CAT 3 Flashcards
Which of the following are signs of hypocalcemia? Select all that apply.
A. Chvostek’s sign
B. Gray-Turner’s sign
C. Homan’s sign
D. Trousseau’s sign
Explanation
Answer: A and D
A is correct. Chvostek’s sign is an indication of hypocalcemia. This sign is positive if you tap your finger over a branch of the facial nerves and the patient’s upper lip on the same side twitches.
B is incorrect. Gray-Turner’s sign indicates abdominal issues, not hypocalcemia. Gray-Turner’s sign is ecchymosis around the flanks.
C is incorrect. Homan’s sign indicates a DVT, not hypocalcemia. Homan’s sign is positive when there is deep calf pain and tenderness while extending the leg straight and dorsiflexing the foot.
D is correct. Trousseau’s sign is an indication of hypocalcemia. This sign is positive if you inflate a BP cuff past the systolic blood pressure and observe a carpopedal spasm.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Subject: Adult Health
Lesson: Endocrine
Reference: Fong, J., & Khan, A. (2012). Hypocalcemia: updates in diagnosis and management for primary care. Canadian family physician Medecin de Famille Canadien, 58(2), 158–162.
There has been an increased incidence of SIDS in your hospital, and many of the new mothers delivering babies at your hospital are asking for more information about the syndrome. As a nurse on the Mother-Baby floor, you are placed in charge of creating a teaching handout for new mothers about SIDS prevention. It is important to include which of the following points in the gift? Select all that apply.
A. ‘Back-to-sleep’ is the safest position for infants to sleep; place them supine in their crib for all naps and at night.
B. Risk factors for SIDS include a hard crib mattress and hypothermia.
C. Cigarette smoking in the house can be a risk factor, so all family members should be encouraged to quit.
D. It is okay to leave stuffed animals and toys in the crib as long as they are away from the infant’s face.
Explanation
A is correct. This is the safest position for infants to sleep and should be included in the teaching handout.
B is incorrect. There are many risk factors for SIDS, but these are not. A soft mattress or bedding is a risk factor rather than a hard crib mattress. This is because if an infant rolls over onto his stomach in his and cannot turn back over, a soft mattress can suffocate them. A hard mattress will not conform to their face as quickly and be easier for them to breathe around. Hypothermia is also not a known risk factor for SIDS, slightly overheating, and thermal stress can be a cause.
C is correct. Smoking is a known risk factor for SIDS, and family members should be given information to help them quit to prevent SIDS.
D is incorrect. It is not safe for stuffed animals and toys to be in the crib when the infant is asleep due to the risk of suffocation.
NCSBN Client Need
Topic: Physiological Adaptation Subtopic: Alterations in Body Systems
Reference:
Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 483
Select the domain of pain that is accurately paired with its appropriate nonpharmacological, alternative, complementary pain management intervention
A. The spirit domain of pain: Reiki
B. The mind domain of pain: Massage
C. The body domain of pain: Self hypnosis
D. The social domain of pain: Music therapy
Explanation
Correct Answer is A
Correct. Reiki is a nonpharmacological, alternative, complementary pain management intervention for the spirit or spiritual, domain of pain. Reiki is performed by the reiki therapist by placing their hands above the person, or lightly on the person, to promote the client’s own healing processes including the management and control of pain.
Examples of other nonpharmacological, alternative, complementary pain management interventions for the spirit, or spiritual, domain of pain include prayer, meditation, and spiritual healing.
Choice B is incorrect. Massage is not a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain; massage, instead, is a nonpharmacological, alternative, complementary pain management intervention for the body domain of pain.
Choice C is incorrect. Self-hypnosis is not a nonpharmacological, alternative, complementary pain management intervention for the body domain of pain; self-hypnosis, instead, is a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain.
Choice D is incorrect. Music therapy is not a nonpharmacological, alternative, complementary pain management intervention for the social domain of pain; music therapy, instead, is a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain.
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 preparing to give morphine to a client with renal calculi and severe pain rated 9/10. Vitals are stable. What is the next step the nurse need to take?
A. Clamp the intravenous tubing next to the injection port.
B. Give the medication slowly over 2 minutes.
C. Identify the client using the client’s ID band.
D. Check the client’s intravenous site for patency.
Explanation
Choice D is correct. The nurse should first ensure that the IV site is patent. Morphine should not be given if the IV site is infiltrated or not patent.
Pre-procedural assessment: should include an appropriate clinical and vascular access site assessment of the patient before administering IV medications. An optimal clinical evaluation consists of evaluating the reason for drug treatment, the drug name, dose, route, rate of administration, and frequency. The nurse should verify that the patient is clinically suited for the ordered medication (i.e., no contraindications or drug-drug interactions). The nurse should also confirm that the vascular site is functional (i.e., aspirate for positive blood return and encounter no resistance when manually flushing the vascular access device). This assessment must be done before initiating the procedure steps.
Procedure: Following the pre-procedural assessment, the nurse should go ahead with the system (here, administering morphine). This will include a. gathering the medication, equipment and placing at the bedside b and identifying the patient, using two identifiers, according to the institutional policy (Choice C) c, and explaining the procedure and rationale for the procedure d and positioning the patient e. proceeding with the IV medication f. assessing the patient for any signs of infiltration or extravasation, and monitoring the patient for potential adverse effects and reactions before, during, and post-administration.
A nurse is expected to adhere to” seven rights” of medication administration: right medication, right patient, correct dose, right time, right route, right reason, and proper documentation. Some have added the eighth right, which is: Right response. These will help reduce Medication errors.
Right Medication (Check the medication label and compare the name against the order/ medication admin record – MAR).
Right Patient (Check the name on the order and the patient; use two identifiers, use the barcode system to identify if available, and ask the patient to state his/her name).
Right Dose (Check the order and verify the accuracy and appropriateness of the dose).
Right Time (Verify when the last dose was given, check the ordered drug's frequency, and verify that the requested medication is being offered at the correct time).
Right Route (Check the order, check the appropriateness of the route, and verify that the patient can take the medication via the ordered route).
Right Documentation (Always document the time, route, and any other pertinent information in the chart AFTER administering the ordered drug).
Right Reason (Always confirm the reason for giving the drug; Check the patient history).
Right response (Always ask, check, and verify if the drug has produced the desired effect. For example, is the pain better after giving analgesics? Is nausea better after an anti-emetic? Is the blood pressure controlled after anti-hypertensive?).
Choice A is incorrect. The nurse should clamp the tubing to ensure that the medication goes directly to the client and does not get backed up the pipe. This is, however, not the first action of the nurse.
Choice B is incorrect. Morphine should be given slowly over 2 minutes; this is, however, not the initial intervention.
Choice C is incorrect. The nurse should always verify and confirm the identity of the client to prevent medication errors. This is, however, not the next action for the nurse to take. This step is a mandatory initial step during the initiation of the procedure and not the pre-procedure assessment. The nurse should first ensure that the medication administration route is safe and perform the access site assessment. There is no point in starting the procedure steps and completing the identification step of intravenous medication administration if there is no functional IV access in place.
Reference
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier.
An altered physical condition caused by the nervous system adapting to repeated drug use is:
A. Addiction
B. Physical dependence
C. Psychological dependence
D. Withdrawal
Explanation
Answer and Rationale:
Some drugs are frequently abused or have a high potential for addiction. Drugs that cause dependency are restricted to use in situations of medical necessity if they are allowed at all. According to law, drugs that have a significant potential for abuse are placed into categories called schedules.
The correct answer is B. A, C, and D are incorrect.
o Addiction refers to the overwhelming feeling that drives someone to use a drug repeatedly, although it is not medically necessary.
o Psychological dependence occurs when an individual has few signs of physical discomfort when a drug is withheld. However, the individual feels an intense, compelling desire to continue the use of the drug.
o Withdrawal is a term used to describe physical signs of discomfort that an individual experiences when a drug is no longer available.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 2: Drug Classes, Schedules, and Categories
Lesson: Drugs with a Potential for Abuse
Reference: Core Concepts in Pharmacology (Holland/Adams)
Increased levels of which of the following hormones is related to hyperemesis gravidarum?
A. Testosterone
B. Progesterone
C. Aldosterone
D. Estrogen
Explanation
Nausea and vomiting, also known as morning sickness, are common during the first trimester of pregnancy for many women. If nausea and vomiting interfere with an adequate intake of fluid and food and persists past 20 weeks of gestation, it is termed hyperemesis gravidarum.
The cause is unknown, but elevated hormone levels and the relaxation of smooth muscles, which results in delayed gastric emptying, are believed to contribute to this condition. Hyperemesis can cause problems for the mother and fetus. Severe hyperemesis gravida- darum can result in preterm labor. The dehydration that occurs may lead to reduced placental perfusion and inadequate oxygenation to the fetus. Fetal growth can be compromised, leading to an infant who is small for gestational age. Also, women with hyperemesis gravidarum in the second trimester have an increased risk for preterm labor, pre-eclampsia (i.e., an increase in blood pressure, protein in the urine, and edema), and placental abruption.
The correct answer is D. The cause of hyperemesis is thought to be related to high levels of estrogen and human chorionic gonadotropin (HCG). A is incorrect. Testosterone is the primary male hormone. B is incorrect. Progesterone is a relaxant and does not promote vomiting. C is incorrect. Aldosterone is a male hormone.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Chapter 7: Care of the Woman With Complications During Pregnancy
Lesson: Care of the Woman with Hyperemesis Gravidarum
Reference: Safe Maternity and Pediatric Nursing (Louise Linnard-Palmer)
Which of the following are true regarding an electronic medical record? Select All That Apply.
A. It cannot be used as a legal document in a lawsuit
B. Nurses can enter data by checking boxes and adding free full text
C. It allows primary care providers to directly order in the computer
D. It is economical and easy to learn and implement
Explanation
The correct answers are B and C.
Choice B: Computerized records have boxes to check and choices to make so that nurses do not have to write assessment findings by hand each time they evaluate a patient. They also have room for adding free text. Choice C: Computerized Provider Order Entry (CPOE) allows providers to enter all orders directly into the computer, electronically communicating requests to the pharmacy, laboratory, and nursing unit.
Choice A is incorrect. Although there is no hard copy of the medical record, the computerized medical history is still considered a legal document, and it can be used in a lawsuit.
Choice D is incorrect. Implementing a computerized record system is expensive, and it requires much planning and education. However, it does significantly increase patient safety concerns.
NCSBN Client Need
Topic: Safe and Effective Care Environment; Subtopic: Coordinated Care
Reference: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 4: Documentation and Interprofessional Communication; Lesson: Electronic Medical Record
A patient is rushed to the ER following a near-drowning episode at a local beach. Does the nurse anticipate which conditions to be present in the patient?
A. Hypoxia, hypercarbia, acidosis
B. Coma, hyperthermia, alkalosis
C. Hypothermia, hypocapnia, alkalosis
D. Hyperthermia, hyperoxia, acidosis
Explanation
A is correct. Following a near-drowning incident, the patient will most likely exhibit symptoms of hypoxia (decreased oxygen levels in the blood), hypercarbia (increased carbon dioxide levels in the blood), and acidosis (respiratory) due to a prolonged period of having a lack of oxygen.
B is incorrect. Although the patient may be in a coma after near-drowning, hyperthermia and alkalosis are least likely. There would be a high chance of acquiring hypothermia, mainly if the patient stayed in the water for too long before being rescued. Alkalosis will not result from a lack of oxygen in the body; instead, acidosis will occur.
C is incorrect. Although hypothermia is a possibility in near-drowning situations, lack of oxygen for long periods will produce hypercapnia/hypercarbia and acidosis.
D is incorrect. Hypoxia will result from long periods without oxygen, not hyperoxia. Hyperthermia is least likely to occur in near-drowning incidents.
References
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
While assessing a laboring mother during a contraction, the nurse notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation?
A. Late deceleration
B. Moderate variability
C. Early deceleration
D. Marked variability
Explanation
Answer: C
A is incorrect. Late decelerations are a decrease in the fetal heart rate that occurs after a contraction. They are a non-reassuring sign on a fetal heart rate strip. In this question, the nurse noticed an early deceleration because it occurred with a contraction, not after.
B is incorrect. Variability on a fetal heart rate is defined as the fluctuations in the fetal heart rate from baseline. A moderate amount of variability is what is expected and is considered a reassuring sign. This question does not mention the variability of the fetal heart rate; instead, it notes an early deceleration.
C is correct. Early decelerations occur when the fetal heart rate decreases at the same time as a contraction. In this question, the nurse noted a decrease from 150 to 120 bpm with the contraction, and then a return to baseline. This occurs due to the pressure of the head of the fetus on the pelvis or soft tissue, and no intervention is required by the nurse after an early deceleration.
D is incorrect. Variability on a fetal heart rate is defined as the fluctuations in the fetal heart rate from baseline. Marked variability is a dramatically increased amount of these fluctuations. This question does not mention the variability of the fetal heart rate; instead, it notes an early deceleration.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological adaptation
Subject: Maternity Nursing
Lesson: Problems with Labor and Delivery
Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.
Which of the following images shows the most appropriate position for an infant who has just had a cleft palate surgery? A. TRENDELENBURG B. RIGHT LATERAL RECUMBENT C. SUPINE D. PRONE
Explanation
Choice D is correct. For a child who is status post cleft palate surgery, it is most appropriate to position them prone. Due to their unique anatomy, they are at an increased likelihood of their tongue falling back into their airway, causing obstruction and respiratory distress. The prone position prevents the tongue from falling backward. A prone position is recommended to facilitate the drainage of excessive secretions post-operatively.
Choice A is incorrect. This is Trendelenburg’s position. It is not recommended in children with a cleft palate due to their risk for airway obstruction caused by their tongue falling back into the airway.
Choice B is incorrect. This is a right lateral recumbent position. Lateral positioning can prevent the tongue from obstructing the airway, and it can be used in infants with cleft palate during feeding and sleep. However, this is not the best position post-surgically. Post-operatively, the goal is to facilitate the drainage of excessive secretions. The prone position is most helpful to serve that purpose.
Choice C is incorrect. This is a supine position. It is not recommended in children with an unrepaired cleft palate due to their risk for airway obstruction caused by their tongue falling back into the airway.
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. Wong’s Essentials of Pediatric Nursing, St. Louis, MO: Elsevier Limited.
When documenting. the statement “Normal speech is audible” is a normal finding of which speech quality?
A. Loudness
B. Articulation
C. Fluency
D. Quality
Explanation
Characteristics of speech to evaluate include rate, rhythm, loudness, fluency, quantity, articulation, content, and pattern.
Answer and Rationale:
The correct answer is A. The term “audible” refers to the loudness of something. B is incorrect. Articulation refers to the production and use of sounds. C is incorrect. Fluency is a speech-language pathology term that means the smoothness or flow with which sounds, syllables, words, and phrases are joined together when babbling. D is incorrect. Speech quality refers to the characteristic features of an individual's voice.
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
The nurse is assigned the care of a client with a sodium level of 122 mEq/L. Which assessment findings does the nurse anticipate based on this lab result? Select all that apply.
A. Confusion
B. Abdominal cramps
C. Increased urine output
D. Hypoactive bowel sounds
E. Nausea and vomiting
Explanation
Answer: A, B, and E
A is correct. A sodium level of less than 135 mEq/L is indicative of hyponatremia - too little sodium in the blood. When sodium falls below 125 mEq/L, it is considered “severe” hyponatremia. Confusion is a common neurological symptom of acute or severe hyponatremia. Sodium plays a very important role in the brain, and low levels of this electrolyte can be devastating producing symptoms ranging from confusion, lethargy, and stupor, to seizures and cerebral edema
B is correct. Abdominal cramps is another symptom of hyponatremia. Because water follows sodium, when there are decreased levels of sodium in the blood there is decreased fluid. This creased a fluid volume deficit, decreased urine output, muscle spasms, and abdominal cramping.
C is incorrect. Increased urine output is not a sign of hyponatremia. Decreased urine output rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. This is due to the relationship of sodium with water. With decreased levels of sodium, less water is pulled into the extracellular space and the intravascular volume is decreased causing decreased renal blood flow and therefore decreased urine output.
D is incorrect. Hypoactive bowel sounds are not a sign of hyponatremia. Hyperactive bowel sounds rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. Sodium plays an important role in muscle cells as well, and when levels are too low there is cramping, spasms, and hyperactive bowel sounds.
E is correct. Nausea and vomiting are common signs of low sodium levels in the blood or hyponatremia.
NCSBN Client Need: Physiological Adaptation
Topic: Fluid and Electrolyte Imbalances
Subject: Fundamentals of care
Lesson: Fluids & Electrolytes
You are assessing a 16-year-old woman with Anorexia Nervosa. Which of the following symptoms and signs would you expect to find? Select all that apply.
A. Lanugo
B. Heavy menstrual periods
C. Hypertension
D. Hypothermia
Explanation
Choices A and D are correct. Lanugo (Choice A) is defined as “fine and soft hair that covers the body and limbs of a human fetus/ newborn.” It is abnormal for a 16-year-old to have lanugo. In a patient who is severely underweight and has lost a large amount of subcutaneous fat, such as in a patient with anorexia nervosa, the body will develop lanugo as a way to insulate itself.
Hypothermia (Choice D) is a severe complication of anorexia nervosa. Subcutaneous fat is necessary to insulate the body and regulate the temperature. Clients with anorexia nervosa lose a significant amount of subcutaneous fat due to malnourishment and weight loss. Consequently, they are prone to Hypothermia.
B is incorrect. Amenorrhea (lack of menstrual period) rather than increased menses is a complication seen in anorexia nervosa—self-inflicted starvation in anorexia nervosa results in malnourishment, hormonal imbalance, and amenorrhea.
C is incorrect. Hypotension is seen in anorexia nervosa, not hypertension. Clients with anorexia are prone to malnourishment and dehydration. Dehydration results in fluid-volume deficit and hypotension. Electrolyte imbalance such as Hypernatremia is also seen due to free water deficit and concentrated body fluids.
NCSBN Client Need:
Topic: Psychosocial Integrity
Reference: Halter, M. J. (2018). Manual of Psychiatric Nursing Care Planning: An Interprofessional Approach. Elsevier Health Sciences.
A patient with bladder cancer is being evaluated for metastasis. Which of the following locations is not a common site for metastasis?
A. Lung
B. Brain
C. Liver
D. Bone
Explanation
NCSBN client need | Topic: Physiologic Adaptation, Illness Management
Rationale:
The correct answer is B. Metastasis is the travel of cancerous cells from one area of the body to another. The brain is not a common site of metastasis for bladder cancer. Cancers at risk for brain metastasis include breast cancer and lung cancer.
Choices A, C, and D are incorrect. The lung, liver, and bone are all common sites of metastasis in bladder cancer. The pelvic structures are also common sites of bladder cancer metastasis.
Reference:
Itano JTaoka K. Core Curriculum For Oncology Nursing. St. Louis, Mo.: Elsevier Saunders; 2005.
The nurse is assigned to care for a client with a chloride level of 90 mEq/L. The nurse identifies which of the following as reasons for this electrolyte imbalance? Select all that apply.
A. Fluid volume excess
B. Metabolic acidosis
C. Vomiting
D. Constipation
E. Congestive heart failure
Explanation
Answer: A and C
A is correct. The normal level for chloride is 96-108 mEq/L. Since this client has a level of 90 mEq/L, which is below the normal range, they are experiencing hypochloremia. Fluid volume excess is a cause of hypochloremia. This is due to a dilutional effect. There is not actually less chloride in the blood, but because there is increased fluid volume, there is a dilutional effect causing a relative hypochloremia.
B is incorrect. Metabolic acidosis is not a cause of hypochloremia. Metabolic alkalosis instead can cause hypochloremia.
C is correct. Vomiting is a common cause of hypochloremia. The stomach acid is hydrochloric acid, or HCl. This acid contains large amounts of chloride, and when the client vomits and loses stomach acid, they lose chloride causing hypochloremia. This loss of HCl also causes metabolic alkalosis.
D is incorrect. Constipation does not cause hypochloremia. Diarrhea can cause hypochloremia due to excessive loss of gastrointestinal contents that contain chloride.
NCSBN Client Need: Reduction of Risk Potential
Topic: Laboratory Values
Subject: Fundamentals of care
Lesson: Fluids & Electrolytes
The nurse gives discharge teaching to a patient going home on Doxycycline. Which of the following patient statements, if made by the patient to the nurse, requires further education? Select all that apply.
A. “I will use sunscreen when I plan on spending time outdoors.”
B. “I am glad that, unlike most antibiotics, I won’t have to use a backup method of birth control.”
C. “If I get a white coating on my tongue, I will immediately stop the medication.”
D. “I should take this medication after I eat a meal.”
E. “I will follow up with my doctor visits and get my labs checked every month.”
Explanation
Doxycycline is a tetracycline antibiotic that fights bacteria in the body. It is used to treat many different bacterial infections, such as acne, urinary tract intestinal, respiratory, and eye infections, gonorrhea, chlamydia, syphilis, periodontitis.
The correct answers are B, C, and D.
B- A backup method of birth control is needed. C- The medication should be taken on an empty stomach. D- A white tongue is a common side effect, and the medication should not be stopped.
A is incorrect. It is always appropriate to wear sunscreen when going outside.
E is incorrect. The patient does need to follow up and have his renal function checked.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 22: Drugs for Bacterial Infections
Lesson: Tetracyclines
Core Concepts in Pharmacology (Holland/Adams)
You have administered a mildly sedating medication to promote sleep. An hour after your client was given this medication, you client is jittery and hyperactive. What has most likely occurred?
A. A sentinel event
B. An idiosyncratic side effect
C. An adverse effect
D. A medication error
Explanation
Correct Answer is B. It is most likely that an idiosyncratic side effect to this sedating medication has occurred. Simply defined, an idiosyncratic side effect unexpected and unexplainable effect to a medication.
Choice A is incorrect. A sentinel event is a variance and a medical error that has, or could have, cause harm to the client.
Choice C is incorrect. An adverse effect to a medication is a serious effect to a medication that is often needed to be discontinued.
Choice D is incorrect. There is no evidence in this question that indicates that a medication error that violated one or more of the Rights of Medication administration has occurred.
Reference: Berman, Audrey, Snyder, Shirlee and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition)
The nurse gives discharge teaching to a patient going home on Doxycycline. Which of the following patient statements, if made by the patient to the nurse, requires further education? (Select all that apply):
A. “I will use sunscreen when I plan on spending time outdoors.”
B. “I am glad that, unlike most antibiotics, I won’t have to use a backup method of birth control.”
C. “If I get a white coating on my tongue, I will immediately stop the medication.”
D. “I should take this medication after I eat a meal.”
E. “I will follow up with my doctor visits and get my labs checked.”
Explanation
The correct answers are B, C, and D. These statements require further teaching.
Doxycycline is a tetracycline antibiotic that fights bacteria in the body. It is used to treat many different bacterial infections, such as acne, urinary tract intestinal, respiratory, and eye infections, gonorrhea, chlamydia, syphilis, periodontitis.
This patient will have to use a backup method of birth control (Option B). Birth control pills also may not work as well if the patient is taking doxycycline. The mechanism underlying this is felt to be due to antibiotics’ effects on reducing small intestinal bacteria. Decreased bacteria leads to decreased hydrolysis of the hormone, which in turn, results in increased fecal loss of the hormone and results in lower circulating levels of ethinylestradiol. This long-held belief has been challenged in recent studies. Still, until the availability of extensive studies, it is advised that patients take a backup method (other forms of birth control) when the patient is taking this medicine.
The white coating (Option C) is glossitis, a common side effect of Doxycycline, but the patient should not stop the medication. This should not be confused with thrush since thrush presents more with painful whitish patches involving not just tongue but also the palate.
The medication needs to be taken on an empty stomach because food can interfere with its absorption and reduces efficacy. The client should not take Doxycycline after eating (Option D).
Choices A and E are incorrect. These statements reflect correct understanding and DO NOT need further teaching.
Option A- This statement reflects a correct understanding by the client and does not need further teaching. With Doxycycline, there is increased photosensitivity/ Phototoxicity. When prescribing doxycycline, physicians usually advise patients on the use of a high sun protection factor (SPF) sunscreen. A broad-spectrum sunscreen to protect against UVB and UVA wavelengths should be recommended. Using a hat, avoiding sun are other teaching points. Option E- This patient needs to follow up and have their labs checked. No further teaching required.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Pharmacological & Parenteral Therapies.
Reference:
Core Concepts in Pharmacology (Holland/Adams); Chapter 32: Drugs for Skin Disorders; Lesson: Acne & Acne Related Disorders
Select the complication of intravenous therapy that is accurately paired with one of its treatments. Select all that apply.
A. Catheter embolus: Place a tourniquet distal to the intravenous site
B. Site ecchymosis: Apply cool moist compresses
C. Infiltration: Stop the IV and elevate the affected limb
D. Phlebitis: Culture the catheter and site if drainage is present
E. Fluid overload: Assess the client’s plasma sodium level
Explanation
Correct Answers are C and D
Correct. One of the treatment interventions, when an infiltration occurs, is to stop the IV and elevate the affected limb. Other interventions include the application of warm or cold compresses as indicated by the type of intravenous solution that infiltrated and starting another IV in an alternative limb when possible and when not, another IV should be started proximal to the infiltrated site.
A culture of the intravenous catheter and the intravenous site should be done if drainage is present when phlebitis or thrombosis occurs as a complication of intravenous therapy. Other corrective treatment interventions include the immediate cessation of intravenous therapy, elevation of the affected limb, and the application of warm compresses.
Choice A is incorrect. You would not place a tourniquet distal to the intravenous site for a catheter embolus. Instead, you would place a tourniquet as high on the limb as possible and proximal and not distal to the intravenous site for a catheter embolus. This prevents the migration of the catheter pieces.
Choice B is incorrect. Site ecchymosis is treated with the application of warm and not cool moist compresses. Other interventions for site ecchymosis is include elevation of the affected limb and applying pressure to the intravenous therapy insertion site after the IV has been discontinued.
Choice E is incorrect. Fluid overload is not treated with an assessment of the client’s plasma sodium level. It can, however, be treated with stopping the intravenous therapy or reducing its rate by raising the client’s head of the bed and the administration of diuretics to decrease fluid volume, as ordered.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
You are educating a 25-year-old obese client (Body Mass Index, BMI of 31) at 12 weeks gestation, who presents for a routine antenatal check-up. She gained 3 pounds compared to pre-pregnancy weight. Which of the following statement(s) by the client reflect correct understanding regarding recommended weight changes in pregnancy? Select all that apply.
A. “Since I am obese, I should try to lose weight now to limit my risk of gestational diabetes.”
B. “Typically, there is a 3 to 6 pounds of weight gain during the first trimester of pregnancy.”
C. “In the third trimester, a weight gain of 2 pounds or more each week is considered high.”
D. “I should aim to gain a total of 25 to 35 pounds during this pregnancy.”
E. “Going forward in my pregnancy, I should aim to gain ½ pound per week.”
Explanation
The Correct Answers are B, C, and E.
Weight gain is considered crucial during pregnancy. A pregnant woman should be educated regarding what is deemed to be reasonable in terms of pregnancy weight gain and the implications of gaining too much or too little weight. The client needs to keep track of the rate of weekly weight gain. Guidelines have been proposed to assist with determining the rate of healthy weekly weight gain. Weight gain of 3 to 6 pounds during the entire first trimester (first three months) is considered normal and healthy (Choice B). Gaining 2 pounds or more per week at any time (Choice C) during pregnancy would be abnormally high, and such a client should focus on limiting the further rate of weight gain.
The client in the question has already gained 3 pounds, which is healthy. Going forward, she should aim to learn about 8 to 17 pounds in the next six months ( about half a pound per week for the rest of her pregnancy). This is based on the recommended weight gain of 11-20 pounds during the entire pregnancy for someone with a BMI of 30 or above (obese). Recommended weight gain is based on pre-pregnancy BMI and is shown in the table below:
Choices A and D are incorrect. Weight-loss is dangerous during pregnancy. Regardless of their pre-pregnancy weight, every woman is expected to gain weight during pregnancy. The amount of recommended weight gain, however, is based on their pre-pregnancy BMI. A weight gain of 25 to 35 pounds (Choice D) is an ideal range recommended for those clients with healthy pre-pregnancy BMI (18.5 to 24.9). For an obese client, a variety of 11 to 20 pounds during the entire pregnancy is considered ideal. Gaining more than recommended weight will put the clients at risk for maternal hyperglycemia, reduced glucose tolerance, and increased risk of fetal complications. Fetal complications include increased risk of preterm delivery, of having a newborn who is large for gestational age (LGA), and of requiring a cesarean delivery). Gaining less than recommended weight increases the risk for small for gestational age (SGA) babies. The following table gives recommendations for a healthy rate of weekly weight gain:
The nurse is in the screening room of a women’s health clinic. The nurse notices a particular woman that says for the past few months she has back and leg pain, spotting after intercourse with her husband, and vaginal discharge. The nurse suspects:
A. Cervical Cancer
B. Endometrial Cancer
C. Ovarian cancer
D. Vaginitis
Explanation
A is correct. Signs and symptoms of cervical cancer include back and leg pain, spotting between menstrual periods and after intercourse, vaginal discharge, and lengthening of a menstrual period. A Pap Smear is needed to assess cellular changes and check for cancerous and precancerous conditions.
B is incorrect. Endometrial cancer manifests as menorrhagia (excessive menstrual bleeding), low abdominal pain, backache, constipation due to pressure from an enlarging mass. A biopsy is needed to confirm the diagnosis.
C is incorrect. Initial signs and symptoms of ovarian cancer include an increasing abdominal girth due to ovarian enlargement; Constipation, due to rectal pressure from the enlarging mass; Anemia, vomiting, and cachexia.
D is incorrect. A bacterial infection causes vaginitis. Signs and symptoms include pruritus, burning urination, dysuria, dyspareunia, and a foul-smelling vaginal discharge.
Reference
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
A 34-year old female arrives at the emergency department after developing pain in her left calf. What are the important questions to ask this patient while assessing her? Select all that apply
A. Is your left calf bigger than your right calf?
B. Are you pregnant?
C. Have you been on any long car or plane rides recently?
D. Do you take any birth control?
E. Do you take any antidepressants?
Explanation
The correct answers are A, B, C, and D. This patient needs to be assessed for a deep vein thrombosis because of her risk factors like age, possible birth control use, and long travel. Asking these questions can be crucial in diagnosing the patient and obtaining further ultrasound imaging.
E is incorrect. This question is not pertinent related to deep vein thrombosis.
NCSBN Client Needs
Topic: Reduction of Risk Potential
Sub-Topic: Potential for Alterations in Body Systems
Subject: Adult Health
Lesson: Hematologic System
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013V
You are providing education to the parents of a toddler suffering from gastroesophageal reflux disease (GERD). You know they understand your teaching when they make which of the following statements? Select all that apply.
A. “We should feed him 6 small meals a day instead of a few big ones.”
B. “Making sure he is sitting upright while eating may help the reflux.”
C. “He should try to sleep on his left side. so that his stomach can empty more easily.”
D. “There are no medications that can help with this disease. so we will have to make lifestyle changes.”
Explanation
Answer: A and B
A is correct. Small, frequent meals are an excellent recommendation to help alleviate GERD symptoms. This will ensure the stomach does not overfill and help decrease the amount of reflux the patient is experiencing.
B is correct. The upright position is very important for GERD patients while they are eating. This is a good education. Upright positioning will help to prevent or decrease the passage of gastric contents into the esophagus.
C is incorrect. Left-side lying is not the recommended position overnight for patients suffering from GERD. These parents do not understand your teaching. You should teach them to encourage an upright position to help with GERD overnight. This can be accomplished in the hospital by elevating the head of the bed, or at home by using pillows to prop the head up.
D is incorrect. This is not true. While the healthcare provider will likely recommend lifestyle changes before prescribing any medications, there are a variety of pharmacological interventions that can be tried if severe symptoms persist. These include medications such as omeprazole and ranitidine.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Gastrointestinal
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
The nurse is admitting a child diagnosed with epiglottitis. admission. Then asking the admission questions, which vaccination would be most important for the nurse to ask the mother about?
A. Tdap
B. Influenza
C. Hib
D. MMR
Explanation
Answer: C
A is incorrect. Tdap stands for Tetanus, Diphtheria, and Pertussis. While this vaccination is very important, it is not related to epiglottitis. There is no indication to ask specifically about this vaccination.
B is incorrect. The seasonal influenza vaccination is very important, and all children over 6 months of age should receive it every year. While it is important to check on all vaccinations, the flu shot is not specifically related to epiglottitis so there is no indication to ask specifically about this vaccination.
C is correct. Hib - haemophilus influenzae type B - is the most common cause of the bacterial infection that causes epiglottitis. Incidence has been significantly decreased by the Hib vaccination. That is why the nurse should ask the mother about this vaccination during the admission questions.
D is incorrect. MMR stands for Measles, Mumps & Rubella. This is a very important childhood vaccination that all children should receive, but there is no relation between this specific vaccine and epiglottitis. Therefore, there is no indication to ask specifically about this vaccination.
NCSBN Client Need:
Topic: Health promotion and maintenance
Subject: Pediatric
Lesson: Respiratory
You are assessing a 2-month-old infant and note the following vital signs:
Pulse: 132 RR: 36 BP: 82/58
Which of the following actions are appropriate given these vital signs? Select all that apply.
A. Continue your assessment
B. Notify the healthcare provider
C. Administer acetaminophen
D. Document the vital signs.
Explanation
Answer: A and D
These vital signs are all within the normal limits of an infant. Typical crucial signs for an infant are:
Pulse: 90-140 RR: 25-40 BP: 85/60
A is correct. It is appropriate to continue with your assessment because these vital signs are within normal limits for an infant. There are no new vital signs or matters that require your immediate attention, so it is correct to continue with your assessment of this patient.
B is incorrect. Based on the information given in the stem of this question, there is no indication that the nurse needs to notify the healthcare provider. All of these vital signs are within the normal limits for an infant, so the nurse should continue with her assessment. If she notes something out of normal limits in her head to toe assessment, then it may be necessary to notify the healthcare provider, but based only on the vital signs that you were given in the question, it would be incorrect to inform the healthcare provider.
C is incorrect. Based on the information given in the stem of this question, there is no indication that the nurse needs to administer acetaminophen. Acetaminophen is a pain reliever and fever reducer. We were not given temperature in this question, so we have no information to indicate to us that the patient is febrile and needs medication. Additionally, the vital signs are all within normal limits. Based only on this information, there is no reason to suspect pain. The nurse should continue her assessment and use the FLACC scale to evaluate the infant for pain. But, since that information was not provided, administering acetaminophen is incorrect.
D is correct. It is appropriate to continue with your document your findings because these vital signs are within normal limits for an infant. There are no new vital signs or matters that require your immediate attention, so it is correct to proceed with documentation.
NCSBN Client Need:
Topic: Health promotion and maintenance
Subject: Pediatrics
Lesson: Development
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
Which of the following statements are true regarding COVID-19? Select all that apply.
A. COVID-19 is caused by the Staphylococcus aureus bacteria.
B. COVID-19 is spread through droplet transmission.
C. Immunocompromised patients are most at risk of severe COVID-19.
D. Headaches, malaise, and loss of appetite are the most common symptoms of COVID-19.
E. N95 masks are preferred while attending COVID-19 patient.
Explanation
The correct answers are B, C, and E.
COVID-19 is indeed spread through droplet transmission(Choice B). This means that when someone coughs or sneezes, the secretions have the virus and can then infect another person. The droplets can also live on a surface and then be transmitted to another person. Percurrent CDC guidelines, Droplet precautions should be used by healthcare personnel to prevent the spread of the infection. But if a patient will be undergoing aerosolizing procedures like intubation, nebulizations, etc; airborne precautions with negative pressure isolation rooms are used.
The patients that are most likely to suffer significantly from COVID-19 are those who are immunocompromised (Choice C)and have a weak immune system. This includes the geriatric population, the chronically ill, patients going through chemotherapy or other cancer treatments, and patients with other pre-existing conditions like Diabetes/Cardiac issues. These patients have a high risk of complications and a high risk of dying from COVID-19.
When available, N95 masks (Choice E) are preferred while attending to COVID-19 patients. The ‘N95’ designation means that when subjected to careful testing, the respirator blocks at least 95 percent of tiny (0.3 microns) test particles. These masks are typically used in Airborne precautions, but in dealing with confirmed COVID-19 patient, N95 is preferred over face mask as per current CDC guidelines. However, due to a shortage of N95, CDC is currently allowing Surgical masks (Face masks) as well if N95 is not available. However, when specific aerosolizing procedures are being done (nebulization, intubation) on a COVID19 patient, N95 masks MUST ALWAYS BE used.
Choice A is incorrect. The COVID-19 disease is NOT caused by the Staphylococcus aureus bacteria. COVID-19 is the name of the disease caused by the SARS-COV2 virus. This stands for sudden acute respiratory syndrome coronavirus 2. Because this is a viral illness, antibiotics will not be effective in treating the disease. The Staphylococcus aureus bacteria is a dangerous, gram-positive bacteria that often cause skin infections.
Choice D is incorrect. These are not the most common symptoms of COVID-19. Instead, fever, cough, and shortness of breath are the most common symptoms concerning for COVID-19. This is a respiratory illness, so monitor for respiratory symptoms such as cough, shortness of breath, sneezing, dyspnea, etc.
The following video describes COVID-19 in detail:
NCSBN Client Need:
Topic: Effective, safe care environment Subtopic: Infection control and safety.
Reference: 2019 Novel Coronavirus (2019-nCoV) Situation Summary. (2020, March 9). Retrieved from https://www.cdc.gov/coronavirus/2019-nCoV/summary.html
Clients’ functional levels in terms of the activities of daily living, including those relating to hygiene and bathing, in the descending order of technical ability are entirely independent, requires the use of an assistive device or equipment, semi-dependent, moderately dependent and dependent. Whose theory has levels of independence most similar to these?
A. Kurt Lewin
B. Hans Seyle
C. Abraham Maslow
D. Dorothea Orem
Explanation
Correct Answer is D
Correct. Dorothea Orem’s theory has levels of independence/dependence that are the most similar to those above. Dorothea Orem’s Self Care theory describes the degree to which our clients can fulfill their self-care needs. Clients can be in the supportive mode and able to care for their own self-care needs, in a partly compensatory manner when they need some assistance and help in terms of their individual self-care needs, and compensatory when they need complete assistance from another to meet their self-care needs.
Kurt Lewin developed the theory of planned change. The phases of planned change, according to Kurt Lewin, are unfreezing, change, and refreezing; Hans Style developed the stress response theory. This theory is known as the General Adaptation Syndrome or GAS. According to this theory, the body responds physiologically to stressors, and the four stages of GAS in correct sequential order are alarm, resistance, exhaustion, and death. And lastly, Abraham Maslow developed the Hierarchy of Human Needs, which prioritizes human needs from the most basic and essential to the most complex and not necessary for life.
Choice A is incorrect. Kurt Lewin developed the theory of planned change. The phases of planned change, according to Kurt Lewin, are unfreezing, change, and refreezing, which are not similar to the levels of independence as listed in the question.
Choice B is incorrect. Hans Selye developed the stress response theory. This theory is known as the General Adaptation Syndrome or GAS. According to this theory, the body responds physiologically to stressors, and the four stages of GAS in correct sequential order are alarm, resistance, exhaustion, and death, which are not similar to the levels of independence as listed in the question.
Choice C is incorrect. Abraham Maslow developed the Hierarchy of Human Needs, which prioritizes human needs from the most basic and essential to the most complex and not necessary for life. These human needs in the proper descending order from the highest to the lowest priority are the:
Physical needs
Psychological needs
Love and belonging
Self-esteem and the esteem of others
Self-actualization
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
In which of the following cases would take a rectal temperature be contraindicated? Select All That Apply.
A. A newborn who has hypothermia
B. A child who has pneumonia
C. An older client who is post myocardial infarction
D. A teenager who has leukemia patient receiving erythropoietin to replace red blood cells
E. An adult patient who is newly diagnosed with pancreatitis
Explanation
Answer and Rationale:
The correct answers are A, C, D, and E.
Rectal temperature should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery.
The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve. Therefore, patients who are post-MI should not have a rectal temperature taken.
Assessing a rectal temperature is also contraindicated in patients who are neutropenic, who have certain neurologic disorders, and in patients with low platelet counts.
B is incorrect. A child with pneumonia can have a rectal temperature taken.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Resource: The Art and Science of Patient-Centered Nursing
Chapter 24: Vital Signs
Lesson: Temperature
Which of the following is true regarding therapeutic communication with infants (1 month to 12 months)? Select all that apply.
A. They use crying as a means for communication and you should take their crying seriously.
B. They are able to comprehend 5-10 words at this age.
C. They respond to touch and therefore patting and rubbing are effective calming methods.
D. They respond better to a low-pitched voice.
Explanation
Answer: A and C
A is correct. At this age, most communication is still nonverbal. Infants use crying as a means for discussion, and therefore you should take their crying seriously.
B is incorrect. Infants are not yet able to comprehend words. They will be attentive to your voice and other sounds, but they are not, however, prepared to understand what anyone is saying. Therefore trying to explain or rationalize something with them will be ineffective. Instead, you are just speaking to gain their attention and create interaction.
C is correct. Infants are very responsive to touch. Patting, rocking, stroking, cuddling, and rubbing them are effective ways to calm them down. Therapeutic communication with an infant will be less focused on the actual words you say, and more focused on how you interact with them to create a therapeutic environment.
D is incorrect. A nursing strategy for therapeutic communication with infants is to speak in a high-pitched voice, not a low pitched voice. The theory is that infants respond better to high-pitched voices because they sound more like their mothers and are soothed by this.
NCSBN Client Need:
Topic: Effective, safe care environment
Subtopic: Coordinated care
Subject: Pediatrics
Lesson: Development
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
The nurse is caring for a patient who has just returned from an intravenous urography procedure. Which of the following nursing interventions is most important at this time?
A. Assess the venipuncture site for redness
B. Monitory urinary output
C. Instruct the client to remain motionless
D. Encourage the patient to drink at least 1 L of fluid
Explanation
NCSBN client need | Topic: Physiological integrity, Reduction of Risk Potential
Rationale:
The correct answer is D. Dye used during intravenous urography is sometimes nephrotoxic. Thus patients should be encouraged to increase fluids unless contraindicated.
Choice A is incorrect. While the venipuncture site should always be monitored, some redness is expected and not alarming. Therefore, this is not a necessary action.
Choice B is incorrect. Monitoring urinary output is a critical nursing intervention because it may be the first sign of nephrotoxicity. However, increasing fluids is more urgent.
Choice C is incorrect. This client does not need to remain motionless following an intravenous urography procedure.
Reference:
Williams LHopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co.; 2011.
