FUNDAMENTALS Flashcards
A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider?
A. Decreased blood urea nitrogen (BUN) level
B. Decreased glomerular filtration rate (GFR)
C. Decreased fasting plasma glucose
D. Decreased hemoglobin A1C
Explanation
Metformin is an oral anti-diabetic indicated for diabetes mellitus type II. Metformin may cause renal impairment, and a decrease in glomerular filtration rate (GFR) would be such evidence. A reduction in the blood urea nitrogen (BUN) level does not indicate nephrotoxicity, and a decrease in both the hemoglobin A1C and fasting plasma glucose would be therapeutic effects of the medication.
Which part of the laryngeal cartilage is a full circular ring and is the narrowest part of the airway in young children?
A. Hyoid
B. Arytenoid
C. Cricoid
D. Thyroid
Explanation
C is the correct answer. The cricoid appears as a full circular ring and is the most narrow part of the airway. While intubating, it can be useful to place pressure on the cricoid to make the airway more comfortable to access.
A is incorrect. The hyoid is a semi-circle ring, not a circular ring. It helps support the tongue.
B is incorrect. The arytenoid muscle is at the back of the larynx and allows the vocal cords to work correctly.
D is incorrect. The thyroid is an organ that sits below the “Adam’s apple” and is not a part of the airway.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-topic: Pathophysiology
Subject: Adult Health
Lesson: Respiratory System
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013
A 25-year-old is found unconscious with fever and a noticeable rash. Which of the following tests will most likely be a priority order?
A. Blood sugar check
B. CT scan
C. Blood cultures
D. Arterial blood gases
Explanation
Answer and Rationale:
The correct answer is C. Blood cultures would be ordered to investigate the source of fever and rash. A is incorrect. Abnormal blood sugar levels should not present with fever or a rash. B is incorrect. A CT scan is not indicated to find the source of a rash. D is incorrect. ABGs are not indicated to test the source of fever or rash.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Taylor’s Clinical Nursing Skills
Chapter 8: Skin Disorders
Lesson: Rashes
A 30-year old female on a cardiac unit states to the nurse, “I’m just not sure my incision is ever going to look right. I don’t want to look like a freak.” What should the nurse say to comfort her?
A. “It will heal fine.”
B. “Why are you worrying?”
C. “What do you think you will look like?”
D. “Tell me more.”
Explanation
C is the correct answer. C encourages the patient to explain what they think they will look like, which in turn leads to open conversation.
A is incorrect. This statement is inappropriate from a nurse regarding any situation because it may not heal properly in the end. This also doesn’t allow the patient to express any feelings. It shuts the patient down the open conversation.
B is incorrect. This statement is demeaning towards the patient because it is asking the patient why she feels a certain way instead of talking about the feelings.
D is incorrect. Even though this may be an excellent therapeutic communication technique in some situations, it isn’t the best answer. It does not acknowledge the patient’s feelings of disfigurement but only tells the patient to keep talking.
NCSBN Client Need
Topic: Psychosocial integrity
Sub-topic: Therapeutic Communication
Subject: Psychiatric Health
Lesson: Therapeutic Communication
Reference: Townsend, 2013
The cardiac nurse is evaluating cardiac markers to determine whether or not their patient’s heart has suffered from muscle damage. The nurse is aware of that. If damage has occurred, CK-MB levels will be their highest after how many hours?
A. 3 to 6
B. 1 to 2
C. 48 to 72
D. 18
Explanation
NCSBN client need | Topic: Physiological adaptation, reduction of risk potential
Rationale:
The correct answer is D. CK-MB or creatine kinase, myocardial muscle, levels measure muscle cell death, and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels first begin elevating about 3 to 6 hours after a cellular injury or myocardial infarction and stay elevated for about 48 to 72 hours.
Choice A is incorrect. While CK-MB levels begin to rise about 3 to 6 hours after myocardial cellular death, they do not peak until 18 hours.
Choice B is incorrect. CK-MB enzyme levels will not have risen yet by 1 to 2 hours. Standards do not begin to rise until 3 to 6 hours and hit their peak around 18 hours.
Choice C is incorrect. At 48 to 72 hours, CK-MB enzyme levels will have likely returned to normal.
Reference:
Sole M, Klein D, Moseley M. Introduction To Critical Care Nursing. 1st ed. St. Louis, Mo.: Saunders; 2009.
You are working in the Emergency Department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), the general immediate assessment and stabilization should include: (Select all that apply)
A. Activate the stroke team
B. Check and treat the glucose
C. Order an immediate CT or MRI of the brain
D. Administer rtPA
Explanation
Correct answers: A, B, and C. According to the AHA, the immediate general assessment and stabilization should include: assess the ABCs and vital signs, provide oxygen as needed, obtain an IV, check glucose and treat as needed, perform an essential neurologic screening, activation of the stroke team, order an immediate CT or MRI of the brain, and obtain an ECG. All of these actions should be included within the first 10 minutes after arrival at the ED. The decision of whether or not to give rtPA will depend on the results of the CT scan or MRI. If the provider determines that there is no brain hemorrhage, the team should complete the fibrinolytic checklist before deciding whether or not to give rtPA.
NCSBN Client Need
Topic: Management of Care
Sub-Topic: Establishing Priorities
Subject: Critical Care
Lesson: Neurologic; Prioritization
Reference: American Heart Association. Advanced Cardiovascular Life Support: Provider Manual. Adult Suspected Stroke Algorithm. March 2016 eBook edition.
A. Warfarin (coumadin)
B. Finasteride (Propecia. Proscar)
C. Celecoxib (Celebrex)
D. Clonidine (Catapres)
E. Transdermal Nicotine (habitrol)
F. Clofazimine (Lamprene)
Explanation
Fetal age affects the type of drug effect:
Before the 20th day after fertilization: Drugs were given at this time typically have an all-or-nothing effect, killing the embryo or not affecting it at all. Teratogenesis is unlikely during this stage.
During organogenesis (between 20 and 56 days after fertilization): Teratogenesis is most likely at this stage. Drugs reaching the embryo during this stage may result in spontaneous abortion, a sublethal gross anatomic defect (exact teratogenic effect), covert embryopathy (a permanent subtle metabolic or functional defect that may manifest later in life), or an increased risk of childhood cancer (e.g., when the mother is given radioactive iodine to treat thyroid cancer); or the drugs may have no measurable effect.
After organogenesis (in the 2nd and 3rd trimesters): Teratogenesis is unlikely, but drugs may alter the growth and function of customarily formed fetal organs and tissues. As placental metabolism increases, doses must be higher for fetal toxicity to occur.
Answer and Rationale:
The correct answers are A and B.
Warfarin (coumadin) has a pregnancy category X. It is associated with central nervous system defects, spontaneous abortion, stillbirth, prematurity, illness, and ocular defects when given any time during pregnancy and a fetal warfarin syndrome when given during the first trimester.
Finasteride (Propecia, Proscar) also has a pregnancy category X, which has a high risk of causing permanent damage to the fetus.
C is incorrect. Celebrex in large doses causes congenital disabilities in rabbits, but it is not known if the effect is the same on humans.
D is incorrect. Clonidine (Catapres) crosses the placenta, but no adverse fetal effects have been observed.
E is incorrect. Nicotine replacement products have been assigned to pregnancy category C (nicotine gum) and category D (transdermal patches, inhalers, and spray nicotine products).
F is incorrect. Clofazimine has been assigned to pregnancy category C.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Resource: Safe Maternity and Pediatric Nursing Care
Chapter 3: Human Reproduction and Fetal Development
Lesson: The Effects of Medications on Fetal Development
You are a registered nurse who is performing the role of a case manager in your hospital. You have been asked to present a class to newly employed nurses about your role. your responsibilities and how they can collaborate with you as the case manager. Which of the following is a primary case management responsibility associated with reimbursement that you should you include in this class?
A. The case manager’s role in terms of organization wide performance improvement activities.
B. The case manager’s role in terms of complete. timely and accurate documentation.
C. The case manager’s role in terms of the clients’ being at the appropriate level of care.
D. The case manager’s role in terms of contesting denied reimbursements
Explanation
Important Fact:
RN case managers have a primary case management responsibility associated with reimbursement because they are responsible for ensuring the patient is cared for at the appropriate level, consistent with medical necessity and current patient needs.
Answer & Rationale:
The correct answer is C. A failure to ensure the appropriate level of care jeopardizes reimbursement. For example, care in an acute care facility will not be reimbursed when the client’s current needs can be met in a subacute or long-term care setting. A, B, and D are incorrect. Nurse case managers do not have organization-wide performance improvement activities, the supervision of complete, timely, and accurate documentation or challenging denied reimbursements in their role. These roles and responsibilities are typically assumed by quality assurance/performance improvement, supervisory staff, and medical billers, respectively.
Resource
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Management of Care
Chapter 6: Healthcare Delivery Systems
Lesson: Providers of Healthcare
Reference: Kozier and Erb’s Fundamentals of Nursing
Which of the following comments by the patient reflect an understanding of the proper use of a metered-dose inhaler? Select All That Apply.
A. “I will be careful not to shake the canister before using it.”
B. “I will hold the canister upside-down when using it.”
C. “I will inhale the medication through my nose.”
D. “I will continue to inhale when the cold propellant is in my throat.”
E. “I will only inhale one spray with one breath.”
F. “I will activate the device while continuing to inhale.”
Explanation
Patients need repeated instruction on how to use inhalers and nebulizers effectively and safely. Overuse may result in serious side effects and eventual ineffectiveness of the medication. Patients must understand that it is essential to keep track of dosing with MDIs to make sure they are not using an empty canister. While some MDIs have integrated dose, counters, not all MDIs do, and it can be challenging to know when the cartridge is empty.
Answer and Rationale:
The correct answers are D, E, and F. A B and C are incorrect. Common mistakes that patients make when using metered-dose inhalers include failing to shake the canister, holding the canister upside down, and inhaling through the nose rather than the mouth.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Interventions
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer)
Chapter 36: Oxygenation and Perfusion
Lesson: Teaching Patients About Inhaled Medications
A client with lung cancer has recently had a left lower lobe removal. Which priority will the postoperative intervention be performed in the care of this patient?
A. A tracheostomy
B. A mediastinal tube
C. Incentive spirometer
D. Closed chest drainage system
Explanation
NCSBN client need | Topic: Reduction of Risk Potential / Potential for Complications of Diagnostics Tests, Treatments or Procedures
Rationale:
The correct answer is D
Correct. A patient with a recent lower lobe lung removal will have a chest tube drainage system to collect the blood and drainage and to prevent it from accumulating in the chest.
Choice A is incorrect. The patient will likely not have a tracheostomy.
Choice B is incorrect. A mediastinal tube is unlikely to be prescribed for this client.
Choice C is incorrect. The patient may use an incentive spirometer during their recovery; it is not a priority nursing action.
Reference:
Lewis S, Dirksen S, Heitkemper M, Bucher L, Harding M. Medical-Surgical Nursing.
A client has a pressure ulcer with a shallow. Partial skin ¬thickness. Eroded area but no necrotic regions. The nurse would treat the area with which dressing?
A. Alginate
B. Dry gauze
C. Hydrocolloid
D. No dressing is indicated
Explanation
Important Fact:
Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions. The stage of breakdown will determine treatment. Nurses should review standing orders from their facility and any additional physician’s orders for pressure ulcer care.
Answer & Rationale:
The correct answer is C. Hydrocolloid dressings protect shallow ulcers and promote an appropriate healing environment. A is incorrect. Alginates are used for wounds with significant drainage. B is incorrect. Dry gauze will stick to new granulation and result in more damage. D is incorrect. A dressing is necessary to protect the wound and help advance healing.
Resource
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Basic Care & Comfort
Chapter 36: Skin Integrity & Wound Care
Lesson: Pressure Ulcers
Reference: Kozier &Erb’s Fundamentals of Nursing
The nurse is placing the patient with a chronic kidney on a cardiac monitor. This action is primarily performed because:
A. Patients with chronic kidney disease are prone to hypertension
B. Hyperkalemia may result in dysrhythmias
C. Cardiac monitoring is necessary to evaluate the need for hemodialysis
D. Patients with chronic kidney disease may experience false episodes of asystole
Explanation
NCSBN client need | Topic: Physiological Integrity, Reduction of Risk Potential
Rationale:
The correct answer is B. Patients with chronic kidney disease retain electrolytes such as potassium, which may lead to imbalances. Hyperkalemia, or excess serum potassium levels, often results in cardiac dysrhythmias.
Choice A is incorrect. While patients with chronic kidney disease may experience hypertension, a cardiac monitor does not evaluate the patient for this occurrence.
Choice C is incorrect. Cardiac monitoring may show dysrhythmias, which could suggest the need for hemodialysis. However, this is not the primary method doctors use to evaluate this need.
Choice D is incorrect. False episodes of asystole is not a concern with chronic kidney disease.
Reference:
Williams LHopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co.; 2011.
When an elderly home health client suddenly develops delirium. what is the first thing the home health nurse should assess for?
A. Drug intoxication
B. Increased hearing loss
C. Cancer metastases
D. Congestive heart failure
Explanation
Delirium is an acute and reversible syndrome. It is characterized by changes in memory, judgment, language, mathematical calculation, abstract reasoning, and problem-solving ability. The most common causes of delirium are infection, medications, and dehydration.
Some symptoms of delirium include:
Hallucinations Restlessness, agitation or combative behavior I am calling out, moaning, or making other sounds. Being quiet and withdrawn — especially in older adults Slowed movement or lethargy Disturbed sleep habits Reversal of night-day sleep-wake cycle The correct answer is A. Drug intoxication, from prescription or OTC medications, is more common in the elderly, due to slower metabolism and absorption. Combinations of digoxin, diuretics, analgesics, and anticholinergics should be examined. Answers B, C, and D are incorrect. Although the other options can lead to delirium, the onset is gradual, not sudden.
NCSBN Client Need
Topic: Psychosocial Integrity
Chapter 23: Promoting Health in the Older Adult
Lesson: Health Assessment and Promotion
Reference: Fundamentals of Nursing (Kozier and Erb)
Which of the following nursing actions can an LPN/LVN perform on a patient who has a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA)?
A. Obtain wound cultures during dressing changes.
B. Plan ways to improve the client’s oral protein intake.
C. Assess risk for further skin breakdown.
D. Educate the client about home care of the leg ulcer.
Explanation
The correct answer is A. LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound cultures. Options B, C, and D: Teaching, assessment, and planning of care are complex actions that should be carried out by a registered nurse.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Chapter: Delegation
Lesson: At-Risk Patients
Reference: Fundamentals of Nursing (Wilkinson/Barnett)
Upon entering a client’s room. the nurse finds the client lying on the floor. What is the first action the nurse should implement?
A. Call for help to get the client back in bed
B. Assist the client back to bed
C. Establish if the client is responsive
D. Ask the client what happened
Explanation
Answer and Rationale:
The correct answer is C. Assessing if the patient is responsive is the primary concern of the nurse in this example. A and B are incorrect. The client’s responsiveness is a priority before moving the client. D is incorrect. This answer option would be the least important among the options given.
NCSBN Client Need
Topic: Safe and Effective Care Environment
Subtopic: Safety and Infection Control
Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn)
Chapter 26: Safety, Security, and Emergency Preparedness
Lesson: Falls
You are the nursing supervisor in a long-term care facility. One of the major considerations that you apply into your practice is strict infection control prevention measures because you are knowledgeable about the fact that the normal aging process is associated with the deterioration of the body’s normal defenses. Which theory of aging supports your belief that strict infection control prevention measures are necessary?
A. The Programmed Longevity Theory
B. The Immunological Theory of Aging
C. The Endocrine Theory
D. The Rate of Living Theory
Explanation
Important Fact:
Programmed theories assert that the human body is designed to age and there is a certain biological timeline that bodies follow. All of these theories share the idea that aging is natural and “programmed” into the body.
Error theories, such as the Rate of Living Theory, assert that aging is caused by environmental damage to the body’s systems, which accumulates over time.
Answer & Rationale:
The correct answer is B. The theory of aging that supports your belief that strict infection control prevention measures are necessary is the Immunological Theory of Aging. The Immunological Theory of Aging states that aging leads to the decline of the person’s defensive immune system and the decreased ability of the antibodies to protect us against infection. A, C and D are incorrect. The Programmed Longevity theory of aging states that genetic instability and changes occur such as some genes turning on and off lead to the aging process; the Endocrine Theory of aging states that aging results from hormonal changes and the biological clock’s ticking; and Rate of Living Theory states that one’s longevity is the result of one’s rate of oxygen basal metabolism.
Resource
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Chapter 10: Lifespan of Older Adults
Lesson: Theories of Aging
Reference: Fundamentals of Nursing (Wilkinson/Barnett/Smith)
A patient is started on a daily amount of Phenytoin (Dilantin) 200mg PO in two divided doses. What instruction. Suppose given by the nurse to the patient. Is INCORRECT?
A. “You will need annual labs to determine the medication level in your body.”
B. “Remember to never skip a dose of this medication.”
C. “You need to increase your intake of vitamin D while taking this medication.”
D. “Maintain good oral hygiene and visit your dentist regularly.”
Explanation
Dilantin acts by desensitizing sodium channels in the CNS. It may cause dysrhythmias, such as bradycardia, severe hypotension, and hyperglycemia. Weekly monitoring of Dilantin levels should be done weekly until therapeutic levels are reached. After therapeutic levels are reached, most physicians request levels to be checked at least every three months.
Answer & Rationale:
The correct answer is A. Proper instruction includes telling the client that, initially, weekly labs need to be drawn, NOT annual labs. B, C, and D are incorrect. Each of these statements reflects correct nursing instruction for a client taking Dilantin. It is essential for a patient newly started on Dilantin to receive weekly labs initially to check the CBC. Patients need to have their RBCs, WBCs, and platelets monitored because Dilantin can cause those numbers to fall.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological and Parenteral Therapies
Chapter 11: Drugs for Seizures
Lesson: Seizures
Reference: Core Concepts in Pharmacology (Holland/Adams)
The nurse is educating a woman with an above-average BMI on her risk factors. Which of the following issues does not correlate with an above-normal BMI pre-pregnancy?
A. Gestational diabetes
B. Preeclampsia
C. Swelling
D. Frequent UTI
Explanation
NCSBN client need | Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care
Rationale:
The correct answer is D. Frequent urinary tract infections are not associated with maternal above average body mass index.
Choices A, B, and C are incorrect. The development of gestational diabetes, preeclampsia, and swelling are positively correlated with maternal above-average BMI. Other issues include increased C-section rates, stillbirth, and poor wound healing.
Reference:
Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014
The nurse is preparing to suction a client to obtain a sputum sample. Before performing this procedure. the nurse should:
A. Hyperoxygenate the client
B. Provide the client with a small snack
C. Initiate NPO status
D. Confirm the order with the physician
Explanation
NCSBN client need | Topic: Physiological Integrity, Reduction of Risk Potential
Rationale:
The correct answer is A. Patients about to undergo a suctioning procedure should first be hyper oxygenated. Suctioning interrupts the patient’s breathing, and hyperoxygenation prevents harm.
Choice B is incorrect. Providing the patient with a snack is not a necessary action before suctioning.
Choice C is incorrect. A patient about to undergo a suctioning procedure does not require NPO status.
Choice D is incorrect. There is no reason to confirm this procedure with the physician. Suctioning is a popular way to collect a sputum sample.
Reference:
Williams LHopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co.; 2011.
According to the National Council of State Boards of Nursing. the five rights of the delegation include: Select all that apply
A. Right task
B. Right circumstance
C. Right person
D. Right direction and communication
Explanation
Correct answers: A, B, C, D.
All of these are among the five rights of delegation, according to the NCSBN. The fifth right is the right supervision and evaluation. The proper task means that the responsibility falls within the scope of practice and job description of the person delegated the responsibility. The right circumstance implies that the patient/client is stable enough to have someone other than an RN be responsible for the job. The right person implies that the person doing the job has the skill and knowledge to complete it safely. The right direction and communication mean that the RN must be very specific in what the job involves and how it should be done. This right also means that the LPN/LVN must also communicate back to the RN about the completion of the task or any problems with the completion. Finally, every job must be monitored by the RN to evaluate the outcomes of the procedure. Documentation should be completed per facility policy, but the RN should always ensure that the documentation is correct and complete.
NCSBN Client Need
Topic: Management of Care
Sub-topic: Assignment and Delegation
Subject: Leadership and Management
Lesson: Assignment/Delegation
Reference: National Council of State Boards of Nursing. National Guidelines for Nursing Delegation. Journal of Nursing Regulation. Accessed online on February 11, 2020, at https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf.
A nurse who primarily works on an adult-only unit and has been pulled to work on a floor that provides care to patients of all ages. What would be the appropriate action of this nurse?
A. Accept the assignment. but ask to be paired with a more experienced LPN.
B. Accept the assignment. But explain the situation to the charge nurse and ask for a quick orientation before starting.
C. Take the assignment but tell the charge nurse she will only care for adult patients.
D. Refuse to take the assignment. As caring for infant and child population is not within his scope of practice.
anation
While the LPN may specialize in a specific type of nursing or feel more comfortable caring for a particular patient population, she should be able to use her skillset to safely and independently care for other people as well. However, the LPN should let the charge nurse know her background before beginning her shift so she can familiarize himself with new equipment, ask questions, and identify resources.
The correct answer is B. The nurse should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting. A is incorrect. The nurse’s skill set should be adequate to allow her to work independently, no matter what the age of the clients. ‘ C is incorrect. The nurse should not refuse to care for patients who are not adults but should rely on her knowledge and skills to provide care to patients of all ages. D is incorrect. The nurse should not refuse an assignment. Also, if the nurse is licensed, her scope of practice covers infant and child populations, regardless of whether she has worked with these age groups before or not.
NCSBN Client Need
Topic: Safe and Effective Care Management
Subtopic: Coordinated Care
Chapter 4: Legal Aspects of Nursing
Lesson: Delegation
Reference: Fundamentals of Nursing (Kozier and Erb)
Your new client presented with a history of a positive home pregnancy last night. She has abdominal pain. some vaginal bleeding. and you note an adnexal mass on palpation. You order a progesterone lev.el, which returns as 13 ng/mL. Your initial impression is:
A. Early normal pregnancy
B. Possible ectopic pregnancy
C. Abnormal intrauterine pregnancy
D. Incorrect home pregnancy test
Explanation
Correct Answer: B.
The nurse should suspect a possible ectopic pregnancy. Abdominal pain, vaginal bleeding, and an adnexal mass are the classic triad for an ectopic pregnancy. The developing chorion produces progesterone. A normal progesterone level is > 15 ng/mL. A lower than normal progesterone level is uncommon in normal pregnancies but is very common in an ectopic pregnancy. Further testing will usually be done to confirm the diagnosis.
NCSBN Client Need
Topic: Reduction of Risk Potential
Sub-topic: Potential for Alterations in Body Systems
Subject: Maternal & Newborn Health
Lesson: Antepartum
Reference: American Family Physician. Determining Ectopic Pregnancy Risk Using Progesterone Levels. https://www.aafp.org/afp/2006/0601/p1892.html. Accessed online 01/20/20
After experiencing a traumatic amputation and related body image disturbance. The nurse documents the nursing diagnosis of body image disturbance related to changes in appearance secondary to:
A. Severe trauma
B. Loss of a body part
C. Chronic disease
D. Loss of body function
lanation
Answer and Rationale:
The nursing diagnosis is Body Image Disturbance. When referencing a nursing diagnosis that is secondary to a condition/experience, it is essential to be specific.
The correct answer is B. Although the amputation was related to severe trauma, being specific about what type of injury, the loss of a body part, gives precise information to other health care team members who may assume care of this client. A is incorrect. The loss of limb was caused by severe trauma but is not the most appropriate answer to this question. C is incorrect. The amputation is a chronic condition but is not a disease. D is incorrect. While the loss of body function will become evident, it is about the loss of the limb, which is the most appropriate answer.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Chapter 13: Psychosocial Health and Illness
Lesson: Body Image
Reference: Fundamentals of Nursing (Wilkinson and Barnett)
What should the nurse do during assessment when a patient reports swelling in his ankles?
A. Measure his ankles at their widest point
B. Ask the patient to elevate his feet to better visualize his ankles
C. Press fingers in the edematous area evaluating for a remaining indentation after the nurse removes his/her fingers
D. Evaluate further for brown hyperpigmentation that is associated with venous insufficiency
Explanation
Answer and Rationale:
The correct answer is C. Reports of swelling require evaluation for pitting edema. A is incorrect. B is incorrect. The patient’s ankles should be evaluated for pitting edema. Elevating his feet is an intervention to prevent the pooling of fluid. However, it is not part of the assessment for edema. D is incorrect. Hyperpigmentation is an indication of late-stage chronic venous insufficiency. Assessing for hyperpigmentation is not an immediate assessment necessary for the report of swelling of the ankles.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer)
Chapter 25: Health Assessment
Lesson: Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems
The 8 to 10-week ultrasound verifies all of the following except:
A. Estimated Due Date
B. Pelvic shape
C. The absence of fetal abnormalities
D. Confirm pelvic health assessed at the first prenatal appointment
Explanation
NCSBN client need | Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care
Rationale:
The correct answer is C. At the 8 to 10-week ultrasound; the radiologist will not be able to rule out all fetal abnormalities.
Choices A, B, and D are incorrect. Ultrasounds performed during this period do help determine the due date as well as verify the pelvic shape and health.
Reference:
Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014
The patient has just arrived from the operating room having just had a hypophysectomy performed. In order to reduce the possibility of surgical complications. which position is the best option for this patient?
A. Trendelenburg
B. Side-lying
C. Semi-fowler’s to Fowler’s
D. Reverse Trendelenburg
Explanation
NCSBN client need | Topic: Reduction of Risk Potential: Surgical Complications and Health Alterations
Rationale:
Choice C is correct. Hypophysectomy is generally performed via the transsphenoidal route to remove tumors from the pituitary gland. Semi-Fowler’s to Fowler’s position is the most appropriate position as it facilitates drainage and prevents swelling to the head and neck or an increase in intracranial pressure.
Choice A is incorrect. Trendelenburg would be a precarious position in this patient, increasing intracranial pressure and creating swelling.
Choice B is incorrect. Side-lying does not promote draining, which will be needed in this patient’s care.
Choice D is incorrect. Reverse Trendelenburg is too drastic a position for this patient.
Reference:
Hardy J. Transsphenoidal hypophysectomy. Journal of Neurosurgery. 1971;34(4):582-594. DOI:10.3171/jns.1971.34.4.0582.
You are caring for a patient with new order for nitroglycerin ointment one inch applied to the skin twice a day to prevent angina. To use nitroglycerin correctly, you know to:
A. Apply only to the upper chest
B. Rub the ointment into the skin until it disappears
C. Rotate the application sites
D. Cover the application site with a gauze dressing
Explanation
Correct Answer: C. To apply nitroglycerin correctly, be sure to rotate the application sites with each application to avoid irritation from the medication. Topical nitroglycerin is used to help prevent angina in coronary artery disease. The medication comes with a supply of paper applicators with a small ruler on the paper for proper measurement of the drug. Apply the appropriate amount of ointment on the paper and apply the cream to an area of skin the size of the article. Do not rub the cream into the skin until it disappears. Tape the paper into place and do not cover with gauze. The cream usually is applied to the chest, back, upper arms, or other parts of the torso.
NCSBN Client Need
Topic: Pharmacological and Parenteral Therapies
Sub-Topic: Medication Administration
Subject: Pharmacology
Lesson: Medication Administration; Cardiovascular
Reference: U.S. National Library of Medicine. Medline Plus. Nitroglycerin Topical. https://medlineplus.gov/druginfo/meds/a682346.html. Accessed online on October 21, 2019.
During the initial triage of a burn victim, you are asked to use the rule of 9’s to estimate their total body surface area (TBSA) that is burned. You observe burns over both arms, the anterior trunk, head, and neck. What is their estimated TBSA burned?
Explanation
Answer: 45%
The rule of 9’s makes it very easy to estimate the TBSA burned for any patient. The body is broken down into regions and assigned a percentage as follows:
Head and Neck = 9%
Anterior trunk = 18%
Posterior trunk = 18%
Arms = 9% each
Legs = 18% each
Genitals = 1%
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Basic care, comfort
Subject: Adult Health
Lesson: Burns
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
The nurse is caring for a patient with atrial fibrillation, who is on warfarin. Which of the following alternative therapies should the nurse advise this patient to avoid? (select all that apply)
A. Ginger
B. Aloe
C. Garlic
D. Ginko biloba
Explanation
A, C, and D are correct. This patient is at risk of bleeding due to the blood-thinning medication warfarin. The nurse should educate the patient to avoid any substances that may further increase the risk of bleeding. Ginger is used in alternative/complementary medicine to relieve nausea and vomiting but may increase bleeding risk. Garlic is used in alternative/complementary medicine for reducing high cholesterol levels but may increase the risk of bleeding. Ginkgo Biloba is used in alternative/complementary medicine to relieve symptoms of intermittent claudication but may affect blood glucose levels and increase the risk of bleeding.
B is incorrect. Aloe is used in alternative/complementary medicine to relieve constipation. It may cause electrolyte imbalances and decreased blood glucose levels, but is not known to increase the risk of bleeding.
Subject: Pharmacology
Lesson: Hematology
Topic: adverse effects/contraindications/side effects/interactions, hemodynamics
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 94-95)
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.
