Board 2

Safety and Infection

100

9) A client in the outpatient clinic has a leg immobilizer applied and receives teaching from the registered nurse (RN) on the use of crutches. The practical nurse reinforces the RN’s teaching prior to discharge. Which instructions would require the RN to intervene? Hold one crutch in each hand when standing up from a chair Hold both crutches on the same side when standing up from a chair Touch the back of legs to the seat of the chair when preparing to sit Use an armrest or seat for assistance when lowering body into a chair

1 Standard-type crutches remove the weight from one or both legs and shift it to the upper body. Therefore, if a client is lacking the upper body strength or balance required to use crutches, a walker may be prescribed instead. To rise from a chair, the client holds both crutches by the hand grips with the hand on the same side, slides to the edge of the chair, and grasps the armrest with the other hand or places it on the seat. The client then pushes down on the crutches and the armrest, and uses the unaffected leg for support to rise from the chair. 
To sit in a chair, the procedure is reversed. The client backs up to the chair until the seat isfelt against the legs, and moves both crutches into the hand on the same side and holds them by hand grips. The client then pushes down on the crutches, reaches back to the armrest or seat with the other hand, uses the unaffected leg for support, and lowers the body into the chair. (Option 2).This instruction by the PN is correct; both crutches should be held on the same side. The side on which the crutches are held may vary based on health care provider instructions and the client’s injury, physical condition, and degree of upper body strength. The client should not hold crutches on both sides of the chair or in front when getting into or up from a chair. (Option 1) (Option 4) This instruction by the PN is correct; crutches should never be used as total support, hand should always be placed on the armrest or seat of the chair for assistance.

200

10) A parent calls the clinic nurse concerned about a 5-year old with a nosebleed. The parent says the child had a similar incident one week ago while at school. Which instructions should the nurse provide? Select all that apply. 1) Apply a cold cloth to the bridge of the nose 2) Apply continuous pressure to the nose for 10 minutes 3) Have the clid lie down and turn to the left side 4) Keep the child calm and quiet 5) Take the child to the emergency department

1, 2, 4 The initial step in treatment is to tilt the client’s head forward and apply direct, continuous pressure to the nose for 5-10 minutes (Option2). Pressure should be aapplited to the soft, compressible ares below the nasal bone; holding pressure on the nasal bridge does not provide effective relief. Holding a cold cloth or ice pack to the bridge of the nose may also help to induce vasoconstriction (Option 1), Keeping the child quiet and calm may help provide the adequate time and pressure necessary for clotting (option 4). Option 3: A common mistake in epistaxis treatment includes having the client lie down and/ or tilt the head back. These positions can cause blood to drain into the mouth and throat, increasing the risk of swallowing or aspirating blood. The client should sit upright and tilt the head forward. Option 5: Epistaxis is rarely an emergent condition and usually responds to home treatment. However, emergency care should be sought if the client has difficulty breathing, bleeding is excessive and not controlled with multiple attempts with home measures, or the bleeding resulted from an injury that may have cause nasal fracture.

300

11). The nurse auscultates rhonchi in a client with a tracheostomy tube and performs endotracheal suctioning to clear secretions. Which nursing interventions are most appropriate to limit the risks associated with suctioning? Select all that apply. 1). Apply suction only while withdrawing catheter 2) Instill sterile normal saline to loosen secretions 3) Limit aspiration time to 10 seconds with each suction pass. 4) Maintain sterile technique throughout suctioning procedure 5) Preoxygenate with 100% oxygen.

1, 3, 4, 5 Endotracheal suctioning is performed to maintain a patent airway if a client cannot mobilize secretions independently. Inserting a catheter into the airway compromises the sterility of the lower airway and increases the risk for infection. Suctioning removes oxygen in addition to secretions, placing the client at risk for hypoxemia. High suction levels or the contact of the catheter with the trachea can cause trauma, such as barotrauma and damage to the tracheal mucous. In order to decrease the occurrence of these complications: *Use sterile technique throughout suctioning process. *Pre-oxygenate with 100% oxygen for 3-4 breaths. *Aspirate during withdrawal of catheter only, limiting each suction pass to 10 seconds. *Allow client 4-5 recovery breaths between suction passes to replenish oxygen. (Option 2): Instilling 5-10 mL of sterile normal saline solution (NSS) is thought to help loosen thick secretions and stimulate cough. Although saline lavage is a common practice in some facilities, the installation of NSS into the airway prior to suctioning is not recommended. It can dislodge bacteria, causing increased bacterial colonization, and can stimulate excessive coughing.

400

12). When caring for an adult client who is in soft wrist restraints, what is the appropriate nursing action to prevent interference with medical treatment? 1) Assess Braden scale every 2 hours 2) Assess peripheral circulation and neurovascular status every hour 3) Offer liquids, nutrition, and toileting every 4 hours 4) Release the restraints and perform range of motion exercises (ROM) every 30 minutes.

2 Wrist restraints can cause skin breakdown and circulatory and neurovascular deficits. According to the guidelines, the nurse assesses skin integrity and neurovascular status (pulses, color, skin temperature, sensation, movement) every hour. Option 1: The Braden scale is a risk assessment tool used in acute and long-term care settings to identify clients at risk for pressure ulcers. It is usually performed daily. Option 3: unless the client is receiving continual IV fluids, enteral feedings, or has an indwelling urinary catheter, fluids, nutrition, and tolieting are offered every 2 hours or as needed. Option 4: restraints are released, ROM exercises are performed, and skin integrity is assessed every 2 hours or as needed.

500

13) The nurse is reinforcing teaching about constipation prevention to a client. Which statements by the client indicate a need for additional instruction? Select all that apply. 1) “I will go to the restroom when I have the urge to have a bowel movement” 2) “I will increase my exercise to at least 3 times a week.” 3) “I will increase my intake of fruits and vegetables.” 4) “I Will increase my tea or coffee consumption to stimulate the bowel.” 5) “I will use a laxative every other day if needed.”

4, 5 The client and/or caregiver is taught the following to prevent constipation: *Consume 20-30 g of fiber a day; fiber softens stool and increases bulk, stimulating defecation. High fiber foods include fruits, vegetables, whole grains, nuts, seeds, and legumes. *Drink 2-3 L of fluids a day; avoid caffeinated beverages which promote diuresis. Exercise at least 3 times a week; movement stimulates peristalsis and defecation (Option 2) *Maintain a healthy bowel regimen; avoid delaying defecation when the urge is felt; defecate at the same time each day, and track bowel movements to identify if there is a change in bowel patterns (Option 1) *Avoid laxatives and enemas unless prescribed by healthcare provider; overuse can cause dependency. Option 4: Consuming 8 glasses of water and fruit juices is recommended. Clients should avoid caffeineated beverages, which promote diuresis, which may lead to dehydration, and worsen constipation. Option 5: Overuse of laxatives or enemas can lead to dependency and fluid and electrolyte imbalance.

NCLEX FUN!

100

13). A 6 month old is admitted with bacterial meningitis. Which action is the priority of care? 1) Administering antibiotics 2) Avoiding environmental stimuli 3) Initiating seizure precautions 4) Measuring head circumference

1 Bacterial meningitis occurs when infection causes inflammation in the meninges of the brain and spinal cord. This inflammation may lead to hydrocephalus and increased intracranial pressure (ICP). Due to the risk for severe complication from meningitis and increased ICP, the priority of care is immediate antibiotic therapy. Lumbar puncture (LP) with cerebrospinal culture is performed to determine the causative organism. Antibiotic choice may be adjusted later based on LP results. The client should remain on isolation precautions for a minimum of 24 hours following initiation of antibiotic therapy. Option 2: Clients with meningitis are often very sensitive to stimuli. Although environmental stimuli should be reduced as much as possible, the priority of care is initiating antibiotic therapy. Option 3: Seizures may occur in infants with bacterial meningitis and are often accompanied by a shrill-high pitched cry. There is no indication that this client has experienced a seizure. The nurse should carefully monitor for seizure activity and place the client on seizure precautions if necessary. However, antibiotic therapy is the most critical intervention in treating bacterial meningitis. Option 4: Although obtaining an initial head circumference is necessary to monitor for changes related to increasing ICP, the priority is obtaining blood cultures and administering antibiotics as soon as they are prescribed.

200

15) Which action by the healthcare worker indicates a need for further teaching? 1) The nursing assistant wears gloves while giving the client a bath. 2) The nurse wears goggles while drawing blood from the client. 3) The doctor washes his hands before examining the client. 4) The nurse wears gloves to take the client’s vital signs.

4 It is not necessary to wear gloves to take the vital signs of the client under normal circumstances. If the client has active infection with methicillin resistant staphylococcus aureus, gloves should be worn. The other answer choices indicate knowledge of infection control by the actions, so answers 1, 2, and 3 are incorrect.

300

14) Which action by the healthcare worker indicates a need for further teaching? 1) The nursing assistant wears gloves while giving the client a bath. 2) The nurse wears goggles while drawing blood from the client. 3) The doctor washes his hands before examining the client. 4) The nurse wears gloves to take the client’s vital signs.

4 It is not necessary to wear gloves to take the vital signs of the client under normal circumstances. If the client has active infection with methicillin resistant staphylococcus aureus, gloves should be worn. The other answer choices indicate knowledge of infection control by the actions, so answers 1, 2, and 3 are incorrect.

400

16) Which client should be assigned to a private room if only one is available? 1) The client with Cushing’s syndrome 2) The client with diabetes 3) The client with acromegaly 4) The client with myxedema

1 The client with Cushing’s syndrome has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed, and he should not have a roommate because of the possibility of infection. In answer 2, the client with diabetes poses no risk to other clients. The client in answer 3 has an increase in growth hormone and poses no risk to himself or others. The client in answer 4 has hyperthyroidism or myxedema and so poses no risk to others or himself.

500

17) The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available? 1) Intravenous access supplies 2) Emergency intubation equipment 3) Intravenous fluid administration pump 4) Supplemental oxygen

2 For a child with LTB and the possibility of complete obstruction of the airway, emergency intubation equipment should always be kept at the bedside. Intravenous supplies and fluid will not treat an obstruction, so answers 1 and 3 are incorrect. Answer 4 is incorrect because although supplemental oxygen is needed, the child will need to be intubated for it to help.

Health Promotion and Maintenance

100

A nurse is instructing the client who had a herniorrhaphy how to reduce postoperative swelling following the procedure. Which of the following would the nurse suggest to the client to prevent swelling? a. Apply heat to the abdomen. b. Elevate the scrotum. c. Limit fluids. d. Maintain a low-roughage diet.

Answer: B Rationale: Following herniorrhaphy, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The client is also instructed to apply a scrotal support when out of bed. Cold compresses reduce swelling and inflammation, whereas heat and is indicated for joint and muscle stiffness. Cold causes vasoconstriction and heat causes vasodilation. Fluids are needed for the healing process, and a low fiber diet will alleviate overstimulation of GI tract, but prolonged low-fiber diet will cause constipation.

200

A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard? a. Void into a bedpan and then empty the urine into the toilet. b. Purchase extra bottles of scented disinfectant for daily bathroom cleansing. c. Have one bathroom strictly set aside for the client's use for the next 2 months. d. Disinfect the toilet with bleach after voiding for 6 hours after a treatment.

Answer: D Rational: After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours after the treatment. Using a bedpan for voiding is of no value in this situation. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use.

300

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

Answer: C Rationale: Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention.

400

The nurse is providing discharge instructions to a client following gastrectomy. Which measure will the nurse instruct the client to follow to help prevent dumping syndrome? a. Eat high-carbohydrate foods. b. Limit the fluids taken with meals. c. Ambulate following a meal. d. Sit in a high-Fowler’s position during meals.

Answer: B Rationale: The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods including fluids, such as fruit nectars; to assume a low-Fowler’s position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.

500

A nurse manager on an oncology nursing unit notes an increased incidence of infection and serious consequences for clients on the unit. Which action by the nursing manager is most beneficial in this situation? a. Review asepsis policies at a mandatory in-service for staff. b. Spot-check all staff for good handwashing practices. c. Develop standard protocols to identify and treat clients with infection. d. Institute protective precautions for all clients receiving chemotherapy.

Answer: C Rationale: Treatment delays have a serious negative impact on neutropenic clients with infection. Nursing units should have standardized protocols to obtain cultures and diagnostic tests, and to start antibiotics as soon as a client is suspected of having an infection. In-services and spot-checking for good handwashing practice are good ideas as part of a comprehensive infection control practice but are not as important as standard protocols that ensure rapid diagnosis and treatment. Not all clients on chemotherapy will need protective precautions.

Physiological Integrity:Pharmacological Therapy

100

Lab results indicate that a client receiving heparin has a prolonged bleeding time. Which medication is the antidote for heparin?

A. Aquamephyton (phytonadione)
B. Ticlid (ticlopidine)
C. Protamine sulfate (protamine sulfate)
D. Amicar (aminocaproic acid)

Answer C is correct. Protamine sulfate is the antidote for heparin overdose. Aquamephyton is the antidote for sodium warfarin overdose; therefore, answer A is incorrect. Ticlid is used to inhibit platelet aggregation and decrease the incidence of strokes; therefore, answer B is incorrect. Amicar is used in the management of hemorrhage caused by thrombolytic agents; therefore, answer D is incorrect.

200

A client with allergic dermatitis has a prescription for a Medrol (methylprenisolone) dose pack. The client asks why the number of pills decreases each day. The nurse’s response is based on the knowledge that a gradual decreasing of the daily dose is necessary to prevent:

A. Cushing’s syndrome
B. Thyroid storm
C. Cholinergic crisis
D. Addisonian crisis

Answer D is correct. Gradual decreasing of the daily dose of steroid medication is necessary to prevent an Addisonian crisis caused by adrenocortical hyposecretion. Cushing’s syndrome is the result of adrenocortical hypersecretion; therefore, answer A is incorrect. Answer B is incorrect because a thyroid storm is the result of untreated hyperthyroidism. Answer C is incorrect because a cholinergic crisis is the result of overmedication with anticholinesterase drugs

300

The physician has discharged a client with diverticulitis with a prescription for Metamucil (psyllium). When teaching the client how to prepare the medication, the nurse should tell the client to:

A. Dissolve the medication in gelatin or applesauce
B. Mix the medication with water and drink it immediately
C. Sprinkle the medication on ice cream or sherbet
D. Take the medication with an ounce of antacid

Answer B is correct. Metamucil should be mixed with the recommended amount of water and drunk immediately. Answers A, C, and D are improper ways of preparing the medication; therefore, they are incorrect.

400

A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching?

A. “When drawing up my insulin, I should draw up the regular insulin first.”
B. “When drawing up my insulin, I should draw up the NPH insulin first.”
C. “It doesn’t matter which insulin I draw up first.”
D. “I cannot mix the insulin, so I will need two shots.”

Answer A is correct. Regular insulin should be drawn up before the NPH. They can be given together, so there is no need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer C is incorrect because it does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times.

500

A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:

A. Agonist effect
B. Synergistic effect
C. Antagonist effect
D. Excitatory effect

Answer B is correct. The combination of the two medications produces an effect greater than that of either drug used alone. Agonist effects are similar to those produced by chemicals normally present in the body; therefore, answer A is incorrect. Antagonist effects are those in which the actions of the drugs oppose one another; therefore, answer C is incorrect. Answer D is incorrect because the drugs would have a combined depressing, not excitatory, effect.

Physiological Integrity: Pharmacological Therapy 2

100

1. A patient in CCU (Coronary Care Unit) is receiving Digoxin (Lanoxin) and Furosemide (Lasix). In assessing the patient’s lab values, which of the following might the nurse expect to see?

a. Increase specific gravity of urine
b. Hyperkalemia
c. Hypokalemia
d. Hypernatremia

C. Loop diuretics such as Lasix result in potent diuresis. The most common side effects are electrolyte imbalances such as hypokalemia, hyponatremia making choices (1), (2) and (4) incorrect. In addition, Digoxin taken in combination with loop diuretics can result in digitalis toxicity, so the nurse should be alert to this and normal serum lab values for Digoxin (Norm: 0.5-2.0 ng/ml). The nurse should be aware that there is a very small variance between therapeutic and toxic levels of this drug.

200

3. A client is discharged on Digoxin (Lanoxin) following hospitalization for Atrial Fibrillation. In preparing a Discharge Teaching Plan, the nurse would NOT include which of the following?

a. Take pulse correctly and count for one full minute
b. Report any signs and/or symptoms such as ocular
disturbances, anorexia, etc., to M.D. promptly c. Take another dose of medication if first dose is vomited
d. Withhold drug if heart rate falls below 60 bpm

C. A client should NOT repeat a dose if first dose is vomited, as one would not know how much of the original dose was absorbed, and could possibly lead to excess Digoxin levels, which can cause arrhythmias, or slow heart rate below 60 bpm. Choices (1), (2) and (4) would be included in a teaching plan.

300

5. On a tour of the labor and delivery suite, a prospective couple asks the nurse when do you put the erythromycin ointment in the baby’s eyes. The correct response would be:

a. “It is only done if the mother has a chlamydia infection at the time of delivery.”
b. “It is only used if the baby has signs or symptoms of an eye infection.”
c. “It is placed in the eyes immediately after the delivery.”
d. “It is placed in the eyes after the parents have had a chance to hold the baby.“

D. The medication may irritate the baby’s eyes, thereby, the bonding process should be initiated before the medication is instilled in the eyes.

400

7. A patient being treated for schizophrenia is started on Thorazine 200mg qid. The doctor has ordered Cogentin for this patient. The nurse is aware that the Cogentin is given:

a. To decrease the incidence of seizures
b. To reduce side effects of the Thorazine
c. To potentiate the action of Thorazine
d. To improve and stabilize mood

B. Thorazine blocks the neurotransmitter dopamine resulting in side effects that look like Parkinson’s disease. Cogentin reduces side effects such as stiffness, pill rolling tremor, mask-like face and cogwheeling rigidity associated with the Thorazine.

500

10. A patient has been placed on Prozac [Fluoxetine] to treat a major depression. The nurse is aware that Prozac is an SSRI which is different from a tricyclic antidepressant. Two advantages of Prozac related to side effects would be:

a. Facilitates weight loss and doesn’t potentiate seizures
b. Improves sleep and builds bone density
c. Strengthens immune system and improves sleep
d. Improves mood and stabilizes mood swings

A. Tricyclic antidepressants tend to cause weight gain and potentiate seizures.