FUNDAMENTALS ii Flashcards
The patient’s EKG shows a QT interval of 0.56 seconds. Which of the following would not be a cause of this result?
A. Hypothermia
B. Myocardial ischemia
C. Hyperthyroidism
D. Hypocalcemia
Explanation
C is correct. This patient’s QT interval is prolonged (normal QTI is 0.36-0.44 seconds). Hypothyroidism could cause a prolonged QT interval, not hyperthyroidism. All other answers are possible causes of a prolonged QT interval.
A is incorrect. Hypothermia is a possible cause of a prolonged QT interval.
B is incorrect. Myocardial ischemia is a possible cause of a prolonged QT interval.
D is incorrect. Hypocalcemia is a possible cause of a prolonged QT interval.
Subject: Adult health
Lesson: Cardiovascular
Topic: Fluid and electrolyte imbalances, diagnostic tests
References: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1242)
Which of the following suspected diagnoses requires immediate referral for a 21-year-old patient with complaints of scrotal pain?
A. Epididymitis
B. Inguinal hernia
C. Testicular torsion
D. Hydrocele
Explanation
Answer and Rationale:
The correct answer is C. Testicular torsion requires immediate surgical intervention to prevent strangulation of the testicle. A is incorrect. Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. The onset of pain is typically over a day or two. The pain may improve with raising the testicle. B is incorrect. An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object. D is incorrect. A hydrocele is a sac filled with fluid that forms around a testicle. They're usually painless and are most common in babies, but they can affect males of any age.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 23: Male Genitalia and Rectal Assessment
Lesson: Scrotum and Testes Abnormalities
A patient is being discharged from the hospital after being diagnosed with lupus erythematosus. The patient is advised to follow up with what to monitor his condition?
A. HgbA1C
B. Daily blood pressure checks
C. Monthly urine specimens
D. Monthly CBC
Explanation
Answer and Rationale:
The correct answer is C. A patient with SLE needs monthly urine specimens to check for proteinuria and any kidney functioning damage. A, B, and D are incorrect:
o A: If the client has a history of diabetes, the A1C may be checked at specified intervals, but it is not indicated because of a Lupus diagnosis.
o B: Daily blood pressure checks are reported for a client with a diagnosis of hypertension or on new medication for blood pressure/heart disease.
o D: Monthly CBC is not meant for a Lupus patient.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Chapter 12: Stress and Adaptation
Lesson: Auto-Immune Disorders
Reference: Fundamentals of Nursing (Wilkinson and Barnett)
Which of the following symptoms would indicate to the nurse that a patient may be experiencing renal calculi?
A. Mild. bilateral pain spasms in flanks
B. Oliguria
C. Hypotension
D. Nausea and sweating
Explanation
D is correct. Renal calculi (kidney stones) occur when a patient develops large uric acid/calcium/cystine/struvite crystals in the urine. Patients experience extreme pain when passing a kidney stone, so nausea and sweating secondary to severe pain would be an indicator/expected result of renal calculi.
A is incorrect. Pain spasms would be unilateral, depending on the location of the stone. Pain is typically severe.
B is incorrect. Blood in urine, or hematuria, would be expected due to trauma, not low urine output (oliguria).
C is incorrect. The patient would not be expected to experience hypotension (low blood pressure) in the case of kidney stones. Blood pressure is usually elevated due to severe pain.
Subject: Adult health
Lesson: Renal
Topic: illness management, system-specific assessment
Reference: (DiGiulio & Keogh, 2014, p. 364)
Which of the following are true regarding physiological changes during pregnancy? Select all that apply.
A. Increase in heart size.
B. Increase in gastric motility
C. Reduced renal threshold for glucose
D. Decreased basal metabolic rate
Explanation
Answer: A and C
A is correct. There is an increase in heart size during pregnancy, as well as a shift upward and to the left due to the displacement of the diaphragm as the uterus enlarges.
B is incorrect. There is a decrease in gastric motility, which can sometimes cause poor appetite.
C is correct. The renal threshold for glucose is reduced during pregnancy.
D is incorrect. There is an increased basal metabolic rate as metabolic function increases during pregnancy.
NCSBN Client Need:
Topic: Health Promotion and Maintenance Subtopic: N/A
Reference: McKinney et al. (2013)., p. 223
Subject: Maternal health
Lesson: Antepartum
While volunteering at a summer camp as the RN on duty, a child playing soccer falls and breaks their arm. It appears to be a compound fracture. Place the following actions in order of nursing priority when dealing with this injury:
Assess the damage while calling for help
Apply ice to the area
Elevate the arm
Cover the open wound with a clean dressing
Apply ice to the area Elevate the arm Assess the injury while calling for help Cover the open wound with a clean dressing Apply ice to the area
xplanation
Compound fractures are fractures with bone fragments protruding through the skin. It is especially important to know how to treat them so that infection is prevented. As always, the first nursing priority action is to assess the injury. Next, the nurse should cover the open wound with a clean dressing so that infection is prevented. The next nursing action is to elevate the arm, and lastly, apply ice to the area. These nonpharmacological interventions will reduce swelling and pain while waiting for help. This child will need to go to the hospital for possible surgery and casting of the extremity.
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: Child Health
Lesson: Musculoskeletal
Which of the following treatments are options for treating hyperkalemia? Select all that apply.
A. Spironolactone
B. Kayexalate
C. Glucose and insulin
D. Dialysis
Explanation
Answer: B, C, and D
A is incorrect. Spironolactone is a potassium-sparing diuretic. Therefore it increases the potassium that is reabsorbed and put back in circulation. This would increase the potassium in the serum, which is the opposite of what we want for hyperkalemia treatment. Spironolactone is an appropriate treatment for hypokalemia.
B is correct. Kayexalate is an enema that causes potassium to be excreted in the feces. This lowers the amount of potassium in circulation and is an appropriate treatment for hyperkalemia.
C is correct. Glucose and insulin are a standard and effective treatment for hyperkalemia when administered together. Insulin transports glucose into the cells for cellular metabolism and takes potassium with it. So, by administering glucose and insulin, the insulin ends up taking both the glucose-regulated and extra potassium into the cells. By transporting potassium to the intracellular space, the amount of potassium in the serum is decreased.
D is correct. Dialysis is an appropriate treatment for hyperkalemia. If the kidneys are not working, the patient will become hyperkalemic. Dialysis can remove the excess potassium from the blood.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Pharmacological therapies
Subject: Fundamentals
Lesson: Electrolytes
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
A patient who is taking Lasix knows that he should increase the intake of what food?
A. Cantaloupe
B. Iceberg lettuce
C. Plums
D. Apples
Explanation
Lasix is the most frequently prescribed loop diuretic. It can increase urine output, even when blood flow to the kidneys is diminished. The rapid excretion of large amounts of water caused by loop diuretics may produce adverse effects, such as dehydration and electrolyte imbalances. Potassium loss may result in dysrhythmias. Therefore, potassium supplements and foods high in potassium are encouraged.
The correct answer is A. Cantaloupe has high levels of potassium in it, which tends to be lower in a patient taking Lasix.
B, C, and D are incorrect. Each of these options offers little no value of potassium to the diet.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 28: Drugs for Fluid, Acid-Base and Electrolyte Disorders
Core Concepts in Pharmacology (Holland/Adams)
The patient undergoes a bedside thoracentesis. Which action by the nurse is appropriate?
A. Explain that patient may resume normal activity.
B. Prepare the patient for chest x-ray.
C. Monitor sputum for signs of bleeding
D. Label specimen with patient’s name. date. and fluid volume contained in sample
Explanation
C is correct. The nurse should assess the patient’s sputum following thoracentesis and monitor for blood. Blood in the sputum following this procedure may be related to lung trauma.
A is incorrect. The patient should rest on the unaffected side for one hour following the procedure to allow the puncture site to heal. If the patient remains free from dyspnea and other complications in that hour, regular activity may be resumed.
B is incorrect. A chest x-ray is only indicated after a thoracentesis if the pneumothorax is suspected or if the patient is on mechanical ventilation.
D is incorrect. The lab specimen should be labeled with the patient’s name, date, source of the fluid, and diagnosis.
The nurse is discussing infection control with a group of nursing students. It would be correct to state that the contact precautions with general hand hygiene measures should be sufficient for which of the following conditions? Select all that apply.
A. Respiratory Syncytial Virus (RSV)
B. Mumps
C. Rubella
D. Varicella
E. Scabies
F. Clostridium Difficle
Explanation
Choices A and E are correct. Conditions requiring the usual contact precautions include Respiratory Syncytial Virus (RSV) and Scabies. RSV is spread through contact with surfaces and contact with infectious droplets. Droplet precautions are not necessary for RSV. CDC recommends standard and contact precautions for RSV. Other conditions requiring the usual contact precautions include:
Mucocutaneous Herpes Simplex Virus (HSV). Methicillin-Resistant Staphylococcus Aureus (MRSA). Pediculosis.
Contact precautions protect against organisms that spread through contact with the patient or the patient’s environment. Personal Protective Equipment (PPE) required for contact precautions include gloves and a gown. In contact precautions, the nurse/visitor must perform hand hygiene before entering the patient’s room and after leaving the room. One can clean hands either with an alcohol-based hand sanitizer or soap and water.
However, in diarrheal illnesses such as Clostridium difficile or norovirus, one must follow contact precautions but with an additional requirement. It requires visitors to perform hand hygiene by cleaning hands with soap and water after leaving the patient room. These special contact precautions are referred to as Contact Enteric precautions, and the isolation sign on the patient room must clearly state this requirement. Alcohol-based disinfectants do not kill Clostridium spores or norovirus. Therefore, soap and water are mandatory to clean hands upon leaving the patient’s room.
Choices B and C are incorrect. Mumps and Rubella require droplet precautions. Rubella ( German measles) and Rubeola ( Measles) sound similar, but they are two different diseases. Rubeola ( measles) spreads by airborne route and needs airborne isolation, whereas Rubella needs droplet isolation.
Choice D is incorrect. Varicella-Zoster Virus causes Chickenpox and Shingles. Varicella ( Chickenpox) needs both contact and airborne isolation precautions, not just contact precautions. Both contact and airborne precautions are used in Varicella and “disseminated” Herpes Zoster ( shingles) until all the lesions dry and crust over. In contrast, standard precautions alone are sufficient for “localized” Herpes Zoster in immunocompetent patients if the lesions can be contained/ covered.
Choice E is incorrect. Clostridium difficle is a bacteria that causes diarrhea and is highly contagious. It spreads by contact and fecal-oral route. Contact precautions are certainly used to prevent Clostridium difficle spread. However, an additional requirement of cleaning hands with soap and water upon leaving the patient’s room is mandatory. To standardize infection control practices and to specify this additional hand hygiene requirement, many hospitals have adopted special signage, “contact enteric precautions.”
Please note the difference in the signage of contact precautions vs. contact-enteric precautions below:
The nurse is providing nutritional instruction to a patient of African-American heritage. The nurse is aware that which of the following foods is frequently found in the African-American diet?
A. Fried Foods
B. Spicy Rice and Beans
C. Raw fish
D. Red meat and starches
Explanation
NCSBN client need | Topic: Psychosocial Integrity / Cultural Awareness
Rationale:
The correct answer is A. People of African-American heritage tend to eat a more substantial content of fried foods than other American raves.
Choice B is incorrect. While African-Americans, like all races, may have a preference: for spicy rice and beans, this diet is found primarily in those of Spanish heritage.
Choice C is incorrect. Those of Asian heritage commonly consume raw fish.
Choice D is incorrect. Those of European heritage most commonly consume red meat and starches like pasta and potatoes.
Reference:
Lewis S, Dirksen S, Heitkemper M, Bucher L, Harding M. Medical-Surgical Nursing.
While working in the ICU, you suspect that your patient’s central venous catheter has become infected. Place the following actions in the correct order of nursing priorities:
Prepare to administer antibiotics as ordered.
Remove the catheter.
Notify the health care provider
Obtain blood cultures.
Document the incident.
Correct Answer is: Notify the health care provider Remove the catheter. Obtain blood cultures. Prepare to administer antibiotics as ordered. Document the incident.
Explanation
It is essential first to notify the health care provider, as they will need to prepare for the insertion of a new central venous catheter quickly to ensure medication administration interruptions are minimized. Next, the nurse needs to remove the catheter. Removing the source of the infection is a nursing priority and should be completed as quickly as possible to prevent the spread of disease any further. Next, the nurse should obtain blood cultures. This will identify the type of organism causing the infection so that the health care provider can choose an appropriate antibiotic. It is essential to obtain blood cultures before administering antibiotics. The next action is administering medicines to treat the infection, but only after blood cultures have been received. Lastly, the nurse should document the incident.
NCSBN Client Need
Topic: Pharmacological and Parenteral Therapies Subtopic: Central Venous Access Devices
Reference:
Ignatavicius D, Workman M: Medical-surgical nursing: Patient-centered collaborative care, ed 7, St. Louis, 2013, Saunders, p. 232
Explanation
It is essential first to notify the health care provider, as they will need to prepare for the insertion of a new central venous catheter quickly to ensure medication administration interruptions are minimized. Next, the nurse needs to remove the catheter. Removing the source of the infection is a nursing priority and should be completed as quickly as possible to prevent the spread of disease any further. Next, the nurse should obtain blood cultures. This will identify the type of organism causing the infection so that the health care provider can choose an appropriate antibiotic. It is essential to obtain blood cultures before administering antibiotics. The next action is administering medicines to treat the infection, but only after blood cultures have been received. Lastly, the nurse should document the incident.
NCSBN Client Need
Topic: Pharmacological and Parenteral Therapies Subtopic: Central Venous Access Devices
Reference:
Ignatavicius D, Workman M: Medical-surgical nursing: Patient-centered collaborative care, ed 7, St. Louis, 2013, Saunders, p. 232
Explanation
Answer: magical
Magical thinking is the belief that one’s own thoughts, wishes, or desires can influence the external world. This is common in the preschool-age child. They often think that their actions or misbehaving are what caused them to become sick, and view their illness as a punishment. It is the nurse’s job to help the child understand that the disease is not their fault.
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.
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
Important Fact:
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.
Resource
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)
While working in triage in a pediatric emergency room. You are notified that a patient on their way in is suspected of having impetigo. What actions should the nurse take to prevent the spread of this disease? Select all that apply.
A. Initiate droplet precautions
B. Set up a decontamination room
C. Use standard precautions
D. Initiate contact precautions
Explanation
Answer: C and D
A is incorrect. Droplet precautions are not appropriate for impetigo. It is spread through contact with the skin, not respiratory droplets.
B is incorrect. Although very contagious, a decontamination room is not indicated for impetigo.
C is correct. As with every patient, standard precautions should always be followed. This will be especially important for your patient with impetigo because handwashing will prevent the spread of the infection.
D is correct. Contact precautions are appropriate to prevent the spread of impetigo. Staff should be made aware of the precautions with the proper signs and gowns, and gloves should be readily available outside of the room.
NCSBN Client Need:
Topic: Safe and Effective Care Environment Subtopic: Safety and Infection Control
Reference: Hockenberry, WIlson (2011), pp. 696-698
Subject: Child Health
Lesson: Integumentary
When observing a patient on antivirals. The nurse notices the patient has developed bruising. This could indicate which of the following?
A. The patient is being abused by a family member.
B. The patient is experiencing minor adverse reactions
C. The patient is not taking the medications as ordered.
D. The patient may be experiencing bone marrow suppression.
Explanation
Answer and Rationale:
The correct answer is D. Bruising or bleeding when taking antivirals could indicate possible bone marrow suppression and may require dosage adjustments or a medication change. A is incorrect. While abuse of any patient is a possibility, the question is regarding the use of antivirals and the symptom of bruising, which is an indication of bone marrow suppression. B is incorrect. Bruising is not an adverse reaction, but maybe an indication of something more serious. C is incorrect. While the patient may not be taking the medication correctly, the most appropriate answer is D. The nurse should ask the patient/caregiver to clarify how much medicines he/she is taking and how often. However, the most likely source of bruising (among these answers) is the suppression of bone marrow.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 19: Drugs for Fungal, Viral and Parasitic Diseases
Lesson: Antiviral Medications
Reference: Core Concepts in Pharmacology (Holland/Adams)
A high school boy was involved in a head-on motor vehicle collision. He suffered a concussion, a femur fracture, and rib fractures. Three days after ORIF surgery, his heart rate increases from 72 to 110 bpm and his respirations from 18 to 24. What complication does the nurse suspect this patient is experiencing?
A. Sepsis
B. Fat emboli
C. Pulmonary embolism
D. Deep vein thrombosis
Explanation
B is the correct answer. After suffering from a femur fracture, a patient is at high risk for developing fat emboli syndrome that can cause occlusions in the bloodstream. Fat embolism syndrome is characterized by hypoxia, pulmonary issues, shortness of breath, and confusion.
A is incorrect. Sepsis may be likely due to the new surgical procedure, but a fat embolus is more likely due to the femur fracture.
C is incorrect. A pulmonary embolism is possible, but a fat embolus is more likely.
D is incorrect. This is likely due to a new surgical procedure, but a fat embolus is more likely due to the femur fracture.
NCSBN Client Need
Topic: Physiological Adaptation
Sub-topic: Potential for Alterations in Body Systems
Subject: Adult Health
Lesson: Musculoskeletal Trauma and Orthopedic Surgery
Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013
The school nurse is attending to a student who has gotten a chemical cleaner in their eyes. In which order should the following actions be performed? Document the occurrence Check the pH of the eye Irrigate the eye Call the child’s parent Assess Visual acuity
Correct Answer is: Irrigate the eye Check the pH of the eye Assess Visual acuity Document the occurrence Call the child’s parent
Explanation
When a chemical injury is sustained, the school nurse should irrigate the student’s eye, check the pH of the eye, assess the child’s visual acuity, document the occurrence, and call the child’s parents to inform them of the occurrence, actions taken, and outcome.
NCSBN client need |Topic: Physiological integrity, physiological adaptation
Reference:
Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby
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 patients should have their temperature measured orally? Select All That Apply.
A. A 61-year-old woman who has had oral surgery
B. A 44-year old man with chest pain with oxygen via. nasal canula
C. An 83-year-old woman with diarrhea
D. A 29-year-old patient with an earache
Explanation
The correct answers are B, C, and D. There is no contraindication for oral temperature measurement in any of these patients (Choices B, C, and D). The oral temperature is measured with the probe placed under the tongue, and the lips closed around the instrument. Oxygen delivered by nasal cannula does not affect the accuracy of the measurement.
Choice A is incorrect. Oral surgery may falsely increase the local temperature by causing surgery-related inflammation. Oral temperature measurement is contraindicated in:
Patients who have altered mental status because they may not cooperate fully. Rectal thermometers are indicated in children and in patients who will not or cannot work fully. Those who are mouth breathers. Mouth breathing can affect the accuracy of oral temperature. Those who have had a recent oral intake of cold or hot foods/ drinks Those who have recently smoked Those who have recently undergone oral surgery.
NCSBN Client Need
Topic: Health Promotion and Maintenance.
Reference: Nursing Health Assessment: A Best Practice Approach (Walters Kluwer)
Chapter 5: Vital Signs and General Survey; Lesson: Temperature
The nurse is teaching a patient relaxation techniques. Which of the following statements by the patient indicate he understands the instruction he has been provided? Select all that apply.
A. “I must breathe in and out in rhythm.”
B. “I should check my pulse and expect it to be faster.”
C. “I can expect my muscles to feel less tense.”
D. “I will be more relaxed and less aware.”
Explanation
Relaxation techniques are useful in many situations, including childbirth and consist of rhythmic breathing and progressive muscle relaxation. When these techniques are implemented, many people see a reduction in the need for pharmacologic measures to relieve stress and anxiety.
Answer and Rationale:
The correct answers are A, C, and D. B is incorrect. When relaxation techniques are properly implemented, the patient should experience a decreased pulse rate.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Fundamentals of Nursing 8th Edition (Wolters and Klewer)
Chapter 41: Stress and Adaptation
Lesson: Stress Management Techniques
You are working in the Emergency Department. Your adult patient has an endotracheal tube (ETT) in place, and a team member is providing assisted ventilation. You know that the medications that can be instilled in the ETT include: (Select all that apply)
A. Morphine
B. Lidocaine
C. Epinephrine
D. Atropine
Explanation
Correct answers: B, C, and D. According to the American Heart Association, lidocaine, epinephrine, and atropine can all be given via the ETT. It is essential to know that the dosage of a medication given via the endotracheal tube will usually be higher than if provided via the IV or IO routes. An easy way to remember what medications you can give via the ETT is by remembering the NAVEL mnemonic: N = Naloxone, A = Atropine, V = Vasopressin, E = Epinephrine, and L = Lidocaine. In the pediatric population, do not give vasopressin via an ETT. Medications other than these can damage the airways if instilled into the tube.
NCSBN Client Need
Topic: Pharmacological and Parenteral Therapies
Sub-Topic: Medication Administration
Subject: Pharmacology
Lesson: Medication Administration
Reference: American Heart Association. Advanced Cardiovascular Life Support: Provider Manual. ACLS Pharmacology Summary Table. March 2016 eBook edition.
What EKG rhythm represents a third-degree heart block?
Explanation
A is the correct answer. This rhythm represents a 3rd-degree heart block because there is no QRS complex after every other p wave. This is because the AV node has no conduction during a 3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with each other.
B is incorrect. This rhythm represents a 1st-degree heart block. This rhythm occurs when the AV conduction is slowed, therefore creating a more extended time between the p wave and the QRS complex.
C is incorrect. This rhythm represents a 2nd-degree heart block or Mobitz 2. This occurs when the AV node is taking longer to conduct. The PR interval may be regular or lengthened. This rhythm indicates problems in the Purkinje system.
D is incorrect. This rhythm is sinus tachycardia, which is a heart rate over 100 bpm.
The nurse arriving for their shift is told in a report that the patient has been battling asymptomatic chemotherapy-induced anemia. The nurse recognizes that the patient will likely require a blood transfusion when their hemoglobin drops below:
A. 8
B. 13
C. 10
D. 19
Explanation
NCSBN client need | Topic: Physiological Adaptation, Reduction of Risk Potential
Rationale:
The correct answer is A. Hemoglobin levels are considered alarming and may require blood transfusions when below 8 g/dL. Normal hemoglobin levels are 13.5 to 17.5 g/dL for men and 12 to 15.5 for women.
Choice B is incorrect. While 13.0 g/dL is lower on the results of appropriate labs, this level would likely not dictate a blood transfusion.
Choice C is incorrect. 10.0 g/dL is considered low hemoglobin for both men and women, but since this patient is not experiencing any symptoms, they’ll not likely need a blood transfusion at this time.
Choice D is incorrect. 19.0 g/dL is a high result and may require retesting. A patient with a hemoglobin of 19 wouldn’t need blood products.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
The patient with tuberculosis is now on isoniazid. Which laboratory test should be monitored at least monthly?
A. PT and PTT
B. CBC
C. BUN
D. Liver enzymes
Explanation
Answer and Rationale:
Isoniazid is a bacteriocidal for actively growing organisms and a bacteriostatic for dormant mycobacteria. It is selective for M. tuberculosis. Isoniazid is used alone for chemoprophylaxis, or in combination with other antitubercular drugs when treating active disease.
The correct answer is D. Although it is rare, liver toxicity is a severe adverse effect of Isoniazid. Healthcare providers should monitor for signs of jaundice, fatigue, elevated liver enzymes, and loss of appetite. Liver enzyme tests are usually performed monthly during therapy to identify early hepatotoxicity. A B and C are incorrect. While the physician may order these tests periodically, they are not indicated as a monitoring tool during Isoniazid therapy.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Pharmacological Therapies
Chapter 22: Drugs for Bacterial Infections
Lesson: Tuberculosis
Reference: Core Concepts in Pharmacology (Holland/Adams)
Which of the following statements about appendicitis are true? Select all that apply
A. McBurney’s point tenderness is a sign of appendicitis.
B. Appendicitis is more common among males.
C. A low carbohydrate diet is a risk factor for appendicitis.
D. Lower left quadrant pain is a sign of appendicitis.
Explanation
Answer: A and B
A is correct. McBurney’s point tenderness refers to right lower quadrant pain. This is suggestive of appendicitis.
B is correct. Appendicitis is more common amongst males than females.
C is incorrect. A high carbohydrate diet, or a low fiber diet, are risk factors for appendicitis.
D is incorrect. Lower right quadrant pain is concerning for appendicitis, not left.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Reduction of Risk Potential
Subject: Adult Health
Lesson: Gastrointestinal
Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing. Elsevier Health Sciences.
A patient presents with around. Non-tender nodule on the left wrist that is more pronounced upon flexion. The nurse would recognize this as what condition?
A. Olecranon bursitis
B. Bouchard node
C. Ganglion cyst
D. Pillar cyst
Explanation
C is correct. Ganglion cysts are common, benign tumors over a tendon sheath or joint capsule. They are typically non-tender unless the tumor puts pressure on a nerve. When on the wrist, they become more noticeable with flexion. A ganglion cyst generally resolves on its own and does not require treatment, but maybe drained/removed if causing discomfort.
A is incorrect. Olecranon bursitis is a common form of bursitis that occurs at the tip of the elbow. It typically presents as a large, soft, red, painful nodule due to inflammation of the bursa.
B is incorrect. A Bouchard node refers to hard, non-tender bony overgrowths on the proximal interphalangeal joint, commonly seen in osteoarthritis.
D is incorrect. A pilar cyst is a fluid-filled cyst that originates in a hair follicle. Pillar cysts are commonly found on the scalp.
Subject: Adult health
Lesson: Musculoskeletal
Topic: alterations in body systems, pathophysiology
Reference: (Jarvis, 2012, p. 609-612)
Which of the following are signs of decreased cardiac output in a pediatric patient with a history of CHF? Select all that apply.
A. Feeding difficulties
B. Polyuria
C. Bradycardia
D. Irritability
Explanation
Answer: A and D
A is correct. Feeding difficulties are often an early symptom of decreased cardiac output in a pediatric patient, especially in infants. It becomes harder for them to coordinate the suck, swallow, breathe sequence needed to breast or bottle-feed, and they begin having trouble feeding.
B is incorrect. Polyuria is not a sign of decreased cardiac output. Instead, oliguria is. With decreased cardiac output, there is less perfusion to the kidneys, and with less renal blood flow, the body makes less urine leading to oliguria.
C is incorrect. Bradycardia is a very ominous sign in children, and would not occur until the child is in heart failure. Tachycardia is a more appropriate symptom of decreased cardiac output, as the body starts do recognize the reduced amount of blood being pumped to its organs, it will try to compensate by increasing the heart rate. This will correct decreased cardiac output for a little while but is not sustainable and, if left untreated, will progress to more severe symptoms.
D is correct. Irritability is a classic sign of decreased cardiac output in pediatric and infant patients. Because they cannot explain to you how they are feeling, irritability, restlessness, and fussiness are often their way of showing that something is going on.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Subject: Child Health
Lesson: Cardiovascular
Reference: McKinney E, James S, Murray S, Ashwill J: Maternal-child nursing, ed 4, St. Louis, 2013, Saunders.
Which of the following are true regarding aortic regurgitation in the pediatric client with complex congenital heart disease? Select all that apply
A. Aortic regurgitation increases preload in the left ventricle.
B. Aortic regurgitation leads to a systolic murmur
C. Aortic regurgitation causes decreased cardiac output
D. Aortic regurgitation increases left ventricle end diastolic pressure.
Explanation
Answer: A, C, and D
With aortic regurgitation, during diastole, there is a backward flow of blood from the aorta into the left ventricle. The blood should be moving forward into the systemic circulation, but when the heart relaxes, there is a small amount of ‘regurgitation,’ and the blood trickles back to where it came from. With this increased amount of blood flowing back into the left ventricle, there is increased preload in the left ventricle (A is correct), a decrease in cardiac output (B is correct), and an increased left ventricular end-diastolic pressure (D is correct). C, however, is incorrect, because aortic regurgitation does not cause a systolic murmur but rather a diastolic murmur. The blood backflows across the aortic valve when the heart relaxes during diastole, causing a diastolic murmur.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological Adaptation
Reference: Brorsen, A. & Roglet, K. (2011). Pediatric Critical Care. Burlington, MA: Jones & Bartlett Learning.
Which of the following arrhythmias are fatal without immediate intervention? Select all that apply.
A. Ventricular fibrillation
B. Ventricular tachycardia with a pulse
C. Wenckebach Phenomenon
D. Asystole
Explanation
Answer: A and D
A is correct. Ventricular fibrillation, or v-fib, is a fatal rhythm without immediate intervention. The priority is to defibrillate the patient and initiate CPR between shocks. In this rhythm, the ventricles are just quivering, and there is no productive diastole or systole. This means there is really no cardiac output, and the body will be quickly deprived of oxygen if action is not taken.
B is incorrect. Ventricular tachycardia is divided into two different rhythms: V-tach with a pulse, and pulseless v-tach. As surprising as it may sound, some patients tolerate ventricular tachycardia with a pulse. When you see this rhythm on the monitor, your first action should be to assess your patient and determine if they have a pulse. Pulseless v-tach is fatal without immediate intervention.
C is incorrect. Wenckebach Phenomenon is another name for AV Block 2nd degree, or Mobitz I. This type of heart block is characterized by a PR interval that is progressively longer and longer until there is a beat that is dropped entirely. While this type of heart block does need to be addressed, it is not fatal without immediate intervention. The only kind of heart block that is considered a deadly rhythm is a 3rd-degree heart block.
D is correct. Asystole is a fatal rhythm without immediate intervention. It is characterized by a flat line with no rhythm or electrical activity. Because there is no electrical activity present, this is not a shockable rhythm. Instead, CPR should be initiated immediately with high-quality compressions.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Pharmacological therapies
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.:
Subject: Adult Health
Lesson: Cardiac
