NCLEX- RN Practice Exam 10

EXPLANATION

✔Correct answers:

Avoid tea and coffee on the day of the test. Caffeine can affect the results of an EEG by stimulating the brain, potentially leading to inaccurate readings. Therefore, it is important to avoid tea, coffee, and other caffeinated beverages on the day of the test.

The procedure will take approximately 45 minutes to 2 hours. An EEG typically takes about 45 minutes to 2 hours to complete. Patients should be aware of the duration so they can plan their day accordingly and reduce anxiety about the length of the procedure.

Wash your hair the night before the test. Clean hair is important for an EEG because oils and hair products can interfere with the electrode placement and the quality of the readings. Patients should wash their hair the night before and avoid using any hair products afterward.

Think of the EEG electrodes as stickers that need to stick to the skin. If the skin (or hair in this case) is oily or dirty, the stickers won't stick properly and won't work as well.

Nurses should provide clear and comprehensive instructions to ensure patients are properly prepared for an EEG, which will help ensure accurate and reliable test results.

• Instruct the patient to avoid caffeinated beverages, including tea and coffee, on the day of the test.
• Inform the patient that the EEG procedure will take approximately 45 minutes to 2 hours.
• Advise the patient to wash their hair the night before the test and avoid using hair products such as gels, sprays, or oils.
• Clarify any questions or concerns the patient may have about the procedure.

✘Incorrect answer options:

Drinking cola is permissible on the day of the test. This is incorrect because cola contains caffeine, which can affect the EEG results. All caffeinated beverages should be avoided.

Withhold all medications on the day of the test. This is incorrect because patients should not withhold medications unless specifically instructed by their healthcare provider. Some medications may need to be continued to avoid adverse health effects.

No food or drink (NPO status) is required on the day of the test. This is incorrect because patients do not need to fast for an EEG. They can eat and drink normally, except for avoiding caffeinated beverages.

EXPLANATION

✔Correct answers:

Avoid activities that involve bending over. After cataract surgery, it is important to avoid activities that increase intraocular pressure, such as bending over, lifting heavy objects, or straining. Increased intraocular pressure can interfere with healing and potentially damage the surgical site.

Wear an eye shield over the surgical eye during sleep. Wearing an eye shield at night protects the surgical eye from accidental rubbing or injury during sleep, which is crucial for preventing postoperative complications and promoting proper healing.

Report any decrease in visual acuity to the surgeon. Any decrease in visual acuity after surgery should be reported immediately to the surgeon, as it could indicate complications such as infection, hemorrhage, or issues with the intraocular lens implant.

Use acetaminophen (Tylenol) for mild eye discomfort. Acetaminophen is recommended for managing mild discomfort after cataract surgery because it is effective in relieving pain without increasing the risk of bleeding, unlike NSAIDs.

Think of the eye after surgery like a fragile plant you've just repotted. You need to handle it gently and avoid knocking it over or exposing it to stress to ensure it grows properly.

Nurses should provide comprehensive instructions to ensure patients understand how to care for their eyes after surgery and recognize signs of potential complications.

• Instruct the patient to avoid bending over, lifting heavy objects, and straining to prevent increased intraocular pressure.
• Recommend wearing an eye shield at night to protect the surgical eye from accidental trauma.
• Advise the patient to report any changes in vision, such as decreased visual acuity, to the surgeon immediately.
• Suggest using acetaminophen for pain management, and advise against the use of NSAIDs unless specifically instructed by the surgeon.
• Encourage adherence to prescribed eye drop regimen to prevent infection and reduce inflammation.

✘Incorrect answer options:

Notify the surgeon if eye scratchiness is experienced. Mild scratchiness and discomfort are common after cataract surgery and usually resolve on their own. However, if the scratchiness is severe or persists, it should be reported. Routine mild scratchiness does not typically require immediate notification.

Sudden severe eye pain is a normal occurrence. Sudden severe eye pain is not normal after cataract surgery and could indicate a serious complication such as increased intraocular pressure, infection, or hemorrhage. This symptom requires immediate medical attention and should be reported to the surgeon right away.

EXPLANATION

✔Correct answers:

A client with diabetes mellitus, A client suffering from malnutrition, A client with renal failure. These patients are at the highest risk for developing metabolic acidosis due to the underlying pathophysiological mechanisms that affect acid-base balance.

A client with diabetes mellitus: Diabetic ketoacidosis (DKA) is a common complication in patients with diabetes mellitus, particularly type 1 diabetes. In DKA, the lack of insulin leads to the breakdown of fats for energy, producing ketones, which are acidic and can lead to metabolic acidosis.

A client suffering from malnutrition: Malnutrition can lead to a state of catabolism, where the body breaks down muscle and fat for energy. This process can produce acidic byproducts, such as ketones, leading to metabolic acidosis. Additionally, malnutrition can result in a deficiency of bicarbonate, which is a buffer for acids.

A client with renal failure: The kidneys play a crucial role in maintaining acid-base balance by excreting hydrogen ions and reabsorbing bicarbonate. In renal failure, the kidneys' ability to perform these functions is impaired, leading to the accumulation of acids in the body and resultant metabolic acidosis.

Think of the body as a factory. If the factory's waste disposal system (kidneys) is broken, waste (acids) will build up. Similarly, if the factory runs out of supplies (nutrition), it might start using suboptimal processes that create more waste (acids).

Nurses should monitor at-risk patients closely for signs and symptoms of metabolic acidosis and provide appropriate interventions.

• Monitor blood glucose levels in diabetic patients and educate them on the importance of insulin management to prevent DKA.
• Assess nutritional status and encourage adequate intake of nutrients to prevent malnutrition and its complications.
• Regularly evaluate renal function in patients with renal failure and monitor for signs of acidosis, such as rapid breathing, confusion, and lethargy.
• Administer appropriate treatments, such as insulin for DKA, nutritional support, and medications to manage renal function and acid-base balance.

✘Incorrect answer options:

A client experiencing severe anxiety: Severe anxiety can lead to respiratory alkalosis due to hyperventilation, not metabolic acidosis.

A client diagnosed with pneumonia: Pneumonia primarily affects the respiratory system and can lead to respiratory acidosis due to impaired gas exchange, rather than metabolic acidosis.

A client with asthma: Asthma can lead to respiratory acidosis or alkalosis depending on the severity and phase of the attack (e.g., hypoventilation vs. hyperventilation), but it does not typically cause metabolic acidosis.

EXPLANATION

✔Correct answers:

Elevated temperature, Excessive sweating, Restlessness:  Thyrotoxicosis, also known as thyroid storm, is a life-threatening condition that can occur in individuals with Graves' disease. It is characterized by the excessive release of thyroid hormones, leading to a hypermetabolic state.

Elevated temperature: One of the hallmark signs of thyrotoxicosis is a significant increase in body temperature (hyperthermia). This is due to the heightened metabolic activity driven by excessive thyroid hormone levels.

Excessive sweating: Increased sweating is another common symptom of thyrotoxicosis. The body's increased metabolic rate generates more heat, prompting excessive sweating as the body attempts to cool down.

Restlessness: Patients experiencing thyrotoxicosis often exhibit restlessness and agitation. The excess thyroid hormones can lead to heightened nervous system activity, causing symptoms such as anxiety, tremors, and restlessness.

Think of thyrotoxicosis like a car engine that is overheating and running too fast. The elevated temperature is like the engine getting too hot, excessive sweating is like the car trying to cool down, and restlessness is like the engine running rough and fast.

Nurse Carter should closely monitor the patient for these symptoms and prepare to take immediate action to manage the thyrotoxicosis and prevent complications.

• Monitor the patient's vital signs frequently, paying close attention to temperature, heart rate, and blood pressure.
• Administer antipyretics as prescribed to manage fever and provide comfort.
• Provide a cool environment and cooling measures, such as cool compresses or fans, to help reduce body temperature.
• Administer beta-blockers as prescribed to help manage symptoms such as tachycardia and restlessness.
• Ensure that the patient is receiving appropriate thyroid hormone-blocking medications and other treatments as prescribed.
• Educate the patient and family about the signs and symptoms of thyrotoxicosis and the importance of seeking immediate medical attention if they occur.

✘Incorrect answer options:

Slow heart rate: Bradycardia, or a slow heart rate, is not associated with thyrotoxicosis. Instead, patients typically exhibit tachycardia (rapid heart rate) due to the increased metabolic and sympathetic nervous system activity.

Pale skin: Pale skin is not a typical symptom of thyrotoxicosis. In fact, patients may have flushed or warm skin due to the increased blood flow and metabolic rate.

EXPLANATION

✔Correct answers:

Reduced urine output, Significant proteinuria (3+), Elevated blood pressure of 168/116 mm Hg: Severe preeclampsia is characterized by a range of symptoms that indicate significant end-organ dysfunction and hypertension.

Reduced urine output: Oliguria, or reduced urine output, is common in severe preeclampsia due to impaired renal function caused by severe hypertension and endothelial damage.

Significant proteinuria (3+): Proteinuria is a key diagnostic criterion for preeclampsia. Significant proteinuria (3+ or greater) indicates severe renal involvement and damage to the glomeruli, leading to the leakage of proteins into the urine.

Elevated blood pressure of 168/116 mm Hg: Blood pressure readings of 160/110 mm Hg or higher on two occasions at least four hours apart, while on bed rest, are indicative of severe preeclampsia. This level of hypertension poses significant risks for both the mother and the fetus, including the risk of stroke and placental abruption.

Think of severe preeclampsia as a car’s warning lights indicating major issues. High blood pressure is like the engine overheating, proteinuria is akin to oil leaking, and reduced urine output is like the fuel gauge dropping rapidly—each a sign that immediate intervention is needed.

Nurses should monitor for signs and symptoms of severe preeclampsia to provide timely and effective management to prevent complications.

• Frequent monitoring of blood pressure to assess for any further increases and response to treatment.
• Measurement of urine output and proteinuria to monitor renal function and the severity of preeclampsia.
• Assessment of neurological status and reflexes to detect any signs of worsening condition, such as the onset of eclampsia.
• Administration of antihypertensive medications as prescribed to manage high blood pressure.
• Providing education and support to the patient and family about the condition and the importance of close monitoring and treatment adherence.

✘Incorrect answer options:

Convulsions: Convulsions are associated with eclampsia, not preeclampsia. Eclampsia is a severe complication of preeclampsia and involves the onset of seizures.

Uterine contractions: Uterine contractions are not a typical sign of severe preeclampsia. They may indicate preterm labor but are not directly related to the diagnostic criteria for severe preeclampsia.

Muscular cramps: While muscular cramps can occur in pregnancy due to various reasons such as electrolyte imbalances, they are not specific indicators of severe preeclampsia.

EXPLANATION

✔Correct answer:

Administer oxygen via mask. An oxygen saturation level of 76% is critically low and indicates severe hypoxemia, which requires immediate intervention. Administering oxygen via mask will help increase the oxygen levels in Mr. Jones' blood, which is crucial for maintaining vital organ function and preventing further complications. This immediate action is necessary to stabilize the patient before any further assessments or notifications.

Chronic bronchitis is characterized by chronic inflammation of the bronchial tubes, leading to increased mucus production and obstruction of airflow. This can result in inadequate oxygen exchange and low oxygen saturation levels. Rapid administration of oxygen helps to improve oxygen delivery to tissues and organs.

Think of a car running out of gas. The first action would be to refuel it immediately to keep it running. Similarly, for a patient with low oxygen saturation, providing supplemental oxygen immediately helps to "refuel" the body with the necessary oxygen.

Nurse Kelly should follow protocols for oxygen administration and continuously monitor the patient’s response to the intervention.

• Administer oxygen via a mask at an appropriate flow rate to quickly improve oxygen saturation.
• Monitor the patient's vital signs and oxygen saturation closely to assess the effectiveness of the oxygen therapy.
• Position the patient in a high Fowler's position to facilitate easier breathing and better lung expansion.
• Once the patient is stabilized, notify the physician of the patient’s condition and the interventions taken.
• Document the event, interventions, and the patient’s response in the medical record.

✘Incorrect answer options:

Notify the physician. While it is important to notify the physician, the immediate priority is to address the critically low oxygen saturation level. Administering oxygen should be the first action before notifying the physician.

Reassess the oxygen saturation level in 15 minutes. This option is incorrect because waiting 15 minutes without intervention could lead to further deterioration of the patient's condition. Immediate action is required to address the severe hypoxemia.

Check the patient's pulse. While checking the pulse is part of a comprehensive assessment, the critical issue at hand is the low oxygen saturation. Administering oxygen takes precedence to stabilize the patient.

EXPLANATION

✔Correct answer:

A cheese omelet. A cheese omelet is a safe choice for a child with celiac disease. Celiac disease is an autoimmune disorder where ingestion of gluten leads to damage in the small intestine. Gluten is found in wheat, barley, and rye. Eggs and cheese do not contain gluten, making a cheese omelet a gluten-free and safe option for someone with celiac disease.

In celiac disease, the ingestion of gluten triggers an immune response that damages the lining of the small intestine, leading to malabsorption of nutrients. Adhering to a strict gluten-free diet is essential to manage symptoms and prevent complications associated with celiac disease.

Think of gluten as a harmful ingredient for someone with celiac disease, much like a person with a nut allergy must avoid nuts. Just as a person with a nut allergy can safely eat foods without nuts, a person with celiac disease can safely eat foods without gluten, like a cheese omelet.

Nurses should provide clear guidance and education on identifying gluten-containing foods and making safe food choices.

• Educate the family about reading food labels carefully to identify gluten-containing ingredients.
• Provide a list of naturally gluten-free foods such as fruits, vegetables, meat, poultry, fish, dairy products, and gluten-free grains like rice and quinoa.
• Suggest gluten-free substitutes for commonly consumed gluten-containing foods, such as gluten-free bread and pasta.
• Encourage the family to prepare meals at home to have better control over ingredients and avoid cross-contamination.
• Discuss the importance of avoiding cross-contamination in the kitchen by using separate utensils, cookware, and preparation surfaces for gluten-free foods.

✘Incorrect answer options:

A ham sandwich on whole-wheat toast. This option is incorrect because whole-wheat toast contains gluten, which is harmful to someone with celiac disease.

Spaghetti and meatballs. Traditional spaghetti is made from wheat flour, which contains gluten. Unless the spaghetti is specifically labeled gluten-free, this meal is not safe for someone with celiac disease.

A hamburger with ketchup. While the hamburger patty and ketchup might be gluten-free, the bun is typically made from wheat flour and contains gluten. A gluten-free bun would be necessary to make this meal safe for someone with celiac disease.

EXPLANATION

✔Correct answer:

Exophthalmos. Exophthalmos, or bulging eyes, is a hallmark symptom of Grave's disease. Grave's disease is an autoimmune disorder that leads to overactivity of the thyroid gland (hyperthyroidism). This excessive thyroid hormone production can cause various systemic effects, including the characteristic bulging of the eyes due to inflammation and tissue buildup behind the eyes.

Grave's disease stimulates the thyroid gland to produce excessive amounts of thyroid hormones, leading to an accelerated metabolic rate. The immune system mistakenly attacks tissues around the eyes, causing inflammation, swelling, and tissue deposition, which results in exophthalmos. This symptom is specific to Grave's disease and helps differentiate it from other forms of hyperthyroidism.

Think of the thyroid gland as the body's engine. In Grave's disease, the engine is running too fast, causing various parts to overwork. The eyes, being particularly sensitive, show visible signs of this "over-revving" by bulging outwards.

Nurses should monitor and manage symptoms of hyperthyroidism and provide supportive care for eye symptoms associated with exophthalmos.

• Monitor vital signs, including heart rate and blood pressure, as hyperthyroidism can cause tachycardia and hypertension.
• Educate the client about the importance of medication adherence to manage thyroid hormone levels effectively.
• Provide instructions on eye care, such as using lubricating eye drops to prevent dryness and irritation.
• Encourage the client to wear sunglasses to protect the eyes from sunlight and wind.
• Discuss the possibility of referral to an ophthalmologist for specialized eye care if needed.

✘Incorrect answer options:

Bradycardia. Bradycardia, or a slow heart rate, is not associated with Grave's disease. Instead, hyperthyroidism typically causes tachycardia, or a fast heart rate, due to the increased metabolic rate.

Decreased appetite. Clients with Grave's disease usually experience an increased appetite due to the heightened metabolic rate, not a decreased appetite.

Weight gain. Weight loss is more common in Grave's disease due to the increased metabolic rate, despite increased appetite. Weight gain is not typically observed in hyperthyroidism unless there is an unusual intake of calories far exceeding metabolic demands.

EXPLANATION

✔Correct answer:

A complete tracheostomy set. Epiglottitis is a severe and potentially life-threatening condition characterized by inflammation and swelling of the epiglottis, which can lead to a sudden and complete airway obstruction. In such emergencies, it is critical to have a complete tracheostomy set readily available. A tracheostomy might be necessary if intubation is not possible due to severe swelling, ensuring a secure airway can be quickly established to prevent asphyxiation.

Epiglottitis typically involves bacterial infection, leading to rapid swelling of the epiglottis and surrounding tissues. This swelling can block the airway, causing difficulty in breathing, stridor, and potential respiratory arrest. Immediate intervention with a tracheostomy can be lifesaving if the airway becomes completely obstructed.

Imagine a blocked drainpipe that is completely obstructed. To quickly relieve the blockage and allow water to flow, you need to create a new opening. Similarly, in a case of severe epiglottitis, a tracheostomy creates a new airway opening directly into the trachea, bypassing the obstructed area.

Nurses must be prepared to act swiftly in cases of epiglottitis by having all necessary emergency equipment on hand and knowing how to use it effectively.

• Ensure a complete tracheostomy set is at the bedside, including tracheostomy tubes, dilators, and all necessary sterile equipment.
• Monitor the client's respiratory status closely, watching for signs of airway obstruction such as stridor, drooling, and increased work of breathing.
• Maintain a calm and reassuring presence to reduce the client’s anxiety and avoid agitation, which can worsen airway obstruction.
• Avoid any procedures that might provoke the child, such as throat examination or unnecessary movement, which could exacerbate the obstruction.
• Be prepared to administer supplemental oxygen and assist with ventilation if necessary until a definitive airway can be secured.

✘Incorrect answer options:

Supplies for establishing intravenous access. While IV access is important for administering medications and fluids, it is not the immediate priority in a situation where airway obstruction is the primary concern. Establishing a secure airway takes precedence.

A pump for administering intravenous fluids. Similar to IV access, while fluid administration is important, it is secondary to ensuring the airway is patent. Without a clear airway, the administration of fluids will not address the immediate risk of respiratory failure.

Supplemental oxygen equipment. Although supplemental oxygen is important, it will not be effective if the airway is completely obstructed. The priority is to establish a patent airway, which may require a tracheostomy.

EXPLANATION

✔Correct answer:

A significantly high fever. In cases of bacterial pneumonia, it is common to observe a significantly high fever as the body responds to the infection. Bacterial pneumonia is an acute infection of the lung parenchyma, and the body’s immune response to the invading bacteria typically results in a high fever. This is a key indicator of bacterial pneumonia, often accompanied by other symptoms like productive cough, difficulty breathing, and chest pain.

Bacterial pneumonia involves inflammation of the alveoli in the lungs, which can fill with fluid or pus. This inflammation and fluid accumulation trigger a systemic immune response, leading to a high fever as the body attempts to fight off the bacterial infection.

When you have an infection, your body turns up the heat (fever) to help fight off the invaders, much like how you might increase the temperature in your home to create an unfavorable environment for pests.

Nurses should closely monitor the child's temperature, respiratory status, and overall condition to manage symptoms and prevent complications.

• Monitor vital signs frequently, including temperature, respiratory rate, and oxygen saturation.
• Administer antipyretics as prescribed to manage fever and provide comfort.
• Encourage fluid intake to prevent dehydration and help loosen mucus.
• Assist with respiratory treatments, such as nebulization or chest physiotherapy, to improve airway clearance.
• Educate the caregivers about signs of worsening condition and the importance of completing the full course of antibiotics.

✘Incorrect answer options:

A cough that is nonproductive. Bacterial pneumonia typically presents with a productive cough rather than a nonproductive one. The cough usually brings up mucus that may be yellow or green, indicating the presence of infection.

Symptoms of rhinitis. Rhinitis (inflammation of the nasal mucous membrane) is more commonly associated with upper respiratory infections, such as the common cold, rather than bacterial pneumonia, which affects the lower respiratory tract.

Episodes of vomiting and diarrhea. While these symptoms can occur, especially in younger children, they are not primary indicators of bacterial pneumonia. They might be more associated with gastrointestinal infections or side effects of antibiotics rather than the pneumonia itself.

EXPLANATION

✔Correct answer:

Risk for aspiration. Following a tonsillectomy, the primary concern is ensuring the child's airway remains clear and preventing aspiration. The surgical site is vulnerable, and the child may have residual effects from anesthesia, both of which increase the risk of aspiration. Keeping the airway patent and monitoring for any signs of bleeding, which can also lead to aspiration of blood, are crucial.

Aspiration can occur if blood or other secretions enter the airway. This can lead to serious complications such as pneumonia or respiratory distress. In the immediate postoperative period, ensuring that the child’s airway is protected and clear of obstructions is of utmost importance.

Imagine if you have just had a throat surgery and you are not fully awake or in control of swallowing. Ensuring nothing accidentally goes down the wrong way, like food or saliva, is critical to avoid choking or lung problems.

Nurses must closely monitor for signs of bleeding and aspiration, such as frequent swallowing, coughing, or changes in breathing. Proper positioning and vigilance are essential in this critical period.

• Position the child on their side or with the head slightly elevated to facilitate drainage and reduce the risk of aspiration.
• Monitor for signs of bleeding, such as frequent swallowing, throat clearing, or visible blood in saliva.
• Keep suction equipment nearby and ready for use if needed to clear the airway.
• Educate parents and caregivers on the importance of monitoring the child closely and reporting any signs of distress immediately.

✘Incorrect answer options:

Body image disturbance. While changes in body image could be a concern for some surgeries, it is not a primary concern immediately following a tonsillectomy, especially in a child.

Impaired verbal communication. This can be an issue post-tonsillectomy due to throat pain and swelling, but it is not the immediate priority. Ensuring the child's safety by preventing aspiration takes precedence.

Pain. Pain management is indeed important and will be a key part of care, but the risk for aspiration presents a more immediate threat to the child’s safety and well-being in the immediate postoperative period.

EXPLANATION

✔Correct answer:

"Remove the hearing aid when using a hair dryer or hairspray." It is important to remove the hearing aid when using a hair dryer or hairspray because the heat from the hair dryer can damage the electronic components of the hearing aid, and the chemicals in hairspray can clog the microphone and other parts of the device, potentially affecting its functionality.

Hearing aids are delicate electronic devices designed to amplify sound for individuals with hearing impairment. Exposure to high temperatures or chemicals can degrade the materials and components of the hearing aid, leading to malfunction or reduced performance. Ensuring proper care and maintenance is crucial for the longevity and effectiveness of the hearing aid.

Think of the hearing aid as a smartphone. Just as you wouldn't use a hair dryer or spray chemicals near your phone because it might get damaged, you should avoid exposing your hearing aid to similar conditions to keep it working properly.

Nurses should provide comprehensive care instructions to clients fitted with hearing aids to ensure they understand how to properly use and maintain their devices.

• Instruct the client to remove the hearing aid before using a hair dryer or applying hairspray to prevent damage.
• Advise the client to keep the hearing aid dry by removing it before showering or swimming.
• Inform the client that hearing aids should not be worn during MRI scans, as the magnetic field can interfere with the device and potentially cause harm.
• Explain that the hearing aid should be turned off when not in use to conserve battery life and prolong the device's functionality.

✘Incorrect answer options:

"Keep the hearing aid on while showering to prevent water damage." This statement is incorrect because hearing aids should be removed before showering to avoid water damage. Moisture can severely impair the functioning of electronic components in the hearing aid.

"Wear the hearing aid during MRI scans for better communication with staff." This statement is incorrect because hearing aids should be removed before MRI scans. The strong magnetic fields used in MRI can interfere with the hearing aid and pose a risk to the client.

"Turn off the hearing aid while wearing it to conserve battery life." This statement is incorrect because turning off the hearing aid while wearing it defeats its purpose. The hearing aid should be turned off only when not in use to conserve battery life.

EXPLANATION

✔Correct answer:

Encourage the parent or guardian to stay in the room with the child. It is essential to provide comfort and security to a hospitalized toddler, and having a parent or guardian present is crucial for this. A familiar face can help reduce the child's anxiety and fear in an unfamiliar environment. The presence of a parent or guardian not only offers emotional support but also aids in comforting the child during assessments and treatments.

Toddlers experience separation anxiety, and being in a hospital can be particularly stressful and frightening for them. Keeping the parent or guardian close helps mitigate this stress and promotes a sense of security and well-being, which is essential for the child's emotional and psychological health.

Imagine you are in a foreign place, feeling scared and alone. Having a close friend or family member with you would make you feel safer and more secure. For a toddler, their parent or guardian provides that same sense of comfort and reassurance.

Nurses should facilitate the presence of parents or guardians and involve them in the care of their child as much as possible to promote a healing and comforting environment.

• Encourage parents to stay with their child during hospital stays to provide comfort and reduce anxiety.
• Involve parents in the care process, such as assisting with feeding, comforting, and participating in play activities.
• Provide education and support to parents to help them understand the hospital routines and how they can best support their child.
• Create a child-friendly environment by allowing familiar items, like a favorite blanket or toy, to remain with the child.

✘Incorrect answer options:

Request the parent or guardian to leave the room during assessments. This option is incorrect because it can increase the child's anxiety and fear. Having a parent present during assessments provides emotional support and helps the child feel more secure.

Suggest the parent or guardian take the child’s favorite blanket home as outside items are not allowed. This option is incorrect because familiar items, such as a favorite blanket, can provide significant comfort to a child in an unfamiliar hospital environment. Removing these items can increase the child's distress and discomfort.

Inform the child that screaming is not acceptable behavior. This option is incorrect because toddlers often express their fear and anxiety through crying or screaming, which is a normal reaction to stress. Instead of reprimanding the child, it is better to comfort and reassure them.

EXPLANATION

✔Correct answer:

"We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." This statement indicates a need for further instruction because hot dogs are a choking hazard for young children, especially toddlers. According to pediatric guidelines, foods that are round and can easily block a child's airway should be avoided or cut into very small, non-round pieces. Hot dogs are particularly risky due to their shape and size, which can lead to choking if not properly prepared.

Toddlers have smaller airways and are still developing their chewing and swallowing skills. Foods that are tough to chew, sticky, or round can easily cause choking. Hot dogs are one of the leading foods associated with choking in young children, and it's crucial to educate parents about safe food choices.

Imagine giving a small ball to a toddler to play with; there's a high risk they might put it in their mouth and choke. Similarly, foods like hot dogs, if not properly prepared, can become "small balls" in their throats, posing a significant choking hazard.

Nurses should provide clear guidance on safe food practices for toddlers to prevent choking incidents.

• Educate parents about foods that pose choking risks, including hot dogs, grapes, nuts, and raw vegetables.
• Advise parents to cut foods into small, irregularly shaped pieces that are less likely to obstruct the airway.
• Encourage supervision during meal times to promptly address any signs of choking.
• Provide resources or demonstrations on proper food preparation techniques to reduce choking hazards.

✘Incorrect answer options:

"It is okay to give my child white grape juice for breakfast." While fruit juices should be given in moderation due to their high sugar content, occasional servings like white grape juice can be part of a balanced diet. It's important to limit the quantity to avoid excessive sugar intake, but this statement does not indicate an immediate need for further instruction.

"My child can have a grilled cheese sandwich for lunch." A grilled cheese sandwich is generally a safe and acceptable food choice for a toddler. It provides protein and calcium, which are important for growth and development.

"For a snack, my child can have ice cream." While ice cream should be given in moderation due to its sugar and fat content, occasional servings are acceptable. It's more important to ensure that the child's overall diet is balanced and nutritious.

EXPLANATION

✔Correct answer:

Clean the eye with warm water to remove any exudate before instilling the eye drops. Before administering eye drops to a client with conjunctivitis, it is crucial to clean the eye to remove any discharge or exudate. This step helps ensure that the medication will come into direct contact with the conjunctival surface, increasing its efficacy. Cleaning the eye also helps prevent the spread of infection and reduces discomfort for the client.

Conjunctivitis, also known as pink eye, is characterized by inflammation of the conjunctiva, often accompanied by discharge, redness, and irritation. Removing exudate prior to medication administration ensures that the eye drops can work effectively by not being hindered by any obstructions or contaminants.

Think of it like painting a wall. Before you start, you need to clean off any dust or dirt so that the paint can adhere properly and look smooth. Similarly, cleaning the eye ensures that the medication can do its job effectively without any barriers.

Nurses should follow a proper procedure for administering eye drops, especially in pediatric clients, to ensure the treatment is effective and to minimize discomfort.

• Explain the procedure to the child and caregiver to reduce anxiety and gain cooperation.
• Wash hands thoroughly before and after the procedure to prevent the spread of infection.
• Use a clean, warm, damp cloth or cotton ball to gently wipe away any discharge from the inner to the outer corner of the eye.
• Instruct the child to tilt their head back and look up to facilitate the administration of the drops.
• Gently pull down the lower eyelid to create a small pocket where the eye drops can be instilled.
• Administer the prescribed number of drops and avoid touching the dropper tip to the eye or any other surface to maintain sterility.

✘Incorrect answer options:

Allow the child to instill his own eye drops. This option is inappropriate because a 7-year-old may not have the necessary coordination or understanding to properly administer the medication, which could result in ineffective treatment or contamination of the eye dropper.

Permit the mother to instill the eye drops. While involving caregivers in the care process can be beneficial, it is crucial for the nurse to ensure that the eye drops are administered correctly, especially during initial treatments. The nurse can demonstrate the proper technique to the mother for future administrations but should handle the procedure in the clinical setting to ensure proper technique and hygiene.

Hold the eye drops if the eye appears clear from redness or edema. This option is incorrect because conjunctivitis requires a full course of treatment to resolve the infection completely. Symptoms may subside before the infection is entirely cleared, and discontinuing treatment prematurely can lead to recurrence or worsening of the infection.

EXPLANATION

✔Correct answer:

A client who is six months pregnant with abdominal pain and a client with facial lacerations and a broken arm. During a disaster situation, it is important to prioritize patient safety and minimize the risk of complications or further harm. Placing a pregnant client with abdominal pain in the same room as a client with facial lacerations and a broken arm is a reasonable choice because both conditions do not pose a risk of cross-contamination, and their conditions are relatively stable compared to the other options. The emergency room staff can monitor both clients closely without exacerbating their conditions. Additionally, their care needs are different enough that they can be managed concurrently without interference.

Pregnancy with abdominal pain requires monitoring for potential obstetric complications, but it does not typically involve infectious conditions. Facial lacerations and a broken arm, while serious, do not carry a high risk of infection or require isolation. The separation of these two clients is practical, as their care needs do not overlap significantly in a way that could compromise their safety.

Imagine you have a room in your house with two people needing help. One has a headache (abdominal pain) and the other has a scraped knee (facial lacerations and broken arm). Both can be helped without making each other's condition worse. But you wouldn't put someone with the flu (chest pain/puncture wound) in the same room as someone with a cold (fixed pupils/head injury) because they could make each other sicker.

During disaster triage and placement, nurses must prioritize based on the severity and type of injuries to ensure that clients can be managed effectively without causing additional harm.

• Ensure that the pregnant client with abdominal pain is monitored for any signs of preterm labor or complications.
• Administer appropriate wound care and pain management for the client with facial lacerations and a broken arm.
• Maintain a calm and reassuring environment to reduce stress for both clients.
• Coordinate with other healthcare providers to ensure timely and appropriate care for both clients.

✘Incorrect answer options:

A client with schizophrenia experiencing visual and auditory hallucinations and a client with ulcerative colitis. This combination is inappropriate because the client with schizophrenia may be disruptive to the environment needed for a client with ulcerative colitis, who requires a calm, stress-free setting to avoid exacerbation of symptoms.

A child with fixed and dilated pupils and his parents, and a client with a frontal head injury. Both of these conditions are neurological emergencies. Placing them together can create a chaotic environment, making it difficult to manage the acute needs of both patients simultaneously. These clients require focused and intensive care.

A client with a large puncture wound to the abdomen and a client with chest pain. This combination is inappropriate because both clients have potentially life-threatening conditions that require close monitoring and significant medical intervention. Placing them together could overwhelm the care providers and delay critical interventions.

EXPLANATION

✔Correct answer:

The 30-year-old experiencing a multiple sclerosis exacerbation and receiving cortisone via a central venous catheter. The client with multiple sclerosis (MS) experiencing an exacerbation and receiving cortisone through a central venous catheter should be prioritized. MS exacerbations can significantly impact a patient's neurological function, and timely administration of corticosteroids is critical to reduce inflammation and prevent further deterioration. The central venous catheter also necessitates careful monitoring to prevent infections, ensure patency, and manage complications.

Corticosteroids like cortisone are essential in managing MS exacerbations to reduce inflammation and immune responses, which helps in alleviating acute symptoms and improving the patient's condition. Any delay in administering these medications can prolong the exacerbation and worsen the patient's neurological status.

Think of the body's immune system as a fire alarm. In MS, the alarm is triggered unnecessarily, causing inflammation (the fire) in the nervous system. Cortisone acts like a fire extinguisher, putting out the fire and preventing damage. A central venous catheter is like a direct pipeline to deliver the extinguisher exactly where it's needed, making prompt and proper administration crucial.

Nurse Taylor should prioritize this patient to ensure the central venous catheter is functioning correctly, administer the cortisone as prescribed, and monitor the patient for any adverse reactions.

• Assess the central venous catheter site for signs of infection, such as redness, swelling, or discharge.
• Ensure the patency of the catheter and verify the correct dosage and administration rate of cortisone.
• Monitor the patient for potential side effects of corticosteroids, including changes in blood glucose levels, mood swings, and signs of infection.
• Provide patient education on the importance of adhering to the corticosteroid regimen and recognizing symptoms of complications.
• Document all assessments, interventions, and patient education provided during the visit.

✘Incorrect answer options:

The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube. While this client requires attention for nutrition and PEG tube management, their condition is likely stable, and any issues can be managed with proper care. This scenario is less urgent compared to the need for timely administration of corticosteroids in an MS exacerbation.

The 5-month-old who was discharged a week ago with pneumonia and is on amoxicillin liquid suspension. This infant needs close monitoring to ensure recovery from pneumonia and adherence to antibiotic therapy. However, the risk associated with a delayed dose of amoxicillin is generally less critical than the immediate need for corticosteroids in an MS exacerbation.

The 50-year-old with MRSA receiving Vancomycin through a PICC line. While the risk of infection and complications from a PICC line is significant, the administration of corticosteroids for an MS exacerbation takes precedence due to the potential for rapid neurological decline if not promptly treated. The MRSA patient requires close monitoring but is comparatively more stable.

EXPLANATION

✔Correct answer:

Report the incident to the nursing supervisor. When a nurse is suspected of falsifying documentation, this is a serious issue that requires immediate attention. Reporting the incident to the nursing supervisor is the appropriate next step because it ensures that the situation is addressed according to institutional policies and procedures. The nursing supervisor has the authority and responsibility to initiate an investigation, which may include conducting an audit, interviewing witnesses, and implementing necessary actions to maintain patient safety and uphold professional standards.

Falsifying documentation can have severe consequences for patient safety, including medication errors, inadequate treatment, and compromised care continuity. It is both an ethical and legal violation that must be managed through the proper channels to ensure accountability and to prevent recurrence.

Imagine a restaurant where a chef is suspected of not following health protocols, such as failing to wash their hands before cooking. The restaurant manager (nursing supervisor) needs to be informed to investigate and take corrective measures to ensure food safety (patient care).

In reporting the incident, the charge nurse should provide detailed documentation of the suspected falsification, including dates, times, and specific instances. Clear, factual reporting is crucial for an effective investigation.

• Notify the nursing supervisor with a factual, unbiased report of the suspected behavior.
• Continue to monitor Nurse Williams' activities to gather additional evidence if needed, while maintaining patient care standards.
• Support the investigation process by providing any necessary documentation and cooperating with the nursing supervisor and other relevant authorities.
• Ensure patient safety by rechecking the medication records and verifying that all patients have received their prescribed medications.
• Educate staff on the importance of accurate documentation and ethical practices in nursing to prevent future incidents.

✘Incorrect answer options:

Place Nurse Williams on immediate suspension. Immediate suspension without a thorough investigation can be premature and unfair. It is important to follow due process, which includes verifying the facts and allowing the nurse an opportunity to explain.

Conduct a thorough audit of Nurse Williams' documentation. While an audit may be necessary, it should be initiated by the nursing supervisor or other appropriate authority, not solely by the charge nurse. Reporting to the supervisor ensures that the process is conducted correctly and impartially.

Warn Nurse Williams and monitor her closely. Issuing a warning without further action may not adequately address the seriousness of the situation. Close monitoring alone does not address potential past documentation falsifications and can leave patients at risk.

EXPLANATION

✔Correct answer:

The narcotic inventory has been incorrect on the unit for the last three days. Reporting discrepancies in narcotic inventory is crucial because it indicates potential issues related to drug diversion, misuse, or theft, which are serious concerns that impact patient safety and regulatory compliance. The state Board of Nursing requires that such discrepancies be reported because they reflect on the facility's adherence to controlled substance regulations and the safe management of medications.

Narcotic discrepancies can have significant implications for patient safety, staff accountability, and legal compliance. Controlled substances must be meticulously tracked to prevent misuse, overdose, and illegal distribution. An incorrect inventory suggests that the system for tracking these medications is failing, potentially leading to serious legal and health consequences.

Think of the narcotic inventory like a cash register in a store. If the cash register is consistently short of money, it indicates a problem with theft or accounting. Similarly, an incorrect narcotic inventory suggests potential drug theft or mishandling, requiring immediate attention.

Nurse Rodriguez should report the narcotic inventory issue to the state Board of Nursing to ensure an investigation and corrective actions are taken. This includes implementing stricter controls, conducting audits, and ensuring compliance with regulatory standards.

• Report the narcotic inventory discrepancy to the state Board of Nursing promptly.
• Conduct an internal investigation to identify the cause of the discrepancy.
• Implement stricter controls and monitoring systems for narcotic management.
• Provide additional training to staff on proper narcotic handling and documentation procedures.
• Collaborate with the pharmacy and regulatory bodies to ensure compliance with legal and safety standards.

✘Incorrect answer options:

The facility does not offer educational materials in both Spanish and English. This response is incorrect because while providing educational materials in multiple languages is important for patient understanding and compliance, it is not a situation that necessitates reporting to the state Board of Nursing. It is an issue that should be addressed internally to improve patient care and accessibility.

The patient did not receive a detailed account of bills and services during the hospital stay. This response is incorrect because billing issues are generally handled by the hospital's billing department and do not fall under the purview of the state Board of Nursing. It is important but does not involve patient safety or regulatory compliance to the same extent as narcotic discrepancies.

The nursing assistant assigned to a hepatitis patient did not feed or bathe the client. This response is incorrect because it indicates a performance issue that should be addressed through internal supervision and training. While neglecting patient care is serious, it is typically managed within the facility’s administrative and human resources processes rather than reported to the state Board of Nursing unless it is part of a larger pattern of neglect or abuse.

EXPLANATION

✔Correct answer:

The RN with 3 years of experience in labor and delivery. The RN with 3 years of experience in labor and delivery is the most appropriate choice for caring for a postpartum client with preeclampsia. Preeclampsia is a complex condition characterized by high blood pressure and signs of organ damage, typically occurring after 20 weeks of pregnancy or postpartum. It requires specialized knowledge and experience in obstetric care to monitor and manage both the mother and the newborn effectively. The RN with labor and delivery experience is well-versed in the complications associated with preeclampsia, the necessary assessments, and the interventions required to ensure the safety and health of the client and her baby.

Preeclampsia involves systemic endothelial dysfunction, leading to hypertension and potential damage to organs such as the liver and kidneys. Postpartum management includes monitoring for signs of worsening hypertension, seizures (eclampsia), and ensuring adequate postpartum recovery.

Caring for a client with preeclampsia is like managing a high-risk investment portfolio. Just as an experienced financial advisor would know how to handle complex financial risks, an RN with labor and delivery experience knows how to manage the complexities of preeclampsia in the postpartum period.

The RN with labor and delivery experience will be able to:

• Monitor the client's blood pressure and signs of worsening preeclampsia or eclampsia.
• Administer medications such as antihypertensives and magnesium sulfate as prescribed.
• Provide education to the client about the signs and symptoms of preeclampsia complications and when to seek immediate medical attention.
• Support the client’s postpartum recovery and newborn care, utilizing their specialized knowledge in obstetric care.

✘Incorrect answer options:

The RN with 2 weeks of experience in postpartum care. This response is incorrect because although the RN has postpartum experience, it is limited. Managing preeclampsia requires more specialized and extensive experience.

The RN with 10 years of experience in surgical care. This response is incorrect because while the RN has extensive nursing experience, it is in a different specialty. Surgical care experience does not provide the specific knowledge needed to manage preeclampsia effectively.

The RN with 1 year of experience in the neonatal intensive care unit. This response is incorrect because neonatal intensive care experience focuses on newborns rather than postpartum mothers with conditions like preeclampsia. This RN may not have the necessary skills to manage the complexities of the mother’s condition.

EXPLANATION

✔Correct answer:

Contact the physician. The client’s vital signs indicate a potentially serious condition. A blood pressure of 90/50 mmHg, pulse of 132 beats per minute, and respirations of 30 breaths per minute suggest the patient may be experiencing shock, likely hypovolemic or septic shock, both of which are medical emergencies requiring immediate intervention. Nurse Jenna's priority action should be to contact the physician immediately to report the patient's condition and receive further instructions for treatment.

Hypotension (low blood pressure), tachycardia (rapid heart rate), and tachypnea (rapid breathing) are signs that the body is compensating for a decrease in blood volume or other underlying issues. This can occur due to bleeding, infection, or other complications following surgery. Immediate medical evaluation and intervention are crucial to stabilize the patient and prevent further deterioration.

Think of the patient’s vital signs like a fire alarm going off in a building. Just as you wouldn't ignore the alarm but instead call the fire department immediately to prevent the fire from spreading, Nurse Jenna needs to contact the physician right away to address the potentially life-threatening situation.

Nurse Jenna should contact the physician, providing a detailed report of the patient’s vital signs and any other relevant observations. Concurrently, she should continue to monitor the patient and prepare for any immediate interventions that the physician might order, such as fluid resuscitation or additional diagnostic tests.

• Contact the physician immediately to report the patient's critical vital signs and receive instructions for further management.
• Continue to monitor the patient closely for any changes in condition.
• Prepare to initiate emergency interventions as ordered by the physician, such as administering intravenous fluids or medications.
• Ensure the patient is in a position to promote optimal circulation and breathing, such as lying flat with legs elevated if appropriate and not contraindicated.

✘Incorrect answer options:

Continue to monitor the vital signs. This response is incorrect because while monitoring is important, the priority action should be to contact the physician immediately. The patient’s vital signs indicate a potentially life-threatening condition that requires urgent medical intervention.

Ask the client how he feels. This response is incorrect because the patient’s vital signs indicate a critical situation that needs immediate medical attention. While assessing the patient's subjective symptoms can be helpful, it should not delay the urgent need to contact the physician.

Delegate post-op care to the LPN. This response is incorrect because delegating care does not address the immediate need for medical intervention. The LPN may assist with certain tasks, but the critical nature of the patient's condition requires the RN to take prompt and direct action, including contacting the physician.

EXPLANATION

✔Correct answer:

Initiating a blood transfusion. Initiating a blood transfusion is a task that typically requires the advanced training and critical thinking skills of a registered nurse (RN). This task involves several critical steps, including verifying the patient’s identity, ensuring compatibility of the blood product, monitoring the patient for adverse reactions, and managing any complications that may arise. Due to the complexity and potential risks involved, it is beyond the scope of practice for a licensed practical nurse (LPN) to initiate a blood transfusion.

Blood transfusions carry the risk of serious reactions, such as allergic reactions, febrile non-hemolytic transfusion reactions, and more severe complications like transfusion-related acute lung injury (TRALI) or hemolytic reactions. These require immediate recognition and intervention, necessitating the advanced training of an RN.

Initiating a blood transfusion is like starting a complex machinery. Just as only a qualified technician should start and monitor the machinery to handle any technical issues, only an RN should initiate a blood transfusion due to the need for specialized knowledge and skills.

Nurse Alex should delegate tasks to the LPN that are within their scope of practice and ensure that tasks requiring more advanced knowledge and skills, such as initiating blood transfusions, are handled by an RN.

• Verify the scope of practice for LPNs in the specific healthcare setting and jurisdiction.
• Delegate tasks such as inserting Foley catheters, discontinuing nasogastric tubes, and collecting sputum specimens, which are within the LPN's scope of practice.
• Ensure that tasks involving complex clinical judgment, such as initiating blood transfusions, are performed by RNs.
• Provide adequate supervision and support to LPNs when performing delegated tasks.

✘Incorrect answer options:

Inserting a Foley catheter. This response is incorrect because inserting a Foley catheter is a task that is within the scope of practice for LPNs. They are trained to perform this procedure safely and effectively.

Discontinuing a nasogastric tube. This response is incorrect because discontinuing a nasogastric tube is also within the LPN's scope of practice. It involves removing the tube and ensuring patient comfort and safety during the process.

Collecting a sputum specimen. This response is incorrect because collecting a sputum specimen is a routine task that LPNs are trained to perform. It involves obtaining a sample for diagnostic purposes without requiring advanced clinical judgment.

EXPLANATION

✔Correct answer:

Malpractice. Malpractice refers to professional misconduct or failure to meet the standard of care expected of a healthcare professional, resulting in harm to the patient. In this scenario, Nurse Angela's error in administering an adult-strength dose of Digitalis to a 3-pound infant constitutes a serious deviation from the standard of care, leading to significant and permanent harm. This act is classified as malpractice because it involves a professional's failure to perform their duties competently and safely.

Digitalis is a medication used to treat various heart conditions, but it must be carefully dosed, especially in vulnerable populations like infants. An overdose can lead to severe cardiac and neurological complications. In this case, the incorrect dosage led to permanent heart and brain damage, underscoring the critical importance of adhering to appropriate medication dosages.

Think of a nurse's duty as that of a pilot. Just as a pilot must ensure every safety check is done correctly to avoid accidents, a nurse must administer medications accurately to avoid causing harm. Failing to do so can result in catastrophic consequences, akin to a plane crash.

Nurse Angela should have followed the correct protocols for administering medication, including verifying the correct dosage for the infant's weight and double-checking the medication with another healthcare professional if necessary. Proper training, adherence to safety protocols, and ongoing education are essential to prevent such errors.

• Verify medication dosages, especially in vulnerable populations like infants.
• Adhere to the "five rights" of medication administration: the right patient, the right drug, the right dose, the right route, and the right time.
• Engage in continuing education to stay informed about safe medication practices.
• Implement double-check systems, particularly for high-risk medications.

✘Incorrect answer options:

Negligence. While negligence is a component of malpractice, the term "malpractice" specifically refers to negligence by a professional that results in harm. Negligence is a broader term that can apply to anyone failing to exercise reasonable care, but malpractice is the correct term for this scenario involving professional misconduct by a healthcare provider.

Committing a tort. A tort is a wrongful act leading to legal liability, and malpractice is a type of tort. However, committing a tort is a broad term that doesn't specifically address the professional context of the error. Malpractice is the more precise term for this situation.

Acts of assault. Assault involves intentionally causing apprehension of harmful or offensive contact, which is not applicable in this scenario. Nurse Angela's mistake was not intentional but a result of professional negligence, classifying it as malpractice rather than assault.

EXPLANATION

✔Correct answer:

The patient with Cushing's syndrome. Cushing's syndrome is characterized by prolonged exposure to high levels of cortisol, which can suppress the immune system, making the patient more susceptible to infections. Because of this immunosuppression, patients with Cushing's syndrome are at a higher risk of acquiring infections, and therefore, it is essential to minimize their exposure to potential sources of infection. Assigning the patient with Cushing's syndrome to a private room helps to reduce the risk of infection by limiting contact with other patients and ensuring a controlled environment.

Cushing's syndrome can be caused by endogenous sources (e.g., a tumor producing excess cortisol) or exogenous sources (e.g., long-term use of corticosteroid medications). High cortisol levels can lead to symptoms such as hypertension, hyperglycemia, osteoporosis, muscle weakness, and a higher risk of infections due to immune suppression.

Think of a patient with Cushing's syndrome like a person with a fragile immune system that needs protection from the outside world. Placing them in a private room is like putting them in a safe bubble to minimize their exposure to germs.

Nurse Jamie should prioritize the patient with Cushing's syndrome for the private room to minimize the risk of infection. This assignment allows for better infection control and provides a safe environment for the patient.

• Ensure that the patient with Cushing's syndrome is assigned to a private room to reduce the risk of infection.
• Monitor the patient's vital signs and signs of infection closely.
• Educate the patient and family about the importance of infection prevention measures, such as hand hygiene and avoiding contact with sick individuals.

✘Incorrect answer options:

The patient with diabetes mellitus. This response is incorrect because, although patients with diabetes are at a higher risk of infections, their condition does not typically require isolation or a private room unless they have an active infection or wound that necessitates such precautions.

The patient with acromegaly. This response is incorrect because acromegaly, resulting from excess growth hormone, does not inherently require isolation or a private room. These patients do not have the same vulnerability to infection as those with Cushing's syndrome.

The patient with myxedema. This response is incorrect because while myxedema (severe hypothyroidism) requires close monitoring, it does not typically necessitate isolation unless the patient has an active infection. Patients with Cushing's syndrome are more susceptible to infections due to their immunosuppression.

EXPLANATION

✔Correct answer:

The client undergoing linear accelerator radiation therapy for lung cancer. Linear accelerator radiation therapy, also known as external beam radiation therapy, involves delivering high-energy x-rays or electrons to a patient's tumor from outside the body. Once the treatment is completed, the patient does not retain any radioactivity and does not pose a radiation risk to others, including a pregnant nurse. Therefore, it is safe for a pregnant nurse to care for this client.

External beam radiation therapy targets the tumor with precise radiation beams, minimizing exposure to surrounding healthy tissue. Since the radiation is administered externally and not left in the body, the patient does not emit radiation after the treatment session.

Imagine taking an X-ray at the dentist's office. After the X-ray, you don't emit any radiation and can safely be around others, including pregnant women. Similarly, after external radiation therapy, the patient doesn't pose a radiation risk to others.

Charge Nurse Elena should ensure that the pregnant nurse is assigned to clients who do not pose any radiation risk to her or her unborn child. Clients who have undergone external beam radiation therapy are safe assignments.

• Confirm that the client undergoing linear accelerator radiation therapy has completed the session and does not retain radioactivity.
• Educate the pregnant nurse on the types of radiation therapy and which patients are safe for her to care for.
• Reassure the pregnant nurse about the safety of caring for clients treated with external beam radiation therapy.

✘Incorrect answer options:

The client with a radium implant for cervical cancer. This response is incorrect because radium implants, a form of internal radiation therapy, emit radiation while they are in place. The patient is considered radioactive and poses a risk to others, particularly pregnant women, due to the emitted radiation.

The client recently treated with soluble brachytherapy for thyroid cancer. This response is incorrect because soluble brachytherapy involves ingesting a radioactive substance (such as radioactive iodine) that makes the patient temporarily radioactive. The patient can emit radiation through bodily fluids, posing a risk to others.

The client who just had iridium seeds placed for prostate cancer. This response is incorrect because the placement of iridium seeds (another form of internal radiation therapy) means that the patient is temporarily radioactive. The radioactive seeds can emit radiation, which can be harmful to a pregnant nurse.

EXPLANATION

✔Correct answer:

The whole family needs to undergo treatment. Enterobiasis (pinworm infection) is highly contagious and can easily spread among family members. Therefore, it is recommended that the entire household undergo treatment simultaneously to effectively eradicate the infection and prevent reinfection. This approach helps ensure that all potential carriers are treated, reducing the likelihood of the infection persisting or recurring.

Pinworms lay eggs around the perianal area, causing itching and discomfort. When a person scratches the area, the eggs can get under their fingernails and be transferred to surfaces, bedding, clothing, or directly to other people. Treating only the symptomatic individual may not be sufficient because asymptomatic family members can harbor and spread the infection.

Think of pinworm treatment like tackling a garden pest. If only one plant is treated, the pests on the neighboring plants can quickly reinfest it. Treating the entire garden at once ensures all pests are eradicated.

Nurse Rachel should provide detailed instructions on the proper administration of the medication and emphasize the importance of treating all household members. She should also advise on hygiene measures to prevent reinfection, such as regular handwashing, keeping fingernails short, and daily washing of bedding and clothing.

• Instruct all family members to take the prescribed medication simultaneously.
• Reiterate the importance of hygiene measures to prevent reinfection, such as frequent handwashing, especially after using the toilet and before eating.
• Advise laundering bedding, pajamas, and underwear daily during the treatment period.
• Recommend keeping fingernails short and discouraging nail-biting or scratching the perianal area.
• Explain the need for a follow-up dose of the medication two weeks after the initial treatment to kill any newly hatched worms.

✘Incorrect answer options:

Treatment is not advised for children under 10 years old. This response is incorrect because pinworm infections are common in children, and treatment is necessary regardless of age. Medications such as mebendazole, albendazole, or pyrantel pamoate are safe and effective for children.

Medication therapy will last for one year. This response is incorrect because the treatment for pinworms typically involves a single dose of medication, followed by a second dose two weeks later to eliminate any newly hatched worms. It does not require prolonged therapy.

Intravenous antibiotics will be prescribed. This response is incorrect because pinworm infections are treated with oral anti-parasitic medications, not antibiotics, and certainly not intravenous ones. Antibiotics are used to treat bacterial infections, not parasitic infections like enterobiasis.

EXPLANATION

✔Correct answer:

Check the perianal area with a flashlight 2 or 3 hours after the child has fallen asleep. Enterobiasis, commonly known as pinworm infection, is caused by the parasite Enterobius vermicularis. Female pinworms typically lay their eggs around the perianal area during the night, often causing itching. The best time to check for pinworms is a few hours after the child has fallen asleep because this is when the worms are most active and visible.

Nurse Sara should advise the mother to examine the child’s perianal area using a flashlight 2 to 3 hours after the child has gone to sleep. The mother should look for small, white, thread-like worms around the anus.

Think of pinworms like tiny nocturnal creatures that come out to play at night. Using a flashlight to check for them while the child sleeps is like using a flashlight to spot animals that are active only at night.

Nurse Sara should also instruct the mother on how to collect a specimen using the "tape test." This involves pressing a piece of transparent adhesive tape against the perianal area first thing in the morning before the child bathes or uses the toilet. The tape can then be placed sticky side down on a glass slide or in a plastic bag and taken to the clinic for microscopic examination.

• Explain the timing and method for checking the perianal area for pinworms.
• Provide clear instructions on how to perform the "tape test" for accurate specimen collection.
• Advise the mother to repeat the test for three consecutive mornings to increase the likelihood of detecting the eggs.

✘Incorrect answer options:

Scrape the skin with a piece of cardboard and take it to the clinic. This method is not recommended or effective for collecting specimens for pinworm testing. The adhesive tape method is the standard practice.

Collect a stool specimen in the afternoon. Stool specimens are not typically used to diagnose pinworm infections because pinworm eggs are rarely found in stool. The eggs are more likely to be found around the perianal area.

Bring a hair sample to the clinic for analysis. Pinworms do not infect the hair. Therefore, a hair sample would not be relevant for diagnosing enterobiasis.

EXPLANATION

✔Correct answer:

The patient has a grand mal seizure. Electroconvulsive therapy (ECT) is a medical treatment used primarily for severe depression, and it involves the induction of a controlled seizure in the patient by passing electrical currents through the brain. The therapeutic efficacy of ECT is linked to the induction of a grand mal seizure, also known as a generalized tonic-clonic seizure. This seizure activity is believed to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions.

During ECT, the controlled seizure is the primary mechanism of action. The seizure typically lasts about 30 to 60 seconds and is closely monitored by medical professionals. The seizure itself is necessary for the therapeutic effects of ECT, as it induces neurobiological changes that can lead to improvements in mood and behavior.

Think of the brain as a computer. ECT is like rebooting the computer by temporarily shutting it down (the seizure), which helps to reset its functions and fix any glitches (symptoms of depression).

Nurse Sam should ensure the patient's safety before, during, and after the ECT procedure. This includes monitoring vital signs, providing support during the seizure, and observing the patient during recovery.

• Monitor the patient’s vital signs and level of consciousness before, during, and after the procedure.
• Ensure proper airway management and support during the seizure to prevent injury.
• Provide reassurance and support to the patient post-procedure, as confusion and temporary memory loss are common side effects.

✘Incorrect answer options:

The patient loses consciousness. While loss of consciousness is a component of the seizure induced by ECT, it is not the outcome that indicates the therapy’s effectiveness. The loss of consciousness itself does not produce the therapeutic effect; it is the seizure that is crucial.

The patient experiences vomiting. Vomiting is not an expected or desired outcome of ECT and may indicate a side effect or complication. Effective ECT should not cause vomiting; rather, it should result in the controlled induction of a seizure.

The patient’s ECG shows tachycardia. Tachycardia (an increased heart rate) may occur as a transient response to the seizure but is not an indicator of the effectiveness of ECT. The primary measure of effectiveness is the occurrence of the controlled seizure.

EXPLANATION

✔Correct answer:

The nurse uses gloves to check the client’s vital signs. Checking a client's vital signs, such as measuring blood pressure, temperature, pulse, and respiration, does not typically require the use of gloves unless there is an anticipated contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated equipment. Using gloves for routine vital sign checks can contribute to unnecessary use of personal protective equipment (PPE) and may lead to a false sense of security regarding infection control practices.

Think of gloves like seat belts in a car. You don't need to wear them when the car is parked (checking vital signs), but you do need them when driving on a busy road (potential contact with bodily fluids).

Nurse Laura should educate the healthcare team on the appropriate use of gloves and other PPE. This includes understanding when it is necessary to wear gloves to prevent the spread of infection and when it is not, to ensure resources are used effectively and appropriately.

• Educate staff on standard precautions and the appropriate use of PPE, emphasizing when gloves are necessary.
• Encourage frequent and proper hand hygiene as a critical measure in infection control.
• Regularly review and update infection control policies and practices to align with current guidelines.

✘Incorrect answer options:

The nursing assistant uses gloves while bathing the client. This response is incorrect because wearing gloves while bathing a client is appropriate. Bathing involves potential contact with body fluids, making glove use necessary to protect both the caregiver and the patient from possible contamination.

The nurse uses goggles while drawing the client’s blood. This response is incorrect because using goggles while drawing blood is a valid precaution to protect against potential splashes of blood or body fluids, particularly if there is a risk of spurting blood or an unpredictable patient.

The doctor washes his hands before examining the client. This response is incorrect because hand hygiene before and after patient contact is a fundamental practice to prevent the transmission of infectious agents. Proper hand washing is crucial in all healthcare settings.

EXPLANATION

✔Correct answer:

"That warmth is a normal sensation when the dye is injected." During an arteriogram, a contrast dye is injected into the blood vessels to allow for clear imaging of the arteries. It is common for patients to experience a sensation of warmth or flushing when the dye is administered. This occurs because the contrast medium can cause a transient vasodilation and a warm feeling as it travels through the bloodstream. This sensation is generally harmless and subsides quickly.

The warmth felt during the injection of contrast dye is due to the hypertonic nature of the dye, which can cause temporary vasodilation. The contrast medium may also stimulate transient chemical reactions that result in the feeling of warmth as it passes through the body.

Imagine pouring warm water into a cold cup. Just as you would feel the warmth of the water spread throughout the cup, the patient feels a warm sensation spreading through their blood vessels when the contrast dye is injected.

It is important for nurses to reassure the patient that this sensation is expected and normal. Nurse Kelly should continue to monitor Mr. Thompson for any signs of adverse reactions, but primarily, she should provide reassurance and support to alleviate any anxiety.

• Reassure the patient that the warmth is a normal response to the dye injection.
• Observe the patient for any signs of an allergic reaction or other complications.
• Provide ongoing communication and support to ensure the patient feels safe and informed during the procedure.

✘Incorrect answer options:

"You might be having an allergic reaction. I’ll get an order for Benadryl." This response is incorrect because the sensation of warmth is a common and expected effect of the dye injection, not an indication of an allergic reaction. An allergic reaction would typically present with symptoms such as hives, itching, difficulty breathing, or swelling.

"That warm feeling suggests that the clots in your coronary vessels are dissolving." This response is incorrect because the warmth experienced is not related to the dissolution of clots. The warmth is due to the properties of the contrast dye, not a therapeutic effect on clots.

"I will inform your doctor and have him explain why you're feeling hot." While informing the doctor can be a prudent step if there is any concern, this response does not directly address the patient’s immediate question or provide the reassurance needed. It is important for the nurse to offer an explanation and reassurance first.