NCLEX Review Questions Flashcards

"Do you become short of breath during your normal daily activities?"

The client is reporting a possible finding of heart failure, which can impair a person's normal daily function. The nurse's first question should focus on the client's functional ability as this would also be consistent with heart failure. Although it would be helpful to ask about the use of more pillows when sleeping, this is a finding that usually occurs after the development of dyspnea on exertion. The other options may be helpful, but they are not the primary focus.

Repeated arrhythmia alarms on the monitor

Hyperkalemia may result in cardiac rhythm abnormalities. Moderate hyperkalemia can result in changes to the ECG monitor and set off the alarm. Pain down the outer arm is less likely cardiac in origin; cardiac pain is typically down the inside of the arm. Abdominal cramps or pain is more characteristic of low serum potassium levels. Bradycardia and a weak pulse are serious symptoms of hyperkalemia.

Ascites

Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to the accumulation of fluid in the peritoneal cavity (ascites) due to the increased portal pressure as well as a lowered osmotic pressure. Ascites can lead to shortness of breath, not expiratory wheezing.

Respiratory rate of 34

Stimulation of respiratory center leads to hyperventilation. Thus, decreased CO2 levels result in respiratory alkalosis. Associate a fast respiratory rate with the loss of CO2 and a loss of acid; the loss of acid results in alkaline states. Hypoventilation will cause respiratory acidosis.

Apply bulky, loose sterile dressings to the nose and ears

Applying bulky, loose sterile dressings to the nose and ears permits the fluid to drain while providing a visual reference for the amount of drainage. With the history of trauma and locations of drainage, this may be cerebrospinal fluid (CSF). The drainage should be tested for glucose; if it's positive for glucose, the drainage would contain cerebrospinal fluid and the client would be at risk for a cerebral infection. The nurse should contact the RN charge nurse with these findings.

Observe for neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial findings are central nervous system hyperirritability and gastrointestinal findings. If withdrawal signs are severe, mortality risk is increased. Close monitoring of the infant ensures proper treatment during the period of withdrawal

Ensure that the stump is elevated

Elevating the stump is the priority intervention for the first 24 hours after surgery. This will help prevent pressure due to postoperative swelling, which will minimize pain or discomfort. Without this action, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Analgesics appropriate to the level of pain should be administered as needed in the postoperative period to promote client comfort. After the first day, the residual limb should be flat on the bed.

"I feel pressure in the middle of my chest like an elephant is sitting on my chest."

This is a classic description of chest pain in men caused by myocardial ischemia, requiring immediate assessment and intervention to prevent possible damage to the heart muscle. Pain after spicy food is often the result of irritation and gastric indigestion. The pain with a deep breath is typically from an inflammation of the pleural covering of the lung, called pleurisy. Pain with movement of the chest, such as turning in bed, is typically caused by costochondritis, which is inflammation of the cartilage between the ribs and the sternum, and can be reproduced by palpation of the the painful area.

Inspiratory grunting

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant. The other options are expected findings in newborns.

Temperature of 103 F (39.5 C)

Findings of IE include skin rash (petechiae) and small areas of bleeding (splinter hemorrhages) under the fingernails. Muscle or joint pain or weakness are also common symptoms of IE. Nausea and vomiting may be side effects of the treatment; these findings probably would have appeared shortly after beginning treatment. Prolonged fever after 72 hours of antibiotic therapy indicates the antibiotic regime is not effective against the strain of microorganism - the nurse must call the HCP about this finding. Surgical intervention may be indicated for persistent sepsis after 72 hours of appropriate antibiotic treatment.

Teeth cleaning during regular dental visit

Aspirin (ASA) therapy

Recent use of corticosteroids

Eating a steak dinner

Eating red meat, NSAIDs and steroid use can cause a false positive result; even bleeding gums can cause a false positive result. Using vitamin C supplements and fruit juices can cause a false negative result (because it interferes with the chemical reaction that indicates blood is present.) The test should be repeated and the client should be given specific instructions about special dental, dietary and drug restrictions.

Allergy history

The nurse should review any allergies with the client, especially a reaction to previous tests using contrast media. The elderly and those with diabetes and/or heart disease are at greater risk of developing kidney failure following administration of the dye. To avoid this complication, kidney function should be tested (creatinine). The client may be instructed to use a laxative or enema prior to the test and to be NPO for 8-12 hours before the test is done. The client should void prior to the procedure.

Level of consciousness (LOC)

Cerebral blood flow undergoes a significant increase during seizure activity with a depletion of oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should continuously monitor the client’s LOC. Even when seizures are controlled, the client may be unconscious for a period of time. Note that this is a neurological question and requires a neurological answer and monitoring LOC is the only neurological response.

Measure the pH of aspirated gastric contents

Bubbling or coughing would indicate the possibility of the tube being in the airway, but neither are used to determine placement in the stomach. Forcing air through the NG tube and auscultating the abdomen for the sound of the air is an unreliable method to determine tube placement. Measuring the pH of aspirated stomach contents confirms gastric placement.

Apply snug gauze and secure with tape

Check for distal capillary refill

Apply pressure for 5 to 10 minutes

Five to 10 minutes of pressure ensures adequate coagulation at the site. Checking capillary refill indicates if there are any changes to blood flow to the hand. The dressing can be removed prior to the next stick or within 24 hours.

Reassess the child's temperature

The nurse should listen to and show respect for what the parent is saying, because the parent is more sensitive to the variations in the child's condition. However, the nurse knows that a low-grade fever (99-101 F or 37.2-38.3 C) is common after surgery, which is why the nurse should first reassess the temperature before implementing any intervention. Usually the surgeon is contacted if the temperature is higher than 101.5 F (38.6 C).

Estrogen replacement therapy for the past three years

Post-menopausal women using hormone replacement therapy have a higher risk of deep vein thrombosis and pulmonary embolism. The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, especially if the woman is a smoker and/or overweight. The other information in the client's history is unremarkable for postoperative complications.

"My child was diagnosed with an ear infection two days ago."

Contributing factors of seizures in children include age (more common in the first two years of life), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention. Although drinking more fluids may be an indication of infection, the statement that the child has an active infection is the best response.

Have the client sit up on the side of the bed

Correct!Placing the client in sitting position will promote lung expansion and effective coughing, facilitating the sputum specimen collection. While drinking liquids helps to loosen secretions over time, they should not be given when collecting a specimen. Spraying the throat with saline may cause irritation, coughing, and reduce oxygenation. The specimen needs to come from deep in the lungs, not the nose or mouth.

Notify the health care provider (HCP)

INR is used to evaluate the therapeutic effectiveness of warfarin. The therapeutic range for INR is 2 to 3; a client with a 5.5 INR is at risk for bleeding (and the nurse will probably find bleeding with an INR at this level). The warfarin should be held until the nurse has communicated with the HCP. Because the half-life of warfarin is about 40 hours, there is no need to stop it prior to notifying the provider. Heparin has no influence on an INR.

White blood cell count (WBC)

Hematocrit and hemoglobin

Albumin

Erythrocyte sedimentation rate (ESR)

Decreased hematocrit and hemoglobin may reveal the client has anemia as a result of the bloody diarrhea characteristic of this inflammatory bowel disease A low protein albumin level would indicate that the client is experiencing a nutritional deficit due to malabsorption. Increased numbers of white blood cells and an elevated erythrocyte sedimentation rate (ESR) indicate active inflammation. Blood urea nitrogen is related to kidney function and T3 and T4 are related to thyroid function; these lab values do not provide information related to the diagnosis.

Reassess the client's allergies

Ask the client to remove all metal jewelry

Confirm that a signed consent is in the chart

Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Sedation is necessary only in cases of extreme anxiety.

Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device

Confirm pressure setting of 45 mm Hg

Check for appropriate fit

In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35 to 55 mm Hg. Explanations to the clients should support their informed decision-making capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching.

96mg.

6 mL/1 x 80 mg/5 mL = 480/5 = 96 mg

Or

Ratio:
80 mg/5 mL = x/6 mL
5x = 480
x = 96 mg

Facial flushing

Treatment for Raynaud’s and for hypertension is the use of a vasodilator such as nifedipine. As a result of the vasodilating effect facial flushing can occur. Cyanosis of the lips is not a documented finding. The urinary output may increase due to the vasodilation and the resulting increased blood flow through the kidneys. The pain in the fingers should decrease.

11:15 am

The onset of action and peak for lispro (Humalog), a rapid-acting insulin is about 10 to 15 minutes. Other rapid-acting insulins are insulin aspart (NovoLog) and insulin glulisine (Apidra).

Tranquilization, numbing of emotions

Most antianxiety medications, such as alprazolam (Xanax), work quickly. They produce tranquilizing effects and may numb the emotions. Don't forget that if part of an answer is incorrect, the entire answer is incorrect. The three incorrect options each contain incorrect information (analgesia, phobias and tachycardia). Also note that the question is asking for ”expected effects” and not side effects.

"This is a common and temporary side effect of this medication."

The best response would be to explain that a dark tint of the tongue is a common and temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the intestinal tract. After addressing the client's initial concern and the reason for the call, the nurse can ask about the upset stomach and then ask the client to come to the clinic if necessary.

Antihistamine

Older adults are susceptible to the side effect of anticholinergic medications, such as antihistamines. Antihistamines often cause confusion, especially at higher doses. In fact, first-generation antihistamines are included in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

No bowel movement for three days

Side effects of opioid analgesic use include respiratory depression, sedation and constipation. The incision site may be bruised after surgery and it may itch, pull or feel numb, but this is unrelated to oral opioid use. Dry mouth is a possible side effect of acetaminophen with codeine, but not necessarily dry cough.

Borderline renal function

Gentamicin is not metabolized; it is excreted by glomerular filtration. This aminoglycoside is highly toxic to the kidneys and requires close monitoring of renal function, including creatinine levels. Aminoglycosides are used to treat severe infections, such as septicemia, and are only given for a short period of time due to their toxic effects.

Pain therapy is based on a client's report of pain

Every person’s unique pain experience must be assessed, understood and treated. Because older adults have a slower metabolism and a greater ratio of body fat to muscle fat than younger people do, smaller doses of analgesics may be sufficient to relieve pain and may be effective longer. Therefore, the amount of medication needed is dependent on the client's needs and reports of pain relief; the nurse should not automatically give the maximum ordered dose. Immediate pain relief relates more to acute pain than chronic pain management.

Notify the charge nurse that the client is already receiving heparin

Enoxaparin (Lovenox) and heparin should not be given together because of the increased anticoagulant effect. Enoxaparin can be given 30 minutes after the heparin is discontinued. The aPTT lab is not routinely assessed while a client is taking enoxaparin.

Lithium (Eskalith, Lithobid)

Furosemide (Lasix)

Lithium generally should not be given with diuretics. Furosemide may reduce excretion of lithium, which could result in lithium toxicity. Additionally, side effects of lithium are polyuria and polydipsia. The nurse should clarify the order before administering lithium and furosemide together.

Prevents the medication from tissue irritation

Deep injection, or Z-track, is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the medication. Oil-based or thick medication is commonly given in this manner for the same reason.

2tablet(s).

1.25 mg = 1250 mcg: 1250 mcg/625 mcg = 2 or 2 tablets. Using Dimensional Analysis: Tablet = (1.25 mg/625 mcg) X (1000 mcg/1 mg) = 2

"Drink at least eight glasses of water a day."

Trimethoprim/sulfamethoxazole (Bactrim, Septra, Sulfatrim) is a highly insoluble medication and requires a large volume of fluid intake. This medication can be taken with or without regard to food. The full prescribed amount should be taken at evenly spaced intervals until the medication is finished. Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as pills, the patch or ring.

Exercise by doing weight-bearing activities

Weight-bearing exercises are beneficial in the prevention and treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced and prevented if the client includes weight-bearing exercises, vitamin D and calcium supplements in the treatment protocol.

Urinary output of 32 mL per hour

For children, the expected urine output is about 1 mL/kg/hour of urine. For a child who weighs 30 kg, 32 mL/hour is adequate urinary output. You will note that since the question is indirectly asking about intake (fluid replacement), the best response will probably have something to do with output.

Place client on a pressure-reducing mattress

The client with a spinal cord injury is risk for skin breakdown due to immobility and decreased sensation. A cushion should be used on the wheelchair and the bed should have a foam pad, air mattresses or a pressure-reducing mattress. Reducing the risk of skin breakdown also includes repositioning the client, using skin care products to protect the skin and adequate liquid and nutritional intake.

Position client in an upright position while eating

An upright position facilitates proper chewing and swallowing. To prevent aspiration, thicker foods should be offered or thickening should be added to liquids. Tilting the chin down helps swallowing. Dry foods such as crackers or pretzels may increase the risk for choking.

The client may experience bradycardia during the procedure

Cardiac dysrhythmias, including bradycardia, can result from vagal nerve stimulation during fecal impaction removal. The risk is higher in older adults or clients who have had cardiac surgery. Although it is correct that removing a fecal impaction should be done prior to a bath and that diet, exercise and fluids can help prevent an impaction, these are not the priority for this client in this situation. The presence of hemorrhoids is not a contraindication for manually removing fecal impactions.

Perform frequent oral care

Frequent cleansing and stimulation of the mucous membrane is important for clients with a nasogastric tube to prevent development of lesions, infection and to promote comfort. Ice chips or mints may be contraindicated and need to be ordered specifically when NG tubes are present. Lemon and glycerin swabs have no mechanical or cleansing value and should not be used.

Potato chips

Children with celiac disease should eat a gluten-free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible by persons diagnosed with celiac disease.

Excessive fluoride intake on a regular basis

The findings indicate fluorosis, a condition characterized by an increase in the extent and degree of the enamel's porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride. You will notice that two of the options address medications but there is nothing in the stem of this question to indicate that the child is taking any medications. Poor dental hygiene can damage teeth, but it would not appear chalky-white.

Wrap the child's hand in mittens or socks to prevent scratching

Toddlers with atopic dermatitis need to have fingernails cut short and hands covered so they will not be able to scratch the skin lesions. Prevention of new lesions is important due to the risk of possible secondary infections. The clue in the stem is that the client is a toddler. Because toddlers have a short attention span and minimal self-control, and dermatitis is inflammation of the skin, the best response is to place the child's hands in mittens or socks to prevent scratching.

Avoid heavy, large meals

Controlling portion size is important for a heart-healthy diet. Eating large, heavy meals can pull blood away from the heart for digestion, possibly resulting in angina. Thus, it increases the risk of myocardial infarction. The client should also reduce sodium intake to about 2,300 mg/day (or less). Clients should also limit unhealthy fats and cholesterol; select low-fat protein sources; and eat more fruits, vegetables and whole grains.

Determine available community and personal resources

The couple has experienced a sudden loss event that has resulted in disequilibrium. The most important initial crisis intervention focuses on identifying resources and obtaining assistance for housing and other immediate needs. Information on home safety, relaxation exercises and grief counseling are of value after meeting the initial needs for shelter.

"I don't remember anything about what happened to me."

Repression is unconscious and involuntary forgetting of painful events, ideas, conflicts; there is no memory of the topic. One response is a statement indicating the use of suppression as an ego-defense mechanism, but this is incorrect because suppression is under conscious and voluntary control. Another incorrect response is an example of projection, where someone else is blamed for the situation.

Social isolation related to altered thought processes

Hostility and absence of involvement are data supporting a diagnosis of social isolation. The psychiatric diagnosis and the client’s idea of the purpose of the medication suggests altered thinking processes. When answering this question, be sure to compare the data in the stem to each of the options. Notice that the incorrect options can be eliminated because there's no mention of anxiety or difficulties with sensory or verbal communication.

"Is there anything you need from me to perform the ritual bath?"

Rituals are processes that allow the bereaved to acknowledge the reality of death. Religious rituals specifically offer meaning and provide hope within the context of the particular faith tradition. Nurses should inquire about rituals or observances following death and respect these. The other options are inappropriate and culturally insensitive.

72 year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy

8 year-old client with acute myelogenous leukemia, for whom all treatment options have failed

91 year-old with Alzheimer’s disease, who is no longer able to eat or drink oral fluids

Hospice care provides services for clients who are at the end of their life, usually with less than 6 months to live. There are no age requirements. Palliative care is provided by a multi-disciplinary team in a variety of settings, including the home, hospital or extended-care facilities. Clients actively seeking a cure or treatment for their disease do not meet the criteria for hospice care.

Ask the client what foods are acceptable

Many Hispanic clients subscribe to the rebalancing of "hot" and "cold" in the postpartum period. After giving birth, when a woman has lost blood, she is considered to be in a cold state; therefore, she needs to restore her humoral balance. What defines "cold" and "hot" can best be explained by the client and this needs to be incorporated into the plan of care. Note that the correct response is a “data collection” response, which allows for client feedback about what the client is really saying about the food. Notice that it is the only client-centered option.

Clarifies the meaning of client communication

Clarification is both a facilitating and therapeutic communication strategy. Approval, changing the focus or subject, and advising are non-therapeutic or barriers to effective communication.

Explore what is going on with the client

The nurse should assist this verbally aggressive client to put angry feelings into words and then to engage in problem solving. The client exhibits being in the angry stage of loss.

Early stage of alcohol withdrawal

This client's blood alcohol concentration is more than twice the legal limit in most states. After a period of heavy or prolonged alcohol use, people will experience alcohol withdrawal symptoms, such as insomnia, tremors, hyperactivity, hypertension, tachycardia and diaphoresis. The client must be treated immediately to prevent progression to more severe alcohol withdrawal symptoms, including seizures (which may begin 6-48 hours after cessation of alcohol intake) and delirium tremens (DTs).

With fear of rejection resulting in increased rage toward the battered individual

In the absence or potential absence of the battered individual, the fear of rejection and loss only serve to increase the batterer’s rage at the partner. Behaviors that are common in the batterer include extreme jealousy, refusing to take responsibility for the abuse and denying or minimizing the seriousness of the violence and its effects on the victim.

Eye movement desensitization and reprocessing (EMDR)

Selective serotonin reuptake inhibitors (SSRIs)

Cognitive behavioral therapies

The only two FDA approved medications for the treatment of PTSD are the SSRIs sertraline (Zoloft) and paroxetine (Paxil). There are other medications that are helpful for specific PTSD symptoms, but narcotics should not be used since they don't relieve psychogenic pain and there's a risk of dependence. Most people who experience PTSD undergo some type of psychotherapy, most commonly cognitive-behavioral therapy and/or group psychotherapy, EMDR and hypnotherapy.

Often take part in active sports

Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental characteristics of adolescents, such as impulsivity, inexperience and peer pressure, often place them in unsafe situations. Adolescents do not want to appear differently to their peers and would probably not willingly offer information about their disease to others.

Identify learning needs

With the focus on health promotion, the nurse should first identify any learning needs. Once learning needs are identified, the nurse would know if meal planning assistance is needed. Reviewing medications and discussing health history are part of the initial assessment. Helpful hint: since this is a very general question, you should look for a response that's more general.

Enlargement of the breasts

Of all the options, the most commonly expected physical finding due to maternal hormones is breast engorgement. This can occur in both boys and girls. Mongolian blue spots commonly appear at birth or shortly thereafter; they are flat, blue, or blue-gray skin markings near the buttocks. The newborn scrotum can be filled with clear fluid (which was squeezed into the scrotum during the birth process); it will be reabsorbed over the next few months. Lanugo is the fine downy hair that may be present on the backs and shoulders of newborns, particularly premature infants.

Smoking cessation

Stopping smoking is the priority for clients at risk for cardiac disease because of the effects of reduced oxygenation and constriction of blood vessels. Notice that three of the options are all actions that indirectly reduce cardiac risk factors. Ask yourself which of the options should happen first or which one would have an immediate impact on the body: weight, stress, exercise or smoking?

Decrease in total body water and an increase in proportion body fat

Because older clients have a decline in lean body mass and changes in total body water in which to distribute medications, more medication remains in the circulatory system with potential for medication toxicity. Increased proportion of body fat results in greater amounts of fat-soluble medications being absorbed, leaving less in the circulation, and thus increasing the duration of action of the medication.

"Get your blood pressure checked again within the next 48 to 72 hours"

The blood pressure reading is moderately high and should be rechecked within a few days. Since the client states it is "usually much lower" the elevated BP could be a concern but it is not clear what the client considers to be a "much lower" BP. The nurse should measure the blood pressure in the other arm and compare the two readings. Waiting two or three weeks for follow-up is too long.

Provide discussion of concerns without the presence of parents or guardians

While the family is an important component in the care of an adolescent, it is also important to spend time alone with the adolescent. This is an opportunity for the nurse to hear the teen's perspective and to really listen to his/her concerns.

Color

Acrocyanosis (blue hands and feet) is the most common Apgar score deduction and is a normal adaptation in the newborn in response to the environment. If the environment is cool, then the hands and feet would display a more bluish discoloration. On average it lasts for about 48 to 72 hours. Recall that the maximum score is 10 for Apgar, so 1 or 2 points lower would suggest a problem that is probably not as severe as a problem related to heart rate, muscle tone or cry (respirations).

"When a child of this age asks a question, give a simple answer."

During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask one question, they are looking for one answer. When they are ready, they will ask about the other pieces of information by the use of specific questions.

Confirm that no hearing loss

Hearing loss may result in the client answering questions inappropriately, which may be misinterpreted as a short-term memory loss. Asking clients to state their birthdate is used to assess long-term memory. Observing the client during activity may be done for mobility concerns or deficits. Having the client read something can be used to assess vision problems.

Empty the child's mouth in any case of suspected poisoning

Emptying the mouth of the poison prevents any further ingestion. It should be done first to minimize further contact with the substance. Vomiting should never be induced unless told to do so by the Poison Control Center or a health care professional. First aid for inhaling toxic substances is to move the child to fresh air.

The presence of environmental hazards

A safe environment for the client with increasing memory loss is a priority focus of home care. Note that the other options would be included in the documentation – with importance being in this order: "environmental hazards,""over-the-counter medications," "intake changes" and then "respite care." The question is asking the reader to prioritize, which usually means that all the responses are correct but one is more important than the rest.

Urine and saliva will be radioactive for 24 hours after ingestion

The client's urine and saliva are radioactive for 24 hours after ingestion. The practical nurse should reinforce the RN's teaching to double flush the commode after use, use disposable utensils, and avoid close contact with children and pregnant women for 48 to 72 hours. Because the treatment may cause nausea, it's best if the client doesn't eat two hours before or after iodine administration. It is not necessary to wash laundry separately or in hot water.

Remove soft elbow/arm restraints every 2 hours under supervision

The goal after surgery is to protect the new repair and stitches, which requires some temporary changes in feeding, positioning and activity for the infant. The priority is to wear arm restraints (for the first 10 days after surgery) to keep him from putting his hands in his mouth; the restraints can be removed only for bathing or for exercising the arms. When the infant acts hungry, he will be given a clear liquid feeding using either a syringe fitted with a special soft tubing or a special cleft lip feeder. The infant can be positioned on his side or back to keep him from rubbing his face in the bed. The RN will provide instructions about care of the incision line prior to discharge.

Wash hands thoroughly with soap and warm water after contact with the child

Hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. The child does not have to be confined to bed and s/he can safely return to daycare or school one week after symptoms began. Infants and young children usually do not develop jaundice.

Keep the nose and mouth covered

An RRD, or "dirty bomb," generates radioactive dust and smoke, which can be dangerous if inhaled. The nurse should initiate measures to limit contamination, instructing victims to cover their noses and mouths. Neither lying down or covering the head does anything to limit exposure. Victims should move into a building where the walls and windows have not been broken and then remove their outer layer of clothing (sealing them in a plastic bag, if available) to help minimize exposure.

Contacts need to be traced and screened

Active tuberculosis is a reportable disease because people who had contact with the client must be traced, evaluated for the disease, and possibly treated prophylactically. Statistics are kept and trends documented, but that is not the primary reason for required reporting.

"I know you are upset. But please control yourself and sit down. Otherwise I will have to call security."

Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help.

Support the client in a sitting position until the dizziness subsides

The findings suggest postural or orthostatic hypotension. The nurse should help the client to sit and dangle on the side of the bed until the dizziness subsides and the blood pressure stabilizes. This will prevent the client from potential injury.

Identify vulnerable clients

Use a "two to transfer" policy

Install and use bed alarms

Use "low beds" for at-risk clients

Fall prevention involves managing a client's underlying fall risk factors and then implementing strategies to reduce falls. Using restraints, including side rails, can actually increase the risk of fall-related injuries and deaths. Clients with neurocognitive disorders cannot process the information we provide when we attempt to reorient them to our reality. The other techniques listed are used (in combination) to help prevent falls in health care facilities.

One caregiver applies a transfer belt and uses the stand-and-pivot technique

The algorithm for safe client handling and transferring an alert and cooperative client to a chair states: one caregiver applies a gait/transfer belt, uses the stand-and-pivot technique and transfers the client toward the strong side. A friction-reducing device is placed under the client to assist in turning or moving the person in bed, not transferring to a chair. A two person lift is unsafe.

Immediately wash hands with vigor

The immediate action of vigorously washing the hands will help remove any possible contamination. If the site bleeds it will help remove the contaminate. Then, the sequence of actions would be options "notify," "look up" and "contact."

Report the client's findings to the physical therapist

Gather more information about the location, duration and intensity of the pain

Report the client's findings to the nursing supervisor for further assessment

The needs of the client can be best addressed by further assessment of the client (collecting more information about the findings of pain) and then communicating the client's needs to the interdisciplinary team members. Before any medication is given or any appointments are made, more information about the pain is needed.

Talk with the client to work out a mutual plan

The nurse should talk with the client to determine how the practice of meditation can be incorporated into the morning schedule. Respect for differences must be incorporated into a client's plan of care.

Notify the attending physician

The first action would be to notify the attending physician for further orders. Then the family member(s) can be contacted about his condition. When a client has an advanced directive, it is not appropriate to perform CPR on him.

The nurse transfers the care of the client to another nurse

Nurses must practice in a manner consistent with professional standards and be knowledgeable about professional boundaries. A nurse’s challenge is to be aware of feelings and to always act in the best interest of the client, avoiding inappropriate involvement. In this case, the nurse did all the right things - aware of her feelings, she consulted with her supervisor and together they decided it would be best if this client were no longer assigned to this nurse. If the nurse had acted on her feelings, this would have been a boundary violation and she could have been subject to board of nursing disciplinary action.

An 81 year-old female with a history of coronary artery disease (CAD) reporting dyspnea, nausea, and unusual discomfort in the upper back

These findings suggest a myocardial infarction (MI). Older adults and women of any age may not always have the classic findings of chest, inner arm, or jaw pain, numbness or tingling of the left arm. The stress of a tragic event can elevate BP temporarily; the nurse can retake the client's BP at a later time. Increased urinary output is an expected finding after taking a diuretic and intermittent claudication is a common and expected finding in PAD.

Improve the quality of care in a proactive manner

Continuous quality improvement is used to identify ways to correctly do the right thing at the right time. It involves proactive problem-solving. The overall goal of CQI is to improve health care.

"Have the client lift and move the walker out at arms length then walk into the walker.”

The nurse should give clear and concise information to the UAP about what is expected to safely complete any task, which is why the option about using the walker is correct. The person assisting the client to ambulate should walk on the client's weak, not strong, side. UAP cannot assess or evaluate a client ("let me know if the client uses the quad cane correctly"; only nurses can perform the steps of the nursing process. If a client gets dizzy, the UAP should assist the client to sit (or ease the client to the floor is s/he begins to fall.)

"Since I am late for lunch, would you perform my client's blood glucose test?"

Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs) can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses are accountable for all nursing care; if UAPs cannot complete assignments, they should notify the nurse, who will reassign the task.

Client health status

Poor communication among providers

Family preferences

Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care.

Information can be released if there is written consent from the client

HIPAA guidelines are strict as to who has access to and can relay information. In order to release written, verbal or electronic information about a client there must be a signed consent form (unless the client is a threat of harm to self or others). In addition, a written request for information is commonly asked for prior to release of any client information.

"The client's treatments are..."

The correct option gives the health care provider background information about the client, including age, primary diagnosis, treatments, etc. Stating that the client's condition is deteriorating is the situation (S). Stating, "I would like you to..." is the request or recommendation (R). Vital signs are part of the assessment (A). Using SBAR is an effective technique used to improve communication with other members of the health care team. This, in turn, helps to foster a culture of safety.

Face the client while asking questions as the interpreter translates the information

Communication is important, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, the nurse should face the client and allow the interpreter to translate the content. Facing the client allows nonverbal communication to take place between the client and nurse. Notice that only one option includes the content of this question (collecting data from a client). The other options focus on the “interpreter or the family.” Usually, the client-centered option is the best choice.

The nurse could be fired for breach of confidentiality

Even though the client was not identified by name, someone could probably figure out who the nurse was writing about. Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy.

Use standardized forms for client handoffs

Standardized forms improve information for communication between caregivers. Most problems/poor outcomes involve some element of poor communication. The options of keeping good working relationships and using a professional tone of voice on the phone is good practice but not as useful for minimizing the chance of errors. Documenting at the end of the shift is incorrect practice and may lead to poor communication, as critical findings may be forgotten and not recorded.

Encourage the client to discuss this decision with the health care provider and family

The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill.

Bring the communication focus back to the client

Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. The other options are non-productive and may even make matters worse.

“Health care decisions can be made based on the client's wishes."

Health wishes are written in a legal document such as a living will or advanced directives. These wishes are obtained when clients are medically and cognitively able to do so. Such instructions are to be followed if clients are no longer able to make decisions because of cognitive impairment or unconsciousness. One incorrect response defines a health care surrogate or a durable power of attorney. Another incorrect response defines medical directives and not part of a living will. The final incorrect response is associated with the DNR, which may be predetermined by the client as written in a legal document.

Measure blood pressure, pulse and respirations

UAP can perform standard tasks with predictable outcomes, such as measuring vital signs. They are trained to assist the client with activities of daily living. UAPs cannot assess, plan, teach or evaluate clients.

An older adult client diagnosed with cystitis who has an indwelling urethral catheter

LPNs who are reassigned to work on a different unit should be assigned to clients who are stable. The older adult diagnosed with cystitis is the most stable and the outcomes for care are fairly predictable. The other clients have more complex problems, as well as a higher risk for instability. LPNs should not accept an assignment that is beyond their knowledge or skills.

Complete and accurate documentation of assessments and interventions

The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony.) Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.

"Have the client sit on the side of the bed for three to five minutes before standing."

It is important to give clear and concise information when assigning a task or activity to the UAP. The nurse should also ask the UAP to report client concerns after completing the task but the UAP cannot assess the client; only nurses can assess, plan and evaluate client care.

Explore for further identification about the nature of the problem

Helping staff manage conflict is part of the charge nurse's role. It is appropriate to work with the LPN in order to work out problems with minimal intervention from administration when possible. Further definition of the problem and associated issues would be a first step. The nursing process can be used to collect more data before plans or interventions are made.

Keep a time log for what was done during the hours worked

The first step in planning for time management is to establish what tasks were done and when they were completed. This provides a baseline for needed changes in any activities and time use log. The key words in this question are “time management," “most effective," and “initial development.” Remember the first step in the nursing process is data collection - this applies to both caring for clients and developing management skills.

Transformational

A transformational style of management involves staff members in the decision-making processes. Staff members review current policies and provide feedback to their leader in the pursuit of the common good.

Hold the medication and contact the health care provider

LPNs do not give IV push medications. The LPN will need to contact the health care provider and ask to have the medication delivered by another route.

Clients have a right to know about any prescribed or over-the-counter medications

Clients diagnoses have no influence on their right to know about the medications that they are prescribed. Clients have a right to refuse treatment and to be informed about the use and side effects of their medications.

Case management is a collaborative process designed to meet complex client needs

Case management is a collaborative process of organizing and coordinating resources and services within and across multiple settings. The focus is on cost-savings as well as quality and continuity of care. Case management nurses work closely with physicians, nurses, social workers to meet the complex health needs of the client, Case management is "client-centric" and all members of the team, including the client, work together to achieve desired outcomes. Cases that involve high-risk diagnoses (such as AIDs/HIV, cancer, people with cognitive deficits) or high-volume cases (such as total hip or total knee replacements) are often selected for case management.

Discuss with the client to find out about the preferred herbal preparation

Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it's possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects

Request an immediate private meeting with the health care provider and the UAP

Assertive communication respects the needs of all parties to express themselves in a private location, but not at the expense of others. The PN charge nurse needs first to protect clients and other staff from this display of inappropriate behavior and come to the assistance or defense of the employee.

Report this immediately to the nurse manager

The incident must be reported to the appropriate supervisor, either the charge nurse or the nurse manager, for both ethical and legal reasons. This is not an incident that a coworker can resolve without referring to an appropriate authority. The key words here are “appropriate initial action” and “recent pattern of behavior” regarding wasted narcotics. Ask yourself about your legal responsibility in this situation.

Removes time and distance barriers from the delivery of care

Telehealth is the use of technology to deliver health care, health information, or health education at a distance. People in rural areas or homebound clients can communicate with providers via telephone, email or video consultation, thereby removing the barriers of time and distance for access to care. Although increased access to information and collaboration between the client and provider can be empowering, this is not the primary reason for using telecommunications/telehealth.

Achievement or status of progress related to prior goals

Evaluation process of the clinical problem-solving process (the nursing process) should focus on the clients' status, progress toward goal achievement and ongoing re-evaluation of the plan of care. LPN/VN's gather, observe, record and communicate client responses to nursing interventions.

"When I emptied my urine catheter bag it looked like rusty colored water."

Although nurses need to report diverse information to case managers through phone calls and documentation, they need to immediately report findings that suggest serious changes in a clients' condition. The change in the color of urine to “rusty” suggests blood, a potential danger sign. This requires immediate reporting, documentation and further assessment.

A female interpreter who does not know the client

When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter is needed. But, it may be inappropriate to have a male interpreter for a female client because the client may not be as forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client. The best response is to have a female interpreter who does not know the client.

Assist the client while transfering from the bed to a chair

The UAP can assist with routine activities of daily living, including transferring clients from a bed to a chair or wheelchair. When performed correctly, these routine tasks usually have a predictable outcome. The option about checking the client's skin involves assessment and monitoring the client's response is evaluation, both of which are nursing-only activities. A physical therapist would teach the client to ambulate with an orthotic.

The client's self-report of pain is the most important consideration

Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is and when it is. To help answer this question, consider that the correct response is the only one that is client-centered.

Inform charge nurse and give information about advance directives

For each admission, nurses should verify a copy of the current advance directive. If there is none, the practical nurse should inform the charge nurse and offer written information about advance directives to the client. It is then the client’s choice to sign it. The witness of signature for an advanced directive must be someone not involved in direct care of the client. Social service staff are approved nationwide to witness signatures on advance directives. One option only deals with recording the information and is not sufficient. In another option the nurse should avoid making assumptions that the client has been informed of health care choices. Another option represents an action to be done after written information is given.

Occupational therapist

An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with the tasks that are needed for smaller movements to maintain activities of daily living or for work actions. A physical therapist works with general movement problems, mobility stability, range of motion or strength training exercises. The key terms in this question are "difficulty drawing up the insulin dosage" and "osteoarthritis." Combined, these terms should call to mind the need for fine motor skills.

The client diagnosed with a peptic ulcer who has been vomiting most of the day

The client with the peptic ulcer should be checked immediately and findings reported to the charge nurse and/or health care provider. A perforated peptic ulcer could cause nausea, vomiting and abdominal distention, and may be a life-threatening situation.

True

The nurse reviews the information in the consent form with the client and witnesses the client's signature. The nurse verifies the client has the capacity to make choices and understands the consequences prior to the client signing the consent.

True

Quality improvement is essential for all health care providers. Nurses engage in quality improvement initiatives to facilitate collaborative practice, improve client outcomes, and enhance overall quality of care.

True

Negligence means doing something that a "reasonably prudent" person, under similar circumstances, would not do. Negligent conduct can be an act, or a failure to act, that causes (unintended) harm to the client.

False

Nurses serve an important role in the organ donation process through providing families with support and resources. Nurses are responsible for knowing their local laws and institutional policies about organ donation.

True

Each nurse practice act/nursing act defines the scope of activities that constitute the duty of a nurse licensed in that state/province/territory.

True

Nurses can legally access information that is required to provide nursing care for clients assigned to them. Accessing client information for purposes other than providing nursing care is a breach of confidentiality.

True

The care the nurse provides must be within the legally defined scope of practice, as well as the nurse's education and experience.

True

According to ethical principles, many laws (including most nurse practice acts), and agency policies, it is the legal duty of nurses to protect client confidentiality. Nurses should report violations of client confidentiality and/or privacy.

False

The nurse should never carry out a health care provider’s order that is unclear or inappropriate. The nurse should contact the HCP immediately to clarify the order.

False

An advance directive is a legal document that indicates client preferences for treatment or life-saving measures. Clients are encouraged, but not required, to have an advance directive.

Before having direct contact with a client

Prior to eating

After cleaning a wound

After contact with inanimate objects in the immediate vicinity of the client

Handwashing is still the simplest and most effective strategy to prevent the spread of infection. It is necessary to wash one's hands to protect oneself prior to eating, after removing gloves following any client procedure, and even after having contact with intact skin or objects in the client's room. However, it is not necessary to wash hands after handling every chart (although using an alcohol-based hand rub would be advisable).

Attach a monitoring band to the client's wrist

A wander management system is used to give people with dementia and other "at risk" clients the ability to move freely where they live. The sensor in the bracelet trips an alarm that's attached to exterior doors if the client attempts to leave the facility. It is inappropriate to use restraints or other restrictive devices to keep clients in chairs or beds (unless they are potentially harmful to themselves or others.) Reality orientation is inappropriate for someone with dementia.

Ask the registered nurse (RN) to notify the health care provider for clarification

The nurse should clarify the order with the person who wrote the illegible or confusing order. If the PN reports to an RN, then the RN should obtain written clarification. In some states PNs may write verbal or telephone orders and in other states this is not allowed by the state’s nurse practice act.

Stay with client and observe for airway obstruction

For the client’s safety, the client should not be left unattended. The nurse must remain at the bedside, observe respirations and type of seizure activity, and prepare to clear the airway if it's obstructed. The nurse should not not place anything in the client’s mouth. A code is called only if pulse or respirations are absent after the seizure

The nurse is sleep-deprived

The nurse is interrupted when preparing the medication

The unit is short-staffed

The nurse works in the intensive care unit (ICU)

There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions, and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients.

Perform hand hygiene after direct contact with the client and before leaving the room

Keep all equipment in the client’s room for his/her sole use

Keep the door to the room closed, with a notice for visitors

Place the client in a single room

Contact precautions are recommended in acute care settings for MRSA when there’s a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room, with the door closed; the sign on the door instructs visitors to report to the nurse before entering the room. All equipment, such as stethoscopes and blood pressure devices, should be for the client’s sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and his/her environment and before leaving the isolation room. Contact precautions require health care workers to wear gloves and a gown; a face mask is not necessary for routine care.

"Activated charcoal binds with the poison to limit absorption from the digestive tract."

Activated charcoal binds to the poison through the entire GI tract; it is estimated that it reduces absorption by almost 60%. Activated charcoal is a fine, black powder that is odorless, tasteless, and nontoxic. It is often used after gastric lavage in the emergency treatment of certain kinds of poisoning.

Riding in a car

Car accidents are a leading cause of death in infants and children, as well as a major cause of permanent brain damage and spinal cord injury. Although all the other options pose a danger to young children, drowning is actually the second most common cause of accidental death among children.

Serve the dinner in the seclusion room, maintaining observation

Seclusion is ordered by a physician and requires continuous observation, unless the order is discontinued or amended. It is incorrect to amend the seclusion or mealtime. Meals can be eaten in the seclusion room with the nurse continuing the 1:1 observation. Meals must be offered on time and should not be withheld. Contracts for safe behavior are meaningless in the presence of psychotic behavior (mania).

Droplet precautions

Meningococcal meningitis is an infection caused by the bacteria Neisseria meningitis. The first action for nurses to take is to initiate droplet precautions. The initial therapeutic management of acute bacterial meningitis includes droplet precautions, anti-infective therapy (a cephalosporin or penicillin), monitor neurological status along with vital signs, institute seizure precautions, and maintain optimum hydration.

Children should not share or wear other children's coats, hats and scarves

Lice can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair on the head. Insecticide spraying will not affect head lice and checking their heads monthly is not necessary. Washing hands after recess is a good idea, but will have no impact on the spread of head lice.

Explain that this rash is no longer contagious and does not require isolation

Fifth disease is a viral illness with an uncertain period of communicability (perhaps one week prior to and one week after the onset). Children are not contagious after the appearance of the rash, which gives a "slapped cheek" appearance. Isolation of the child with fifth disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care provider to give to the school. Notice that two of the options focus on the content of this question (a rash); the other options do not. Note the word “antibiotics” in one option, but there is nothing in the question to indicate there's an “infection.”

Receiving blood product transfusions prior to 1992

The client who was transfused prior to blood screening for hepatitis C (1992) may show findings of hepatitis C many years later. Raw shellfish ingestion and travel to foreign countries with poor sewage control can increase the risk of developing hepatitis A, but not hepatitis C. Most commercial tattoo parlors are licensed and follow standard safety precautions, so the likely cause of developing hepatitis B or C after a tattoo or a piercing is very low.

"Until the child is about 2 years-old."

The American Academy of Pediatrics now recommends that infants and toddlers remain in rear-facing car safety seats until age 2 years (or when they physically outgrow the limits of the seat.) They can then transition to sitting in belt-positioning booster seats when they have reached about 4 feet 9 inches tall and are between 8 to 12 years-old. Children under age 13 years should ride in the back seat of the car.

Complete an incident report

To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client.

Require the nursing assistant to wash hands again with soap and water

Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nurse assistant and to correct practice errors as needed. Clostridium difficile (C. diff) is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by this bacterium, the nurse should require the nursing assistant to wash his/her hands with soap and water, especially after providing care for this client.

Place night lights in the bedroom and bathroom

Family members and the client should understand the simple actions they can take to help prevent falls in the home. More falls occur in the bedroom than in any other location; a simple environmental change would be to add night lights in the bedroom and bathroom. Muscle strengthening and balance exercises, taking calcium and wearing glasses may be all indicated for this client, but using night lights is an immediate and effective action to help prevent falls.

Previous life-threatening allergic reaction to the antibiotic neomycin

According to the CDC, if a person has experienced a life-threatening reaction to the antibiotic neomycin or gelatin s/he should not get the MMR. Vaccines can be given to children with mild cold symptoms, but it might be better to wait until they feel better. There is no relationship between the MMR and an allergy to peanuts. The CDC recommends administering the first MMR between 12 and 15 months and the second dose between 4 to 6 years of age.

Presence of an indwelling urinary catheter

Catheter-associated urinary tract infections is the most common HAI in the acute care hospital setting. Surgical site infections, bloodstream infections and pneumonia are the other categories of infections.

Positive Mantoux test with an abnormal chest x-ray

The client who must be placed in airborne precautions is the client with a positive Mantoux test (also called PPD) and an abnormal chest film because these could be suspicious tuberculin lesions. The client would be placed in a private room. Health care workers would have to use a HEPA filter respirator when in the room providing care for the client. Although the CMV virus is not highly communicable, it can be spread from person to person by direct contact; the virus is shed in the urine, saliva, semen and to other body fluids.

True

Standard precautions are used to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. Respiratory hygiene/cough etiquette is now considered part of standard precautions.

False

Contaminated clothing should be removed quickly, but it should be cut off instead of pulled over your head. Place contaminated clothing inside a plastic bag, seal the bag and then place inside another plastic bag.

True

The farther away people are from a radiation source, the less their exposure; as a rule, if you double the distance, you reduce the exposure by a factor of four. The amount of radiation exposure typically increases with the time people spend near the source of radiation.

True

Bed alarms and sensor pads can be used to alert caregivers when a client is attempting to get up from a bed or chair, especially clients who are at risk for falls. This is an effective alternative to the use of restraints.

False

Health care providers are required to specify the duration and circumstances for which restraints are required and for how they should be used. Nurses and HCP’s must frequently monitor clients to reassess for the continued need for restraints.

True

Wearing a tamper-proof safety device reduces the risk of abduction. The sensor shows the location of the infant and the security system can activate other devices (such as cameras, door locks, public address systems, sirens, and other alarms) in the event of an attempted abduction.

True

Disaster triage categories range from most urgent (first priority), urgent, nonurgent (the walking wounded), and dead/catastrophic.

False

Normally, hands can be decontaminated with an alcohol-based hand rub when they are not visibly soiled. However, alcohol does not kill C. difficile spores. Using soap and water for hand hygiene is recommended after caring for a client with CDI.

True

Clients with an abscess or draining wounds who test positive for Staphylococcus aureus (MRSA), group A streptococcus, are placed on contact precautions.

True

During any client-transferring task, if any caregiver is required to lift a client who weighs more than 35 lbs (15.9 kg), then the client should be considered to be fully dependent, and assistive devices should be used for the transfer.

Privacy, autonomy, peer interaction

Adolescents display the need for privacy, autonomy, and peer interaction concurrent with an evolving sense of identity.

Cooperatively with other preschoolers

Cooperative or associative play is typical of the preschool period. School-age children would play board games, toddlers engage in side-by-side or parellel play, and adolescents would be more likely to play the hand-held computer games.

Spinal column manipulation

The underlying theory of chiropractic medicine is that interference with transmission of mental or electrical impulses between the brain and the body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation or misalignment. Notice that this is a specific question, which means it requires a specific response. Eliminate the two general options (electrical energy fields and mind-body balance). Now pay attention to the word “manipulation” in one option and the word "exercise" in the other remaining option. Return to the question to look for a clue to help with the choices. Focus on the words "treatment for illness" rather than "chiropractic" and go with what is known. An educated guess for "treatment of illness" is more likely to be "manipulation."

Scan the bladder using a portable ultrasound scanner

Urinary retention and incomplete bladder emptying can result from urethral obstruction, as seen in BPH. The nurse can palpate the area from the umbilicus towards the symphysis pubis; an empty bladder rests behind the symphysis pubis and should not be palpable. The nurse can also percuss this area; a urine-filled bladder produces a dull sound. But a bladder ultrasound the most effective technique since it will digitally register bladder volume. Routine catheterization to check for post void residual is not recommended; but if bladder distention is greater than 200 mL, the client may need to be catheterized.

Ability to cook meals

Ability to write checks

Ability to take medications

Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment.

Irregular hip symmetry

Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation. The leg is shortened on the affected side. One check for hip dislocation is the Ortolani click; if it is found, it is called a positive response.

Maintain good nutrition

Nurses can play a pivotal role in reinforcing nutritional education. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low birth-weight babies. Specifically, teens need to increase their intake of protein, vitamins and minerals (including iron.)

Lung remodeling and permanent changes in lung function

While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help the nurse when reinforcing the need for daily management of the disease, regardless if the client "feels better" or not.

The client who had chemotherapy for cancer four days ago

Immunization with this vaccine is contraindicated with clients that are immunosuppressed. The pneumovax vaccine is to be given at least a week apart from other vaccines. The other two options do not warrant suspicion of immunological problems.

The pregnancy and the physical changes that are involved

During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts. Ambivalence is a normal, expected emotion. You should be able to determine that two of the options occur later in the pregnancy. The option about the potential risk for termination of the pregnancy is unrelated to the question being asked

Provides antibodies

Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach.

Decreased sensation of thirst

Older adults do not drink because they do not feel as thirsty as younger people. Other risk factors for minimal ingestion of fluids in older adults may include fear of incontinence, inability to drink fluids independently or it's simply too painful to get up from a chair.

Meningococcal conjugate vaccine (MCV4)

Tetanus, Diphtheria, Pertussis vaccine (Tdap)

Seasonal influenza vaccine

Human papillomavirus (HPV) vaccine

Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it.

Request the RN to counsel the woman to consent to HIV screening

The client's behavior places her at high risk for HIV. While it would be a good idea to draw blood to test for STDs, this can't be done without informed consent of the client. Since the woman is already at a clinic seeking health care, it would be best to provide information (and possibly begin treatment) now, instead of simply referring her to another health care facility. The best response is for the RN to provide information and counsel the woman to consent to HIV screening.

Makes the moral judgment that "stealing is wrong"

The stage of concrete operations is depicted by logical thinking and moral judgments. This stage is associated with school-aged children from ages 7 to about 11. It is a time when children develop transitive thinking and reversibility concepts. They do well with inductive logic, which involves going from a specific experience to a general principle. They do not do well with deductive logic, or the use of a general principle to determine an outcome of a specific event.

"The radiation from a mammography is equivalent to one hour of sun exposure."

A client would have to have numerous procedures during the course of a year to be at risk for cancer. The correct response is concise and gives the client a point of reference. The other options are either judgmental and nontherapeutic ("tanning in the nude"), inaccurate and having the potential for causing more concern (getting more radiation from a chest x-ray), or do not address the client's concern (it's "not dangerous").

Observe a return demonstration

Because injecting insulin is a psychomotor skill, observing a return demonstration is the best strategy to know or evaluate whether the client has learned the proper technique.

Auscultate the area

Auscultation of the abdomen will find a bruit, which will confirm the presence of an abdominal aneurysm. The other actions would be contraindicated because placing pressure on the area might cause the aneurysm to leak or rupture.

Role play communication strategies

Because Alzheimer's disease is a progressive chronic illness that challenges caregivers, the nurse can be of great assistance in helping the family to identify changes in language, as well as ways to communicate with their loved one that will help avoid or minimize difficult behaviors. The client should feed and bathe him or herself as long as physically possible. Exercise is important for Alzheimer's victims, but walking or enjoying other physical activities are more important than specific exercise routines.

Myelination of the spinal cord is completed during the toddler years

Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, which occurs sometime between the ages of 18 to 24 months. The other options are incorrect. Notice that both the question and the correct option has the word “toddler” in them.

Expected finding(s)

The adolescent client should be assessed for scoliosis by asking the client to bend forward and touch his or her toes. The client's spine should be straight and without curvature or asymmetry.

Expected finding(s)

A common age-associated change with the musculoskeletal system is the decline in muscle mass and strength.

Abnormal finding(s)

The fontanel should be flat; a sunken fontanel indicates possible dehydration

Abnormal finding(s)

Normal mental function includes orientation to person, place and time.

Expected finding(s)

Asymmetry in the scrotum is normal, with the left usually larger or hanging lower than the right.

Abnormal finding(s)

Normally, you should hear bowel sounds in all four quadrants in a healthy client.

Abnormal finding(s)

There should be no dimples; in fact "orange peel" skin is a late sign of breast cancer.

Abnormal finding(s)

Normal respiratory rate in adolescents and adults is 12-20 breaths per minute.

Expected finding(s)

Balancing on one foot, with eyes shut, is one sign of normal cerebellar function.

Abnormal finding(s)
The soft palate should be reddish pink; spots are a sign of possible infection.

Older Adult

Integrity vs. Despair (approximately age 65 years & older)

Adolescence

Identity vs. Role Confusion (approximately age 12-18 years)

Early Adulthood

Intimacy vs. Isolation (approximately age 18-40 years)

Early Childhood

Autonomy vs. Shame & Doubt (approximately 18 months to 3 years)

Adulthood

Generativity vs. Stagnation (approximately age 40-64 years)

Infant

Trust vs. Mistrust (approximately birth to 18 months)

School Age

Industry vs. Inferiority (approximately age 6-11 years)

Preschool

Initiative vs. Guilt (approximately age 3-5 years)

False

The safest time to offer analgesia is when dilation is between 4 to 7 centimeters.

False

Pregnancy can occur with unprotected intercourse at or before the first menstrual cycle after birth. Nurses should caution women to avoid pregnancy for the first three months after delivery to allow the body time to heal.

True

The nurse should provide information about interventions that will help the new mother cope with the common physical and emotional changes she is experiencing. For example, the client can apply ice or a cold pack to the perineum and use a gentle squeeze of warm water for cleansing after voiding.

True

Normal bleeding and discharge should be more watery and pink-brown colored (lochia serosa) about 3 to 5 days after delivery. It may take up to 2 to 4 weeks for discharge to taper off completely.

True

Tapping on the glabella (flat bone between the eyebrows) causes a neurologically healthy baby to close both eyes. This is referred to as the glabellar reflex.

False

The normal color all over for the newborn is pink; a pink baby earns a score of 2. A baby who is pink with pale blue toes/feet and fingers/hands will receive a score of 1 on the APGAR test.

False

Engagement means that the baby's head no longer floats freely, but has dropped down into the pelvis. In a multipara, engagement normally occurs about two weeks before birth.

True

Positioning the laboring mother on her (left) side usually results in a higher fetal oxygen saturation. Other measures to increase fetal oxygenation (and placental perfusion) include administering oxygen to the laboring woman.

False

Chloasma is a skin discoloration of pregnancy. The first breast milk is called colostrum. Colostrum is low in fat, high in carbohydrates, protein and antibodies and is easy for the newborn to digest.

True

RhoGAM® is administered to Rh negative women after any possible exposure to fetal blood, such as after each ectopic pregnancy, miscarriage, abortion or amniocentesis. RhoGAM® will be given to help prevent problems associated with incompatible blood types in future pregnancies.

False

There are several findings of pregnancy during the first trimester. Increased vascularity in the vagina is called Chadwick's sign; the increased vascularization and softness of the uterine isthmus is Hegar's sign; and the softening of the cervix is Goodell's sign.

False

Pregnancy tests measure the hormone human chorionic gonadotropin (hCG) in the urine or in the blood. Levels can be first detected about 12 to 14 days after conception and peak in the first 8 to 11 weeks of pregnancy.

True

When the fetus is active, its heart rate will accelerate by about 15 beats per minute above the baseline. Average fetal heart rate is about 130 BPM when near term.

False

The third stage of labor is placental separation and expulsion and lasts about 5 to 30 minutes. The fourth stage of labor is maternal adaptation, occurring 1 to 2 hours after birth.

False

In the third trimester, an awake, healthy fetus should move at least 3 times per hour. If the baby does not move, the mother should drink a glass of juice and then start a new count.

Ask the client about current feelings or thoughts

The initial step in anxiety intervention is observing, identifying and validating anxiety. The behaviors suggest that the client may be anxious or nervous about the topic being asked about in the interview.

"What have you done that you feel most guilty about? What steps can you begin to take to help you deal with your feelings of guilt?"

The best response is the one that encourages the client to get in touch with his or her feelings and to utilize problem-solving steps to reduce the feelings of guilt. If you are not sure about the correct response, you'll notice that two of the options focus on “drinking,” which is not discussed in the question. These two answers can be eliminated. One other option is a guilt-provoking statement and this would never be considered appropriate; this, too, can be eliminated

"I have tried leaving in the past, but have always gone back."

Battered individuals stay in abusive relationships for a variety of reasons. They may blame themselves for being abused and often believe they can keep the peace if they stay. There is a fear of danger if they try to leave, including threats made by the batterer to hurt the children. All members in the family suffer from the effects of abuse, even if they are not battered themselves.

"Have you thought about hurting yourself?"

It's important to determine if someone, who has voiced thoughts about death, is considering a suicidal act. This response is most therapeutic under the circumstances. To respond by saying things are not so bad, denies the validity of the client’s statement. To ask if the family or anyone knows of these feelings lacks focus on the client and would also be in violation of the rights of the client. Many times, when there doesn't seem to be an urgent physiologic need, look for a response that focuses on the safety of the client.

The phases of loss or the grief process according to Dr. Kubler-Ross are: denial, anger, negotiation, depression and acceptance.

An excited state accompanied by disorientation, hallucinations and tachycardia

Delirium tremens (DTs) is a severe form of alcohol withdrawal that usually occurs within 72 hours after the last drink. During DTs, the person experiences both physical and mental hyperexcitability. Common findings include agitation, confusion, disorientation and hallucinations. The physical component of DTs includes diaphoresis, tachycardia, hypertension, tremors, fever, and eventually, if not treated, grand mal seizures, severe dehydration and death.

Learning, creativity and judgment

Dementia is not a single disease but a general term used to describe symptoms such as impairments to memory, communication and thinking. There are many causes of dementia and although we generally associate dementia with aging, we know that it is due to degenerative changes to the brain. The other options include expected changes due to aging but are not necessarily due to cognitive impairment related to dementia.

Engage in meaningful and understandable verbal communication

The data supports impaired verbal communication. The outcome must be related to the diagnosis and supporting data. So the most appropriate outcome would be for the client to engage in meaningful and understandable verbal communication. When trying to narrow the options down, look at the two similar but dissimilar answers. That would lead to options that both focus on “verbal” communication and interaction. Notice the word “feelings” in one option and ask: Are feelings in the stem of this question? Because no data is presented about feelings or to thinking processes, the option about expressing feelings would not be an appropriate outcome. Remember, content cannot be in your answer that is not in the question.

"What type of assistance does your mother require?"

The initial question should focus on the client's needs, as the family sees them. Because the client is cognitively impaired, the client is not a reliable source of information for decision making. The sequence of questioning after this would be to ask if the family is able to care for the client, to determine what medications the client is taking, and then to ask the family's opinion of other living arrangements, such as assisted living facilities or nursing homes.

Shaking hands allows the use of touch in a professional manner

The therapeutic use of touch is a basic part of the nurse-client relationship. However, in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some facilities may even have a no-touch policy, especially when working with clients who have a history of sexual trauma. Even reassuring touching can be misinterpreted by the client

Explore the family's past patterns for dealing with death

When a problem is identified, it is important for the nurse to collect accurate data. This is crucial to ensure that the client and the family's needs are addressed. But because the question is addressing the family's distress, the initial action should be directed at the family, and not the client. You should also notice that the word “death,” which is used in the question, only appears in the correct response ("exploring the family's past patterns for dealing with death.")

Visual hallucinations

Spiders reported to be crawling on surfaces

Spiders not found in the room

Charting should be factual and not judgmental. It is important to evaluate the client's statements. The nurse looks to see if there are indeed spiders in the room surfaces. When the client sees something that is not present, this is called a visual hallucination. Because this client did not feel crawling spiders, tactile hallucinations is not an acceptable answer.

Spiritual healing

For many Christian Scientists, they may decide to pray first about a challenge, including health issues. For the believer, medical treatments may interfere with drawing closer to God. Notice that two of the options are both associated with religion. The word “healing” in one option is a hint if it is associated with the words in the stem “motor vehicle accident.”

"Tell me about your pregnancy experience."

The nurse must help the mother actualize the loss by encouraging her to talk about it. Advice and clichés are inappropriate and not comforting.

Yin, the negative force that represents darkness, cold, and emptiness

According to Chinese folk medicine, health is represented as a balance of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness; excessive yin predisposes one to nervousness. Notice that the content of this question “yin and yang” appears in two of the options. Because the client is experiencing more negative items (“anxiety” and “cannot care for self”), eliminate the “positive force” in the one option and select the "negative force" option as the correct answer.

"I can understand that the confusion is upsetting to you."

Communicating caring and empathy while acknowledging the client's feelings is the most appropriate and therapeutic response. Developing a plan for dealing with the effects of memory loss can be done later if it is agreed upon by the client.

Touch the newborn after looking at the child

In many cultures, an "evil eye" is cast when looking at a person without touching. Thus, the spell is broken by touching while looking or assessing. Remember that quotations in the stem of the question are often the most important content in the question (evil eye). You should make the association between the words “looking” and “seeing” (eye). Also note that the answer needs to refer to the newborn, not the parents (“give the newborn the evil eye”).

Within one to two weeks after initiation of antidepressant medication and psychotherapy

As the findings of depression decrease due to treatment, the client may acquire the energy to develop a plan and follow through with a suicide attempt. Sudden changes in behavior, such as excessive happiness, are indicators that a client may have decided on a suicide plan.

Repeatedly checking that a door is locked

Obsessive-compulsive disorder is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions.) People know their thoughts and behaviors don't make sense, but they are often unable to stop them. Verbalized suspicions reflect a paranoid thought process. Repetitive, involuntary movements are characteristic of some antipsychotic medication side effects.

A child with autism spectrum disorder (ASD) has difficulty with social interactions and verbal and nonverbal communication; the child also exhibits repetitive behaviors. ASD is considered a neurodevelopmental disorder.

This group of disorders was formerly referred to as “dementia, delirium, amnestic and other cognitive disorders."

Nutritional deficiencies are common among clients who suffer from chronic alcohol abuse and are related to malabsorption of fat, nitrogen, sodium, water, thiamine, folic acid and vitamin B12. Wernicke-Korsakoff syndrome (also called Wernicke encephalopathy) is caused by a lack of thiamine (vitamin B1).

A client with schizophrenia experiences hallucinations and delusional thoughts. There are different types of schizophrenia, but often the client is unable to think rationally, communicate properly, make decisions or remember information.

Clients with obsessive compulsive disorder (OCD) cannot control their obsessions and/or compulsions, even though they recognize that they are unreasonable or excessive.

A drug holiday refers to the deliberate interruption of pharmacotherapy for a defined period and for a specific clinical purpose. Sometimes a clinician will give a child with attention deficit hyperactivity disorder (ADHD) a "vacation" from medications on weekends or during summer break from school.

Clients with bipolar disorder may experience mood swings ranging from mania to depression, with periods of normal mood and activity in between. Sometimes the mood swings can be unusually intense or extreme; at other times, they are less extreme.

A person who repeatedly self-induces vomiting will have scraped or raw areas on the knuckles. Bulimia nervosa is a type of eating disorder that involves binging (eating large amounts of food) and purging (vomiting).

ECT can be used as a treatment for severe depression when medication does not ease the symptoms of clinical depression. ECT is not a cure for depression. ECT can also be used to treat clients with symptoms of delusions, hallucinations or suicidal thoughts.

Sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved to treat PTSD. Other medications may be used off-label or as adjunct treatment. For example, prazosin (Minipress) may be used to decrease nightmares.

True

Religious beliefs impact all aspects of a client's life, including health and illness. Research supports that worship and prayer contribute to positive emotions, including hope and spiritual contentment.

True

Nurses must be aware of and sensitive to the cultural needs and beliefs of their clients and their families, as well as themselves. Nurses must engage in self-awareness and critical reflection of their own beliefs to provide culturally sensitive care to all clients. This is especially true when caring for clients with mental health disorders because biases can hinder the therapeutic relationship.

False

Clients with Wernicke's aphasia may have no understanding of language in any modality – spoken or written. They can speak, but what they say makes no sense. Communication may be more effective using non-verbal techniques, such as actions, movements, props and gestures.

False

Mental health problems can often lead to alcohol or drug use and abuse. Many clients who suffer from substance use disorder are also diagnosed with mental health disorders (and vice versa). Mental and substance use disorders share some underlying causes, including changes in brain composition, genetics and early exposure to stress and trauma.

True

Although the nurse can inspect the client's mouth after giving oral medications in tablet form, medications given in oral liquid form can prevent the client from hiding and hoarding medications.

False

Stress activates the sympathetic nervous system (norepinephrine and epinephrine) and the endocrine system (especially the pituitary gland). The sympathetic nervous system is responsible for stimulating the "fight-or-flight" response often associated with stress. The process under which the body confronts stress is the General Adaptation Syndrome.

False

People use defense mechanisms to protect themselves from things they don't want to think about or deal with. Primitive defense mechanisms, such as denial, regression, acting out and projection, are often used by children and can have short-term advantages, but become less effective when used long term.

False

The time span of the grieving process varies and there is no set time limit for how long an individual grieves. Also, the stages of grieving are not linear; they may pass and later return.

False

Abuse can affect clients across the lifespan, from children to older adults. Abuse can be physical, emotional or sexual. Depending on the jurisdiction, nurses may be mandated to report elder abuse; all U.S. states have enacted laws and policies related to child abuse and neglect.

False

Although mutually defined, the nurse-client relationship is time-limited, goal-directed and bounded by standards of care and of professional practice. It is not a social relationship. In fact, one of the blocks to therapeutic communication is the social response.

Muscle-setting exercises

The client will use crutches (or a walker) and will be non-weight bearing for up to 12 weeks or until the tibia fracture has healed. Active and passive range of motion exercises will be prescribed, but initially, the nurse should encourage the client to perform basic isometric exercises like quadriceps setting, wiggling the toes and ankle exercises. When the cast is dry, the client can be allowed up in a chair or wheelchair with the leg elevated.

Oozing liquid stool

When the bowel is impacted with hardened feces, there is often a frequent seepage of brownish liquid around the obstruction. This is often mistaken for uncontrolled diarrhea. Be careful to report only the objective facts; for example, the the client is oozing brownish liquid from the rectum.

Use a moistened soft brush or cloth to clean the teeth and gums

The nurse should use a soft cloth or soft brush to perform mouth care so that the infant can adjust to the routine of cleaning the mouth and teeth. You will note that two of the options refer to "brush" the teeth, but that the word "soft" is used in the correct option (which would make sense because the client is an infant). Based on the number of teeth, this infant is most likely between 8 and 12 months of age.

Increase fiber intake to include 20 to 30 grams daily

Incorporating high-fiber foods, especially whole grains, fruits and vegetables, into the diet is the first step in improving bowel function. For someone eating 2000 calories a day, this would work out to be about 25 grams of fiber. The client should also increase fluid intake. Changing a person's diet should reduce the need for chemical laxatives.

Keep conversations short

Keeping conversations short will promote the older adult client’s comfort by decreasing the demands on the client’s breathing and energy. Increased intake of fluids is not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client’s rest. Monitoring vital signs is an important assessment but not related to promoting the client’s comfort.

Continue with a regular diet and include oral electrolyte replacement drinks

Current recommendations for mild to moderate diarrhea are to maintain an age-appropriate diet and include rehydration fluids. Some doctors now recommend the CRAM diet (cereal, rice and milk) because milk provides fat and protein and the CRAM foods are shown to ease diarrhea faster. The BRAT diet, consisting of bananas, rice, applesauce, and toast or tea, should be avoided for children with acute gastroenteritis because it is low in energy foods, protein and fat. Both the CRAM and BRAT diets require oral hydration therapy.

Accept the client’s report of pain

Although all of the actions are correct, the first and most important piece of information for data collection is to accept what the client is telling about the pain, i.e., “the client’s report.”

4100mL.

(1200 mL + 400 mL + 2400 mL + 100 mL) = 4100 mL. The amount of irrigation fluid must be included in intake; only the urine collected from the indwelling urinary catheter is considered output.

Sodium

The client with Meniere's disease has an excess accumulation of fluid in the inner ear. A low sodium diet will aid in reduction of the fluid. If you are not sure about which answer to select, look at the "similar/dissimilar" options; in this case, it's the two minerals: calcium and sodium. Then you should consider which mineral is typically restricted in diets: calcium or sodium?

Leftover turkey on a sandwich and fresh pineapple

A turkey sandwich using leftover turkey (as opposed to sliced lunch meat) is appropriate because it is not a highly processed food and fresh pineapple has low sodium. Any food with more than 480 mg of sodium per serving should be considered a high-sodium food. A sodium restricted diet should consist of less than 2 grams of sodium per day. A regular diet should include 4 to 6 grams of sodium per day. All the other choices contain one or more high-sodium foods.

Use oxygen during meals to minimize oxygen deficits

Clients with emphysema breathe easier with the use of oxygen during eating. This allows adequate oxygen for digestion as well as general cellular needs. Clients with emphysema should also limit salt intake; too much sodium can cause fluid retention that may interfere with breathing.

"I will trim corns and calluses regularly."

Clients who have diabetes mellitus, and/or have arterial peripheral vascular disease, often have decreased circulation and sensation in one or both feet. With older adults vision may also be impaired. Therefore, these clients need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks that have not been mended and always wear shoes or slippers when out of bed. They should not cut their toenails, corns and calluses by themselves; they should have them trimmed by providers who specialize in foot care.

Improve food choices but continue a regular schedule of meals and snacks

Currently, calorie-controlled diets with strict meal plans are rarely suggested for clients who are diagnosed with diabetes mellitus. Plan to incorporate food changes into the client's existing dietary patterns. Clients need to learn how to read labels and identify specific canned foods, frozen entrees, or other foods that are acceptable and those that should be avoided because of additives. No specific percentage of fats, protein or carbohydrates is generally recommended.

Fecal impaction

Obstruction of the urethra causes urinary retention by blocking the normal flow of urine out of the body. Elderly clients with acute urinary retention often have severe constipation or fecal impaction. The combination of a full bladder and constipation will cause abdominal bloating and discomfort. Many other conditions can cause urinary obstruction, including benign prostatic hyperplasia in men, organ prolapse in women, urinary tract stones, and tumors. The bloating could be attributed to extra tummy fat and indigestion, but these would not cause urinary retention. Although inadequate fiber intake can cause constipation, the greater priority is treating the fecal impaction.

High fat, high-calorie

CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a gluten-free diet.

Whole milk is difficult for a younger infant to digest

Cow's milk is generally not given to children less than one year old because it is difficult to digest. Also, it contains little iron and creates a high renal solute load. Solid food introduction varies by health care provider, but it is usually started between 4 and 6 months of age. Water with fluoride is recommended for the prevention of dental caries. Apple juice is not considered a supplement, but rather a clear liquid with little nutritional value other than being a liquid with sugars.

Soup, blenderized soft foods, ice cream, milk

In a child with cleft palate repair, the parents should prepare soft foods and avoid those foods with particles that might traumatize the surgical site. The key to answering this question is to pay attention to the age of the child. Also, focus on the words "best" and "cleft palate repair several days ago." Only the correct answer has all "soft" foods in the response.

Individuals following a very low-calorie diet need professional monitoring

A very low-calorie diet (VLCD) is a short-term weight loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5 pounds per week. Anyone considering this type of diet should be under the care of health professionals. VLCDs are generally considered safe and common side effects (such as fatigue, constipation or diarrhea) are usually minor and improve within a few weeks. Of course, the best way to maintain weight loss is through a combination of behavioral therapy, exercise and more modest dietary restrictions. The exchange diet, which groups food together by nutritional content, is typically reserved for individuals with diabetes.

Play electronic hand-held games

Immobilization with traction must be maintained until bone ends are in satisfactory alignment. Activities that increase mobility interfere with the goals of treatment.

Focusing on pleasant mental pictures of a relaxing scene

Guided imagery is a technique that uses pleasant mental visuals of a relaxing scene that can be recalled by the client to reduce stress, anxiety or pain. Repeating a word to oneself describes meditation. Closing the eyes and focusing on a blank screen is also a form of meditation; a person uses a mental picture of a blank black screen and attempts to think of nothing. Counting while breathing is considered slow deep breathing.

False

Somatic pain is also known as musculoskeletal pain because it originates in tissues such as the skin, muscle, joints, bones and ligaments. Neuropathic pain originates from the nervous system.

False

A colectomy is the primary treatment for colon cancer. The cancerous part of the large intestine is removed and the remaining bowel is joined together (anastomosis). The client will not need a colostomy. Bowel movements may be more frequent after a colectomy.

True

Children with neurogenic bladder complications or spina bifida may successfully learn self-catheterization as young as 6 or 7. Training initially starts with performing the procedure using a doll.

False

Urinary incontinence is not normal, regardless of the client's age. Kegel exercises, medications (anticholinergics, topical estrogen), medical devices (pessary), or surgery (sling procedures, bladder neck suspension) can help to counteract incontinence.

False

If the residual volume exceeds the amount of formula given in the previous 2 hours, it may be necessary to consider reducing the rate of the feeding. Current protocols state not to stop feedings unless there are other signs of intolerance (such as bloating, abdominal pain, emesis or nausea).

False

Clients with gout should eat a low-purine diet because purines are turned into uric acid, which aggravates the symptoms of gout. Almost any food contains purines: organ meats, anchovies and sardines in oil, mushrooms, spinach, dried beans and peas contain higher levels. The pureed diet is indicated when chewing or swallowing is difficult or causes discomfort.

False

A dry mouth and dehydration will activate the thirst center, which is located in the hypothalamus. As a result, there will be a conscious desire to drink. There will also be a series of subconscious steps to correct the dehydration, including vasopressin secretion by the pituitary gland.

False

Complementary & integrated health therapies are widely used among clients for various disorders and are often used in conjunction with medical treatment. Pain management may consist of pain medication, as well as relaxation or acupuncture. Complementary & integrated health therapies may also be effective at reducing anxiety, improving mood and increasing a client's sense of control over the environment.

False

Iron is considered a trace mineral. The seven major minerals are: calcium, magnesium, sodium, potassium, phosphorus, sulfur and chlorine.

True

A cane can provide stability when walking. The standard cane is fine if it's only needed for balance but if the client needs the cane to bear weight, an offset cane with four tips might be best.

True

Insomnia is a sleep disorder. There are 2 types of insomnia: primary and secondary.

True

Although most energy needs could be met by fats and proteins, the brain requires carbohydrates, specifically glucose. Neurons need a constant supply of glucose since they cannot store it.

True

Babies should have a minimum of 4 to 8 wet diapers a day. Babies can become quickly dehydrated. Other signs of dehydration in infants include sunken fontanels, decrease or absence of tears, dry mouth and irritability.

False

Prior to conception and during early pregnancy, women need to add 400 ug of folic acid (vitamin B9) each day. Research has demonstrated this significantly reduces the risk of neural tube defects.

True

In a healthy client, a nitrogen balance is achieved when dietary intake is balanced by excretion of urea wastes. A negative nitrogen balance occurs if excretion is greater than the nitrogen content of the diet, as seen in burns, infections, injuries, fever or starvation.

False

The accepted sites for intramuscular injections include the deltoid muscle, vastus lateralis muscle and ventrogluteal muscle. The dorsogluteal muscle should not be used for IM injections due to the risk of sciatic nerve damage.

False

Hypervolemia (circulatory or fluid overload) develops when too large a volume of blood is given too quickly. To avoid hypervolemia, blood products should be infused at a rate no faster than 2 to 4 mL/kg/hour (but not to exceed a 4 hour hang time).

False

CR means 'controlled release' and this medication must not be crushed. Do not crush any oral medication that ends in the following abbreviations: CR (controlled release), CD (controlled delivery), LA (long acting), SR (sustained release), XL (extended release), XR (extended release) or XT (extended release).

True

There is an inherent risk of adverse effects when a client combines herbal agents with prescription drugs. Because herbal remedies have drug actions of their own, the client taking prescription drugs should not take herbal supplements or over-the-counter drugs until they have discussed these with their health care providers.

False

Lactated Ringer's is an isotonic fluid solution used in many different clinical situations, including fluid resuscitation. An example of a hypotonic fluid is 0.45% sodium chloride.

True

Transdermal medication application requires adequate tissue perfusion to absorb and distribute the medication. Skin permeability varies based on hydration, temperature, age (the skin of babies and the elderly is more permeable than that of other age groups) and ethnicity (the skin of Caucasians is more permeable than that of African Americans). Therefore an older client would be more sensitive to medication administered this way than a younger adult.

True

Intravenous pressure must exceed atmospheric pressure during CVC insertion to prevent air from entering the catheter and traveling to the heart and lungs. Any client, regardless of his or her diagnosis, should be asked to bear down during CVC insertion.

False

Schedule I drugs have no medical use and there is a high potential for abuse. Examples of Schedule I drugs include heroin and LSD. While morphine and short-acting barbiturates like secobarbital also have a high risk for abuse, they also have safe and accepted uses; they are examples of Schedule II drugs.

True

Medications given sublingually and rectally bypass metabolism by gastrointestinal and hepatic enzymes. When a medication is given orally, the amount of available medication is reduced before it reaches the general circulation due to the first-pass effect.

True

Applying pressure to the inner aspect of the eye for about a minute or so helps decrease systemic absorption of the medication.

False

Furosemide is a loop diuretic. It inhibits absorption from the ascending loop of Henle in the renal tubule. It is used to treat pulmonary edema, chronic heart failure, hypertension and other conditions of the liver and kidneys.

True

Ondansetron is in a class of medications called serotonin 5-HT3 receptor antagonists. It blocks the action of serotonin, a substance that may cause nausea and vomiting.

False

Propofol is a short-acting sedative. It takes effect very quickly and provides sedation for less than 10 minutes in most clients. It is often used for conscious sedation for outpatient procedures.

False

Aspirin is a potent antiplatelet medication but it can cause significant side effects when taken in large amounts. Most health care providers will order a daily dose of 81 mg (the amount in a baby aspirin) to 325 mg.

True

Calcium channel blockers include amlodipine, diltiazem and verapamil and are used to treat hypertension. Other antihypertensives that do not cause severe constipation should be considered for older adults.

False

Normal saline is used to infuse IV insulin. Regular insulin is the only insulin that can be given intravenously.

False

Dry-powder inhalers are contraindicated for acute asthma attacks because they do not deliver rapidly acting medication for bronchodilation. Rescue therapy may include albuterol (salbutamol-Canada) or epinephrine.

False

Antacids can reduce the absorption of many medications. It is recommended to take an antacid at least 1 hour before or 2 hours after taking other medications.

True

Chlorpromazine impairs body temperature regulation, so the client should avoid temperature extremes (e.g., exercise, hot weather, hot baths, showers, or saunas).

True
t
Cyclosporine is an immunosuppressant; it is commonly used, along with other medications, to prevent transplant rejection. It may also be used to treat clients with rheumatoid arthritis and psoriasis.

True

The maximum dose of acetaminophen is 4 grams (4000 mg) in 24 hours. Hepatotoxicity can occur when the client exceeds the maximum dose.

False

Levothyroxine is a thyroid hormone used to treat hypothyroidism. This medication should be taken on an empty stomach, 30 to 60 minutes before breakfast.

False

The INR or prothrombin time (PT) is performed to monitor therapeutic warfarin levels. The nurse should check the partial thromboplastin time (PTT) and/or the plasma heparin concentration (anti-factor Xa assay) lab results for the client receiving IV heparin.

True

Oral potassium chloride (KCl) should be taken with meals and a full 8-ounce (236 mL) glass of water or juice to reduce its possible stomach-irritating or laxative effects. The client should not chew or suck the extended-release tablet.

False

Naloxone is used to reverse the effects of narcotic (opioid) depression. It is not effective in counteracting depression due to barbiturates, tranquilizers or other non-narcotic anesthetics or sedatives.

Bone Resorption Inhibitors bind to hydroxyapatite in bone and inhibit bone resorption by decreasing the number and activity of osteoclasts.

They are primarily used in the prevention and treatment osteoporosis in postmenopausal women; they are also used to treat osteoporosis due to other causes, e.g., Paget’s disease of the bone and corticosteroid therapy.

Some Antirheumatics relieve pain (analgesics), some reduce inflammation (NSAIDs & steroids), while others control the underlying disease (disease modifying rheumatoid arthritis drugs or DMARDs & biologic drugs, like infliximab).

DMARDs are used as long-term solutions to control symptoms of rheumatoid arthritis by slowing down joint destruction and preserving joint function. Biologic agents (IM or IV only) target specific components of the immune system; biologic agents may be used alone, but are often given with other DMARDs to increase the benefits and limit potential side effects.

ACE Inhibitors slow the activity of the enzyme angiotensin converting enzyme (ACE), which decreases the production of angiotensin II. As a result, blood vessels relax and dilate, blood pressure is lowered, and more oxygen-rich blood can reach the heart.

They are primarily used to control blood pressure, treat heart failure, and to help prevent strokes.

Antituberculars have various actions that affect mycobacteria, with most having bactericidal (for example, rifampin) and/or bacteriostatic (for example, isoniazid) actions.

They used in the treatment and prevention of tuberculosis (TB).

Osmotic Diuretics are low-molecular-weight substances that produce a rapid loss of sodium and water by inhibiting their reabsorption in the kidney tubules and the loop of Henle. They also increase the osmolality of plasma, which increases diffusion of water from the intraocular and cerebrospinal fluids.

They are mainly used in the management of cerebral edema to decrease intracranial pressure.

Calcium Channel Blockers (CCBs) slow the rate at which calcium passes into the heart muscle and into the vessel walls; this relaxes the vessels and allows blood to flow more easily through them, thereby lowering blood pressure.

They are used to treat hypertension, angina, and abnormal heart rhythms (atrial fibrillation, paroxysmal supraventricular tachycardia). They are also used for client post-MI who cannot tolerate beta-blockers.

Beta Blockers block norepinephrine and epinephrine from binding to beta receptors on nerves. By blocking the effects of these neurotransmitters, they reduce heart rate and reduce blood pressure by dilating blood vessels.

They are used to treat hypertension; heart failure; arrhythmias; angina (but not for immediate relief); glaucoma (ophthalmic); sometimes used in heart attack patients to prevent future heart attacks; also used prophylactically for migraine headaches.

Minerals/electrolytes/pH modifiers are taken to correct imbalances of substances in the blood (minerals and electrolytes) or to make the urine more alkaline (pH modifiers).

They are used in the prevention and treatment of any deficiencies or excesses of electrolytes. Acidifiers and alkalinizers are also used to prevent crystals from forming in the urine and inhibit the formation of kidney stones. Magnesium sulfate is used for pre-eclampsia and eclampsia. Some of these meds are used to neutralize gastric acid.

Non-steroidal Anti-inflammatory Drugs (NSAIDs) block the cyclooxygenase (COX-1 & COX-2) enzymes and reduce prostaglandins throughout the body, thereby reducing inflammation, pain, and fever.

They are used to control mild-to-moderate pain, reduce fever, and to treat various inflammatory conditions, such as osteoarthritis.

Opioid Analgesics interact with opioid receptors in the central nervous system, acting as agonists of endogenously occurring opioid peptides (eukephalins and endorphins); this action alters perception and response to pain. They can be categorized as long-acting, short-acting, or rapid-onset agents. Fentanyl is a rapid-acting and long-acting Opioid Analgesic approved for cancer breakthrough pain. They are all Schedule II drugs.

They are used in the management of moderate-to-severe pain.

Antivirals are designed to work in one of two ways - they either inhibit the ability to multiply or they mimic the virus attachment protein, disrupting the replication process.

They are commonly used in the management, prevention, and/or treatment of viral infections, such as HIV, herpes simplex and cytomegalovirus, pneumonia, measles and mumps, and influenza strains (including swine flu).

Some Oral Antidiabetic Agents (sulfonylureas and meglitinides) work by stimulating insulin release from the beta cells of the pancreas - glipizide is a sulfonylurea. Other (biguanides) improve insulin’s ability to move glucose into cells, especially muscle cells. Some (thiazolidinediones) enhance insulin effectiveness in both muscle and adipose tissue. Others (alpha-glucosidase inhibitors) block enzymes that help digest starches, slowing the rise in blood sugar.

These medications are used to treat type 2 diabetes mellitus.

Antiplatelet Agents block the formation of blood clots by preventing the clumping of platelets.

They are used to treat and prevent thromboembolic events, e.g., stroke, myocardial infarction, peripheral vascular disease. They are used after stent, artificial heart values, and other devices that are placed inside the heart or blood vessels.

Rapid-acting insulin, such as insulin lispro, covers insulin needs for meals eaten at the same time as the injection. Short-acting insulin covers insulin needs for meals eaten within 30 to 60 minutes. Intermediate-acting insulin covers insulin needs for about half of the day or overnight (and is often combined with rapid- or short-acting insulin). Long-acting insulin covers insulin needs for about one full day.

Insulin is used in the treatment of type 1 diabetes mellitus and may be used to treat type 2 diabetes mellitus.

Thrombolytics convert plasminogen to plasmin, which then degrades fibrin in clots.

They are used for the acute management of coronary thrombosis (MI), massive pulmonary emboli, deep vein thrombosis, and arterial thromboembolism.

Selective Serotonin Reuptake Inhibitors (SSRIs) block the reabsorption (reuptake) of serotonin.

They are used primarily to treat moderate-to-severe depression and chronic fatigue syndrome; they may also be used to treat premenstrual dysphoric disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and generalized anxiety disorder.

Penicillins belong to a group of antibiotics called beta-lactams, which exert bactericidal action by inhibiting bacterial cell wall production. Currently the group includes more than 20 antibiotics.

Used in the treatment and prophylaxis of wide range of bacterial infections including streptococcal infections, syphilis and Lyme disease.

Monoamine oxidase inhibitors (MAOIs) prevent the enzyme monamine oxidase from breaking down the neurotransmitters norepinephrine and serotonin (also known as monoamines) in the brain.

They are typically used to treat depression.

Immunosuppressants inhibit cell-mediated immune responses. Azathioprine can also be categorized as an Antirheumatic.

Most of these drugs are used in the prevention of transplantation rejection reactions; others are used in the management of selected autoimmune diseases (for example, nephritic syndrome of childhood and severe rheumatoid arthritis).

Cephalosporins belong to a group of broad spectrum, semi-synthetic beta-lactam antibiotics derived from the mold Cephalosporium. The mechanism of action is the same as penicillins (they interfere with bacterial cell wall synthesis). An example of a 1st generation Cephalosporin is cephalexin.

They are mainly used in the treatment and prophylaxis of a wide variety of bacterial infections, such as respiratory tract infections, skin and soft-tissue infections, and urinary tract infections.

Some Vascular Headache Suppressants(ergot derivatives) directly stimulate alpha-adrenergic and serotonergic receptors, producing vascular smooth muscle vasoconstriction. Others (5-HT1 or selective serotonin receptor agonists, such as sumatriptan) work by narrowing dilated blood vessels and blocking nerves from transmitting signals of pain to the brain.

They are used for the treatment of vascular headaches (migraines and cluster headaches).

Skeletal Muscle Relaxants act centrally on the spinal cord or brain stem and inhibit neuronal transmission; dantrolene is the only one that acts directly on skeletal muscle. These medications are typically classified by their pharmacologic properties as either antispasticity (baclofen & tizanidine) or antispasmodic (cyclobenzaprine & carisoprodol) agents.

These drugs are used to treat spasticity associated with spinal cord diseases (such as cerebral palsy, multiple sclerosis) or lesions; they may also be used as adjunctive therapy in the symptomatic relief of acute painful musculoskeletal conditions

Non-steroidal Anti-inflammatory Drugs (NSAIDs) block the cyclooxygenase (COX-1 & COX-2) enzymes and reduce prostaglandins throughout the body, thereby reducing inflammation, pain, and fever.

They are used to control mild-to-moderate pain, reduce fever, and to treat various inflammatory conditions, such as osteoarthritis.

Anticoagulants work by inhibiting clotting factor synthesis, inhibiting thrombin, or by interfering with blood platelet formation. Enoxaparin is classified as a low-molecular-weight heparin (LMWH).

They are used to prevent or treat blood clots associated with stroke, heart attack, heart valve disease, coronary artery disease, heart failure, arrhythmia, atrial fibrillation, deep vein thrombosis, and pulmonary embolism.

Nonopioid Analgesics target and block the chemical substances released by the brain in response to injury (particularly prostaglandin) that facilitate the transmission of the pain stimuli to the brain.

These drugs are used to control mild-to-moderate pain and/or fever.

Antineoplastics inhibit or prevent the development, maturation or spread of neoplastic cells by various different mechanisms of action. Many damage the DNA of cancer cells; others interfere with the cancer cell's metabolism or affect cell division (methotrexate is classified as an antimetabolite); still others create an unfavorable environment for cancer cell growth (hormones). Methotrexate is also listed in the drug category: Antirheumatic.

They are used in the treatment of various solid tumors, lymphomas, and leukemias. They may also be used in some autoimmune disorders (such as rheumatoid arthritis).

Antiasthmatics either relax the smooth muscles that line the airway (bronchodilators), block the inflammation that narrows the airways (corticosteroids), counteract substances that cause the air passages to constrict and secrete mucus (leukotriene modifiers), or prevent allergic reactions or asthma symptoms. Montelukastis aleukotriene antagonist; it can also be categorized as a Bronchodilator.

They are used in the management of acute and chronic episodes of reversible bronchoconstriction associated with asthma. The goal of therapy is to treat acute attacks (short-term control) and to decrease incidence and intensity of future attacks (long-term control).

Tetracyclines exert their bacteriostatic effect by inhibiting protein synthesis in bacteria. They are broad spectrum anti-infectives.

They are typically used in the treatment of respiratory tract infections, acne and skin infections, genital infections (syphilis, Chlamydia), urinary tract infections, Lyme disease, mycoplasmal infections and rickettsial infections and the infection that causes stomach ulcers (helicobacter pylori).

Some Anticonvulsants are thought to generally depress central nervous system function. Others (such as GABA inhibitors) are thought to target specific neurochemical processes, suppress excess neuron function, and regulate electrochemical signals in the brain. Clonazepam is also categorized as a Benzodiazepine.

They are primarily used to help control epileptic seizures; they are also used to treat neuropathic pain (associated with diabetes, shingles, and fibromyalgia), migraine headaches, and bipolar disorder.

Sulfonamides are bacteriostatic and have a broad spectrum of activity against both gram-positive and gram-negative bacteria.

They are typically used in the treatment of urinary tract infections and also some types of bacterial pneumonia (Pneumocystis Carinii), shigellosis, as well as some protozoal infections.

Antianginals are vasodilators - they dilate the blood vessels, improving blood flow and allowing more oxygen-rich blood to reach the heart muscle and they also relax the veins.

They are used to treat and prevent attacks of (acute) angina.

Benzodiazepinesde press the CNS, probably by potentiating GABA, which is an inhibitory neurotransmitter. Midazolamcan also be categorized as a Sedative/Hypnotic. These are all Schedule IV drugs.

They are primarily used to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures. Midazolam is used as an agent for sedation/anxiolysis/amnesia

Some Antiarrhythmics slow down the heart (the calcium channel blockers, digoxin, and beta-blockers); other slow the heart’s electrical impulses by blocking the heart’s potassium channels (amiodarone, sotalol, dofetilide). They are generally classified by their effects on cardiac conduction tissue (Class IA, IB, IC, II, III, IV). Flecainide is in Class IC.

They are used in the suppression of (potentially lethal) cardiac arrhythmias.

The action of Macrolides is mainly bacteriostatic.

They are used in the treatment of various systemic and local bacterial infections of the respiratory tract, gastrointestinal tract, and soft tissues; they are also effective in treating severe acne and sexually transmitted infections. They are used prophylactically in the prevention of whopping cough and the prevention of endocarditis in dentistry.

Angiotensin Receptor Blockers block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced.

They are primarily used to control high blood pressure and treat heart failure. In addition, they slow the progression of kidney disease due to high blood pressure or diabetes.

Some Antiemetics may inhibit the chemoreceptor trigger zone in the medulla by blocking dopamine receptors; others act by decreasing the sensitivity of the vestibular apparatus. Phenergan has different effects on the brain - both antihistamine and anticholinergic activity.

They are used to manage the various causes of nausea and vomiting, including surgery, anesthesia, antineoplastic and radiation therapy, and motion sickness.

Aminoglycosides are bactericidal; they primarily act by inhibiting protein synthesis in bacteria and compromising the structure of the bacterial cell wall.

They are used in the treatment and prophylaxis of severe infections, such as septicemia, severe urinary tract infections, and hospital-acquired respiratory infections, caused by aerobic, gram-negative bacteria, e.g., as Escherichia coli and Klebsiella species.

Laxatives are typically classified as either bulk-forming agents, osmotics, salines, stimulants (such as bisacodyl) or stool softeners.

They are used to treat or prevent constipation or to prepare the bowel for radiologic or endoscopic procedures.

Antidiarrheals work in a variety of ways. Some slow the passage of stools through the intestines (like loperamide). Others decrease the secretion of fluid into the intestine and inhibit the activity of bacteria (bismuth subsalicylate).

They are used to control and to provide symptomatic relief of acute and chronic nonspecific diarrhea.

Some of these Oral Antidiabetics (sulfonylureas and meglitinides) work by stimulating insulin release from the beta cells of the pancreas. Other (biguanides) improve insulin’s ability to move glucose into cells, especially muscle cells. Some (thiazolidinediones - like rosiglitazone) enhance insulin effectiveness in both muscle and adipose tissue. Others (alpha-glucosidase inhibitors) block enzymes that help digest starches, slowing the rise in blood sugar.

These medications are used to treat type 2 diabetes mellitus.

Corticosteroids mimic the effect of hormones produced naturally by the adrenal glands. When the dose exceeds the body's usual hormone levels, they will suppress inflammation, as well as the immune system; they are also used for their antineoplastic activity.

Oral forms are used to treat inflammation and pain associated with arthritis and autoimmune diseases (such as lupus, Crohn's). Inhaled medications are used to treat asthma and allergies. Topical applications help heal skin conditions. The injected forms are used treat the pain and inflammation of arthritis, gout and other inflammatory diseases.

Bronchodilators relax bronchial smooth muscle. Relaxing these muscles makes the airways larger and allows air to pass through the lungs. Some also increase mucociliary clearance (beta agonists). Albuterol (Proventil) is a short-acting (or rescue) medication and can also be categorized as an Antiasthmatic.

Short-acting medications are used as needed as asthma "rescue" medications. Long-acting medications are used every day to control asthma in conjunction with an inhaled steroid.

Beta Blockers block norepinephrine and epinephrine from binding to beta receptors on nerves. By blocking the effects of these neurotransmitters, they reduce heart rate and reduce blood pressure by dilating blood vessels. The spelling of many beta blockers often end with “lol.”

They are used to treat hypertension; heart failure; arrhythmias; angina; glaucoma (ophthalmic); sometimes used in heart attack patients to prevent future heart attacks; also used prophylactically for migraine headaches.

Antipsychotics work by blocking a specific subtype of the dopamine receptor (the D2 receptor). The 2nd generation of these medications not only block D2 receptors but also a specific subtype of serotonin receptor (5HR2A receptor). Risperidone (Risperdal) is a 2nd generation antipsychotic.

They are used in the treatment of acute and chronic psychosis, especially when accompanied by increased psychomotor activity. Off-label uses include Tourette’s syndrome, substance abuse, stuttering, obsessive-compulsive disorder, post-traumatic stress disorder, depression, bipolar disorder and personality disorders.

Antihistamines compete with histamine for histamine receptor sites and when they occupy the histamine receptor sites, they prevent histamine from causing allergic symptoms.

They are used for relief of symptoms associated with allergies (including rhinitis, urticaria and angioedema) and as adjunctive therapy in anaphylactic reactions. Some are used to treat insomnia (diphenhydramine), motion sickness (dimenhydrinate and meclizine), Parkinson-like reactions (diphenhydramine), and other nonallergic conditions.

Antifungal agents are also called antimycotic agents; they kill or inactivate fungi.

They are used to treat systemic, localized, or topical fungal infections (including yeast infections).

Tricyclic Antidepressants inhibit the nerve cell's ability to reuptake serotonin and norepinephrine, resulting in increased levels of these neurotransmitters in the brain. They also block the action of acetylcholine and histamine (which causes many of the side effects of these meds).

They are used to relieve depression and may also be used to treat obsessive compulsive disorder and bedwetting. Off-label uses include panic disorder, bulimia, and chronic pain (migraine, diabetic neuropathy & post herpetic neuralgia).

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) block or delay the reuptake of serotonin and norepinephrine by the presynaptic nerves. The increased levels of these neurotransmitters elevates mood.

They are primarily used to treat depression, but are also used to treat anxiety disorder, panic disorder and other mood disorders.

Some of these Antiparkinson Agents replenish dopamine, while others mimic the role of dopamine or block the effects of other chemicals that cause problems in the brain when dopamine levels drop. Ropinirole (Requip) is a dopamine agonist.

They are used to help relieve the symptoms of parkinsonism (such as tremor or trembling in the hands, arms, legs, jaw, and face; stiffness or rigidity of the arms, legs, and trunk; bradykinesia; poor balance and coordination).

Some of these Anti-Alzheimer's Agents (cholinesterase inhibitors, like donepezil) are thought to prevent the breakdown of acetylcholine by blocking the activity of acetylcholinesterase. Others (NMDA receptor antagonists) helps regulate the activity of glutamate, a chemical involved in the processing, storage and retrieval of information.

They are used to treat Alzheimer's disease.

Thiazide Diuretics are derived from a chemical called benzothiadi(A)zene. They work in the distal convoluted tubule by decreasing the kidney’s reabsorption of sodium and chloride (which results in increased urine production) and they also help dilate blood vessels.

They are used alone or in combination with loop diuretics in the treatment of hypertension or edema due to heart failure or other causes.

Calcium Channel Blockers slow the rate at which calcium passes into the heart muscle and into the vessel walls; this relaxes the vessels and allows blood to flow more easily through them, thereby lowering blood pressure.

They are used to treat hypertension, angina, and abnormal heart rhythms (atrial fibrillation, paroxysmal supraventricular tachycardia). They are also used for client post-MI who cannot tolerate beta-blockers.

Potassium-sparing Diuretics are used to conserve potassium in clients receiving thiazide or loop diuretics; they decrease sodium reabsorption in the collecting tubules of the kidneys.

They are often used in clients with heart failure; they do not significantly lower blood pressure.

Some of the Antiulcer Agents (PPIs) block the secretion of gastric acid by the gastric parietal cells (one example is pantoprazole). Others (H-2 receptor blockers) stop the action of histamine on the gastric parietal cells, which inhibits the secretion of gastric acid. Remember, the spelling of PPIs often end with "prazole."

These drugs are used in the treatment and prophylaxis of peptic ulcer and gastric hypersecretory conditions, e.g., Zollinger-Ellison syndrome and also to manage the symptoms of gastroesophageal reflux disease (GERD).

Sedatives/Hypnotics are substances that moderate activity and excitement while inducing a calming effect (and may be anxiolytic) or substances that may induce drowsiness and sleep. Most all are Schedule IV drugs. Temazepamis a intermediate-acting benzodiazepine.

They are used to provide sedation, usually prior to procedures. Selected agents are useful as anticonvulsants, skeletal muscle relaxants, adjuncts in general surgery and adjuncts for the treatment of alcohol withdrawal syndrome.

Vasopressors are potent vasoconstrictors, producing a rise in blood pressure (increase in mean arterial pressure).

They are used to control blood pressure in hypotensive states, such as (cardiogenic, septic) shock, drug reactions, spinal anesthesia. They can also be used to prolong anesthesia and to treat certain heart rhythm problems, including cardiac arrest.

Loop Diuretics work in the ascending limb of the loop of Henle (where magnesium & calcium are reabsorbed). Disrupting the reabsorption of these 2 ions brings about increased urine production (which lowers blood volume) and results in lowered blood pressure. They also cause the veins to dilate, which lowers blood pressure mechanically.

They are used to treat acute pulmonary edema and manage edema; they can also be used to reduce intracranial pressure and to treat hyperkalemia.

Antianxiety Agents act at many levels in the CNS to produce anxiolytic effect. They may produce CNS depression and the effects may be mediated by GABA (an inhibitory neurotransmitter).

They are used in the treatment of Generalized Anxiety Disorder (GAD) and Panic Disorder; they are also used in the management of anxiety associated with depression.

ACE Inhibitors slow the activity of the enzyme angiotensin converting enzyme (ACE), which decreases the production of angiotensin II. As a result, blood vessels relax and dilate, blood pressure is lowered, and more oxygen-rich blood can reach the heart. The spelling of many angiotensin-converting enzyme (ACE) inhibitors end with "pril".

They are primarily used to control blood pressure, treat heart failure, help prevent strokes.

Lipid-lowering Agents reduce LDL (“bad”) cholesterol by inhibiting the enzyme in the liver (HMG-CoA reductase) responsible for making cholesterol. Along with diet and exercise, they are used to reduce blood lipids in an effort to reduce the morbidity and mortality of atherosclerotic cardiovascular disease and its sequelae.

Decrease serum phosphate

Aluminum binds phosphates in the gastrointestinal tract. Phosphates tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel and Basaljel are commonly used to lower phosphate levels

Should be taken in the morning

A thyroid supplement, such as levothyroxine (Levothroid, Levoxyl, Synthroid), should be taken on an empty stomach, in the morning. Morning dosing minimizes the side effects of insomnia and an empty stomach facilitates absorption.

The same analgesic dosage will be continued

Dying clients who have been in chronic pain will probably continue to experience pain even though they are unresponsive. Pain medication should be continued at the same dosage that was considered effective when the client was more alert and responsive.

Avoid the use of salt substitutes

Captopril is an angiotensin converting enzyme (ACE) inhibitor. Captopril is used to control blood pressure, treat heart failure, and help prevent strokes. Because it can cause an accumulation of potassium (or hyperkalemia), clients should avoid the use of salt substitutes, which are generally potassium-based. The generic names of ACE inhibitors often end with "pril."

Emphasize the importance of a return visit after completing antibiotic therapy

A liquid suspension, not tablets, will be prescribed for the toddler and the nurse should reinforce how to store and measure the liquid. The child should be examined again after completion of the full course of antibiotics to assess hearing or to check for findings of a persistent infection and/or middle ear effusion. There is no need to discuss surgery or any other treatment at this time.

Mental status

Cimetidine (Tagamet) is a histamine H2-receptor antagonist, used to treat gastric ulcers. Clients over age 50 or who are severely ill may become temporarily confused while taking H2 blockers, especially cimetidine.

Enhanced pain relief

Combination of analgesics with different mechanisms of action can afford greater pain relief.

Muscle cramps

Furosemide (Lasix) is a loop diuretic used to treat edema and hypertension. It can cause dehydration and electrolyte imbalances (hypokalemia and hypomagnesemia), which can result in muscle cramps. This is the most important finding. Dizziness, lightheadedness, or headache may occur as the client adjusts to the medication. The nurse should reinforce that the client should get up slowly when rising from a sitting or lying position but to tell the health care provider if these findings persist or become worse. Increased urine production is an expected action of the medication. Some people experience constipation when taking this medication.

10mL.

250 mg/5 mL = 500 mg/X mL 250x = 2500 x = 2500/250 = 10 mL

"I will notify the health care provider if I have any difficulty swallowing."

"I will swallow it with 8 ounces of water."

"I will stand or sit quietly for 30 minutes after taking it."

Alendronate (Fosamax) can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication.

"You may notice an orange-red color to your urine."

Rifampin can cause reddish-orange discoloration of the urine and other body fluids. It is harmless, but the client needs to be aware of it. The nurse should caution the client not to wear soft contacts while taking this medication.

Administer the medication in two separate injections

Intramuscular injections should not exceed a volume of 1 mL for small children. Medication doses exceeding this volume should be split into two separate injections of 1 mL each. In adults the maximum intramuscular injection volume is commonly 5 mL depending on the characteristics of the site. The vastus lateralis of the thigh should be used to administer IM medications to a toddler (12 to 36 months of age).

Dyshrythmias

Conditions that increase the risk of digoxin-induced dysrhythmias include hypokalemia and increased serum digoxin levels. The nurse should reinforce the importance of eating high-potassium foods (spinach, bananas, potatoes) and report signs of hypokalemia, such as nausea, general muscle weakness and irregular pulse. Tingling or other unusual sensations are associated with hyperkalemia. Altered LOC is not associated with hypokalemia. Persistent hypokalemia can cause polyuria, not oliguria.

7mL.
Dimensional analysis:

X mL = 1 mL/40 mg X 10 mg/kg X 1 kg/2.2 lbs X 62 lbs = 620/88 = 7.05 or 7 mL

Ratio :
62 lbs/x = 1 kg/2.2 lbs = 28.19 kg
10 mg/x = 1 mL/40 mg = 10/40 = 0.25
0.25 X 28.19 = 7.05 or 7 mL

“Count the number of doses as the inhaler is used.”

Dropping the canister into a bowl of water assesses the amount of medications remaining in a metered-dose inhaler is the old way of checking how much was left in the canister. Now clients should be instructed to calculate how many doses are in each canister and keep track of the number of doses used. Some of the newer canisters have counters.

“That was done correctly. Did you have any problems with the insertion?”

Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect because there is no data in the stem to support these comments.

"Notify the health care provider if you notice any unusual bruising on your skin."

Enoxaparin (Lovenox) is a low molecular weight heparin and can result in the complication of bleeding. The client should monitor for any indication of unusual bleeding in the skin, mucous membranes or urine. The medication will be given subcutaneously, not by the IV route. Unlike heparin, enoxaparin does not require routine laboratory monitoring.

Theophylline (Elixophyllin, Theo-24, Uniphyl)

Digoxin (Lanoxin)

It is necessary to monitor blood levels for the client taking theophylline and digoxin to prevent the client from developing toxicity.

Nonsteroidal anti-inflammatory medications

Warfarin is indicated in the prophylaxis and treatment of blood clots, atrial fibrillation and cardiac valve replacements. Taking warfarin and a nonsteroidal anti-inflammatory medication, such as ibuprofen, or an antiplatelet medication, such as aspirin, may increase the risk for bleeding. Garlic and ginkgo biloba can also increase the risk of bleeding if taken with warfarin.

Recent prescribed use of an MAO inhibitor

SSRIs should not be taken concurrently with MAO inhibitors due to serious, life-threatening medical condition called serotonin syndrome. Serotonin syndrome symptoms may occur within several hours of taking a new drug. It may be necessary to allow two to five weeks (or more) between stopping a MAOI and starting the SSRI (or vice versa).

The catheter is located in the vaginal canal

For an adult female, a urinary catheter is inserted about 2-3 inches (5-7 cm) in the urinary meatus until the urine flow begins. If urine does not flow, the catheter can be rotated gently and carefully inserted a bit further. When a catheter is inserted 4-5 inches (10-12 cm) with no urine return, the catheter is probably in the vaginal canal.

Continue to monitor the respirations

Normal respirations range 12 to 20 BPM; respirations 8 or less are a cause for concern. Vigorous stimulation is not indicated. It is also not necessary to ask the RN to check findings.

Spinal

Spinal x-rays must be obtained to identify any abnormalities, especially in the neck area. In addition, blood and urine samples must be obtained, along with a signed consent form. To help answer this question, you should remember that the person experiences grand mal seizure activity during ECT. In reading the options, you'll notice that three options are assessing a very small area of the body. Finally, consider which area of the body would potentially have severe consequences if not evaluated before the procedure.

Administer a laxative to the client the evening before the test

Bowel preparation is important to clean out the large intestine to allow for the visualization of the kidney, bladder and ureters. Clients are often given the osmotic bowel preps the night before, such as Colyte, and an enema in the morning of the test. Beginning the day before the test, a clear liquid diet is prescribed and the client is NPO after midnight.

Client reports prickling sensation in the right hand

A prickling sensation, or paresthesia, may be an indication of compartment syndrome and requires immediate action by the nurse. The client may also report extreme pain, there may be pallor and an absent or diminished pulse on the affected extremity. The nurse should report the findings to the RN charge nurse, who will then split the cast to help relieve the pressure and contact the health care provider. The other findings are normal for a client in this situation.

Respiratory rate

Tachypnea is one of the first clues that the client is not being adequately oxygenated. The compensatory mechanism for decreased oxygenation is increased respiratory rate. To help answer this question, you will notice that the problem in the question is respiratory (short of breath), so you should look for a response with this focus.

Remove air out of the pleural space to restore normal intrathoracic pressure

With a tension pneumothorax, the lung is collapsed due to air in the pleural space and this trapped air continues to build up; the pressure of this air pushes on and displaces the mediastinum. The classic sign of a tension pneumothorax is a deviation of the trachea away from the side of the tension. This is an emergency situation and is not the result of a surgical procedure. Insertion of a chest tube will remove the air, which will reduce the intrathoracic pressure, and allow the lung to re-inflate.

No special preparation is necessary for the client

This is a noninvasive procedure. Because this is an ultrasound test for the venous circulation, it does not require any special preparation (as compared to an ultrasound of the uterus that requires a full bladder).

Continue to monitor the drainage

Several hundred milliliters of drainage can be expected from the T-tube in the initial 24 to 48 hours after a duct exploration. The nurse's responsibility is to continue to monitor the drainage and notify the health care provider if the findings indicate leakage of bile into the peritoneum or a blocked duct. The tube should not be clamped unless there is a specific order to do so (tube is clamped 3 to 4 days postop) while client is eating and for a few hours afterwards to test for duct patency. If nausea and vomiting occur when the tube is clamped, this indicates the duct is not patent and the nurse should remove the clamp. Keeping the head of the bed elevated will help to facilitate drainage.

Lower eyelid

Keratitis is a corneal ulcer or abrasion caused by exposure to the air from lack of or minimal blink reflex. Treatment involves the application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.

Assist him to stand by the side of the bed to void

When a male is not able to use a urinal unassisted, the client should stand by the side of the bed to void. This is the most desirable position for normal voiding for male clients. Given the client’s age, he most likely also has some degree of prostate enlargement, which may also interfere with voiding.

Potassium

Hyperglycemia induces osmotic diuresis, causing water and electrolyte loss, especially potassium. Most clients with DKA have moderate to severe dehydration and will be initially treated in an intensive care unit. The client is given IV fluids with potassium to replace the fluid loss. The other electrolytes listed (magnesium and calcium) are not on a BMP. Creatinine is part of the BMP but it measures kidney function.

Hemoglobin

Hemoglobin is the oxygen-carrying protein component of the red blood cell. Normal hemoglobin range for children is approximately 11-13 gm/dL. Beta thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia. The only treatment is blood transfusions (every month) or a bone marrow transplant. With frequent blood transfusions, the body is unable to eliminate the excess iron contained in the transfused blood; over time this can result in tissue and organ damage.

Assist the client to a safe position away from hazards

Clients with seizure disorders (or epilepsy) often experience symptoms that warn them that a seizure is going to happen, called an aura. The most important action to implement in this situation is to place the client in a safe position so that if a seizure occurs, the client will not be injured. The LPN/VN should stay with the client and send someone to notify the RN (who can bring medication to prevent seizure activity). Noise reduction and light dimming may be beneficial in preventing an impending seizure, but they are not the priority. Remember to consider safety first when there isn't an immediate physical need.

Determine responsiveness of the client

Electrical interference can be mistaken for ventricular fibrillation, in which case the client would respond when checked. Therefore, the most important initial action would be to check to see if the client is responsive or not. It would be inappropriate to initiate CPR or prepare to administer emergency drugs without first determining that the client is unresponsive.

Abdominal ultrasound

Third-semester painless vaginal bleeding suggests placenta previa. Placenta previa is diagnosed through an abdominal ultrasound. This may be followed up with a transvaginal ultrasound. The health care provider would not perform a vaginal exam; vaginal exams may increase the risk of heavy bleeding. If the bleeding is unusually heavy and cannot be controlled and/or the baby is in distress, an emergency c-section may be necessary.

The incision was made in order to insert the catheter into the abdominal cavity

The preferred procedure in the surgical treatment of hydrocephalus is placement of a ventriculoperitoneal (VP) shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, usually the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt can be guided into the peritoneal cavity.

Apply suction for no more than 10 seconds

Applying suction for more than 10 seconds may result in hypoxia, by suctioning oxygenated air out of the airway. The clue was to read the question correctly - it asked about prevention of hypoxia associated with suctioning. Although the other responses are important and correct actions, hypoxia results from actions that decrease the oxygen supply.

Liver enzymes

INH, as well as other long-term by-mouth medications, can cause hepatocellular injury. The nurse anticipates monitoring liver enzymes (ALT, AST and alkaline phosphatase) because these are released into the blood when the liver is damaged.

Flush the feeding tube with 30 mL of warm water

The nurse will flush the tube with approximately 30 mL of warm water every 4 hours to maintain patency and check GRV every 4-6 hours (it's best to do both at the same time.) Residuals should be returned to the stomach because they contain electrolytes, nutrients, and digestive enzymes. Current evidence shows that acceptable GRVs range can from 150-500 mL and that a single elevated GRV simply requires ongoing monitoring. Although the nurse will monitor the client's response during the tube feeding, the nurse should have assessed bowel sounds and measured gastric pH (as well as GRV) before starting the feeding.

True

A laparoscopy involves injecting carbon dioxide or nitrous oxide gas into the abdominal cavity to expand the area for better viewing. Many people experience shoulder pain for a few days after the procedure because the gas irritates the diaphragm, which shares some of the same nerves as the shoulder.

False

Pulse oximetry estimates oxygen (O2) saturation (SpO2) of capillary blood and these estimates typically correlate to arterial O2 saturation measurements (SaO2) when used correctly. But, pulse oximetry cannot detect hypercapnia or acidosis. An ABG is needed for accurate measurements of PaO2, PaCO2 and blood pH.

True

The nonrebreather mask delivers the highest percentage of oxygen of any of the high flow systems. It should be used only in medical emergencies, for a relatively short time (6 to 8 hours); any longer and the client risks pulmonary oxygen toxicity.

True
During hemodialysis, blood is diverted from the body; if it is not replaced at the proper rate and osmolality, complications such as shock could develop.

False

Evidence-based practice recommends aspirating gastric contents to test the pH (which should be below 5) and/or obtaining an x-ray if there are concerns about the placement (and before instilling any feedings or medications).

True

A foam dressing with a fluid-proof backing is a good choice for treating full thickness wounds. This dressing will absorb moderate amounts of drainage and cushion the wound site. A secondary dressing, such as Kerlix, may be needed to secure the primary dressing in place.

False

5 to 7 pounds (2.3 to 3.2 kg) of traction is recommended for Buck’s skin traction – any more weight and the boot will be pulled off the leg! Buck’s traction is used to immobilize, position and align the lower extremity. It is one of the most commonly used types of traction.

False

Pacemakers use low-energy electrical pulses to speed up a slow heart rhythm, help control abnormal or fast rhythms, and coordinate electrical signaling between the chambers of the heart. Implantable cardioverter defibrillators (ICD) use both low-energy and high-energy electrical pulses (these high-energy pulses treat the life-threatening arrhythmias).

False

Suctioning should only be done when clinically necessary and when the client is physically unable to cough up secretions on his or her own. Clinical indicators for suctioning include coarse breath sounds, noisy breathing, increased or decreased pulse, increased or decreased respiration, and prolonged expiratory breath sounds.

False

It may take three or four days for the bowel to return to normal function after a colostomy.

True

An MRI uses powerful, magnetic fields and radiofrequency energy to create clear pictures of internal body structures. Because of these magnetic fields, clients must remove all metal objects. Clients with shrapnel, a pacemaker or any surgically implanted joints may not be able to have this test.

True

The client should fast for at least 8 to 12 hours before a lipid panel blood draw; the client can drink clear liquids. Lipids include cholesterol, triglycerides, high-density lipoprotein (HDL) and low-density lipoprotein (LDL).

True

During an esophageal manometry a thin, pressure-sensitive tube is passed into the esophagus. As the client swallows, the tube measures the pressure of the muscle contractions. This test is used to determine the cause of dysphagia, to evaluate for signs of GERD or to evaluate chest pain that may be coming from the esophagus.

True

ELISA stands for enzyme-linked immunosorbent assay (it is also known as EIA, or enzyme immunoassay). This laboratory test is used to detect antibodies in the blood. It is used for clinical diagnosis, screening blood products and testing individuals who believe they may have been exposed to other infectious substances or viruses, such as HIV.

False

A myelogram uses a special dye (oil-based, water-soluble and even air-contrast) and an x-ray (fluoroscopy) to make pictures of the bones and the subarachnoid space between the bones in the spine. Electrical activity in muscles is measured by an electromyogram (EMG); this may be a painful test.

False

Barium takes up to four days to be completely excreted so that its radio occlusive properties do not interfere with the CT scan.

False

An IVC shows the bile ducts. It is the intravenous pyelogram (IVP) that visualizes the kidneys and urinary system.

False

A variety of different allergy tests can be used. One or more allergen-specific IgE antibody tests may be performed by either intradermal injection or by scratching the skin. Alternately, a radioallergosorbent test (RAST) can measure antibodies in the blood. A Schick test detects the presence of diphtheria toxin.

True

The prefix “bil-“ refers to bile, a product of the liver that is stored in the gallbladder and excreted into the small intestine. Testing for bilirubin in the blood helps identify liver disease and any obstruction of the gallbladder or bile ducts. Urobilinogen is a breakdown product of bilirubin and can be detected with a urinalysis.

True
This commonly-ordered test includes: glucose, calcium, sodium, potassium, carbon dioxide (CO2), chloride, blood urea nitrogen (BUN) and creatinine. A related test is the comprehensive metabolic panel (CMP), which consists of 14 specific tests.

False

The QRS complex of the ECG represents the time it takes for depolarization of the ventricles. The duration of the QRS complex is normally 0.06 to 0.12 seconds. The P wave represents depolarization of the atria.

True

The urine obtained from a clean catch urine specimen can be used for a variety of tests, including urinalysis, cytology and urine culture. The nurse will need to instruct (or reinforce teaching to) the client about the correct procedure to obtain a clean catch specimen.

There are several types of hemophilia. All types can cause abnormal or exaggerated bleeding and poor blood clotting. Common sites for bleeding are the joints, muscles and gastrointestinal tract.

Beck’s triad (hypotension; jugular vein distention; and distant/muffled heart sounds) are the classic symptoms of cardiac tamponade. Cardiac tamponade is where blood or fluid accumulates in the pericardial space and acts to compress and constrict the heart.

Atrial fibrillation (AFib) is the most common type of irregular heartbeat. Many clients have no symptoms. A client with AFib is five times more likely to have a stroke than someone without AFib.

The most common finding of sickle cell disease is pain (sickle cell crisis). This is caused by the characteristic crescent-shaped red blood cells getting stuck and blocking blood vessels. Clients with sickle cell disease often also have anemia and are more prone to infections.

Occlusive arterial disease (also known as peripheral artery disease) is caused by arteriosclerosis. The classic symptoms appear during walking or exercise and are relieved with rest.

Raynaud’s phenomenon is a condition where cold temperatures or strong emotions cause blood vessel spasms, which block blood flow to the fingers, toes, ears and nose.

Systolic heart failure is when the heart muscle cannot pump/eject the blood out of the heart. Diastolic heart failure is when the heart muscles are stiff and do not fill up with blood easily. As the heart’s pumping action becomes less effective, blood backs up in other areas of the body (congestive heart failure).

In disseminated intravascular coagulation (DIC), the proteins that control blood clotting become overactive, increasing a client’s risk for serious bleeding. This can be due to inflammation, infection or cancer.

Thrombophlebitis is a swollen or inflamed vein due to a blood clot.

STEMI is a type of heart attack when the coronary artery is completely blocked off by an occlusion. The client will experience crushing, non-remitting retrosternal pain, diaphoresis, nausea/vomiting and dyspnea.

Finding

After the initial infection subsides, the body's immune system continues to damage the heart muscle, weakening the heart. Myocarditis is a common cause of dilated cardiomyopathy.

Etiology

Myocarditis is an inflammation of the myocardium (the middle layer of the heart wall) and it is usually caused by a viral infection (it can also be caused by bacteria, parasites and fungi). Other viruses associated with myocarditis include the common cold (adenovirus), rubella, parvovirus B19 (which causes fifth disease) and HIV.

Etiology

Causes of aortic insufficiency include ankylosing spondylitis, endocarditis, hypertension, Marfan syndrome, syphilis and systemic lupus erythematosus. Marfan syndrome is an inherited disease of connective tissues. In the past, the main cause of aortic insufficiency was rheumatic fever.

Etiology

Pulmonary stenosis is a congenital defect affecting the pulmonary valve. It is the second more common congenital heart defect.

Etiology

Aortic stenosis can be a congenital disorder, but it is more commonly caused by the buildup of calcium deposits that narrow the valve, which is seen in older adults. Another cause of aortic stenosis is rheumatic fever.

Finding

In aortic stenosis, the aortic valves do not open fully, causing decreased blood flow from the heart. Dyspnea, syncope and angina are the three classic findings of aortic stenosis.

Etiology

Pulmonary stenosis is, by definition, a narrowing of the pulmonary valve

Finding

The most common symptoms of pulmonary stenosis are rapid or heavy breathing, dyspnea, tachycardia and peripheral edema (swelling in the feet, ankles, face, eyelids and/or abdomen).

Finding

Dyspnea, chest pain, and syncope are the three classic findings of pulmonary stenosis.

Finding

Findings of mitral valve regurgitation depend on the severity and how quickly the condition develops. Common findings include heart murmurs, shortness of breath, fatigue and paroxysmal nocturnal dyspnea.

Etiology

Any disease or problem that weakens or damages the valve or heart tissue around the valve can cause mitral valve regurgitation (also called mitral valve insufficiency).

Finding

The main finding of pericarditis is a sharp, stabbing pain in the center or left side of the chest. By definition, chest pain is a finding.

Etiology

Pericarditis is inflammation of the pericardium (the thin, sac-like covering of the heart). A common cause of pericarditis includes viral infections, including pneumonia and influenza; other causes include bacterial or fungal infections.

Etiology

Rheumatic fever is usually caused by an untreated streptococcal infection. The risk for developing endocarditis increases if a person had rheumatic fever or rheumatic heart disease (usually as a child).

Finding

Endocarditis is inflammation of the inside lining of the heart chambers (endocardium) and heart valves. Heart murmurs are heard in a majority of clients with endocarditis.

False

The portal vein has no direct connection to the left atrium, which receives blood from the pulmonary vein.

True

In systole, the ventricles contract. So the right ventricle should be pushing blood through the pulmonic valve, not backward through the tricuspid.

True

During diastole (ventricular filling), the mitral valve is open to allow blood to flow from the atria to the ventricles.

False

The aorta is the largest artery of the body. It exits the left ventricle to distribute oxygenated blood to the body.

False

The septum is a wall; normally there should be no opening between the ventricles.

True

The arteries contain a fibrous outer layer (tunica adventitia) that is stiff enough to hold them open when cut. The veins collapse when cut.

False

All veins lead to the heart; it is arteries that lead away from it. The pulmonary vein returns oxygenated blood from the lungs to the left atrium.

True

Unlike arteries, veins do not contain an elastic membrane lining; they instead rely on valves to keep blood flowing in a single direction, back to the heart.

True

There is an anterior (superior) vena cava and a posterior (inferior) vena cava; both bring blood from the body back to the heart.

False

Blood flows from the atria (sometimes incorrectly called "auricles") to the ventricles.

True

The aorta's first two branches are the right and left coronary arteries, which bring blood to the myocardium.

False

The "endo (inside) cardium (heart)" is the layer inside the myocardium.

The mitral valve controls flow between the left atrium and left ventricle.

True

The aorta leaves the left ventricle, which contains oxygen-rich blood from the lungs.

False

In systole the heart muscle squeezes or contracts; in diastole, it relaxes.

Cor pulmonale

Cor pulmonale is an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system.

Emphysema

Emphysema is a chronic and progressive disease of the lungs that causes shortness of breath due to over-inflation of the alveoli.

Tension Pneumothorax

A tension pneumothorax occurs when air gets trapped in the pleural cavity and as the pressure increases, it pushes the mediastinum to the other side of the chest, which compresses the other lung. This is a life-threatening condition.

Tonsillitis

Tonsillitis is an inflammation of the tonsils, due to either viral or bacterial infections or immunologic factors. Findings are similar to pharyngitis (sore throat).

Myasthenia Gravis

Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal muscles. It is caused by a defect in the transmission of nerve impulses to muscles. Muscles that control eye and eyelid movement, facial expression, chewing, talking, swallowing, and breathing are often affected.

Severe Acute Respiratory Syndrome (SARS)

SARS is a viral infection causing acute respiratory distress and sometimes death.

Pneumonia

Pneumonia is an inflammatory process that results in edema of the lung tissues. Fluid moves into the alveoli and this can cause hypoxia. Pneumonia is caused by bacteria, viruses, fungi or chemicals.

Cystic Fibrosis

Cystic fibrosis is a hereditary disorder that causes severe damage to the lungs and digestive systems. It is a disorder that affects the exocrine glands, causing them to produce thick and sticky mucus.

Ménière's Disease

A chronic disorder of the inner ear that usually affects only one ear. It usually develops between the ages of 40-60 years.

Cataract

A clouding of the lens in the eye that affects vision. Most cataracts are related to aging.

Chronic Open-angle Glaucoma

The most common type of glaucoma. The increase in pressure is often small and develops slowly.

Acute Closed-angle Glaucoma

Occurs when fluid is suddenly blocked and can't flow out of the eye, resulting in a quick, severe rise in eye pressure. This is a medical emergency.

Retinal Detachment

Separation of the light-sensitive membrane (retina) from its supporting layers.

False

Guillain-Barré is a progressive, inflammatory autoimmune response occurring in the peripheral nervous system. The autoimmune response results in damage to myelin sheath and slows or alters nerve conduction. It is not caused by an acute infection.

True

Ischemic strokes account for about 87% of all stroke cases and are caused by an obstruction within a blood vessel supplying blood to the brain (either a thrombosis or embolism).

True

Many things can trigger migraine headaches, including hormonal changes, stress, sensory stimuli and sleep (too much or too little). Common food triggers include alcohol, aged cheeses (which contain tyramine), chocolate, overuse of caffeine and MSG.

False

Rigid contracture of muscles (the tonic phase) is usually brief. The clonic component is the rhythmic shaking that occurs during the seizure; it lasts longer than the tonic component. A generalized tonic-clonic seizure is also known as a grand mal seizure.

True

These are some of the classic findings of meningitis, which can occur quickly or over several days after exposure. However, infants may present with high fever, constant crying, excessive sleepiness or irritability and poor feeding.

True

Trigeminal neuralgia is one of more common causes of chronic and excruciating facial pain. Anticonvulsants help to decrease pain impulses and produce pain relief. The muscle relaxant baclofen may be used as an adjunct to anticonvulsants.

False

Delirium, or acute confusional state, is not a disease but a transient and potentially reversible disorder of cognition. It is often mistaken for a neurocognitive disorder (formerly referred to as dementia) or even an acute schizophrenic reaction.

False

Questions requiring a simple yes or no response are used if thinking abilities are impaired.

False

The pain of a cluster headache comes on suddenly and usually subsides quickly, before even over-the-counter pain relievers such as ibuprofen or acetaminophen can start working. Triptans can provide effective acute treatment for cluster headaches.

True

Clients diagnosed with myasthenia gravis experience progressive muscle weakness. To minimize the risk of aspiration and to facilitate chewing and swallowing, anticholinesterase inhibitors, such as pyridostigmine (Mestinon), should be taken before meals.

False

Parkinson's disease does not initially affect intellectual ability; however, some clients with PD may eventually experience changes in memory, thinking or reasoning. Also, many clients may develop depression later in the disease process, which is characterized by withdrawal, sadness, loss of appetite and sleep disturbances.

True

The American Stroke Association lists this as one initial warning sign of a stroke, along with sudden confusion, sudden trouble speaking or understanding, sudden trouble seeing or sudden headache.

There are several causes of inflammation of the liver, but hepatitis is usually caused by a virus. Hepatitis can heal on its own with no significant consequences or it can progress to scarring of the liver (cirrhosis).

Intestinal obstruction is a partial or complete blockage of the bowel. It is usually due to either a mechanical reason or an ileus (a condition where there is no structural problem causing the bowel not to contract correctly - such as following surgery).

A low-fiber diet is the most common cause of diverticular disease. The disease is made up of two conditions: diverticulosis and diverticulitis.

Scar tissue from cirrhosis in loss of liver function and can cause: portal hypertension, hepatic encephalopathy, gastrointestinal bleeding, infection, ascites and hepatorenal syndrome.

Cholecystitis is inflammation of the gallbladder caused by an obstruction of the cystic duct (usually by stones). Clients may experience nausea, vomiting and fever. Risk factors include increasing age, obesity or rapid weight loss, medication and pregnancy.

Crohn's disease is an inflammatory bowel disease. Unlike ulcerative colitis, inflammation affects the entire thickness of the bowel wall and can affect any part of the digestive tract (although it most commonly affects the ilium and beginning of the colon).

A peptic ulcer is a sore on the lining of the stomach or duodenum. The bacterium called Helicobacter pylori is a major cause of peptic ulcers; NSAIDs are another common cause of peptic ulcers.

Treatment for pancreatitis includes IV fluids, antibiotics and pain relievers; many clients will require an endoscopic retrograde cholangiopancreatography (ERCP) to examine the bile and pancreatic ducts.

Ulcerative colitis is a disease that causes inflammation and sores (ulcers) in the lining of the rectum and colon (large intestine).

Complications of GERD include bronchospasm, chronic cough or hoarseness, dental problems, esophageal ulcer and Barrett's esophagus (a change in the lining of the esophagus that can increase the risk of cancer).

Benign Prostatic Hypertrophy

An enlarged prostate does not necessarily raise the risk of cancer, but men may develop urinary tract infections, hematuria, bladder stones, and bladder or kidney damage.

Renal Calculi

Although kidney stones (nephrolithiasis) may be small, passing one can be very painful. Dehydration is a major risk factor for kidney stone formation.

Cystocele

This hernia-like disorder occurs when the urinary bladder protrudes through the wall of the vagina. Treatments include estrogen, surgery, or mechanical support by pessary.

Syphilis

Syphilis is a sexually transmitted disease (STD) with 4 distinct stages. In the primary stage, painless sores appear. Skin rashes and flu-like symptoms occur in the secondary stage. If untreated, syphilis is eventually fatal.

Chronic Kidney Disease

In addition to pruritus, pigmentary disorders, and ecchymosis, clients with chronic kidney disease may also have xerosis (dry skin), uremic frost, half-and-half nails.

Acquired Immune Deficiency Syndrome (AIDS)

When the CD4 cell (a type of lymphocyte) count falls below 200 cells/microliter, clients are at risk for developing opportunistic infections; antiretroviral treatment should be started or changed.

Graves' disease

Graves' disease is an autoimmune disorder that leads to overactivity of the thyroid gland.

Myxedema coma

Myxedema coma/crisis usually affects older women who have long-standing, undiagnosed or undertreated hypothyroidism. The crisis is triggered by a significant stress, such as infection, a systemic disease, certain medications or exposure to a cold environment.

Hypoparathyroidism

Hypoparathyroidism is a disorder in which the parathyroid glands do not produce enough parathyroid hormone (PTH). PTH helps control serum levels of calcium, phosphorus, and vitamin D.

Hypopituitarism

These findings are associated with a deficiency of luteinizing hormone (LH) & follicle stimulating hormone (FSH), which are pituitary hormones. Findings of hypopituitarism are directly related to the missing hormone (thyroid-stimulating hormone (TSH), LH, growth hormone (GH), adrenocorticotropic hormone (ACTH), and/or prolactin).

Addison's disease

Addison's disease is a disorder that occurs when the adrenal glands do not produce enough hormones (glucocorticoid hormones, mineralcorticoid hormones and sex hormones).

Cushing syndrome

Cushing syndrome is caused when the adrenal gland secretes too much cortisol or when someone takes too much corticosteroid medication.

False

In children, too much growth hormone causes gigantism, resulting in an abnormal increase in height and bone growth. Acromegaly occurs in adulthood.

False

Central diabetes insipidus may be caused by damage to the hypothalamus (or pituitary gland).

True

This test is used to determine the cause of polydipsia and polyuria – central diabetes insipidus (DI), nephrogenic DI or psychogenic polydipsia.

True

With SIADH, hypersecretion of antidiuretic hormone (ADH) causes hyponatremia. As serum sodium drops, extra water enters cells and causes them to swell. Convulsions, shock, coma and death may occur with cerebral edema and increased brain cell volume.

False

This rare but deadly metabolic state is more common in the elderly with type 2 diabetes mellitus. HHS is characterized by hyperglycemia and severe dehydration without ketoacidosis.

True

Extra parathyroid hormone (PTH) results in hypercalcemia. There is also increased calcium in the urine, which may cause kidney stones. If the client's serum calcium levels are only slightly elevated, s/he should drink plenty of fluids to minimize the risk of developing kidney stones.

False

With type 2 DM, the pancreas produces insulin, but it's not enough and/or the body cannot use it properly (insulin resistance). Type 1 DM is when beta cells stop producing insulin.

True

Type 2 diabetes can often be managed with proper diet and exercise. Some clients also require additional treatment with oral hypoglycemic agents, like metformin.

True

If the client is conscious and alert, the nurse can offer 15-20 g of carbohydrates (4 ounces of juice or regular soda, or 1 tablespoon honey) to the client. Glucagon is used if the client is unconscious.

False

Clients should take this medication in the morning with a full glass of water. Levothyroxine should be taken on an empty stomach, at least one hour before any other medications or vitamins.

False

Osteoarthritis is typically the result of normal aging and wear and tear on the joints; it is not an autoimmune disease. With osteoarthritis, there is loss of cartilage in the joints. Eventually, the cartilage wears away and bones rub against each other, causing pain, swelling and stiffness.

False

Charcot's joint is a degenerative condition affecting one or more joints and results in joint instability and hypermobility, along with numbness and tingling or loss of sensation in the affected joints (usually in the feet). Treatment includes casting (for up to 12 weeks) and no weight-bearing on the foot followed by wearing a brace.

True

Although this degenerative disorder cannot be cured, it can be traced to a trauma or repeated stress. Selective strengthening of the inner portion of the quadriceps muscle will help normalize the tracking of the patella. Cardiovascular conditioning can be maintained by stationary bicycling, pool running or swimming.

False

Obesity, because it stresses joints, is a risk factor in the development of traumatic osteoarthritis. Rheumatoid arthritis, although not fully understood, seems to be an autoimmune disorder.

False

Pathological means that a bone or joint was weakened by a disease process. Stress fractures are caused by the repetitive application of force (such as overuse) or by a condition that weakens the bone (osteoporosis); stress fractures are most common in the weight-bearing bones of the lower leg and foot.

True

Clients with SLE often experience photosensitive rashes. Exposure to sunlight can also cause migraine headaches, nausea and joint pain.

False

Firm, non-tender, subcutaneous nodules develop in some chronic active cases of rheumatoid arthritis. They are serious extra-articular manifestations found in the lungs, eyes and blood vessels. Heberden's and Bouchard's nodes are bony enlargements of the joints involving the hand; these nodes are strongly familial (inherited) and are characteristic of osteoarthritis.

True

Clients with SLE often experience photosensitive rashes. Exposure to sunlight can also cause migraine headaches, nausea and joint pain.

True

Osteomalacia is softening of bone. It may be caused by poor dietary intake or poor absorption of calcium and other minerals; it is a characteristic feature of vitamin D deficiency in adults. The more obvious effects may appear in major weight-bearing joints such as the back, hips and legs.

True

Type 1 osteoporosis is related to decreased estrogen levels in postmenopausal women. Risk factors include a family history of osteoporosis, low body weight, smoking and drinking a large amount of alcohol.

False

Nothing can reverse the damage already done by osteoporosis. These medications can sometimes slow or halt the progress of the disease.

True

Paget's Disease attacks the mechanism that replaces old cells with new ones. The overactive osteoclasts rapidly restore bone cells and, as a result, the bone that is formed is abnormal, i.e., enlarged, not as dense, brittle and prone to fractures.

False

Peripheral vascular disease lead to an amputation, often of the foot, but indications for total hip replacement include osteoarthritis, rheumatoid arthritis, trauma (such as fracture of the femoral head), failure of a prosthesis or avascular necrosis of the femur due to steroid use.

True

X-ray images are necessary to first show where the bone should be moved and afterward to show whether it is positioned for ideal healing.

False

Clients diagnosed with gout and who are overweight should lose weight slowly. Quick weight loss may cause uric acid kidney stones to form.

True

These are all potential complications of orthopedic surgery.

False

Alcohol and iodine-based products can accelerate corrosion of the metal and can cause skin staining. Skeletal traction pins can be cleaned with normal saline, sterile water or even plain soap and water.

True

Lying on the stomach will help stretch the hip flexor muscles. The client should lie in the prone position for about 20 minutes, 3 to 4 times a day.

False

When the nurse suspects compartment syndrome, the cast should be split and constrictive bandages released. The limb should not be elevated above the level of the heart because this compromises arterial perfusion, which compounds the ischemic problem.

False

Sarcomas are cancers that begin in connective or supportive tissue, e.g., bone, cartilage, fat or muscle. Lymphomas and myelomas are cancers that begin in the cells of the immune system.

True

This staging system signifies the extent or severity of a client's cancer. The T stands for the extent of the primary tumor and N is for lymph node involvement.

False

Each monoclonal antibody recognizes only one particular protein, so different antibodies have to be used to target different types of cancer. For example, trastuzumab (Herceptin®) is used to treat certain breast cancers.

True

Hodgkin disease is a malignancy of the of lymph tissue (found in the lymph nodes, spleen, liver and bone cancer).

True

This vaccine, which is given to adolescent boys and girls, can prevent diseases cause by the human papillomavirus (HPV). This includes several different types of cancer and genital warts.

True

The most common sites for melanoma in fair-skinned women (including fair-skinned Hispanics) are the lower legs and upper back. For fair-skinned men, the most common site for melanoma is the upper back. Melanomas in dark-skinned people often appear in the mouth, palms of the hands, soles of the feet and under the nails.

True

Most colon polyps are benign growths. But some growths can turn into colon cancer. Polyps found during a colonoscopy can be removed and examined.

False

Childhood cancers, if diagnosed and treated early, are highly curable.

False

Lung cancer is the leading cause of cancer deaths in women in the U.S. and Canada.

True

Using high-energy radiation, the DNA of the cancer cells is damaged and the cell will die. X-rays, gamma rays and charged particles are types of radiation used for cancer treatment. Internal radiation therapy (brachytherapy) is another treatment for cancer.

True

Along with fluid replacement and medications to increase cardiac output, this type of shock must be treated with the appropriate anti-infective agent(s).

True

The cervical spine must be simultaneously stabilized when assessing the airway, and before breathing and circulation are assessed.

True

The essential treatment for clients with hypovolemic shock is to restore fluid volume and blood pressure. The client may also need medications to help increase cardiac output and mean arterial pressure, such as dobutamine (Dobutrex) and norepinephrine (Levophed).

False

In the initial stage of shock, only subtle changes in clinical signs may be seen. Hypotension does not typically occur until the progressive stage of shock. Pallor, cool and clammy skin, altered level of consciousness and irregular heart rhythms are the other classic findings of the progressive stage.

True
Cardiogenic shock typically develops following an acute MI, especially a ST-segment elevation MI (STEMI). However, cardiogenic shock can result from any cardiac dysfunction that causes acute myocardial ischemia.

False

Cardioversion is an elective procedure that is used to treat dysrhythmias, like atrial fibrillation. It involves synchronized shocks specific to the arrhythmia. Defibrillation is used for the immediate treatment of life-threatening arrhythmias, like ventricular fibrillation. It involves non-synchronized shocks during the cardiac cycle.

True

Flail chest results when two or more rib fractures occur in two or more places, causing the flail segment to separate from the rib cage. It often occurs from blunt trauma associated with accidents. Paradoxical respirations are the inward movement of a part of the thorax during inspiration and the outward movement during expiration. Clients also have severe chest pain, dyspnea and possible tachycardia and hypotension with flail chest.

False

Intracranial pressure is the pressure inside the skull and brain tissue. Altered LOC is often one of the earliest signs that a client has increased ICP. LOC is also the most important component of the neurological assessment in a high acuity and emergent client situation. Increased ICP can be caused by trauma, hemorrhage, tumors, edema or inflammation.

False

Spina bifida is the most frequently occurring and permanently disabling birth defect in the U.S. Findings vary depending on the level of the lesion and type of defect, but spina bifida is not associated with seizures.

True

Most hydrocephalus occurs in infancy and may be associated with a myelocele or myelomeningocele. Common findings of increased ICP include full or bulging fontanels, macrocephaly, poor feeding, vomiting and irritability.

True

In acyanotic (or 'pink') heart defects, blood is shunted from left to right within the heart, so oxygenated blood is recirculated. In contrast, cyanotic (or 'blue') heart defects involve a shunt that recirculates some venous blood, thus starving the body tissues of needed oxygen.

False

In RDS (also known as hyaline membrane disease) the lungs lack the surfactant that enables the alveoli to exchange blood gases.

False

Bronchiolitis is usually caused by the respiratory syncytial virus (RSV). RSV can also cause croup, ear infections and pneumonia in young children. Mild cases usually respond to rest, fluids and humidified air. Hospitalization may be required for severe cases of RSV.

True

Ventilators use pressure to blow air into the airways and lungs. Although ventilator support can help premature infants survive, the machine's pressure may irritate the infant's lungs. Other causes of BPD include high levels of oxygen therapy, infections and heredity.

True

Some of the more common causes of apnea include apnea of prematurity, obstructive sleep apnea, and apnea secondary to head trauma, infections or toxins. Apnea is an unexplained episode of cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, marked hypotonia, and cyanosis and/or pallor.

False

The most common form of croup is acute laryngotracheobronchitis or viral croup, which is an infection of both the upper and lower respiratory tracts. The classic "barky" harsh cough, stridor and fever are treated with antipyretics and cool air/mist.