NCLEX-RN Practice Questions: Critical Care and Patient Management, Exams of Nursing

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NCLEX New Generation Exam Updated 2023-2024/

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The nurse witnesses the collapse of a child while outdoors. The child is not breathing and has a pulse of 50/min. The nurse calls emergency services and initiates rescue breathing. After 2 minutes of rescue breaths, the child is still not breathing and is pale with a pulse of 30/min. What is the nurse's next action?

1. Initiate chest compressions Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains <60/min and there are signs of poor perfusion (skin pallor), the nurse should initiate chest compressions and reassess the pulse every 2 minutes The charger nurse is responsible for making room assignments multiple clients. Which pari of client assignments to a shared room is appropriate?
2. Client who had a bowel resection 1 day ago and client with asthma exacerbation. When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had a recent bowel resection surgery. The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide?
3. "I plan to attend my grandchild's graduation next month" Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview, the nurse should assess:

• Access to psychiatric medications
• Availability of help during a crisis (counselor, family)
• Future goals and plans
• Home and environment risks

• Overall affect and level of energy
• Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to attempt death by suicide The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention?

1. Administer potassium supplement In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3. mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine

1.5 mg/dL [133 μmol/L], anuric, weight <99.2 lb [45 kg]). The nurse cares for a client with a terminal disease who created a do not attempt resuscitation (DNAR) directive. The client stops breathing and loses their pulse. The client's adult child states, "Please, do whatever you can to save them!" Which intervention is appropriate?

3. Explain the client's resuscitation directive to the client's child Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes should be followed, even if they conflict with the wishes of loved ones The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?
4. Client who underwent coronary artery stent placement via femoral approach 3 hours ago and is reporting severe back pain A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially

life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of the abdomen) The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing?

4. Peripheral arterial disease Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. WRONG
5. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and possible intact or ruptured blister) Stage 1: Intact skin with nonblanchable redness Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar A client with type 1 diabetes mellitus has prescriptions for NPH insulin and regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the breakfast tray has arrived. What action should the nurse take? Click the exhibit button for additional information.
6. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first

Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid- acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic - RN: Regular before NPH). To prepare the mixed dose: Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the entire quantity. A client is receiving packed RBCs intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin intravenous piggyback (IVPB) amphotericin B. What is the nurse's best action?

4. Wait 1 hour after blood transfusion finishes administering amphotericin B Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of amphotericin B and the symptoms of a blood transfusion reaction (eg, chills, fever, hypotension, kidney injury), the nurse's best action is to complete the blood transfusion and allow one hour of observation before initiating amphotericin B (Option 4). This enables the nurse to distinguish between transfusion-related reactions and adverse effects from amphotericin B. Findings that require further investigation in a client with penetrating stab wounds to the neck, chest, and/or abdomen include: Unilateral chest wall expansion (one side of the chest expands more than the other) and diminished breath sounds, which indicate the presence of air (eg, open pneumothorax) or fluid in the pleural space (eg, hemothorax, pleural effusion) Vital sign instability (eg, tachycardia, hypotension, tachypnea, hypoxemia) and signs of poor perfusion (eg, skin pallor), which are concerning for hemorrhage and respiratory compromise For each finding below, click to specify if the finding is consistent with the disease process of hemothorax or tension pneumothorax. Each finding may support more than one disease process. Hemothorax: results from the accumulation of blood loss in the pleural cavity --> loss of intravascular blood vlolume: tachycardia, hypotension, unilateral diminished breath sounds Pneumothorax is characterized by air inside the pleural space, which disrupts the negative pressure that maintains lung expansion, causing the lung to collapse either partially or

completely. Tension pneumothorax develops if air enters but cannot escape the pleural space --

this trapping compresses the heart and great vessels and displaces the midline structures (trachea) to the opposite side. Tension pneumothorax: tachycardia, hypotension, subcutaneous emphysema/crepitus on palpitation (air gets into the tissue under the skin), unilateral diminished breath sounds (also tracheal deviation, hyperresonance to percussion) Endoctracheal intubation would worsen the existing pneumothorax by delivering positive pressure ventilation, which would increase intrathoracic pressure ==> compress the heart and great vessels and lead to cardiac arrest. Which intervention does the nurse anticipate next? WRONG

4. Chest tube insertion A tension pneumothorax is life-threatening and requires immediate chest tube placement to decompress the pleural space, promote reexpansion of the compressed lung, relieve compression of the heart and great vessels, and restore hemodynamic stability. The chest tube should be connected to a water seal drainage system and suction, which promotes evacuation of air and reestablishment of negative pressure in the pleural cavity. The water seal acts as a one-way valve, allowing air to exit the pleural space but not enter it The nurse is assisting the client with repositioning in bed when the chest tube becomes dislodged from the client's chest. Which action should the nurse perform first?
5. Cover the insertion site with the palm of a gloved hand If a chest tube is accidentally dislodged from the client's chest, the priority is to cover the insertion site to prevent atmospheric air from entering the pleural space. Ideally, a dry, sterile gauze dressing is placed over the site and taped on three sides; this allows intrapleural air to escape and prevents development of a tension pneumothorax. However, if the nurse does not have immediate access to sterile gauze, the priority is to place the palm of a clean, gloved hand firmly over the site until a dressing can be obtained The client's chest tube is reinserted and connected to a new water seal drainage system. Which of the following observations require follow-up with the health care provider? Select all that apply.
6. 150 mL sanguineous output 1 hour after chest tube reinsertion

• The presence of excess blood (>100 mL/hr of sanguineous output) in the collection chamber indicates possible hemorrhage from the stab wound or a complication of chest tube insertion (eg, lung rupture) (

2. Continuous bubbling in the water seal chamber --> indicates an air leak Intermittent bubbling (eg, during expiration) is expected in the water seal chamber until the pneumothorax is resolved; however, continuous bubbling indicates an air leak. Continuous, gentle bubbling is expected in the suction control chamber, which maintains and controls suction to the chest drainage system Diminished breath sounds on the affected side, tidaling, and pleuritic pain are expected findings. There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? WRONG
3. Client with a broken, protruding right tibia and gray, pulseless foot When prioritizing clients for treatment, emergent needs should be managed first, followed by urgent and then nonurgent. The client with an open fracture and impaired distal perfusion (eg, absent distal pulses, capillary refill >3 sec) has an emergent need for care as limb loss may occur without rapid intervention A large, open head wound and a Glasgow Coma Scale score of 3 is indicative of severe neurological trauma. This client has a poor prognosis regardless of treatment (expectant) and would be the lowest priority. After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting?
4. 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree Signs of abuse may include: Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures) Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid

Repeated injuries in varied stages of healing (eg, bruises, burns, fractures ) (Option 4) Injuries to genitalia Lapsed time between the injury and the time when care is sought Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age, mechanism of injury) The nurses on a medical-surgical unit maintain a public social media page. Which of the following social media posts written by a nurse breaches client confidentiality? Select all that apply.

1. "I private-messaged everyone a cute story about our sweet client with dementia."
2. "It breaks my heart that our paraplegic client was so neglected by her husband."
3. "The client in room 5 is positive for influenza, so please remember your flu vaccines!"
4. "Wash your hands well if you had room 4 this week! Cultures are positive for Clostridioides difficile ." The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used.
5. Perform hand hygiene and open sterile urinary catheterization kit
6. Apply sterile gloves and place fenestrated drape with shiny side down
7. Use nondominant hand to grasp penis below glans
8. Use dominant hand to cleanse meatus with cotton balls or swab sticks
9. Use dominant hand to insert catheter until urine return is observed
10. Advance catheter to tubing bifurcation and inflate balloon The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan? WRONG

2. Grilled chicken sandwich on white bread, applesauce Clients with end-stage renal disease are unable to excrete potassium; therefore, the nurse should teach them to choose foods low in potassium to maintain normal serum potassium levels (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Grilled chicken sandwich on white bread and applesauce are low in potassium These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels When caring for a client with ulcerative colitis, which of the following nursing activities are appropriate for the registered nurse to delegate to the licensed practical nurse? Select all that apply. WRONG
3. Administer a prescribed suppository
4. Monitor for a change in bowel sounds
5. Remind the client to track daily weights Ulcerative colitis (UC) is a chronic disease characterized by inflammation and ulcerations in the large intestines, resulting in urgent, frequent, bloody diarrhea; abdominal pain; fever; and fatigue. Frequent diarrhea may cause weight loss and electrolyte imbalances; therefore, the client should be taught to measure daily weights. When the nurse provides education about starting risperidone, which statement by the client's parent indicates a need for further teaching? WRONG
6. It is normal for the client to become shaky and restless when agitated."

Second-generation (atypical) antipsychotic medications (eg, risperidone/Risperidal , quetiapine/Seroquel, olanzapine/Zyprexa) are used to treat schizophrenia, bipolar disorder, and other mental health disorders. One of the main adverse effects the nurse should recognize with second-generation antipsychotic medications is extrapyramidal symptoms (EPSs). EPSs include manifestations of akathisia (ie, restlessness, fidgeting) , parkinsonism (eg, tremors, shuffling gait), and tardive dyskinesia (eg, lip smacking, facial grimacing). These symptoms are important to monitor because they may be easily mistaken for agitation or negative schizophrenic symptoms (eg, pacing, rocking) (Option 4). The health care provider may prescribe anticholinergics (eg, benztropine/Cogentin, diphenhydramine/Benadryl) or benzodiazepines to treat EPSs. The nurse should teach that the sedating effects of second-generation antipsychotic medications (eg, drowsiness, hypersomnia [ie, excessive daytime sleepiness]) are common. The staff nurse caring for a client with a history of substance use disorder approaches the charge nurse and says, "My client is constantly requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority at this time?

3. Instruct the nurse to notify the health care provider about the lack of pain relief Administration of a placebo (a substance with no therapeutic effect) outside of a consented research trial is unethical and deceitful. When faced with an ethical dilemma, the nurse should address the client's needs prior to reporting or documenting the unethical behavior. Clients with a history of substance use disorder and increased opioid tolerance often require a higher-dose analgesic or stronger opioid (eg, hydromorphone) to achieve pain relief. The priority action by the charge nurse is to instruct the staff nurse to contact the health care provider to discuss the client's frequent requests for morphine to alleviate uncontrolled pain A nurse receives change-of-shift report on four clients. Which client should the nurse assess first?
4. Client with a bowel resection receiving total parenteral nutrition who had 4800 mL of urine output over the past 12 hours Total parenteral nutrition (TPN) is an IV nutrition feeding that may be prescribed to clients with dysfunction of the gastrointestinal tract (eg, short bowel). Glucose (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose and assess

for symptoms of hyperglycemia (eg, polydipsia, polyuria , headaches, blurred vision). A urine output of 4800 mL over the past 12 hours (ie, 400 mL/hr) may indicate hyperglycemia (Option 3). Symptomatic clients should be assessed and treated immediately because hyperglycemia can lead to seizures, coma, or death. An elderly client with chronic kidney disease is admitted with urosepsis. Based on the admitting diagnosis and laboratory results, which prescriptions would the nurse question? Select all that apply. Click on the exhibit button for additional information.

2. Continue home dose of valsartan

• Chronic kidney disease impairs the excretion of excess potassium and can potentiate hyperkalemia, which can lead to life-threatening arrhythmias (eg, ventricular fibrillation). ACE inhibitors (eg, lisinopril, ramipril) or angiotensin II receptor blockers (eg, valsartan, losartan, irbesartan ) can be used to manage hypertension secondary to renal disease; however, these drugs can worsen hyperkalemia

3. Obtain CT scan of abdomen with contrast

• Clients with chronic kidney disease and elevated creatinine are unable to excrete the iodinated contrast administered for CT scans. Toxic effects from the contrast can occur; therefore, this prescription should be clarified before the scan. Urosepsis is a type of bloodstream infection that originates from the urinary tract. The initial treatment of sepsis focuses on the management or prevention of septic shock, mainly by administering boluses of isotonic IV fluids (fluid resuscitation) and IV broad-spectrum antibiotics (Option 1). Blood and urine cultures are obtained, ideally before the first dose of antibiotics (Option 4). Continuous vital sign and cardiac telemetry monitoring are initiated as hyperkalemia (high potassium of 6.5) and sepsis cause cardiovascular disturbances (eg, dysrhythmias and hypotension, respectively) While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action?

2. Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2). Code blue should only be initiated if cardiac arrest occurs A client is at 28 weeks gestation with suspected preeclampsia. Which of the following signs/symptoms indicate that the client has developed this syndrome? Select all that apply.

2. Epigastric pain
3. Headaches and blurry vision
4. Proteinuria Preeclampsia is a multisystem disorder that can occur during pregnancy and is defined as new- onset hypertension and proteinuria or signs of end-organ damage. Cerebral symptoms (eg, headache, visual changes) from severe hypertension and/or epigastric pain secondary to decreased liver perfusion and hepatic damage can occur. Pregnancy causes an intravascular volume expansion larger than the rise in the number of red blood cells, resulting in hemodilution. The nurse is performing a medication reconciliation during a clinic visit with a client recently prescribed lithium. Which of the client's home medications is the priority to clarify with the health care provider?
5. Hydrochlorothiazide Lithium is a mood stabilizer most often used to treat bipolar affective disorders. Lithium has a very narrow therapeutic index (0.8-1.2 mEq/L [0.8-1.2 mmol/L]) that should be closely monitored; it also has the potential for many drug interactions. Several medications can cause increased lithium levels, including thiazide diuretics (eg, hydrochlorothiazide), nonsteroidal anti-inflammatory drugs, and antidepressants. Thiazide diuretics have demonstrated the greatest potential to increase lithium concentrations , with a possible 25%-40% increase in concentrations (Option 2). The nurse should assess the client for signs and symptoms of lithium toxicity and report the findings to the health care provider. Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first?
6. Child with bruising behind the ears after a football injury Bruising behind the ear (eg, Battle sign) following head trauma may indicate a basilar skull fracture (Option 3). Because of their close proximity to the brainstem , basilar skull fractures

pose a risk of serious intracranial injury, which is the most common cause of traumatic death in children. Other signs include blood behind the tympanic membrane, periorbital hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client requires cervical spine immobilization, close neurologic monitoring, and support of airway, breathing, and circulation. Vomiting with oral intake may indicate infection (viral or bacterial). Most serious abdominal processes (eg, obstruction, intussusception, appendicitis) also have abdominal pain. This client may require IV fluids and antiemetics but is not a priority. A pregnant client at 38 weeks gestation is admitted to the labor and delivery unit reporting contractions, severe abdominal pain, and dark vaginal bleeding. What is the nurse's priority action?

3. Palpate the abdomen and apply a fetal heart rate monitor Placental abruption (abruptio placentae) occurs when the placenta prematurely detaches from the uterine wall. This life-threatening complication can interrupt fetal oxygen supply and cause maternal hemorrhage. Associated symptoms may include frequent contractions, abdominal pain , dark red vaginal bleeding , uterine tenderness, and elevated uterine resting tone. Priorities include assessment of maternal vital signs, palpation of the abdomen/uterus, and continuous fetal heart rate monitoring If monitoring indicates fetal distress and/or maternal hemodynamic compromise, the health care team will prepare for emergency cesarean birth. The nurse in the emergency department is assessing telemetry strips for assigned clients. Which client tracing is a priority for the nurse to assess? An ST-segment elevation myocardial infarction (STEMI) occurs when at least one of the coronary arteries is completely occluded. The ST segment is the portion of the ECG between the QRS complex and the T wave. Prompt treatment (eg, percutaneous coronary intervention, thrombolytics) is needed to restore myocardial oxygen supply and limit myocardial damage (Option 3). PQRST wave (ECG) see diagram

he charge nurse is educating a new nurse on IV start technique for a 6-year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required?

3. "I will hold the child's hand as a soothing measure. Children with autism spectrum disorder (ASD) respond well to brief, concrete, and developmentally appropriate communication (i.e. pictures). The nurse can ease anxiety during procedures by involving caregivers and reducing stimulation. Physical touch and eye contact may activate a stress response in children with ASD. The nurse cares for a client with an established ascending colostomy. Which statement made by the client indicates that further teaching is required?
4. "I change the appliance and bag every other day"

• Peristomal skin irritation may also occur if the ostomy appliance is removed and changed too frequently. The appliance should be changed every 5-10 days (Option 3). The ostomy bag is emptied when one-third full. The client with a colostomy is encouraged to drink plenty of fluids to prevent dehydration (the semiliquid consistency of stool from an ascending colostomy results in increased fluid loss) and decrease intake of gas-forming foods (beans, onions, broccoli). The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first?

4. Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 F (38.3 C)

• Arteriovenous (AV) graft placement involves surgical connection of an artery and a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection of an AV graft may cause thrombosis, graft failure , or systemic infection. Fever in a postoperative client may indicate infection of the graft site, which warrants immediate notification of the health care provider (HCP); this client may require antibiotics and surgical removal of the graft (Option 4). The nurse is planning care for a client with bipolar disorder and acute mania who is being admitted involuntarily after attempting to run across a five-lane highway. Which intervention is the priority to include in the care plan?

3. Offer high-calorie snacks the client can eat while on the move and during tasks When caring for a client with mania, the nurse should prioritize physiological needs over psychological or self-fulfillment needs. The nurse can address imbalanced nutrition in a manic client by providing high-calorie snacks and finger foods that the client can carry and eat without having to sit down. Bipolar disorder is characterized by alternating episodes of depression and mania. Manic clients demonstrate hyperactivity and distractibility and may refuse to sit still long enough to drink or eat, placing them at risk for inadequate nutritional intake. Click to highlight below the 2 findings that are a safety concern.
4. Clients may forget to take medications due to cognitive decline, limited hand mobility, and sensory alterations. This can be problematic because older adults often have various health conditions and take multiple medications. Clients can have difficulty remembering familiar faces and the surrounding environment; they will often become disoriented (eg, wandering and lost in the neighborhood ). This becomes a safety risk because they are unable to find their way back home and can become lost for long periods of time. Becoming more withdrawn indicates the client may be feeling depressed. The nurse should assess for other symptoms of depression (eg, hopelessness, loss of pleasure); however, this finding does not pose an immediate safety concern. For each characteristic below, click to specify if the characteristic is consistent with the disease process of Alzheimer disease or delirium. Alzheimer Disease: irreversible, hallucinations, speech changes (word-finding difficulties_ Delirium: acute onset, hallucinations, speech changes Alzheimer disease is an irreversible, progressive form of dementia. Speech changes, and memory and social skills slowly decline as the disease progresses, while hallucinations tend to appear later in the course of the disease. Delirium is an acute, reversible, alteration in mental state involving a reduced or fluctuating level of consciousness, speech changes, and hallucinations.

Complete the following sentence by choosing from the list of options. The nurse suspects the client's condition is caused by Neurodegenerative changes in the brain Alzheimer disease (AD) is caused by neurodegenerative changes in the brain. As individuals age, some develop insoluble amyloid plaques in the brain tissue. Amyloid plaques cause an inflammatory response that leads to cell damage and neuron death in surrounding areas. In clients with AD, more plaques are apparent, especially in areas of the brain that are essential for memory and cognitive function (eg, hippocampus). Ultimately, plaques will involve other areas of the brain, including the parts responsible for language and reasoning (eg, cerebral cortex). In addition to excess amyloid plaques, clients with AD also have abnormal accumulations of twisted protein (tau) that collect inside nerve cells and cause neuronal death. The brain will eventually shrink by the final stage of the disease. The client is attempting to remove a newly inserted peripheral IV. Which of the following interventions are appropriate at this time? Select all that apply. 2.Ask the unlicensed assistive personnel to stay with the client until a sitter is available 3.Play the client's favorite music and look at family photos together 4.Reassure the client that this is a safe environment 5.Reinforce the IV insertion site dressing with gauze Clients with moderate-stage Alzheimer disease (AD) may develop disruptive behaviors as they become unable to communicate their needs. When a client with AD is agitated or aggressive, the nurse should assess for and resolve causes of discomfort, provide distraction, and reassure the client. The nurse should secure lines, tubes, and drains and obtain a sitter if needed to maintain safety. Which of the following statements by the nurse are appropriate? Select all that apply.

1. "Have you considered joining a caregiver support group?"
2. "Let's talk about services that can help you care for your spouse."

Nurses play an important role in recognizing caregiver distress and assisting caregivers in accessing services (eg, respite care, adult day centers, in-home services) that reduce their burden and provide time for the caregiver's own self-care. Acknowledging the caregiver's distress and offering services such as a caregiver support group provide reassurance and offer the caregiver a safe space to discuss challenges of caregiving with others who can relate and understand Relating with the client (eg, "I understand what you are going through. I am here for you") is NOT appropriate or therapeutic because only the caregiver can understand what they are experiencing. The nurse is teaching the client's spouse about managing worsening symptoms during the evening and night. Which of the following statements by the spouse indicate a correct understanding of the teaching?

1. "I can verbally redirect my spouse when my spouse refuses care." 2."I should avoid offering my spouse caffeine in the afternoon."
2. "I will keep the lights on and the blinds open during the day." Clients with Alzheimer disease may experience neuropsychiatric symptoms (eg, agitation, aggression, delusions, hallucinations) as the disease progresses. Many clients experience worsening of these symptoms during the late afternoon and evening (eg, sundowning). The nurse should teach the caregiver about techniques to reduce distress and manage symptoms of sundowning, including: Verbally redirecting the client when the client refuses care. Redirection shifts the client's attention from a distressing situation and eases their anxiety and frustration (Option 1). Promoting a normal daytime/nighttime cycle by restricting caffeine later in the day, and increasing daytime exposure to light (eg, keeping lights on/blinds open ) encourages a normal circadian rhythm (Options 2 and 4). The nurse conducts a developmental assessment of a 4-year-old child. Which of the following tasks does the nurse anticipate that the child will perform successfully?
3. Draw a circle
4. Use a spoon and fork
5. Walk up and down the stairs Preschool-age children begin to master more gross motor activities while rapidly increasing their fine motor abilities. The preschooler age 4 should have the fine motor skills to manipulate small tools (eg, scissors, pencil) and therefore be able to draw simple shapes (eg, circle, square) and perform more self-care activities (eg, eating with a spoon and fork) (Options 1 and 4).

The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Option 5). It is normal for preschool-age children to be unable to sit quietly for longer than 15 minutes at a time. Jump rope: age 5 The nurse in the public health clinic is caring for a client with pubic lice. Which of the following statements should the nurse include in the education? Select all that apply.

2. Remove nits from pubic hair with a fine-toothed nit comb." 3."Sexual partners should also receive treatment." 4."Wash clothes and linens with hot water." 5."Wash pubic hair with lice treatment shampoo." Pediculosis pubis (ie, "crabs") is an infestation of pubic lice. Clients with pubic lice should be given the following instructions: Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5) After treatment, remove nits with a fine-toothed nit comb , fingernails, or tweezers (Option 2) Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4) Sexual partners should also receive pubic lice treatment (Option 3) A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate for a client experiencing a seizure?
3. Administer oxygen as needed if client becomes cyanotic

• Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1). 3.Move the client from the chair to the floor to prevent a fall
• Assist seated or standing clients to lie down (left lateral) while protecting the head, and position the client on the side to maintain a patent airway and prevent aspiration 4.Record the duration of seizure activity for documentation

• Record and document the time and duration of the seizure Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury. The nurse auscultates the lung sounds of a client with shortness of breath. Then, the nurse notifies the health care provider about the adventitious sounds heard. Which medication prescription should the nurse anticipate? Listen to the audio clip. (Headphones are required for best audio quality.)

2. Bumetanide Coarse crackles = presence of fluid or mucus in lower respiratory tract - < pulmonary edema/fibrosis --> loop diuretic Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excretion by the kidneys Clients with asthma or chronic obstructive pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) and systemic corticosteroids (eg, methylprednisolone) may be prescribed to these clients upper respiratory infections or chronic bronchitis ==> guaifensin to loosen and improve the expectoration of mucus Math: The nurse is preparing to administer a continuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the available medication contains 400 mg of dopamine in 250 mL of D5W. At what rate in milliliters per hour (mL/hr) should the nurse program the infusion pump? Answer: 16

Dopamine is an inotrope and vasopressor used to treat distributive shock and maintain cardiac output. To calculate the dopamine infusion rate in milliliters per hour, the nurse should first identify the prescribed dose (eg, 5 mcg/kg/min) and available medication (eg, 400 mg/250 mL) and then convert to milliliters per hour (eg, 16 mL/hr). The nurse is caring for an African American client with disseminated intravascular coagulation. Which locations are best to assess for the presence of petechiae?

1. Buccal mucosae and conjunctivae of the eyes Petechiae are reddish or purple pinpoints on the skin that occur due to bleeding from capillaries. Petechiae usually occur due to blood vessel injury or bleeding disorders (eg, thrombocytopenia, disseminated intravascular coagulation). Petechiae and similar skin conditions are often challenging to detect in dark-skinned clients as dark pigmentation makes it difficult to assess skin color changes. In dark-skinned clients, petechiae can best be assessed in the conjunctivae of the eyes and the buccal mucosae. The palms of the hands and soles of the feet are ideal locations for assessing other skin color changes that may occur in dark-skinned clients, such as jaundice (ie, yellowing of the skin due to increased bilirubin in the blood). However, these are not ideal locations to assess for petechiae in a dark-skinned client. The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment?
2. House is heated by a wood-burning stove An open wood-burning stove is a fire hazard that may cause physiologic damage from smoke inhalation or burns (Option 2). The nurse should investigate the family's access to other utilities and determine whether the stove is the home's only source of heat. Houses built before 1978 have a high probability of containing lead-based paint. The nurse on the antepartum unit is performing shift assessments of several clients that are pregnant. Which client assessment is the priority to report to the health care provider?
3. Client with preeclampsia with 3+ reflexes and 2 beats of clonus Clients with preeclampsia are at risk for developing preeclampsia-associated seizure activity (eg, eclampsia ) due to increased central nervous system irritability. The presence of neurologic

manifestations (eg, hyperreflexia, clonus ) may indicate worsening preeclampsia and can precede seizure activity (Option 4). This client is at the most immediate risk of harm and is the priority to report to the health care provider. Clients with gestational diabetes mellitus are more susceptible to infection (eg, urinary tract infection, vaginal yeast infection). Although the client's report of dysuria may indicate a urinary tract infection, the assessment findings do not indicate immediate risk After addressing a group of female high school students about sexual health and hygiene, the nurse recognizes that teaching about human papillomavirus (HPV) and genital warts has been effective when hearing which of the following client statements? Select all that apply.

1. "A person's genital warts may come back again, even after receiving treatment." 3."Infection with HPV increases my risk of cervical cancer." 4."Since I am sexually active, I should receive the HPV vaccine series. Treatment for genital warts (eg, topical podophyllin, cryotherapy) is usually effective but does not prevent warts from recurring (Option 1). High-risk HPV strains (eg, types 16 and 18) increase the risk of oral, genital, and cervical cancers (Option 3) .The HPV vaccine helps prevent several HPV strains and is most effective if received before initiation of sexual activity. Clients who are already sexually active may still benefit from HPV vaccination (Option 4). (Option 2) Because HPV infection in females age <21 rarely progresses to malignancy, most clinical organizations recommend initiation of cervical cancer screening (eg, Pap testing) at age 21, regardless of sexual history. Subsequently, overdiagnosis and treatment (eg, cervical excision procedures) leading to negative future reproductive outcomes (eg, preterm birth) are minimized. The charge nurse is making client assignments for the oncoming shift. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant?
2. Client with a methicillin-resistant Staphylococcus aureus wound infection Health care workers (HCWs) who are pregnant do not carry a high risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) as long as appropriate infection precautions (ie, contact precautions) are in place (Option 3). Even if the HCW who is pregnant were to contract MRSA, there are few known harmful effects to the fetus. Because TORCH infections ( T oxoplasmosis, O ther [eg, syphilis], R ubella, C ytomegalovirus, H erpes simplex virus) can cause fetal abnormalities , HCWs who are pregnant should not be assigned clients with these infections. Clients receiving brachytherapy have radioactive implants placed in a body cavity. To safely care for these clients, HCWs limit/cluster client time and keep a distance of at least 6 ft (1.8 m)

unless wearing lead shielding for direct care. If possible, HCWs who are pregnant should not care for these clients because fetal radiation exposure is teratogenic. A nurse is caring for a client admitted with unstable angina. After 5 minutes on an IV nitroglycerin infusion, the client reports improving chest pain but a new dull, throbbing headache. What is the appropriate nursing action?

2. Document the finding and administer prescribed acetaminophen Nitroglycerin is an antianginal medication that causes potent vasodilation (both coronary and systemic) and i s used in the treatment of acute coronary syndrome (eg, unstable angina, myocardial infarction). Vasodilation relieves chest pain by decreasing venous return to the heart, resulting in decreased preload (ie, decreased oxygen demand). IV nitroglycerin administration requires continuous cardiac monitoring and frequent blood pressure assessment (ie, every 15 minutes for the first hour). Headache is an expected adverse effect from vasodilation of cranial vessels and should decrease with continuing nitroglycerin therapy. As long as the client does not have severe hypotension (eg, systolic blood pressure <90 mm Hg), the finding can be documented and the headache treated with aspirin or acetaminophen (Option 2). If the headache becomes severe or persistent despite acetaminophen, the health care provider (HCP) may temporarily decrease the dosage. The nurse should not arbitrarily stop the infusion or decrease the rate. Which of the following situations would be classified as an adverse event, requiring the nurse to complete an incident report?
3. Cerebrospinal fluid sample is sent to the laboratory labeled as a urine sample
4. Nurse fails to report a potassium of 6.5 mEq/L (6.5 mmol/L) to the health care provider
5. Postpartum client after epidural anesthesia falls while ambulating to the bathroom 5.Provider prescribes 5000 units of heparin; nurse gives 1 mL (10,000 units/mL) of heparin An incident / adverse event is an unforeseen or unintended outcome that results in harm , or has the potential to cause harm , which may or may not have been preventable. Examples of client incidents include falls, mislabeled laboratory specimens , and medication administration errors (Options 1, 4, and 5). Communication errors may also be classified as

adverse events because the omission or miscommunication of critical information may result in harm, incomplete treatment, or inadequate follow-up (Option 3). Other incident types involving health care staff may include needlestick injuries or confidentiality breaches of protected health information. A nurse is caring for a client at 37 weeks gestation who is undergoing a contraction stress test. Which fetal strip should the nurse associate with a negative contraction stress test? A contraction stress test (CST) evaluates fetal well-being under stress by identifying uteroplacental insufficiency. Uterine blood flow is decreased during uterine contractions, which stresses the fetus during labor. Contractions are stimulated using either oxytocin administration or nipple stimulation. A fetal tracing is evaluated until 3 uterine contractions, each lasting 40-60 seconds, are captured within 10 minutes. A negative test has no late or variable decelerations and is associated with good fetal outcomes (Option 2). A positive test includes late decelerations with ≥50% contractions. A suspicious or equivocal test includes variable or prolonged decelerations or late decelerations with <50% contractions. intrapartum fetal monitoring Fetal monitoring gives a clear picture of the FHR, and is the strongest indicator of how the fetus is tolerating the labor process Done to evaluate how fetus tolerates labor & to identify possible hypoxic insult to fetus during labor Fetal monitoring has two components:

• the woman's contractions
• looking at how the fetus is tolerating labor by identifying changes in the fetal heart rate. Fetal monitoring may be internal or external Fetal monitoring may be continuous or intermittent

A nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm area of induration. The client emigrated from Nigeria 1 year ago and reports no symptoms. Which of the following actions would be appropriate by the nurse?

1. Ask the client about a history of bacille Calmette-Guérin vaccination
2. Obtain a prescription for a chest x-ray from the health care provider If a client's tuberculin skin test (TST) is positive, the nurse should: Ask clients who emigrated from high-prevalence countries if they have received the bacille Calmette-Guérin (BCG) vaccine. It is commonly administered to children in high-prevalence countries but causes false-positive PPD tests (Option 1). Interferon-gamma release assay testing is preferred in BCG-vaccinated clients because it does not produce false-positive results. Obtain a prescription for a chest x-ray to differentiate latent TB from active disease in asymptomatic clients (Option 5) PPD test is positive because there is an induration >10 mm and the client emigrated from a high-prevalence country <5 years ago. There is no indication to repeat the TST. Airborne precautions NOT droplet Latent TB infection vs Active TB disease A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thrombolytic therapy due to which reason?
3. Client's symptoms started 12 hours earlier Thrombolytic therapy (ie, t-PA ) is used to dissolve blood clots and restore perfusion in clients with ischemic stroke. The nurse should assess for contraindications to t-PA due to the risk for hemorrhage. Clients have a 3 - to 4.5-hour window from onset of symptoms to receive t-PA to achieve full effectiveness of thrombolytic therapy

Recent major surgery within the past 14 days is a contraindication because t-PA dissolves all clots in the body and may therefore disrupt the surgical site.

• To receive t-PA, clients must have a systolic blood pressure (BP) ≤185 mm Hg and diastolic BP ≤110 mm Hg. In addition, BP should be maintained at ≤180/105 mm Hg throughout the administration of thrombolytic therapy and 24 hours thereafter
• Loss of the gag reflex and other major functions would most likely make the client a candidate for thrombolytics due to proof of deficits from stroke. Other contraindications include hemorrhagic stroke and stroke or head trauma within the past 3 months. A nurse is teaching an inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the teaching?

1. Administer scheduled anticoagulants
2. Apply sequential compression devices
3. Have clients ambulate regularly as tolerated
4. Instruct clients to point and flex the feet in bed Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1) Application of compression devices or antiembolism stockings to limit venous stasis (Option 2) Frequent ambulation , 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5) Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees. A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question?

3. Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client who is HIV positive The best way for health care workers to protect themselves against possible HIV transmission is to consistently follow standard (universal) precautions with all clients, regardless of HIV status. HIV is transmitted through contact with blood, breast milk, semen, and vaginal secretions. No extra precautions are needed for routine care of clients that are HIV positive because the virus is not spread through casual contact, droplets, or aerosolized particles. Some nurses have the common misconception that double-gloving reduces the risk of contracting HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Option 3). In compliance with standard precautions, situations in which blood or body fluids may splash or be sprayed (eg, suctioning, irrigation) require additional personal protective equipment (eg, face shield, gown) as necessary. A client comes to the emergency department with crushing substernal chest pain. Which of the following interventions should the nurse anticipate? Select all that apply.
4. Administer IV pain medication
5. Check blood pressure and heart rate 3.Obtain a 12-lead ECG 4.Obtain blood specimens The nurse needs to quickly identify the signs and symptoms of myocardial infarction and initiate interventions to preserve cardiac muscle. The nurse should also recognize that female and older clients may have nonspecific symptoms (eg, fatigue, indigestion, shortness of breath). Initial interventions in the emergency management of chest pain include: Insert 2 large-bore IV lines and administer prescribed medications (eg, nitroglycerin , analgesic ) (Option 1). The nurse should also anticipate a prescription for an antiplatelet agent (eg, aspirin) if the client has not already received a dose. Assess airway, breathing, circulation (eg, vital signs , heart and lung sounds), and pain (Option 2). Obtain diagnostics (eg, 12 - lead ECG , chest x-ray, blood specimens for cardiac markers and electrolytes ) (Options 3 and 4).