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

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NCLEX

READINESS STUDY GUIDE

What intervention is essential prior to starting a client on atorvastatin therapy?

1. Assessing for muscle strength
2. Assessing the client's dietary intake
3. Determining if the client is on digoxin therapy
4. Monitoring liver function tests

Correct Answer: 4

Rationale Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy.

Question: 2 The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of the teaching?

1. "I need to be on bedrest for the duration of my pregnancy."
2. "I will notify my health care provider if I start having low backaches."
3. "Pelvic pressure is to be expected after cerclage placement."
4. "The cerclage will be removed once my baby is at 28 weeks."

Correct Answer: 2 Rationale

Cervical cerclage is placed to prevent preterm delivery , usually in clients with histories of second-trimester loss or premature birth. A heavy suture is placed transvaginal or trans-abdominally to keep the internal cervical closed. Placement occurs at 12–14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions, pelvic pressure) and rupture of membranes (Option2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is determined by the health care Provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36–37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates). Educational objective: Following cerclage placement, discharge teaching includes recognizing and reporting signs of preterm labor (eg, low back aches, contractions, pelvic pressure) or rupture of membranes and understanding activity restrictions (eg, bed rest for a short time after placement)

Question: 3

During the first prenatal assessment, the client reports the last normal menstrual period starting on March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected intercourse on March 15. Using Naegele's rule, what is the estimated date of birth?

1. December 8

2. December 12
3. December 22
4. December 30

Correct Answer: 1

Rationale Various methods to determine the estimated date of birth (EDB) include the use of Naegele's rule, ultrasound, uterine height measurement (McDonald's measurement), and auscultation of fetal heart rate with a Doppler device. The most accurate dating of pregnancy involves the use of ultrasound around the 16th-18th week of pregnancy. However, Naegele's rule can be used to quickly determine an EDB early in the pregnancy. This calculation uses the date of the first day of the last normal menstrual period (LMP) for the determination of EDB.

• EDB = (LMP minus 3 months) + 7 days This client's LMP is March 1, minus 3 months = December 1. Add 7 days to obtain EDB =December 8. Clients who conceive in January, February and most of March will deliver in the current year. Those who conceive after March will deliver in the following year; as a result, a third step is adding 1 to the current year to determine the estimated date of birth. For example, LMP of May 10, 2014 would have an EDB of February 17, 2015. It is important to note that Naegele's rule is based on a client having a menstrual cycle of 28 days. It therefore may not be as accurate if the client has a shorter or longer menstrual cycle. (Option 2) Using the last day of the LMP to calculate EDB provides an inaccurate due date as clients may have varying lengths of menstrual bleeding. (Option 3) Conception occurs around the time of ovulation and is about 14 days from the beginning of the LMP. Eggs are fertile for about 12- hours after ovulation with sperm able to remain fertile for 24-72 hours. Implantation of the trophoblast occurs about 7-10 days after fertilization. Using the conception date calculates the gestational age of the embryo approximately 2 weeks later than the true gestational age.

(Option 4) Spotting around the time the next menstrual period is due may be considered normal and is probably caused by implantation of the trophoblast into the uterine endometrial lining. This is not considered a problem but using this occurrence to date the pregnancy erroneously delays the EDB by 4 weeks. It is important to calculate EDB from the beginning of the last normal menstrual period.

Educational objective: Naegele's rule provides a quick determination of the estimated date of birth (EDB). EDB = (LMP minus 3 months) + 7 days. If the LMP occurs in January, February, or March, the EDB will be in the current year. If the LMP occurs after March, the EDB will be in the next year.

Question: 4

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan?

1. Have an ophthalmologic examination every 6 months
2. Take the medication on an empty stomach
3. Take vitamin D and calcium supplements
4. Wear a Medic Alert bracelet

Correct Answer: 1

Rationale Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to

Reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of Systemic lupus erythematosus ( SLE ). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual Disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo Regular ophthalmologic examination every 6-12 months (Option 1). (Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (A common side effect). (Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) Therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation are not required. (Option 4) There are no effects of hydroxychloroquine that would require wearing a Medic Alert bracelet.

Educational objective: Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.

Question: 5

The nurse is caring for a client diagnosed with Guillain-Barre syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client?

1. Diaphoresis with facial flushing
2. Hypoactive or absent bowel sounds
3. Inability to cough or lift the head

4. Warm, tender, and swollen leg

Correct Answer: 3

Rationale GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include:

• Inability to cough
• Shallow respirations
• Dyspnea and hypoxia
• Inability to lift the head or eyebrows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence of hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure.

Educational objective:

Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barre syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation.

Question: 6

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulses paradoxus?

1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip
2. Compare apical and radial pulses for any deficit
3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle.
4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/

Correct Answer: 3

Rationale

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. The cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension , narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.

The procedure for measurement of pulsus paradoxus is as follows:

1. Place client in semi-recumbent position
2. Have client breathe normally
3. Determine the SBP using a manual BP cuff
4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP
5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure
6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure.
7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox. 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade. (Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. (Option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option 4) This is the formula for calculating mean arterial pressure. Educational objective: The nurse should assess the client for pulsus paradoxus when cardiac tamponade is suspected. The amount of paradox is the difference between the pressures heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard throughout inspiration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg, this may indicate cardiac tamponade.

Question: 7

The nurse is developing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?

1. Canned baby food is more expensive than food prepared at home
2. Finger foods can be introduced before the child has teeth
3. New foods should be introduced at least 5-7 days apart
4. Rice cereal can be mixed with cow's milk to increase nutritional intake

Correct Answer: 3

Rationale The introduction of solid foods generally occurs at 4-6 months. The process usually starts with a form of iron-fortified infant cereal , such as rice or oatmeal. Cereal can be mixed with breast milk, formula, or water. When introducing new foods, it is important to allow 5-7 days between foods to observe for any allergies to a particular food. Allergic responses often worsen with subsequent exposure, so it is a priority to identify food triggers as soon as possible (Option 3). (Option 1) A mashed portion of soft fruits or fully cooked vegetables made at home is less expensive than commercially prepared baby food. Carrots, peas, and bananas are examples of early foods that are simple to prepare. However, this is not the highest priority. (Option 2) When an infant reaches age 6-8 months, pureed fruits and vegetables are introduced to provide needed vitamins. After introducing purees, it is also appropriate to begin offering simple finger foods, such as teething crackers and small pieces of fruit, soft vegetables, or cheese. These foods help children develop motor skills and learn to chew, even before they have teeth. (Option 4) Cow's milk is not introduced until after the first year because it lacks crucial vitamins and minerals for appropriate growth and is also more difficult for an infant to digest.

Educational objective: Solid foods are introduced at age 4-6 months, beginning with iron- fortified cereal and progressing to soft fruits and vegetables. Five to 7 days should elapse before a new food is introduced to observe for allergies. Simple finger foods may be introduced at age 6-9 months. Cow's milk should not be introduced until after age 1 year.

Question: 8

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

1. Hematocrit of 30% (0.30)
2. Partial thromboplastin time of 110 seconds
3. Platelet count of 80,000/mm3 (80 x 109/L)
4. Prothrombin time of 11 seconds

Correct Answer: 2

Rationale Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. (Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of

80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm3 (50 x 109/L). (Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning.

Educational objective: Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin

Question: 9

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team?

1. Need for discharge to a skilled nursing facility
2. Nutritional consult with instructions on a high-calorie diet
3. Option of palliative care
4. Physical therapy prescription to promote activity

Correct Answer: 3

Rationale This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments (Option 3). Palliative care may eventually include hospice care, after it

is determined that the client has a life expectancy of less than 6 months. The nurse should advocate for the client and collaborate with members of the health care team to explore care options based on the client's wishes. (Option 1) This client has not clearly demonstrated a need for skilled nursing; additional assessment is needed to determine the most appropriate discharge setting. (Option 2) A high-calorie diet is appropriate for a client with weight loss, but many clients may have difficulty maintaining weight due to factors such as advanced disease and poor appetite. It is not the highest priority in this client, who is nearing the end of life and has expressed an interest in avoiding further testing and hospitalization. (Option 4) Physical therapy may be appropriate to help this client maintain current abilities. However, a client with disease this advanced is not likely to tolerate more activity or gain much additional functional capacity. Therefore, physical therapy is not the highest priority at this point.

Educational objective: The client with an advanced, terminal disease (eg, chronic obstructive pulmonary disease) is often an appropriate candidate for palliative care. Palliative care emphasizes quality of life and symptom control and may eventually include hospice care based on the client's life expectancy.

Question: 10

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take?

1. Give all medications, including acetaminophen, and reassess in 30 minutes
2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes
3. Hold the haloperidol and notify the health care provider (HCP) immediately
4. Hold the hydrochlorothiazide and notify the HCP immediately

Correct Answer: 3

Rationale This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol , fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever , muscular rigidity , altered mental status, and autonomic dysfunction (e.g., sweating, hypertension, and tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU).

(Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms.

Educational objective: NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication

Question: 11

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse?

1. "I will help you get ready; then we can walk to the dining room together."
2. "I'll have breakfast brought to your room."
3. "It's okay. You can join us when you are ready."
4. "You'll feel better when you get up."

Correct Answer: 1 Rationale Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is

not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self-esteem. (Option 2) This action reinforces the client's desire to stay in the room and is not therapeutic. (Option 3) This response is non-therapeutic; the client needs assistance with ADLs. (Option 4) Clients with depression often do feel better after even minimal exercise and activity. However, this response does not give the client direction or structure.

Educational objective: Clients with low energy, lethargy, or fatigue associated with major depressive disorder need structure and direction in performing basic ADLs, including personal hygiene and grooming. The nurse needs to provide assistance to the client in completing ADLs and in initiating social interaction with others.

Question: 12

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed?

1. "I bought a new nightlight for the hallway to the bathroom."
2. "I feel so much more secure wearing my electronic fall alert device."
3. "I walk in my stockings at home because it helps to relieve my bunion pain."
4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape."

Correct Answer: 3

Rationale According to the Centers for Disease Control and Prevention, 1 out of 3 adults aged >65 experience a fall every year. Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home. There are multiple simple strategies that can help reduce falls in the home environment and these include:

• Exercising regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore, decreasing fall risk.
• Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double- sided tape) (Options 1 and 4).
• Using grab bars and non-skid bath mats in the bathroom.
• Wearing shoes or slippers with non-skid soles , both inside and outside of the home.
• Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care provider (HCP).
• Getting regular vision exams.
• Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of knowing help is available immediately if a fall occurs (Option 2).

Educational objective: Many falls in the home can be prevented by exercising regularly , getting regular vision exams, maintaining a well-lit, clutter-free environment , using grab bars in the bathroom, periodically reviewing medications and side effects with a pharmacist and/or HCP, and wearing an electronic fall alert device.

Question: 13

A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action?

1. Advise the parent to give a pacifier whenever the infant cries
2. Ask the parent to describe what is done to "keep the baby quiet"
3. Assess the infant's pattern and frequency of crying
4. Explore the parent's support system

Correct Answer: 3

Rationale During the first 3-4 months of life , it is not unusual for an infant to cry 1-3 hours a day in response to being hungry, thirsty, tired, in pain, bored, or lonely. A very young, first-time parent may not have an appreciable understanding of normal infant behavior and may perceive normal crying as excessive. It is most important for the nurse to assess the infant's pattern and quality of crying to better understand whether it is normal behavior or a sign of something more serious that requires further evaluation and treatment. The nurse needs to determine:

• What "all the time" means
• When the "all the time" crying started
• What makes the crying worse and what makes it better?
• The quality of the crying (tone, pitch, loudness)
• Length and quality of periods of silence (Option 1) A pacifier would be appropriate to calm and soothe this infant. However, the nurse needs to first assess the pattern and quality of the crying along with the methods the parent is already using. (Option 2) Finding out what the parent is already doing to comfort the child is part of the nursing assessment. In this case, however, it is more important to determine if the crying is normal or abnormal. (Option 4) Exploring the parent's support system is an appropriate nursing action to determine if the parent has anyone to turn to when

frustrated in caring for the infant. However, it is not the most important assessment.

Educational objective: When a parent tells the nurse that an infant cries "all the time," the priority nursing action is to assess the pattern, quality, and frequency of the child's crying. This will help the nurse determine if the crying is normal infant behavior or a sign of a more serious condition that requires further evaluation and treatment.

Question: 14

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first?

1. Client with charred, leathery skin over entire back, chest, and legs
2. Client with cool skin, shivering from sitting in water until rescued
3. Client with diabetes who was unable to take prescribed insulin today
4. Client with high-pitched, crowing inspiratory respirations

Correct Answer: 4

Rationale Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client should be classified as emergent , requiring immediate treatment and possibly prophylactic intubation (Option 4).

(Option 1) Using the rule of nines, clients with full-thickness burns to the chest, back, and legs are suspected to have at least 72% total body surface area burns and should be classified as expectant (black tag). (Option 2) Clients with wet clothing or cold water immersion are at risk for hypothermia but can be easily self-managed by provision of warm, dry blankets; this client should be classified as Non-urgent (green tag). Untreated hypothermia may lead to decreased cerebral metabolism, dysrhythmias, and coagulopathies. (Option 3) Clients with diabetes mellitus who are unable to receive insulin may develop hyperglycemia, which is unlikely to cause rapid deterioration. This client can perform self-care and should be classified as nonurgent (green tag).

Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color- coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (Expectant).

Question: 15

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle this situation?

1. Call security to escort the family member to the waiting room
2. Have the family member stand or sit in an area that is not in the staff's way

3. Inform the family member that relatives are not allowed in rooms during emergency situations
4. Let the family member stay and assign a staff person to explain what is happening

Correct Answer: 4

Rationale If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The charge nurse should be prepared to escort family members from the room if they become disruptive.

(Option 1) Calling security is appropriate only if the family member is disruptive or abusive to the staff. (Option 2) This could increase the family member's anxiety and result in a traumatizing experience if this person does not understand what is occurring during the resuscitation effort. (Option 3) Many professional organizations support allowing a family member to stay during emergency situations, in accordance with specific hospital policy.

Educational objective: The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

Question: 16

The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication?

1. "I have gained a few pounds since I started this medication."
2. "I have had a sore throat for 3 days and feel feverish today."
3. "I have noticed increased salivation and drooling."
4. "I often feel sleepy when I take this medication."

Correct Answer: 2

Rationale Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis , cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (e.g., sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2). (Option 1) Weight gain is a common side effect. Clients should be educated about weight management. (Option 3) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling. (Option 4) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve.

Educational objective:

Clozapine, an atypical antipsychotic, is used to manage schizophrenia in clients who have not improved with other medications. Clozapine may cause agranulocytosis, which increases the risk of life-threatening infection. Clients receiving clozapine should be monitored for signs of infection (eg, fever, flulike symptoms).

Question: 17

The nurse admits a postoperative client following weight loss surgery. Which prescription should the nurse question?

1. Begin a sugar-free, clear liquid diet
2. Insert nasogastric tube for uncontrolled nausea
3. Place client in low Fowler position during mealtimes
4. Start morphine via patient-controlled analgesia

Correct Answer: 2

Rationale Bariatric surgery for weight loss involves a surgical modification of the client's stomach and/or small intestine to restrict the client's intake. Postoperative nursing care focuses on managing pain and nausea and monitoring for complications (eg, infection, fluid and electrolyte imbalance, dumping syndrome, anastomotic leak). Nasogastric tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can cause hemorrhage and anastomotic leak (Option 2). Postoperative nausea would be controlled using IV antiemetics.

(Option 1) Clients are placed on a clear liquid diet for the first 48-72 hours after bariatric surgery to promote healing. The diet is restricted to low-carbohydrate (eg, sugar-free) liquids to decrease the risk of dumping syndrome , rapid emptying into the small intestines that causes

unpleasant vasomotor symptoms (eg, sweating, dizziness, cramping, diarrhea). (Option 3) After bariatric surgery, low Fowler position is preferred during mealtimes as it slows gastric emptying, reducing the risk of dumping syndrome. (Option 4) Morphine and patient-controlled analgesia pumps are commonly used to manage pain after bariatric surgery.

Educational objective: Nasogastric tube placement is contraindicated after gastric surgery due to the potential for disturbing the surgical site, which can result in hemorrhage and anastomotic leak.

Question: 18

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene?

1. "Elevate your scrotum and apply an ice bag to reduce swelling."
2. "Practice coughing to clear secretions and prevent pneumonia."
3. "Stand up to use the urinal if you have difficulty voiding."
4. "Turn in bed and perform deep breathing every 2 hours."

Correct Answer: 2 Rationale An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure (eg, heavy lifting). Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment

to prevent bowel ischemia or perforation. Strangulation symptoms include abdominal distension, severe pain, nausea, and vomiting. To prevent hernia reoccurrence after surgical repair , the client is taught to avoid activities that increase intraabdominal pressure (eg, coughing, heavy lifting) for 6-8 weeks (Option 2). If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing.

(Option 1) Scrotal support garments and ice packs help decrease postoperative pain and scrotal swelling. The scrotum should be elevated with a pillow while the client is in bed. (Option 3) The nurse monitors urine output to assess for difficulty voiding after inguinal hernia repair. Male clients are encouraged to stand when voiding to improve bladder emptying. (Option 4) To prevent postoperative complications (eg, pneumonia, constipation) following inguinal hernia repair, the client should reposition frequently, ambulate as soon as possible, and practice deep breathing every 2 hours.

Educational objective: After inguinal hernia repair surgery, clients should avoid coughing and heavy lifting, ambulate early, turn and deep breathe every 2 hours, and stand when voiding. Scrotal elevation and ice packs help decrease pain and swelling.

Question: 19

A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm?

1. Atrial flutter

2. Sinus rhythm with premature atrial contractions (PACs)
3. Sinus rhythm with premature ventricular contractions (PVCs)
4. Ventricular tachycardia

Correct Answer: 3 Rationale A PVC is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement). (Option 1) Atrial flutter is an atrial dysrhythmia identified by recurring, regular, sawtooth shaped flutter waves that originate from a single ectopic focus in the atria. (Option 2) A PAC is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape than the P wave that originated in the sinus node. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle.

Educational objective: