FUNDAMENTALS Flashcards
A woman is in the labor and delivery suite at 37 weeks’ gestation. She has been under her obstetrician’s care for preeclampsia, during labor. The labor nurse notices that the fetus is experiencing heart rate decelerations. You are on the neonatal resuscitation team that responds to the call from the labor room nurse. The infant is born but does not respond to tactile stimulation. The group moves the infant to the warmer. You evaluate the infant and confirm he is still not breathing. You begin positive pressure blowing with room air. Another team member notes that the heart rate is 72 bpm, and the newborn’s chest is not moving with PPV on room air. The next appropriate action is to:
A. Reposition the infant to open the airway
B. Begin CPR
C. Suction the infant with a bulb syringe
D. Increase the oxygen concentration
Correct Answer: A.
Reposition the infant to open the airway while ensuring that you have a good seal with the mask on the newborn’s face. Following that action, a team member should suction the infant’s mouth and nose. Until the team establishes sufficient ventilation, there is no indication to increase oxygen concentration or begin CPR. The AHA and AAP focus on positive-pressure ventilation as the single most crucial step in the resuscitation of the newborn.
While working in the pediatric emergency department, you receive a 2-year-old patient from EMS who has ingested an unknown amount of an unknown poison. Upon arrival to the ED, place the following actions in order of priority nursing actions.
- Ensure no further exposure to poison
- Assess the patient
- Administer antidote if available.
- Identify the specific type of poison. Assess the patient Ensure no further exposure to poison. Administer antidote if available. Identify the specific type of poison.
Correct Answer is: Assess the patient Ensure no further exposure to poison. Identify the specific type of poison. Administer antidote if available.
Explanation
Poisoning is a frequent cause of admission to pediatric emergency departments. The priority of nursing action will always be to assess the patient. Follow the ABCs, and intervene as appropriate. If the child does not have an airway, establish one. If they are not breathing, manually ventilate them. If circulation is inadequate, provide fluid boluses or vasopressors for support as prescribed by the health care provider. The next priority nursing action is to ensure there is no further exposure to the poison. Are there still pills in the patient’s mouth? Is the poison on their skin? Ensure that it is completely removed before proceeding. Next, the nurse needs to take action to identify the specific toxin. This could mean asking the parents or witnessed what happened, or looking at the pills themselves if there are any available. The last priority action is to administer the antidote if available.
NCSBN Client Need:
Topic: Safe and Effective Care Environment Subtopic: Safety and Infection Control
Reference: Hockenberry M, Wilson D: Wong’s nursing care of infants and children, ed 9, St. Louis, 2011, Mosby, p. 622
Subject: Child Health
Lesson: Gastrointestinal disorders
Which of the following conditions may cause an increased cortisol level in a client?
A. Addison’s disease
B. Congestive heart failure
C. Renal failure
D. Cushing’s disease
Explanation
Cortisol is best known for helping support the body’s natural “fight-or-flight” instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance.
The correct answer is D. Cushing’s syndrome produces elevated cortisol levels. A is incorrect. Addison’s disease produces decreased cortisol levels. B and C are incorrect. Neither of these conditions is associated with cortisol levels.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Chapter 12: Stress and Adaptation
Lesson: Endocrine System Responses
Reference: Fundamentals of Nursing (Wilkinson/Barnett)
Place the following 8 rights of medication administration in the correct order:
Right time
Right patient
Right response
Right medication
Right documentation
Right dose
Right route
Right reason
Right patient Right medication Right dose Right time Right route Right response Right reason Right documentation
Explanation
Answer: B, D, F, G, A, E, H, C
Right patient, right medication, right dose, right route, right time, right documentation, right reason, and the right response is the correct order of the rights of medication administration.
First, the nurse should verify the right patient by using two patient identifiers. Next, she should verify the correct medication on both the order and the medication label. Next, she should verify the right dose as written in the order and check that it is an appropriate dose for the patient. Next, the right route should be verified in the order and the nurse should check if it is safe to administer via this route for this patient. Next, the right time should be verified; the nurse should check that the medication is being administered at the ordered time and frequency. Next, right documentation. The nurse should document the administration of the medication as well as pertinent information such as vital signs, lab values, and/or injection sites. Next is the right reason. Ensure the patient is receiving the medication for an appropriate rationale given their history and the indications for the medication. Lastly, the nurse should monitor the patient for the right response. Ensure the expected response to the medication is observed and that appropriate follow up monitoring is also documented.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological adaptation
Subject: Fundamentals
Lesson: Medication Administration
Reference: Nursing 2014 Drug Handbook. (2014). Lippincott Williams & Wilkins. Philadelphia, Pennsylvania.
Which of the following wounds has serosanguineous exudate? See exhibit
A. Image A
B. Image B
C. Image C
D. Image D
Explanation
Answer: B
A is incorrect. This exudate is serous.
B is correct. This is the photo that shows serosanguinous exudate.
C is incorrect. This exudate is sanguineous.
D is incorrect. This exudate is purulent.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological Adaptation
Reference: Ignatavicius D, Workman ML: Medical-surgical nursing: Patient-centered collaborative care, ed 7, Philadelphia, 2013, Saunders
Subject: Adult Health
Lesson: Integumentary
A 90-year-old woman has been bedridden at home for two weeks. Which of the following, if observed by the nurse, is not an expected finding due to immobility?
A. A decrease in bone density.
B. Loss of short term memory.
C. Atelectasis.
D. High serum calcium level.
Explanation
Choice B is correct. Loss of short-term memory is not an expected complication of prolonged immobility and warrants further assessment. Short term memory loss may indicate medication effects, Alzheimer’s dementia, or Lewy body dementia.
Choices A, C, and D are incorrect. Decreased bone density (osteoporosis), atelectasis, and hypercalcemia are all expected due to prolonged immobility.
Risk factors related to mobility can affect every organ system. The musculoskeletal system can experience contractures, joint ankylosis, and the depletion of necessary minerals/ loss of bone density.
Hypercalcemia (Choice D) may occur with prolonged immobility. Prolonged immobilization deranges bone remodeling because of the lack of mechanical stress. This causes an imbalance between bone formation and bone resorption where resorption exceeds formation. Consequently, there is a net efflux of calcium from the bone.
Respiratory complications such as atelectasis (Choice C) and pneumonia may occur. Gastrointestinal manifestations (constipation) may occur due to decreased peristalsis. Immobile individuals are also more prone to orthostatic hypotension, decreased metabolism, and skin breakdown/ decubitus ulceration.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential
Reference:
Fundamentals of Nursing (Wilkinson and Barnett); Chapter 32: Physical Activity and Mobility; Lesson: Effect of Immobility
A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself forming an obstruction is called what?
A. Intussusception
B. Pyloric stenosis
C. Hirschsprung’s disease
D. Omphalocele
Explanation
Answer: A
A is correct. A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself, forming an obstruction, is called intussusception.
B is incorrect. Pyloric stenosis is the enlargement and stiffening of the pylorus, the opening from the stomach into the duodenum. This prevents the passage of food into the duodenum and results in projectile vomiting.
C is incorrect. Hirschsprung’s disease is a congenital anomaly that results in mechanical obstruction.
D is incorrect. Omphalocele is a congenital disability in which an infant’s intestine or other abdominal organs are outside of the body, protruding through a hole in the umbilical region.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Hematology
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
You are caring for a 12-year-old patient with a history of seizures. During her stay, you notice that she begins staring blankly. During this period, you are unable to get her attention, and she does not speak. You suspect that this is a:
A. Petit mal seizure
B. Simple partial seizure
C. Grand mal seizure
D. Myoclonic seizure
Explanation
Correct Answer: A. The petit mal (or absence) seizure is characterized by blank staring and impaired level of consciousness. This type of seizure usually begins between the ages of 3 and 15 years. In the simple partial (or Jacksonian) seizure, the patient will be in an awake state but will exhibit abnormal motor or autonomic behaviors that can affect any part of the body. The grand mal (or tonic-clonic) seizure is the type of seizure in which there is a rapid extension of the arms and legs with sudden jerking and eventual loss of consciousness of the patient. It is often accompanied by incontinence and post-ictal confusion. During the myoclonic seizure, the patient may be awake or with short periods of loss of consciousness. During this seizure, the patient will have abnormal motor behavior in one or more muscle groups that lasts a few seconds to a few minutes.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-Topic: Pathophysiology
Subject: Child Health
Lesson: Neurologic
Reference: Centers for Disease Control and Prevention. Epilepsy: Types of Seizures. https://www.cdc.gov/epilepsy/about/types-of-seizures.htm. Accessed online October 2,
The patient presents with shortness of breath. Bilateral crackles in the lungs. Weak pulses. And frothy pink sputum. Which order should the nurse question for this patient?
A. O2 via nasal cannula or mask
B. Losartan
C. Fowler’s position
D. Diltiazem
Explanation
D is correct. The patient is showing signs of systolic heart failure. Diltiazem and other calcium channel blockers are contraindicated in systolic heart failure because they produce a negative inotropic effect that can exacerbate systolic dysfunction and cause heart failure symptoms to worsen. The nurse should question this order to determine if there is a more appropriate medication to accomplish the intended effect with a lower risk of complications.
A is incorrect. The patient is experiencing a worsening of heart failure symptoms, including shortness of breath. The patient will likely require supplemental oxygen to promote adequate tissue perfusion.
B is incorrect. Losartan is indicated for systolic heart failure patients. Afterload is increased in systolic heart failure due to increased peripheral resistance. Losartan is an angiotensin II receptor blocker that will relax the blood vessels and decrease afterload.
C is incorrect. Fowler’s position is indicated for patients with heart failure symptoms. Fowler’s post promotes oxygenation by allowing maximum chest expansion.
Subject: Adult health
Lesson: Cardiovascular
-or-
Subject: Pharmacology
Lesson: Cardiovascular
Topic: Illness management, the potential for alterations in body systems, system-specific assessments, expected actions/outcomes
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 797)
In preparing for his admission of a toddler who has been diagnosed with febrile seizures. which of the following is the most important nursing action?
A. Order a stat admission CBC.
B. Place a urine collection bag and specimen cup at the bedside.
C. Place a cooling mattress on his bed.
D. Pad the side rails of his bed.
Explanation
Children between 6 months and five years are at higher risk for fever-induced (febrile) seizures. Febrile seizures are not associated with neurological seizure disorders. The priority in nursing care for a patient (of any age) who has experienced a seizure is to implement safety precautions that decrease the likelihood of injury if/when another seizure occurs.
The correct answer is D. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence. A is incorrect. Only a physician can order lab work. B is incorrect. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. C is incorrect. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Chapter 32: Safety
A 30-year-old man was involved in a head-on collision and was unconscious for two minutes prior to EMS arrival. Five minutes before arriving to the hospital, the paramedic notices clear fluid draining from the patient’s nose. Having seen this before, the paramedic places a drop from the patient’s nose onto a piece of gauze. The nurse is looking for a clinical finding that is called “halo’s sign.” What type of fracture does the paramedic suspect the patient has?
A. Depressed skull fracture
B. Traumatic linear skull fracture
C. Subarachnoid hemorrhage
D. Basilar skull fracture
Explanation
D is the correct answer. Halos sign is an indication of a basilar skull fracture. Rhinorrhea can occur from a basilar skull fracture. When this finding is assessed, the provider can place a drop from the nose onto a piece of gauze. The CSF will form a ring around the outside of the drop. This is halo’s sign.
A, B, and C are incorrect because halo’s sign is clinically linked to a basilar skull fracture. Although halo’s sign can sometimes occur because of a depressed or linear skull fracture, it is not likely. Halo’s sign is almost always an indicator of a basilar skull fracture. A CSF leak occurs in about 20% of patients after suffering from a basilar skull fracture. This occurs because of a break in the temporal bones of the skull, which are the bones that are most commonly broken. CSF fluid can leak through the subarachnoid space after the destruction of the meningeal structure.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-topic: Alterations in Body Systems
Subject: Adult Health
Lesson: Peripheral Nerve and Spinal Cord Problems
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013
You are taking care of a 7-year-old female in the pediatric bone marrow transplant unit. She has been in the hospital for about a year and is working on her school work with the hospital teacher. You note that she is growing increasingly frustrated with her math homework. You know that her successful completion of academic demands is vital to her psychosocial development, as she is in which state of psychosocial development?
A. Industry vs. Inferiority
B. Autonomy vs. Shame and Doubt
C. Trust vs. Mistrust
D. Initiative vs. Guilt
Explanation
Answer: A
A is correct. Industry vs. Inferiority is the typical stage of development for school-age children, which are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in Inferiority.
B is incorrect. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like a toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure, and it results in shame and self-doubt.
C is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop a sense of confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build Mistrust.
D is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, which are 3 to 5-year-olds. In Initiative vs. guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Development
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Explanation
Answer: A
A is correct. Industry vs. Inferiority is the typical stage of development for school-age children, which are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in Inferiority.
B is incorrect. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like a toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure, and it results in shame and self-doubt.
C is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop a sense of confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build Mistrust.
D is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, which are 3 to 5-year-olds. In Initiative vs. guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Development
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Explanation
Answer: Vastus lateralis.
In infants, all intramuscular injections should be administered in the vast lateralis, if possible. This site provides the most developed muscle and is the most developmentally appropriate.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological Adaptation
Reference: Hockenberry M, Wilson D: Wong’s nursing care of infants and children, ed 9, St. Louis, 2011, Saunders
Subject: Fundamentals
Lesson: Medication administration
You are working in the newborn nursery, taking care of a 2-day old infant with a fetal alcohol spectrum disorder, and at the same time, preparing the family for discharge. Which of the following educational points are essential to include? Select all that apply.
A. Regular therapy appointments will need to be scheduled.
B. An individualized education plan should be formulated with the child’s school when he is preparing for kindergarten.
C. With proper therapy. the condition will improve.
D. A regular infant diet should be followed.
Explanation
Answer: A and B
A is correct. Therapy will be incredibly important for this infant after discharge. Physical therapy, occupational therapy, and speech therapy should all be involved with this infant. They will keep track of milestones and help aid in the development, motor skills, and cognitive abilities of the infants. Parents should be educated about the importance of these therapies so that they take them seriously and keep up with their appointments.
B is correct. This child will require special education when starting school. The parents should be educated about this need so that they are realistic about their culture and prepared for the future needs of the child. Individualized education plans will be accommodated through the school system, and the therapists and health care providers of the child can help inform them.
C is incorrect. Fetal alcohol spectrum disorder is a lifetime disability. There is no cure. Even with proper occupational therapy, physical therapy, and speech therapy, there are expected delays in the life of this infant. He or she will likely have difficulties with poor judgment, cognition, impulse control, memory, and learning for his or her entire life. Emphasizing the chronicity of this disease may help the mother refrain from consuming alcohol during any future pregnancies, and will ensure she is educated about the needs her child will face in the future.
D is incorrect. Infants with fetal alcohol spectrum disorder face challenges, including weak growth. They are often of short stature, low weight, and have smaller heads than average. Because of this, their nutritional needs will be unique. A nutritionist should be consulted to work with the family before discharge and teach them about the proper formulas/diet plan for their infant to maximize growth.
Which potential nursing problem is the highest priority for a patient who is in the immediate postoperative stage?
A. Risk for infection
B. Risk for fluid volume deficit
C. Risk for hemorrhage
D. Risk for altered body image
Explanation
C is correct. Patients are at risk of illness during the post-operative stage. Of the options listed, this potential problem would be the highest priority and would result in the most severe complications.
A is incorrect. This patient would be at risk for infection due to new surgical procedures, but this would not be as high a priority as the risk for bleeding.
B is incorrect. This patient would be at risk for dehydration and fluid volume deficit due to blood loss and decreased oral intake, but this would not be as high a priority as the risk for illness.
D is incorrect. This patient may be at risk for altered body image due to new surgical procedures. Still, this psychosocial problem would not be as high a priority as the physiological problem of risk for illness.
Subject: Leadership/management
Lesson: Prioritization
Topic: potential for complications from surgical procedures
Reference: (DiGiulio & Keogh, 2014, p. 634)
The nurse is providing discharge teaching to a patient receiving sulfamethoxazole. Which of the following instructions should be given during this teaching?
A. Discontinue taking this medication when symptoms are alleviated
B. Restrict fluid intake to prevent hypertension
C. Drink plenty of fluids
D. Go to the emergency department if the urine turns a dark brown or yellow
Explanation
NCSBN client need | Topic: Physiological Integrity, Pharmacological and Parenteral therapies
Rationale:
The correct answer is C. Sulfamethoxazole is used to treat urinary tract infections and should be taken with plenty of water. Each dose should be taken with a full glass of water.
Choice A is incorrect. Antibiotics should not be discontinued until the entire prescribed course is completed. I am stopping this medication when symptoms may contribute to antibiotic resistance.
Choice B is incorrect. This medication should be taken with plenty of fluids to prevent adverse effects.
Choice D is incorrect. Dark brown urine is a common side effect of using sulfamethoxazole and does not warrant a visit to the emergency department.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
You are caring for a client at the end of life who is terminally ill, confused, and no longer able to give informed consent. The doctor has spoken to the spouse about the need for a feeding tube because the client is malnourished and has a failure to thrive. The spouse, who is the client’s healthcare surrogate, states that she wants the tube feedings to begin as soon as possible so that the spouse will “not die of starvation”; however, the client’s advance directive, which was written five years ago, states that the client does not want a feeding tube or any other life-saving measures. What should you say to the client’s spouse about the feeding tube?
A. “I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive.”
B. “I agree that starvation is a bad way to die. I will contact the doctor and let the doctor know that you have agreed to place the feeding tube.”
C. “You cannot make that decision for your husband even though the doctor will probably give your husband the feeding tube.”
D. “Feeding tubes are not recommended for clients at the end of life who are affected with malnutrition and a failure to thrive.”
Explanation
Choice A is Correct. You would respond to the client’s spouse with, “I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive.” An advance directive supersedes the wishes of the healthcare surrogate.
Choice B is incorrect. You would not respond to the client’s spouse with, “I agree that starvation is a bad way to die. I will contact the doctor and let the doctor know that you have agreed to place the feeding tube.” The client should not get the feeding tube because they have chosen to NOT have one in their advance directive.
Choice C is incorrect. You would not respond to the client’s spouse with, “You cannot make that decision for your husband even though the doctor will probably give your husband the feeding tube” because this statement does not recognize or address the client’s spouse’s feelings or beliefs in a therapeutic manner.
Choice D is incorrect. You would not respond to the client’s spouse with “Feeding tubes are not recommended for clients at the end of life who are affected with malnutrition and a failure to thrive” because this statement is not only false, it does not underscore the need to follow the client’s wishes as stated in their advance directive.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
Which of the following lab values would be most significant in determining renal function in a client with a history of polycystic kidney disease?
A. BUN 90 mg/dL
B. Serum Potassium 7.0 MEq/L
C. Uric Acid 7.5
D. Creatinine 8.7 mg/dL
Explanation
Answer and Rationale:
Polycystic kidney disease is a genetic disorder that causes fluid-filled cysts to grow inside the kidneys. Unlike simple kidney cysts that may develop later in life, PKD cysts can change the shape of organs and alter the functioning of organs. Several tests can evaluate renal functioning.
The correct answer is D. Creatinine is a specific indicator of renal function/failure. A is incorrect. Although BUN is a measure of kidney function, patients without kidney disease who are dehydrated can show an elevation in BUN.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Chapter 28: Urinary Elimination
Lesson: Renal Disease
Reference: Fundamentals of Nursing (Wilkinson and Barnett)
In the report, you are told your 58 y.o. a male patient is anemic. Which of the following lab values would you expect for them? Select all that apply.
A. WBC 15.9
B. Hbg 7.5
C. Sodium 147
D. Hct 23.5%
Explanation
Answer: B and D
A is incorrect. This is a normal white blood cell count. A high or low WBC could indicate either infection or immunosuppression, but would not be reflective of anemia.
B is correct. Hemoglobin of 7.5 is low for a 58-year-old male. The standard reference range is 13.5 to 17.5. Low hemoglobin levels indicate anemia.
C is incorrect. Sodium is an electrolyte commonly monitored in metabolic panels. The normal level is 135-145. High or low levels can indicate things such as dehydration or overhydration and typically result in neurological changes, but do not reflect anemia.
D is correct. The hematocrit level is the percentage of blood components, which are red blood cells. A reasonable standard for an adult male is 45% to 52%. A hematocrit of 23.5% indicates anemia.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Subject: Adult Health
Lesson: Laboratory Values
Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing. Elsevier Health Sciences.
the nurse is caring for a patient with a diagnosis of prediabetes, which is not appropriate teaching for preventing progression from typing two diabetes diagnosis.
A. Maintain healthy weight
B. Perform moderate exercise regularly
C. Discuss dietary recommendations
D. Test daily blood glucose via fingerstick
Explanation
D is correct. Testing blood glucose daily may be appropriate to monitor the patient’s response to specific interventions, but is not typically indicated for prediabetes. This option pertains to monitoring/assessment, not prevention measures.
A is incorrect. Weight is a significant risk factor in developing type 2 diabetes. There is no information about the patient’s current weight status, so losing weight would not necessarily be indicated, but maintaining a healthy weight would be appropriate to reduce the patient’s risk for disease progression.
B is incorrect. Regular, moderate exercise reduces the risk of developing diabetes because it can help control both weight and blood sugar. Average levels of activity cause the body to use glucose, reducing serum levels. The American Diabetes Association recommends 30 minutes of exercise at least five times per week.
C is incorrect. The nurse should provide teaching about general dietary recommendations/modifications to reduce the patient’s risk of developing type 2 diabetes. If it is determined that the patient would benefit from further education, the nurse should schedule a patient for a meeting with the unit diabetes educator before discharge.
Subject: Adult health
Lesson: Endocrine
Topic: health screening, lifestyle choices, the potential for alterations in body systems, illness management
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1221)
According to Freud’s psychosexual stages, children from 2-3 years old are in the ___________ stage.
Explanation
Answer: anal
According to Freud’s psychosexual stages, children from 2-3 years old are in the anal scene. This is the stage when toilet training occurs. If children can complete this activity, they pass out of the anal stage, but if they struggle, then they may become ‘stuck’ in their psychosexual development.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Development
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
Which of the following are potential causes of metabolic alkalosis? Select all that apply.
Explanation
Answer: A and C
A is correct. Vomiting is a cause of metabolic alkalosis. There are a lot of acids in stomach contents, so losing those acids through vomiting leads to alkalosis.
B is incorrect. Diarrhea is a cause of metabolic acidosis. There are a lot of bases (bicarbonate) in diarrea, so losing them leads to acidosis.
C is correct. Antacids used in excess are a cause of metabolic alkalosis. Antacids have a lot of base in them, so taking too much leads to alkalosis.
D is incorrect. Starvation is a cause of metabolic acidosis. This is because when the cells are starving, the body starts to break down fat. The breakdown of fat leads to ketone production, and ketones are acid. So, too many ketones lead to acidosis.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Pharmacological therapies
Subject: Fundamentals
Lesson: Acid-Base
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
The Maternal Serum Screen 4 (MMS4) of an obstetrics client shows decreased maternal serum alpha-fetoprotein and Estriol and increased hCG. What strategy should the nurse include in the plan of care?
A. Refer to the physician
B. Tell the woman to increase her folic acid intake
C. Refer for amniocentesis
D. Order a plasma glucose level
Explanation
The Maternal Serum Screen 4 (MSS4) is a blood test performed during pregnancy to help identify potential risks to the developing fetus. Its purpose is to screen for possible neural tube defects, Down syndrome, or trisomy 18 in the developing baby. Four substances in the blood are measured: Alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), estriol, and inhibin A.
AFP is a substance made by the baby that enters the amniotic fluid and the mother’s bloodstream. A small amount of AFP is usually found in amniotic fluid and the mother’s blood. When the amount is high, it is a signal to the physician to look further for the possibility of a neural tube defect.
Estriol, hCG, and inhibin A come from the developing baby and placenta and can be measured in the mother’s blood. A woman who is carrying a baby with Down syndrome may have lower blood levels of AFP and estriol and higher blood levels of hCG and inhibin A than women with an unaffected baby. A woman who is carrying a baby with trisomy 18 may have lower blood levels of AFP, estriol, hCG, and inhibin A than women with unaffected babies. The MSS4 detects the same number of neural tube defects and trisomy 18 cases as other currently available maternal serum prenatal screens.
When inhibin A is used with AFP, hCG, estriol, and the mother’s age, approximately 10-15% more babies with Down syndrome can be detected before birth.
Remember that not even the MSS4 can detect all babies with Down syndrome before they are born.
The correct answer is A. The combination of results presented in this situation may be the result of a fetus with Down syndrome. The physician needs to be notified of the results, and the nurse would anticipate a referral for an amniocentesis. B is incorrect. A neural tube defect can be detected with MSAFP, but once the error has occurred, an increase in folic acid will not change it. Taking folic acid before becoming pregnant and continuing through the pregnancy can be beneficial to prevent neural tube defects. C is incorrect. The physician will order an amniocentesis if needed, not the nurse. D is incorrect. To check the plasma glucose level is not indicated based on these test results.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Chapter 3: Human Reproduction and Fetal Development
Lesson: Maternal Laboratory Monitoring
Reference: Safe Maternity and Pediatric Nursing (Louise Linnard-Palmer)
You are a nurse in the Emergency Department of the local hospital. You are caring for a 60-year-old man with a sudden-onset headache that he describes as “the worst he has ever had.” You know that red flags for a problem include: Select all that apply
A. Confusion
B. Nuchal rigidity
C. Hypotension
D. Age greater than 50 years
Explanation
Correct answers: A, B, and D.
Red flags for headaches include confusion, nuchal rigidity, age greater than 50 years (or less than five years). Hypertension, rather than hypotension, is another red flag. Other signs and symptoms that should trigger a warning about the severity of headaches include fever, weight loss, papilledema, disordered motor function, onset with exertion, and change in frequency, severity, or other features. Any combination of these symptoms may indicate increased intracranial pressure and brain hemorrhage.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-topic: Medical Emergencies
Subject: Critical Care
Lesson: Neurologic
Reference: Dodick DW. Clinical clues and clinical rules: primary vs. secondary headache. Adv Stud Med. 2003;3:S550–S555
When assessing the new stoma of a client diagnosed with Crohn’s disease. Which of these will alert the healthcare provider that the stoma has retracted?
A. Narrowed and flattened
B. Concave and bowl-shaped
C. Dry and reddish-purple
D. Pinkish-red and moist
Explanation
A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. Monitoring for signs of proper healing and educating the client/caregivers on signs of complicated healing ae notable. Complications that could arise from retracted stoma include difficulty maintaining appliance placement, which could lead to leakage and irritated skin.
The correct answer is B. A stoma that has retracted will appear concave and bowl-shaped. A is incorrect. A narrow, flattened, or constricted stoma indicates stenosis. C is incorrect. A dry, dusky, or reddish-purple stoma indicates ischemia. D is incorrect. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. It should appear pinkish-red and moist.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Basic Care and Comfort
Chapter 49: Fecal Elimination
Lesson: Fecal Elimination Problems
Reference: Fundamentals of Nursing (Kozier and Erb)
The nurse has been assigned to provide care for a group of patients that includes a patient with Mycoplasma pneumonia and a patient with Clostridium difficile diarrhea. What approach should the nurse use to best protect against the transmission of these infections to other patients?
A. Perform hand hygiene before, after and between providing direct patient care.
B. Don examination gloves whenever in direct contact with any patient.
C. Cleanse equipment such as thermometers or stethoscopes between patients.
D. Maintain a distance of 3 feet away from patients who are coughing.
Explanation
Correct Answer is A. The Centers for Disease Control and Prevention cite handwashing as the single most effective wayto prevent the transmission of disease. The effectiveness of other measures is dependent upon the foundation of appropriate hand hygiene.
B is incorrect – While many nurses do use exam gloves whenever in contact with patients, this will not be effective without practicing hand hygiene.
C is incorrect – While cleaning shared equipment will help prevent transmission of disease, it is not the most effective measure and is ineffective if the nurse had not practiced hand hygiene.
D is incorrect – Maintaining a distance of three feet from others who are coughing is recommended; however, this is not always feasible when providing patient care. Again, hand hygiene is the most effective preventative measure.
Reference:
Centers for Disease Control and Prevention. Clean Hands Count for Safe Healthcare. 2016.
Explanation
Correct Answer is A. The Centers for Disease Control and Prevention cite handwashing as the single most effective wayto prevent the transmission of disease. The effectiveness of other measures is dependent upon the foundation of appropriate hand hygiene.
B is incorrect – While many nurses do use exam gloves whenever in contact with patients, this will not be effective without practicing hand hygiene.
C is incorrect – While cleaning shared equipment will help prevent transmission of disease, it is not the most effective measure and is ineffective if the nurse had not practiced hand hygiene.
D is incorrect – Maintaining a distance of three feet from others who are coughing is recommended; however, this is not always feasible when providing patient care. Again, hand hygiene is the most effective preventative measure.
Reference:
Centers for Disease Control and Prevention. Clean Hands Count for Safe Healthcare. 2016.
Explanation
Answer: osmotic
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Pharmacological and Parenteral Therapies
Subject: Child Health
Lesson: Renal
Reference: Whyte, D.A., & Fine, R.N. (2008). Acute renal failure in children. Pediatrics in review, 29(9), 299-307
Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit?
A. Bowel sounds of 14 per minute
B. High-pitched bowel sounds at a rate of 4 per minute
C. Bowel sounds greater than 60 per minute
D. Low-pitched bowel sounds at a rate of 30 per minute.
xplanation
Answer and Rationale:
Bowel sounds are high pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult.
The correct answer is B. Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. A is incorrect. Bowel sounds of 14 per minute are considered normal. C is incorrect. Although bowel sounds more significant than 30 per minute is considered hyperactive, it is not as immediate a concern as option B. D is incorrect. Bowel sounds usually are high-pitched. However, the rate of bowel sounds is WNL. This option does not pose much concern as answer B.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Chapter 22: Health Assessment
Lesson: Auscultating the Abdomen
Reference: Fundamentals of Nursing (Wilkinson and Barnett)
The nurse places a patient with hypovolemia in the position depicted in the Exhibit. Which of the following positions does it represent?
A. The prone position.
B. The supine position.
C. The Trendelenburg position.
D. The Sims’ position.
Explanation
Correct Answer is C. This picture shows the Trendelenburg position. In this position, the body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. This position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. It is also used to improve the effects of spinal anesthesia and also to prevent air embolism during central venous cannulation.
Choice A is incorrect. The prone position is when a patient is placed in a horizontal position with the face oriented down. A prone position is often used during surgical procedures, especially for those needing access to the spine and the back. It is also used to increase oxygenation in patients with respiratory distress. A Prone position is depicted in the image below:
Choice B is incorrect. The supine position is when a patient is placed in a horizontal position with the face oriented up. A supine position is often used during surgical procedures, especially for those needing access to the thoracic area/ cavity. A Supine position is depicted in the image below:
Choice D is incorrect. A Sim’s position is when a patient lies on his/her left side, left hip and lower extremity straight, and right hip and knee bent. It is also called a lateral recumbent position. Sim’s status is usually used for rectal exams, treatments, and enemas. A Sims position is shown below:
Additional Reading
Fowler’s position: is another position an RN needs to be aware of since it has many implications during nursing care. This is when a patient is seated in a “semi-sitting” position when the head of the bed is elevated at a 45 to 60 degrees angle. There are variations in Fowler position: Low ( 15-30 degrees), Semi-Fowler (3-45 degrees), Standard (45-60 degrees), and High Fowler’s (60-90 degrees). Fowler’s position is depicted in the image below:
Fowler has been used as a way to help with peritonitis. Fowler’s can be used:-
To promote oxygenation during respiratory distress because it allows maximum chest expansion and relaxation of abdominal muscles. E.g., infants with respiratory distress. To increase comfort during eating and other activities. To improve uterine drainage in post-partum women. To minimize the risk of aspiration in patients with oral or nasal gastric feeding tubes. Fowler's position aids Peristalsis and swallowing by the effect of gravitational pull.
NCSBN Client Need:
Topic: Basic Care and Comfort. Sub-Topic: Non-pharmacological comfort interventions.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.
