FUNDAMENTALS Flashcards
The process of absorbing drugs before elimination after they have been excreted into bile and delivered to the intestines is called:
A. Hepatic clearance
B. Total clearance
C. Enterohepatic cycling
D. First-pass effect
Explanation
Before drugs can be clinically useful, they must be absorbed. Absorption is the process of a drug moving from its site of delivery into the bloodstream. The chemical composition of a drug, as well as the environment into which a drug is placed, work together to determine the rate and extent of drug absorption. Absorption can be accomplished by administering the drug in a variety of different ways (orally, rectally, intramuscularly, subcutaneously, inhalation, topically, etc.). If a drug is administered intravenously, the need for absorption is bypassed entirely.
For drug absorption to be most efficient, the properties of the drug itself and the pH of the environment where the drug is located must be considered. Most drugs are either weak acids or weak bases. Drugs that are weak acids will pick up a proton when placed in an acidic environment and will, thus, be un-ionized.
Other factors that also impact drug absorption include the following:
Physiologically, a drug’s absorption is enhanced if there is a large surface area available for absorption (villi/microvilli of the intestinal tract) and if there is a large blood supply for the drug to move down its concentration gradient. The presence of food/other medications in the stomach may impact drug absorption – sometimes enhancing absorption and other times, forming insoluble complexes that are not absorbed (it depends on the specific drug). Some drugs are inactivated before they can be absorbed by enzymes, acidity, bacteria, etc.
Answer and Rationale:
The correct answer is C. Drugs, and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. A is incorrect. Hepatic clearance is the amount of drug eliminated by the liver. B is incorrect. Total clearance is the sum of all types of removal, including renal, hepatic, and respiratory. D is incorrect. The first-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of medicine, making it into circulation.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 4: What Happens After a Drug Has Been Administered
Lesson: Drug Absorption
Reference: Core Concepts in Pharmacology (Holland/Adams)
A diabetic patient receives ten units of Regular insulin and 20 units of NPH insulin each day after breakfast. After following the usual preparation steps for administering insulin. What should the nurse do next?
A. Draw up NPH insulin first. because it is clear
B. Either insulin can be drawn first. as long as 30 units are given
C. Draw up Regular insulin first. because it is clear
D. Administer each type of insulin separately for accuracy
Explanation
Regular (short-acting) insulin is clear.NPH (intermediate-acting) is cloudy. Giving one injection is more efficient and comfortable for the patient.
The correct answer: C
The correct procedure for administering short-and long-acting insulin together is :( REMEMBER: ALWAYS CLEAR BEFORE CLOUDY) or remember the mnemonic: RN (Regular to NPH).
Verify orders for insulin types and doses. Wash hands and put on gloves. Roll NPH (cloudy vial) insulin between palms to mix contents of the bottle. Do NOT shake! Clean tops of vials with alcohol prep for 5-10 seconds. Inject 20 units of air into NPH vial and remove the syringe. ( Air equal to the volume that will be withdrawn from the bottle) Inject ten units of air into Regular (clear vial) vial and withdraw ten units. ( Air equal to the volume that will be withdrawn from the bottle) Remove the syringe. Insert the syringe into NPH (cloudy vial) vial and withdraw 20 units. Administer immediately. Within 5-10 minutes, combined insulins may be affected.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 29: Drugs for Endocrine Disorders
Lesson: Insulin Preparation
Reference: Core Concepts in Pharmacology (Holland/Adams)
The health fair nurse is evaluating patients for osteoporosis. Which of the following patients is at the greatest risk of developing this disease?
A. A 27-year-old woman who jogs three times a week
B. A 60-year-old woman who has smoked cigarettes for 40 years
C. A 70-year-old man who suffers from alcoholism
D. A 25-year-old man with asthma
Explanation
NCSBN client need | Topic: Maintenance and health promotion, health screening
Rationale:
The correct answer is B. A 60-year-old woman who smokes cigarettes is at risk of developing osteoporosis. Osteoporosis occurs more frequently in women than men and occurs more regularly in patients who smoke, consume alcohol, and are over the age of 50. Genetics also play a role.
Choice A is incorrect. Women’s bone density is at its highest at age 30 and begins to deteriorate afterward. Exercise is considered a protective effect against this disease.
Choice C is incorrect. While men can be diagnosed with osteoporosis, it is much less common. The 60-year-old woman would be much more likely to contract this illness than her male counterpart.
Choice D is incorrect. A 25-year-old male with asthma is not at an increased risk of developed osteoporosis.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
According to Freud’s psychosexual stages, children from 0-1 years old are in the ___________ stage.
Explanation
Answer: oral
According to Freud’s psychosexual stages, children from 0-1 years old are in the oral stage. In this stage, children are interested in putting things in their mouths, sucking and tasting. They will put unfamiliar objects in their mouth and derive pleasure from oral activities.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Pediatrics
Lesson: Development
Reference: Ricci, S. S., & Kyle, T. (2009). Maternity and pediatric nursing. Lippincott Williams & Wilkins.
The patient tells his nurse that he has no one he trusts to make healthcare decisions if he becomes incapacitated. What should the nurse suggest he prepare?
A. Combination advance medical directive
B. Durable power of attorney for health care
C. Living will
D. Proxy for health care
Explanation
Answer and Rationale:
The correct answer is C. The living will is a document whose precise purpose is to allow individuals to record specific instructions about the type of health care they would like to receive in particular end-of-life or incapacitated states. A is incorrect. The combination advance medical directive appoints a proxy (agent) whom the client trusts to make decisions. The client has stated he has no one he believes in making decisions for him. B is incorrect. A durable power of attorney for health care appoints an agent that the person trusts to make decisions in the event of incapacity. The patient has told the nurse he has no one he can trust. D is incorrect. A proxy is an agent. The client has stated he has no one that he trusts to designate.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Coordinated Care
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer)
Chapter 42: Loss, Grief, and Dying
Lesson: Ethical and Legal Dimensions
The nurse is caring for a client who is taking prescribed venlafaxine. Which statements made by the client would be highly concerning to the nurse?
A. “I have trouble sleeping at night.”
B. “I experience diarrhea at least once a day.”
C. “I just cannot go on like this anymore.”
D. “I am using artificial tears for my dry eyes.”
Explanation
Venlafaxine is a medication that is indicated for depression. Side-effects of venlafaxine include dry eyes and mouth. Diarrhea. And sleep disturbances. The client’s comment of not wanting to go on anymore should concern the nurse because anti-depressants may cause thoughts of suicide. Thus. The nurse needs to immediately follow-up with this client.
Which of the following are complications of acute tubular necrosis (ATN)? Select all that apply.
A. Metabolic acidosis
B. High thyroxine levels
C. Hyponatremia
D. Decreased parathyroid levels.
Explanation
Answer: A and C
A is correct. With ATN, the kidneys are not able to excrete excess hydrogen ions or reabsorb bicarbonate. Due to the inability to excrete the excess acid (hydrogen ions) paired with the inability to hang on to the needed base (bicarbonate), and acidosis ensues. This is due to the malfunction of the kidneys, not the lungs, so it is classified as metabolic acidosis.
B is incorrect. ATN is associated with low thyroxine levels, not high. Thyroid hormones have prerenal and intrinsic renal effects. Because they increase renal blood flow and glomerular filtration rate (GFR), ATN is often associated with low thyroid levels.
C is correct. ATN can cause hyponatremia. Due to lower urinary output, there is hypervolemia and relative dilutional hyponatremia.
D is incorrect. ATN can cause increased parathyroid levels. This is considered a secondary hyperparathyroidism.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Subject: Adult Health
Lesson: Renal
Reference: Basu, G., & Mohapatra, A. (2012). Interactions between thyroid disorders and kidney disease. Indian journal of endocrinology and metabolism, 16(2), 204–213. DOI:10.4103/2230-8210.93737
Which of the following is an example of the appropriate care of a client with neutropenia?
A. Routine hand washing
B. Offer a semi-private room
C. Provide fresh fruits and vegetables
D. Have the patient wear a mask when out of the room
Explanation
Neutropenia is a condition associated with a low neutrophil count, which is a type of white blood cell. Neutrophils are made in the bone marrow and fight off infections. Because the neutrophil count is low, the patient is more susceptible to infections, and preventive measures must be implemented.
Neutropenia can lead to life-threatening infections. Generally, the longer the neutropenia lasts, and the more severe it is, the more likely the patient will develop a disease. The National Cancer Institute has a grading scale correlating a patient’s ANC and the risk of infection. He single most important preventive measure is hand washing. Before any contact with a neutropenic patient, caregivers and others should wash their hands. Other preventive measures have been tried, but there’s little evidence to support their use. However, many of these practices remain in place, so follow your institution’s guidelines.
Infections often develop from endogenous bacteria, so patients should maintain good personal hygiene, including handwashing and oral care. Patients should avoid crowds and others who are ill. Avoiding uncooked meats, seafood, eggs, and unwashed fruits and vegetables may be prudent, though the effectiveness hasn’t been established.
Procedures that break the skin, such as venipunctures, biopsies, and I.V. therapy, may also introduce infection. Because trauma to the mucous membranes increases the risk of disease, you shouldn’t use catheters, enemas, rectal suppositories, or rectal thermometers. Common infection sites include the mucosa of the GI, urinary, and respiratory tracts.
The correct answer is D. The patient should wear a mask when leaving his hospital room to prevent exposure to any airborne pathogens that may cause infection. A is incorrect. Handwashing should be meticulous and frequent to help decrease the risk of exposure to pathogens. B is incorrect. A neutropenic patient should have a private room. C is incorrect. Fresh fruits, vegetables, and flowers can contain pathogens that may infect the patient. All food should be thoroughly cooked. Plants and flowers are not allowed in the patient’s room.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
An emergency room nurse is assigned to triage. Four people check-in at the same time. Which patient should receive priority care?
A. 29-year old female two week post-cesarean section that complains of a headache and leg swelling
B. 8 year old female with LLQ pain for three days
C. 55 year old male with RUQ pain & a history of pancreatitis
D. 3 year old female with pain upon urination
Explanation
A is correct. This patient is at risk for preeclampsia, which is a severe condition that can lead to seizures. The woman is at risk for preeclampsia anytime through pregnancy, as well as six weeks post-partum. Symptoms include headache, blurred vision, proteinuria, swelling in hands/face, and high blood pressure. If treatment is started, this condition can be controlled.
B, C, and D are incorrect because those patients are less of a priority. The patient with preeclampsia is most important in this situation. The patient in answer B most likely has constipation issues. The patient in answer C is most likely having a pancreatitis flare-up, but this can wait longer than the 29-year old with preeclampsia. The patient in answer D is most likely suffering from a UTI, which is common at this age because of potty training, female anatomy, not wiping correctly. She will need an antibiotic, but this is not urgent.
NCSBN Client Need
Topic: Safe and Effective Care Environment;Sub-topic: Care Management
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013
The nurse is educating a client about modifiable risk factors and risk factors that are not. Which of the following is most likely able to be corrected?
A. Genetic predisposition
B. Lifestyle choices
C. Depression
D. All of the above
Explanation
Answer and Rationale:
The correct answer is B. Lifestyle choices are the risk factors that are most likely able to be corrected. Poor lifestyle choices place a person at risk, and they are often considered risky behaviors. A is incorrect. While genetics, age, and gender may predispose a person to certain risk factors, they are NOT modifiable risks. C is incorrect. Depression may be a risk factor for developing other health issues. However, depression is not independently modifiable. Depression is an illness that must be treated and monitored. Because A and C are incorrect, D is also wrong.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Chapter 24: Promoting Family Health
Lessons: Modifiable Risk Factors and Non-modifiable Risk Factors
Reference: Fundamentals of Nursing (Kozier and Erb’s)
The nurse is caring for a patient with a nasogastric tube. Irrigation should be performed every 4 hours to assess for NG tube patency. The nurse should instill how many milliliters of water or normal saline?
A. 15 – 25 mL
B. 20 – 30 mL
C. 20 – 40 mL
D. 30 – 50 mL
Explanation
NCSBN client need | Topic: Basic Care and Comfort: Nutrition
Rationale:
The correct answer is D. NG tubes should be watered every 4 hours with 30 – 50 mL of water or normal saline.
Choices A, B, and C are incorrect.
Reference:
Perry A, Potter P, Ostendorf W, Perry A. Skills Performance Checklists For Clinical Nursing Skills & Techniques. Maryland Heights, MO: Elsevier Mosby; 2014.
Which of the following is an example of the implementation step of the nursing process? Select All That Apply.
A. The nurse carefully removes the bandages from a burn victim’s arm
B. The nurse assesses a patient to check her nutritional status
C. The nurse forms a nursing diagnosis for a patient with a seizure disorder
D. The nurse repositions a bed-bound patient every two hours to prevent decubitus ulcers
E. The nurse checks the client’s insurance coverage at the initial interview
F. The nurse verifies community resources for a patient with dementia
Explanation
https://images.app.goo.gl/tFaVsPvgiaPvqSFQ9
The correct answers are A, D, and F. During the implementation step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.
B, C, and E are incorrect.
B is the Assessment part of the nursing process.
C is the Planning part of the nursing process.
E is the Data Collection part of the nursing process.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Coordinated Care
Resource: The Art and Science of Patient-Centered Nursing Care
Chapter 14: Implementing
Lesson: Implementing the Plan of Care
The nurse is inserting a peripheral intravenous catheter. The nurse is correct in performing which action? Place each action in the correct order.
Apply tourniquet and palpate a vein for insertion.
Clean the skin with approved solution.
Tape and secure the IV site.
Stabilize the vein below the insertion site (digital traction)
Puncture the skin and vein with the stylet.
Apply pressure above the insertion site and connect the IV tubing.
Observe for blood return and advance the catheter.
Explanation
Inserting a peripheral IV requires the application of a tourniquet proximal to the targeted site. The skin should then be cleaned with an approved solution (circular motion), and then digital stabilization should be applied distally. Once the vein is selected and stabilized, the nurse should insert the stylet at an appropriate angle. Once blood return is seen in the chamber, the nurse should advance the needle a quarter of an inch and then thread in the catheter. Pressure should be held proximally, and the IV site should be flushed to verify patency. The nurse should then secure the place.
Which of the following steps is the final step that is used during the physical assessment of the abdomen?
A. Inspection
B. Deep palpation
C. Percussion
D. None of the above
Explanation
Answer and Rationale:
A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the age of the individual, the severity of the illness, the preferences of the nurse, the location of the examination, and the agency’s priorities and procedures.
The correct answer is B. Deep palpation is cautiously done after light palpation when necessary because the client’s responses to deep palpation may include their tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A is incorrect. Inspection is typically the first step of an assessment. C is incorrect. Percussion of the abdomen should be done before any palpation, especially deep palpation. Because A and C are incorrect, D is also wrong.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Chapter 30: The Health Assessment
Lesson: Abdomen
Reference: Fundamentals of Nursing (Kozier and Erb’s)
When instructing a patient with Type 1 Diabetes about exercise guidelines, which of the following instructions are MOST appropriate for the nurse to give to the patient? Select all that apply.
A. “Be sure to eat a simple carbohydrate snack before you exercise.”
B. “Do not administer insulin immediately before and after exercise.”
C. “It is best to eat a more complex carbohydrate before you exercise so that you don’t bottom out.”
D. “You may want to leave an energy drink with electrolytes in your gym locker in case you need it.”
E. “It is smart to alert your gym that you have type one diabetes.”
Explanation
Exercise is a vital part of managing Type 1 Diabetes. Exercise benefits patients with Type 1 diabetes because it increases insulin sensitivity, which may reduce the amount of insulin needed to maintain a healthy blood sugar level. Patients should be advised to eat a small snack containing 15 to 30 grams of carbohydrates, such as fruit juice, fruit, crackers, or even glucose tablets before exercise.
A, B, and E are the correct answers. Eating a simple carbohydrate before exercise can help boost the blood sugar before use. Patients should not administer insulin immediately before or after training, as this may cause blood sugar levels to drop too much. Notifying the gym that the patient has diabetes will be helpful in the event of an emergency. By doing this, if the patient experiences an emergency, responders can be alerted and take proper precautions.
C is incorrect. It takes longer for the body to break down a complex carbohydrate, and the patient needs the energy supplied by a pure sugar when exercising.
D is incorrect. Energy drinks are high in sugar and should be avoided.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
The health care provider has delivered an order for restraints on a patient who is attempting to pull out their intravenous fluids. Which of the following knots is most appropriate for securing the controls to the bed frame?
A. Full-bow tie
B. Fishermen’s knot
C. Quick release tie
D. Slip knot
Explanation
NCSBN client need | Topic: Safety and Infection Control: Use of Restraints
Rationale:
The correct answer is C. A quick-release knot, also known as a half-bow tie, is the only appropriate tie to employ in the use of restraints.
Choice B, C, and D are not secure knots to use when restraining a patient.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
The nurse is reviewing the laboratory results of a patient scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)?
A. Glycosylated hemoglobin (HgbA1C) of 7.2%
B. International Normalized Ratio (INR) of 3.5 seconds
C. Hematocrit (HCT) of 42%
D. Blood urea nitrogen (BUN) level of 5
Explanation
An INR of 3.5 seconds is elevated and needs to be reported because the client may bleed. The HgbA1C is elevated but would not impact a client scheduled for surgery. The hematocrit of 42% is within normal limits, and a BUN level of 5 is decreased but poses no threat to the client.
In pediatrics, monitoring development is incredibly important. Development that moves from the center of the body outward to the extremities is _________________ development.
Explanation
Answer: proximodistal
Development that moves from the center of the body outward to the extremities is proximodistal. The terms proximal and distal are both essential in anatomy. Proximal refers to a body part that is “situated nearer to the center of the body or the point of attachment.” and distal refers to a body part that is “situated away from the center of the body or the point of attachment.” For example, the elbow is proximal to the wrist, and the ankle is distal to the knee. In development, proximodistal development is healthy. The proximal parts of the body, like the trunk, develop sooner than the distal portions. This is why infants can hold their head up or roll over before they develop excellent motor skills like a pincer grasp. Proximodistal development means that the most distal parts of the body, like fingers and toes, are some of the last to develop, which explains why it takes much longer for infants to do things like hold a crayon and color than it does to raise their arms.
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.
The nurse is caring for a group of clients. Which client should the nurse see first?
Drag and drop each client in order of priority starting with the first client to be seen.
65-year-old newly admitted with an acute coronary syndrome (ACS) who is receiving a heparin infusion.
51-year-old client who has a discharge prescription following a heart failure exacerbation.
46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site.
31-year-old client three days post-operative who requires a sterile dressing change.
Correct Answer is:
65-year-old newly admitted with an acute coronary syndrome (ACS) who is receiving a heparin infusion.
46-year-old client two days post-operative from a vaginal hysterectomy reporting burning at the indwelling catheter site.
31-year-old client three days post-operative who requires a sterile dressing change.
51-year-old client who has a discharge prescription following a heart failure exacerbation.
Explanation
The nurse initially should see the client with ACS because of the instability that coincides with this condition. The client who is two days post-operative complaining of burning at the urinary catheter site should be assessed next. Further, the client requiring a sterile dressing change who is three days post-operative should be evaluated seen next. Finally, the client requesting discharge teaching should be seen last because of its low priority.
A nurse is caring for a client who has Lyme disease. The nurse should anticipate a prescription for which medication?
A. finasteride
B. doxycycline
C. valacyclovir
D. diphenhydramine
Explanation
Lyme disease is a disease that is caused by the bacteria Borrelia burgdorferi, which is carried by deer ticks. Symptoms of Lyme disease include a localized rash progressing to generalized symptoms. Doxycycline is one of the antibiotics used to treat this infection. The other options are not applicable as finasteride is indicated for benign prostate hypertrophy. valacyclovir is an anti-viral indicated for herpes infections and diphenhydramine is indicated for seasonal allergies.
You are a nurse in the local childcare facility. You are feeding an infant whose mother has expressed breast milk for feeding, halfway through the food. You notice that the juice you are supplying is not for this child. You have mistakenly picked up the liquid for another woman’s child. You should: Select all that apply
A. Inform the parent of the child you are feeding
B. Inform the mother of the child whose milk you fed to the child
C. Complete an incident report per facility policy
D. Inform the providers who are caring for the infants
Explanation
Correct answers: A, B, C, and D.
All of these actions are appropriate and expected in this situation. Also, the team should assess both of the mothers for any infectious process. Additionally, the nurse should educate both sets of parents that the risk of transmission of the disease is small. The mother may have concerns about exposure to hepatitis B and C; however, these infections cannot be spread from a woman to an infant through breastfeeding. Probably the most critical intervention is to put processes in place to prevent mix-ups of milk.
NCSBN Client Need
Topic: Safety and Infection Control
Sub-topic: Reporting of Incident
Subject: Maternal & Newborn Health
Lesson: Newborn
Reference: Centers for Disease Control and Prevention. Breastfeeding. https://www.cdc.gov/breastfeeding/recommendations/other_mothers_milk.htm. Accessed online on 01/24/20.
A 3-year old presents to the emergency department with signs of respiratory distress. The child has epiglottitis associated with a high fever. Is apprehensive and is drooling. The nurse must avoid which of the following?
A. Listening to the child’s lungs
B. Assessing the child’s vital signs
C. Weighing the child
D. Inspecting the child’s mouth and throat with a tongue blade
Explanation
Important Fact:
The symptoms of epiglottitis may resemble the signs of upper airway infection. These may include sudden onset of a severe sore throat, fever, loud voice, and a cough. Worsening symptoms may also involve drooling and leaning forward in a sitting position.
Answer and Rationale:
The correct answer is D. When there are symptoms of epiglottitis, a tongue blade should not be used to assess the throat visually. The use of a tongue blade on the infected tissue might result in further swelling and inflammation, potentially closing off the child’s airway completely. The nursing assessment should include listening to the lungs, assessing vital signs, and obtaining a weight. Therefore, A, B, and C are incorrect.
Resource
NCSBN Client Need:
Topic: Physiological Integrity
Chapter 32: Child With a Respiratory Condition
Lesson: Common Respiratory Disorders
Resource: Safe Maternity & Pediatric Nursing Care/ Lenard-Palmer/Coats
Which of the following is a critical lab value? Select all that apply.
A. Sodium: 134 mEq/L
B. Potassium: 7.8 mEq/L
C. Calcium: 9.2 mg/dl
D. Magnesium: 2.0 mEq/L
Explanation
Answer: B
A is incorrect. The average value for sodium is 135-145 mEq/L. 134 is considered slightly low but is not a critical lab value.
B is correct. The average value for potassium is 3.5-5.0 mEq/L. 7.8 is a critical value, and the patient is at risk for arrhythmias and death.
C is incorrect. The average value for calcium is 9.0 - 10.5 mg/dl. This is a typical lab value.
D is incorrect. The average value for magnesium is 1.3-2.1 mEq/L. This is a typical lab value.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Risk of the potential reduction
Subject: Fundamentals
Lesson: Laboratory Values
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
The home care nurse is assessing a client whose husband passed away nearly half of a year ago for healthy coping. Which of the following is not a robust coping mechanism?
A. Looking at photographs of the client’s husband
B. Getting together with friends more frequently than before
C. Having difficulty eating
D. Expressing a strong desire to visit their husband’s grave every few weeks.
Explanation
NCSBN client need | Topic: Psychosocial integrity, Grief and loss
Rationale:
The correct answer is C. Having a difficult time eating nearly half a year after an injury is not a healthy coping mechanism. While typical in the first few weeks following a loved one’s death, this length of time indicates a need for intervention.
Choice A is incorrect. Looking at old photographs of the patient’s husband is a healthy way to deal with grief.
Choice B is incorrect. Getting together with friends is an excellent way to cope with grief and loss. Many patients will spend more time with their friends after the passing of a spouse.
Choice D is incorrect. Feeling a strong desire to visit a loved one’s grave every few weeks is an essential part of the grieving process.
Reference:
Wilson S. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. Journal of Clinical Nursing. 2008;17(8):1120-1120. DOI:10.1111/j.1365-2702.2006.01939.x.
Which of the following anatomical characteristics are descriptive of the congenital heart defect Tetralogy of Fallot? Select all that apply.
A. There is a hole between the two ventricles called a ventricular septal defect.
B. There is an overriding aorta.
C. The pulmonary arteries are stenosed.
D. There is right ventricular hypertrophy.
Explanation
Answer: A, B, C, and D
A is correct. Tetralogy of Fallot is a congenital heart defect composed of four different errors, a VSD being one of them. The VSD is a hole between the right and left ventricles, which allows the oxygenated and deoxygenated blood to mix in which is essentially one ventricle.
B is correct. Tetralogy of Fallot is a congenital heart defect composed of four different defects, an overriding aorta being one of them. This means that the aorta is positioned over the VSD instead of over the left ventricle where it should be.
C is correct. Tetralogy of Fallot is a congenital heart defect composed of four different defects, pulmonary stenosis being one of them. The pulmonary arteries are narrowed and hardened, making it difficult for the right ventricle to pump blood to the lungs.
D is correct. Tetralogy of Fallot is a congenital heart defect composed of four different defects, right ventricular hypertrophy being one of them. This portion of the error is actually due to another part: the pulmonary stenosis. Because these vessels are narrowed and hardened, it is difficult for the right ventricle to pump blood through them and out to the lungs. This puts extra work on the heart, and after time the muscle of the right ventricle gets more substantial or hypertrophy due to the extra work.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Subject: Child Health
Lesson: Cardiovascular
Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing. Elsevier Health Sciences.
When caring for an infant during cardiac arrest. Which pulse must be palpated to determine cardiac function?
A. Carotid
B. Brachial
C. Pedal
D. Radial
Explanation
Accurate assessment of heart rate, breathing, and the color is an essential part of infant resuscitation, and the guidelines state that heart rate may be assessed using a stethoscope, or palpating the umbilical, brachial or femoral pulse
The correct answer is B. The brachial pulse is the most accessible pulse on an infant and, therefore, it is the site of choice.
A is incorrect. The carotid pulse may be difficult to palpate due to the fatty tissue that typically, and often, surrounds an infant’s neck.
C and D are incorrect. The radial and pedal pulses may not be reliable indicators of cardiac function.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Chapter 33: The Child with a Cardiac Condition
Lesson: Nursing Considerations for Cardiac Assessment
Safe Maternity and Pediatric Nursing (Linnard-Palmer and Coats)
Which of the following opportunistic infections are a sign that a patient with HIV now has AIDS? Select all that apply.
A. Stomach Ulcers
B. Symptomatic Tuberculosis
C. Toxoplasmosis of the brain
D. Osteoporosis
E. Pneumocystis carinii pneumonia
Explanation
NCSBN client need | Topic: Physiological Integrity, Illness Management
Rationale:
The correct answers are B, C, and E. Generally, tuberculosis, or TB, does not affect those with healthy CD4 levels. Symptomatic TB is a sign of AIDS. An infection with Toxoplasmosis of the brain indicates a serious infection directly related to the condition. Affecting the lung, pneumocystis carinii pneumonia is typical of patients with AIDS and a serious sign of low CD4 counts.
Choice A is incorrect. While some people with HIV or AIDS may have stomach ulcers, they are not indicative of an AIDS diagnosis.
Choice D is incorrect. Osteoporosis, a condition where a reduction in bone strength increases a person’s risk of bone breakage. This is not a sign of AIDS.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
The patient with appendicitis is experiencing discomfort before her appendectomy. The nurse should avoid which of the following non-pharmaceutical therapies to relieve this discomfort?
A. Apply ice packs to the abdomen
B. Practice breathing exercises with the patient
C. Use a heating pad
D. Encourage rest
Explanation
NCSBN client need | Topic: Physiological Adaptation, Basic Care and Comfort
Rationale:
The correct answer is C. Heat should not be applied to the abdomen of patients experiencing pain from appendicitis. Heat may cause a rupture of the appendix, which puts the client at risk for a life-threatening condition known as peritonitis.
Choice A is incorrect. Applying ice packs to the abdomen of a patient experiencing discomfort related to appendicitis is an appropriate non-pharmaceutical intervention.
Choice B is incorrect. Using breathing techniques to work through the pain of appendicitis is an appropriate non-pharmaceutical intervention.
Choice D is incorrect. Encouraging plenty of rest is an excellent way to prevent and manage pain from appendicitis.
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
Which of the following infection control activities should be delegated to an experienced nursing assistant?
A. Asking clients about the duration of antibiotic therapy.
B. Demonstrating correct handwashing techniques to client and family.
C. Disinfecting blood pressure cuffs after clients are discharged.
D. Screening clients for upper respiratory tract symptoms.
Explanation
In nursing, delegation refers to indirect care. The intended outcome is achieved through the work of someone supervised by the nurse. It involves defining the task, determining who can perform the job, describing the expectation, seeking agreement, monitoring performance, and providing feedback to the delegate regarding performance. While some nursing assistants may be proficient in tasks or be familiar with symptoms of diseases or disorders, clinical tasks such as assessments and education should always be assigned to a licensed nurse.
The correct answer is C. Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. Options A, B, and D: The other options should be carried out by a licensed nurse.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Chapter 28: Leading, Managing, and Delegating
Lesson: The Nurse as a Delegator
Reference: Fundamentals of Nursing (Kozier and Erb)
You are on the night shift caring for a 65-year-old patient in the Emergency Department of a small. Rural hospital. The nearest medical center is approximately 80 minutes away by ground transport. The patient was admitted 15 minutes ago with crushing chest pain that started about 30 minutes before arrival. The emergency medical services (EMS) team started oxygen before arrival and administered aspirin 325 mg by mouth. On arrival. You ordered a 12-lead EKG. Based on that test. The physician has made the diagnosis of ST-elevation myocardial infarction (STEMI). You prepare for:
A. Emergency coronary artery bypass
B. Immediate percutaneous coronary intervention (PCI)
C. Fibrinolytic therapy
D. Admission to the intensive care unit
Explanation
Correct Answer: C.
Fibrinolytic therapy. After the diagnosis of STEMI, the next step in the process is to determine the availability of PCI. Since you are working the night shift in a small, rural hospital, it is unlikely that a team is available for angiography and PCI. Since PCI must be done within 90 minutes, transport to a more significant medical center with those capabilities cannot be accomplished within this time frame. Therefore, fibrinolytic therapy should be implemented as soon as possible. An emergency coronary bypass is not indicated. Although the patient should be admitted to an ICU, fibrinolytic treatment should be done in the Emergency Department.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-topic: Alterations in Body Systems
Subject: Critical Care
Lesson: Cardiovascular
Reference: Merck Manual. Acute myocardial infarction. Accessed online on February 1, 2020, at https://www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/acute-myocardial-infarction-mi
