NCLEX READINESS STUDY GUIDE QUESTIONS WITH 100% VERIFIED ANSWERS AND RATIONALES UPDATED 20, Exams of Nursing

Download NCLEX READINESS STUDY GUIDE QUESTIONS WITH 100% VERIFIED ANSWERS AND RATIONALES UPDATED 20 and more Exams Nursing in PDF only on Docsity! 1 NCLEX READINESS STUDY GUIDE What intervention is essential prior to starting a client on atorvastatin therapy? 1. Assessing for muscle strength 2. Assessing the client's dietary intake 3. Determining if the client is on digoxin therapy 4. Monitoring liver function tests Correct Answer: 4 Rationale Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. Question: 2 The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of the teaching? 1. "I need to be on bedrest for the duration of my pregnancy." 2. "I will notify my health care provider if I start having low backaches." 3. "Pelvic pressure is to be expected after cerclage placement." 4. "The cerclage will be removed once my baby is at 28 weeks." Correct Answer: 2 Rationale 2 Cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second-trimester loss or premature birth. A heavy suture is placed transvaginal or trans-abdominally to keep the internal cervical closed. Placement occurs at 12–14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions, pelvic pressure) and rupture of membranes (Option2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is determined by the health care Provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36–37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates). Educational objective: Following cerclage placement, discharge teaching includes recognizing and reporting signs of preterm labor (eg, low back aches, contractions, pelvic pressure) or rupture of membranes and understanding activity restrictions (eg, bed rest for a short time after placement) Question: 3 During the first prenatal assessment, the client reports the last normal menstrual period starting on March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected intercourse on March 15. Using Naegele's rule, what is the estimated date of birth? 1. December 8 5 Reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of Systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual Disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo Regular ophthalmologic examination every 6-12 months (Option 1). (Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (A common side effect). (Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) Therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation are not required. (Option 4) There are no effects of hydroxychloroquine that would require wearing a Medic Alert bracelet. Educational objective: Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required. Question: 5 The nurse is caring for a client diagnosed with Guillain-Barre syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing 2. Hypoactive or absent bowel sounds 3. Inability to cough or lift the head 6 4. Warm, tender, and swollen leg Correct Answer: 3 Rationale GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: • Inability to cough • Shallow respirations • Dyspnea and hypoxia • Inability to lift the head or eyebrows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence of hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure. Educational objective: 7 Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barre syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation. Question: 6 The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulses paradoxus? 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip 2. Compare apical and radial pulses for any deficit 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle. 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3 Correct Answer: 3 Rationale Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. The cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. 10 Educational objective: Solid foods are introduced at age 4-6 months, beginning with iron- fortified cereal and progressing to soft fruits and vegetables. Five to 7 days should elapse before a new food is introduced to observe for allergies. Simple finger foods may be introduced at age 6-9 months. Cow's milk should not be introduced until after age 1 year. Question: 8 A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30) 2. Partial thromboplastin time of 110 seconds 3. Platelet count of 80,000/mm3 (80 x 109/L) 4. Prothrombin time of 11 seconds Correct Answer: 2 Rationale Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. (Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 11 80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm3 (50 x 109/L). (Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning. Educational objective: Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin Question: 9 An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team? 1. Need for discharge to a skilled nursing facility 2. Nutritional consult with instructions on a high-calorie diet 3. Option of palliative care 4. Physical therapy prescription to promote activity Correct Answer: 3 Rationale This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments (Option 3). Palliative care may eventually include hospice care, after it 12 is determined that the client has a life expectancy of less than 6 months. The nurse should advocate for the client and collaborate with members of the health care team to explore care options based on the client's wishes. (Option 1) This client has not clearly demonstrated a need for skilled nursing; additional assessment is needed to determine the most appropriate discharge setting. (Option 2) A high-calorie diet is appropriate for a client with weight loss, but many clients may have difficulty maintaining weight due to factors such as advanced disease and poor appetite. It is not the highest priority in this client, who is nearing the end of life and has expressed an interest in avoiding further testing and hospitalization. (Option 4) Physical therapy may be appropriate to help this client maintain current abilities. However, a client with disease this advanced is not likely to tolerate more activity or gain much additional functional capacity. Therefore, physical therapy is not the highest priority at this point. Educational objective: The client with an advanced, terminal disease (eg, chronic obstructive pulmonary disease) is often an appropriate candidate for palliative care. Palliative care emphasizes quality of life and symptom control and may eventually include hospice care based on the client's life expectancy. Question: 10 15 not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self-esteem. (Option 2) This action reinforces the client's desire to stay in the room and is not therapeutic. (Option 3) This response is non-therapeutic; the client needs assistance with ADLs. (Option 4) Clients with depression often do feel better after even minimal exercise and activity. However, this response does not give the client direction or structure. Educational objective: Clients with low energy, lethargy, or fatigue associated with major depressive disorder need structure and direction in performing basic ADLs, including personal hygiene and grooming. The nurse needs to provide assistance to the client in completing ADLs and in initiating social interaction with others. Question: 12 The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? 1. "I bought a new nightlight for the hallway to the bathroom." 2. "I feel so much more secure wearing my electronic fall alert device." 3. "I walk in my stockings at home because it helps to relieve my bunion pain." 4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape." Correct Answer: 3 16 Rationale According to the Centers for Disease Control and Prevention, 1 out of 3 adults aged >65 experience a fall every year. Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home. There are multiple simple strategies that can help reduce falls in the home environment and these include: • Exercising regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore, decreasing fall risk. • Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double- sided tape) (Options 1 and 4). • Using grab bars and non-skid bath mats in the bathroom. • Wearing shoes or slippers with non-skid soles, both inside and outside of the home. • Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care provider (HCP). • Getting regular vision exams. • Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of knowing help is available immediately if a fall occurs (Option 2). Educational objective: Many falls in the home can be prevented by exercising regularly, getting regular vision exams, maintaining a well-lit, clutter-free environment, using grab bars in the bathroom, periodically reviewing medications and side effects with a pharmacist and/or HCP, and wearing an electronic fall alert device. Question: 13 17 A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? 1. Advise the parent to give a pacifier whenever the infant cries 2. Ask the parent to describe what is done to "keep the baby quiet" 3. Assess the infant's pattern and frequency of crying 4. Explore the parent's support system Correct Answer: 3 Rationale During the first 3-4 months of life, it is not unusual for an infant to cry 1-3 hours a day in response to being hungry, thirsty, tired, in pain, bored, or lonely. A very young, first-time parent may not have an appreciable understanding of normal infant behavior and may perceive normal crying as excessive. It is most important for the nurse to assess the infant's pattern and quality of crying to better understand whether it is normal behavior or a sign of something more serious that requires further evaluation and treatment. The nurse needs to determine: • What "all the time" means • When the "all the time" crying started • What makes the crying worse and what makes it better? • The quality of the crying (tone, pitch, loudness) • Length and quality of periods of silence (Option 1) A pacifier would be appropriate to calm and soothe this infant. However, the nurse needs to first assess the pattern and quality of the crying along with the methods the parent is already using. (Option 2) Finding out what the parent is already doing to comfort the child is part of the nursing assessment. In this case, however, it is more important to determine if the crying is normal or abnormal. (Option 4) Exploring the parent's support system is an appropriate nursing action to determine if the parent has anyone to turn to when 20 3. Inform the family member that relatives are not allowed in rooms during emergency situations 4. Let the family member stay and assign a staff person to explain what is happening Correct Answer: 4 Rationale If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The charge nurse should be prepared to escort family members from the room if they become disruptive. (Option 1) Calling security is appropriate only if the family member is disruptive or abusive to the staff. (Option 2) This could increase the family member's anxiety and result in a traumatizing experience if this person does not understand what is occurring during the resuscitation effort. (Option 3) Many professional organizations support allowing a family member to stay during emergency situations, in accordance with specific hospital policy. Educational objective: The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place. Question: 16 21 The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication? 1. "I have gained a few pounds since I started this medication." 2. "I have had a sore throat for 3 days and feel feverish today." 3. "I have noticed increased salivation and drooling." 4. "I often feel sleepy when I take this medication." Correct Answer: 2 Rationale Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (e.g., sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2). (Option 1) Weight gain is a common side effect. Clients should be educated about weight management. (Option 3) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling. (Option 4) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve. Educational objective: 22 Clozapine, an atypical antipsychotic, is used to manage schizophrenia in clients who have not improved with other medications. Clozapine may cause agranulocytosis, which increases the risk of life-threatening infection. Clients receiving clozapine should be monitored for signs of infection (eg, fever, flulike symptoms). Question: 17 The nurse admits a postoperative client following weight loss surgery. Which prescription should the nurse question? 1. Begin a sugar-free, clear liquid diet 2. Insert nasogastric tube for uncontrolled nausea 3. Place client in low Fowler position during mealtimes 4. Start morphine via patient-controlled analgesia Correct Answer: 2 Rationale Bariatric surgery for weight loss involves a surgical modification of the client's stomach and/or small intestine to restrict the client's intake. Postoperative nursing care focuses on managing pain and nausea and monitoring for complications (eg, infection, fluid and electrolyte imbalance, dumping syndrome, anastomotic leak). Nasogastric tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can cause hemorrhage and anastomotic leak (Option 2). Postoperative nausea would be controlled using IV antiemetics. (Option 1) Clients are placed on a clear liquid diet for the first 48-72 hours after bariatric surgery to promote healing. The diet is restricted to low-carbohydrate (eg, sugar-free) liquids to decrease the risk of dumping syndrome, rapid emptying into the small intestines that causes 25 2. Sinus rhythm with premature atrial contractions (PACs) 3. Sinus rhythm with premature ventricular contractions (PVCs) 4. Ventricular tachycardia Correct Answer: 3 Rationale A PVC is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement). (Option 1) Atrial flutter is an atrial dysrhythmia identified by recurring, regular, sawtooth shaped flutter waves that originate from a single ectopic focus in the atria. (Option 2) A PAC is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape than the P wave that originated in the sinus node. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. Educational objective: 26 PVCs are wide and distorted and occur early in the underlying rhythm. They are usually not harmful in the client with a healthy heart. PVCs in the client with myocardial infarction indicate ventricular irritability and should be assessed immediately. Question: 20 An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? 1. "A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall." 2. "Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure." 3. "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." 4. "The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results." Correct Answer: 3 Rationale The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic 27 shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option 4). (Options 1 and 2) Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls. Educational objective: An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion. Question: 21 The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of Bell's palsy with unilateral facial droop and drooling 2. History of multiple sclerosis and reporting recent blurred vision 3. Reports unilateral facial pain when consuming hot foods 4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14 Correct Answer: 4 Rationale 30 experience fractures of the vertebral column and spinal processes as cancer weakens and decalcifies the vertebrae. This client should be evaluated next to rule out spinal cord involvement. Educational objective: Joint dislocations may constitute an orthopedic emergency. Because articular tissues, blood vessels, and nerves are stretched and compressed, neurovascular compromise may occur. Prolonged disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity. Question: 23 The post-anesthesia care unit nurse receives a report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? 1. Absent bowel sounds 2. Borborygmi sounds 3. High-pitched and gurgling sounds 4. Swishing or buzzing sounds Correct Answer: 1 Rationale Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered 31 absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds. (Option 2) Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. (Option 3) High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery. (Option 4) A swishing, humming, or buzzing sound (bruit) may be cardiovascular in origin; a bruit indicates turbulent blood flow as with artery dilation (aneurysm) or narrowing (obstruction). A bruit can best be auscultated with the bell of the stethoscope. Educational objective: Bowel sounds following abdominal manipulation may be absent for 24- 48 hours. Any disease process that causes an increase in peristalsis may cause borborygmi (loud, gurgling sounds). Swishing and humming sounds heard best with the bell of the stethoscope may be indicative of turbulent blood flow. Question: 24 The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? 1. "I will be sure we use condoms during intercourse as long as I have lesions." 2. "I will not touch the lesions to prevent spreading the virus to other parts of my body." 32 3. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower." 4. "I will use warm running water and mild soap without perfumes to wash the area." Correct Answer: 1 Rationale Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesions are painful and appear as multiple small, vesicular lesions. Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include: • Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak (Option 1). After the outbreak has resolved, condoms should be used in future sexual encounters as the transmission is possible even in the absence of active lesions. • Keep the area with lesions clean and dry. • Avoid the use of perfumed soaps and bubble baths. • Maintain proper hand hygiene and avoid touching the lesions to prevent spreading. • Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning. (Option 2) Vesicles contain numerous virus particles, leading to the possibility of self-inoculation. This can be prevented by avoidance of hand contact with lesions during an outbreak. (Option 3)The use of a hairdryer in a cool setting is an effective means of drying the lesions and promoting client comfort. (Option 4) Warm water provides symptomatic relief. Mild soap containing no perfumes reduces the risk of irritation to the area. Educational objective: Clients experiencing an outbreak of genital herpes should abstain from sexual activity when lesions are present and use condoms in future 35 aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection. (Option 1) Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as ondansetron (Zofran), can provide relief. (Option 2) Evidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no earlier than every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions and hypertonic solutions (eg, total parenteral nutrition, propofol, blood) require more frequent changes (eg, 4-24 hours) due to increased risk for infection. (Option 3) Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued. This therapy is expected. Educational objective: Manifestations of phlebitis associated with a peripheral IV catheter include pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis. Question: 27 The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? 1. Assess mental status and orientation 2. Give on an empty stomach for rapid effect 36 3. Hold if 3 soft stools occur in a day 4. Mix with fruit juice to improve the flavor Correct Answer: 3 Rationale Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood brain barrier, leading to neurological dysfunction (Option 1). Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia. Educational objective: Increased ammonia levels in the blood can lead to hepatic encephalopathy, a complication of liver disease. Lactulose, a laxative, removes ammonia and is given orally with juice, milk, or water or rectally via enema to produce 2-3 soft bowel movements a day. 37 Therapeutic effects are evident via laboratory results and improving mental status. Question: 28 The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28-year-old with infective endocarditis and heart rate of 105/min 2. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min 3. 65-year-old with tachycardia of 110/min after liver biopsy 4. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min Correct Answer: 3 Rationale The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. (Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections can require several weeks of antibiotics. This client is not the priority. (Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority. (Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening. Educational objective: 40 (Option 3) Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with pain medications and IV fluids but is not a priority over the client with testicular torsion. (Option 4) Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidney stones are very painful but in most cases cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the client with testicular torsion. Educational objective: Testicular torsion can result in testicular ischemia and necrosis from inadequate blood supply. There is a short time frame (4-6 hours) in which testicular torsion can be treated to prevent death of the testicle, and the client will most likely require emergency surgery. Question: 2 A client with dilated cardiomyopathy has the rhythm shown in the exhibit. Which action should the nurse take first? 1. Assess the client for a pulse 2. Assess the oxygen saturation 3. Initiate cardiopulmonary resuscitation (CPR) 4. Prepare to defibrillate the client Correct Answer: 1 Rationale Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, Chest pain, and acute heart failure. The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in 41 VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol). (Option 2) Oxygen saturation should be assessed after the presence of a pulse has been established. (Options 3 and 4) CPR and defibrillation should be initiated only in a client who is pulseless. Educational objective: The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion. Question: 3 Which statement by a client with a diagnosis of dependent personality disorder would the nurse? recognize as progress toward a positive therapeutic outcome? 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin." Correct Answer: 3 Rationale Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include: • Difficulty in making day-to-day decisions • An excessive need for advice, reassurance, and nurturance from others • Lack of self-confidence - afraid to do things on one's own • Afraid of confrontation or expressing disagreement with others 42 • Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself. A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a therapeutic outcome. (Option 1) Clients with dependent personality disorder will often express appreciation or make flattering comments to the nurse/therapist to gain approval. (Option 2) Clients with dependent personality disorder lack confidence in their own abilities; this client is expressing self-doubt and is not showing evidence of improvement. (Option 4) The need to stay with someone while the client's parents are away is not evidence of progress toward a therapeutic outcome; the client cannot tolerate being alone. Educational objective: Clients with dependent personality disorder have an extreme need to be taken care of by another person, cannot make decisions on their own, and have intense fear of separation and being left alone. The ability to make a decision and act on one's own would indicate progress toward a therapeutic outcome. Question: 4 A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type II diabetes, 2 months post bilateral above- knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis 45 assess for any history of asthma or other respiratory problems and report to the HCP. Question: 6 When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting 2. Second-trimester client with dysuria and urinary frequency 3. Second-trimester client with obesity reporting decrease in fetal movement 4. Third-trimester client with right upper quadrant pain and nausea Correct Answer: 4 Rationale Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, and stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. (Option 1) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. (Option 2) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. 46 (Option 3) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority. Educational objective: HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications including placental abruption, stroke, and death may occur if HELLP syndrome is not treated immediately. Question: 7 A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1. Hemoglobin and hematocrit levels 2. Human chorionic gonadotropin level 3. Serum folate level 4. White blood cell count Correct Answer: 1 Rationale Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron 47 absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. (Option 2) Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to determine if a client is pregnant. It is not affected by iron deficiency anemia or pica. (Option 3) Increased folic acid consumption is necessary during pregnancy to reduce the risk for neural tube defects in the developing fetus. However, folate levels are not related to pica. (Option 4) A white blood cell count should be assessed when a client is suspected of having an infection. There is no indication that this client has an infection. Educational objective: Pica is the constant craving for and consumption of nonfood and/or nonnutritive food substances that may occur in pregnancy. It may be accompanied by iron deficiency anemia. Hemoglobin and hematocrit levels are useful in these clients to screen for anemia. Question: 8 A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? 1. Inject into the upper arm where the sleeve can be pulled up 2. Inject into the most accessible vein 3. Inject through the clothing into thigh and hold in place for 10 seconds 4. Take the child inside, remove excess clothing, and inject into the thigh 50 Question: 10 The nurse is teaching the parents of a 4-month-old who has developed positional plagiocephaly (flat head syndrome). Which statement by the parents indicates a need for further teaching? 1. "I should alternate head positions when the infant is supine." 2. "I should place the infant in the prone position during naps." 3. "I will minimize the amount of time the infant is in a car seat." 4. "I will place interesting toys opposite the affected side." Correct Answer: 2 Rationale Positional plagiocephaly (flat head syndrome) occurs when an infant's soft, pliable skull is placed in the same position for an extended time. Positional plagiocephaly has become common due to the Safe to Sleep (formerly Back to Sleep) campaign, which advocates for infants to sleep in the supine position to prevent sudden infant death syndrome (SIDS). The risk of SIDS utweighs the benefit of a shapely head; the infant should not be placed in the prone position to sleep, even for a daytime nap (Option 2). Plagiocephaly can usually be prevented or corrected by: • Frequently alternating the supine infant's head position from side to side (Option 1) • Minimizing the amount of time an infant's head rests against a firm surface (eg, car seat) (Option 3) • Placing pictures and toys opposite the favored (affected) side to encourage turning the head (Option 4) • Placing the infant in the prone position for 30-60 min/day ("tummy time") Educational objective: Positional plagiocephaly, or flattening of the skull, can develop when infants spend a lot of time in the same position. Positioning techniques 51 (eg, "tummy time," alternating the head position) can prevent or correct plagiocephaly. Infants should always be placed in the supine position to sleep. Question: 11 A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurse's first action? 1. Administer morphine to the infant 2. Administer oxygen via mask 3. Assess infant's vital signs and pulse oximetry 4. Place the infant in the knee-chest position Correct Answer: 4 Rationale Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect. This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee- to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect. (Option 1) Morphine may be considered if the dyspnea is not relieved by the knee-to-chest position. (Option 2) If oxygen saturation remains low, oxygen may need to be administered. (Option 3) Vital signs and pulse oximetry may be checked after the infant has been placed in the knee-chest position. 52 Educational objective: To relieve a hypercyanotic episode, or "tet spell," the nurse should place the infant or child in the knee-chest position. Question: 12 The nurse administers 8 units of regular insulin subcutaneously at 11:30 AM to a client with type 1 diabetes mellitus and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated, and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction? 1. 12:30 PM 2. 2:00 PM 3. 5:00 PM 4. 6:00 PM Correct Answer: 2 Rationale The client is at highest risk for experiencing an insulin-related hypoglycemic reaction when the drug peaks. The peak indicates the time during which insulin works at its maximum strength to lower the blood glucose. Regular insulin is short-acting and peaks 2-5 hours after administration. The onset of regular insulin is 30 minutes-1 hour with duration of 5-8 hours. (Option 1) 12:30 PM is 1 hour after insulin administration. Rapid-acting insulins (lispro, aspart, glulisine) reach peak effect in 30 minutes-3 hours. (Option 3) 5:00 PM is 5.5 hours after insulin administration. Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin that reaches peak effect in 4 hours. (Option 4) 6:00 PM is 6.5 hours after insulin administration. Detemir reaches peak around this time (varies from 4-9 hours). 55 (Option 1) It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. (Option 2) Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. (Option 3) Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted. Educational objective: Bed bugs spread quickly and travel in bedding, clothing, and furniture. It is important to recognize bed bug bites and eliminate this pest from the home. Client treatment aims to minimize itching until the rash is gone. Question: 15 An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" 2. "My blood pressure this morning was 158/84 mm Hg." 3. "Sometimes I feel somewhat dizzy when I stand up." 4. "Will you look at my tongue? It feels thicker than normal." Correct Answer: 4 Rationale Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life threatening as it progresses to the airways. Angioedema is an adverse effect of ACE 56 inhibitors (eg, enalapril, lisinopril, and captopril) and occurs more commonly in African American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client (Option 4). (Option 1) A persistent, dry, hacking cough is a common side effect of ACE inhibitors. It is not life-threatening, but the medication should be discontinued or changed to resolve the cough. (Option 2) The nurse should review the client's blood pressure readings over the past month since starting enalapril. The client may need a dosage change or an additional medication. This should be reported but is not the priority in this situation. (Option 3) Occasional dizziness upon rising (ie, orthostatic hypotension) is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before standing up. Educational objective: Swelling of the tongue can be a sign of angioedema in clients taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this immediately to the health care provider. Angioedema occurs more commonly in African American clients Question: 16 The nurse reviews the laboratory results of several clients. Which finding should the nurse report to the health care provider immediately? 1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) 2. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 nmol/L) 3. Client with a new prosthetic aortic valve who has an INR of 3.0 57 4. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L) Correct Answer: 1 Rationale Narrow therapeutic index medications have a higher chance of producing adverse effects due to a very small difference between therapeutic and toxic levels. These medications require close monitoring of serum drug levels for adequate, but not toxic, dosing. Clients should also be monitored for signs of toxicity, which are specific to each medication. Phenytoin (Dilantin) is an antiseizure medication with a therapeutic index of 10-20 mcg/mL (40-79 mcmol/L) (Option 1). Tube feedings decrease phenytoin absorption, which reduces serum drug concentrations and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Phenytoin toxicity produces nystagmus, dysarthria, ataxia, and encephalopathy. (Option 2) A heart rate of 62/min is expected in a client taking digoxin (therapeutic index 0.5- 2.0 ng/mL [0.6-2.6 nmol/L]). Digoxin toxicity produces gastrointestinal symptoms (nausea, vomiting, and diarrhea), bradycardia, and visual disturbances (blurred vision, yellow-green halos). (Option 3) The therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. (Option 4) Anorexia is a common side effect of lithium (therapeutic index 0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Lithium toxicity produces nausea, vomiting, ataxia, and tremors. Educational objective: Tube feedings decrease phenytoin (Dilantin) absorption, which reduces serum drug concentrations (therapeutic index 10-20 mcg/mL [40-79 mcmol/L]) and may precipitate seizures. The nurse should pause tube 60 (Option 4) This aPTT is too high. This client is at risk for bleeding. The heparin should be titrated down based on the heparin drip protocol. Educational objective: The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5–2 times normal, or an aPTT of 46–70 seconds. Question: 19 The nurse is preparing medications for the following 4 clients. Which prescription should the nurse clarify with the health care provider before administration? 1. Acetaminophen for a client with a temperature of 102.2 F (39 C) with productive cough 2. Azathioprine for a client with Crohn disease with leukopenia who is reporting malaise 3. Baclofen for a client with multiple sclerosis who reports dizziness when changing positions 4. Colchicine for a client with an acute gout attack who reports intense, burning left toe pain Correct Answer: 2 Rationale Azathioprine is an immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel diseases (eg, Crohn disease) and to prevent organ transplant rejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. However, leukopenia (white blood cell count <4,000/mm3 [4 × 109/L]) can be a severe adverse effect of the drug and 61 should be reported to the health care provider before administering the medication due to high risk for infection (Option 2). (Option 1) Acetaminophen is a nonopioid analgesic with antipyretic properties. The client with a productive cough and fever should be assessed further for infection. This prescription would be appropriate. (Option 3) Baclofen is an antispasmodic drug commonly prescribed to clients with multiple sclerosis to relieve uncomfortable spasms and muscular pain. Dizziness when attempting to stand or changing positions (ie, orthostatic hypotension) is a common adverse effect but is not a contraindication. (Option 4) Colchicine is prescribed for clients with an acute attack of gout because it decreases the inflammation and pain associated with deposition of uric acid crystals in the joints. This is an appropriate prescription. Educational objective: Azathioprine is an immunosuppressant drug that can cause bone marrow suppression and increase the risk for infection. Leukopenia, a severe adverse effect of azathioprine, should be reported to the health care provider before the medication is administered. Question: 20 The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage 62 Correct Answer: 4 Rationale The new nurse has the basic skills to provide insulin coverage if necessary, perform wound care (eg, assessment, sterile dressing changes, documentation), and provide diabetic teaching for this client. (Option 1) A more experienced nurse should care for this client as frequent assessments are needed to determine artery patency and changes in circulatory status distal to the graft, especially in the presence of a diminished pedal pulse. (Option 2) A more experienced nurse should care for this client due to frequent assessments and neurologic checks to determine the possible development of target organ disease (eg, brain, heart, lungs, kidneys), especially in the presence of headache and visual disturbances. (Option 3) A more experienced nurse should care for this client due to airway management, aspiration precautions, blood pressure control, and frequent assessments to determine changes in neurologic status. Educational objective: The registered nurse makes assignments according to staff members' experience, knowledge, and skill level. The more experienced nurse is assigned to clients who are less stable and require more in-depth analysis of assessment data to implement and plan care. The less experienced graduate nurse is assigned to more stable clients who require basic nursing care. Question: 21 Which client does the nurse assess first after receiving morning report? 1. Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site 2. Client with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday 3. Client with atrial fibrillation and an irregular heart rate of 94/min 65 Question: 23 The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse? 1. "Bring the child to the health care provider's (HCP) office immediately." 2. "Give your child something warm to drink." 3. "Massage the child's feet gently until they warm up." 4. "Place the child's feet in warm water immediately." Correct Answer: 4 Rationale The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F[40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4). Once re-warming has been effective, the child should be seen by an HCP as soon as possible (Option 1). (Option 2) Giving the child something warm to drink is an appropriate intervention; however, re-warming the child's feet in warm water is the priority action. (Option 3) Massaging a body part that has sustained a cold injury is contraindicated due to the risk of tissue injury. Educational objective: The most important treatment for suspected chilblains/pernio or frostbite is re-warming of the affected area by immersion in warm (104 F [40 C]) 66 water. The individual can also be given a warm liquid to drink and should be seen by an HCP as soon as possible. Question: 24 A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital? 1. Client at 8 weeks gestation with spotting and pulse of 90/min 2. Client with a compound femoral fracture and an oozing laceration 3. Client with fixed and dilated pupils and no spontaneous respirations 4. Client with paradoxical chest movement throughout respirations Correct Answer: 4 Rationale Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with flail chest (ie, paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise, which requires immediate treatment (Option 4). (Option 1) Spotting at 8 weeks gestation may indicate complications of pregnancy (eg, miscarriage, ectopic pregnancy, hydatidiform mole). With stable vital signs, this client would be classified as nonurgent as the fetus is not at the age of viability and there is no evidence of risk to the mother's life. (Option 2) The client with a compound fracture and oozing laceration would be classified as urgent and require care within 2 hours to prevent life-threatening complications (eg, hemorrhagic shock). 67 (Option 3) Absent respirations and fixed pupils indicate severe neurologic damage or death. Therefore, this client would be classified as expectant. Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color- coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant). Question: 25 The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1. Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis 4. Request prescription for potassium infusion Correct Answer: 2 Rationale This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate 70 and magazines. Hoarding disorder is the persistent difficulty with discarding possessions, no matter their value. Removal of the items will cause the client to experience severe anxiety. Question: 27 A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? 1. Acetaminophen 1000 mg IVPB every 8 hours 2. Cefazolin 2 g IVPB once, now 3. Norepinephrine 0.02-2.0 mcg/kg/min titrated IV 4. Normal saline 2 L via rapid IV bolus Correct Answer: 4 Rationale Hypotension, tachycardia, and low central venous pressure (normal: 2- 8 mm Hg) may indicate hypovolemic shock. Central venous pressure is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects the client's fluid volume status. This client is recovering from major abdominal surgery and has a low- grade fever, placing the client at risk for fluid volume losses (eg, blood loss during surgery, insensible losses [sweating]). This client should be treated with isotonic fluids (eg, normal saline, lactated Ringer solution) to restore adequate fluid volume status. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and end-organ perfusion (Option 4). (Option 1) Acetaminophen is an analgesic and antipyretic that reduces fever and pain; however, the client's hemodynamic stability should be addressed first. (Option 2) Cefazolin, a cephalosporin antibiotic, may be prescribed prophylactically to prevent intra-abdominal infection after major 71 abdominal surgery. Medications timed "now" should be administered within 90 minutes. This intervention should be performed after stabilizing the client's hemodynamic status. (Option 3) If the client remains hypotensive following a fluid bolus, vasopressor or inotropic medications (eg, norepinephrine, dopamine) should be initiated. However, vasopressor medications are not effective without first restoring circulatory fluid volume as there is insufficient volume to compress within the vascular space. Educational objective: Hypotension, tachycardia, and decreased central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and perfusion. Question: 28 After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first? 1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago 2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate (TURP) 3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing 4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night Correct Answer: 4 Rationale The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the night before 72 surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia), teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well. (Option 1) Tramadol (Ultram) 50-100 mg orally every 4-6 hours is prescribed for moderate-tosevere postoperative pain. The client was medicated 1.5 hours ago. The drug onset is 1 hour, the peak is 2-3 hours, and the duration is 4-6 hours. Therefore, this client is most likely stable at this time. The nurse does not need to care for this client first. (Option 2) Moderate-to-mild bleeding 1-2 days after undergoing TURP is expected. Pink urine is a normal assessment finding. The nurse does not need to care for this client first. (Option 3) The client who is scheduled for discharge is stable and needs teaching about how to change the surgical dressing. The nurse does not need to care for this client first. Educational objective: To prioritize client care, the nurse first identifies the type of problem the client has, expected findings, associated complications, and desired outcomes. The nurse then uses clinical judgment to decide which client has the most urgent need, and then cares for that client first. Question: 29 The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self- inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the best response by the nurse? 75 Diaper 2: 52 − 30 = 22 g Diaper 3: 46 − 30 = 16 g Total mg of urine: 58 g = 58 mL Total output: (Emesis) + (Urine) = 120 mL + 58 mL = 178 mL Educational objective: Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid Question: 32 The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. "I am having problems extending my fingers since this morning." 2. "I can't take any of the pain medicine because it makes me feel sick." 3. "I have to scratch under the cast with a nail file because of the itching." 4. "I noticed a warm spot on my cast, and a bad smell is coming from it." Correct Answer: 1 Rationale Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue 76 damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy). (Option 2) The nurse should educate the client about ways to prevent medication-related nausea, or the HCP may consider switching pain medications. This would be addressed last. (Option 3) The client must be instructed to never stick anything inside the cast; this can lead to altered skin integrity and infection. This would be addressed third. (Option 4) A warm spot on the cast with a foul odor can indicate infection under the cast, especially if the client has been sticking objects inside to scratch the skin. This would be addressed second. Educational objective: Volkmann contracture (wrist contracture, inability to extend the fingers) occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention. Question: 33 The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin Correct Answer: 3 77 Rationale Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin (Option 3). Clean, dry linens and clothing should be provided. (Option 1) Wound care and incontinence specialists are useful resources in developing a bowel and/or incontinence management plan; however, the highest priority is promotion of skin integrity. (Option 2) Rectal tubes and other indwelling containment devices can cause skin/mucosal breakdown, decreased response of the anal sphincter, and infection. Skin integrity may be maintained without the risks associated with these devices; however, if other measures fail, these devices may be used. (Option 4) Absorptive incontinence products (eg, pads, undergarments) can be used after interventions to prevent incontinence and maintain perineal hygiene have failed. Incontinence products such as adult briefs may cause chemical irritation of the skin, further exacerbating skin breakdown. These products should wick moisture away from the client's skin. Educational objective: Interventions to prevent and handle fecal incontinence should be implemented from least to most invasive. Maintenance of skin integrity through perineal and perianal hygiene is the highest priority. Implementation of containment products (eg, absorbent pads, adult briefs, and rectal tubes) can be considered after hygiene practices fail. Question: 34 80 The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers 4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice Correct Answer: 1 Rationale The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a deep vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic anticoagulation. This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a venous embolus can lead to a pulmonary embolus, which is potentially life-threatening. (Option 2) Itching is to be expected due to drying of the skin under the cast. The nurse can suggest directing the air from a hair dryer on a cool setting under the cast to help relieve itching. This is not a potentially life-threatening event. (Option 3) This client is most likely using the crutches incorrectly or they are not fitted correctly. Pressure on the ulna or radial nerves can lead to numbness and tingling of the fingers and hand weakness. This symptom needs intervention, but it is not potentially life-threatening. (Option 4) Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE (rest, ice, compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may require aspiration, but the condition is not potentially life-threatening. 81 Educational objective: Cramping calf pain following joint replacement surgery can indicate the presence of a venous thrombosis and needs immediate intervention with diagnostic testing as the condition is potentially life-threatening. Question: 37 The parent of a 1-year-old says to the nurse, "I would like to start toilet training my child as soon as possible." What information does the nurse provide to the parent that correctly describes a child's readiness for toilet training? 1. "A good time to start toilet training is when your child can dress and undress autonomously." 2. "When your child can sit on the toilet until urination occurs, you can start toilet training." 3. "Your child may be ready to start toilet training when able to communicate and follow directions." 4. "Your child will be ready to start toilet training at about age 15 months." Correct Answer: 3 Rationale Toilet training is a major developmental achievement for the toddler. The degree of readiness progresses relative to development of neuromuscular maturity with voluntary control of the anal and urethral sphincters occurring at age 18-24 months. Bowel training is less complex than Bladder training; bladder training requires more self-awareness and self- discipline from the child and is usually achieved at age 2.-3. years. In addition to physiological factors, developmental milestones rather than the child's chronological age signal a child's readiness for toilet training. These include the ability to: • Ambulate to and sit on the toilet 82 • Remain dry for several hours or through a nap • Pull clothes up and down • Understand a two-step command • Express the need to use the toilet (urge to defecate or urinate) • Imitate the toilet habits of adults or older siblings • Express an interest in toilet training (Option 1) In order to achieve toilet training, the child will need to be able to pull clothing up and down but not necessarily dress and undress autonomously. (Option 2) Having the child sit on the toilet until urination occurs is not appropriate and will not facilitate bladder control; any urination that occurs is accidental and not due to sphincter control. However, the child should have the ability to remain on the toilet for about 5 – 8 minutes without getting off or crying. (Option 4) Age 15 months is too early to begin toilet training; voluntary control of the anal and urethral sphincters does not occur until age 18-24 months. Educational objective: Readiness for toilet training is dependent on the child's ability to voluntarily control the anal and urethral sphincters, which usually occurs at age 18-24 months. Other developmental and behavioral indicators of toilet training readiness include the child's ability to express the urge to defecate or urinate, understand simple commands, pull clothing up and down, and walk to and sit on the toilet. Question: 38 The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? 1. "Half of my vision looks like its being blocked by a curtain." 2. "I have to use reading glasses to see small print." 3. "My vision seems cloudy and I notice a lot of glare." 4. "The colors don’t seem as bright as they used to." 85 Question: 40 A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the "Y" site. The nurse reviews a prescription from the health care provider to discontinue the normal saline. What is the most appropriate nursing action? 1. Change the rate of the normal saline to 10 mL/hr 2. Clarify the prescription with the health care provider 3. Flush the IV with normal saline and then convert it to a saline lock 4. Turn off the normal saline and disconnect it from the "Y" site Correct Answer: 2 Rationale Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA medicationthrough the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the prescription to discontinue the normal saline. (Option 1) A "keep-vein-open" rate (eg, 5-20 mL/hr) may be appropriate; however, a prescription is necessary before the nurse can implement this. (Option 3) This client is still receiving PCA, so it is inappropriate to convert the IV to a saline lock. In addition, this does not address the need to flush the PCA medication through the line. (Option 4) Continuous IV fluids may be required to deliver the PCA boluses; before discontinuing the normal saline, the nurse should receive clarification from the health care provider. Educational objective: 86 Continuous IV fluids are often necessary with use of a patient-controlled analgesia (PCA) pump; the fluids maintain an open vein and provide a vehicle for PCA delivery. Question: 41 A graduate nurse (GN) is caring for a client with acute appendicitis who is awaiting surgery. Which action by the GN would require the precepting nurse to intervene? 1. Administers morphine IV PRN for pain 2. Initiates continuous normal saline IV 3. Provides a heating pad for abdominal discomfort 4. Teaches client about prescribed strict NPO status Correct Answer: 3 Rationale Appendicitis is inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and Inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. Appendicitis is often treated surgically via removal of the appendix (ie, appendectomy). Nurses caring for clients with appendicitis should avoid interventions that increase intestinal blood circulation, gut motility, or appendiceal intraluminal pressure. The application of heat to the abdomen (eg, heating pad, warm blanket) increases intestinal circulation and the risk for appendiceal perforation (Option 3). (Option 1) Pain and nausea may be managed with prescribed IV analgesics (eg, morphine) and antiemetics. (Option 2) NPO status and vomiting contribute to dehydration, which frequently requires continuous IV fluids (eg, normal saline) to maintain fluid and electrolyte balance. 87 (Option 4) Food and drink increase gastric motility, thereby increasing circulation to the appendix and risk of perforation. The nurse should teach the client about remaining NPO before surgery. Educational objective: Appendicitis is an inflammation of the appendix that often requires surgical treatment. Nurses caring for clients with appendicitis should avoid applying heat to the abdomen as this increases appendiceal swelling and the risk of appendix perforation, which is a medical emergency. Question: 42 While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?" Correct Answer: 2 Rationale Five rights of delegation Right task • Within delegatee's scope of practice • Routine, frequently recurring task; minimal potential risk • Established sequence of steps; requires little to no modification for individual clients 90 (Options 1 and 2) The client post cholecystectomy with incisional pain and the client reporting nausea after open reduction of the right femur are in need of nursing attention. However, these are not life-threatening problems. (Option 4) The client with type 2 diabetes mellitus has a blood glucose level of 250 mg/dL (13.9 mmol/L), but this is not immediately life- threatening compared to the client with hypoglycemia. Educational objective: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is a serious condition that occurs when the proportion of insulin exceeds the glucose in the blood. Clients respond rapidly to nursing intervention (eg, sugar tablets, orange juice). Question: 44 The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction? 1. "Even though I am getting nicotine in my patches, I am not being exposed to all of the other toxic stuff in cigarettes." 2. "I can't get lung cancer because I don't smoke." 3. "My husband needs to take smoking cessation classes." 4. "We installed a radon detector in our home." Correct Answer: 2 Rationale Smoking is responsible for 80%-90% of all lung cancers. Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer as well. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace. (Option 1) Smoking cessation is the best way to prevent lung cancer. Nicotine replacement therapy (eg, patches, gum, inhalers, lozenges) is 91 effective in helping smokers quit by reducingcravings. Although users receive a low dose of nicotine, they do not receive the other toxins that cigarettes include. (Option 3) The best way to reduce the risk of lung cancer is to avoid both firsthand and secondhand smoke. Smoke from someone else's burning cigarette contains the same carcinogens as those found in mainstream smoke and creates a health risk to those inhaling it. (Option 4) Exposure to high levels of radon can cause lung cancer. Radon levels must be tested before a home can be sold. Educational objective: Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace Question: 45 A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met? 1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% 2. Documentation shows that 100% of nurses attended an inservice seminar on the topic 3. Nurses report an increased number of written reminders given to appropriate clients 4. Surgeons who admit to the unit report increased satisfaction with current client IS used Correct Answer: 1 Rationale 92 The best indicators of a successful intervention (desired effect achieved) are objective criteria. This is an objective measurable result that can be correlated with the intervention. (Option 2) Attending an inservice seminar for staff education is an important and necessary step for intervention implementation. However, the intervention will be successful only if the information is applied and the desired outcome is achieved. (Option 3) Reporting the number of written reminders given to respective clients is necessary. However, this reporting of intervention achievement is subjective as recall can be inaccurate. Even if it were an accurate recounting, it does not prove that the intervention succeeded. The appropriate focus should be on client outcomes, not nursing staff behaviors. (Option 4) Although approval from surgeons provides helpful support for the intervention, an objective evaluation beyond personal opinions is required. Educational objective: The effectiveness of an intervention should be determined by objective measurable outcomes that can be correlated with the intervention. It should not be based only on opinion or staff activities. Question: 46 Several children are brought to the emergency room after a boating accident in which they were thrown into the water. The children are now 6 hours post-admission to the clinical observation unit. Which client should the nurse evaluate first? 1. Client who did not require CPR but now has a new oxygen requirement of 2 L via nasal cannula to maintain a saturation of 95% 2. Client who did not require CPR but was coughing on arrival to the hospital and is now crying inconsolably and asking for the mother 3. Client who received CPR for 2 minutes on the scene and whose respiratory rate has now dropped from 61/min to 18/min 4. Client who was briefly submerged in water and received rescue breaths on the scene and is now irritable and refusing food and drink 95 A client is being discharged home after open radical prostatectomy. Which statement indicates a need for further teaching? 1. "I will try to drink lots of water." 2. "I will try to walk in my driveway twice a day." 3. "I will wash around my catheter twice a day." 4. "If I get constipated, I will use a suppository." Correct Answer: 4 Rationale Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation (Option 4). (Option 1) Fluid intake should be encouraged in this client. (Option 2) The client is at risk for postoperative deep vein thrombosis and pulmonary embolism. Ambulation is an important part of preventing these serious surgical complications. Ambulation will also help reduce constipation. (Option 3) The client who goes home with an indwelling catheter should learn how to clean around the catheter at the urinary meatus with warm water and soap to prevent infection. Educational objective: Clients who have had an open radical prostatectomy for prostate cancer should avoid anything that could cause strain on the rectal area. Straining, suppositories, and enemas are contraindicated in these clients, and interventions should be implemented to prevent constipation. 96 Question: 49 A graduate nurse (GN) is inserting an oropharyngeal airway in a client emerging from general anesthesia. The nurse preceptor intervenes when the GN performs which action? 1. Inserts oropharyngeal airway (OPA) into mouth with curved end pointing upward 2. Measures OPA against the cheek and jaw angle before insertion 3. Rotates OPA tip downward once it reaches the soft palate 4. Tapes OPA to ensure it is secure and to prevent dislodgement Correct Answer: 4 Rationale An oropharyngeal airway (OPA) is a temporary, artificial airway device used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client will often cough or gag, indicating a need to remove the OPA; clients may also independently remove or expel the OPA. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth, as an obstructed (eg, taped) OPA may cause choking and aspiration (Option 4). (Options 1 and 3) The OPA should be inserted with the distal end pointing upward toward the roof of the mouth to prevent displacement of the tongue and obstruction of the trachea. Once the OPA reaches the soft palate (eg, back of the mouth), the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency. (Option 2) Appropriate OPA size should be measured prior to insertion, as inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the flange next to the client's cheek. With correct sizing, the OPA curve will reach the jaw angle. Educational objective: 97 An oropharyngeal airway (OPA) is a temporary artificial airway used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. An OPA should never be taped in place, due to the risk of choking and aspiration when the client awakens. Question: 50 The emergency department nurse performs an admission assessment for a client with priapism of about 3 hours duration who also has sickle cell anemia. What assessment finding is of most concern and warrants immediate notification of the health care provider? 1. Bluish discoloration of the erect penis 2. Drank a 6-pack of beer 8 hours ago 3. Extreme penile pain rated as 9 on 0-10 scale 4. Has not voided for at least 6 hours Correct Answer: 1 Rationale Priapism is a sustained, painful erection often associated with sickle cell anemia, as the sickling (crescent shaping) of red blood cells can lead to penile vascular occlusion, erectile tissue hypoxia, and tissue necrosis. Bluish discoloration is of most concern as it can be a sign of ischemia to the penis. (Option 2) Some factors, such as alcohol intake; spinal cord injury; and phosphodiesterase-5 enzyme inhibitor (ie, sildenafil), psychotropic (ie, trazodone), and illegal (ie, cocaine) drugs can contribute to the development of priapism. Possible penile ischemia is a more urgent concern than alcohol intake. (Option 3) Extreme pain related to tissue hypoxia is an expected, characteristic manifestation of priapism and requires analgesia, but it is not as urgent a concern as possible penile ischemia. (Option 4) Difficulty voiding and urinary retention are complications associated with priapism. It is important to monitor urine output as