CATEGORY 1
In a healthcare setting, a seasoned nurse is mentoring a novice nurse in providing client education. The novice nurse is tasked with creating written materials for a multicultural client population. Which of the following actions by the novice nurse align with cultural competence in providing written materials? Select all that apply.
1. Asking the seasoned nurse for assistance with translations.
2. Incorporating culturally sensitive imagery in the materials.
3. Designing materials with diverse language options.
4. Relying solely on electronic translation tools for language diversity.
5. Creating materials only in the novice nurse's preferred language.
1. Asking the seasoned nurse for assistance with translations is an action that aligns with cultural competence. Seeking help from someone experienced ensures accurate and culturally sensitive translations.
2. Incorporating culturally sensitive imagery in the materials is an action that aligns with cultural competence. Visual aids can enhance understanding and convey information in a culturally sensitive manner.
3. Designing materials with diverse language options is an action that aligns with cultural competence. Offering materials in multiple languages accommodates the diverse linguistic needs of the client population.
A client with complaints of severe heart palpitations visits the Emergency Room (ER). After having their labs drawn, it was discovered that the client has hyperkalemia. Which of the following should be monitored by the nurse to ensure that the client's hyperkalemia improves? Select all that apply.
1. Check the client's lunch tray for salt substitutes.
2. Check the client's heart rate for regularity.
3. Monitor the client's respiratory rate.
4. Ensure that a reduced dosage of ACE inhibitors is increasing potassium levels.
5. Check that serum potassium levels are increasing.
Checking the client's lunch tray for salt substitutes, monitoring the client's respiratory rate, and checking the client's heart rate for regularity should be monitored by the nurse to ensure that the client's hyperkalemia improves. Ensuring that a client is not adding salt substitutes to their food, such as Mrs. Dash, which contains potassium, is imperative in improving hyperkalemia. An increase in potassium levels in the body can lead to the lungs being unable to remove carbon dioxide from the body, resulting in hyperventilation or shortness of breath. Too much potassium in the body can also affect the electrical activity of the heart and lead to cardiac arrhythmias.
An oncology nurse is caring for a woman newly diagnosed with breast cancer and the client has requested to speak to a chaplain. Which of the following is the best action for the nurse to take?
Requesting a spiritual care consult from the primary health care provider.
Ordering a spiritual care consult.
Encouraging the client to contact their personal spiritual leader.
Encouraging the client's family to contact their personal spiritual leader.
Ordering a spiritual care consult is the correct answer because placing this order without a health care provider is within the RN scope of practice.
1115: A 15-year-old female with a history of depression and recent relationship troubles with her close friends is brought to the emergency department by her concerned parents after they found an empty bottle of maximum-strength acetaminophen in her room. Upon questioning, the patient tearfully admits to ingesting 15 tablets of the medication 45 minutes ago. She is visibly anxious and frequently looks at the marks on her wrists, which seem to be superficial scratches.
Vital signs as of 1115:
As the nurse prepares to address the situation, several orders from the primary care provider come in. Which of the following orders should the nurse prioritize and carry out first?
Correct Answer: B. Administer acetylcysteine (Mucomyst) orally
Although gastric lavage can help remove any remaining acetaminophen from the stomach, it is not the priority intervention in this situation. Administering the antidote, acetylcysteine (Mucomyst), should be the primary focus to counteract the toxic effects of acetaminophen on the liver. Acetylcysteine is the antidote for acetaminophen toxicity and should be administered as soon as possible to maximize its effectiveness in preventing liver damage.
It’s a busy evening shift, and the hospital has just sounded an alarm for a disaster drill. The unit manager informs the nurse that they need to make room for potential mass casualty admissions. The nurse is given four clients and must decide who to prioritize for discharge to accommodate new admissions. Who should be considered FIRST for discharge?
A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.
During a clinical rotation, a bilingual nursing student is approached by one of the healthcare providers in regard to assisting with some interpreting needs for a client. Which of the following actions are appropriate for the nurse to engage in before allowing the nursing student to serve as an interpreter? Select all that apply.
1. Assessing the nursing student's medical proficiency
2. Incorporating cultural sensitivity into the teaching process.
3. Verifying the legal implications and boundaries associated with interpreting in an educational context, including any student-specific considerations.
4. Confirming a clear understanding of client confidentiality regulations.
5. Allowing the student to interpret everything since the student is the only one who speaks the same language as the client.
Assessing the nursing student's medical proficiency is essential to determine their capability to effectively serve as an interpreter, as they may not have the appropriate level of knowledge or understanding in order to explain complex terms or procedures.
Incorporating cultural sensitivity into the teaching process, considering the impact on effective communication and understanding within the educational environment is necessary. This is important for effective communication and understanding within the educational environment, especially when interpreting.
Verifying the legal implications and boundaries associated with interpreting in an educational context, including any student-specific considerations is an appropriate action. This ensures that the nurse and nursing student are aware of any specific regulations related to interpreting in an educational context.
Confirming a clear understanding of client confidentiality regulations and how they apply when a nursing student is participating in interpreting is an appropriate action. This is vital to maintain privacy and compliance with legal standards during the interpretation process.
A nurse is conducting an evaluation of the client's stress management practices who reports using deep-breathing exercises to manage work-related stress. Which of the following practices suggest effective use of the technique in a work-related context? Select all that apply.
1. Taking short breaks during the workday to practice relaxation techniques.
2. Alternating nostril breathing to reduce stress.
3. Focusing on a word or phrase that helps to relax when practicing deep-breathing exercise.
4. Holding the breath for a long period during deep-breathing exercises.
5. Ignoring work-related stressors and suppressing emotions.
Taking short breaks during the workday to practice relaxation techniques is an effective strategy. Taking short breaks to practice relaxation techniques, including deep-breathing exercises, is a positive strategy for managing work-related stress.
Alternating nostril breathing to reduce stress is an effective strategy. Alternating nostril breathing increases the efficiency of oxygen exchange in the lungs, which can have a calming effect on the body and mind.
Focusing on a word or phrase that helps to relax when practicing deep-breathing exercise is an effective strategy. Focusing on a calming word or phrase, is a common technique in mindfulness-based practices and can enhance the effectiveness of deep-breathing exercises.
A client currently undergoing peritoneal dialysis (PD). Which of the following complications most commonly associated with peritonitis would necessitate healthcare provider notification?
Nausea, vomiting, and/or diarrhea.
A change in mental status.
A rigid, board-like abdomen and leukocytosis.
Generalized weakness and muscle aches.
The best choice is a rigid, board-like abdomen and leukocytosis. Inflammation of the peritoneum, often caused by an infection, results in a rigid, board-like abdomen and an elevated white blood cell count (leukocytosis), which are classic findings of peritonitis.
A 68-year-old male with a history of hypertension and diabetes has undergone a cardiac catheterization to evaluate potential coronary artery disease. He has a known allergy to iodine-based contrast agents, which required premedication with corticosteroids and antihistamines. The procedure was successful, but the patient experienced brief hypotension during the administration of the contrast material. The patient has been transferred to the cardiac step-down unit for observation, and the nurse is aware of the potential complications that can arise in the initial 24 hours post-procedure. Which complication should the nurse monitor closely during this period?
B. Thrombus formation
In the initial 24 hours after a cardiac catheterization, the nurse should closely monitor for thrombus formation. Thrombus formation at the catheterization site can lead to serious complications, such as decreased blood flow to the extremities or embolization to other parts of the body. While the other options (angina at rest, dizziness, and falling blood pressure) can be potential concerns, thrombus formation is the most critical complication to monitor for during the immediate post-procedure period.
A 25-year-old male is seen in the endocrinology clinic for unexplained fatigue, weight gain, and low energy levels. After a series of diagnostic tests, he is diagnosed with hypothyroidism. The healthcare provider prescribes levothyroxine (Synthroid) 50 mcg/day by mouth. As the nurse educates the client about this medication, which point should be emphasized?
A. Should be taken in the morning
The nurse is working with a teenage client who attempted suicide. The client is frustrated by the suicide screening questionnaire and doesn't understand why it needs to be answered. Which of the following explanations by the nurse is most appropriate for this client? Select all that apply.
1. We must conduct this questionnaire to keep you and our staff safe.
2. These questions will help us take care of you in the safest way.
3. You do not have to answer these questions now but you will later.
4. Please do not be upset with the staff for doing their jobs.
5. I am sorry the questions upset you but we have to do this by law.
We must conduct this questionnaire to keep you and our staff safe is the most appropriate explanation for this client. Teenage clients can understand abstract reasoning and that while they may not agree with something, it must be done by someone else.
These questions will help us take care of you in the safest way is the best explanation for this client. A teenage client may not particularly like this answer but it is truthful and concise allowing the client to understand the reason behind a monotonous task.
A nurse is preparing to administer potassium chloride to a client with hypokalemia. Which of the following actions by the nurse demonstrates safe administration of potassium chloride?
1. Administering potassium chloride using a controlled infusion pump.
2. Administering potassium chloride as a rapid IV push.
3. Mixing potassium chloride with another medication in the same IV bag.
4. Administering potassium chloride.
Administering potassium chloride using a controlled infusion pump is correct. Potassium chloride should be administered using a controlled infusion pump to ensure a slow and controlled rate of administration. Rapid administration of potassium chloride can cause cardiac arrhythmias or other adverse effects. Using an infusion pump allows for accurate dosing and minimizes the risk of rapid potassium fluctuations in the bloodstream.
The nurse is doing a medication reconciliation for a client on a medical-surgical unit. The client reports taking Lisinopril, Atorvastatin, Famotidine, and Sertraline.
Which of the following statements by the client would be most concerning to the nurse?
"I break the atorvastatin in half, so it is easier to swallow"
"I only take famotidine at bedtime"
"I have noticed I cough a lot at night"
"I have been anxious lately and my hands sometimes shake"
"I have been anxious lately and my hands sometimes shake" is correct. Anxiety and tremors are hallmark signs of serotonin syndrome. Serotonin syndrome occurs with sertraline toxicity. It is characterized by excess serotonin stimulation leading to anxiety, tremors, agitation, diaphoresis, and muscle rigidity. Left untreated, it can be lethal.
"I break the atorvastatin in half, so it is easier to swallow" is incorrect. Atorvastatin is not an extended-release medication and therefore can be broken in half prior to administration.
"I only take famotidine at bedtime" is incorrect. This is the correct administration time for famotidine.
"I have noticed I cough a lot at night" is incorrect. This is the classic presentation of an angiotension-converting-enzyme (ACE) cough. Lisinopril inhibits the production of angiotensin-converting-enzymes in the lungs. Coughing is a common side effect of Lisinopril. While this can be uncomfortable, it is not an acute danger to the client. As such, it is not the most concerning statement.
A 43-year-old male with a history of recurrent renal calculi is admitted to the emergency department presenting with severe left flank pain radiating to the groin, nausea, and an episode of vomiting. He also reports burning and urgency during urination. His vital signs reveal a temperature of 100.8ºF (38.2ºC), blood pressure of 145/90 mmHg, pulse of 100 beats/min, and respiratory rate of 20 breaths/min. The client is visibly anxious and uncomfortable due to the severity of the pain. The nurse is assigned to care for the patient and must prioritize the nursing goals to ensure optimal care. Which nursing goal should be the top priority for this client?
C. Manage pain
Managing pain is always a priority because it ultimately improves the quality of life. The cornerstone of ureteral colic management is analgesia, which can be achieved most expediently with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs).
A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?
D. Notify the healthcare provider of the child’s status
These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care.
The nurse is caring for a client who was injured in a natural disaster. The client has shown symptoms of anxiety since the incident and is asking the nurse for alternative ways to manage their anxiety symptoms. Which of the following alternative therapies would be beneficial for the client to try? Select all that apply.
1. Aromatherapy
2. Breathing techniques
3. Yoga
4. Pharmaceuticals
5. Cognitive behavioral therapy
Aromatherapy is an effective alternative therapy for anxiety and would be beneficial for the client to try.
Breathing techniques are an effective alternative therapy for anxiety and would be beneficial for the client to try.
Yoga is an effective alternative therapy for anxiety and would be beneficial for the client to try.
A client with a terminal illness expresses a desire to spend their remaining days at home. Which of the following actions by the nurse demonstrate support for the client's end-of-life preferences? Select all that apply.
1. Establishing a clear plan for medication management at home.
2. Collaborating with home healthcare services to arrange for in-home care.
3. Providing education and resources to the client and their family for at-home care.
4. Discouraging the client from expressing preferences to avoid unrealistic expectations.
5. Informing the client that spending their remaining days at home is unsafe.
Establishing a clear plan for medication management at home is supportive as it addresses a crucial aspect of the client's care. It ensures that the client receives necessary medications at home, promoting their comfort and well-being.
Collaborating with home healthcare services to arrange for in-home care is a proactive step that aligns with the client's preference. It helps in arranging the necessary support and care at home, enhancing the client's quality of life and fulfilling their end-of-life wishes.
Providing education and resources to the client and their family for at-home care supports the client's preference by empowering them and their family to make informed decisions. It ensures they are aware of available support services, facilitating the possibility of at-home care.
A nurse who suffers from varicose veins works 12-hour shifts on a medical-surgical unit and is 36 weeks pregnant. She has been diagnosed with a deep vein thrombosis of her left leg. The healthcare provider explains the likely underlying cause using Virchow's triad. Which of the following statements indicate the nurse understands the explanation provided? Select all that apply.
My uterus can impede blood return and contribute to venous stasis
I should wear compression stockings and avoid standing for long periods of time
Varicosities may contribute to venous stasis and endothelial damage
I will need to take blood thinners for the rest of my life.
Pregnancy induces a hypercoagulable state in the body
Virchow's triad helps to explain the risk of deep vein thrombosis; hypercoagulability, venous stasis, and endothelial damage are the three factors that increase risk.
Pregnancy induces a hypercoagulable state in the body is a statement that indicates the nurse understands the explanation provided. Hypercoagulability is one of Virchow's triad.
My uterus can impede blood return and contribute to venous stasis is a statement that indicates the nurse understands the explanation provided. Venous stasis is one of Virchow's triad.
I should wear compression stockings and avoid standing for long periods of time is a statement that indicates the nurse understands the explanation provided. Compression stockings and avoiding standing for long periods of time can help reduce venous stasis.
Varicosities may contribute to venous stasis and endothelial damage is a statement that indicates the nurse understands the explanation provided. Venous stasis and endothelial damage are part of Virchow's triad.
During a school screening program for children aged 6-12, a nurse is tasked with evaluating their growth parameters. She encounters a 9-year-old girl who is shorter than her peers and seems to have less muscle development. To align her observations with typical growth expectations for school-age children, what would the nurse expect to see?
D. Yearly weight gain of about 5.5 pounds per year
A school nurse is assessing 8-year-old Timmy, who was brought to the school health office by his teacher due to concerns about his recent behavior. The teacher reports that Timmy has been asking to go to the bathroom frequently during class, appears tired, and has been caught sneaking snacks during lessons. Upon further questioning, Timmy’s mother, who was called to the school, mentions that he has been drinking more water than usual at home, has an increased appetite, and has had a few episodes of bedwetting in the past month. She also notes that despite eating more, he seems to have lost some weight. Given these observations and suspecting diabetes, which symptom is most likely to prompt parents to seek medical evaluation for their school-age child?
C. Bedwetting
While all of the symptoms listed can be indicative of diabetes mellitus, bedwetting in a school-age child who previously had control over their bladder is often the most alarming symptom for parents. It represents a regression in a previously acquired skill and can be distressing for both the child and the parents. This symptom, combined with the other signs, would likely prompt parents to seek medical evaluation.
A nurse is working in a maternity unit assisting a new mother with breastfeeding techniques. Which of the following interventions should the nurse implement to promote attachment between the newborn and the mother? Select all that apply.
1. Showing the mother how to hold the baby skin-to-skin while breastfeeding.
2. Teaching the mother about the cues that indicate the baby is hungry.
3. Advising the mother to schedule feeding to train the newborn early.
4. Recommending using formula to extend sleep patterns.
5. Suggesting limiting the time the newborn spends with the mother to encourage independence.
Showing the mother how to hold the baby skin-to-skin while breastfeeding is an intervention the nurse should implement. This technique enhances the mother-newborn attachment and stimulates breastfeeding success by encouraging hormonal responses that promote milk production and maternal bonding.
Teaching the mother about the cues that indicate the baby is hungry is an intervention the nurse should implement. Recognizing these cues helps the mother respond promptly to her baby's needs, fostering an early and strong emotional bond and effective feeding practices.
Advising the mother to schedule feeding to train the newborn early is not an intervention the nurse should implement. Scheduled feedings can interfere with the establishment of a natural feeding pattern and may not align with the newborn's actual nutritional needs, potentially hindering attachment and breastfeeding success.
In the hospital, a client who was the primary breadwinner for their family has suffered a spinal cord injury and is now facing long-term paralysis. Which of the following actions should the nurse take first?
1. Asking the client about their feelings and concerns regarding the future.
2. Encouraging the client to consider alternative career options.
3. Providing the client with resources for financial assistance.
4. Discussing potential physical therapy and rehabilitation options.
Asking the client about their feelings and concerns regarding the future is the first action the nurse should take. When a client faces a life-altering event such as a spinal cord injury, their emotional and psychological well-being is a priority. Before addressing practical concerns like finances or rehabilitation, it is necessary to understand the client's emotional state and provide a supportive environment where they can express their feelings and fears.
A nurse in the intensive care unit (ICU), is responsible for caring for a client who recently underwent a central venous access procedure. Which of the following action should the nurse take immediately if signs of infection are observed at the central line insertion site?
Applying an antibiotic impregnated patch over the infection site
Reporting to the physician and requesting immediate removal of the central line
Changing the dressing and continuing monitoring for further signs of infection
Placing a transparent dressing with additional steri-strips over the line.
Reporting to the physician and requesting immediate removal of the central line is the immediate action the nurse should take. Prompt removal of the central line is crucial to prevent the spread of infection and further complications. The physician will assess the situation and determine the appropriate course of action.
A 62-year-old client arrives at a community health fair where the nurse is offering blood pressure screenings. Upon assessment, the nurse notes that the client’s blood pressure is 160/96 mmHg. The client claims that their blood pressure is “usually much lower” and they recently started new medication for arthritis. What would the nurse advise the client to do?
A. Go get a blood pressure check within the next 15 minutes
The blood pressure reading is moderately high with the need to have it rechecked after a few minutes to verify. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke.
A 29-year-old female client, who is a professional dancer, presents to the emergency department after a performance complaining of severe lower abdominal pain, fever, and an unusual vaginal discharge. She mentions that she had similar symptoms two months ago and was treated in an urgent care clinic. She also reports having multiple sexual partners in the past year and inconsistent condom use. Given the clinical presentation and her history, which of the following infections is most frequently associated with a recurrence of pelvic inflammatory disease (PID)?
Correct Answer: B. Chlamydia
Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It’s usually caused by a sexually transmitted infection. Chlamydia and gonorrhea are the most common causes of PID. Among these options, Chlamydia is the most frequently associated with PID. It’s essential to diagnose and treat Chlamydia promptly as it can lead to serious complications if left untreated, including infertility.