts logical.”
B. “Clothes disheveled”
C. “Alert and oriented to place, person, and time”
D. “Judgment intact”
Explanation
Choices A, C, and Dare correct. Each of these answer options is subjective data based on a conversation with the patient. These would not be included in the objective assessment of general appearance and behavior.
Subjective data are information from the client’s point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing.
Observations of the patient’s appearance and behavior provide information about various aspects of the patient’s health. Representation of the patient’s body build, posture and gait are essential. Uncoordinated or spontaneous body movements should be documented. Hygiene and grooming should be observed, and any deficits should be noted. Clues to mood and mental health care are provided by speech, facial expressions, ability to relax, eye contact, and behavior.
Choice B is incorrect. General appearance and behavior represent objective data that the nurse obtains through observation. This would be included in the documentation asked in the question.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer);Chapter 25: Health Assessment;Lesson: Performing a General Survey
Which of the following patients should have their temperature measured orally? Select All That Apply.
A. A 61-year-old woman who has had oral surgery
B. A 44-year old man with chest pain with oxygen via. nasal canula
C. An 83-year-old woman with diarrhea
D. A 29-year-old patient with an earache
Explanation
The correct answers are B, C, and D. There is no contraindication for oral temperature measurement in any of these patients (Choices B, C, and D). The oral temperature is measured with the probe placed under the tongue, and the lips closed around the instrument. Oxygen delivered by nasal cannula does not affect the accuracy of the measurement.
Choice A is incorrect. Oral surgery may falsely increase the local temperature by causing surgery-related inflammation. Oral temperature measurement is contraindicated in:
Patients who have altered mental status because they may not cooperate fully. Rectal thermometers are indicated in children and in patients who will not or cannot work fully. Those who are mouth breathers. Mouth breathing can affect the accuracy of oral temperature. Those who have had a recent oral intake of cold or hot foods/ drinks Those who have recently smoked Those who have recently undergone oral surgery.
NCSBN Client Need
Topic: Health Promotion and Maintenance.
Reference: Nursing Health Assessment: A Best Practice Approach (Walters Kluwer)
Chapter 5: Vital Signs and General Survey; Lesson: Temperature
When giving an oral medication, it is essential to ensure there are no reasons to withhold the medication. Out of the following circumstances, when should the nurse comfortably give a prescribed dose of warfarin?
A. After the patient has tested positive for pregnancy.
B. After the patient has eaten a large kale salad.
C. While the patient is receiving epidural anesthesia.
D. When the patient has a platelet count below 30,000/mcL.
v
Explanation
Choice B is correct. While warfarin is a medication with many food-drug interactions, there is no reason to hold the drug in a situation like this. Warfarin exerts its anticoagulant effect by antagonizing vitamin K and thereby, reducing vitamin-K dependent clotting factors. Kale is a food that decreases warfarin’s effect because Kale is rich in vitamin K. Rather than holding the medication, the nurse should give warfarin as prescribed and notify the prescribing physician regarding the patient’s Kale intake. Physician may request the labs to be drawn before the next due dose or within 48 hours, to check if the INR remained within therapeutic range, between 2.0 and 3.0.
Choice A is incorrect. Warfarin is a teratogen and can cross the placenta to reach the developing fetus. It may cause birth defects (fetal warfarin syndrome), stillbirths and/ or miscarriages. Fetal warfarin syndrome is characterized by low birth weight, slower growth, mental retardation, deafness, small head size, and malformed bones, cartilage, and joints. Warfarin is strictly contraindicated during pregnancy. Pregnant women with venous thrombosis are anticoagulated with low molecular weight heparin or unfractionated heparin.
Choice C is incorrect. A patient new to warfarin therapy and who is on epidural anesthesia should not be initiated on warfarin because they are at an increased risk of bleeding at the epidural site. A hematoma in such a location may lead to significant neurological compromise. All anticoagulants carry the risk of causing spinal bleeding/ hematoma when used in conjunction with epidural/spinal anesthesia, so caution is warranted.
Choice D is incorrect. Normal platelet count is greater than 150,000/microliter. A platelet level below 30,000 is considered too low to receive warfarin therapy. Often, anticoagulation is held once platelets are lower than 50,000. Platelet count less than 50,000 is associated with increased risk of intracranial bleeding.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
When assessing a patient’s eyes for accommodation, which of the following actions would the nurse perform? Select All That Apply.
A. Bring a penlight from the side of the patient’s face and briefly shine the light on the pupil.
B. Hold a forefinger, a pencil, or another straight object about 10 to 15 cm (4” to 6”) from the bridge of the patient’s nose
C. Hold a finger about 6” to 8” from the bridge of the patient’s nose
D. Darken the room
E. Ask the patient to look straight ahead
F. Ask the patient to first look at a close object, then at a distant object, and then back at the close object.
Explanation
The Accommodation Eye Test is performed to test reflex accommodation on the eyes. Healthy eyes can seem distant or close objects. This is done by dilating and narrowing the pupils. Pupils will narrow to direct and consensual responders.
Choices B and F are correct. To test accommodation, the nurse would hold the forefinger, a pencil, or another straight object about 4-6 inches from the bridge of the patient’s nose. Then the nurse would ask the patient to first look at the purpose, then at a distant object, then back to the object being held. The pupil constricts typically when looking at a near object and dilates when looking at a distant object. A, C, D, and E are incorrect. These are all steps that should be done when testing for convergence. The nurse would darken the room and ask the patient to look straight ahead. The nurse would then bring the penlight from the side of the patient’s face and briefly shine the light on the pupil, observing the reaction. When testing for convergence, the nurse would hold a finger about 6-8” from the bridge of the patient’s nose and move it toward the patient’s nose.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn);Chapter 25: Health Assessment;Lesson: Types of Visual Examinations
Select the sensory impairment that is accurately paired with one of its possible causes or a method for assessing it. Select all that apply:
A. Impaired gustatory sensation: Using the Grady Scale
B. Impaired tactile sensation: Diabetes
C. Impaired auditory sensation: Using the Braden Scale
D. Impaired Stereognosia: Alzheimer’s disease
E. Impaired Proprioception: Morse Scale
Explanation
Correct Answers are B and D. Impaired tactile sensation is often caused by peripheral neuropathy secondary to diabetes. Peripheral neuropathy, a long term complication of diabetes, is characterized by the person’s inability to feel things like heat, cold, and a painful stimulus like the prick of a needle in their feet.
Impairedstereognosisis the lack of the client’s ability to identify an everyday object with tactile sensations and without visual cues.Impaired Stereognosiais associated with Alzheimer’s disease.
Choice A is incorrect. The impaired gustatory sensation is assessed by providing the client with small tastes of sweet, sour, salty, and spicy foods to identify for their feelings. Grady Scales used to determine levels of consciousness and not gustatory sensation.
Choice C is incorrect. The impaired auditory sensation is assessed by using an audiometer or a tuning fork.
Braden Scales used to screen clients for their risk of developing a pressure ulcer. The Braden Scale uses scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing a pressure ulcer. Score categories include 19-23 = no risk; 15-18 = mild risk; 13-14 = moderate risk or less than 9 = severe risk
Choice E is incorrect. Proprioception is the sense of the relative position of body segments about other body segments. Examples of tests used to assess Proprioception include the Finger-Nose test, the Heel-shin test, Thumb finding test.
Morse scale is used to assess a patient’s risk of falling, not proprioception. It consists of six variables that are quick and easy to score. This history of falling - immediate or within 3 months; Secondary diagnosis; Ambulatory aids; Intravenous therapy; Gait and Mental status.
NCBSN Client needs:
Category: Psychosocial Integrity Sub-Topic: Sensory/Perceptual Alterations.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
Which of the following is the most appropriate way to document a patient’s refusal of medication?
A. “Patient refused the heparin injection when I tried to give it.”
B. “Heparin refused during shift.” Risks reviewed.”
C. “Patient stated she did not want the SQ heparin injection at this time.”
D. “Subcutaneous heparin injection was attempted per physician’s order.”
Explanation
Choice D is correct. Documentation in healthcare should be objective, thorough, but direct. It should also be articulate with proper grammar and spelling.
While documenting the refusal of medication, the nurse shouldchart:
Assessment of patient's mental status, including patient's statements and behaviors.
Information and risks of treatment refusal that were disclosed to the patient and the patient's response(in his own words).
Patient's questions and your response.
Choices A, B, and C are incorrect. When documenting, the nurse should use objective terms. Documentation should not include allusive/oblique remarks ( Choice A), generalities, assumptions, or opinions.
As much as possible, documentation should be articulate and include proper grammar and spelling ( Choice B). Abbreviations should be avoided. Using SC or SQ to document the subcutaneous administration route is forbidden because it may be confused with SL ( sub-lingual). The correct method is to document as Sub-Q, subQ, or subcutaneous. (Choice C).
NCSBN Client Need
Topic: Physiological Integrity;Subtopic: Reduction of Risk Potential
Resource: Fundamentals of Nursing (Taylor/Linnis/Lynn);Chapter 16: Documenting, Reporting, Conferring, and Using Informatics;Lesson: Documenting Refusal of Medication
The nurse is supervising a new graduate place in an intravenous catheter. Select all the nursing interventions that have been proven effective in terms of beginning and maintaining intravenous access.
A. Not attempting an intravenous start more than one time
B. Using the shortest length catheter as possible
C. Using the smallest size catheter as possible
D. Reviewing the medical history to determine any previous untoward effects of IV access
E. Using the most distal hand veins when possible
F. Applying warm compresses to the site for 10 minutes
Explanation
Choices B, C, and F are correct. Using the shortest length catheter as possible, using the smallest size catheter as possible, and applying warm compresses to the site for 10 minutes for vasodilation are three effective nursing interventions for beginning and maintaining intravenous therapy.
Other effective nursing interventions include:
not attempting to start an intravenous line for more than two times reviewing the client’s medical history to determine if there are any contraindications to a specific IV site, like a history of mastectomy or prior lymph node dissection. to use the most distal veins of the arm,not the hand. Hand veins should be avoided whenever possible to prevent inadvertent nerve damage.
Choice A is incorrect. Intravenous attempts can be attempted more than one time.It is preferred to keep the attempts to two or less.
Choice D is incorrect. Although the nurse should review the medical history, the purpose of this review is to determine if there are any contraindications to a specific IV site, like a mastectomy. The purpose of this review is not to identify any previous untoward effects of IVs. For example, if the client had an IV site infection or superficial thrombophlebitis with prior IV site, it is irrelevant to the current IV access.
Choice E is incorrect. It is not appropriate to use most distal hand veins. Distal hand veins should be avoided whenever possible to prevent inadvertent nerve damage.
Which of the following is an example of a nurse-initiated nursing action? Select All That Apply.
A. The nurse administers 1000 mg of Cipro to a patient with pneumonia
B. The nurse consults with a psychiatrist for a patient who is abusing prescription pain medications
C. The nurse checks the skin of bedridden patients for break down
D. A nurse orders a kosher meal for an orthodox Jewish patient
E. The nurse records the intake & output of a patient as prescribed by her physician
F. The nurse prepares a client for minor surgery according to facility protocol
Explanation
Choices C, D, and F. Nurse-initiated interventions, also known as independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs that are written on the nursing care plan, as well as other activities that nurses can initiate without the direction or supervision of another healthcare personnel. A nurse-initiated intervention is an autonomous action based on the scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes.
Nursing interventions are actions performed by the nurse to :
Monitor patient health status and response to treatment Reduce risks Resolve, prevent, or manage a problem Promote independence with ADLs Promote an optimum sense of physical, psychological, and spiritual well-being Give patients the information they need to make informed decisions and be independent.
Nurse-initiated interventions do not require a physician’s order. Instead, like patient goals, they are derived from the nursing diagnosis.
Choices A and E are incorrect. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or physician supervision. For example, intake-output monitoring protocol is often prescribed by the physician.
Choice B is incorrect. Consulting with a psychiatrist is a collaborative intervention, not an independent nursing action.
NCSBN Client Need I Topic: Safe and Effective Care Environment; Subtopic: Coordinated Care
Which of the following are components of a comprehensive health assessment? Select All That Apply.
A. Goals and outcomes
B. Examination of body systems
C. Nursing diagnoses
D. Collaborative problems
Explanation
The correct answer is B. In a comprehensive assessment; the nurse collects subjective and objective data. This includes a history of the current problem, medical history, and common symptoms, as well as a head-to-toe physical examination.
The three most common types of nursing assessments are emergency, comprehensive, and focused. Emergency and focused assessments center on the highest priority problem. Comprehensive assessments cover a broader range of data. The amount and type of information vary depending on the patient’s needs, purpose of data collection, health care setting, and the nurse’s role.
Choice A is incorrect. Goals and outcomes are addressed in the nursing care planning in the Planning and Evaluation stages.
Choice C is incorrect. Data from the comprehensive assessment is used to identify an appropriate nursing diagnosis and care plan. The nursing diagnosis is not, however, considered part of the actual evaluation.
Choice D is incorrect. Each part of a collaborative problem focuses on different aspects and concerns.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Reference: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 1: The Nurse’s Role in Health Assessment; Lesson: Types of Nursing Assessments
Select the complication(s) of intravenous therapy that is (are) accurately paired with its possible cause.
A. Mechanical phlebitis: A loose insertion site dressing
B. Bacterial phlebitis: The lack of catheter stabilization
C. Chemical phlebitis: The administration of a vein irritating medications
D. Extravasation: The lack of catheter stabilization
E. Infiltration: A catheter that is too small for the selected vein
F. Site ecchymosis: Removing the tourniquet before starting the IV fluid flow.
G. Cellulitis: The lack of medical aseptic technique
H. Catheter embolus: Reinserting the stylet into the catheter during IV starts
I. Thrombophlebitis: The failure to change the IV site at least every 5 days
Explanation
Correct Answers are C, D, and H.
Correct. Chemical phlebitis can be caused by the administration of a vein irritating medications, among other causes; extravasation can be caused by the lack of catheter stabilization, among other reasons; and catheter embolus can be caused by reinserting the stylet into the catheter during IV starts, among other reasons.
Choice A is incorrect. A loose insertion site dressing does not cause mechanical phlebitis
Choice B is incorrect. The lack of catheter stabilization does not cause bacterial phlebitis.
Choice E is incorrect. Infiltration is not caused by a catheter that is too small for the selected vein; it can, however, be caused by too large a catheter for the chosen thread.
Choice F is incorrect. Site ecchymosis is not caused by removing the tourniquet before starting the intravenous fluid flow. It can, however, be caused by starting the intravenous fluid flow before removing the tourniquet.
Choice G is incorrect. The lack of medical aseptic technique does not cause cellulitis; it can, however, be caused by the lack of sterile technique, which is over and above therapeutic aseptic technique.
Choice I is incorrect Thrombophlebitis can be caused by a failure to change the IV site at least as every 72hours, which is less than five days.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.
Which of the following special considerations should the nurse make when caring for a Hindu patient based on her religion? (Select all that apply).
A. Provide all vegetarian meals.
B. Handle the client’s temple garments with care.
C. Be sure the bathroom is equipped with a shower and not just a tub.
D. Be aware that the patient will likely refuse blood transfusions.
E. Arrange for female nursing staff to provide care for the client as much as possible.
F. Be aware that the patient will likely refuse pain medication.
Explanation
Choices C and E are correct. Hindus prefer to wash in free-flowing water (e.g., a shower instead of a tub bath) ( Choice A). If a shower is not available, provide a jug of water for the person to use in the tub. Hindus practice ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Most Hindus are lactovegetarians. Most will not eat beef and avoid bovine-derived medications because they believe in the reincarnation of certain gods. Fasting usually means eating only “pure” foods, such as fruit or yogurt, but it is not expected of the sick. Hindu women are modest and usually prefer to be treated by female medical staff ( Choice E).
Choice A is incorrect. Although some Hindus will eat eggs and even chicken, most are lactovegetarians, consuming milk but no eggs.
Choice B is incorrect. Hindus may wear a “sacred thread” or religious jewelry around their body or wrist. Mormons, not Hindus, wear “temple garments.”
Choice D is incorrect. Jehovah’s Witnesses—not Hindus—refuse to accept blood transfusions or blood products, which they view as morally wrong.
Choice F is incorrect. Christian Scientists—not Hindus—would be likely to refuse pain medication.
NCSBN Client Need:Topic: Psychosocial Integrity
Reference: Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith)
he nurse caring for a client who has received third-degree burns to his arm notes that he is scheduled for an escharotomy. The nurse plans to keep a close eye out for which of the following anticipated outcomes of this procedure?
A. Frank bleeding from the site
B. Reduced Edema
C. Return of pulses distal to the site
D. The formation of granular tissue
Explanation
NCSBN client need | Topic: Physiologic Adaptation, Therapeutic procedures
Rationale:
The correct answer is C. Escharectomies are completed to remove eschar, slough, or dead tissue from the skin and to relieve compartment syndrome, which sometimes occurs after severe burns. Health care providers consider these procedures successful when pulses distal to the site return.
Choice A is not correct. While some bleeding is expected after this procedure, frank bleeding is too much bleeding and may indicate a problem or adverse response to the therapy.
Choice B is incorrect. This procedure generally does not impact the formation of swelling.
Choice D is incorrect. The creation of granular tissue is not the intention of this procedure.
Reference:
Williams LHopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co.; 2011.
The nurse manager is supervising a unit with patients that have an advance directive. Which client would the nurse manager suggest to the staff to utilize the advance directive?
A. The client with a traumatic brain injury who is displaying decerebrate posturing.
B. The client who is on a mechanical ventilator with a C6 spinal cord injury.
C. The client in chronic renal disease who is being placed on dialysis.
D. The client diagnosed with terminal cancer who is mentally retarded.
Incorrect
Correct Answer(s): A
45%
of peers have answered
Explanation
A is correct. The client must lose his capacity in decision making for an advance directive to take place. Examples of these client conditions are terminal persistent vegetative state and irreversible coma. Decerebrate posturing indicates the inability to make informed decisions.
B is incorrect. The client on a mechanical ventilator can still be conscious and make decisions. The client can even communicate using non-verbal communication.
C is incorrect. A client receiving dialysis can still make conscious decisions and does not need an advance directive.
D is incorrect. Mental retardation does not mean that the client cannot make decisions for himself unless he or she has a legal guardian that can make decisions on his/her behalf.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
What findings are expected when assessing a patient with atelectasis? Select All That Apply.
A. Decreased breath sounds
B. Increased tactile fremitus
C. Hyperresonance
D. Shortness of breath
E. Decreased oxygen saturation
Explanation
Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure changes and the exchange of gas by diffusion in the lungs. Areas of the lung with atelectasis cannot fulfill the function of respiration. Coughing, chest pain, cyanosis, dyspnea, and tachycardia are common symptoms of atelectasis.
Answer and Rationale:
The correct answers are A, B, D, and E. With atelectasis, lung tissue has collapsed, which leads to less mass that provides oxygenation. The oxygen saturation is decreased, as well as breath sounds. Additionally, the patient will experience shortness of breath. Because lung tissue is consolidated, tactile fremitus is increased. C is incorrect. The percussion sound may be dull, but not hyper resonant, as a result of consolidation.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer)
Chapter 38: Oxygenation and Perfusion
Lesson: Respiration
Which of the following is considered a normal blood glucose value for a 30-year-old male? Select All That Apply.
A. 55 mg/dl
B. 112 mg/dl
C. 70 mg/dl
D. 98 mg/dl
Explanation
The determination of blood glucose levels allows health professionals to monitor the administration of oral hypoglycemic medications. Any laboratory data about a client must be compared to the agency or performing laboratory’s norms for that particular test and the client’s age, gender, and other characteristics.
Normal blood sugar levels are less than 110 mg/dL after not eating for at least eight hours. And they’re less than 140 mg/dL two hours after eating.
During the day, levels tend to be at their lowest just before meals. For most people without diabetes, blood sugar levels before meals hover around 70 to 80 mg/dL. For some people, 60 is standard; for others, 90 is the norm.
The correct answers are B, C, and D. A is incorrect. The standard range for serum glucose levels is 60-115.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Chapter 12: Stress and Adaptation
Lesson: Endocrine System Responses
Reference: Fundamentals of Nursing(Wilkinson/Barnett)
The cardiac nurse is evaluating cardiac markers to determine whether or not their patient’s heart has suffered from muscle damage. The nurse is aware of that. If damage has occurred, CK-MB levels will be their highest after how many hours?
A. 3 to 6
B. 1 to 2
C. 48 to 72
D. 18
Explanation
NCSBN client need | Topic: Physiological adaptation, reduction of risk potential
Rationale:
The correct answer is D. CK-MB or creatine kinase, myocardial muscle, levels measure muscle cell death, and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels first begin elevating about 3 to 6 hours after a cellular injury or myocardial infarction and stay elevated for about 48 to 72 hours.
Choice A is incorrect. While CK-MB levels begin to rise about 3 to 6 hours after myocardial cellular death, they do not peak until 18 hours.
Choice B is incorrect. CK-MB enzyme levels will not have risen yet by 1 to 2 hours. Standards do not begin to rise until 3 to 6 hours and hit their peak around 18 hours.
Choice C is incorrect. At 48 to 72 hours, CK-MB enzyme levels will have likely returned to normal.
Reference:
Sole M, Klein D, Moseley M. Introduction To Critical Care Nursing. 1st ed. St. Louis, Mo.: Saunders; 2009.
The nurse is managing a unit with a newly hired nurse who is currently in the orientation phase of employment. The group is faced with a situation where the newly hired employee is needed to perform patient care. Which practice is within the requirements of the Joint Commission on the Accreditation of Health Care Organizations (JCAHO)?
A. Do not let the new nurse perform any duties until orientation is completed.
B. The new nurse may perform patient care since he/she is already licensed
C. Provide the nurse with necessary educational materials/modules, then allow the nurse to proceed with patient care
D. Give the new nurse a peer to assist with care while assessing competency
Explanation
Rationale: By allowing the newly hired nurse to work with a preceptor, as suggested by JCAHO, the staff would be able to assess and evaluate clinical competency and identify areas that need further training. The correct answer is option D. Option A does not allow the staff to observe the new nurse’s skill, therefore incorrect. Licensure is not a measure of competence. Therefore option B is also false. Educational modules will help identify the nurse’s knowledge regarding various aspects of care but does not allow assessment of performance and clinical competency. Option C is, therefore, incorrect.
Reference:
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Kelly, P; Marthaler, M; Nursing Delegation, Setting Priorities, and Making Patient Care Assignments, 2nd Edition; Cengage Learning, 2010
Which of the following clinical manifestations would alert the nurse to the possibility of Kawasaki disease in her 8-year-old patient? Select all that apply
A. Strawberry tongue
B. Fruity breath
C. Drooling
D. Bright red, swollen lips
Explanation
Answer: A and D
A is correct. Kawasaki disease is a swelling in the walls of the arteries throughout the body. Because of this inflammation, a strawberry tongue is a common identifying symptom. Other signs and symptoms include a high fever that persists for five or more days, a rash on the torso and groin, bloodshot eyes, bright red, swollen lips, and red palms and soles of the feet.
B is incorrect. Fruity breath is not a sign of Kawasaki disease. Fruity breath is characteristic of a child presenting with DKA.
C is incorrect. Drooling is not a sign of Kawasaki disease. Fruity breath is characteristic of a child presenting with epiglottitis.
D is correct. Kawasaki disease is a swelling in the walls of the arteries throughout the body. Because of this inflammation, bright red, swollen lips are a common identifying symptom. Other signs and symptoms include a high fever that persists for five or more days, a rash on the torso and groin, bloodshot eyes, a strawberry tongue, and red palms and soles of the feet.
NCSBN Client Need:
Topic: Effective, safe care environment
Subtopic: Coordinated care
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatrics
Lesson: Endocrine
Which of the following images correctly demonstrates an atrial septal defect? A .choice B .choice C .choice D .choice
Explanation
Choice A is correct. This image shows a heart with an atrial septal defect ( ASD) or communication between the left and the right atrium. An ASD leads to mixing the blood as the blood passes along the opening in the interatrial septum. Because the pressure on the left side is higher than the right, oxygenated ( pure) blood moves from left atrium to right atrium ( left to right shunt), then to the right ventricle, across the pulmonic valve, and then into pulmonary circulation ( lungs). This type of left to right shunting does not cause cyanosis.
If the ASD is small, the shunting is insignificant. On the other hand, if the ASD is large, a large volume left-to-right shunt increases the preload on the right ventricle. As a result, the right ventricle hypertrophies and eventually fails ( heart failure). In addition, continued increased blood flow through the pulmonary valves into pulmonary arteries and lungs ends up causing pulmonary hypertension. Therefore, the complications of a large ASD include heart failure and pulmonary hypertension. Patients may present with dyspnea, fatigue, exercise intolerance, palpitations, or signs of right-sided heart failure. Arrhythmias may occur. A stroke or a transient ischemic attack following a diagnosis of deep venous thrombosis should raise a strong suspicion of ASD ( venous blood clot moving through the ASD to arterial side and causing a stroke).
ASD Murmur: In a moderate to large ASD, the nurse can auscultate a crescendo-decrescendo systolic ejection murmur ( second intercostal space at the left sternal border, pulmonic area). The murmur occurs because the left-to-right shunt results in increased right ventricular stroke volume across the pulmonary valve. The murmur is quiet at the beginning of systole, increases mid-systole, and then decreases at the end of systole (crescendo-decrescendo)
Choice B is incorrect. This image shows a heart with coarctation of the aorta, a narrowing or stricture in the aorta.
Choice C is incorrect. This image shows a heart with a ventricular septal defect; communication between the left and right ventricles.
Choice D is incorrect. This image shows a heart with truncus arteriosus, a defect where the pulmonary artery and aorta formed into one vessel instead of two separate ones.
NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care
You are the nurse in the medical unit. You are caring for an eighty-year-old woman with a long-standing history of asthma. You are preparing to give a dose of theophylline to the patient. You know that the most critical observation before giving this dose is:
A. Temperature
B. Blood Pressure
C. Urinary Output
D. Pulse
Explanation
Correct Answer: D. A severe side effect of theophylline is an increased or erratic pulse rate. The nurse should evaluate the character of the pulse and the price since one of the side effects of theophylline is cardiovascular arrhythmias. Severe side effects, including arrhythmias, usually occur when the theophylline level is too high in the body. Theophylline should be given on an empty stomach with a full glass of water. Although theophylline does not cure asthma, it can help to control symptoms if taken regularly. Other common side effects of theophylline include nausea, diarrhea, headache, insomnia, restlessness, vomiting, and seizures. Administration of theophylline can affect the patient’s blood pressure and urinary output, but these effects are less common. Theophylline does not typically change the patient’s temperature.
NCSBN Client Need
Topic: Pharmacological and Parenteral Therapies
Sub-Topic: Adverse Effects/Contraindications/Side Effects/Interactions
Subject: Pharmacology
Lesson: Respiratory
Reference: U.S. National Library of Medicine. Medline Plus. Theophylline. https://medlineplus.gov/druginfo/meds/a681006.html. Accessed online on October 21, 2019.
You are precepting a new graduate LPN and begin to review sickle cell anemia. You explain to her that the normal allele for hemoglobin is S, and the abnormal allele for sickle hemoglobin is s. You know she understands your teaching when she tells you that the type of hemoglobin your patient with sickle cell anemia has is
A. ss
B. Ss
C. SS
D. sC
Choice A is correct. Sickle cell anemia is an autosomal recessive disease, meaning a person must harbor two abnormal alleles to exhibit the disease. In the description, normal allele is denoted by the letter “S” where as the abnormal allele with letter “s”. Therefore, based on the description in the question, the genotype ss best represents a sickle cell anemia (sickle cell disease).
Choice B is incorrect. Ss represents a carrier state where the patient has one normal (S) allele, and one abnormal (s) allele. Carrier state will not present any signs or symptoms of the disease to the individual but it is of importance because the abnormal allele may be passed on to the offspring.
Choice C is incorrect. Based on the description given the question, S represents a normal allele. Therefore, SS represents a normal genotype.
Choice D is incorrect. Hemoglobin SC disease occurs in those patients that have one copy of the gene for sickle cell disease and one copy of the gene for hemoglobin C disease.
The nurse is discussing the use of medications to prevent organ rejection with the health care provider. Which of the following medicines is not used to avoid organ rejection?
A. Oxybutynin chloride
B. Prednisone
C. Tacrolimus
D. Cyclosporine
Explanation
NCSBN client need | Topic: Physiological Integrity, Pharmacological and Parenteral therapies
Rationale:
The correct answer is A. Oxybutynin chloride is an anti-cholinergic medication often used for overactive bladder. This medication is not used to prevent organ rejection.
Choice B is incorrect. Prednisone, a glucocorticoid medication, is frequently used in conjunction with other medicines to prevent organ rejection.
Choice C is incorrect. Tacrolimus is an immunosuppressive medication used to prevent organ rejection.
Choice D is incorrect. Cyclosporine is an immunosuppressive medication used to prevent organ rejection.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
Which form of therapy would most likely be used to treat a group of clients affected by phobias?
A. Behavioral psychotherapy
B. Cognitive behavioral psychotherapy
C. Psychoanalysis
D. Cognitive psychotherapy
Explanation
Choice A is correct. Behavioral psychotherapy is useful for patients who are adversely affected by phobias, substance-related disorders, and other addictive disorders. Some of the techniques used with behavioral therapy include operant conditioning as put forth by Skinner, aversion therapy, desensitization therapy, modeling, and complementary and alternative stress management techniques.
B is incorrect. Cognitive-behavioral psychotherapy is a treatment that combines cognitive psychotherapy and behavioral psychotherapy. It is also referred to as dialectical behavioral therapy. The most common use of this type of therapy is for clients with a personality disorder who are at risk for injury to themselves and others.
C is incorrect. Psychoanalysis deals with the client’s subconscious and focuses on past and current issues. It is conducted only by experienced psychotherapists.
D is incorrect. Cognitive psychotherapy is primarily used to treat patients with depression, anxiety disorders, or eating disorders. It is aimed at altering the client’s perspective and attitudes relating to stressors.
NCSBN Client Need
Topic: Psychosocial Integrity
Reference:
Fundamentals of Nursing (Kozier and Erbs);Chapter39: Self Concept;Lesson:Factors Affecting Self Concept
Your client lacks insight into and an awareness of the temporary physical limitations that they will have after a complete hip replacement. Which social support would be the most beneficial to this client?
A. A physical therapist who specializes with clients who have had a total hip replacement
B. A close non medical friend who has had a total hip replacement six months ago
C. A nurse who specializes in education for clients who have had a total hip replacement
D. A non medical person who has had a total hip replacement six months ago
Explanation
Correct Answer is B
Correct. The social support person who would be the most beneficial to this client is a close nonmedical friend who has had a total hip replacement six months ago. People with a close friendship typically can talk with and communicate with others in an open, honest, and nonconfrontational manner without judgments. This close friend may be able to share their experiences after a total hip replacement to give their friend some insight into their recovery period.
Choice A is incorrect. A physical therapist that specializes in clients who have had a total hip replacement is not considered social support. Instead, this is a member of the healthcare team. Social supports are individuals or networks of individuals who are not part of the multidisciplinary team that provides care to the client but, instead, family, friends, or community networks.
Choice C is incorrect. A nurse who specializes in education for clients who have had a total hip replacement is not considered social support. Instead, this is a member of the healthcare team. Social supports are individuals or networks of individuals who are not part of the multidisciplinary team that provides care to the client but, instead, family, friends, or community networks.
Choice D is incorrect. Although a non-medical person who has had a total hip replacement six months ago may be useful to this client in terms of their lack of insight, ideally the client would benefit the most from the help of a person that they already have a close relationship with, such as a close friend.
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
You are a pediatric emergency room nurse triaging patients on a busy night. A 1-month-old present with the following symptoms: projectile vomiting after feeding, visible peristaltic waves across the epigastrium, and an olive-shaped mass in the epigastrium just right of the umbilicus. Based on your assessment, choose the image showing the anatomy the nurse expects this patient to demonstrate
Explanation
This image demonstrates hypertrophic pyloric stenosis; hypertrophy of the circular muscles of the pylorus. This causes the narrowing of the pyloric canal and does not allow food to pass from the stomach to the duodenum. The symptoms the child presents with are particular to pyloric stenosis, and this is what the nurse expects the surgeons to find when the operating rate. A shows an image of the normal anatomy of the stomach. C shows the anatomy of a hiatal hernia. A patient with this anatomy would not present with these symptoms. Lastly, D shows the anatomy of a patient with stomach cancer. Although patients with stomach cancer would present with vomiting, it would not be projectile vomiting directly after a feed as it is in pyloric stenosis.
NCSBN Client Need
Topic: Physiological adaptation Subtopic: Pathophysiology
Reference:
Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 454
The Registered Nurse is preparing a patient for a pneumonectomy. What teaching should the nurse discuss with the patient?
A. Instruct patient to lie on non-operative side following procedure.
B. Expect remaining lung to return to normal function within 2-6 hours.
C. Advise patient to avoid coughing, assure that nurse will use wall suction to clear secretions.
D. Keep head of bed elevated at 30-45 degree angle post-procedure.
Explanation
Correct Answer is D. Keeping the head of the bed between 30-45 degrees will minimize respiratory efforts and facilitate recovery post pneumonectomy. This intervention will also prevent post-pneumonectomy pulmonary edema. The patient should lie on the operative side and should have the head of the bed raised to 45 degrees as soon as awake. These positions minimize the gravitational effect on capillary pressure in the remaining lung.
A is incorrect. Lying on the non-operative slides will increase the risk of pulmonary edema and therefore, should be avoided. The patient would be instructed to lie on the backor operative side only to prevent leaking of fluid into the operative side ( pulmonary edema) and to allow full expansion of the remaining lung.
B is incorrect. The remaining lung will require 2-4 days to adjust to increased blood flow.
C is incorrect. Deep breathing, coughing, and splinting are encouraged during the post-op period to promote the expansion of the lung. Wall suction is contraindicated after pneumonectomy.
NCBSN Client need:
Topic: Reduction of Risk Potential. Sub-Topic: Use precautions to prevent injury and/or complications associated with a procedure or diagnosis
Reference:
Jones & Fix, 2015, p. 127-128
A 15-month-old infant is brought to the well-baby clinic for immunizations. On assessment, he was found to have a “runny” nose, and his mother tells the nurse that he has had it for over a week. Overall assessment findings indicate that the baby is well, except for a mild upper respiratory infection. According to his immunization card, his last immunization was at nine months old when he received DPT 2, OPV 2, and HIB 2 vaccines. The plan of care for this infant would be:
A. Administer DPT 3, OPV3, HIB 3 and Hepatitis B vaccines
B. Administer DPT 3, OPV 3, HIB 3, hepatitis and MMR vaccines
C. refer the infant to the physician for mild upper respiratory tract infection
D. Do not administer any vaccine and schedule a return visit in 2 weeks to see if the URI has resolved
Explanation
At 15 months, the recommended vaccines are DPT 3, OPV 3, HIB 3, Hepatitis B, and MMR. A mild URI is not a contraindication to the administration of any vaccine.
It is not necessary to refer the child to a physician at the moment. The correct answer is option B. Options A, C, and D are incorrect.
Reference:
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins
The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is most at risk for hypokalemia?
A. A client with hyperemesis gravidarum
B. A client in renal failure
C. A client in diabetic ketoacidosis
D. A client with third degree burns
Explanation
Answer: A
A is correct. Hyperemesis gravidarum is a pregnancy complication that is characterized by severe nausea, vomiting, weight loss, and possibly dehydration. The intense vomiting is why this condition puts the patient at risk for hypokalemia. Gastrointestinal fluids are rich in potassium, and any patient losing large amounts of their stomach acid will be at risk for hypokalemia. This could include vomiting, NG tube suctioning, or diarrhea.
B is incorrect. A client in renal failure will be at risk for hyperkalemia, not hypokalemia. The kidneys will be unable to excrete potassium as they normally do, and there will be a build up of potassium in the blood leading to hyperkalemia.
C is incorrect. A client in diabetic ketoacidosis will be at risk for hyperkalemia, not hypokalemia. When a client is in diabetic ketoacidosis (DKA) glucose is unable to be transported into cells due to the lack of insulin. The body resorts to breaking down fat cells for energy, which produce ketones and drive the blood pH down. Due to the acidity and high glucose content of the blood, fluid and potassium are driven out of the cells and into the blood, causing hyperkalemia. If the client was experiencing alkalosis, they would be at risk for hypokalemia.
D is incorrect. A client with third degree burns will be at risk for hyperkalemia, not hypokalemia. Burns destroy tissue and lyse cells, causing large amounts of intracellular potassium to be released into the vascular space therefore causing hyperkalemia.
NCSBN Client Need: Physiological Adaptation
Topic: Fluid & Electrolytes imbalances
Subject: Fundamentals of care
Lesson: Fluids & Electrolytes
The parents of a 2-year old with Hirschsprung’s disease is talking to the nurse in the family clinic. They ask the nurse about treatment options for Hirschsprung’s disease; the nurse understands that the treatment of choice would be
A. A colostomy
B. Senna concentrate
C. Polyethylene glycol
D. Colectomy
Explanation
A is incorrect. A colostomy is done to relieve symptoms of colonic obstruction. It is a temporary treatment for the condition until the client is old enough to undergo a colectomy.
B is incorrect. Hirschsprung’s disease does not respond to medication due to the missing nerves in the colon.
C is incorrect. Hirschsprung’s disease does not respond to medication due to the missing nerves in the colon.
D is correct. In Hirschsprung’s disease, the aganglionic section of the colon is removed, and the unaffected, functioning ends are attached to each other. In some cases, a Pull-through procedure is done, where a surgeon removes the segment of the large intestine lacking nerve cells and connects the first part to the anus.
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
Which statement about the crisis is accurate?
A. Crises require lengthy care and support from nurses.
B. Crises destroy the person’s motivation to learn.
C. Crises lead people to surround themselves with others.
D. Crises are typically self-limiting and brief in duration.
Correct
Answer
Explanation
Correct Answer is D
Correct. Crises are typically self-limiting and brief in duration, and, with the help of others, including nurses, the client should be able to resolve the crisis healthily.
Because crises are typically self-limiting and brief in duration, treatment and support are usually short term and not long term. Crises are associated with a severe state of discomfort, and, as such, they motivate the client to learn to solve and resolve this state of disequilibrium. Lastly, people in crisis tend to detach and separate themselves from others rather than to surround themselves with other people.
Choice A is incorrect. Crises and typically short-lived and brief, so they do not usually require lengthy care and support from nurses.
Choice B is incorrect. Crises are associated with a severe state of discomfort, and, as such, they motivate the client to learn to solve and resolve this state of disequilibrium.
Choice C is incorrect. People in crisis tend to detach and separate themselves from others rather than to surround themselves with other people.
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.
Which of the following would the nurse recognize as a risk factor for developing a gastric ulcer? (select all that apply)
A. Smoking
B. Alcohol
C. Aspirin
D. Spicy foods
E. NSAIDS
Explanation
A, B, C, and E are correct. Tobacco, alcohol, aspirin, and NSAID use are all known to increase the risk of both gastric and duodenal ulcers.
D is incorrect. Spicy foods do not cause gastric ulcers but can make symptoms worse when ingested if an abscess is present due to irritation.
Subject: Adult health
Lesson: Gastrointestinal
Topic: Elimination, dependencies/substance use disorder, nutrition, and oral hydration
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 987)
The unit manager notices that the nurse has been taking an extra 15 minutes for the lunch break thrice in the past week. Which action by the nurse manager is most appropriate?
A. Continue to observe the nurse’s behavior.
B. Make written notes on the nurse’s file.
C. Ask the nurse to check in with her before and after taking his lunch.
D. Mention the incident to the nurse concerned in an informal manner.
Explanation
A is incorrect. The behavior is becoming a pattern and should warrant intervention by the nurse manager. The manager should talk to the concerned nurse regarding the situation.
B is incorrect. This is only the third time that the incident occurred and did not warrant any formal documentation of behavior.
C is incorrect. This is a punitive action for the nurse manager to take. The manager should talk to the nurse first before implementing action.
D is correct. The nurse manager should talk to the nurse regarding the behavior informally. This is to find out the reason behind the issue and provide solutions.
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.
A neonate is suspected of having a tracheoesophageal fistula. Which symptom would the nurse observe from the neonate?
A. Hypersensitive gag reflex
B. Dry mouth
C. Cyanosis
D. Decreased level of consciousness
Explanation
A is incorrect. A hypersensitive gag reflex is not related to a tracheoesophageal fistula.
B is incorrect. An infant with a tracheoesophageal fistula would display excessive salivation and drooling, not a dry mouth.
C is correct. Cyanosis is a significant symptom in the infant with a tracheoesophageal fistula. This may be due to the aspiration of feeding when the infant is fed.
D is incorrect. A decreased level of consciousness is not related to a tracheoesophageal fistula.
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
