RANDOM Flashcards
The nurse is taking care of a pediatric client in an asthma attack. To promote comfort, the nurse instructs the client to assume which position?
A. High Fowler’s position
B. Prone position
C. Side-lying positiOn
D. Dorsal position
CORRECT ANSWER: A
Explanation
Rationale: The High Fowler’s position facilitates the breathing process for children during an asthma attack. The prone, side-lying, or dorsal areas do not promote comfort in children during an asthma attack. Option A is the correct answer, while options B, C, and D are incorrect.
Reference:
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
The nurse is talking to the client who has suffered a stroke which resulted in the difficulty of understanding spoken words. Which action by the nurse is most appropriate when talking to the client?
A. Giving simple instructions to the client.
B. Talk to the client in a raised tone of voice
C. Encourage the client to respond to every statement by the nurse.
D. Consistently shift topics of conversation.
CORRECT ANSWER A
Explanation
A is correct. The client with receptive difficulty should only be given simple instructions when communicating with them. This makes the task of understanding what the nurse said much easier for the client.
B is incorrect. The nurse should talk to the client in a soft, audible voice. The client can hear the nurse’s words, but he is having difficulty understanding them.
C is incorrect. Pressing the client for a response to every statement by the nurse puts on undue pressure on the client, leading to frustration.
D is incorrect. The nurse should gradually shift topics of conversation and inform the client when there will be a topic change. This decreases confusion on the part of the client.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
The nurse is assisting in the placement of an indwelling Foley catheter in a male patient. The nurse knows to inflate the balloon on the catheter at which step in the procedure?
A. Upon meeting resistance
B. As soon as urine is observed in the tubing
C. After advancing to the point of bifurcation
D. After fully advancing the length of the catheter
CORRECT ANSWER C
Explanation
Answer: C
A is incorrect. It is not appropriate to inflate the balloon on the catheter upon meeting resistance. In a male client, this could cause serious trauma to the urethra. The nurse must ensure that the catheter is fully inside the bladder before the balloon is inflated.
B is incorrect. It is not appropriate to inflate the balloon on the catheter as soon as urine is observed in the tubing. The catheter will not be fully in the bladder as soon as urine is observed, and inflating the balloon at this point would cause trauma.
C is correct. The nurse should inflate the balloon on the catheter once she reaches the point of bifurcation. This is achieved by slowly advancing the catheter, observing the tubing for urine to appear, and then continuing to advance to the point of bifurcation after urine is observed. This will ensure the balloon is in the bladder before the nurse inflates it.
D is incorrect. It is not appropriate to fully advance the length of the catheter in every client. The length of the urethra and distance to the bladder will vary, and therefore the catheter will be advanced different lengths depending on the client. Fully advancing the catheter could result in an excessive length of the catheter sitting in the bladder, which can cause pain and irritation to the client.
NCSBN Client Need:
Topic: Reduction of Risk Potential
Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures
Subject: Fundamentals
Lesson: Elimination
The nurse works on a medical/surgical unit and cares for a patient receiving Lanoxin (Digoxin) and Furosemide (Lasix). The nurse knows that which of the following. If reported by the patient. Must be assessed immediately?
A. Night sweats and headache.
B. Vomiting and halos around lights.
C. Stomach upset and headache.
D. Low blood pressure and dark urine
[17%]
CORRECT ANSWER B
Explanation
Important Fact:
Furosemide and digoxin are often used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Patients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats.
Answer & Rationale:
The correct answer is B. Lasix causes the patient to lose potassium. Digoxin, if taken with a low potassium level, can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. A and C are incorrect. While night sweats, headaches, and upset stomach are essential symptoms and should not be ignored; these symptoms are not the most urgent symptoms that need to be assessed. D is incorrect. Low blood pressure and dark urine are symptoms of dehydration. These symptoms should be assessed, but are not the most urgent.
You are ready to administer a unit of packed red blood cells to your client. Which of the following nursing interventions is a high priority for you once the transfusion has begun to be infused?
A. Directly monitor the client and their responses to the transfusion continuously for at least 30 minutes after the transfusion began.
B. Directly monitor the client and their responses to the transfusion continuously for at least 15 minutes after the transfusion began.
C. Start the infusion by adjusting the rate of the infusion to less than 30 mL per minute.
D. Start the infusion by adjusting the rate of the infusion to less than 20 mL per minute.
Explanation
Correct Answer is B
Correct. The nurse must directly monitor the client and their responses to the transfusion continuously for at least 15 minutes after the bleeding began because transfusion reactions if they occur, are most likely to manifest within 15 minutes after the transfusion started.
Choice A is incorrect. Although you would directly monitor the client and their responses to the transfusion continuously for some time, this duration is typically less than 30 minutes after the bleeding began.
Choice C is incorrect. You would start the infusion by adjusting the rate of the injection to a volume that is less than 30 mL per minute; rates of 30 mL per minute can lead to a more severe reaction than a much lower price would.
Choice D is incorrect. You would start the infusion by adjusting the rate of the injection to a volume that is less than 20 mL per minute; rates of 20 mL per minute can lead to a more severe reaction than a much lower price would.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
A client with Raynaud’s disease has just been prescribed ephedrine. What is the nurse’s most appropriate action?
A. Provide dietary instructions to the client.
B. Question the prescription to the physician.
C. Instruct the client regarding adverse effects.
D. Administer the medication initially to the client.
CORRECT ANSWER B
Explanation
A is incorrect. Providing dietary instructions to the patient is an inappropriate action as this medication is contraindicated for the patient’s existing disease.
B is correct. Clients with Raynaud’s disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction. The nurse should question the physician regarding this prescription.
C is incorrect. The nurse’s most appropriate action would be to question the physician’s prescription as the medication is contraindicated in the patient’s present condition.
D is incorrect. The nurse should not administer the initial dose of a medication he knows will do the patient harm. The nurse should question the physician regarding the prescription.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006
A nurse is reviewing the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 of 30 mm Hg, and HCO3-of 22 mEq/L. Does the nurse know that these results indicate?
A. Metabolic acidosis, compensated
B. Respiratory alkalosis, compensated
C. Metabolic alkalosis, uncompensated
D. Respiratory acidosis, uncompensated
CORRECT ANSWER B
Explanation
The normal pH ranges between 7.35-7.45. A respiratory condition would show an inverse relationship between the PCO2and the pH, as seen in this case. In a metabolic state, the HCO3- would have direct contact with the pH. Because the pH is at 7.45, which is within the normal range, this is an indication that compensation has occurred. Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014
At 25 weeks gestation, a pregnant client presents with uterine growth size that is less than expected, absence of fetal ballottement, and an easily palpable fetus. What is this likely related to the development of?
A. Oligohydramnios
B. Macrosomia
C. Hydramnios
D. Amniotic fluid embolism
CORRECT ANSWER A
Explanation
The correct answer is A. Oligohydramnios results from a severe reduction in the amount of amniotic fluid. It results in less than expected fetal growth. Also, because of the low amount of amniotic fluid, the fetus will be more easily outlined and palpated.
B is incorrect. Macrosomia is defined as a newborn who is significantly larger than average. These babies have a birth weight of more than 8 lbs, 13 oz.
C is incorrect. Hydramnios is a condition in which excessive amounts of amniotic fluid accumulates during pregnancy.
D is incorrect. Amniotic fluid embolism is characterized by an acute collapse of mother and baby due to an allergic-type response to amniotic fluid entering the mother’s circulatory system.
NCSBN Client Need
Health Promotion and Maintenance
Chapter 11: Nursing Care of the Woman with Complications During Labor and Birth
Lesson: Care of the Woman and Fetus at Risk
Safe Maternity and Pediatric Nursing Care (Linnard-Palmer/coats)
The RN is caring for a patient with a new medication order of amiodarone. Which intervention is not appropriate for this patient?
A. Monitor ECG.
B. Check BP every 4 hours.
C. Report shortness of breath.
D. Avoid ingesting grapefruit.
CORRECT ANSWER B
Explanation
B is correct. Hypotension is an adverse effect of amiodarone. A decrease in blood pressure usually occurs within the first several hours of administration, so BP should be checked more frequently than every 4 hours initially.
A is incorrect. Amiodarone may cause QT prolongation, which can lead to worsening arrhythmias.
C is incorrect. Shortness of breath should be reported as it may indicate ARDS related to the new medication.
D is incorrect. Grapefruit and grapefruit juice may interfere with amiodarone.
Subject: Pharmacology
Lesson: Cardiovascular
Topic: Medication administration, adverse effects/contraindications/side effects/interactions
Reference: (Vallerand & Deglin, 2007, p.148-149)
An experienced nurse is caring for a 24-hour old newborn in the nursery. She suspects asphyxia in utero. All of the following assessment findings would indicate asphyxia in utero except:
A. There is a present palmar-grasp reflex.
B. The nurse strokes the sole of the newborn’s feet but there is no response.
C. The neonate is unresponsive when the nurse claps her hands above him.
D. The neonate has weakand ineffective sucking.
CORRECT ANSWER A
Explanation
A is correct. A present palmar-grasp reflex indicates that there is an intact neurologic response from the neonate.
B is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence in Babinski reflex indicates asphyxia in utero.
C is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence in the Startle reflex indicates asphyxia in utero.
D is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes the newborn. This absence or depression in the sucking reflex indicates asphyxia in utero.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
The nurse is working with a child who has is undergoing diagnosis for rheumatic fever. The nurse knows that they should ask about which of the following untreated infections in the patient’s history?
A. Urinary tract infection
B. Seasonal Flu
C. Streptococcal infection
D. Whooping cough
CORRECT ANSWER C
Explanation
NCSBN client need | Topic: Maintenance and Health Promotion, Health screening
Rationale:
The correct answer is C. An untreated streptococcal infection, specifically Group B streptococcus, may lead to rheumatic fever, a severe condition with cardiac implications. Nurses should advocate for strep throat testing when patients complain of a sore throat in the clinic.
Choice A is incorrect. Urinary tract infections, or bacterial colonization of the urinary tract, are not related to rheumatic fever.
Choice B is incorrect. The seasonal flu is not associated with rheumatic fever.
Choice D is incorrect. A streptococcal infection may affect the patient’s skin, throat, the urinary tract, and many other sites but is not responsible for rheumatic fever.
Reference:
Williams LHopper P. Student Workbook For Understanding Medical-Surgical Nursing. Philadelphia: F.A. Davis Co.; 2011.
Which of the following is a critical aspect and component of a milieu environment?
A. Ergonomically correct furniture
B. Consistent boundaries
C. A balanced eco-system
D. Esthetically pleasing barriers
CORRECT ANSWER B
Explanation
Correct Answer is B
Correct. Consistent boundaries are a critical aspect and component of a milieu environment. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors, such as changing and non-consistent rules and boundaries, which have been eliminated from the environment of care.
Choice A is incorrect. Ergonomically correct furniture is not a critical aspect and component of a milieu environment; this type of furniture is, however, a crucial part of workplace safety, occupational safety, and the maintenance of health. Instead, a milieu environment is an environment that is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors.
Choice C is incorrect. A balanced eco-system is not a critical aspect and component of a milieu environment; balanced eco-systems are, however, a crucial part of global health and wellness. Instead, a milieu environment is an environment that is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors.
Choice D is incorrect. Esthetically pleasing barriers are not a critical aspect and component of a milieu environment; esthetically pleasing fences may, however, add to a human’s sensory satisfaction and feelings of wellbeing.
Reference: Sommer, Sheryl, Janean Johnson, Karin Roberts, Sharon Redding, Lois Churchill, Norma Jean Henry, and Mendy McMichael. (2013) RN Mental Health Nursing 9.0; ATI Nursing Education.
Arrange Maslow’s hierarchy of needs from the highest to the least priority. Physiological needs Safety Love and belonging Esteem Self-actualization
Correct Answer is: Physiological needs Safety Love and belonging Esteem Self-actualization
Explanation
In needs theories, human needs are ranked on an ascending scale according to how essential the requirements are for survival. One of the most renowned needs theorists, Abraham Maslow, lists human necessities on five levels.
The correct order from highest to least priority is :
Physiological needs- Needs such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance are crucial for survival. Safety- The need for security has both physical and psychological aspects. The person needs to feel safe, both in the physical environment and in relationships. Love and belonging- The third level of needs includes giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging. Esteem- The fourth level of needs encompasses esteem for oneself (dignity, achievement, mastery, freedom) and the need to be accepted and valued by others (e.g., social status, prestige). Esteem needs constitute one of the key stages in achieving contentment or self-actualization. Self-actualization- When the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop one’s maximum potential, and realize one’s abilities and qualities. This is a higher-level need on Maslow's pyramid so, a lower priority.
Reference: Kozier & Erb’s Fundamentals of Nursing
Your client has consumed an 8 ounce can of ginger ale, a 4-ounce container of apple sauce, and 6 ounces of lean meat for lunch. You will document this client’s fluid intake as:
A. 80
B. 160
C. 180
D. 240
CORRECT ANSWER D
Explanation
Correct Answer is D
Correct. You will document this client’s fluid intake as 240 MLS or cc s because the client has consumed a total of 8 ounces of fluid and, because each ounce has 30 MLS or ccs, it is calculated as follows:
30 x 8 = 240 MLS or cc s
The apple sauce and lean meat do not count as fluid.
Choice A is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 80 MLS or cc s. Try this calculation again.
Choice B is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 160 MLS or cc s. Try this calculation again
Choice C is incorrect. The client has consumed a total of 8 ounces of fluid, so the total consumed is more than 180 MLS or cc s. Try this calculation again
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
Which of the following are examples of an intervention that is appropriate for a patient with hearing impairment? Select All That Apply.
A. Minimize background noise and close the door
B. Patient explains the plan to accommodate hearing impairment
C. Provide a communication board or picture to assist teaching
D. Stand in front of the patient and explain any procedure
CORRECT ANSWERS A,C,D
Explanation
Answer and Rationale:
A, C, and D are correct. Each of these options is an intervention. B is incorrect. This answer option is the expected outcome of the goal that is set for the patient.
NCSBN Client Need
Topic: Health Promotion and Maintenance
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer)
Chapter 14: Ear Assessment for Advanced and Specialty Practice
Lesson: Communicating with the Hearing Impaired
A client is receiving allopurinol (Zyloprim) and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following?
A. Facial swelling is expected in the first few days of therapy.
B. Drink at least 3000 mL per day.
C. Do not eat while taking this medication.
D. This medication begins working immediately.
CORRECT ANSWER B
Explanation
NCSBN client need | Topic: Physiological Integrity, Pharmacological and Parenteral Therapies
Rationale:
The correct answer is B. Allopurinol is prescribed to patients with gout or kidney stones and works by reducing the amount of uric acid produced by the body. Patients taking this medication should be encouraged to drink plenty of water, at least 3,000 mL per day.
Choice A is incorrect. Facial swelling is not normal and may indicate an emergency reaction. Patients who experience swelling should seek medical attention as soon as possible.
Choice C is incorrect. Eating with this medication is appropriate.
Choice D is incorrect. This medication does not work immediately and may take a few months to reach full effectiveness.
Reference:
Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011
The client admitted to the gynecology ward for premature labor is given terbutaline to arrest labor. The nurse should monitor which parameter when administering this medication?
A. Breath sounds
B. Urine output
C. Pain
D. Level of consciousness
CORRECT ANSWER A
Explanation
A is correct. One of the most common side effects of terbutaline is pulmonary edema. The nurse should monitor the client’s breath sounds and assess for respiratory crackles and difficulty of breathing to detect if pulmonary edema is present.
B is incorrect. Terbutaline does not have any effect on urine output.
C is incorrect. Terbutaline is a tocolytic agent; it arrests labor and uterine contractions; it may decrease the client’s pain levels during contractions, but it is not the nurse’s priority assessment.
D is incorrect. Terbutaline does not have any effect on the client’s level of consciousness.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family
You are providing discharge teaching for a 3-year-old patient with CHF. She is going home on digoxin. Which instructions are essential to teaching her parents regarding the administration of this medication? Select all that apply.
A. Administer one hour before or two hours after meals.
B. Mix the medication with milk or applesauce to ensure she drinks it all.
C. If the child vomits after administering a dose. repeat the dose.
D. Call the doctor is the child starts eating poorly and vomiting frequently.
CORRECT ANSWERS A, D
Explanation
Answer: A and D
A is correct. This is the appropriate instruction to ensure proper absorption of digoxin. It is best to advise the parents to create a schedule and administer it at the same time each day, often before breakfast in the morning.
B is incorrect. This is not an appropriate action when administering digoxin. For the medication to be absorbed correctly, it must be taken on an empty stomach. Never administer digoxin with food.
C is incorrect. This is not an appropriate action when administering digoxin. A second dose should not be delivered, even if the child vomited after their first dose. Digoxin toxicity is severe, and overdosing the child should always be avoided. Due to the potential toxicity, it is not advisable to administer a second dose, even if the child vomited.
D is correct. Poor feeding and frequent vomiting are signs of digoxin toxicity. This should be taught to the parents at discharge so that they can monitor their child for these symptoms and call the health care provider if they occur. This is the result of a timely lab test to determine the serum digoxin level and early treatment if toxicity has occurred.
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.
A client in acute exacerbation of ulcerative colitis underwent diagnostic tests and was found to have elevated serum osmolality and urine specific gravity. Which condition could have caused this?
A. renal insufficiency
B. diabetes insipidus
C. hypoaldosteronism
D. deficient fluid volume
CORRECT ANSWER D
Explanation
Rationale: A characteristic of ulcerative colitis is watery diarrhea. The client loses large volumes of fluid causing hemoconcentration and elevation in the serum osmolality and urine specific gravity. Hypoaldosteronism, renal insufficiency, and diabetes insipidus are not associated with ulcerative colitis. The correct answer is option D, while options A, B, and C are incorrect.
Reference:
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.
Calculate the equianalgesic of oral morphine when the client’s effective dosage of IV morphine was 75 mg per day. Fill in the blank.
______ mg of Oral Morphine
Explanation
The Correct Answer is 225mg of oral morphine.
The calculation of the equianalgesic of oral morphine when compared to IV morphine, which is always used to calculate equianalgesic, is done with a 3 to 1 ratio. In other words, the IV morphine is 3 times as potent as oral morphine. This calculation is shown below.
Oral Morphine : IV Morphine = 3:1 ratio
75 mgof IV Morphine = (3x 75)= 225 mg of oral morphine.
NCSBN Client Need:
Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management; Dosage Calculation.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).
The Charge RN is making assignments on the orthopedic unit. The patient is a 90-year-old woman who is two days post-operative arthroplasty. Vital signs are stable, and the patient’s post-op course has been uneventful. The most appropriate nursing assignment for this patient would be:
A. The Charge RN
B. Another RN
C. An LVN/LPN with 5 years of experience in orthopedics
D. An LVN/LPN with 5 years of experience in geriatric care
Explanation
Correct Answer: D.
The Charge RN knows that this patient has been stable following her surgery. The assumption is that she will require routine post-op care. A Registered Nurse can probably be used more effectively with another patient requiring more teaching or advanced assessment. The responsibility for this patient can be handled by an LPN/LVN after the initial evaluation. However, given the patient’s advanced age, she potentially will have needs particular to the geriatric population. Therefore, the most appropriate assignment is to the LVN/LPN with five years of experience in geriatric care.
NCSBN Client Need
Topic: Management of Care
Sub-topic: Assignment and Delegation
Subject: Leadership and Management
Lesson: Assignment/Delegation
Reference: Weydt, A., (May 31, 2010) “Developing Delegation Skills” OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 1. Accessed online on February 11, 2020, athttps://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation-Skills.html
A client has been placed on a sodium-restricted diet following a myocardial infarction. Which of the following would be the most appropriate meals to suggest?
A. Turkey. 1 fresh sweet potato. 1/2 cup fresh green beans. milk. and 1 orange
B. Broiled fish. 1 baked potato. ½ cup canned beets. 1 orange. and milk
C. Canned salmon. fresh broccoli. 1 biscuit. tea. and 1 apple
D. A bologna sandwich. fresh eggplant. 2 oz fresh fruit. tea. and apple juice
CORRECT ANSWER A
Explanation
People with heart failure may improve their symptoms by reducing the amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt. Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup. Patients should be encouraged to follow a low-sodium diet to help manage symptoms of hypertension and to reduce edema. One of the most natural things a patient can do at home to reduce sodium intake is to eat fresh vegetables rather than canned. If canned vegetables are the only Option, the patient should rinse the plants with clean water and cook them with new, unsalted water.
The correct answer is A.
B is incorrect. Canned vegetables should be avoided.
C and D are incorrect. Canned or processed meats are higher in sodium and should be avoided.
NCSBN Client Need
Topic: Physiological Integrity
Subtopic: Basic Care and Comfort
Fundamentals of Nursing
Chapter 51: Circulation
Lesson: Alterations in Cardiac Functioning/Dietary Consideration
In the report, you are told your 58 y.o. a male patient is anemic. Which of the following lab values would you expect for them? Select all that apply.
A. WBC 15.9
B. Hbg 7.5
C. Sodium 147
D. Hct 23.5%
CORRECT ANSWERS B, D
Explanation
Answer: B and D
A is incorrect. This is a normal white blood cell count. A high or low WBC could indicate either infection or immunosuppression, but would not be reflective of anemia.
B is correct. Hemoglobin of 7.5 is low for a 58-year-old male. The standard reference range is 13.5 to 17.5. Low hemoglobin levels indicate anemia.
C is incorrect. Sodium is an electrolyte commonly monitored in metabolic panels. The normal level is 135-145. High or low levels can indicate things such as dehydration or overhydration and typically result in neurological changes, but do not reflect anemia.
D is correct. The hematocrit level is the percentage of blood components, which are red blood cells. A reasonable standard for an adult male is 45% to 52%. A hematocrit of 23.5% indicates anemia.
NCSBN Client Need:
Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Subject: Adult Health
Lesson: Laboratory Values
Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing. Elsevier Health Sciences.
A client with major depression just returned from a weekend pass with his family. What should be the nurse’s first action upon the client’s return?
A. Ask the children about how the visit went.
B. Ask the client’s wife if he has been taking his medication.
C. Ask the client about how the visit went.
D. Check the client for sharps or other objects that can be used to harm himself.
CORRECT ANSWER D
Explanation
A is incorrect. The nurse should discuss how the visit went to have an idea of how the client is coping with his family. This is, however, not the priority intervention.
B is incorrect. The nurse should ensure that the patient has been taking his medications during the weekend. This is to ensure that the pharmacological aspect of his treatment is being continued. This is, however, the primary intervention of the nurse.
C is incorrect. The nurse should discuss how the visit went to have an idea of how the client is coping with his family. This is, however, not the priority intervention.
D is correct. The nurse’s primary concern is always the safety of the client. The nurse needs to check the client for sharps or other items that the client can use for self-harm.
Reference
Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014
Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012
A patient who has recently been brought to the emergency room after experiencing a very traumatic event appears calm and in total control. The nurse assesses this behavior as which of the following defense mechanisms?
A. Projection
B. Denial
C. Rationalization
D. Regression
CORRECT ANSWER B
Explanation
NCSBN client need | Topic: Psychosocial integrity, coping mechanisms
Rationale:
The correct answer is B. Denial is a coping mechanism used to protect a patient from a traumatic experience. A patient in denial will behave as though the trauma never occurred.
Choice A is incorrect. Projection is a defense mechanism where the patient takes their personal feelings and places them onto someone else, believing the other person is experiencing the undesired feelings.
Choice C is incorrect. Rationalization involves working to find a good reason for something negative occurring.
Choice D is incorrect. Regression is a coping mechanism where a patient behaves in a manner reminiscent of an earlier, safe time in their life.
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.
The nurse is caring for a client receiving a continuous heparin infusion. Which of the following laboratory data should the nurse monitor? Select all that apply.
A. Partial thromboplastin time (PTT) B. Platelet count C. Prothrombin time (PT) D. Neutrophil count E. International normalized ratio (INR)
CORRECT ANSWERS A, B
Explanation
A client receiving a heparin infusion will need their PTT and platelet count monitored closely. Heparin prolongs the PTT (goal is 1½ to 2 times the control value) and should be observed frequently. Platelet counts that decrease approximately 50% may be indicative of heparin-induced thrombocytopenia, which should be reported. PT and INR are significant if the client is taking warfarin.
The nurse is assessing patients in the gynecology clinic for a prescription of oral contraceptives. Which patient will the nurse recommend to the physician to be prescribed oral contraceptives?
A. a 29 year old woman that has had a history of abortion
B. a 32 year old breastfeeding woman
C. a 34 year old whose father died of a cerebrovascular accident
D. a 41 year old woman who smokes
CORRECT ANSWER A
Explanation
A is correct. A history of abortion is not a contraindication for oral contraceptives.
B is incorrect. Oral contraceptives are contraindicated in breastfeeding women because high levels of estrogen decrease the woman’s milk supply.
C is incorrect. Oral contraceptives are contraindicated in women with a family history of cerebrovascular accidents or myocardial infarction because of their increased tendency toward clotting as an effect of increased estrogen.
D is incorrect. Women who smoke and are over 40 years old are contraindicated to take oral contraceptives.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
Your 75 year old female client complains of pain due to post-herpetic neuralgia. She is taking Naproxen. Which of the following coanalgesics should be added to her pain management regimen?
A. Oxycodone
B. Acetaminophen
C. Ibuprofen
D. Topical Lidocaine
CORRECT ANSWER D
Explanation
Choice D is correct.
Topical lidocaine, is a co-analgesic. Coanalgesics are also referred to as “adjuvant analgesics.” It is crucial to use adjuvant analgesics for adequate pain control before moving to initiate opioid analgesics ( WHO pain ladder).
Topical Lidocaine is very useful in local control of post-herpetic neuralgia pain. The lidocaine patch provides analgesia by reducing abnormal firing of sodium channels on injured pain nerve fibers directly under the piece. Topical patches are considered relatively safe because only less than 5% of the topically applied lidocaine is absorbed.
Choice A is incorrect. Oxycodone is not a coanalgesic. It is an opioid analgesic.
Choice B is incorrect. Acetaminophen is not a coanalgesic. It is classified under nonopioid analgesics.
Choice C is incorrect. Ibuprofen not an analgesic. It’s a nonopioid analgesic and an NSAID (a non-steroidal anti-inflammatory agent) like Naproxen.
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing.
A client in the post-anesthesia care unit is semiconscious and dyspneic. He exhibits retraction of intercostal muscles, and his oxygen saturation is 88%. What is the nurse’s priority action at this time?
A. Place a pillow under the client’s head
B. Insert an oropharyngeal airway
C. Administer oxygen by mask
D. Reposition the client in a side-lying position.
CORRECT ANSWER D
Explanation
Choice D is correct. The priority action in the care of a post-anesthesia client is to secure a patent airway. The most common cause of airway obstruction in a semiconscious or unconscious patient is the tongue. The anesthetic agents and muscle relaxants used during surgery may cause relaxation of tongue and jaw muscles, causing posterior movement of the language and epiglottis, which leads to the obstruction of the airway.
The client is dyspneic, using intercostal muscles and manifesting symptoms of airway obstruction. Repositioning in the side-lying position with the face slightly down is a simple initial nursing action that can prevent occlusion of the pharynx and allow the drainage of mucus from the mouth.
If repositioning fails to improve the condition, other airway positioning maneuvers (for example, head-tilt-chin lift, jaw-thrust) should be attempted. Supplemental oxygen (Choice C) can be administered once the airway patency is established. If these initial interventions fail to maintain a patent airway, then an airway adjunct (Oropharyngeal or Nasopharyngeal airway) should be used (Choice B).
AIRWAY MANAGEMENT
Post-Anesthesia client in respiratory distress
INITIAL INTERVENTIONS
- Repositioningg in the side lying position.
- Head-tilt chin-lift; jaw thrust maneuvers (before attempting these, make sure there is no cervical spine injury)
- Supplemental oxygen
- Suctioning
LATER INTERVENTION
- Oropharyngeal Airway (in unconcious patients)
- Nasopharyngeal airway (in semiconscious or unconscious patients)
Choice A is incorrect. A pillow under the head increases the risk of aspiration or airway obstruction.
Choice B is incorrect. Because the issue is airway obstruction, efforts to promote an open airway are most appropriate. The first step, however, is to open the airway via non-invasive measures. A simple initial intervention, such as repositioning, may help by making the tongue move forward. If those initial non-invasive measures fail, move to insert an airway adjunct. Additionally, because this client is semiconscious, a nasopharyngeal airway would be appropriate if the initial interventions failed.
If the patient is semi-conscious and can cough, they still have a gag reflex, and an oral airway is contraindicated. An oropharyngeal (Guedel) airway helps to secure a patent airway by preventing the tongue from blocking the epiglottis. However, because of the depth of an adequately inserted oropharyngeal airway, it can only be used in an “unconscious” client with no gag reflex.
Choice C is incorrect. The issue is airway obstruction, not the percentage of available oxygen (Fio2). Providing supplemental oxygenation without addressing the airway obstruction is futile.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Physiological Adaptation
Resource: Kozier and Erb’s Fundamentals of Nursing; Chapter 37: Perioperative Nursing; Lesson: Postoperative Phase
Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
A. A 36 year old female client with abdominal pain
B. A 56 year old male client with a leg amputation
C. A 76 year old female client with terminal cancer
D. An 84 year old male client with severe arthritis
CORRECT ANSWER B
Explanation
Correct Answer is B
Correct. The 56-year-old male client with a leg amputation would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain. Contralateral massage, or stimulation, unlike other cutaneous nonpharmacological comfort interventions, entails the stimulation of the opposite part of the body rather than the direct stimulation of the painful, affected area. For this reason, contralateral stimulation of the intact opposite leg will promote comfort and the decrease phantom pain that has occurred as a result of the amputation.
Choice A is incorrect. A 36-year-old female client with abdominal pain would not benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain; alternative comfort measures and pain management interventions may be indicated.
Choice C is incorrect. A 76-year-old female client with terminal cancer would not benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain; alternative comfort measures and pain management interventions may be indicated.
Choice D is incorrect. An 84-year-old male client with severe arthritis would not benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain; alternative comfort measures and pain management interventions may be indicated.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
