NCLEX Practice Exam for Foundation of Nursing

EXPLANATION

✔Correct answer:

Promote venous blood return. When Nurse Claire uses long, firm strokes from the distal (farther from the heart) to the proximal (closer to the heart) areas, she is promoting venous blood return. This technique assists in moving blood through the veins back toward the heart, helping to prevent pooling of blood in the extremities. This approach is particularly useful for patients with limited mobility, as it aids circulation and helps reduce the risk of venous stasis, which can contribute to edema and pressure injuries.

Imagine blood in the veins as water in a hose. By pushing the water toward the source with firm, upward strokes, it’s easier to keep the water flowing smoothly back. Similarly, firm strokes from distal to proximal areas help "push" blood back to the heart.

Here are a few additional benefits of using this bathing technique:

• Improves circulation, particularly in patients who are bedridden or have limited movement.
• Reduces the risk of developing blood clots and pressure ulcers by encouraging blood flow.
• Provides an opportunity to assess the patient’s skin condition, noting any areas of redness, pressure injury, or edema.
• Can be a relaxing experience for the patient, promoting comfort and a sense of well-being.

✘Incorrect answer options:

Allow for a thorough skin assessment. While bathing does allow the nurse to assess the skin, this is not the primary purpose of the distal-to-proximal technique. The primary goal of moving from distal to proximal is to encourage venous return. Skin assessment can be performed with or without specific directional strokes.

Reduce physical strain on the nurse. Although using proper body mechanics is essential to avoid physical strain, the technique of moving from distal to proximal does not specifically reduce strain on the nurse. It’s the positioning and ergonomic movements that prevent strain, rather than the direction of bathing strokes.

Trigger vasoconstriction to enhance circulation. Vasoconstriction is the narrowing of blood vessels, which typically reduces blood flow, not enhances it. The distal-to-proximal strokes promote venous blood return through gentle pressure, but they do not directly cause vasoconstriction. In fact, warm water during a bath is more likely to cause vasodilation (widening of blood vessels), which further aids circulation.

EXPLANATION

✔Correct answer:

Have the patient expectorate the sputum into a sterile container. The correct procedure for collecting a sputum specimen for culture and sensitivity testing is to have the patient expectorate (cough up) the sputum directly into a sterile container. Using a sterile container is essential to prevent contamination of the specimen, which could affect the accuracy of the culture results. The sputum sample should ideally be collected in the morning, as secretions have accumulated overnight, which increases the yield of organisms for testing.

Think of collecting a sputum sample like taking a water sample from a pond. If you collect it in a clean container, you get an accurate idea of what’s in the water. But if the container isn't sterile, you might introduce foreign particles, contaminating the sample.

Here are some additional steps Nurse Sarah should take to ensure proper collection of the sputum sample:

• Instruct the patient to rinse their mouth with water (not mouthwash) prior to collection. This removes oral bacteria and minimizes contamination, while allowing the sample to reflect the lower respiratory tract's content.
• Encourage the patient to take deep breaths and then cough deeply to produce sputum from the lungs, not saliva from the mouth.
• Collect the specimen early in the morning for the best sample quality.
• Ensure the container is sealed tightly after collection, and label it with the patient’s information before sending it to the lab.

✘Incorrect answer options:

Have the patient place the specimen in a container and enclose it in a plastic bag. While enclosing the container in a plastic bag after collection may be part of standard procedure, it is crucial that the sample is collected in a sterile container to prevent contamination. The primary focus here should be on the sterility of the container during collection.

Have the patient expectorate the sputum while the nurse holds the container. Although the nurse can assist with the procedure, it is best for the patient to handle the container to avoid contamination. This allows the patient to directly deposit the sputum into the sterile container without risk of accidental contamination from the nurse’s hand.

Offer the patient an antiseptic mouthwash just before they expectorate the sputum. Antiseptic mouthwash should not be used prior to sputum collection, as it can kill bacteria and potentially alter the sample, leading to inaccurate culture results. A simple rinse with water is preferred to reduce oral contaminants without affecting the lower respiratory tract bacteria.

EXPLANATION

✔Correct answer:

Phlebitis. The symptoms Nurse Karen observes—tenderness, burning, swelling, warmth, and erythema (redness) at the I.V. site—are classic signs of phlebitis, an inflammation of the vein. Phlebitis can occur after prolonged I.V. use (typically after 48–72 hours), especially when an I.V. catheter is in place for extended periods or if the solution administered is irritating to the vein. Phlebitis is characterized by warmth, redness, and tenderness along the vein, and can cause discomfort for the patient.

Think of phlebitis like an irritated hose. If water flows through a hose constantly, it might start to wear and get inflamed from the friction. Similarly, the vein becomes irritated from the I.V. fluid, causing warmth, redness, and tenderness.

If phlebitis is suspected, Nurse Karen should take the following steps:

• Discontinue the I.V. line immediately to prevent further irritation to the vein.
• Apply a warm compress to the affected area to reduce discomfort and inflammation.
• Assess the patient’s symptoms and document the findings, including the size and extent of the erythema and warmth.
• Notify the healthcare provider, especially if symptoms are severe, as the patient may need further treatment or monitoring.
• Consider restarting the I.V. in a different location if continued I.V. therapy is needed.

✘Incorrect answer options:

Infection: While infection can cause similar symptoms, it typically involves more systemic signs, such as fever or chills, along with purulent drainage at the I.V. site. Infection is also less likely to appear precisely at 72 hours without other indicators.

Infiltration: Infiltration occurs when I.V. fluid leaks into the surrounding tissue rather than staying within the vein. Signs of infiltration include coolness, swelling, and a pale appearance at the I.V. site, as opposed to warmth and erythema. Tenderness and burning can also be present, but the absence of warmth and erythema makes infiltration unlikely in this case.

Bleeding: Bleeding at the I.V. site usually presents as visible blood around the catheter insertion site, often without warmth, redness, or tenderness. While bleeding could lead to irritation, it does not typically cause the symptoms of phlebitis described here.

EXPLANATION

✔Correct answer:

Administering a stimulant medication in the evening to help with energy. Administering a stimulant medication in the evening would NOT promote restful sleep. Stimulants, such as caffeine, certain medications, or other stimulating substances, increase alertness and energy, which can interfere with the natural process of falling asleep. They work by increasing the release of neurotransmitters like dopamine and norepinephrine, which elevate heart rate and enhance focus, making it more difficult for the patient to relax and wind down. Therefore, giving a stimulant close to bedtime is counterproductive to achieving restful sleep.

Think of the mind and body like a car engine. Giving a stimulant at night is like pressing the gas pedal just when you want the engine to slow down and stop. Instead of helping the car (the body) come to a restful stop, it revs it up, making it harder to relax and "park" for the night.

Here are some effective strategies Nurse Emily could consider to enhance her patient’s relaxation and sleep:

• Dimming the lights and reducing noise in the room: Lowering light levels and minimizing noise helps create a calm environment that signals the brain it’s time to rest, supporting natural melatonin production.
• Encouraging a cup of herbal tea: Non-caffeinated herbal teas, such as chamomile or valerian root, can have calming effects that promote relaxation before bed.
• Providing a warm blanket and adjusting room temperature: Maintaining a comfortable temperature is essential, as a room that’s too hot or too cold can disrupt sleep quality.

✘Incorrect answer options:

Dimming the lights and reducing noise in the room. This action supports restful sleep by reducing environmental stimuli that can prevent relaxation. A dark, quiet environment enhances melatonin release, which is necessary for sleep.

Encouraging the patient to drink a cup of herbal tea before bed. Herbal teas (caffeine-free options) can promote relaxation, and certain teas like chamomile have mild sedative properties, making them ideal for encouraging sleep.

Providing a warm blanket and adjusting the room temperature to a comfortable level. Ensuring the patient is warm and comfortable and that the room temperature is suitable helps prevent discomfort that could interrupt sleep.

EXPLANATION

✔Correct answer:

Gently pull just below the cuff and invert the gloves when removing them. The safest technique for removing contaminated gloves is to pull just below the cuff and carefully invert each glove as it is removed. By turning the gloves inside out during removal, Nurse Maria ensures that any pathogens on the glove's outer surface are contained inside, minimizing the risk of transferring contaminants to her skin or other surfaces. This technique keeps the contaminated surface away from her hands and prevents potential cross-contamination.

Imagine peeling a banana without touching the inner fruit. By pulling the peel downward and turning it inside out, you keep the inner fruit clean. Similarly, inverting the gloves as they’re removed keeps contaminants on the inside, away from your skin.

Here are the steps Nurse Maria should follow to safely remove her gloves:

• Pinch the outside of one glove at the wrist (just below the cuff) without touching the skin, and slowly pull it down and off, turning it inside out.
• Hold the removed glove in the gloved hand, then slide two fingers under the cuff of the remaining glove on the other hand, avoiding contact with the outside surface.
• Peel off the second glove over the first glove, ensuring both gloves are now inside out, with the contaminated side contained.
• Dispose of the gloves immediately in the appropriate waste container and perform hand hygiene thoroughly.

✘Incorrect answer options:

Wash the gloves before removing them. Washing contaminated gloves is not recommended because water or soap can cause pathogens to spread or splatter, increasing the risk of contamination. Gloves should be removed and discarded immediately without washing.

Gently pull on the fingers of the gloves when removing them. Pulling on the fingers to remove gloves may increase the risk of the glove snapping back or tearing, which could expose the skin to pathogens. Additionally, this method does not invert the gloves, leaving contaminants exposed and increasing the risk of cross-contamination.

Remove the gloves and then turn them inside out. Removing the gloves and then turning them inside out increases the chance of contamination, as the hands may come into contact with the contaminated outer surface during removal. The proper technique is to invert each glove as it is removed.

EXPLANATION

✔Correct answer:

Rapid eye movement (REM) stage. Vivid dreaming most commonly occurs during the REM (Rapid Eye Movement) stage of sleep. During this stage, brain activity is similar to the wakeful state, and the brain produces intense, vivid dreams due to increased neural activity. REM sleep is characterized by rapid movement of the eyes, increased heart rate, and temporary paralysis of most voluntary muscles to prevent individuals from acting out their dreams. This stage usually cycles multiple times throughout the night, with longer REM phases occurring in the later parts of sleep.

Think of the brain during REM sleep as a "movie projector" playing vivid dream scenes. The brain is active and creating detailed, realistic dreams, similar to watching an exciting movie with clear images and emotions.

Stages of Sleep: Here’s a brief overview of the different stages of sleep, to help understand where vivid dreaming fits in:

• Stage I non-REM sleep: This is the lightest sleep stage, where the body begins to relax and slow down, making it easy to wake up. Dreaming is rare in this stage.
• Stage II non-REM sleep: This is a deeper sleep stage than Stage I, but still relatively light. Heart rate and body temperature decrease. Dreaming is uncommon, though brief mental imagery might occur.
• Stage III non-REM sleep (Delta stage): Also known as deep sleep or slow-wave sleep, this stage is critical for physical restoration. Dreaming rarely occurs here.
• REM sleep: This is where vivid dreaming primarily occurs. The brain is highly active, while the body remains immobile, preventing the dreamer from physically reacting to dreams.

✘Incorrect answer options:

Stage I non-REM sleep. This is the lightest stage of sleep, where the body starts to relax, but vivid dreams are rare. It is mainly a transitional phase as one falls asleep and can be easily awakened.

Stage II non-REM sleep. This stage represents a slightly deeper level of sleep than Stage I, but vivid dreaming does not typically occur here. Brief mental images may happen, but they are not the intense, detailed dreams seen in REM sleep.

Delta stage (Stage III non-REM sleep). Also called slow-wave sleep, this is the deepest sleep stage, where the body focuses on physical restoration. Dreaming is uncommon in this stage, as brain activity slows down significantly.

EXPLANATION

✔Correct answer:

0.5 mL. Nurse Elena needs to administer 50 units of Humulin regular insulin. The concentration on the vial label states that there are 100 units per 1 mL. To calculate the correct volume in milliliters (mL) to draw up, we can use a simple ratio and proportion formula:

1. Known concentration: 100 units = 1 mL
2. Desired dose: 50 units

To find the required volume in mL, set up the proportion:

(Desired Dose / Concentration) = Volume to Draw

Volume to Draw = (50 units / 100 units) × 1 mL

Volume to Draw = 0.5 mL

Therefore, Nurse Elena should draw up 0.5 mL of insulin to administer the correct dosage of 50 units.

Think of this like measuring ingredients in a recipe. If the recipe says 100 grams of sugar is equal to 1 cup, then to get 50 grams, you would use half a cup. Similarly, for insulin, if 100 units is 1 mL, then 50 units is 0.5 mL.

When administering insulin, Nurse Elena should also keep the following in mind:

• Double-check the insulin type (Humulin regular insulin) and concentration (100 units per 1 mL) to ensure accuracy.
• Verify the dose with another nurse if required by hospital policy, as insulin is a high-alert medication.
• Use an insulin syringe calibrated in units to accurately measure the dosage.
• Monitor the patient’s blood glucose level before and after administration to evaluate the insulin's effectiveness.

✘Incorrect answer options:

0.75 mL. This would provide 75 units of insulin, which is more than the ordered dose of 50 units.

1 mL. This would provide 100 units of insulin, double the prescribed dose.

2 mL. This would provide 200 units of insulin, four times the prescribed dose, which could lead to severe hypoglycemia and is unsafe.

EXPLANATION

✔Correct answer:

Numbness. Numbness is NOT typically associated with the anger stage of grief in Kübler-Ross's model. In the anger stage, patients often feel emotions such as rage, envy, and resentment, as they may be struggling with feelings of unfairness, helplessness, or frustration toward their situation or those around them. Anger may be directed toward themselves, healthcare providers, family members, or even life itself.

Numbness, however, is more commonly associated with the denial stage or initial shock, where individuals may feel emotionally disconnected or detached as a way to protect themselves from the overwhelming reality of their condition. Numbness is a protective mechanism that allows individuals to cope with a loss that they are not yet ready to process emotionally.

Think of anger as an intense, fiery emotion where people feel deeply engaged with their circumstances, questioning and protesting the unfairness of their situation. In contrast, numbness is like turning off that fire altogether, where the person may feel disconnected or blank.

Here are some ways Nurse Lisa can support her patient during the anger stage of grief:

• Practice active listening and allow the patient to express their anger without judgment. This can help the patient feel validated and understood.
• Encourage the patient to express their feelings constructively, such as through talking, journaling, or engaging in gentle physical activities if appropriate.
• Educate family members about the anger stage to help them understand that these reactions are a normal part of the grieving process.
• Maintain a calm and empathetic demeanor, as anger is often a way for patients to cope with the fear or sadness underlying their situation.

✘Incorrect answer options:

Rage, Envy, and Resentment are all feelings typically associated with the anger stage of grief. During this stage, patients may experience a range of negative emotions, including anger at the perceived unfairness of their situation, envy toward others who are healthy, and resentment toward caregivers or loved ones. These feelings are normal and reflect the internal struggle to accept the reality of their condition.

EXPLANATION

✔Correct answer:

Centers for Disease Control (CDC). The Centers for Disease Control and Prevention (CDC) is the primary organization in the United States that provides evidence-based guidelines and recommendations for infection control practices, including isolation procedures. The CDC publishes guidelines for healthcare professionals on managing infectious diseases, preventing transmission, and implementing appropriate isolation precautions. These guidelines are widely accepted and are designed to protect both healthcare workers and patients by controlling the spread of infections in healthcare settings.

Think of the CDC as the “instruction manual” for handling infectious diseases in healthcare. Just like you follow specific instructions to safely use equipment, healthcare providers rely on CDC guidelines to ensure proper safety measures are in place when dealing with infections.

When dealing with a patient in isolation, Nurse Alex should follow these CDC-recommended guidelines for effective infection control:

• Identify the type of isolation needed based on the patient’s infection (e.g., contact, droplet, airborne precautions).
• Use appropriate personal protective equipment (PPE) such as gloves, masks, gowns, or eye protection, as specified by the CDC for each type of isolation.
• Ensure proper hand hygiene practices before and after contact with the patient or contaminated surfaces.
• Educate visitors and other healthcare staff on infection control protocols to prevent the spread of infectious agents.

✘Incorrect answer options:

National League for Nursing (NLN) – The NLN primarily focuses on nursing education and the advancement of nurse training and competencies. It does not provide guidelines for infection control or isolation practices.

American Medical Association (AMA) – The AMA focuses on advancing medical education, advocating for healthcare improvements, and representing the interests of physicians. While it addresses healthcare issues broadly, it does not publish specific infection control guidelines.

American Nurses Association (ANA) – The ANA is dedicated to promoting nursing standards, advocating for nurses’ rights, and providing resources to advance the nursing profession. However, it does not provide detailed infection control guidelines like the CDC. The ANA might refer to CDC guidelines in its resources but does not develop them independently.

EXPLANATION

✔Correct answer:

Roll the vial gently between the palms. To properly mix a powdered medication with a diluent, rolling the vial gently between the palms is the best technique. This action allows the powder to dissolve evenly in the solution without creating bubbles or froth, which can occur if the vial is shaken vigorously. Rolling the vial gently ensures a smooth and consistent mixture, which is essential for accurate dosing and administration of the medication.

Think of mixing a powdered drink mix in water. If you shake it too hard, it might foam or create bubbles, making it difficult to drink smoothly. Gently swirling or rolling it, however, blends the powder without introducing unwanted bubbles.

When reconstituting powdered medications, Nurse Tanya should also take the following steps to ensure safe and effective preparation:

• Read the medication instructions carefully for the correct amount and type of diluent to use, as each medication may have specific requirements.
• Use aseptic technique when adding the diluent to maintain sterility.
• Inspect the solution after mixing to ensure there are no visible particles, which could indicate incomplete dissolution.
• Label the vial with the reconstitution date and time, along with any specific storage instructions, if the medication will not be used immediately.

✘Incorrect answer options:

Shake the vial vigorously. Shaking the vial can introduce bubbles or froth into the solution, which may lead to inaccurate dosing and make it difficult to draw up the medication. Shaking can also damage certain medications that are sensitive to agitation.

Invert the vial and let it stand for 1 minute. Simply inverting the vial and letting it stand is not sufficient to mix the powder thoroughly with the diluent. This technique will likely leave the powder undissolved at the bottom of the vial, resulting in an uneven mixture.

Do nothing after adding the solution to the vial. Doing nothing after adding the diluent would leave the powdered medication incompletely dissolved. It is essential to mix the medication to ensure it is fully dissolved and evenly distributed in the solution for accurate administration.

EXPLANATION

✔Correct answer:

All of the choices. When applying restraints, Nurse Jamie has several legal responsibilities to ensure that the use of restraints is justified, appropriate, and compliant with healthcare regulations. Each of the actions listed is legally required and essential to protect both the patient’s rights and Nurse Jamie's professional accountability.

• Document the patient’s behavior: It is crucial to record the specific behaviors or conditions that justify the use of restraints. This documentation provides a clear rationale for the intervention and demonstrates that restraints are being used as a last resort to ensure safety.
• Document the type of restraint used: Accurate documentation of the type and method of restraint is necessary for transparency and to ensure continuity of care. This allows other healthcare providers to understand the approach taken and make informed decisions about ongoing care.
• Obtain a written order from the physician, except in emergencies when immediate protection is necessary: Legally, restraints should not be applied without a physician's order, except in cases where immediate action is needed to prevent harm. In such emergency situations, a verbal order must be obtained as soon as possible afterward. This ensures that restraint use is supervised and sanctioned by a licensed healthcare provider, maintaining ethical and legal standards.

Think of these responsibilities like following a checklist when you borrow something valuable. You document why you need it, what exactly you’re taking, and get permission from the owner. Similarly, restraints must be justified, documented, and authorized to protect both the patient and the healthcare provider.

Here are additional considerations Nurse Jamie should keep in mind when applying restraints:

• Ensure restraints are applied in a way that does not restrict circulation, breathing, or cause physical harm.
• Conduct frequent assessments of the patient’s physical and emotional status to determine if restraints can be removed.
• Provide basic needs such as hydration, toileting, and range of motion exercises to ensure patient comfort and reduce adverse effects of restraint use.
• Reassess the need for restraints regularly and aim to remove them as soon as the patient’s safety is no longer at risk.

✘Incorrect answer options:

Each of the individual options alone would not be sufficient to meet Nurse Jamie’s legal obligations. All three components (documenting behavior, documenting the type of restraint, and obtaining a physician’s order) are legally required and collectively ensure compliance with professional and regulatory standards.

EXPLANATION

✔Correct answer:

Fixed, dilated pupils. Fixed, dilated pupils are one of the clearest indicators of imminent death and are often observed at the moment or immediately following death. Pupils that are fixed (unresponsive to light) and dilated indicate a loss of neurological function and are a classic sign of brain death. In the absence of other life signs, fixed and dilated pupils are considered a reliable marker that death has occurred.

Imagine the pupils as windows. In a living person, the "window blinds" can open and close in response to light. When a person is at the point of death, the "blinds" are stuck open, signifying the brain is no longer controlling the body's responses.

Here are some additional signs that Nurse Michelle might observe as death becomes imminent and ways she can provide care during this time:

• Monitor for irregular, slow, or shallow respirations, known as "Cheyne-Stokes" breathing, which often occurs in the final stages.
• Observe for a drop in blood pressure and a weak or thready pulse, as circulatory function deteriorates.
• Provide comfort measures such as moistening the patient’s mouth and repositioning to ensure comfort.
• Offer emotional support to the patient’s family, explaining what to expect and being available to answer questions.

✘Incorrect answer options:

A weak, slow pulse. Although a weak, slow pulse is often observed as death approaches, it is not as definitive as fixed, dilated pupils. The pulse can fluctuate as the body nears death and may persist even when other functions have ceased.

Increased muscle tone. Muscle tone typically decreases as death approaches due to a lack of neurological control. Increased muscle tone is not a common indicator of imminent death, as the body generally relaxes and may even experience muscle flaccidity.

Slow, shallow respirations. Slow, shallow respirations are a common sign of declining respiratory function as death approaches, often progressing into Cheyne-Stokes breathing. However, respiration alone does not definitively indicate death, as breathing patterns can be irregular in the hours leading to death.

EXPLANATION

✔Correct answer:

Denial, anger, bargaining, depression, acceptance. According to Elisabeth Kübler-Ross's model, the five stages of grief or the stages of death and dying occur in the following order: Denial, Anger, Bargaining, Depression, and Acceptance. This model, often referred to as the DABDA model, was developed to describe the emotional and psychological stages that individuals may experience when confronted with terminal illness, significant loss, or death. Each stage represents a different emotional response to the reality of impending death or loss.

1. Denial – This is often the first reaction, where the individual refuses to accept the reality of their situation, as a way of temporarily coping with the shock.
2. Anger – As denial fades, the person may feel intense anger or frustration. This anger can be directed at themselves, others, or the situation itself.
3. Bargaining – In this stage, the person may try to negotiate or make deals (often with a higher power) in an attempt to delay or prevent the inevitable.
4. Depression – This stage involves deep sadness or despair as the individual begins to fully understand the reality of their situation and the losses they are facing.
5. Acceptance – Finally, the individual reaches a stage of acceptance, where they come to terms with the reality of their situation and may feel a sense of peace.

Imagine someone receiving unexpected and difficult news. First, they might refuse to believe it (denial), then feel frustrated or unfairly treated (anger), then try to negotiate for a different outcome (bargaining), feel sorrowful about the situation (depression), and finally come to terms with it and prepare to move forward (acceptance).

Here are some ways Nurse Emma can support her terminally ill patients through these stages:

• Provide empathetic listening and avoid forcing the patient to "move on" from any stage they are experiencing.
• Offer emotional support tailored to each stage; for example, providing reassurance during denial, listening actively during anger, and offering comfort during depression.
• Encourage the involvement of family members and loved ones, as they can provide additional support throughout the process.
• Refer to counseling or support groups as needed, as these resources can offer patients coping mechanisms and emotional support.

✘Incorrect answer options:

Anger, bargaining, denial, depression, acceptance. This sequence incorrectly places anger and bargaining before denial, which does not align with Kübler-Ross's model. Denial is typically the initial response.

Denial, anger, depression, bargaining, acceptance. This sequence incorrectly places depression before bargaining, which is not consistent with the established progression in Kübler-Ross's model.

Bargaining, denial, anger, depression, acceptance. This option is also incorrect as it starts with bargaining instead of denial, which is usually the first stage in the model.

EXPLANATION

✔Correct answer:

Check the syringe to verify that the correct insulin dose has been drawn up. The first priority for the patient in preparing a syringe with insulin is to verify that the correct dose has been drawn up in the syringe. Administering the incorrect dose of insulin can have serious consequences, including hypoglycemia or hyperglycemia. Ensuring that the syringe contains exactly 40 units of U-100 NPH insulin before proceeding with the injection is essential to patient safety. This step should always be done before selecting an injection site or cleaning the skin.

Imagine you're measuring ingredients for a recipe. Before you pour it in, you double-check that you have the right amount because adding too much or too little would ruin the recipe. Similarly, double-checking the insulin dose ensures the "recipe" for proper blood sugar management is accurate.

When teaching a patient to self-administer insulin, Nurse Angela should also emphasize these steps:

• Explain the importance of double-checking the insulin dose every time, even if the patient is experienced in self-administration.
• Teach the patient to hold the syringe at eye level to clearly see the dose markings when verifying the dose.
• Ensure that the patient understands the differences between insulin types and how to recognize U-100 syringes, which are calibrated specifically for U-100 insulin.
• Discuss the appropriate injection sites and rotation schedule after verifying the correct dose.

✘Incorrect answer options:

Assess the injection site. Assessing the site is important but secondary to ensuring the correct dose is prepared. Proper dose verification must happen before site assessment.

Select the appropriate injection site. While selecting an appropriate site is necessary, it comes after confirming the correct dose. Without a correct dose, selecting the injection site is premature.

Clean the injection site in a circular motion with an alcohol sponge. Cleaning the site is part of the injection preparation but should only be done once the correct dose has been verified and the injection site selected.

EXPLANATION

✔Correct answer:

Encourage the patient to increase fluid intake, use mild soap during baths, and apply lotion to the affected areas. Dry skin, also known as xerosis, can be uncomfortable for patients and, if left untreated, can lead to cracking, itching, and even infection. Proper nursing interventions are aimed at rehydrating the skin and preventing further moisture loss. Increasing fluid intake helps hydrate the skin from the inside out, which is essential in maintaining skin elasticity and hydration. Using mild soaps minimizes irritation because many conventional soaps contain harsh chemicals and fragrances that strip natural oils from the skin, worsening dryness. Applying lotion after bathing or washing is crucial as it helps lock in moisture, particularly when done on damp skin. Lotions or moisturizers, especially those containing emollients like lanolin or humectants like glycerin, are effective in maintaining skin hydration.

Think of dry skin like a dry sponge. If you pour water on a dry sponge, it absorbs moisture and becomes more flexible. However, if you use soap with harsh chemicals on the sponge, it might lose its absorbent properties. Adding lotion is like adding a layer of protection that prevents the sponge from drying out too quickly.

Here are some practical steps Nurse Samantha can take to help improve Mr. Reyes' skin condition:

• Educate the patient about the importance of regular hydration and the effects of dry skin on overall health.
• Advise the patient to use lukewarm water instead of hot water when bathing, as hot water can worsen dryness by stripping away skin oils.
• Recommend hypoallergenic, fragrance-free lotions and soaps to avoid potential skin irritation.
• Encourage the patient to apply lotion or cream within a few minutes after bathing to maximize moisture retention.

✘Incorrect answer options:

Refrain from bathing the patient until the dryness resolves, and notify the physician. Avoiding bathing may be counterproductive. While excessive bathing or use of harsh soaps can worsen dryness, appropriate bathing practices using mild soaps can help clean and hydrate the skin. Additionally, notifying a physician is not immediately necessary unless there are signs of infection or a severe dermatologic issue. Nursing interventions can be implemented first.

Request a dermatologist consultation and suggest the patient wear home-laundered sleepwear. While consulting a dermatologist may be necessary for severe or persistent skin issues, dry skin is generally manageable with basic nursing care interventions. The suggestion of home-laundered sleepwear is irrelevant to the primary intervention for dry skin. Wearing soft fabrics like cotton might improve comfort, but this alone is insufficient to address dryness.

Ask the dietitian to increase the patient’s dietary fat and take precautions to prevent infection. Although dietary fats do contribute to skin health, dietary changes alone would not provide the immediate relief needed for skin dryness. Increasing dietary fat intake would not provide instant hydration or alleviate dry skin in the short term. Preventing infection is also important, but it is not a primary intervention for general skin dryness unless the dryness has already led to cracks or open areas.

EXPLANATION

✔Correct answer:

Reflecting on her own personal understanding and the significance of death. The most beneficial approach for Nurse Olivia to support terminally ill patients is to reflect on her own personal understanding and the significance of death. Self-reflection is a crucial step in helping healthcare providers develop empathy, emotional resilience, and comfort in dealing with patients who are facing the end of life. By understanding her own beliefs, feelings, and potential fears around death, Nurse Olivia can better empathize with her patients' experiences, respond to their emotional needs, and maintain a calm, supportive presence.

This introspective approach can also help her identify any biases or unresolved personal issues related to death that might interfere with her ability to provide compassionate care. When a nurse is comfortable with the concept of death, it is often easier to be present and supportive, making it more likely for patients to feel understood and less alone.

Think of self-reflection like adjusting a mirror. When a nurse understands her own perspective on death, she can hold up that "mirror" for patients without letting her own fears or biases distort their experience. This reflection helps her to stay focused on the patient's unique journey through the end-of-life process.

Here are some additional ways Nurse Olivia can enhance her understanding and provide support:

• Engage in mindfulness or meditation practices to become more comfortable with difficult emotions that may arise when caring for terminally ill patients.
• Participate in debriefing sessions with colleagues or seek guidance from experienced palliative care nurses to process challenging cases.
• Attend workshops or support groups designed for healthcare providers who work with end-of-life patients.
• Consider journaling as a tool for exploring personal reflections and emotional responses to working with terminally ill patients.

✘Incorrect answer options:

Taking psychology courses focused on gerontology. Although courses on gerontology (the study of aging) may provide valuable insights into the aging process, they do not specifically address the emotional and psychological needs of patients facing death. The focus in gerontology is generally on the broader aspects of aging, rather than the specific challenges and experiences associated with terminal illness and end-of-life care.

Reading literature on thanatology (the study of death and dying). While studying thanatology can help Nurse Olivia gain theoretical knowledge about death and dying, it does not necessarily improve her ability to connect with patients on a personal, emotional level. Theory alone may not provide the depth of personal reflection needed to face her own emotions about death, which is essential for empathic support.

Learning about different cultural beliefs and practices surrounding death. Understanding different cultural perspectives on death is valuable, as it can help Nurse Olivia provide culturally sensitive care. However, this knowledge alone may not help her emotionally connect with patients on an individual level. Self-reflection allows her to explore her own views and biases, which can enhance her ability to support patients from any background.

EXPLANATION

✔Correct answer:

Draw up the regular insulin first, followed by the NPH insulin, in the same syringe. When mixing insulins, it is essential to draw up regular (clear) insulin first, followed by NPH (cloudy) insulin. This sequence prevents contamination of the regular insulin vial with NPH insulin. Regular insulin is short-acting and should remain uncontaminated for accurate and fast action, while NPH insulin is intermediate-acting and appears cloudy due to added components that prolong its action.

Steps for Mixing Insulin Correctly:

1. Inject air into the NPH vial first (without drawing up any solution) to equal the dose of NPH insulin needed.
2. Inject air into the regular insulin vial and then draw up the required dose of regular insulin (clear) into the syringe.
3. Draw up the required dose of NPH insulin (cloudy) into the syringe without introducing any regular insulin back into the NPH vial.

This "clear before cloudy" technique ensures accurate dosing and prevents contamination of the fast-acting insulin with the intermediate-acting insulin.

Imagine you’re painting with two colors: clear water and cloudy paint. If you dip your brush into the clear water first, it stays clean, and then you can dip it into the paint without affecting the water. But if you dip into the cloudy paint first, then put that brush in the clear water, the water becomes contaminated and loses its clarity. Similarly, when drawing up insulin, you draw the clear (regular) insulin first to keep it pure, then add the cloudy (NPH) insulin to the syringe, ensuring each insulin’s effectiveness is preserved.

When preparing to mix insulin, Nurse Sandra should also:

• Double-check the insulin types, doses, and the order (clear before cloudy) to avoid medication errors.
• Verify the dose with another nurse if required, as insulin is a high-alert medication.
• Roll the NPH insulin vial gently between her palms before use to mix the suspension evenly, avoiding shaking to prevent air bubbles.
• Educate the patient on the importance of consistency with injection sites to ensure proper absorption of insulin.

✘Incorrect answer options:

Draw up the NPH insulin first, followed by the regular insulin, in the same syringe. Drawing up NPH (cloudy) insulin first can contaminate the regular insulin vial, altering the potency and effectiveness of the fast-acting insulin.

Use two separate syringes for each type of insulin. Although using separate syringes is safe, it is generally unnecessary for mixing regular and NPH insulin. Combining them in a single syringe is common practice, provided it’s done correctly.

Confirm with the physician before mixing. While verifying with the physician is not harmful, it is unnecessary in this context, as the procedure for mixing regular and NPH insulin is standard and does not usually require confirmation with a physician.

EXPLANATION

✔Correct answer:

Implementing changes after careful evaluation and open discussions with the team. Transitioning from a peer to a supervisor can be challenging, and the best approach for Nurse Leah to foster a positive work environment is to implement changes only after careful evaluation and open discussions with the team. This approach demonstrates respect for her colleagues' perspectives, promotes transparency, and fosters trust. By involving the team in decision-making, Nurse Leah shows that she values their input, which can reduce resistance and create a collaborative atmosphere. Open communication also helps the staff feel included, which can ease the discomfort that may arise from the shift in roles.

Think of leading a group project with friends. Instead of making decisions alone, discussing ideas with the group shows that you respect their input. This makes everyone feel valued and creates a team spirit, even if you’re the one leading the project.

Here are additional strategies Nurse Leah can consider to foster a supportive work environment as a new supervisor:

• Hold regular team meetings to encourage open communication and allow team members to share feedback on changes.
• Be transparent about her goals and vision as a manager, and provide clear reasons for any changes to maintain trust.
• Recognize and praise staff contributions to reinforce a positive and respectful team culture.
• Provide support and guidance rather than just monitoring, so team members see her as an advocate rather than a critic.

✘Incorrect answer options:

Creating written documentation for all assignments. While documenting assignments is helpful for clarity, it does not directly address the challenge of easing role transition discomfort or fostering a positive environment. Written documentation alone may seem impersonal and may not promote collaboration.

Informing the staff that changes are aimed at improving their performance. This approach may come across as critical and may foster resentment rather than trust. Emphasizing that changes are aimed at improving the team as a whole, rather than individual performance, is more effective in building a positive atmosphere.

Conducting private evaluations of each nurse’s clinical performance. While individual evaluations are important for assessing skills and providing feedback, focusing on private evaluations early on could make Nurse Leah seem overly critical or distant. It’s better to start by building rapport through open communication and team involvement.

EXPLANATION

✔Correct answer:

Prevent a patient from becoming confused or disoriented. Restraints should never be used as a way to manage confusion or disorientation. The primary purpose of restraints is to ensure the patient’s physical safety or the safety of others. Using restraints to prevent confusion or disorientation is inappropriate and can actually increase the patient’s anxiety, agitation, and confusion. Restraints should only be applied when there is a clear risk of harm to the patient or others, and after all other less-restrictive interventions have been attempted.

Using restraints to control confusion is like putting a fence around someone to prevent them from feeling lost. It doesn’t address the root cause of their confusion and may, in fact, make them feel more trapped and disoriented.

When working with confused or disoriented patients, there are several alternatives to restraints that can be used to promote safety and minimize distress:

• Use verbal redirection and reassurance to help orient the patient to their surroundings.
• Provide a calm and structured environment with minimal stimuli, which may help reduce agitation and confusion.
• Encourage family involvement to help reassure and orient the patient.
• Consider one-on-one observation or a “sitter” if the patient is at risk of self-harm or injury but is confused.

✘Incorrect answer options:

Prevent a confused patient from pulling out tubes like feeding tubes, IV lines, or catheters. This is an appropriate use of restraints when a patient is at risk of removing essential medical equipment, which could compromise their health. However, all other options (such as covering the tubes or providing redirection) should be tried first.

Prevent a patient from falling out of bed or a chair. Restraints may be used in specific situations to prevent falls, especially if the patient is at high risk of injury. However, non-restrictive measures, such as bed alarms, lowering the bed, and using fall mats, should be considered first.

Discourage a patient from trying to walk alone when assistance is required for safety. If a patient is at high risk of falling and is trying to ambulate without help, restraints may be considered, but only as a last resort after trying all other methods to ensure their safety.

EXPLANATION

✔Correct answer:

Assess and observe the vomit. Nurse Lucy’s first immediate action should be to assess and observe the vomit. By examining the vomit, she can determine whether the codeine tablet or liquid has been expelled. This assessment will guide her next steps, as it will inform her if the medication was likely absorbed or if it may need to be administered again (pending physician orders). Observing the vomit also allows her to identify any unusual contents or signs, such as blood, which may indicate complications requiring further medical attention.

Imagine taking a pill and then feeling sick. Before deciding to take another dose, you’d first check to see if the pill came up with the vomit to avoid doubling the dose. Similarly, Nurse Lucy needs to assess the vomit first to make an informed decision.

After assessing the vomit, Nurse Lucy can take further steps based on her findings:

• If the medication appears to be intact in the vomit, she should document her findings and contact the physician to discuss the need for a possible re-administration.
• If no medication is visible and the patient continues to experience pain, Nurse Lucy should document the incident and consult the physician for further instructions.
• Monitor the patient for ongoing nausea, as additional interventions (like antiemetics) may be needed to prevent future vomiting episodes.

✘Incorrect answer options:

Contact the physician. Although contacting the physician may be necessary, Nurse Lucy should first assess the vomit to gather relevant information. This assessment allows her to provide the physician with a clearer picture of the situation.

Administer the medication again. Re-administering the medication without assessing the vomit could risk double-dosing, especially if some of the codeine was absorbed before the vomiting. Nurse Lucy should only consider re-administration after consulting with the physician.

Inform the patient that no further action can be taken. This response would be inappropriate, as it does not address the patient’s pain or safety. Nurse Lucy should take steps to assess the situation and consider options for effective pain management.

EXPLANATION

✔Correct answer:

25 drops per minute. To determine the correct flow rate, Nurse Claire needs to calculate the number of drops per minute required to infuse 150 mL of solution over 60 minutes, with an IV tubing drop factor of 10 drops per mL.

Step-by-Step Calculation:

1. Total Volume to be Infused: 150 mL

2. Infusion Time: 60 minutes

3. Drop Factor: 10 drops/mL

The formula to calculate the flow rate in drops per minute is:

Flow Rate (drops/min) = (Volume (mL) / Time (min)) × Drop Factor (gtt/mL)

4. Plugging in the Values:

Flow Rate = (150 mL / 60 minutes) × 10 drops/mL

5. Calculate the Flow Rate:

• First, divide the volume by the time:

150 mL ÷ 60 minutes = 2.5 mL per minute

• Then, multiply by the drop factor:

2.5 mL per minute × 10 drops/mL = 25 drops per minute

Therefore, Nurse Claire should set the flow rate to 25 drops per minute to administer the medication over the required 60 minutes.

Think of this calculation like dividing a pie (the total volume) into equal parts (minutes) and determining how much you should serve each minute to ensure the entire pie is finished in time.

To ensure safe and accurate IV medication administration, Nurse Claire should:

• Double-check the physician’s orders for accuracy, including the medication dose, volume, and infusion time.
• Monitor the IV site for signs of infiltration, phlebitis, or infection, as cefazolin can be an irritant.
• Assess the patient for any adverse reactions to the medication, especially since cefazolin is an antibiotic that may cause hypersensitivity reactions in some patients.
• Recheck the flow rate periodically to ensure it remains at 25 drops per minute throughout the infusion.

✘Incorrect answer options:

37 drops per minute. This rate would administer the solution too quickly, delivering more than the ordered amount per minute.

50 drops per minute. This is also incorrect and would cause the solution to infuse at double the required rate, resulting in completing the infusion in half the desired time (30 minutes instead of 60 minutes).

60 drops per minute. This rate would lead to an even faster infusion, completing it in only 25 minutes, which is too rapid and could increase the risk of adverse effects.

EXPLANATION

✔Correct answer:

Tryptophan. Tryptophan is an amino acid found in various foods, including milk, meat, turkey, and eggs. It is often referred to as a "natural sedative" because it plays a role in promoting relaxation and sleep. Tryptophan is a precursor to serotonin, a neurotransmitter that helps regulate mood and sleep, and melatonin, a hormone that controls the sleep-wake cycle. Increased tryptophan levels in the brain can therefore help improve sleep quality and promote drowsiness.

Think of tryptophan as a "building block" that helps the body produce sleep-inducing substances like serotonin and melatonin. Consuming tryptophan-rich foods is like adding pieces to a puzzle that ultimately forms the picture of good, restful sleep.

Here are a few dietary tips that Nurse Jessica can recommend to help her patient incorporate tryptophan for better sleep:

• Encourage the patient to consume a light snack containing tryptophan before bedtime, such as a small glass of warm milk or a few slices of turkey.
• Advise avoiding large, heavy meals before sleep, as these can disrupt digestion and hinder sleep quality.
• Suggest pairing tryptophan-containing foods with complex carbohydrates (e.g., a small bowl of oatmeal), which may help increase the absorption of tryptophan into the brain.
• Educate the patient on avoiding stimulants like caffeine and nicotine in the evening, as they can counteract the calming effects of tryptophan.

✘Incorrect answer options:

Flurazepam and Temazepam are both benzodiazepine medications used as sedatives or sleep aids. They promote sleep by depressing the central nervous system. However, they are not naturally occurring substances found in food and are not suitable for dietary recommendations.

Methotrimeprazine is an antipsychotic and sedative medication that can have sleep-inducing effects, but it is not found naturally in food. This medication is generally used for severe agitation, psychosis, or as an adjunct for pain management in some cases.

EXPLANATION

✔Correct answer:

Pressurized steam penetrates the supplies better. The main reason for using an autoclave for sterilization is that pressurized steam can penetrate materials more effectively, ensuring that all microorganisms, including spores, are destroyed. Autoclaving is a highly effective sterilization method because the combination of high pressure and high temperature allows steam to thoroughly penetrate medical instruments, supplies, and equipment, reaching all surfaces and effectively killing pathogens.

The steam, when pressurized, can achieve temperatures of 121–134°C, which is sufficient to destroy even the most resistant microbial spores. This thorough penetration makes autoclaving a preferred method for sterilizing medical supplies, ensuring that they are completely free of harmful microorganisms and safe for patient use.

Think of an autoclave like a pressure cooker. Just as a pressure cooker allows steam to deeply penetrate food and cook it evenly, an autoclave uses pressurized steam to thoroughly reach all parts of medical supplies, ensuring they are fully sterilized.

When preparing items for autoclaving, Nurse Jessica should consider the following:

• Ensure all items are properly cleaned before sterilization, as organic material can interfere with the sterilization process.
• Arrange items in the autoclave to allow adequate steam circulation around each item, which improves the effectiveness of sterilization.
• Check the autoclave’s pressure, temperature, and time settings to confirm they meet the recommended parameters for effective sterilization.
• Use autoclave indicators (e.g., chemical strips or biological indicators) to verify that the sterilization process has reached the necessary conditions to ensure sterility.

✘Incorrect answer options:

More articles can be sterilized at a time. While autoclaves can process multiple items at once, the primary reason for using an autoclave is not its capacity but its ability to effectively sterilize using pressurized steam. Overloading an autoclave can actually reduce the effectiveness of sterilization.

Steam causes less damage to the materials. Although steam is less likely to damage some materials compared to dry heat, not all materials are compatible with steam sterilization. The purpose of using an autoclave is to achieve effective penetration and microbial destruction, not specifically to reduce material damage.

A lower temperature can be obtained. Autoclaves operate at high temperatures (typically 121–134°C) under pressure. The increased temperature, achieved through pressurization, is necessary to kill all pathogens, including heat-resistant spores. Therefore, obtaining a lower temperature is not a reason for choosing an autoclave.

EXPLANATION

✔Correct answer:

To accurately measure urine output. The primary reason for inserting a Foley catheter, especially in a clinical setting, is often to accurately measure urine output. This is especially important in patients who are critically ill, post-operative, or those with fluid balance concerns, as it allows for precise monitoring of renal function and overall fluid status. By collecting and measuring urine output, healthcare providers can assess kidney function, detect fluid imbalances, and make more informed treatment decisions.

Think of the Foley catheter as a “measuring cup” for the kidneys. Just as a measuring cup allows you to know exactly how much liquid you’re pouring, the Foley catheter helps healthcare providers know exactly how much urine the patient is producing, giving a clear picture of kidney function and fluid balance.

When using a Foley catheter for accurate measurement of urine output, Nurse James should also:

• Ensure proper aseptic technique during insertion to reduce the risk of infection.
• Monitor the urine color, clarity, and volume, documenting any abnormalities.
• Keep the drainage bag below bladder level to prevent backflow and reduce the risk of UTIs.
• Regularly assess the patient for signs of discomfort or complications, such as urinary tract infection or catheter blockage.

✘Incorrect answer options:

To prevent urinary tract infections (UTIs). Foley catheters actually increase the risk of UTIs because they provide a direct pathway for bacteria to enter the bladder. Catheterization is used only when necessary, and proper care is essential to minimize infection risk.

To aid in patient comfort by keeping the bladder empty. While keeping the bladder empty can be a benefit in certain cases, the primary purpose of catheterization in this context is for accurate measurement of urine output. Catheters are generally not used solely for comfort unless clinically indicated.

To encourage spontaneous bladder contractions. Foley catheters do not encourage spontaneous bladder contractions. In fact, prolonged catheter use can sometimes suppress the bladder’s natural ability to contract, leading to bladder atony over time.

EXPLANATION

✔Correct answer:

The organism’s mode of transmission. The first piece of information Nurse Jamie needs to determine is the mode of transmission of the infectious organism. Understanding whether the infection is spread through contact, droplets, or airborne particles is essential in selecting the appropriate isolation precautions. For example, contact precautions are required for infections transmitted through direct or indirect contact, droplet precautions for larger respiratory droplets, and airborne precautions for infections that spread through smaller, suspended particles. Knowing the mode of transmission allows Nurse Jamie to take specific steps to prevent the spread of the infection to other patients and healthcare staff.

Think of the mode of transmission like the "road map" of how the infection travels. Knowing the route (contact, droplet, or airborne) is crucial to blocking that path with the correct precautions.

Once the mode of transmission is identified, Nurse Jamie can implement the appropriate isolation protocols:

• Contact Precautions: Use gloves and gowns, and ensure proper hand hygiene before and after patient contact. This is used for organisms like MRSA or C. difficile.
• Droplet Precautions: Use a mask and encourage patient isolation in a private room. This is used for infections like influenza or meningitis.
• Airborne Precautions: Use an N95 respirator and isolate the patient in a negative pressure room. This is necessary for diseases like tuberculosis or measles.

✘Incorrect answer options:

The organism’s Gram-staining characteristics. While Gram-staining helps classify bacteria as Gram-positive or Gram-negative and can guide initial treatment, it does not provide information on the mode of transmission. Isolation precautions are based on transmission type, not the Gram stain result.

The organism’s susceptibility to antibiotics. Knowing the organism’s susceptibility is essential for treatment, but it is not immediately relevant to determining isolation precautions. Isolation precautions are applied based on transmission risk, regardless of antibiotic susceptibility.

The patient’s susceptibility to the organism. The patient’s susceptibility refers to their risk of acquiring the infection, which is important for prevention strategies but not directly relevant to the type of isolation precautions needed once the infection is present. The focus here is on protecting others from transmission.