Question 1

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases.  Which action is appropriate at this time?
A)Administer an inhaled bronchodilator
B)Check marked insertion depth of the tube
C)Request a prescription for a diuretic
D)Start the client on incentive spirometry

Accepted Answer

11ecbb05_cb2f_547f_b433_9742eb44cb01_MD0009_00 A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option B). Some facilities use capnography to determine placement; if a sensor detects exhaled CO₂ from the tube, it is in the client's airway and must be removed immediately. (Option A) An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration. (Option C) Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse should initially hold feedings and assess tube placement. (Option D) Incentive spirometry promotes expansion of the lungs and resolves atelectasis; however, the priority for this client is assessing for and preventing aspiration. Educational objective: Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration.

Question 2

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially? A)0)9% Sodium chloride B)5% Albumin C)Dextrose 5% and lactated Ringer's D)Dextrose 5% and water

Accepted Answer

11ecbb05_cb31_5051_b433_4b2886420f7f_MD0009_00 Normal saline is the fluid of choice for rapid correction of hypotension in most situations, including hypovolemic and septic shock. It can be administered in large quantities rather rapidly and is inexpensive. (Option B) When 5% albumin, a colloid solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissues into the extracellular vascular space. Although it is equally effective in expanding intravascular fluid volume, it is expensive and not the initial fluid of choice. It can be used in clients with low intravascular protein (albumin) content and hypotension but increased fluid in extravascular tissues (eg, cirrhosis with ascites). (Option C) When dextrose 5% and lactated Ringer's, a hypertonic solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissue into the extracellular vascular space. Although it may be used to expand fluid volume, it is not the initial intravenous fluid of choice. (Option D) When the dextrose in dextrose 5% and water is metabolized, a hypotonic solution is left. In large volumes, it can cause shift of the fluid into the extravascular compartment, which may cause further hypotension in clients with low blood pressure. Hypotonic solutions (0.45% saline or dextrose 5% and water) are typically used to treat hypernatremia. Educational objective: Isotonic solutions are used for immediate fluid resuscitation in clients with hypovolemic shock.

Question 3

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply. A)Allow the client to refuse food if not feeling hungry B)Ask if the client is experiencing any pain or nausea C)Involve the client in meal planning and food selection D)Plan for loved ones to share mealtimes with the client E)Provide oral care before and after meals to alleviate dry mouth

Accepted Answer

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. The goal of end-of-life care is comfort and quality of life. In many cases, clients may be more comfortable when they do not eat or drink. Anorexia is a common complication in clients who are dying and may be exacerbated by many factors (eg, medication, anxiety, underlying disease). The client should be allowed to refuse food and drink (Option A). However, the nurse can implement strategies to stimulate appetite or alleviate symptoms associated with anorexia, including: Assessing the need for analgesia, antiemetic medications (eg, ondansetron), and appetite stimulants (eg, dexamethasone, megestrol acetate, dronabinol) to enhance client comfort and increase intake (Option B) Involving the client in meal planning to encourage autonomy and helping the client select foods that are preferred and well tolerated, regardless of nutritional value, to increase appetite and oral intake (Option C) Providing opportunities for meals with friends/family outside of the client's room, if possible, to promote stimulation and enjoyment (Option D) Providing oral care frequently, especially after eating, and using topical treatments to minimize oral discomfort and dry mouth (Option E) Educational objective: Managing anorexia during end-of-life care includes involving the client in meal planning/food selection; including friends/family at meals; offering preferred foods when the client is hungry; providing frequent oral care; administering antiemetics, analgesics, and appetite stimulants; and allowing the client to refuse food or drink.

Question 4

The nurse will anticipate administration of isotonic IV fluids in which clients? Select all that apply. A)14-day-old client has urine output of 2 mL/kg/hr with flat fontanel B)3-month-old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities C)8-year-old client has serum sodium of 131 mEq/L (131 mmol/L) and blood urea nitrogen of 15 mg/dL (5.4 mmol/L) D)Client is having contractions every 10 minutes and will be receiving an epidural analgesic E)Client received a bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4 hr and pulse is 120/min

Accepted Answer

Isotonic IV fluids expand only the extracellular fluid and are used as fluid replacement for fluid volume deficit. Common examples are normal saline and lactated Ringer's. Capillary refill indicates adequate circulation and perfusion. Normal capillary refill time is less than 3 seconds, and a delay can be an indication of dehydration. Mottling is characterized by patches of pink, pale, and cyanotic skin and can be indicative of poor perfusion (Option B). Clients in labor usually receive 500-1000 mL of isotonic fluids prior to an epidural anesthesia as vasodilation below the epidural site can occur and result in hypotension. Up to 40% of these clients may experience hypotension after an epidural anesthesia. The preadministration of IV fluids can lessen hypotension (Option D). Hyperemesis gravidarum is severe vomiting that can result in dehydration. Despite being given some fluids, this client still needs additional fluids. Minimal obligatory urine output is 30 mL/hr or 120 mL/4 hr. Urine output is the best indicator of adequate rehydration. Tachycardia with pulse of 120/min indicates dehydration unless there is another clear etiology (Option E). (Option A) Urinary output of 2 mL/kg/hr and a flat fontanel are normal findings in an infant. (Option C) Normal serum sodium in children is 138-145 mEq/L (138-145 mmol/L). Hyponatremia often results from excess fluids. There would be no need to give this client additional fluids. Normal blood urea nitrogen (BUN) in children is 5-18 mg/dL (1.8-6.4 mmol/L), and BUN is elevated with dehydration or a need for fluids. This range is normal and does not indicate that additional fluids are required. Educational objective: Indications of a need for IV isotonic fluids include capillary refill more than 3 seconds and mottling, prehydration before an epidural anesthesia, and inadequate urine output and tachycardia due to hyperemesis gravidarum.

Question 5

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply. A)Palliative care focuses on quality of life and can be provided at any time B)Palliative care is only possible with a terminal diagnosis of ≤6 months C)Palliative care is provided by a multidisciplinary team D)Palliative care is another term for hospice care E)Palliative care provides relief from symptoms associated with chronic illnesses

Accepted Answer

Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder. (Option B) Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease (eg, advanced heart failure or cancer). (Option D) The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment. Educational objective: Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families.

Question 6

A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision.  The client's spouse arrives and demands to be with the client.  Which action should the nurse take?
A)Allow the spouse in the room, out of the way of care providers, and explain the events occurring with the client
B)Assist the spouse in observing outside the room through a window and have a chaplain explain the care being provided
C)Explain the client's condition, but inform the spouse that entering the room is not allowed until the client is stabilized
D)Inform the spouse that being in the room during procedures is unsafe for the client, and escort the spouse to the waiting area

Accepted Answer

Family member presence at bedside during invasive procedures or resuscitation efforts is an important component of psychosocial care for the client and family. When a client's support person is allowed to be present at bedside to witness care during acute events, the support person is often able to better understand the client's condition and may have decreased anxiety and better coping with unexpected or poor outcomes (eg, cardiac arrest, death). Therefore, the nurse should, when possible, support and facilitate family presence in the room and provide information about the events that are occurring (Option A). (Option B) Requiring family members to watch through the window, rather than at the bedside, may increase their stress and impair coping. Although chaplains may assist with an individual's emotional or spiritual needs, chaplains are not trained to provide information related to medical or surgical interventions. (Option C) Denying the support person's presence in the room may be appropriate in certain situations (eg, uncontrollable emotional outbursts, interference with care, risks to support person health/safety). However, the nurse should provide the option of being present in the room when possible. (Option D) Although some health care professionals express concern that support person presence may negatively impact client outcomes, there is no evidence for this claim. Educational objective: The presence of family members during invasive procedures supports the psychosocial needs of the client and family. The nurse should reinforce family presence at bedside and provide information to the client's support person about the care being provided.

Question 7

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? A)Ask the client when a spiritual leader or clergy member is coming to visit B)Document the response and notify the health care provider and perioperative team C)Follow up with the client regarding the nature of the spiritual needs or religious practices D)Notify the hospital chaplain and tell the client that the chaplain will come by to assist

Accepted Answer

Spirituality and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care (Option C). (Option A) Asking a client if a spiritual leader or clergy member is coming to visit may alarm the client or raise suspicion about the surgery. It also assumes that the client's religious or spiritual practices involve a spiritual leader or clergy person. (Option B) The nurse should attempt to gather more information before notifying the perioperative team. Simply documenting the questionnaire response does not address the client's spiritual needs. (Option D) The chaplain should not be called until the nurse has assessed the client's specific needs. The client may not wish to see a chaplain. Educational objective: Spiritual, cultural, and religious needs are an important part of the nursing assessment and plan of care. Clients have the right to verbalize and practice their beliefs; the nurse should facilitate spiritual practices within the plan of care.

Question 8

The nurse is caring for 4 clients requiring IV fluid therapy.  For which client should the nurse anticipate the need for isotonic crystalloid administration?
A)25-year-old with a closed-head injury and signs of increasing intracranial pressure
B)45-year-old with acute gastroenteritis and dehydration
C)60-year-old with seizures and serum sodium of 112 mEq/L (112 mmol/L)
D)68-year-old with chronic renal failure and hypertensive crisis

Accepted Answer

Acute gastroenteritis is associated with nausea, vomiting, and diarrhea, placing the client at risk for dehydration and sodium loss. Clients with gastroenteritis are encouraged to increase fluid intake but may require IV fluid therapy. Isotonic crystalloid fluids (eg, 0.9% sodium chloride, lactated Ringer solution) are the treatment of choice due to the similarity in concentration with plasma and ability to increase extracellular fluid (ECF) without moving into the intracellular space. In addition, isotonic fluids may increase sodium levels in clients experiencing excess sodium loss (eg, vomiting, diarrhea) (Option B). (Option A) Hypertonic solutions (eg, 3% sodium chloride) are administered to clients with increased intracranial pressure (ICP) to raise the osmolality of ECF, which decreases cellular swelling by drawing water from the cells. Isotonic fluids are avoided because an increase in circulating isotonic fluid promotes additional fluid shifting into the cells, which further increases ICP. (Option C) The client with a serum sodium of 112 mEq/L (112 mmol/L) is dangerously hyponatremic and at risk for further neurological decline. A hypertonic solution (eg, 3% sodium chloride) is the most appropriate choice to rapidly correct sodium deficits. (Option D) Isotonic solutions can exacerbate fluid overload in clients with chronic renal failure and cause increased blood pressure. Educational objective: Isotonic fluid therapy is used to treat clients with extracellular fluid deficits (eg, dehydration). Clients at risk for cerebral swelling (eg, increased intracranial pressure, hyponatremia) require hypertonic fluid administration to decrease cellular swelling. Isotonic fluid administration may cause fluid overload in clients with renal failure.

Question 9

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily. The client's child reports that the client has trouble swallowing the large KCl pill. The client's potassium level is 3.7 mEq/L (3.7 mmol/L). What action should the nurse take first? A)Consult with the pharmacist to see if other oral forms of KCl are available B)Crush the pill and mix it with applesauce or pudding C)Hold the KCl until the health care provider makes rounds D)Instruct the client to tuck the chin to the chest when swallowing the pill

Accepted Answer

Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsules, dissolvable packets, and effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are currently available and to determine if the medication is safe to crush. If a more appropriate form (eg, liquid) is available, the nurse would then discuss that change in route with the health care provider and obtain an updated prescription. (Option B) Some pills or capsules are sustained-release formulations, and crushing may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. (Option C) The use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L [3.5 mmol/L]), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). (Option D) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill. Educational objective: Oral potassium chloride comes in multiple forms: tablet or capsule, oral liquid, dissolving packets, and effervescent tablets. If a client has difficulty swallowing large pills, the pharmacist can determine availability of other medication forms, which can then be prescribed by the health care provider.

Question 10

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication. What is the most appropriate action for the RN to take? A)Administer the hydromorphone B)Ask the licensed practical nurse to administer the medication C)Ask the unlicensed assistive personnel to take repeat vital signs D)Contact the health care provider

Accepted Answer

A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication. (Option A) A STAT medication dose was administered and cannot be repeated without a new prescription. (Option B) In most states, the registered nurse (RN) cannot delegate the administration of IV opioids to the licensed practical nurse, and it cannot be administered without a new prescription. (Option C) The RN can delegate repeat vital sign checks to the unlicensed assistive personnel, but it is not the most appropriate action. Educational objective: A STAT order indicates that a medication is to be given immediately and only once.

Question 11

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? A)Blisters with a garlic scent near the wrists B)Circular bruised blemishes on the back C)Markings appearing to be human bites on the arms D)Welt-like linear lesions on the back

Accepted Answer

The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures in North America can present with dermatologic findings. Markings that appear to be human bites would require further follow-up as these are not common in alternative medicine. Although nurses should be aware of various cultural practices, any marks consistent with child abuse (eg, bite marks, cigarette burns, bruises in various stages of healing) should be reported to the appropriate authorities. (Option A) Garlic application involves placing crushed garlic directly on the skin. It is thought to heal infections but can cause contact dermatitis and burns on the wrists. This is appropriate to include in a culturally competent care in-service. (Option B) Cupping is used by many cultures to remove illness from the body. The mouth of a steam-filled cup is placed on the skin, causing circular, bruised blemishes. This is appropriate to include in a culturally competent care in-service. Cupping (Option D) Coining is believed by some cultures (eg, Chinese, Vietnamese) to remove illness from the body. A rounded surface (eg, coin, spoon) is firmly stroked on the lubricated skin of the back and can produce weltlike linear lesions. This is appropriate to include in a culturally competent care in-service. Coining Educational objective: To provide culturally competent care, nurses should be aware of alternative medicine practices that can present with dermatologic findings. Any marks consistent with child abuse should be reported to the appropriate authorities.

Question 12

A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy. What question from the nurse best evaluates the effectiveness of the prosthesis on body image? A)"Do you feel you are able to engage in sexual activity with your prosthesis?" B)"Do you wear the prosthesis all the time or only when out of the home?" C)"How do you cope with feelings of self-consciousness?" D)"Since receiving your prosthesis, how do you see yourself differently?"

Accepted Answer

A breast prosthesis is an artificial appliance that is fitted to the external chest wall or inserted into a female client's undergarments to simulate previous symmetry after a mastectomy or breast trauma. This is an option for clients who are not interested in, or are not candidates for, breast reconstruction surgery. This appliance assists in the promotion of well-being, body image, and sexuality. When evaluating the use of a breast prosthesis, nurses should assess the client for body image disturbance using open-ended questions and therapeutic communication (Option D). (Option A) Sexual activity can be affected by the client's overall body image but is not a comprehensive evaluation. (Option B) How often a prosthesis is used is not an indication of its effect on body image. Not all clients feel the need to wear a prosthesis for a healthy body image. (Option C) Although assessing coping techniques and effectiveness is important to the client's ability to cope with the loss of a body part, this question does not evaluate the prosthesis' effect on body image. This question also assumes that the client is or should feel self-conscious. Educational objective: A breast prosthesis is used to help promote a female client's sense of well-being, body image, and sexuality after significant loss of breast tissue (eg, mastectomy, breast trauma). Nurses should use open-ended, therapeutic communication to evaluate the effect of the prosthesis on the client's body image.

Question 13

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time? A)Call emergency medical services and place ice packs on the client's axilla and groin B)Encourage the client to leave the venue to visit a health care provider C)Evaluate whether the client may be intoxicated D)Move the client to an air-conditioned booth and provide a cool sports drink

Accepted Answer

Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated body temperature (hyperthermia), intravascular volume depletion, and electrolyte imbalance. Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping. If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another electrolyte-containing beverage (eg, Gatorade), or water (Option D). The priority is to lower the body temperature to prevent heat stroke, a potentially fatal condition associated with mental status changes (ie, indicating brain damage) and additional organ damage (eg, kidney injury, rhabdomyolysis). (Option A) If the client's temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and groin may help to dissipate heat; further medical help may be necessary. (Option B) The client should not leave until the symptoms subside, especially if driving. It is not necessary to have the client visit a health care provider if symptoms resolve. (Option C) Assessment can be continued once the client has been moved to a cooler environment and provided with hydration. Alcohol consumption may compound heat exhaustion but does not change initial management of the client. Educational objective: Initial management of heat exhaustion includes moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water. Early intervention in heat exhaustion can prevent the development of heat stroke, a potentially fatal condition leading to brain and additional organ damage.

Question 14

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube. The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route? Select all that apply. A)Enteric-coated ibuprofen 200-mg tablet B)Extra-strength acetaminophen 500-mg tablet C)Metoprolol extended-release 50-mg tablet D)Sulfamethoxazole double-strength 800-mg tablet E)Tamsulosin 0.4-mg slow-release capsule

Accepted Answer

Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification. (Options B and D) Double- and extra-strength drugs such as sulfamethoxazole and acetaminophen may be crushed and administered separately through an NG tube as long as they are not enteric-coated. The nurse should flush the tube with water before and after each drug administration. Educational objective: Crushing an enteric-coated, slow-release, extended-release, or sustained-release drug disrupts its designed time of release and is contraindicated. The nurse should contact the PHCP for an alternate prescription if such a drug is prescribed via NG route.

Question 15

The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? Select all that apply. A)Dim lights to prevent overstimulation B)Post a hearing impairment sign on the client's door C)Raise voice to speak more loudly D)Speak directly facing the client E)Tell family to take hearing aids home so they will not be lost

Accepted Answer

Effective communication is the key to ensuring the safety of clients with hearing impairment. To avoid startling the client, the nurse should approach the client from the front and visibly gain the client's attention before speaking. The nurse should stand directly facing the client so that the speaker's face can be seen clearly (Option D). Facial expressions and gestures can help make the meaning clear. If clients communicate with sign language, a professional sign language interpreter should be used when needed. The nurse may post a hearing impairment sign at the head of the bed or on the door to inform all caregivers of the safety concern (Option B). (Option A) Many clients with hearing impairment will lip-read. The room lights should be on so that the speaker's lips and face are well illuminated. (Option C) When speaking to a client with hearing loss, speech should be directed toward the least-affected ear and should be at a normal volume. Raising the voice to speak loudly creates a higher pitch that is harder to understand. (Option E) The nurse should ensure that any hearing aids are functional and in place before attempting to speak to the client. Educational objective: When speaking to a client with hearing impairment, the nurse should have the room lights on, directly face the client, speak at a normal volume toward the least-affected ear, and ensure that any hearing aids are functional and in place. Hearing impairment signs may be posted to promote safety.

Question 16

When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain? A)Client's ethnic background B)Client's report of symptoms C)Client's vital signs D)Extent of client's injury

Accepted Answer

11ecbb05_cb2f_f0c0_b433_2f6ec704288b_MD0009_00 The client's self-report of symptoms is always the most reliable indicator of the client's pain. The nurse does not have the ability to determine the extent of pain the client is experiencing-only the client can report this. In the nonverbal client, the nurse may use nonverbal pain scales such as the Wong-Baker pain rating scale. (Option A) Although clients from various ethnic backgrounds may express pain differently, it is not appropriate for the nurse to assume that ethnic background is a reliable source of information when determining pain. (Option C) Although changes in vital signs may occur in acute pain (generally increased respiratory rate and heart rate), these changes are not the most reliable source of information when determining pain. (Option D) The extent of a client's injury is not a reliable source of information when determining pain because all clients experience pain differently. What one client may feel as excruciating pain another client may not. Educational objective: The most reliable indicator for the client's pain is the client's self-report of symptoms. Nurses should not assume what the client's pain level is based on injury or ethnicity. Although a change in vital signs may occur in the client in pain, this is not the most reliable indicator.

Question 17

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease.  Of the following prescriptions, which one is transcribed correctly?
A)Ranitidine 150 mcg daily by mouth
B)Ranitidine 150 mg per os qhs
C)Ranitidine 150 mcg po qd nightly
D)Ranitidine 150 mg PO at bedtime

Accepted Answer

The nurse has correctly transcribed the prescription using approved abbreviations and standard terminology. (Option A) The abbreviation mcg signifies microgram. This option is incorrect as the medication is to be given daily in units of milligrams and it must be taken specifically at bedtime. (Option B) The abbreviation per os is interpreted as by mouth. The United States Pharmacopeia Institute for Safe Medication Practices Medication Error Reporting Program recommends that per os not be used as it may be read mistakenly as left eye. It equally recommends that the abbreviation qhs not be used as it may be misinterpreted as qhr or every hour, leading to a potential medication administration error. (Option C) The abbreviation mcg signifies microgram, making this option incorrect. The abbreviation qd is on the do-not-use list of The Joint Commission National Patient Safety Goals; it may be mistakenly read as qid (four times daily), which may cause a serious medication administration error. Educational objective: Using approved abbreviations when transcribing health care provider prescriptions promotes client safety and prevents potential medication administration errors. Common abbreviations (per os, qhs, qd) can result in errors and should not be used.

Question 18

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? A)Ask about the client's recent bowel and bladder habits B)Assess the home for sources of excessive noise C)Provide information about respite and adult day care D)Review behavior-management techniques with caregiver

Accepted Answer

Alzheimer disease (AD) is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (eg, agitation, aggression, resistance to care) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination (eg, constipation) or eating (eg, inability to feed oneself). The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs (Option A). Maslow hierarchy of needs (Option B) Environmental stressors (eg, excessive noise, overstimulation) may cause behavioral changes such as agitation or restlessness in clients with AD and should be addressed after intervening to meet the client's basic needs. (Option C) Caregiver support is essential to client care, especially in the home health environment. After addressing the client's needs, the nurse should provide information about community support groups, respite care, and adult day care to help reduce caregiver fatigue. (Option D) The nurse should use behavioral-management techniques (eg, reassurance, distraction, redirection) to assist with deescalation. However, the nurse must assess for and address sources of agitation first. Educational objective: When caring for a client with Alzheimer disease who has increasing or persistent behavioral changes, the nurse should first assess for possible physical stressors such as pain or problems with elimination or eating.

Question 19

The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? A)"Do you have any questions about the diagnosis?" B)"There are medications available to treat Alzheimer disease." C)"This new diagnosis must be frightening for you." D)"We can help you make decisions about your care."

Accepted Answer

Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of feelings and thoughts. (Option A) Questions or statements that prevent the client from expressing feelings (eg, changing the subject) when a client and family are trying to cope with a new diagnosis are not therapeutic and can block communication. Once the nurse understands the client's thoughts and feelings, information can be provided. (Option B) Providing false reassurance is not therapeutic and can block communication. A client and family may not fully understand the progression of Alzheimer disease immediately after receiving the diagnosis. Stating that medications are available to treat the disease may lead to a false belief that it can be cured. (Option D) A client diagnosed with Alzheimer disease may need assistance with care planning, but the nurse should first support the process of coping when the client receives the life-changing diagnosis. Educational objective: When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication.

Question 20

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. A)Arrange for health care workers of the same sex to provide care for the client B)Coordinate with the registered dietician to provide halal meals C)Reposition the immobile client to face the city of Mecca during daily prayer times D)Restrict the number of visitors from the family to preserve the client's privacy E)Upon death, provide the family with supplies for postmortem care

Accepted Answer

Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include: Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer (Option C) - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. Modesty - Care providers should be the same sex as the client whenever possible (Option A). The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable (Option B). During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly. Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day (Option E). (Option D) In Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care. Educational objective: Important aspects of care for Muslim clients include accommodating the following client needs: Facing Kaaba in the holy city of Mecca for prayer, modesty considerations, adherence to dietary practices (halal or kosher meals and possibly fasting during Ramadan), and involvement of family.

Exam 4: Fundamentals

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially?

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply.

The nurse will anticipate administration of isotonic IV fluids in which clients? Select all that apply.

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.

A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision. The client's spouse arrives and demands to be with the client. Which action should the nurse take?

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time?

The nurse is caring for 4 clients requiring IV fluid therapy. For which client should the nurse anticipate the need for isotonic crystalloid administration?

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies?

A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy. What question from the nurse best evaluates the effectiveness of the prosthesis on body image?

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube. The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route? Select all that apply.

The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? Select all that apply.

When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain?

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time?

The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse?

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply.