RExPNMockExam1_Edna

Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as failure to wash hands between clients. A primary infection (1) is synonymous with initial infection. A secondary infection (2) is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection (3) is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

Rationale: The nurse needs to ask for more information to adequately answer the client. Normal discharge is small in amount, clear or cloudy in appearance, and always nonirritating. Anything other than these findings suggests a vaginal infection, with characteristics of the discharge often helping to identify the causative organism. Answer option 1 is an incorrect response that offers false reassurance without further assessment. Answer options 2 and 4 are possible questions to ask after determining baseline information.

Rationale: A blood pressure with a widening pulse pressure, bradycardia, and irregular respirations are associated with increasing intracranial pressure (ICP). This is known as Cushing’s triad and should be reported immediately. Presence of a gag reflex (1), urine output of 50 mh over an hour (3), and temperature of 99.8F and pulse 96 are acceptable assessment findings in a postoperative client.

Rationale: Menarche occurs later in girls who exercise regularly, including athletes and dancers. Answer options 1 and 2 are inappropriate questions for this situation. Asking the age the client’s mother began menstruation (3) is an appropriate question, but it is secondary to asking about exercise or sports.

Rationale: Because of the adolescent developmental task of identity versus role confusion, an adolescent’s greatest concern is self-identity and the question “Who am I?” Teenagers are concerned about all of the issues mentioned in answer options 2, 3, and 4, however they are all part of self-identity.

Rationale: To promote the therapeutic process, the nurse must be able to express caring and concern for the client through the use of empathy. Humor (1) can be therapeutic, but it is not an essential component of the therapeutic relationship. Reframing (3) and confrontation (4) are therapeutic techniques, however they are not foundational to the therapeutic process.

Rationale: The Denver Developmental Screening Test II (DDST-II) is a developmental screening test to assess gross motor skills, fine motor skills, language, and personal-social status. Three-year-old children should be able to coordinate the brain and gross motor function necessary to balance on each foot for one second. Tying shoelaces (1) and pedaling a bicycle (2) are not items assessed on the DDST-II. Dressing without supervision (3) is a DDST-II expectation in a 4-year-old child.

Rationale: By the ages of 3 to 6 years, a child becomes more aware of his or her influence on others and begins to develop a sense of right and wrong. The other answer options (1, 3, 4) are incorrect age ranges for this developmental milestone.

Rationale: The 56-year-old client on warfarin (Coumadin) with an INR of 7.5 should be assessed first by the nurse, because this is an elevated result. Normal is considered between 2 and 3. This result is not therapeutic, and the nurse should assess for bleeding and hemodynamic stability. The nurse should report the result to the physician and implement bleeding precautions. The other results are within normal ranges: hemoglobin for a 25-year-old male is 14-18 g/dl (1); serum calcium is 9.0-10.5 mg/dl (3); BUN is 5-20 mg/dl and creatinine is 0.7-1.5 mg/dl (4).

Rationale: A white blood cell (WBC) count of 17,200 mm3 would be highest priority because the count is elevated and may indicate an acute infection. Normal WBC results are 4300 to 10,800 mm3. The other results are within normal limits: potassium 3.5 to 5.0 mEq/L (1); hemoglobin 13.5 to 18g/dL (male) or 12 to 16g/dL (female) (2): platelets 150,000 to 450,000 mm3 (3).

Rationale: In a second-degree, or partial-thickness, burn both the epidermis and dermis are damaged. A first-degree, superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree, deep, partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue.

Rationale: The solitary play of infancy progresses normally into parallel play, where toddlers (ages 2 to 3) play alongside but not with other children. Solitary play (1) is the first stage of play where the infant (1 -2 years old) plays alone. During associative play (3), 3- to 4-year-old children play together, but it is loosely organized. In cooperative play (4), 4- to 5-year-old children play together, exchange ideas, and interact; cooperative play builds social skills.

Rationale: Allopurinol (Zyloprim) is one of several antigout medications that decreases serum and urine uric acid levels in clients who have a defect in uric acid metabolism. In these clients there is either an overproduction or underexcretion of uric acid. Allopurinol works by inhibition of the enzyme xanthine oxidase, which then blocks uric acid production. Decreased uric acid levels reduce joint inflammation, so the effect of allopurinal is not directly on inflammation (1). Allopurinol does not promote uric acid excretion (2) or relieve pain similar to an analgesic (3).

Rationale: Eczema or atopic dermatitis is a chronic condition with increased sensitivity to environmental allergens. The tendency for eczema is inherited. It is relieved in mild stages by emollient ointments and if moderate to severe by hydrocortisone creams. Topical antiviral agents (1), applying antipruritic cream (2), and applying cold wet compresses (3) will not relieve the discomfort associated with this disorder.

Rationale: Although all of these clients are in need of social services and discharge assistance, the newly diagnosed diabetic client is at greatest risk for complications from the condition and for the potential for poor diet and medication management because of his homelessness. The clients described in the other answer options (2, 3, 4) are less of a priority than the homeless client with newly diagnosed diabetes.

Rationale: Alcohol should be avoided by clients receiving anxiolytic therapy, because it enhances the effect of the medication. Drowsiness may be a side effect of an anxiolytic medication (1). Anxiolytics may be taken with or without food (2). Anxiolytic medications should be taken as prescribed by the ordering physician (3).

Rationale: Dilated blood vessels cause congestion extracranially and intracranially. This tension and stretching of tissue results in the pain of a migraine headache. When blood vessels constrict (2) or spasm (4), blood flow to the brain is decreased and may cause a transient ischemic attack (TIA) or cerebrovascular accident (CVA), but they do not cause a migraine. When blood vessels dilate, blood does not drain from the brain, but the vessels become congested (3).

Rationale: The nurse should not plan to use equipment that is known to be malfunctioning. The nurse could be held liable because he or she was notified by the night nurse and could reasonably foresee that properly functioning equipment would be needed by the client. Asking another nurse to check a malfunctioning pump (1) may be an option, however, if medical equipment is malfunctioning it is best to remove it from service and replace it. Following another nurses suggestion on how to get a malfunctioning pump to work (2) or attempting to use a malfunctioning pump (3) are inappropriate actions and may present safety risks to the client.

Rationale: A helping relationship is most effective when the nurse has come to terms with the client's issues and problems through his or her own process of self-awareness. Values (1) and understanding (3) are important qualities but not more important than self-awareness. Sympathy is not a therapeutic quality (2).

Rationale: The client’s wife should be questioned about medications, because many medications can cause confusion or agitation, either directly or secondarily to the desired effect. The nurse should ask about medications first to rule this out as a cause of the sudden onset of the symptoms. The nurse would also assess for signs of infection, which is also a cause of sudden onset delirium and confusion. The questions in the other answer options (1, 3, 4) are appropriate questions but are a lower priority.

Rationale: The client with stage 3 (severe) anxiety is the highest priority for the nurse to assess first, because she is disoriented and could experience an acute situation, which may pose a safety threat. A client who has paranoid schizophrenia and is pacing the halls should be assessed next as the pacing may escalate. A client who is socially withdrawn and refuses to eat, and a client with severe agoraphobia who refuses to leave her room are lower priority for the nurse to assess.

Rationale: A child must attain sphincter control and be able to communicate the need to void or defecate to the parents before toilet training can be achieved. This usually occurs between 18 months and 2 years of age. The other answer options (1, 2, 3) are incorrect.

Rationale: The body reacts to birth control pills in the same way it would react to a pregnancy. When a female is pregnant or taking birth control pills, the ovarian follicles produce increased levels of estrogen, resulting in the side effect of breast tenderness. Oral contraceptive pills increase estrogen levels, therefore answer option 1 is incorrect. When taking oral contraceptive pills, FSH (3) and LH (4) are suppressed.

Rationale: Psoriasis is a noncontagious autoimmune disease. It usually presents as itchy scales on the scalp, knees, or elbows due to an overproduction of skin cells. Other commonly affected areas are the joints, fingernails, and toenails. Psoriasis does not present as pustules (1), as a macular rash (3), or a vesicular rash (4).

Rationale: Decorticate posturing, described as flexion of the arms, wrists, and fingers, and adduction of the upper extremities, indicates the primary motor areas of the sensorimotor cortex, both anterior and posterior, have damage. The assessment findings described are not specifically related to a stroke (1) or cerebrovascular accident (CVA) and are not commonly seen in clients with epileptic seizure disorder (2). Decerebrate posturing (4) is described as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing may indicate more serious damage and result from disruption of motor fibers in the midbrain and brain stem.

Rationale: To prevent the various diseases caused by tick bites, the tick should be carefully removed immediately with tweezers. The longer the tick remains, the greater the chance that it will transmit a disease such as Lyme disease or Rocky Mountain spotted fever. Bathing with lice shampoo (1), or burning the tick and applying petroleum jelly (3), are not effective methods for tick removal Once the tick is removed, the site should be observed for redness, edema, or other signs of infection; if any of these are present, they should be reported to the client’s physician (4).

Rationale: Menstrual history to include details about any problems is usually a nonthreatening topic to most women and therefore is the best place to begin a gynecologic history. The other answer options (2, 3, 4) are appropriate questions that may be explored after beginning questioning with a less-invasive topic such as menstrual history.

Rationale: Narcolepsy is also known as sleep attacks. It is a syndrome characterized by sudden sleep attacks, sleep paralysis, and visual or auditory hallucinations at the onset of sleep. It is diagnosed by an EEG or by other brain studies that are used to distinguish narcolepsy from an intracranial mass or encephalitis. Insomnia (1) is difficulty falling or staying asleep. Parasomnia (2) is a disruptive sleep disorder that includes nightmares, night terrors, sleep walking, and confusional arousals. Hypersomnia (4) is excessive daytime sleepiness. Clients with hypersomnia can fall asleep at any time, which can be disruptive at work or dangerous when operating machinery or driving.

Rationale: The client’s hair should be free of oils, sprays, and lotions before an EEG. Oily hair or hair care products may interfere with conduction of neurological electrical impulses recorded during an EEG. Therefore client preparation includes shampooing the hair and refraining from using any other hair products. The other answer options (2, 3, 4) are preparations that are not required to be performed before an EEG.

Rationale: The fertilized ovum implants in the endometrium. Implantation in the myometrium (2), peritoneum (3), or cervical os area (4) may result in an ectopic pregnancy.

Rationale: Early symptoms of Parkinson’s disease include coarse resting tremors of the fingers and thumb, also known as pill-rolling movements. Akinesia (1), which is described as complete or partial loss of muscle movement, aspiration (2), and mental deterioration (3) occur later in the Parkinson’s disease process.

Rationale: Many antacids contain calcium. When clients ingest calcium-based antacids on a regular basis, serum calcium may elevate to toxic levels. Normal serum calcium is 9 to 10.5 mg/dL. Antidiarrheals (1), antihistamines (2), and analgesics (4) do not contain enough calcium to significantly alter a client’s serum level.

Rationale: Vitamin K is required for the production of prothrombin. Increased intake of dark green leafy vegetables that are high in vitamin K could reduce the anticoagulation effect of warfarin (Coumadin). The other answer options (2, 3, 4), if stated by this client, indicate that the teaching was effective.

Rationale: In this response, the nurse validates the client’s distress and provides her with an opportunity to talk about her feelings. Because the client is in crisis, decision making is difficult, even for simple tasks; therefore the nurse must be directive as well as supportive. The other answer options (1, 2, 4) do not address the client’s needs and are not therapeutic.

Rationale: The float nurse from the telemetry unit would realize that one form of COPD, such as chronic bronchitis, is likely to change into another form of COPD (such as emphasema). A client who suffers from emphasema would have a pink appearance and have dyspnea. Severe emphasema is also know as the "pink puffer".

Rationale: A classic sign of increasing intracranial pressure and neurological deterioration is an increased systolic blood pressure and decreased diastolic blood pressure (resulting in a widening pulse pressure) accompanied by bradycardia. Hypertension, bradycardia, and bradypnea together are known as Cushing’s triad. The information in answer options 1 and 4 does not indicate deterioration in neurological status. The information in answer option 2 indicates that the client requires continued assessment. Although the BP and pulse may be stable, the GCS has decreased from 14 to 9. A GCS of 15 is the best score with a fully awake, alert, and oriented client. Anything less than 8 is considered a coma.

Rationale: Displacement is a release or redirection of feelings and impulses upon a safe object or person as a substitute for that which aroused the feeling. Identification (1) is a defense mechanism of operating unconsciously, by which a person patterns him or herself after some other person. Substitution (2) is a defense mechanism of turning from an obstructed desire to one whose gratification is socially acceptable. Undoing (3) is not a defense mechanism.

Rationale: Masturbation is a method by which sexual discovery is made and tension is released. This is considered a normal process. The other answer options (2, 3, 4) are incorrect regarding masturbation.

Rationale: Naloxone hydrochloride (Narcan) is a pure opioid antagonist. It is administered intravenously and is the drug of choice for any opioid narcotic overdose. Narcan acts to compete with opioid molecules at the central nervous system receptor sites, thus blocking the opioid effect. The other answer options (1, 3, 4) are not antagonists for opioid narcotics.

Rationale: Repression is the unconscious defense mechanism whereby unacceptable thoughts, feelings, ideas, impulses, or memories are pushed from the conscious mind because of their painful guilt association or disagreeable content and are submerged in the unconscious. Traumatic past events, such as rape, are especially susceptible to repression. Projection (1) attributes strong conflicting feelings or faults to another person. Displacement (3) is the redirection or transferring of emotional impulses or feelings from the original source to something that is more acceptable and less threatening. Dissociation (4) is an alteration in an awake state where the person feels detached from his or her surroundings.

Rationale: Evaluation of the level of consciousness determines if the client is awake, the level of alertness, and the ability to respond to questions. Exploration of recent and remote memory (1) demonstrates the client’s ability to recall, focus, and concentrate. Mood and emotional state (2) are not part of the level of consciousness assessment. Articulation and rate of speech (4) reflect speech and language ability.

Rationale: White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike fungal infection. This condition is also known as “thrush”. Cytomegalovirus (1) may cause a serious viral infection in persons with HIV, resulting in retinal, gastrointestinal, and pulmonary manifestations. Histoplasmosis (2) is an infection caused by inhalation of spores of the fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and lymphadenopathy. Human papillomavirus (4) typically manifests as warts on the hands and feet as well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted without the presence of warts through body fluids with some forms associated with cancerous and precancerous conditions.

Rationale: Based on the information provided, the IV site is likely infiltrated. The nurse should determine if the IV cannula is in the vein by assessing whether there is blood return. If no blood return is found, the cannula should be removed. Based on the initial observation of the IV site as blanched and edematous, the other answer options (1, 2, 4) are inappropriate for assessment next.

Rationale: According to developmental theory, adolescence (ages 12-18) is a time when role identity is found as a result of independence, sexual maturity, and social relationships. Role confusion would result from the inability to integrate all experiences. The preschooler (3 to 5 years) manifests the developmental tasks of initiative versus guilt (1); this is a time of exploration. In the school-age child (ages 6-11), developmental tasks include industry versus inferiority (3). The young adult (ages 19-40) progresses through the developmental tasks of intimacy versus isolation (2).

Rationale: The client experiencing a petit mal or absence seizure displays a sudden vacant look and usually stares straight ahead. The petit mal or absence seizure is often unnoticed by the client or others. Dizziness (1) and/or intense anxiety (3) are not commonly associated with petit mal or absence seizures. An aura (2) is an individualized, subjective auditory, visual, olfactory, or taste hallucination that may precede a seizure. An aura experience is not specific to petit mal or absence seizures.

Rationale: Alopecia is the correct term used for hair loss. Exotropia (2) is a form of strabismus where the eyes deviate outward. Amblyopia (3) is a visual disturbance characterized by poor vision in one eye with or without structural abnormalities. Seborrhea (4) is also known as dandruff and is a form of inflammation of the skin resulting in redness and flaking. It may be seen on any part of the body but is usually seen on the scalp.

Rationale: TIAs are a warning of an impending stroke or cerebrovascular accident (CVA). They may occur hours or days before. TIAs are usually not neurologically damaging (1) or a sign of progressive brain damage (2). Clients should be instructed to report TIAs to their physician and not ignore them (4).

Rationale: In Parkinson’s disease, the tongue may have poor control, which places the client at risk for aspiration. Semisolid food without lumps and thickened liquids stick together so that the tongue can direct the food bolus into the back of the mouth. The client should be encouraged to self-feed (1) to maintain independence and function. Clear fluids with meals (3) or at any time may present a risk of aspiration if there is difficulty swallowing. In Parkinson’s disease, the tongue and entire mouth is likely affected, therefore answer option 4 is not an appropriate choice.

Rationale: Many antacids contain calcium. When clients ingest calcium-based antacids on a regular basis, serum calcium may elevate to toxic levels. Normal serum calcium is 9 to 10.5 mg/dL. Antidiarrheals (1), antihistamines (2), and analgesics (4) do not contain enough calcium to significantly alter a client’s serum level.

Rationale: A wrist restraint applied to prevent removal or maintain a medically necessary treatment, such as a nasogastric tube or intravenous line, legally requires a physician’s order. Any restraint device applied without a physician’s order could be considered grounds for legal action related to false imprisonment. Restraint documentation is required more often than every shift (2). Strict regulation standards guide these requirements and nursing care. Notification of the client’s next of kin is required when restraints are applied (3), but this is not the highest priority in this situation. The least restrictive measures must be taken, therefore, additional restraints (4) should only be used if absolutely necessary.

Rationale: Alcohol should be avoided by clients receiving anxiolytic therapy, because it enhances the effect of the medication. Drowsiness may be a side effect of an anxiolytic medication (1). Anxiolytics may be taken with or without food (2). Anxiolytic medications should be taken as prescribed by the ordering physician (3).

Correct Answer: 25 mL/hr
Rationale: (Dose of insulin that is ordered / Insulin that is available ) x Quantity = (5 / 100) x 500 = 25 mL/hr or 5 units/1 hour x 500 mL/100 units = 2500/100 = 25 mL/hr

Rationale: Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as MRSA, stool infected with Clostridium difficle, draining wounds where secretions are not contained, or scabies. Airborne precautions (1) are used for infected droplets smaller then 5 mcg, such as measles, chickenpox (varicella), or pulmonary TB. Droplet precautions (2) are used for droplets larger than 5 mcg and being within 3 feet of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective environment (4) focuses on clients with a compromised immune system to protect them from incoming pathogens.

Rationale: Estrogen production decreases during menopause and eventually ceases, causing the changes associated with menopause. During menopause, progesterone (2), luteinizing hormone (3), and follicle-stimulating hormone (4) levels also decrease but do not cause the changes associated with decreased estrogen.

Rationale: The nurse would typically expect to find the client with diabetes mellitus type 2 to exhibit the 3 "P"s polydipsia, polyuria, and polyphagia. Polycentric (option 2) means having several central parts, as a chromosome with multiple centromeres.

Rationale: Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation. These three positions (1,2,4) are inappropriate for a client after a liver biopsy.

Rationale: Male clients who want to conceive may try to prevent infertility by avoiding cigarette smoking and other forms of smoking such as cigars, pipes, and marijuana. Keeping the scrotum and testes cooler than body temperature by avoiding tight clothing (2) and excessive heat (3) may maintain and/or increase sperm count. Having frequent intercourse (4) when ovulation is likely to occur is not an instruction specific to the male client.

Rationale: The Glasgow Coma Scale ranges from 3 to 14. A score of 7 or less indicates that a client is in a coma. The lower the score, the more serious the client’s condition. The other answer options (2, 3, 4) indicate that client’s Glasgow Coma Scale score is higher then 7.

Rationale: Tingling in the fingers and headache may be an indication of an adverse reaction to the transfusion. The nurses' priority action is to stop the infusion and begin a normal saline infusion at KVO (keep vein open). The client should be assessedincluding vital signsthen the physician should be notified. The physician should be called (1) after assessment of the patient and implementation of immediate action to stop the transfusion. Slowing the infusion rate (3) is not appropriate if the patient is experiencing a reaction or suspected of having a reaction. Assessment of the IV site (4) is part of the general patient assessment and is not related to a blood transfusion reaction.

Rationale: A urine specimen is obtained for culture to determine the causative organism, then a broad-spectrum antibiotic may be given. After the organism is identified, an organism-specific antibiotic can be prescribed. Cultures are always obtained before antibiotics are administered. Urinalysis is nonspecific and will not identify the causative organism (1). A chest X-ray (3) and red blood cell (RBC) count (4) may be completed before the first dose of antibiotic; however, they do not provide diagnosis of the causative organism.

Rationale: The situation should be communicated to the nurse in charge to determine who would be a suitable peer to cover the assignment while the staff nurse is on a break. The staff nurse should leave the unit for break only when the assignment is appropriately covered. Upon returning from break, the staff nurse would be revitalized and ready to resume responsibilities. The other answer options (1, 2, 3) are inappropriate actions in this situation.

Rationale: Furosemide (Lasix) is a loop diuretic that will eliminate potassium from the body by preventing renal reabsorption in the Loop of Henle. Bananas are an excellent source of potassium. Milk (2), liver (3), and apples (4) are less postassium-rich than bananas.

Rationale: Therapeutic play can allow the child to be informal and release frustrations and feelings of fear, anger, and hostility. It may also help the nurse to gain insight into the child’s needs and feelings. In the hospitalized child, having fun (1) and getting to know other children (3) may be a secondary benefit of therapeutic play. Therapeutic play does not facilitate development of self-control (2).

Rationale: If antibiotics are prescribed, the client should not stop them; rather the entire course should be taken even if there are no signs of infection. Appropriate goals for this client are to be free of signs and symptoms of infection (1), to maintain a dry and intact dressing (2), and to know about reporting changes in the distal extremity (3).

Rationale: According to Piaget’s theory, at age 2 children begin to see that they can make things happen and will experiment with cause-and-effect relationships, for example dropping a toy from a highchair. According to Piaget’s developmental stages, preoperational (2) occurs between the ages of 2 and 7 and includes magical thinking and acquisition of motor skills. Concrete operations (3) occurs between the ages of 7 and 12 and includes logical thinking. Formal operations (4) occurs between the ages 12 and above and includes the development of abstract reasoning.

Rationale: First degree burn since the skin is red in color and without the presence of blisters.

Rationale: Tuberculosis is an airborne contagious disease that is best contained in a negative airflow room. Negative airflow rooms are always private. A private room (1), semiprivate room (2), and a room with windows that can be opened (3) are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

Rationale: Spontaneous bleeding, such as severe epistaxis (nosebleed), can be a life-threatening side effect of heparin therapy. Early detection of the risk for bleeding can be monitored through analysis of the partial thromboplastin time (PTT). Erythema (1), pyrexia (2), and vertigo (3) are not common side effects of heparin therapy.

Rationale: If medications are taken in the prescribed amount and at the prescribed times, therapeutic blood levels will likely demonstrate compliance. Asking the client when the anticonvulsant medication is being taken (1) will support results of monthly blood testing for serum blood levels. A written record of seizure activity (3) and weekly urine specimens (4) will not support compliance with medication.

Rationale: Cranial nerves IX (glossopharyngeal) and X (vagus) control swallowing and the gag reflex. The nurse must assess the gag reflex before administering oral medications or feedings, to prevent the risk of aspiration. Cranial nerve VII (facial) (1) controls the motor function of the face and the taste sensation of the anterior 2/3s of the tongue. Cranial nerve V (trigeminal) (2, 3) controls sensation of the forehead, face, nasal cavity, teeth, and eyes as well as the motor function of the muscles used for mastication. Cranial nerve XII (hypoglossal) (3) controls the motor function of the intrinsic and extrinsic muscles of the tongue.

Rationale: The client needs to learn how to communicate directly with his wife about her behavior. The nurse’s assistance will enable him to practice a new skill and will communicate the nurse’s confidence in his ability to confront this situation. The responses in the other answer options (1, 2, 4) could cause triangulation among the nurse, the client, and his wife.

Rationale: A turning schedule with corresponding documentation is best to ensure that the client is repositioned every 1 to 2 hours. Sliding the client instead of lifting (1) causes friction and possible skin tears. Turning and repositioning the client at least every 3 to 4 hours (2) is too long a period of time without a change of position. Lotion applied to the skin does provide moisture, however vigorous massage (3) may cause tissue damage.

Rationale: A deep partial-thickness burn involves the epidermal and dermal layers of the skin. It is characterized by a wet, shiny, weeping surface with blisters and is painful and very sensitive to the touch. Necrosis (3) and charring (4) are seen with a full-thickness burn. Redness and pain with minimal damage to the epidermis (2) are characteristics of a superficial, or first-degree, burn.

Rationale: Administering oxygen should be the first action of the nurse for this client. With anaphylaxis there is bronchial constriction and subsequent vascular collapse, therefore the airway is of primary concern. The vital signs should be checked (3) after beginning the administration of oxygen. At this point it would be appropriate to insert an IV catheter (2) to administer emergency medications and possibly obtain an arterial blood gas analysis (4) to determine oxygenation status.

Rationale: Untreated gonorrhea in females causes the fallopian tubes to develop fibrous tissue. This tissue hardens and constricts the lumen, causing sterility and a high risk for ectopic pregnancy. The other answer options (1, 2, 3) are not associated effects of gonorrhea in teenage females.

Rationale: Scabies are contagious microscopic mites that manifest as linear burrows, frequently seen between the fingers and toes. Scabies causes intense itching, especially at night. Varicella (2) (chickenpox) is a highly-contagious airborne disease that appears as a vesicular skin rash that is itchy. Contusion (3) is a bruise that results from blood leakage out of capillary vessels into surrounding tissue. Herpes zoster (4) (shingles) is a viral disease seen in older adults and manifests as a painful rash with blisters. Herpes zoster may occur as reactivation of the varicella virus, which is dormant in the ganglion after a primary case of chickenpox.

Rationale: Autonomic dysreflexia is a medical emergency that results when sensory stimulation below the spinal injury triggers a reaction in the intact autonomic system, with resulting reflex arteriolar spasms that increase blood pressure to extremely high levels. A distended bladder is a common trigger of this condition. Perfuse sweating below the level of injury and bradycardia are also seen. Although emotional stress (1), smoking cigarettes (2), and exposure to upper respiratory infections (4) should be avoided in a client with spinal cord injury, they are not associated with triggering autonomic dysreflexia.

Rationale: Nosebleeds can be indicative of high blood pressure in an adult. Of the choices provided, the first action of the nurse should be to check the client's blood pressure. If elevated, the nurse can initiate measures to decrease the blood pressure. The other options are appropriate but not the highest priority. A medication history (1) is critical to determine if the client is on any anticoagulation therapy. After assessment and care, client teaching might include instruction not to pick the nose (3). After the blood pressure is measured, checking the pulse rate (4) would be performed as part of the general vital signs assessment.

Rationale: Immunizations and vaccines enhance the immunological defenses of the host by stimulating the production of protective antibodies (active immunization) or by the actual administration of antibodies for specific diseases (passive immunization). Immunizations do not eliminate the mode of infection transmission (2), introduce a weak secondary infection (3), or block the immune response of the host (4).

Rationale: The statement “I’m sure everything will turn out fine” offers false reassurance and is the least therapeutic response, given the available information. The nurse should listen attentively and encourage the client to verbalize his feelings. Using touch, eye contact, and leaning in towards the client (3, 4) are therapeutic techniques. The question in option 2 is a closed-ended question and will not elicit details regarding the client’s fears.

Rationale: Sperm production occurs in the testes. The prostate (2), epididymis (3), and vas deferens (4) are specific to the male reproductive system and assist sperm to travel and exit the body.

Rationale: Clients with expressive aphasia require teaching and encouragement to use alternative techniques of communication to make their needs known and interact with others. Clients with expressive aphasia may not be able to communicate verbally (1), however they may still communicate using other techniques such as vocal sounds or eye movements. Manipulating the environment (3) is not a related outcome for expressive aphasia. In some cases expressive apashia may not be permanent (4).

Rationale: Petechiae are small pink to purplish macular lesions 1 to 3 mm in diameter usually caused by minor hemorrhage of capillary blood vessels. Purpura (1) is the appearance of red or purple discolorations on the skin that do not blanch on applying pressure. Purpura is associated with bleeding under the skin and is seen in various bleeding disorders. Hematoma (2) is a localized collection of blood outside the blood vessels that is generally the result of hemorrhage. Ecchymosis (4) is a collection of blood under the skin larger than petechiae with diffuse borders.

Rationale: The nurse must consider age, diagnosis, and especially developmental level when planning and deciding which type of play activities would be most therapeutic. The assessment items in the other answer options (1,3, 4) are appropriate, but they are secondary to assessing the child’s developmental level.

Rationale: Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying semi-Fowler's or higher. Skin breakdown (1) in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus (3) is not related to an NG tube. A client who develops profuse diarrhea (4) with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.

Rationale: Guillain-Barre syndrome is an autoimmune disease that destroys the myelin sheath covering of peripheral nerves. Symptoms can be mild to severe involving full body paralysis. Frequently, the muscles controlling respiratory function may be affected, resulting in respiratory failure. The disease causes rapid progressive symmetrical loss of motor function that ascends from the extremities to the head. Although Guillain-Barre syndrome may affect some functions of urinary (1), cardiac (2), and gastrointestinal systems (4), the most important area for the nurse to monitor is respiratory status.

Rationale: Taking the vital signs of a client completing a blood transfusion, who has been stable, is a routine function. The danger of a transfusion reaction is not likely to occur. Because the client is completing the transfusion and has been stable, it is appropriate for the nursing assistant to perform this task. However, it is the nurse’s responsibility to evaluate the vital signs. An indwelling urinary catheter requires assessment by the nurse to determine cause for the catheter not draining well (1). A newly admitted postoperative client (2) requires a nurse assessment. A new post-CVA client (3) is at risk for aspiration and requires monitoring by the nurse when eating for the first time.

Rationale: Family history is not an important factor in the development of pressure ulcers and general skin integrity. Conditions that place the client at risk based on a validated tool such as the Braden scale (3, 4) and areas of skin already broken down (2) require immediate assessment and intervention.

Rationale: The Papanicolaou, or Pap, smear test screens for cervical cancer. The woman should be instructed to avoid intercourse, or inserting anything into the vagina or douching within 24 hours of the test. The test should not be performed during a woman’s menses (1) or if a heavy infectious discharge (3) is present. No type of douche including saline (4) should be used before the examination.

Rationale: MS causes muscle spasticity as loss of the myelin sheath progresses. Muscle relaxants decrease these spasms. Narcotic analgesics (1) are used to treat severe pain, which is usually not associated with MS. Anticholinesterase (2) medications increase the level of the neurotransmitter acetylcholine at the nerve synapse to increase nerve impulse transmissions. These medications are used in the treatment of myasthenia gravis, not MS. Antihypertensives (4) are not routinely used, as hypertension is not related to MS.

Rationale: The “Rule of Nines” is a method used to determine the body surface area (BSA) of a burn injury. It accounts for 9% for each arm, 9% for the head, 18% for the anterior torso, 18% for the posterior torso, 18% for each leg, and 1% for the genitals. The other answer options (1, 2, 4) are incorrect based on the BSA “Rule of Nines” estimate.

Rationale: The eggs of lice, known as nits, are seen as white oval dots attached to hair shafts. The lice are not usually visible. Diffuse pruritic wheals (1) may be seen with localized inflammatory responses such as insect bites. Itchy redness and edema over the area of infestation (3) are not characteristic of head lice. Pruritic papules with linear burrows at the hairline (4) are characteristic of scabies.

Rationale: Popular cognitive-behavioral approaches examine the validity of habitual patterns of thinking and belief systems that influence feelings and behaviors. The other answer options (1, 2,3) are not appropriate with a cognitive behavioral approach.

Rationale: The child, unable to understand his mother’s absence, feels abandoned and reacts by ignoring his mother. The child has developed the sense of knowing his mother will return but is expressing his feelings of abandonment in a passive-aggressive manner. It is important for the mother to continue to stay with the child as much as possible and have an understanding of the reason for the toddler’s behavior in order to maintain a caring relationship. The other answer options (2, 3, 4) are incorrect.

Rationale: To treat and prevent the spread of syphilis, all sexual contacts of the client must be identified and treated. This is a legal requirement not only for syphilis but also for other venereal diseases in all states. The other answer options (1, 3, 4) are important interventions for the client with syphilis after identification of all sexual contacts of the client.

Rationale: Application of a cool, wet dressing followed by an analgesic is usually effective in relieving discomforts related to herpes zoster (shingles). The application of any form of warmth (1, 2, 4) may increase sensitivity of nerve endings and increase pain.

Rationale: The most important change a woman can observe for is that the cervical and vaginal mucous secretions greatly increase just before ovulation. The mucus is clear and is more receptive to sperm. The other answer options (1, 3, 4) are incorrect statements.

Rationale: The nurse should stay on the unit with the assigned clients until a relief nurse is available. The nurse should communicate the situation to the nurse in charge, manager, or supervisor. Leaving the assigned clients without professional coverage is considered abandonment and is unsafe (2, 4). Checking the hospital policy and procedure (3) may be appropriate, but the nurse should still remain on the unit providing nursing care.

Rationale: A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism that can inhibit wound healing. Therefore the client with a burn injury requires increased calories and protein to enable the healing process. Protein intake (1) in the burn client should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased. A hypermetabolic state (2) is not desired and is a complication of a burn injury. Controlling the temperature of the environment (4) has no effect on caloric requirements.

Rationale: Handwashing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all these interventions (2, 3, 4) are acceptable procedures and may assist in preventing the spread of infection, none are as effective as handwashing.

Rationale: Heparin directly affects fibrin clot formation by prolonging the coagulation process. This timing is measured by the partial thromboplastin time (PTT). Warfarin (Coumadin) prolongs prothrombin time (PT) (2); aspirin decreases platelet aggregation (1); and phytonadione (vitamin K) is necessary for prothrombin formation and is used as an antidote for warfarin (4).

Rationale: Fertilization takes place in the fallopian tube, followed by implantation in the uterus. Fertilization in the ovary (1), uterus (2), or cervix (3) is possible but present high risk for ectopic pregnancy or failure to implant.

Rationale: The nurse must gain maximum cooperation from the child while doing an examination. Cooperativeness will be more difficult to elicit if the procedure is painful and invasive. The actions in the other answer options (1, 3, 4) are incorrect and may cause fear, anxiety, and decreased cooperation. Allowing the child to play with the equipment (4) is important but not as important as performing painful procedures last.

Rationale: Hypokalemia heightens sensitivity to digoxin, predisposing the client to digoxin toxicity. Hyponatremia (1), hypernatremia (2), and hyperkalemia (3) are usually not related to or found in clients receiving digoxin unless there is another underlying cause.

Rationale: The answer options (1, 2,3) are acceptable delegation tasks by an LPN to a unregulated care provider or nursing assistant. The LPN cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraints requires frequent assessment to determine physical and emotional status. The nurse is ultimately responsible for the monitoring and care of clients in restraints, including deciding when it is appropriate for restraints to be removed and ensuring that the client’s physical and emotional needs are met.

Rationale: Asking for clarification encourages the client to attempt to put into words vague ideas or unclear thoughts. This is accomplished by directly asking the client to explain what is meant. The value of clarification is to clarify feelings, ideas, and perceptions. Restating (1) is the same as paraphrasing another’s message more briefly using one’s own words. Exploring (2) may be used as a technique of asking relevant questions. Providing feedback (4) is the measure by which the effectiveness of a message is gauged.

Rationale: Because the client was discovered without shoes in the snow, he should be evaluated for frostbite and hypothermia before psychiatric interventions. The clients physical needs must be attended to before his psychiatric needs. If the client is found to need medical attention, admission to a medical unit is appropriate (3); otherwise a more thorough psychiatric assessment should be performed (2). Attempting to contact a family member to obtain an accurate client history will help with meeting both physical and psychiatric needs (4).

Rationale: Clean gloves should be worn to wash a client to prevent transmitting microorganisms from the client to the nurse assistant during the bath. If the nurse assistant is allergic to latex or is latex sensitive, nonallergic and nonlatex gloves should be used. The actions in the other answer options (1, 3, 4) are appropriate.

Rationale: The nurse must be especially alert to any changes in respirations, because morphine decreases the respiratory center function in the brain. An order for morphine should be questioned if the baseline respirations are less than 12 per minute. Neurological status (2) along with pulse and blood pressure would be a priority assessment after respiratory rate. Measurements of temperature (1) and urinary output (4) are part of the overall client assessment but not a priority with morphine.

Rationale: The client scheduled for a cholecystectomy who is complaining of chills should be assessed first by the nurse. This situation is potentially unstable because chills are an indication of an infectious process, which would be a contraindication for the client to undergo surgery. The 55-year-old client who needs assistance with a urinal (1) may be delegated to a NA. The 32-year-old client refusing medication (3) would require assessment and intervention by the nurse to determine the reason for refusing the medication. The 65-year-old with a draining nasogastric tube (4) would require assessment by the nurse.

Rationale: The airway is always checked first in a client who is determined to be unresponsive. If there is no oxygen, blood will not be oxygenated even if the heart is pumping. Action must be taken within 4 to 6 minutes or permanent brain death will occur. After opening the airway and checking for breathing, the next step is to give breaths if the client is not breathing. If the breath does not go in, the nurse may sweep the mouth for a foreign object (4). If the airway is still obstructed, abdominal thrusts and back blows (3) may be performed. If breathing is accomplished, the nurse should check for a pulse and initiate CPR (1) as appropriate.

Rationale: Pelvic infections can cause the formation of scar tissue and obstruct the fallopian tubes. This process can prevent fertilization and actually make her more prone to ectopic pregnancies. The other answer options (1, 2, 3) would be appropriate topics to cover in this client’s history but are not as important as discussing recurrent pelvic infections as a possible cause of infertility.

Rationale: A wet-to-dry dressing is used to debride infected or necrotic wounds. The moistened gauze in contact with the wound increases absorbency to collect exudate and wound debris. A dry gauze pad should be used to cover the wet dressing. A wet-to-dry dressing should not be covered with an occlusive dressing (1) because it will not allow moisture to escape, thereby preventing the drying effect. Tightly packing a wet-to-dry dressing into a wound (2) and allowing the dressing to dry completely before removal (3) are not necessary to achieve the desired effect.

Rationale: This response answers the client’s question honestly and nonjudgmentally. It also helps preserve the client’s self-esteem. The other answer options (1,2, 3) do not directly focus on the client’s self-esteem and do not answer the client’s questions.

Rationale: If the woman has not voided in the last 5 hours since delivery, she should be encouraged to ambulate to the bathroom. This may assist her in voiding, as well as prevent complications related to immobility. Catheterization may be required, but only after she is given the opportunity to void on her own. Heavy postdelivery bleeding (2) is a risk but there is no indication of this problem. This client not being able to void 5 hours postdelivery is not normal (3) and does need to be addressed. Instructing the NA to monitor the fluid intake over 2 hours and report back (4) is a poor option because the urinary retention needs to be addressed now.

Rationale: Catharsis is the sudden release of emotional energy from activities such as talking or exercise, resulting in a sense of relief and improved emotional well-being. Ventilation (1) is what occurred during the session. Reframing (2) is a technique of changing the viewpoint of a situation and replacing it with another that fits the facts well but changes the meaning. Sublimation (3) would not involve clients discussing their problems openly.

Rationale: The nonblinking eye is a cardinal sign of Bell’s palsy. Facial pain (1), slurred speech (2), and sagging facial muscles (4) are not exclusively symptoms of Bell’s palsy. Facial pain may be observed in trigeminal neuralgia. Slurred speech and sagging facial muslces are commonly seen with a cerebrovascular accident (CVA).

Rationale: Diminished wheezing in a child with asthma indicates possible worsening of respiratory obstruction, especially when presented with irritability and pale skin. This child is probably experiencing hypoxia and is at risk for respiratory arrest without immediate intervention. The 1-year-old with vomiting and diarrhea (2) should be seen next because of the risk for hemodynamic instability due to dehydration. The 6-year-old who fell off her bicycle (3) and the 7-month-old who rolled off a chair (4) are lower priorities than the clients in options 1 and 2.

Rationale: Children have fantasies that include imaginary friends as part of the fantasy. At this stage of development, it is considered normal behavior. If this behavior continues into the preschool or school-age developmental stages, it may indicate a psychiatric issue (2, 3, 4).

Rationale: Rolling the swab from the center outward is the correct procedure to culture a wound. The other answer options (1,2,4) describe procedures that can contaminate the wound and/or produce inaccurate results.

Rationale: Kernig’s sign is elicited when the client complains of pain in the lower back with resistance to straightening the leg. This occurs when the leg is extended while the thigh is flexed toward the abdomen. Homan’s sign (1) is pain in the calf when the foot is passively dorsiflexed. This is an early sign of venous thrombosis in the deep veins of the calf. Nuchal rigidty (3) is also a key sign of meningitis, but it refers to neck stiffness. Brudzinski’s sign (4) is the involuntary flexion of the hips and knees when the neck is flexed and occurs due to meningeal irritation.

Rationale: In Erikson’s stage of initiative versus guilt (preschool, ages 3 to 5), children explore their physical world with great inquiry. They also develop a conscience and feel guilty if told they are bad. The task of trust occurs during infancy (birth to 18 months) (1); the task of industry (school age, 6 to 11 years) (2); and the task of autonomy (early childhood, 2 to 3 years) (4).

Rationale: A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Preparing to reinsert a new chest tube (4) is not a priority of the nurse at this moment. Positioning the client on either the left (1) or right side (2) will not make a difference in outcome.

Rationale: A normal ICP reading is 0 to 15 mm Hg. ICP values greater than 25 mm Hg (2, 3, 4) represent a life-threatening condition requiring immediate intervention.

Rationale: Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for being unable to sleep and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV (1), dislodging a skin graft (3), or preventing falls (4).

Rationale: When the client correctly states his birthday and day of the week, it is a direct reflection of the nurse’s reorientation intervention being successful. The other answer options (1, 3, 4) do not necessarily reflect a positive outcome.

Rationale: The fertilized ovum implants in the endometrium. Implantation in the myometrium (2), peritoneum (3), or cervical os area (4) may result in an ectopic pregnancy.

Rationale: An elevated temperature of 38.5C (101.3F) is most indicative of a systemic infection. A white blood cell (WBC) count of 8200/mm3 (1) is within the WBC normal range of 5000-10,000/mm3. Pedal edema (2) is generally not related to an infectious process. Pale skin and nailbeds (4) may be related to an infectious process but not necessarily.

Correct Answer: 8 mL/hr
Rationale: (dose of heparin ordered / dose of heparin available) x Quantity = (800 / 25,000) x 250 = 8 mL/hr or 800 units/1 hour x 250 mL/25,000 units = 200,000/25,000 = 8 mL/hr

Rationale: Digoxin causes hypercalcemia and hypokalemia. Bananas and oranges are high in potassium and low in calcium. The other answer options (1,2) are not directly restricted or encouraged in clients receiveing Lanoxin (digoxin).

Rationale: Communication of a work assignment is considered an essential part of effective delegation. When assigning the task, information should be communicated in a clear, concise manner. The steps of effective delegation include: (a) identify the task; (b) analyze the skill and knowledge needed to accomplish the task; (c) identify the right person; (d) assign the task; (e) validate the person’s understanding by asking him or her to verbalize the main points; and (f) provide feedback and follow-up as needed. Functioning from an authoritarian leadership style (1) and obtaining staff members’ voluntary acceptance of assigned tasks

Rationale: Healthcare institutions must provide adequate staffing with qualified personnel. Nurse managers should try to alleviate short staffing situations by approving overtime, reassigning personnel, restricting admissions, and notifying the direct supervisor. The other answer options (1, 2, 3) are inappropriate and may present safety risks.

Rationale: In a group, an individual has the opportunity to learn that others have the same problems, concerns, and needs. The group can also provide a forum in which new methods of relating to others can be practiced. In psychotherapy, focus remains on the individual even though in a group setting (1). A group fosters the relationship with the therapist regardless of his or her title (2). Individuals may be confronted with their weaknesses in a group, but it is not a key advantage of a group (3).