Fundamentals of Nursing NCLEX Practice Questions Quiz #7 | 70 Questions

Apr 30, | Writing

Questions related to Patient Tubes: NGT, Chest, and Tracheostomy

FNDNRS-07-001

Which of the following is not true regarding the types of a nasogastric tube?

• A. Cantor tube is a single-lumen long tube with a small inflatable bag at the distal end.
• B. Miller-Abbott tube is a long double-lumen used to drain and decompress the small intestine.
• C. Levin tube is a double-lumen nasogastric tube with an air vent.
• D. Sengstaken-Blakemore tube is a three-lumen tube.

Correct Answer: C. Levin tube is a double-lumen nasogastric tube with an air vent.

A Levin tube is a single lumen nasogastric tube while a Salem sump tube is a double-lumen nasogastric tube with an air vent.  The Levin tube is used primarily for long-continued gastric drainage and for gavage feeding. It is also used for diagnostic purposes. Its advantages are that it can be inserted either nasally or orally and that it is firm enough to be passed into an unconscious patient but flexible enough so there is little danger of producing injury.

• Option A: The Cantor Tub is a 10-foot long, single-lumen tube used for intestinal decompression. The Cantor tube has a mercury-weighted rubber tab attached to its perforated tip to help carry the tube through the stomach and intestine. The mercury is placed in the bag with a syringe and needle before the tube is inserted nasally by the doctor.
• Option B: The Miller-Abbott tube is a 10-foot long double-lumen tube that is equipped with a small balloon near the metal tip at the distal end of the tube. One lumen is used for aspiration and irrigation; the other is used for inflating the balloon. Air, water, or mercury (4 to 5 ml) accomplishes inflation. This intestinal tube is used for small bowel suction. The two openings are independent of each other and are clearly marked. 
• Option D: Also referred to as a Blakemore tube, this tube is a three-lumen, esophageal-gastric balloon tube that is used in the treatment of bleeding esophageal varices. One lumen is used to inflate the esophageal balloon, one lumen is used to inflate the gastric balloon, and the third lumen is used for decompression and irrigation of the stomach.

FNDNRS-07-002

A new RN nurse is about to insert a nasogastric tube into a client with Guillain-Barre Syndrome. To determine the accurate measurement of the length of the tube to be inserted, the nurse should:

• A. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the top of the sternum.
• B. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
• C. Place the tube at the tip of the nose, and measure by extending the tube down to the chin and then down to the top of the xiphoid process.
• D. Place the tube at the base of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

Correct Answer: B. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the xiphoid process.

Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump NG tube (Kendall, Mansfield, MA) in adults, the estimated length usually falls between the second and third preprinted black lines on the tube.

• Option A: Apart from the nose-to-ear-to-xiphisternum (NEX) method, several other methods for determining the length of the tube have been described. Among the various options, a formula based on gender, weight, and nose-to-umbilicus measurement while lying flat was found to be safer and more accurate in a study by Santos et al.
• Option C: While the stomach is a highly distensible structure and therefore, can vary in length, the empty stomach is generally around 25 cm long. Thus if one intended to place a tube through the nares and place it in the middle of the stomach, then approximately 55 cm of the tube should be inserted.
• Option D: There are several methods to estimate the depth that an NG should be placed. All methods for estimation will have some margin of error. A common pre-procedure maneuver is to loop the tube over one of the patient’s ears and place the tip at the patient’s xiphoid process and use this as an estimate for the length of the tube that should be inserted.

FNDNRS-07-003

A stroke client who was initially on NGT feeding was able to tolerate a soft diet so the physician ordered the removal of it. The nurse would instruct the client to do which of the following before he removes the tube?

• A. Inhale and exhale simultaneously.
• B. Take a long breath and hold it.
• C. Do a Valsalva maneuver.
• D. Blow the nose.

Correct Answer: B. Take a long breath and hold it.

Holding the breath closes the glottis hence it will be easier to withdraw the tube through the esophagus into the nose, and this method will also prevent aspiration. An NG tube should be removed if it is no longer required. The process of removal is usually very quick. Prior to removing an NG tube, verify physician orders. If the NG tube was ordered to remove gastric content, the physician’s order may state to “trial” clamping the tube for a number of hours to see if the patient tolerates its removal. During the trial, the patient should not experience any nausea, vomiting, or abdominal distension.

• Option A: Instruct the patient to take a deep breath and hold it. This prevents aspiration; holding the breath closes the glottis. Kink the NG tube near the naris and gently pull out the tube in a swift, steady motion, wrapping it in your hand as it is being pulled out. Dispose of tube in garbage bag.
• Option C: The Valsalva maneuver is a breathing technique that can be used to unclog ears, restore heart rhythm or diagnose an autonomic nervous system (ANS). To perform the Valsalva maneuver, the patient should close his mouth, pinch the nose shut and press the air out like blowing up a balloon.
• Option D:  Blowing the nose is a way of clearing out mucus that has collected debris and pollutants from the atmosphere. Most of the time, people blow their nose because of excess mucus production –  a cold, nasal allergy, hay fever, or other conditions. 

FNDNRS-07-004

The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client. Which of the following actions is an inappropriate practice by the nurse?

• A. If bowel sounds are absent, hold the feeding and notify the physician.
• B. Assess tube placement by aspirating gastric content and check the PH level.
• C. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps.
• D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after installation of feeding.

Correct Answer: D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after instillation of feeding.

If the client is comatose, place in a high-Fowler’s which is at a 90-degree level. Position client upright or in full Fowler’s position if possible. Place a clean towel over the client’s chest. Full Fowler’s position assists the client to swallow, for optimal neck-stomach alignment and promotes peristalsis.

• Option A: Inject 30 mL of air into the stomach and listen with the stethoscope for the “whoosh” of air into the stomach. The small diameter of some NG tubes may make it difficult to hear air entering the stomach. It is very important to ensure that the NG tube is in its correct place within the stomach because, if by accident the NG is within the trachea, serious complications in relation to the lungs would appear.
• Option B: Stomach aspirate will appear cloudy, green, tan, off-white, bloody, or brown. It is not always visually possible to distinguish between the stomach and respiratory aspirates. Measuring the pH of stomach aspirate is considered more accurate than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4.
• Option C: For powdered formula, mix according to the instructions on the package. Prepare just enough for the next 24 hours and refrigerate unused formula. Allow the formula to reach room temperature before using. Formula loses its nutritional value and can be contaminated if kept for more than 24 hours. Cold formulas can cause abdominal discomfort.

FNDNRS-07-005

A nurse is checking the nasogastric tube position of a client receiving a long-term therapy of Omeprazole (Prilosec) by aspirating the stomach contents to check for the PH level. The nurse proves the correct tube placement if the PH level is?

• A. 7.75.
• B. 7.5.
• C. 6.5.
• D. 5.5.

Correct Answer: D. 5.5.

Gastric placement is indicated by a pH of less than 4 but may increase to between pH 4-6 if the patient is receiving acid-inhibiting drugs. Measuring the pH of stomach aspirate is considered more accurate than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4.

• Option A: The aspirate of respiratory contents is generally more alkaline, with a pH of 7 or more. Testing the pH of gastric aspirate to show pH ≤5.5 is recommended first-line test to confirm correct placement of nasogastric tubes and reduce the risk of potentially fatal aspiration.
• Option B: The pH readings between 4.5 and 6.0 provided the greatest overall accuracy, however, there was only moderate agreement between observers at pH readings ≥5.0. Compared with studies that have taken aspirate directly from the nasogastric tube, patients undergoing scope procedures had a lower sensitivity at the pH cut-off ≤5.5 for identifying gastric aspirates for the whole group and in the presence and absence of antacid medications.
• Option C: Current healthcare guidelines recommend that the first-line test to confirm correct NGT placement prior to giving food or medications must be that the pH of an NGT aspirate is ≤5.5 (acidic). Nevertheless, false-positive readings might occur if the tube is misplaced in the esophagus or false-negative readings (pH >5.5) may occur in patients who secrete less gastric acid, because of antacid medications, achlorhydria, or buffering by NGT feeds.

FNDNRS-07-006

Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take?

• A. Discard the residual amount.
• B. Hold the due feeding.
• C. Skip the feeding and administer the next feeding due in 4 hours.
• D. Reinstill the amount and continue with administering the feeding.

Correct Answer: D. Reinstill the amount and continue with administering the feeding.

If the residual feeding is less than 100ml, feeding is administered. Fasting volume of the normal stomach ranged from 0 to 98 mL in the study group. The researchers defined high as 100 mL for nasogastric (NG) tubes and 200 mL for gastrostomy (G) tubes and concluded that EN feedings should not be stopped for a single high GRV if there are no other physical examination or radiography findings to show actual gastrointestinal dysfunction.

• Option A: When interpreting Gastric Residual Volume (GRV), clinicians must keep in mind that the stomach has reservoir function and that the stomach fluid is a mixture of both the infused EN formula and normal gastric secretions. Chang and colleagues explained this concept in the article “Monitoring Bolus Nasogastric Tube Feeding by the Brix Value Determination and Residual Volume Measurement of Gastric Contents” published in the Journal of Parenteral and Enteral Nutrition (JPEN) in 2004.
• Option B: In a review article, “Measurement of Gastric Residual Volume: State of the Science,” published in 2000 in MEDSURG Nursing, Edwards and Metheny reported that the literature contained a variety of recommendations for what is considered a high GRV, ranging from 100 to 500 mL. Some sources have even (incorrectly) suggested holding tube feedings for a GRV of greater than 30 mL, or 1.5 times the flow rate, or even one-half of the hourly flow rate.
• Option C: Normal gastric emptying occurs within three hours and after a lag time of approximately one hour for a meal of solid foods. The process is slower for high-fat meals. Liquids empty more quickly (within one hour for a glucose solution and two hours for a protein solution).3 During fasting, the stomach secretes approximately 500 to 1,500 mL2; in the fed state, it secretes approximately 2,500 mL per day.

FNDNRS-07-007

Continuous type of feedings is administered over a __ hour period?  

• A. 4.
• B. 12.
• C. 24.
• D. 36.

Correct Answer: C. 24.

Continuous feeding is administered for 24 hours. An infusion pump regulates the flow. Continuous drip feeding is delivered by either gravity drip or infusion pump. The infusion pump is a better method of delivery than gravity drip. The flow rate of gravity drip may be inconsistent and, therefore, needs to be checked frequently.

• Option A: When feedings are delivered continuously, stool output is reduced, a consideration for the child with chronic diarrhea. Continuous infusions of elemental formula have been successful in managing infants with short bowel syndrome, intractable diarrhea, necrotizing enterocolitis, and Crohn’s disease.
• Option B: Commonly, it is used for 8 to 10 hours during the night for volume-sensitive patients so that smaller bolus feedings or oral feeding may be used during the day. Continuous feeding can be administered at night, so it will not interfere with daytime activities. Continuous feeding increases energy efficiency, allowing more calories to be used for growth. This can be important for severely malnourished children.
• Option D: Continuous drip-feeding may be delivered without interruption for an unlimited period of time each day. Feeding around the clock is not recommended as this limits a child’s mobility and may elevate insulin levels contributing to hypoglycemia.

FNDNRS-07-008

A client is subjected to undergo a chest x-ray to confirm the endotracheal tube placement. The tube should be how many centimeters above the carina?

• A. 2-4 cm.
• B. 1.5-3 cm.
• C. 1-2 cm.
• D. 0.5-1 cm.

Correct Answer: C. 1-2 cm.

Placement of an endotracheal tube is confirmed by a chest x-ray and the correct placement is 1 to 2 cm above the carina. Check patient’s chest x-ray for tube placement and presence of C02 per ET C02 detector after any new intubation; auscultate chest for equal breath sounds bilaterally, and adjust E.T. tube for proper placement.

• Option A: Check tube placement with each ventilator assessment. The optimal placement for the endotracheal tube is 2-3cm above the carina in adults. If repositioning of the endotracheal tube is warranted, suction the tube and then suction the oropharynx.
• Option B: Positioning the ET tip 4 cm above carina as recommended will result in placement of tube cuff inside cricoid ring with currently available tubes. Optimal depth of ET placement can be estimated by the formula “(Height in cm/7)-2.5.”
• Option D: It is suggested that the tip of ET should be at least 4 cm from the carina, or the proximal part of the cuff should be 1.5 to 2.5 cm from the vocal cords. Considering that the length of trachea, as well as the distance from teeth to vocal cords, is variable, securing ET at a fixed length will result in endobronchial intubation or endolaryngeal placement of the ET cuff in some patients.

FNDNRS-07-009

After the client had tolerated the weaning process, the physician ordered the removal of the endotracheal tube and it will be shifted into a nasal cannula. Which of the following findings after the removal requires immediate intervention by the physician?

• A. Sore throat.
• B. Hoarseness of the voice.
• C. Coughing out blood.
• D. Neck discomfort.

Correct Answer: C. Coughing out blood.

A sign of a tracheal or esophageal perforation that prevents oxygen from reaching the lungs and can result in internal bleeding. This life-threatening side effect of being intubated requires immediate medical intervention. When hemoptysis begins after endotracheal intubation, upper airway trauma caused by the intubation procedure, endotracheal tube, or endotracheal suction catheters must be considered. If hemoptysis begins after a latent period of 1 or more weeks after intubation, a tracheo-artery fistula may be the source of hemorrhage.

• Option A: Endotracheal tube (ETT) is often necessary to achieve airway control during general anesthesia. However, postoperative sore throat (POST) is considered as a common adverse event after general anesthesia with ETTs. POST continues to be reported with a high frequency and can sometimes persist for several days
• Option B: The incidence of hoarseness after endotracheal intubation varies widely from 14% to 50% but is mostly temporary. In a retrospective study of 3093 patients who had endotracheal intubation during anesthesia, the incidence of hoarseness was 49% in the immediate postoperative period.
• Option D: Neck discomfort is normal and the client should limit talking if it occurs. Many people will experience a sore throat and difficulty swallowing immediately after intubation, but recovery is usually quick, taking several hours to several days depending on the time spent intubated. In most cases, a person will fully recover from intubation within a few hours to days and will have no long-term complications.

FNDNRS-07-010

The nurse is assessing a client with an endotracheal tube and observes that the client can make verbal sounds. What is the most likely cause of this?

• A. This is a normal finding.
• B. There is a leak.
• C. There is an occlusion.
• D. The endotracheal tube is displaced.

Correct Answer: B. There is a leak.

When conducting the minimal leak technique the client should not be able to make verbal sounds or no air should be felt coming out of the client’s mouth. Because the cuff blocks the flow of air around the tube, speech is not possible. Once the tube is removed (called extubation), the patient will be able to speak. The voice may sound hoarse and the patient may have some throat discomfort for the first few days.

• Option A: Verbal sounds in an intubated patient is not a normal finding. As long as the patient has an endotracheal tube in place, the cuff will need to be inflated. An inflated cuff will prevent the patient from being able to speak. Speech is produced when we exhale air through the vocal cords, causing them to vibrate.
• Option C: Without a gag reflex, saliva would enter the windpipe. This is called aspiration. It was hypothesized that the high minute volume of patients contributes to the inspissation of secretions. It is also possible that some characteristic of the Pneumocystis organism in secretions causes altered adherence characteristics of the sputum, resulting in this problem.
• Option D: If the patient has complete obstruction of the upper airway, a displaced tracheostomy tube will result in immediate respiratory distress and can lead to respiratory arrest. If the patient has an intact or at least a partially open upper airway, the displaced tube may not cause an immediate problem. Therefore, displacement of the tracheostomy tube may not be obvious in the patient with a partial airway.

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FNDNRS-07-011

While changing the tapes on a tracheostomy tube, the client coughs, and the tube is dislodged. Which is the initial nursing action?

• A. Call a respiratory therapist to reinsert the tracheotomy.
• B. Cover the tracheostomy site with a sterile dressing.
• C. Call the physician to reinsert the tracheotomy.
• D. Grasp the retention sutures to spread the opening.

Correct Answer: D. Grasp the retention sutures to spread the opening.

If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary. Once replaced, tie the tube securely, leaving one finger space between ties and the patient’s neck.

• Option A: Ask the patient to breathe normally via their stoma while waiting for the doctor. Check tube position by (a) asking the patient to inhale deeply – they should be able to do so easily and comfortably, and (b) hold a piece of tissue in front of the opening – it should be “blown” during the patient’s exhalation.
• Option B: Covering the tracheostomy site will block the airway. Use tracheostomy covers to protect the airway from outside elements (such as dust, cold air, etc.). All trach tubes have an outer cannula (main shaft) and a neck plate (flange). The flange rests on the neck over the stoma (opening). Holes on each side of the neck plate allow you to insert trach tube ties to secure the trach tube in place.
• Option C: Calling a respiratory therapist or the physician will delay treatment in this emergency situation. Accidental dislodgement of the tracheostomy tube during the first several days is not uncommon and can be life-threatening, particularly in patients with severe oxygenation problems and/or high demands for pressure and volume from the ventilator.

FNDNRS-07-012

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate for the nurse?

• A. Increase the suction pressure so that the bubbling becomes vigorous.
• B. Do nothing since this is an expected finding.
• C. Immediately clamp the chest tube and notify the physician.
• D. Check for an air leak because the bubbling should be intermittent.

Correct Answer: B. Do nothing since this is an expected finding.

Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. The water level in the suction chamber should be at the prescribed level and gentle bubbling should be observed. The level may drop due to evaporation or over-vigorous bubbling, if this occurs top fluid level up as per manufacturer’s instructions.

• Option A: Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. and this is not done without any prescription of the physician. Suction is not always required and may lead to tissue trauma and prolongation of an air leak in some patients.
• Option C: Clamping should be done if there is accidental disconnection of the system. Clamp the drain tubing at the patient end. Clean ends of the drain and reconnect. Ensure all connections are cable tied. If a new drainage system is needed, cover the exposed patient end of the drain with sterile dressing while a new drain is set up. Ensure clamp is removed when the problem is resolved.
• Option D: Chest tubes should only be clamped to check for an air leak or when changing drainage devices. An air leak will be characterized by intermittent bubbling in the water seal chamber when the patient with a pneumothorax exhales or coughs. Continuous bubbling of this chamber indicates large air leak between the drain and the patient. Check drain for disconnection, dislodgement, and loose connection, and assess patient condition. Notify medical staff immediately if a problem cannot be remedied.

FNDNRS-07-013

The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician?

• A. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.
• B. Drainage system maintained below the client’s chest.
• C. Drainage amount of 100ml in the drainage collection chamber.
• D. Occlusive dressing in place over the chest tube insertion site.

Correct Answer: C. Drainage amount of 100ml in the drainage collection chamber.

Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician. Measure date and time, and the amount of drainage, and mark on the outside of the chamber. Record amount and characteristics of the drainage on the fluid balance sheet and patient chart. Drainage that is red and free-flowing indicates a hemorrhage. A large amount of drainage, or drainage that changes in color, should be recorded and reported to the primary health care provider.

• Option A: The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the pneumothorax resolves. Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked. Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no swing in the water seal chamber.
• Option B: Collection chamber (drainage system) is below the level of the chest and secured to prevent it from being accidentally knocked over. The drainage system must remain upright for the water-seal chamber to function correctly. The chest drainage system must be lower than the chest to facilitate drainage and prevent backflow.
• Option D: The classic dressing for chest thoracostomy tube (CTT) insertion sites is petroleum gauze held in place by a secondary dressing of sterile, 4″ x 4″ sponge gauze secured with tape. Studies suggest that petroleum gauze macerates skin over time.

FNDNRS-07-014

A nurse is supervising a student nurse who is performing tracheostomy care for a client. Which of the following actions by the student should the nurse intervene?

• A. Removing the inner cannula and cleaning using universal precaution.
• B. Suctioning the tracheostomy tube before performing tracheostomy care.
• C. Changing the old tracheostomy ties and securing the tube in place.
• D. Replacing the inner cannula and cleaning the site of the stoma.

Correct Answer: A. Removing the inner cannula and cleaning using universal precaution.

When performing tracheostomy care, a sterile field is set up and sterile technique is required. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of the tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection.

• Option B: Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varies and is based on individual patient assessment. The depth of insertion of the suction catheter needs to be determined prior to suctioning. Using a spare tracheostomy tube of the same type and size and a suction catheter insert the suction catheter to measure the distance from the length of the tracheostomy tube 15mm connector to the end of the tracheostomy tube. Ensure the tip of the suction catheter remains within the tracheostomy tube.
• Option C: If tie changes are required before the first tube change – it is imperative that the procedure must be undertaken with both medical and nursing staff present who are able to reinsert the tracheostomy tube in case of accidental decannulation and the appropriate equipment is available at the bedside. Tracheostomy tie changes are performed daily in conjunction with stoma care, or as required if they become wet or soiled to maintain skin integrity.
• Option D: Care of the stoma is commenced in the immediate postoperative period, and is ongoing. Inspect the stoma area at least daily to ensure the skin is clean and dry to maintain skin integrity and avoid breakdown. Daily cleaning of the stoma is recommended using 0.9% sterile saline solution.

FNDNRS-07-015

The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected. What is the most appropriate action for the nurse to take?

• A. Secure the chest tube using tape.
• B. Clamp the chest tube immediately.
• C. Place the end of the chest tube in a container of normal sterile saline.
• D. Apply an occlusive dressing and notify the physician.

Correct Answer: C. Place the end of the chest tube in a container of normal sterile saline.

If a chest drainage system is disconnected, the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency. Immediately place the end of the chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected. Bleeding may occur after insertion of the chest tube.

• Option A: The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. Keep the system closed and below chest level. Make sure all connections are taped and the chest tube is secured to the chest wall.
• Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax. Never clamp a chest tube without a doctor’s order or valid reason. The tube must remain unobscured and unclamped to drain air or fluid from the pleural space. There are a few exceptions where a chest tube may be clamped.
• Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected. Dress the site with a dry occlusive dressing and discard the chest tube and drainage device in the hazardous waste bag. Obtain a post-removal chest X-ray if the physician has ordered it or facility protocol requires it.

Questions related to Laboratory Values

FNDNRS-07-016

A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the following potassium levels, if noted in the client’s record, should be reported before giving the due medication?

• A. 5.1 mEq/L.
• B. 4.9 mEq/L.
• C. 3.9 mEq/L.
• D. 3.3 mEq/L.

Correct Answer: D. 3.3 mEq/L.

The normal potassium level is 3.5 to 5.5 mEq/L. Low potassium levels can be dangerous, especially for people with CHF. Low potassium can cause fatal heart arrhythmias. An abnormal serum K+ level is associated with an increased risk of ventricular arrhythmia and sudden cardiac death (SCD) and these patients are generally prescribed furosemide and potassium chloride (KCl).

• Option A: Furosemide, a short-acting diuretic is commonly recommended as an essential drug in patients with heart failure and fluid retention. A recent study has shown that furosemide administration increases mortality in heart failure rat models. The commonly used drugs, furosemide, and KCl in the treatment of various diseases render the differential expression of proteins in the LV tissue, which is involved in the cardiac conductivity.
• Option B: The risk of hypokalemia increases with the use of a high dose of furosemide, decreased oral intake of potassium in patients with hyperaldosteronism states (liver abnormalities or licorice ingestion), or concomitant use of corticosteroid, ACTH, and laxatives.
• Option C: Careful monitoring of the patient’s clinical condition, daily weight, fluids intake, and urine output, electrolytes, i.e., potassium and magnesium, kidney function monitoring with serum creatinine and serum blood urea nitrogen level is vital to monitor the response to furosemide. If indicated as diuresis with furosemide, replete electrolytes lead to electrolyte depletion and adjust the dose or even hold off on furosemide if laboratory work shows signs of kidney dysfunction.

FNDNRS-07-017

A client went to the emergency room with a sudden onset of high fever and diaphoresis. Serum sodium was one of the laboratory tests taken. Which of the following values would you expect to see?

• A. 130 mEq/L.
• B. 148 mEq/L.
• C. 143 mEq/L.
• D. 139 mEq/L.

Correct Answer: B. 148 mEq/L.

The normal sodium level is 135-145 mEq/L. Diaphoresis and a high fever can lead to free water loss through the skin, resulting in increased sodium level (hypernatremia). Hypernatremia is defined as a serum sodium concentration of greater than 145 meq/l. The human body maintains sodium and water homeostasis by concentrating the urine secondary to the action of antidiuretic hormone (ADH) and increased fluid intake by a powerful thirst response.

• Option A: The basic mechanisms of hypernatremia are water deficit and excess solute. Total body water loss relative to solute loss is the most common reason for developing hypernatremia. Hypernatremia is usually associated with hypovolemia, which can occur in conditions that cause combined water and solute loss, where water loss is greater than sodium loss, or free water loss.
• Option C: Excessive sweating can occur due to exercise, fever, or high heat exposure. Renal losses can be seen in intrinsic renal disease, post-obstructive diuresis, and with the use of osmotic or loop diuretics. Hyperglycemia and mannitol are common causes of osmotic diuresis. Free water loss is seen with central or nephrogenic diabetes insipidus (DI) and also in conditions with increased insensible loss.
• Option D: Sodium excretion also involves regulatory mechanisms such as the renin-angiotensin-aldosterone systems. When serum sodium increases, the plasma osmolality increases which triggers the thirst response and ADH secretion, leading to renal water conservation and concentrated urine.

FNDNRS-07-018

A client is brought to the emergency department and states that he has accidentally been taking two times his prescribed dose of Warfarin (Coumadin). After observing that the client has no evidence of any obvious bleeding, the nurse should do which of the following?

• A. Draw a sample for activated partial thromboplastin time (aPTT) level.
• B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).
• C. Prepare to administer Vitamin K.
• D. Prepare to administer Protamine sulfate.

Correct Answer: B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).

The next action for the nurse to take is to draw a sample for INR and PT level to check the client’s anticoagulation status and risk for bleeding. These results will provide information on how to manage the client by either giving an antidote such as Vitamin K or administering a blood transfusion. Specific evaluation of warfarin toxicity should involve evaluation of the patient’s PT, INR, CBC, and BMP with hepatic function, in addition to the standard co-ingestions and a focused evaluation surrounding their symptoms. 

• Option A: The aPTT determines the effects of heparin therapy. It is recommended that patients undergo measurement of PT/INR and PTT during the initial presentation. For acute exposures, patients should receive serial INR assessments every 12-24 hours. If INR remains normalized at 36 hours and there are no signs of bleeding, no further testing is generally necessary.
• Option C: The results of the INR and PT level will be needed first. For these recommendations, coagulopathy is defined as INR > 1.4. Warfarin toxicity is defined as INR > 3.0 or >3.5 in a patient with a mechanical heart valve. Unintentional toxicity in patients who are treated with warfarin for an underlying condition (most common presentation).
• Option D: Protamine sulfate is the antidote for heparin overdose. Patients with elevated INR displaying evidence of coagulopathy during evaluation, do not need to be started on vitamin K unless the INR is greater than 10 or they have evidence of bleeding.

FNDNRS-07-019

A male client with atrial fibrillation who is receiving maintenance therapy of warfarin (Coumadin) has a prothrombin time of 37 seconds. Based on the result, the nurse will follow which of the following doctor’s orders?

• A. Administering the next dose of warfarin.
• B. Increasing the next dose of warfarin.
• C. Decreasing the next dose of warfarin.
• D. Withholding the next dose of warfarin.

Correct Answer: D. Withholding the next dose of warfarin.

The normal prothrombin time is 9.6 to 11.8 seconds (male adult). A therapeutic level PT level is 1.5 to 2 times higher than the normal level. Since the value of 37 seconds is high, the nurse should expect that the client’s next dose of warfarin will be withheld. Patients receiving treatment with warfarin should have close monitoring to ensure the safety and efficacy of the medication. Periodic blood testing is recommended to assess the patient’s prothrombin time (PT) and the international normalized ratio (INR).

• Option A: The laboratory parameter utilized to monitor warfarin therapy is the PT/INR. The PT is the number of seconds it takes the blood to clot, and the INR allows for the standardization of the PT measurement depending on the thromboplastin reagent used by a laboratory. Therefore, monitoring a patient’s INR while on warfarin is strongly preferable over PT because it allows for a standardized measurement without variations due to different laboratory sites.
• Option B: Routine assessment of INR is essential in the management of patients receiving warfarin therapy. The INR of a patient who is not on anticoagulation therapy is approximately 1.0. If a patient has an INR of 2.0 or 3.0, that would indicate that it takes two or three times longer for that individual’s blood to clot than someone who does not take any anticoagulants.
• Option C: The therapeutic INR goal for patients on warfarin therapy is dependent on the indication but may vary based on the patient’s clinical presentation and provider preference. Most patients on warfarin have an INR goal of 2 to 3. However, specific indications, such as a mechanical mitral valve, require an INR goal of 2.5 to 3.5.

FNDNRS-07-020

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin time is 77 seconds. Based on this result, the nurse anticipated which of the following prescriptions?

• A. Maintain the rate of the heparin infusion.
• B. Decrease the rate of the heparin infusion.
• C. Increase the rate of the heparin infusion.
• D. Discontinue the heparin infusion.

Correct Answer: A. Maintain the rate of the heparin infusion.

The normal activated partial thromboplastin time is between 20 to 36 seconds. In the treatment of deep vein thrombosis, the therapeutic range is to maintain the aPTT level between 1.5 and 2.5 times the normal. This means that the client’s aPTT level should not be less than 30 seconds or greater than 90 seconds. Thus the client’s aPTT of 77 seconds is within the normal therapeutic range, and the dose/rate should not be changed.

• Option B: Therapeutic monitoring for heparin includes activated partial thromboplastin time (aPTT) and activated clotting time (ACT). Both of these are aspects of clotting time, which are prolonged by therapeutic heparin doses. Activated partial thromboplastin time is performed at baseline and every 6 hours until 2 or more therapeutic values are obtained, then aPTT can be assessed every 24 hours.
• Option C: Dose titrations are made based on the results of the aPTT. Hospitals have dosing nomograms specific to their target aPTT, which may vary depending upon the laboratory reagent used for their test. Therapeutic aPTT is considered therapeutic at 1.5 to 2 times control, which also varies from facility to facility based on controls.
• Option D: ACT is less sensitive than aPTT. ACT will only detect abnormalities when there is 95% abnormality rate in the factors, whereas aPTT can detect when there is 70% abnormality. ACT may also be affected when platelets are abnormal, which can result from the administration of heparin. 

FNDNRS-07-021

A nurse is handling a pregnant client who was prescribed to have an Alpha Fetoprotein level. The nurse should explain to the client that this blood test:

• A. Can indicate lung disorders and neural tube defects.
• B. Abnormal levels are associated with an increased risk for chromosome abnormality.
• C. Once the Alpha-Fetoprotein levels are abnormal, amniocentesis will be ordered.
• D. An Alpha-Fetoprotein is a definitive test for neural tube defects.

Correct Answer: C. Once the Alpha-Fetoprotein levels are abnormal, amniocentesis will be ordered.

If the Alpha-Fetoprotein levels are abnormal, the physician will prescribe amniocentesis to confirm or eliminate the diagnosis of a neural tube defect. Alpha-fetoprotein (AFP) is a plasma protein produced by the embryonic yolk sac and the fetal liver. AFP levels in serum, amniotic fluid, and urine function as a screening test for congenital disabilities, chromosomal abnormalities, as well as some other adult occurring tumors and pathologies.

• Option A: Option A is incorrect since Alpha Fetoprotein does not indicate lung disorders. It is pertinent to explain that this is a screening test. Depending on the outcome, more tests may be ordered for the purpose of establishing a diagnosis. A negative test does not necessarily indicate no risk as very low maternal blood alpha-fetoprotein is associated with an increased incidence of Down syndrome.
• Option B: Option B is incorrect because an increase of human chorionic gonadotropin instead is associated with an increased risk for chromosome abnormality. This tumor marker is a glycoprotein encoded by the AFP gene on chromosome 4q25. Prenatal levels in developing human embryos rise from the end of the first trimester and begin to fall after 32 weeks of gestation. Maternal serum AFP forms part of the triple or quadruple screening tests for fetal anomaly.
• Option D: Option D is incorrect because an Alpha Fetoprotein level is a screening test and is not a definitive test. This tumor marker is a glycoprotein encoded by the AFP gene on chromosome 4q25. Prenatal levels in developing human embryos rise from the end of the first trimester and begin to fall after 32 weeks of gestation. Maternal serum AFP forms part of the triple or quadruple screening tests for fetal anomaly.

FNDNRS-07-022

Which of the following laboratory results indicates hypoparathyroidism?

• A. Serum potassium of 3.6 mEq/L.
• B. Serum calcium level of 4.3 mEq/L.
• C. Serum phosphorus level of 5.7 mg/dL.
• D. Serum magnesium level of 1.7 mg/dL.

Correct Answer: C. Serum phosphorus level of 5.7 mg/dL.

The parathyroid is responsible for the absorption of calcium and phosphorus. When a client has hypoparathyroidism, the serum calcium levels are low and the serum phosphorus levels are high. The normal phosphorus level is 2.7 to 4.5 mg/dL. Parathyroid hormone deficiency, also called hypoparathyroidism, results in hypocalcemia, hyperphosphatemia, and increased neuromuscular irritability. Patients may present with myalgias, muscle spasms, and in extreme cases tetany.

• Option A: Calcium is maintained within a fairly narrow range from 8.5 to 10.5 mg/dl (4.3 to 5.3 mEq/L or 2.2 to 2.7 mmol/L). Normal values and reference ranges may vary among laboratories as much as 0.5 mg/dl. Aldinger KA, et al., studied a large group of patients of normal renal function with hypercalcemia to determine the prevalence of hypokalemia and reported that 16.9% had hyperparathyroidism, and the degree and frequency of hypokalemia were greatest at the higher serum calcium levels.
• Option B: Parathyroid hormone activates the PTH receptor, another G-protein coupled receptor, increasing resorption of calcium and phosphorus from bone, enhancing the distal tubular reabsorption of calcium, and decreasing the renal tubular reabsorption of phosphorus. Deficient PTH results in hypocalcemia, hyperphosphatemia, while alkaline phosphatase, a marker of bone formation, is normal.
• Option D: The normal range for blood magnesium level is 1.7 to 2.2 mg/dL (0.85 to 1.10 mmol/L). Another common cause of hypoparathyroidism is abnormally low levels of magnesium (hypomagnesemia) in the blood. This is often called functional hypoparathyroidism because it resolves when magnesium is restored. Magnesium is a mineral that is very important in the function of the parathyroid glands.

FNDNRS-07-023

An adult male client has a hemoglobin count of 12.5 g/dL. Based on the result, the client is most likely having this due to which of the following notes in the client’s record?

• A. Emphysema.
• B. Client living at a high altitude.
• C. Dehydration.
• D. History of an enlarged spleen.

Correct Answer: D. History of splenomegaly.

The normal hemoglobin level for an adult male is 14-16.5 g/dL. An enlarged spleen may cause anemia (low hemoglobin count) in clients. The spleen normally removes old and/or damaged red blood cells from the bloodstream. However, when the spleen enlarges, it traps and stores an excessive number of red blood cells, causing anemia. Sometimes, the spleen also destroys white blood cells and/or platelets causing a low white blood cell count (leukopenia) and a low platelet count (thrombocytopenia). 

• Option A: Anemia of chronic disease (ACD) is probably the most common type of anemia associated with COPD. ACD is driven by COPD-mediated systemic inflammation. Anemia in COPD is associated with greater healthcare resource utilization, impaired quality of life, decreased survival, and a greater likelihood of hospitalization.
• Option B: Living at higher altitudes causes red blood cell production to naturally increase to compensate for the lower oxygen supply. The amount of hemoglobin in blood increases at high altitude. This is one of the best-known features of acclimatization (acclimation) to high altitude. Increasing the amount of hemoglobin in the blood increases the amount of oxygen that can be carried.
• Option C: Dehydration may increase the hemoglobin level by hemoconcentration. Both the hemoglobin and the hematocrit are based on whole blood and are therefore dependent on plasma volume. If a patient is severely dehydrated, the hemoglobin and hematocrit will appear higher than if the patient were normovolemic; if the patient is fluid overloaded, they will be lower than their actual level.

FNDNRS-07-024

A screen test for the detection of human immunodeficiency virus (HIV) reveals a positive ELISA exam. Which of the following tests will be used to confirm the diagnosis of HIV?

• A. Indirect immunofluorescence assay (IFA).
• B. CD4-to-CD8 ratio.
• C. Radioimmunoprecipitation assay (RIPA) test.
• D. p24 antigen assay.

Correct Answer: A. Indirect immunofluorescence assay (IFA)

The indirect immunofluorescence assay (IFA) test and Western Blot test result are considered as confirmatory for HIV. An initial HIV test usually will either be an antigen/antibody test or an antibody test. If the initial HIV test is a rapid test or a self-test and it is positive, the individual should go to a health care provider to get follow-up testing. If the initial HIV test is a laboratory test and it is positive, the laboratory will usually conduct follow-up testing on the same blood sample as the initial test. Although HIV tests are generally very accurate, follow-up testing allows the health care provider to be sure the diagnosis is right.

• Option B: CD4-to-CD8 ratio monitors the progression of HIV. A normal CD4/CD8 ratio is greater than 1.0, with CD4 lymphocytes ranging from 500 to 1200/mm ³ and CD8 lymphocytes ranging from 150 to 1000/mm ³. If the ratio is higher than 1, it means the immune system is strong and the client may not have HIV. If the ratio is less than 1, the client may have HIV.
• Option C: Radioimmunoprecipitation assay (RIPA) test detects HIV protein rather than showing antibodies. Radioimmunoprecipitation assay buffer (RIPA buffer) is a lysis buffer used for rapid, efficient cell lysis and solubilization of proteins from both adherent and suspension-cultured mammalian cells.
• Option D: p24 antigen assay quantifies the amount of HIV viral core protein. One distinctive HIV antigen is a viral protein called p24, a structural protein that makes up most of the HIV viral core, or ‘capsid’. High levels of p24 are present in the blood serum of newly infected individuals during the short period between infection and seroconversion, making p24 antigen assays useful in diagnosing primary HIV infection.

FNDNRS-07-025

The client went to the emergency room with a sudden onset of chest pain and difficulty of breathing. Which of the following results is indicative that the client is experiencing a myocardial infarction?

• A. Myoglobin level of 98 mcg/L.
• B. Troponin T of 0.09 ng/mL.
• C. Troponin I 0.5 ng/mL.
• D. Creatine kinase (CK-MB) 155 units/L.

Correct Answer: A. Myoglobin level of 98 mcg/L.

The normal value of myoglobin is lower than 90 mcg/L; An elevation could indicate a myocardial infarction. Myoglobin, an oxygen-carrying protein found in cardiac muscle and striated skeletal muscle, presents an attractive alternative to CPK and LDH in the emergency department setting for identification of acute myocardial infarction. Myoglobin levels may be elevated in the serum within one hour after myocardial cell death with peak levels reached within four to six hours.

• Option B: The troponin T level is normal. Cardiac troponin T is measured in nanograms per milliliter (ng/mL). If the client’s troponin T level is above the 99th percentile for the test being used, the doctor will likely diagnose a heart attack. Levels that start high and fall suggest a recent injury to the heart. It could be a mild heart attack. 
• Option C: The troponin I level is normal. High levels of troponin are an immediate red flag. The higher the number, the more troponin — specifically troponin T and I — has been released into the bloodstream, and the higher the likelihood of heart damage. Troponin levels can elevate within 3-4 hours after the heart has been damaged and can remain high for up to 14 days.
• Option D: Creatine kinase level has a normal value. The ECG and the determination of serum enzymes creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) may be falsely normal early in acute myocardial infarction.

FNDNRS-07-026

A nurse is caring for a client with diarrhea and dehydration. The nurse determines that the client has received adequate fluid replacement if the blood urea nitrogen decreases to:

• A. 36 mg/dL.
• B. 27 mg/dL.
• C. 18 mg/dL.
• D. 6 mg/dL.

Correct Answer: C. 18 mg/dL.

The normal value of blood urea nitrogen is 8 to 25 mg/dL. Fluid status absolutely affects the levels of BUN and creatinine in the blood, but volume depletion or dehydration tends to affect BUN more so that we see a BUN: creatinine ratio of 20:1 or more in people who are very dry.

• Option A: 36 mg/dl indicates a high level of BUN. Dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or blockage of the flow of urine from the kidney causes both BUN and creatinine levels to go up.
• Option B: 27 mg/dl still indicates dehydration. A patient who is severely dehydrated may also have a high BUN due to the lack of fluid volume to excrete waste products. Because urea is an end product of protein metabolism, a diet high in protein, such as high-protein tube feeding, may also cause the BUN to increase.
• Option D: A low BUN occurs with conditions such as fluid volume overload, malnutrition, etc. Because urea is synthesized by the liver, severe liver failure causes a reduction of urea in the blood. Just as dehydration may cause an elevated BUN, overhydration causes a decreased BUN. When a person has “syndrome of inappropriate antidiuretic secretion” (SIADH), the antidiuretic hormone responsible for stimulating the kidney to conserve water causes excess water to be retained in the bloodstream rather than being excreted into the urine.

FNDNRS-07-027

A client with liver cirrhosis has been advised to follow a high-protein diet. The nurse evaluates the effectiveness of the diet if the total protein level is which of the following values?

• A. 6.9 g/dL.
• B. 4.9 g/dL.
• C. 2.9 g/dL.
• D. 0.9 g/dL.

Correct Answer: A. 6.9 g/dL.

The normal value for total serum protein is 6 to 8 g/dL. The client with liver cirrhosis has low total protein levels secondary to inadequate nutrition. Protein deficiency is often associated with liver disease. The principal cause of protein deficiency is decreased dietary intake. Deficiencies in digestion and absorption that are common in alcoholics contribute to protein deficiency in alcoholic liver disease.

• Option B: 4.9 mg/dl is a low value for total serum protein. The protein requirements in most patients with compensated chronic liver disease are not different from normal but increase during episodes of hepatocellular deterioration. An increased demand for protein after liver injury drains nitrogen from other organs such as muscle.
• Option C: 2.9 mg/dl is a very low total serum protein level. Circulating proteins synthesized by the liver, such as albumin and clotting factors, are frequently decreased in chronic liver disease. Vitamin deficiencies that are common in liver disease contribute to abnormalities of protein metabolism. Hepatic regeneration following hepatic resection or injury is adversely affected by protein and vitamin deficiencies and by alcohol ingestion.
• Option D: 0.9 mg/dl is an abnormally low total serum protein value. This is because some conditions affect the amounts of albumin or globulin in the blood. A low A/G ratio may be due to an overproduction of globulin, underproduction of albumin, or loss of albumin, which may indicate the following: an autoimmune disease. cirrhosis, involving inflammation and scarring of the liver.

FNDNRS-07-028

The nurse is handling a client with chronic pancreatitis. Upon reviewing the client’s record, which of the following serum amylase levels is to be expected?

• A. 50 units/L.
• B. 150 units/L.
• C. 350 units/L.
• D. 650 units/L.

Correct Answer: C. 350 units/L.

The normal serum amylase level is 25 to 151 unit/L. Clients with chronic pancreatitis have an increased level of serum amylase which does not exceed three times the normal value. Serum amylase and lipase levels may be slightly elevated in chronic pancreatitis; high levels are found only during acute attacks of pancreatitis.

• Option A: 50 units/L is a low serum amylase level. Low serum amylase (hypoamylasemia) has been reported in certain common cardiometabolic conditions such as obesity, diabetes (regardless of type), and metabolic syndrome, all of which appear to have a common etiology of insufficient insulin action due to insulin resistance and/or diminished insulin secretion.
• Option B: 150 units/L is within the normal values. However, in the later stages of chronic pancreatitis, atrophy of the pancreatic parenchyma can result in normal serum enzyme levels because of significant fibrosis of the pancreas, resulting in decreased concentrations of these enzymes within the pancreas.
• Option D: 650 units/L is seen with acute pancreatitis since the value may exceed five times the normal value. The sensitivity and specificity of amylase as a diagnostic test for acute pancreatitis depends on the chosen threshold value. By raising the cut-off level to 1000 IU/l (more than three times the upper limit of normal), amylase has a specificity approaching 95%, but sensitivity as low as 61% in some studies.

FNDNRS-07-029

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 10%. Based on the result, the nurse plans to teach the client about the importance of:

• A. Maintaining the result.
• B. Preventing hypoglycemia.
• C. Preventing hyperglycemia.
• D. Avoiding infection.

Correct Answer: C. Preventing hyperglycemia.

Glycosylated hemoglobin A1c level of 8% higher indicates poor diabetic control. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. The test shows an average of the blood sugar level over the past 90 days and represents a percentage. The test can also be used to diagnose diabetes.

• Option A: For an A1c test to classify as normal, or in the non-diabetic range the value must be below 5.7 %. Anyone with an A1c value of 5.7 % to 6.4 % is considered to be prediabetic, while diabetes can be diagnosed with an A1c of 6.5% or higher. Hemoglobin A1c serves as an indicator of overall glycemic control and a reflection of the average blood sugar over the past three months.
• Option B: A falsely low A1c value can result from several conditions including high altitude, pregnancy, hemorrhages, blood transfusions, erythropoietin administration, iron supplementation, hemolytic anemia, chronic kidney failure, liver cirrhosis, alcoholism, folic acid deficiency, sickle cell anemia, and spherocytosis.
• Option D: A1c provides a measure of the glucose concentration over three months. Hemoglobin A1c is often used as an outcome measure to determine if an intervention in a population is successful by showing a decrease in A1c by a certain percentage. Levels of A1c should be measured twice a year in stable patients and at least four times in patients who have glucose fluctuations or those who have had a change in their diabetic treatment.

FNDNRS-07-030

The nurse is reviewing the laboratory result of a client receiving digoxin (Lanoxin) and notes that the result is 2.5 ng/mL. The nurse plans to do which of the following?

• A. Give the next dose.
• B. Notify the physician.
• C. Check the client’s pulse rate.
• D. Increase the next dose as ordered.

Correct Answer: B. Notify the physician.

The normal value therapeutic range for digoxin is 0.5 to 2 ng/mL. A level of 2.5 ng/mL indicates toxicity. The nurse should immediately inform the physician, who may give further instructions about holding the next doses of digoxin. Digoxin toxicity can present acutely after an overdose or chronically, as is often seen in patients on digoxin that develop acute kidney injury. Approximately 1% of CHF patients treated with digoxin develop toxicity. Additionally, 1% of adverse drug effects in patients greater than age 40 are due to digoxin toxicity; the incidence rises to greater than 3% in patients over age 85.

• Option A: Clinical staff should monitor the plasma digoxin level at least 6 hours or 12 hours post-administration of the last loading dose as this is the time to achieve steady-state levels. Recommended thresholds of therapeutic serum digoxin levels are between 0.5 to 2 ng/dl.
• Option C: The physician must request regular electrocardiograms and bloodwork to assess for renal function, and electrolytes require close monitoring. No more than 2 ml of the drug should be injected at the same site. The injection should be made deep into the muscle, and the overlying area massaged post-injection. Intravenous injections are metabolized more efficiently than intramuscular injections and are the preferred route, as only about 80% of the drug is absorbed in intramuscular injections as compared to intravenous dosing.
• Option D: Digoxin has a narrow therapeutic index. The recommended serum levels stand between 0.8 to 2 ng/mL. When measuring a digoxin serum level, it is essential to draw blood at least 6 to 8 hours after the last dose. The toxicity increases as the serum drug levels increase above 2.0 ng/mL.

FNDNRS-07-031

The nurse caring for a client with a serum calcium of 6.8 mg/dL. What would the nurse expect the change on the electrocardiogram (ECG)?

• A. None. This is a normal calcium level.
• B. Prolonged QT interval.
• C. Shortened ST segment.
• D. Widened T wave.

Correct Answer: B. Prolonged QT interval.

The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. The ECG hallmark of hypocalcemia remains the prolongation of the QTc interval because of lengthening of the ST segment, which is directly proportional to the degree of hypocalcemia or, as otherwise stated, inversely proportional to the serum calcium level. The exact opposite holds true for hypercalcemia.

• Option A: High and low levels of ionized serum calcium concentration can produce characteristic changes on the electrocardiogram. These changes are almost entirely limited to the duration of the ST segment, with no change in the QRS complexes or T waves.
• Option C: The ST segment on an electrocardiogram (ECG) normally represents an electrically neutral area of the complex between ventricular depolarization (QRS complex) and repolarization (T wave). However, it can take on various waveform morphologies that may indicate benign or clinically significant injury or insult to the myocardium.
• Option D: A widened T wave occurs with hypercalcemia. On electrocardiography (ECG), characteristic changes in patients with hypercalcemia include shortening of the QT interval. ECG changes in patients with very high serum calcium levels include the following: slight prolongation of the PR and QRS intervals; and T wave flattening or inversion.

FNDNRS-07-032

When providing care for a female client with Addison disease, the nurse should be alert for which of the following laboratory values?

• A. Potassium level of 3.2 mEq/L.
• B. Calcium level of 3.3 mEq/L.
• C. Sodium level of 150 mg/dL.
• D. Hematocrit level of 25%.

Correct Answer: D. Hematocrit level of 25%.

A client with Addison’s disease is at risk for anemia. The normal hematocrit level of a female adult is 35% to 45%. A client with anemia has a low hematocrit level. Addison anemia, better known today as pernicious anemia (PA), is characterized by the presence in the blood of large, immature, nucleated cells (megaloblasts) that are forerunners of red blood cells. (Red blood cells, when mature, have no nucleus). It is thus a type of megaloblastic anemia.

• Option A: The client with Addison’s disease has increased potassium. A deficiency of aldosterone, in particular, causes the body to excrete large amounts of sodium and retain potassium, leading to low levels of sodium and high levels of potassium in the blood.
• Option B: The client with Addison’s disease has an increased calcium level. As not all cases of adrenal insufficiency present with hypercalcemia, adrenal insufficiency is not easily considered an etiology of hypercalcemia. The prevalence of hypercalcemia at the time of diagnosis of Addison’s disease is reported to be ~5.5%–6.0%.
• Option C: The client with Addison’s disease has a low sodium level. The kidneys are not able to retain sodium easily, so when a person with Addison disease loses too much sodium, the level of sodium in the blood falls, and the person becomes dehydrated. Severe dehydration and a low sodium level reduce blood volume and can lead to shock.

FNDNRS-07-033

A client has been undergoing radiotherapy for the treatment of mandibular cancer. After a few sessions, the client is diagnosed with Tumor Lysis Syndrome (TLS). Which of the following findings correlates with TLS?

• A. Phosphorus level of 6 mg/dL.
• B. Phosphorus level of 3 mg/dL.
• C. Phosphorus level of 4 mg/dL.
• D. Phosphorus level of 2 mg/dL.

Correct Answer: A. Phosphorus level of 6 mg/dL.

Tumor lysis syndrome (TLS) is a potentially life-threatening metabolic disorder characterized by elevated phosphorus levels. The normal phosphorus is 2.5 to 4.5 mg/dL. When cancer cells break down quickly in the body, levels of uric acid, potassium, and phosphorus rise faster than the kidneys can remove them. This causes TLS. Excess phosphorus can “sop up” calcium, leading to low levels of calcium in the blood.

• Option B: 3 mg/dL is a normal phosphorus level. Changes in blood levels of uric acid, potassium, phosphorus, and calcium can affect the functioning of several organs, especially the kidneys, and also the heart, brain, muscles, and gastrointestinal tract.
• Option C: 4 mg/dL is a normal phosphorus level. Not all cancer patients are at equal risk of developing TLS. Patients with a large “tumor burden” of cancer cells and/or tumors that typically have rapidly dividing cells, such as acute leukemia or high-grade lymphoma, as well as tumors that are highly responsive to therapy, are at greatest risk of developing TLS.
• Option D: 2 mg/dL is a normal phosphorus level. TLS is not limited to patients receiving traditional chemotherapy; it can also occur in patients receiving steroids, hormonal therapy, targeted therapy, or radiation therapy. Patients who are dehydrated and those with existing kidney dysfunction are at higher risk of developing TLS.

FNDNRS-07-034

A female client went to the clinic with a creatinine clearance of 200 mL/min. Which of the following conditions of the client can cause the increased level of this test?

• A. Renal disease.
• B. Dehydration.
• C. Congestive heart failure.
• D. History of high dietary protein intake.

Correct Answer: D. History of high dietary protein intake.

The normal creatinine clearance for a female is 88 to 128 ml/min. An increased creatinine clearance is often referred to as hyperfiltration and is most commonly seen during pregnancy or in clients with a large dietary protein intake. Dietary protein consumption increases serum creatinine level through protein catabolism rather than decreased clearance. Hence, serum creatinine may be less reliable for estimating GFR or estimating a glomerular hyperfiltration response in studies that manipulate dietary protein.

• Option A: Creatinine clearance has been used for many decades to estimate GFR. It involves a 24-hour urine collection to measure creatinine excretion. As the same sample can be used to measure the protein excretion rate, creatinine clearance is often used for the initial evaluation of renal diseases, such as glomerulonephritis.
• Option B: Dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or blocked urine flow from the kidney causes both BUN and creatinine levels to rise.
• Option C: Congestive heart failure is seen with a decreased creatinine clearance. Low creatinine clearance levels can mean the client has chronic kidney disease or serious kidney damage. Kidney damage can be from conditions such as a life-threatening infection, shock, cancer, low blood flow to the kidneys, or urinary tract blockage. Other conditions, such as heart failure and dehydration, can also cause low clearance levels.

FNDNRS-07-035

A nurse is reviewing the complete blood count (CBC) of a child who has been diagnosed with idiopathic thrombocytopenic purpura. Which of the following laboratory results should the nurse report immediately to the physician?

• A. Platelet count of 30,000/mm3.
• B. Hemoglobin level of 7.5 g/dL.
• C. Reticulocyte count of 6.5%.
• D. Eosinophil count of 700 cells/mm3.

Correct Answer: B. Hemoglobin level of 7.5 g/dL.

The low hemoglobin level indicates that the client has active bleeding, and immediate actions such as additional diagnostic exams and blood transfusions can be suggested. An initial impression of the severity of ITP is formed by examining the skin and mucous membranes. Widespread petechiae and ecchymoses, oozing from a venipuncture site, gingival bleeding, and hemorrhagic bullae indicate that the patient is at risk for a serious bleeding complication.

• Option A: Decreased platelet count is expected in a child with idiopathic thrombocytopenic purpura. Immune thrombocytopenia (ITP) is a syndrome in which platelets become coated with autoantibodies to platelet membrane antigens, resulting in splenic sequestration and phagocytosis by mononuclear macrophages. The resulting shortened life span of platelets in the circulation, together with incomplete compensation by increased platelet production by bone marrow megakaryocytes, results in a decreased number of circulating platelets.
• Option C: Increased reticulocyte is expected in a child with idiopathic thrombocytopenic purpura. The measurement of the content of hemoglobin of reticulocytes (CHr or Ret-He) reflects the synthesis of hemoglobin in marrow precursors and allows the detection of early stages of iron deficiency.
• Option D: An increased eosinophil count is expected in a child with idiopathic thrombocytopenic purpura. Many authors have reported associations between the increased numbers of eosinophils with platelet dysfunctions, such as increased bleeding time, reduction in platelet aggregation induced by various agonists, among other disorders.

Questions related to Parenteral Nutrition

FNDNRS-07-036

A patient receiving parenteral nutrition is administered via the following routes except:

• A. Subclavian line.
• B. Central Venous Catheter.
• C. PICC (Peripherally inserted central catheter) line.
• D. PEG tube.

Correct Answer: D. PEG tube.

Percutaneous endoscopic gastrostomy (PEG tube) is inserted into a person’s stomach through the abdominal wall that is used to provide a means of feeding when oral intake is not adequate. While parenteral nutrition bypasses the digestive system by the administration to the bloodstream.

• Option A: TPN may be administered as peripheral parenteral nutrition (PPN) or via a central line, depending on the components and osmolality. Central veins are usually the veins of choice because there is less risk of thrombophlebitis and vessel damage (Chowdary & Reddy, 2010).
• Option B: Parenteral nutrition may be delivered via femoral lines, internal jugular lines, and subclavian vein catheters in the hospital setting. Central access is required for infusions that are toxic to small veins due to medication pH, osmolarity, and volume.
• Option C: PICC lines may be used in ambulatory settings or for long-term therapy. It is inserted in the cephalic, basilic, median basilic, or median cephalic veins and threaded into the superior vena cava. It can remain in place for up to 1 year with proper maintenance and without complications.

FNDNRS-07-037

A nurse is monitoring the status of a client’s fat emulsion (lipid) infusion and notes that the infusion is 2 hours delay. The nurse should do which of the following actions?

• A. Adjust the infusion rate to catch up over the next hour.
• B. Make sure the infusion rate is infusing at the ordered rate.
• C. Increase the infusion rate to catch up over the next few hours.
• D. Adjust the infusion rate to full blast until the solution is back on time.

Correct Answer: B. Make sure the infusion rate is infusing at the ordered rate.

The nurse should maintain the prescribed rate of a fat emulsion even if the infusion’s time consumed is behind. The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates, and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within ≤7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids.

• Option A: This intervention may cause hyperglycemia. Low-fat PN with a high glucose intake increases the risk of hyperglycemia. In parenterally fed patients with a tendency to hyperglycemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake.
• Option C: C is incorrect since increasing the rate will potentially cause a fluid overload. The risk of PN complications (e.g. refeeding syndrome, hyperglycemia, bone demineralization, catheter infections) can be minimized by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN.
• Option D: If the infusion rate is adjusted to full blast, the patient might undergo fluid overload and other complications. Occurring complications are e.g. the refeeding syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis.

FNDNRS-07-038

A nurse is preparing to hang the initial bag of the parenteral nutrition (PN) solution via the central line of a malnourished client. The nurse ensures the availability of which medical equipment before hanging the solution?

• A. Glucometer.
• B. Dressing tray.
• C. Nebulizer.
• D. Infusion pump.

Correct Answer: D. Infusion pump.

The nurse should prepare an infusion pump prior to hanging a parenteral solution. The use of an infusion pump is important to make sure that the solution does not infuse too quickly or delayed since the parenteral nutrition has a high glucose content. An infusion pump controls the rate at which the TPN solution is given so that the concentrated food does not overload other digestive organs. For many patients receiving TPN, the pump is portable.

• Option A: A glucometer is also needed since the client’s glucose level is monitored every 4 to 6 hours, but it is not an essential item needed. Hyperglycemia is associated with increased hospital complications and mortality in patients receiving TPN. TPN-induced hyperglycemia is associated with increased length of hospital stay, increased risk of complications, and higher mortality in hospitalized patients.
• Option B: A dressing tray is not used before hanging a PN solution. With total parenteral nutrition, a solution of essential nutrients (including proteins, fluids, electrolytes, and fat-soluble vitamins) is given into the veins (intravenously). Because TPN solutions are highly concentrated and thick, the solutions must be given through catheters that are placed in large central veins in the neck, chest, or groin.
• Option C: A nebulizer is not used before hanging a PN solution. Total parenteral nutrition (TPN) is the standard therapy for people who have this problem. TPN can be used to treat a severe disorder that is expected to last for a relatively short time, such as intractable vomiting during pregnancy. It is also used as a long-term therapy.

FNDNRS-07-039

A nurse is conducting a follow-up home visit to a client who has been discharged with parenteral nutrition(PN).  Which of the following should the nurse most closely monitor in this kind of therapy?

• A. Blood pressure and temperature.
• B. Blood pressure and pulse rate.
• C. Height and weight.
• D. Temperature and weight.

Correct Answer: D. Temperature and weight.

The client’s temperature is monitored to identify signs of infection which is one of the complications of this therapy. While the weight is monitored to detect hypervolemia and to determine the effectiveness of this nutritional therapy. Monitoring patients on parenteral nutrition (PN) requires a multidisciplinary approach with effective communication throughout the team. This will help to minimize potential complications and will aid safe, effective, and appropriate use of PN.

• Option A: Temperature should be monitored to watch for infection, however, blood pressure is not as important during total parenteral nutrition. But blood pressure should still be monitored routinely. The risk of infectious complications is increased due to venous access for PN. The likelihood of hyperglycemia-induced complications may depend on concomitant diseases, duration of PN, and life expectancy. 
• Option B: Blood pressure and pulse rate may be checked routinely in a patient with TPN. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN.
• Option C: Monitoring the patient’s height is not necessary during TPN administration. Nutritional status is most effectively assessed and monitored through a combination of anthropometric data, biochemical and clinical measures. A stand-alone measure e.g. weight can rarely provide adequate information.

FNDNRS-07-040

A nurse is preparing to hang a fat emulsion (lipids) and observes some visible fat globules at the top of the solution. The nurse ensures to do which of the following actions?

• A. Take another bottle of solution.
• B. Run the bottle solution under warm water.
• C. Roll the bottle solution gently.
• D. Shake the bottle solution vigorously.

Correct Answer: A. Take another bottle of solution.

Fat emulsions are used as dietary supplements for patients who are unable to get enough fat in their diet, usually because of certain illnesses or recent surgery. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy.

• Option B: Continuous fat infusion over 24 hours is the preferred method in neonates. For this reason, commercial lipid emulsions are repacked to a polypropylene syringe from original commercial bags and administered intravenously to neonates at neonates wards with a higher temperature. The higher temperature in neonatal wards could be an additional factor negatively affecting the stability of lipid emulsion.
• Option C: Storage of lipid emulsion in plastic containers is controversial. It was shown that patients who received lipids delivered in plastic bags are more likely to have hypertriglyceridemia than those who received lipids from glass bottles. This is possible because of a higher proportion of large-diameter fat globules in plastic bags. 
• Option D: An increase in the droplet size is the first indication of formulation stability issues. Moreover, droplets greater than 5 μm can be trapped in the lungs and cause pulmonary embolism. Pulmonary embolism may develop and is associated with a high risk of morbidity and mortality.

FNDNRS-07-041

A client is receiving nutrition via parenteral nutrition (PN).  A nurse assesses the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?

• A. High-grade fever, chills, and decreased urination.
• B. Fatigue, increased sweating, and heat intolerance.
• C. Coarse dry hair, weakness, and fatigue.
• D. Thirst, blurred vision, and diuresis.

Correct Answer: D. Thirst, blurred vision, and diuresis.

Signs of hyperglycemia include excessive thirst, fatigue, restlessness, blurred vision, confusion, weakness, Kussmaul’s respirations, diuresis, and coma when hyperglycemia is severe. Hyperglycaemia is found in up to 50% of PN patients. Important predictors are insulin resistance or diabetes mellitus, severity of the underlying illness, concomitant steroid therapy, and the amount of glucose provided.

• Option A: High-grade fever, chills, and decreased urination are signs of infection. The risk of infectious complications is increased due to venous access for PN. The likelihood of hyperglycemia-induced complications may depend on concomitant diseases, duration of PN, and life expectancy.
• Option B: Fatigue, increased sweating, and heat intolerance are signs of hyperthyroidism. Hyperthyroidism may manifest as weight loss despite an increased appetite, palpitation, nervousness, tremors, dyspnea, fatigability, diarrhea or increased GI motility, muscle weakness, heat intolerance, and diaphoresis.
• Option C: Coarse dry hair, weakness, and fatigue are signs of hypothyroidism. Inquire about dry skin, voice changes, hair loss, constipation, fatigue, muscle cramps, cold intolerance, sleep disturbances, menstrual cycle abnormalities, weight gain, and galactorrhea. Also obtain a complete medical, surgical, medication, and family history.

FNDNRS-07-042

A nurse is caring for a client who disconnected the tubing of the parenteral nutrition from the central line catheter. A nurse suspects an occurrence of an air embolism. Which of the following is an appropriate position for the client in this kind of situation?

• A. On the right side, with head higher than the feet.
• B. On the right side, with head lower than the feet.
• C. On the left side, with the head higher than the feet.
• D. On the left side, with head lower than the feet.

Correct Answer: D. On the left side, with head lower than the feet.

Air embolism happens because of the entry of air into the catheter system. If it occurs, the client should be placed in a left-side-lying position with the head be lower than the feet. This position will lessen the effect of the air traveling as a bolus to the lungs by trapping it on the right side of the heart. It occurs as a result of a pressure gradient that allows air to enter the bloodstream, which can subsequently occlude blood flow. 

• Option A: When removing catheters, it is also recommended to raise CVP by keeping the patient in a supine position or with their head down or Trendelenburg position. Ideally, the venotomy site should be below the level of the heart to ensure adequate central venous pressure at the time of removal. 
• Option B: Patients should be instructed to perform a Valsalva maneuver during catheter removal, if possible. If this is not possible, removing the catheter during active expiration is recommended. It should be ensured that the exit site is covered with impermeable dressing and that pressure is applied afterward for 5–10 min, for hemostasis and prevention of bubble entry. It is recommended that the patient remains supine for 30 min after central venous access removal
• Option C: In cases of venous air embolism, Durant’s maneuver is performed, by placing the patient in the left lateral decubitus and Trendelenburg position. This serves to encourage the air bubble to move out of the right ventricular outflow tract (RVOT) and into the right atrium, thereby relieving the “air-lock” effect responsible for potentially catastrophic cardiopulmonary collapse.

FNDNRS-07-043

A client is being weaned off from parenteral nutrition (PN) and is given a go-signal to take a regular diet. The ongoing solution rate has been 120ml/hr. A nurse expects that which of the following prescriptions regarding the PN solution will accompany the diet order?

• A. Decrease the PN rate to 60ml/hr.
• B. Start 0.9% normal saline at 30 ml/hr.
• C. Maintain the present infusion rate.
• D. Discontinue the PN.

Correct Answer: A. Decrease the PN rate to 60ml/hr.

When a client begins eating a regular diet after a period of receiving PN, the PN is decreased slowly. Gradually decreasing the infusion rate allows the client to remain sufficiently nourished during the transition to a normal diet and prevents an episode of hypoglycemia.

• Option B: Parenteral nutrition is the intravenous administration of nutrition outside of the gastrointestinal tract. Total parenteral nutrition (TPN) is when the IV administered nutrition is the only source of nutrition the patient is receiving. Total parenteral nutrition is indicated when there is an inadequate gastrointestinal function and contraindications to enteral nutrition.
• Option C: Patients who recently received TPN should be monitored daily until stable. They require more frequent monitoring if metabolic abnormalities are detected or if the patient has a risk of refeeding syndrome. Refeeding syndrome can occur in severely malnourished and cachectic individuals when feeding is reintroduced and can lead to severe electrolyte instabilities.
• Option D: PN that is terminated abruptly will cause hypoglycemia. Total parenteral nutrition administration is through a central venous catheter. A central venous catheter is an access device that terminates in the superior vena cava or the right atrium and is used to administer nutrition, medication, chemotherapy, etc. Establishing this access could be through a peripherally inserted central catheter (PICC), central venous catheter, or an implanted port.

FNDNRS-07-044

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to identify the presence of which of the following?

• A. Hypotension.
• B. Crackles upon auscultation of the lungs.
• C. Thirst.
• D. Polyuria.

Correct Answer: B. Crackles upon auscultation of the lungs.

Normally, the weight gain of a client receiving PN is about 1-2 pounds a week. A weight gain of five (5) pounds over a week indicates a client is experiencing fluid retention that can result in hypervolemia. Signs of hypervolemia include weight gain more than desired, headache, jugular vein distention, bounding pulse, and crackles on lung auscultation.

• Option A: Hypertension, not hypotension is expected. Fluid overload can occur for the same reasons that fluid overload can occur with a regular peripheral intravenous flow. The rate is too fast and rapid for the client. The signs and symptoms of fluid overload include hypertension, edema, adventitious breath sounds like crackles and rales, shortness of breath, and bulging neck veins. 
• Option C: Thirst is associated with hyperglycemia. Hyperglycemia can occur as the result of the high dextrose content of the total parenteral nutrition solution as well as the lack of a sufficient amount of administered. This total parenteral nutrition complication can be prevented with the continuous monitoring of the client’s blood glucose levels and the titration of insulin administration based on these levels of insulin. 
• Option D: Polyuria is associated with hyperglycemia. The signs and symptoms of hyperglycemia secondary to total parenteral nutrition are the same as those associated with poorly managed diabetes and they include a high blood glucose level, thirst, excessive urinary output, headache, nausea, and fatigue.

FNDNRS-07-045

A nurse is making initial rounds at the beginning of the shift and notices that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

• A. 10% dextrose in water.
• B. 5% dextrose in water.
• C. 5% dextrose in normal saline.
• D. 5% dextrose in lactated Ringer solution.

Correct Answer: A. 10% dextrose in water.

The client is at risk of hypoglycemia. Hence the nurse will hang a solution that has the highest amount of glucose until the new parenteral nutrition solution becomes readily available. Crystalloid fluids are a subset of intravenous solutions that are frequently used in the clinical setting. Crystalloid fluids are the first choice for fluid resuscitation in the presence of hypovolemia, hemorrhage, sepsis, and dehydration.

• Option B: Option B is also a crystalloid fluid, but contains less glucose than option A. Other clinical applications include acting as a solution for intravenous medication delivery, to deliver maintenance fluid in patients with limited or no enteral nutrition, blood pressure management, and to increase diuresis to avoid nephrotoxic drug or toxin-mediated end-organ damage.
• Option C: Dextrose 5 in .9 Sodium Chloride is a prescription medicine used to treat the symptoms of hypoglycemia. Dextrose 5 in .9 Sodium Chloride may be used alone or with other medications. Dextrose 5 in .9 Sodium Chloride belongs to a class of drugs called Glucose-Elevating Agents; Metabolic and Endocrine, Other.
• Option D: 5% Dextrose in Lactated Ringer’s Injection provides electrolytes and calories, and is a source of water for hydration. It is capable of inducing diuresis depending on the clinical condition of the patient. This solution also contains lactate which produces a metabolic alkalinizing effect.

FNDNRS-07-046

A nurse is caring for a group of clients in a medical-surgical nursing unit. The nurse recognizes that which of the following clients would be the least likely candidate for parenteral nutrition?

• A. A 55-year-old with persistent nausea and vomiting from chemotherapy.
• B. A 44-year old client with ulcerative colitis.
• C. A 59-year old client who had an appendectomy.
• D. A 25-year old client with Hirschsprung‘s Disease.

Correct Answer: C. A 59-year old client who had an appendectomy.

The client with an appendectomy is not a candidate because this client would resume a regular diet within a few days following the surgery. The principal indication for TPN is a seriously ill patient where enteral feeding is not possible. It may also be used to supplement inadequate oral intake. The successful use of TPN requires proper selection of patients, adequate experience with the technique, and awareness of its complications.

• Option A: An indication of TPN are patients with malignancies in whom malnutrition may jeopardize successful delivery of a therapeutic option (surgery, chemo- or radiotherapy). While the indication for TPN may be self-evident in the majority of the patients, it is recommended to have some form of assessment of the nutritional status of the patient prior to institution of TPN in order to plan the treatment and to formulate clear-cut therapeutic goals
• Option B: Malabsorption secondary to sprue, enzyme & pancreatic deficiencies, regional enteritis, ulcerative colitis, granulomatous colitis, and tuberculous enteritis are indications for parenteral nutrition. The indications of TPN are now fairly well defined, as is the knowledge about its limitations, side effects, and complications. Advances in technology have now made it possible for TPN to be delivered at the patient’s own residence, thus reducing hospital costs.
• Option D: Option D is incorrect because parenteral nutrition is indicated in this client since their gastrointestinal tracts are not functional or cannot take in a diet enterally for extended periods. Newborns with gastrointestinal anomalies such as tracheoesophageal fistula, massive intestinal atresia, complicated meconium ileus, massive diaphragmatic hernia, gastroschisis, omphalocele or cloacal exstrophy, and neglected pyloric stenosis.

FNDNRS-07-047

A client is receiving parenteral nutrition (PN) and is suddenly having a fever. A nurse notifies the physician and the physician initially prescribes that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials?

• A. Send them to the laboratory for culture.
• B. Save them for a return to the manufacturer.
• C. Return them to the hospital pharmacy.
• D. Discard them in the unit trash.

Correct Answer: A. Send them to the laboratory for culture.

When the client who is receiving PN has a high temperature, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for an infectious organism. Septic complications of central venous catheters (CVCs) remain a significant cause of patient morbidity and mortality both in the intensive care unit (ICU) and in general hospital wards. Approximately 25% of CVCs inserted have been reported to become colonized, with rates of catheter-related bloodstream infection (CRBSI) varying between 0% and 11%.

• Option B: The solution and tubing should be brought immediately to the laboratory to avoid the growth of other organisms. It has been proposed that TPN, being a potential culture medium, is an independent risk factor for CRBSI. However, there is a paucity of studies related to CVC colonization and CRBSI and in patients receiving TPN via short-term CVCs.
• Option C: Returning the solution to the pharmacy is not the appropriate action. Patients receiving total parenteral nutrition (TPN) are at high risk for bloodstream infections (BSI). The notion that intravenous calories and glucose lead to hyperglycemia, which in turn contributes to BSI risk, is widely held. 
• Option D: Do not discard the solution and tubing immediately. Other studies have shown an increased infection risk without a survival benefit in patients receiving TPN. There is a reported sepsis incidence of between 20% and 30% in patients receiving parenteral nutrition. The high risk of sepsis is a major factor leading to an overall preference for enteral nutrition over parenteral nutrition.

FNDNRS-07-048

A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that there is redness and drainage at the insertion site. The nurse next assesses which of the following?

• A. Time of last dressing change.
• B. Allergy.
• C. Client’s temperature.
• D. Expiration date.

Correct Answer: C. Client’s temperature.

Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. TPN requires a chronic IV access for the solution to run through, and the most common complication is an infection of this catheter. Infection is a common cause of death in these patients, with a mortality rate of approximately 15% per infection, and death usually results from septic shock.

• Option A: Assess skin integrity and wound healing. Skin integrity changes and wound healing are used as parameters in monitoring the effectiveness of TPN feeding.
• Option B: TPN composition is based on the calculated nutritional needs of the client. Before the therapy is started, a thorough baseline assessment will be completed by health care members which include physicians, nurses, dieticians, and pharmacists. Changes in fluid balance, weight, and caloric intake are used to assess TPN effectiveness.
• Option D: Administer TPN at the ordered rate; if the infusion is interrupted, infuse 10% dextrose in water until the TPN infusion is restarted. This substitute infusion provides needed fluid in addition to protecting the client from sudden hypoglycemia; hypoglycemia can result when the high glucose concentration to which the client has metabolically adjusted is suddenly withdrawn.

FNDNRS-07-049

A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has a bounding pulse, jugular distension, and weight gain greater than desired. The nurse determines that the client is experiencing which complication of PN therapy?

• A. Air embolism.
• B. Hypervolemia.
• C. Hyperglycemia.
• D. Sepsis.

Correct Answer: B. Hypervolemia.

The client’s signs and symptoms are consistent with hypervolemia. This happens when the client receives excessive fluid administration or administration of fluid too rapidly. Increased central venous pressure is noticed first as distention of the jugular veins. Maintaining the head of bed elevated will promote ease in breathing. This position also allows pooling of fluid in the bases and for gas exchange to be more available to the lung tissue.

• Option A: An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
• Option C: Hyperglycemia related to sudden increase in glucose after a recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure.
• Option D: CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There’s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation.

FNDNRS-07-050

A nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tube change?

• A. Turn the head to the right.
• B. Inhale deeply, hold it, and bear down.
• C. Breathe normally.
• D. Exhale slowly and evenly.

Correct Answer: B. Inhale deeply, hold it, and bear down.

The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tube changes. The nurse asks the client to take a deep breath, hold it, and bear down. Make sure all connections are clamped and closed. Clamp catheter, position patient in left Trendelenburg position, call health care provider, and administer oxygen as needed.

• Option A: Option A is incorrect because if the intravenous line is on the right, the client turns his or head to the left. This position increases intrathoracic pressure. Central line management is a crucial skill that is necessary on a routine basis to help lessen or prevent catheter-based infections and complications. Initial placement of central lines is typically by trained physicians, physician assistants, and nurse practitioners in a sterile fashion.
• Option C: An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
• Option D: Exhaling can cause the potential for an air embolism during the tube change. Routine evaluation by every team member will ensure that appropriate handling and care of the central line is being performed to help reduce the risk of catheter-associated complications.

FNDNRS-07-051

A nurse observes the client receiving fat emulsions is having hives. A nurse reviews the client’s history and notes which of the following may be caused by the complaint of the client?

• A. Allergy to an egg.
• B. Allergy to peanuts.
• C. Allergy to shellfish.
• D. Allergy to corn.

Correct Answer: A. Allergy to an egg.

Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies. Intravenous fat emulsions (IFEs) are a vital component of total parenteral nutrition, because they provide essential fatty acids. IFE is a sterile fat emulsion that contains egg-yolk phospholipids. Although egg allergy is listed as a contraindication, adverse reactions are uncommon. 

• Option B: Hypersensitivity reactions to TPN can be managed by withholding the TPN and treating with antihistamines if needed until the reaction resolves. Identification, possibly by epicutaneous allergy testing, and removal of the offending agent(s) from the TPN is necessary if TPN therapy must be restarted.
• Option C: Although ingestion of egg lecithin in cooked food is generally tolerated by egg-allergic people, administration of intravenous egg-containing lipid emulsions may cause significant adverse reactions.
• Option D: If the patient has an allergy to amino acids, dextrose, fat emulsion, or any other part of total parenteral nutrition, he should be referred to a doctor first. If the patient has an allergy to corn, corn products, eggs, peanuts, or soybeans, he should talk with a doctor.

FNDNRS-07-052

A client receiving parenteral nutrition (PN) complains of shortness of breath and shoulder pain. A nurse notes that the client has an increased pulse rate. The nurse determines that the client is experiencing which complication of PN therapy?

• A. Air embolism.
• B. Hypervolemia.
• C. Hyperglycemia.
• D. Pneumothorax.

Correct Answer: D. Pneumothorax.

Pneumothorax might happen during parenteral therapy due to inexact catheter placement. In order to prevent this, the nurse obtains a chest x-ray after insertion of the catheter to ensure proper catheter placement. A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the lung to collapse. Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and tachycardia.

• Option A: An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
• Option B: Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia (decreased O2 sats). Notify primary health care providers regarding change in condition. The patient may require IV medication, such as Lasix to remove excess fluids. A decrease or discontinuation of IV fluids may also occur. Raise head of bed to enhance breathing and apply O2 for oxygen saturation less than 92% or as per agency protocol. Monitor intake and output. Pulmonary edema may be more common in the elderly, young, and patients with renal or cardiac conditions.
• Option C: Hyperglycemia related to sudden increase in glucose after a recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure.

FNDNRS-07-053

A nurse is caring for a combative client who is ordered to have a nutritional therapy using parenteral nutrition (PN). The nurse should plan which of the following measures to prevent the client from injury?

• A. Monitor blood glucose twice a day.
• B. Instruct the relative to stay with the nurse.
• C. Measure 24-hour intake and output.
• D. Secure all connections in the parenteral system.

Correct Answer: D. Secure all connections in the parenteral system.

The nurse should plan to secure all connections in the tubing. This will prevent the client from pulling the connections apart. An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.

• Option A: The nurse may monitor the blood glucose but it is unrelated to the situation. Many fatal instances of air emboli in patients with central venous catheters have been reported in the literature. They frequently occur when the tubing becomes tangled while a patient is getting out of bed, causing the catheter to disconnect. Although less common, cracks in the catheter hub can also allow air to enter the venous system.
• Option B: The relative may stay with the patient when necessary. Central venous catheters are also used in applications other than TPN. These include central venous pressure monitoring, rapid infusion of fluids, pulmonary arterial pressure monitoring using Swan-Ganz catheters, and hemodialysis. Also, a central venous catheter is often placed in the right atrium during surgery to remove air that might be introduced elsewhere in the venous system. It is possible for an air embolism to develop during all of these central venous applications.
• Option C: Measuring the I&O of the patient is not related to the situation. An air embolism can develop when the right side of the heart is open to outside air through a disconnected catheter and a negative intrathoracic pressure is present, such as during inspiration. The right side of the heart is open to outside air when the catheter is first inserted and during catheter changes. 

FNDNRS-07-054

Nurse Spencer is caring for an anorexic client who is having a total parenteral nutrition solution for the first time. Which of the following assessments requires the most immediate attention?

• A. Dry sticky mouth.
• B. Temperature of 100° Fahrenheit.
• C. Blood glucose of 210 mg/dl.
• D. Fasting blood sugar of 98 mg/dl.

Correct Answer: C. Blood glucose of 210 mg/dl.

Total parenteral nutrition formula containing dextrose ranges from 5% to 70%. A blood glucose level of 210mg/dl is considered high. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure.

• Option A: Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening. High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.
• Option B: CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There’s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation.
• Option D: Monitor blood sugar frequently QID (four times per day), then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Be alert to changes in dextrose levels in amino acids and the addition/removal of insulin to TPN solution. 

FNDNRS-07-055

Nurse Russell is preparing to give total parenteral nutrition using a central line. Place the following steps for administration in the correct order?

1. Check the solution for cloudiness, particles, or a change in color.
2. Select and flush the correct tubing and filter.
3. Prime the IV tubing through an infusion pump.
4. Maintain an aseptic technique when handling the injection cap.
5. Connect the tubing to the central line.
6. Regulate the electric infusion pump at the ordered rate.

The correct order is shown above.

Total Parenteral Nutrition (TPN), also known as intravenous or IV nutrition feeding, is a method of getting nutrition into the body through the veins. In other words, it provides nutrients for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest.

• Option A: Selecting the correcting tubing is the second step, not handling the injection cap. TPN is usually used for 10 to 12 hours a day, five to seven times a week. Most TPN patients administer the TPN infusion on a pump during the night for 12-14 hours so that they are free of administering pumps during the day. TPN can also be used in both the hospital or at home. 
• Option B: Selecting the correct tubing is not the first step. External tubing should be changed every day and dressings should be kept sterile with replacement every two days.
• Option C: Review physician’s orders and compare to MAR and content label on TPN solution bag and for rate of infusion. Each component of the TPN solution must be verified with the physician’s orders. Complete all safety checks for CVC as per agency policy.
• Option D: Asepsis during handling of the injection cap is not the first step. TPN is administered through a needle or catheter that is placed in a large vein that goes directly to the heart called a central venous catheter. Since the central venous catheter needs to remain in place to prevent further complications, TPN must be administered in a clean and sterile environment.

Questions related to patient positioning 

FNDNRS-07-056

Nurse Aaron is inserting a nasogastric tube to a stroke client. He understands that the best position for the insertion is?

• A. Low Fowler’s.
• B. Sims position.
• C. Trendelenburg.
• D. High Fowler’s.

Correct Answer: D. High Fowler’s.

The best position during a nasogastric tube insertion is sitting or High Fowler’s position in order to prevent the risk of aspiration. Position patient sitting up at 45 to 90 degrees (unless contraindicated by the patient’s condition), with a pillow under the head and shoulders. This allows the NG tube to pass more easily through the nasopharynx and into the stomach.

• Option A: Low fowler’s position is similar to the supine position, and is considered the best position for rest. In a low-Fowler’s position, the patient’s head is inclined at a 15- or 30-degree angle. Insertion of NGT could be particularly difficult in this position. Low Fowler’s position is typically used to reduce lower back pain, during administration of drugs, or during tube feeding.
• Option B: Insertion of NGT would be impossible in Sim’s position. The Sims position is a standard position in which the patient lies on their left side, with right hip and knees bent. The lower arm is behind the back, the thighs flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the right arm is rested behind the body. This is also known as “lateral” position. Sim’s position is often used for rectal examination and treatments.
• Option C: Placing the patient in Trendelenburg position for NGT insertion is highly inappropriate. In Trendelenburg position, the patient is supine on the table with their head declined below their feet at an angle of roughly 16°. Trendelenburg position is typically used for lower abdominal surgeries including colorectal, gynecological, and genitourinary procedures as well as central venous catheter placement.

Sources:

FNDNRS-07-057

Nurse Monica is handling a female client who had undergone a mastectomy. Which is the best position in which she should place the client?

• A. Head of bed elevated at least 30° with the affected arm elevated on a pillow.
• B. Forward side-lying position.
• C. Supine position with the affected arm remains flat.
• D. Head of bed elevated at least 30° with the unaffected arm elevated on a pillow.

Correct Answer: A. Head of bed elevated at least 30°.

Position a post-mastectomy client with the head of the bed elevated at least 30 degrees, with the affected arm elevated on a pillow to promote lymphatic fluid return after the removal of axillary lymph nodes. The patient is draped with the arm free to allow for movements during the procedure. It is important not to hyperextend the arm when positioning the patient; hyperextension may cause significant postoperative neurapraxia.

• Option B: Patient positioning is in a supine position in the operating room, and the breast, chest wall, axilla, and upper arm are exposed, after induction of anesthesia. Many surgeons may include the contralateral breast in the prepped operative field. There has been a growing trend toward breast conservation, and numerous studies have looked at the efficacy of breast-conserving surgery when compared to standard mastectomy techniques.
• Option C: The patient is kept in a supine position with a thin sandbag under the ipsilateral scapula to facilitate axillary dissection. The ipsilateral arm is draped separately and kept free for adduction during axillary dissection. 
• Option D: The patient is placed supine with the ipsilateral arm stretched out level with the shoulder. The head end of the operating table is raised to 30º. The side being operated on is raised by 30º. Lymphedema is less commonly present since the advent of modified mastectomy techniques. Axillary lymph node dissection is the most significant risk factor for the development of lymphedema, with a reported incidence of greater than 20%. 

FNDNRS-07-058

A nurse is caring for a client with severe burns of the face and head. The nurse will place the client in which position?

• A. Trendelenburg.
• B. Head of bed elevated.
• C. Supine position.
• D. Prone position.

Correct Answer: B. Head of bed elevated.

For clients with burns on the face and head, the best position is to elevate the head of the bed to reduce the occurence of facial edema. Elevation will encourage drainage of fluid and allow it to be reabsorbed by the body. The swollen part should be higher than the rest of the limb so that gravity can assist. 

• Option A: Placing the patient in Trendelenburg position would aggravate the facial edema. Physiochemical changes in the extracellular spaces cause protein denaturation, increasing the oncotic pressures, increasing local edema. It is also important to be aware of the requirement for fluid resuscitation, which increases the hydrostatic gradient, ultimately pushing more fluid into the extracellular space, compounding the tissue edema from the initial insult.  
• Option C: If the client has facial swelling it is extremely important to maintain an upright position. The client should avoid lying flat as this encourages fluid collection in the face and head which can lead to difficulty opening the eyes and may also affect breathing.
• Option D: If the patient is placed in a prone position, fluid would accumulate in the face. Burns cause a local cytokine-mediated inflammatory response, creating hyperpermeability of the microvasculature, leading to tissue swelling. For the patient who sustains any facial burns or inhalation injuries, local swelling can occur rapidly and immediately.

FNDNRS-07-059

Which of the following does not match with the appropriate position?

• A. Vaginal examination: Lithotomy position.
• B. Thyroidectomy: Fowler’s position.
• C. Hemorrhoidectomy: Lateral position.
• D. Hypophysectomy: Prone position.

Correct Answer: D. Hypophysectomy: Prone position.

Hypophysectomy is the surgical removal of the hypophysis (pituitary gland). After the surgery, the client’s head is elevated to prevent increased intracranial pressure. CSF fluid around the brain and spine leaks into the nervous system. This requires treatment with a procedure called a lumbar puncture, which involves inserting a needle into the spine to drain excess fluid.

• Option A: Lithotomy position is commonly used during gynecologic, rectal, and urologic surgeries with a patient lying supine with legs abducted 30 to 45 degrees from midline with knees flexed and legs held supported with the foot of the bed lowered or removed to facilitate the procedure.
• Option B: When a patient comes back from having their thyroidectomy surgery, place them in a semi-Fowler’s position. Sitting totally upright would put the patient at a 90-degree angle, but in a semi-Fowler’s position, they are angled between 15 and 45 degrees.
• Option C: In lateral position, the lower extremities are carefully padded between the knees and below the dependent knee to avoid excessive external pressure over bony prominences. The dependent lower extremity is somewhat flexed to avoid stretch or compression of the lower extremity nerves.

FNDNRS-07-060

Nurse Ian is handling a client with gastroesophageal reflux disease. Which of the following positions will best help the client in this case?

• A. Right Lateral Recumbent.
• B. Supine position.
• C. Reverse Trendelenburg position.
• D. Sims position.

Correct Answer: C. Reverse Trendelenburg position.

Reverse Trendelenburg position is advised to a client to promote gastric emptying and prevent gastroesophageal reflux. Studies that monitored esophageal acid exposure after elevation of the head of the bed showed a decrease in reflux activity in adults. Placing blocks under the head of the bed or placing a foam wedge under the patient’s mattress can accomplish this.

• Option A: In the right lateral recumbent position, the individual is lying on their right side. This position makes it easier to access a patient’s left side. The word “lateral” means “to the side,” while “recumbent” means “lying down.”
• Option B: Avoid placing the patient in supine position, have the patient sit upright after meals. Supine position after meals can increase regurgitation of acid. Elevate HOB while in bed to prevent aspiration by preventing the gastric acid to flow back into the esophagus.
• Option D: The Sims position is a standard position in which the patient lies on their left side, with right hip and knees bent. The lower arm is behind the back, the thighs flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the right arm is rested behind the body. This is also known as “lateral” position. This position is often used for rectal or vaginal examination, and treatments.

FNDNRS-07-061

A client with pleural effusion is scheduled to have a thoracentesis. The nurse on duty will assist the client to which position during the procedure?

A. Lying in bed on the unaffected side with the head of the bed elevated about 45°.

B. Forward side-lying position with head of bed flat.

C. Lying in bed on the affected side with the head of the bed elevated about 45°.

D. Supine position with both arms extended.

Correct Answer: A. Lying in bed on the unaffected side with head of bed elevated about 45°.

During thoracentesis, to facilitate removal of pleural fluid from the pleural space, position the client sitting on the edge of the bed, leaning over a bedside table with the feet supported on a stool, or lying in bed on the unaffected side with head of bed elevated about 45°.

• Option B: Patient lies between supine and prone with legs flexed in front of the patient. Arms should be comfortably placed beside the patient, not underneath. However, the head of the bed should be elevated to facilitate drainage of pleural fluid from the pleural space.
• Option C: The patient should lie on the unaffected side. The patient is moved to the extreme side of the bed, the ipsilateral hand is placed behind the head, and a towel roll is placed under the contralateral shoulder. This measure facilitates dependent drainage and provides good access to the posterior axillary space.
• Option D: Patients who are alert and cooperative are most comfortable in a seated position, leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax. Unstable patients and those who are unable to sit up may be supine for the procedure.

FNDNRS-07-062

Nurse Maria is administering a cleansing enema to a client with severe constipation. She will place the client in which position?

• A. Low Fowler’s position.
• B. High Fowler’s position.
• C. Left Sim’s position.
• D. Right Sim’s position.

Correct Answer: C. Left Sim’s position.

During a cleansing enema, place the client in the left Sim’s position to allow the solution to flow by gravity in the natural direction of the colon. Position the patient on the left side, lying with the knees drawn to the abdomen. This eases the passage and flow of fluid into the rectum. Gravity and the anatomical structure of the sigmoid colon also suggest that this will aid enema distribution and retention.

• Option A: Position the patient on his left side in Sims’ position or left lateral position with the right knee flexed, which will adequately expose the anus. This position allows the solution to flow downward by gravity along the curve of the sigmoid colon and rectum, thus improving the effectiveness of the enema.
• Option B: The ideal positions for enema administration are the left-side position and the knee-chest position. It is advised that the patient remains in one of these positions to receive the enema for one-third of the time.
• Option D: The left lateral position is the most appropriate position for giving an enema because of the anatomical characteristics of the colon. Although the length of the tube to be inserted is designated as approximately 5-6 cm, do not try to force it but pull it back slightly if any resistance is felt.

FNDNRS-07-063

What type of client would benefit the most from an elevated head of the bed position?

• A. Patient who had a hemorrhoidectomy.
• B. Patient who had a laryngectomy.
• C. Patient who had a liver biopsy.
• D. Patient who had a lumbar puncture.

Correct Answer: B. Patient who had a laryngectomy.

Place a post-laryngectomy client with the head of bed elevated at 30-45 degrees to maintain a patent airway and reduce edema. Maintain an upright or sitting position during feedings (or place on the lap or in an infant seat); allow to remain in position for 30 minutes afterward. Promotes the flow of fluids and foods through gravity.

• Option A: Post-operative hemorrhoidectomy position is supine position. Supine position, also known as Dorsal Decubitus, is the most frequently used position for procedures. In this position, the patient is face-up. The patient’s arms should be tucked at the patient’s sides with a bedsheet, secured with arm guards to sleds. 
• Option C: Liver biopsy patients should remain in a right side-lying position after the procedure. After the biopsy, the doctor will place a bandage over the cut on the abdomen. The client may be asked to lie on his right side after the biopsy, and he will need to remain lying down for a few hours. Health care professionals will typically check the vital signs regularly for 2 to 4 hours after the procedure.
• Option D: After lumbar puncture, place the client in a supine position for at least 4 hours. As blood will distribute into the epidural space through few spinal segments superiorly and inferiorly, it is not essential to introduce it into the exact place at which the dural puncture was performed. After the procedure, the patient is asked to lie still in a supine position and is then mobilized.

FNDNRS-07-064

Nurse Justin is taking care of a client with deep vein thrombosis. Which position should be provided to the client?

• A. Bed rest with the affected extremity remains flat at all times.
• B. Bed rest with the unaffected extremity on top of the affected extremity.
• C. Bed rest with the affected extremity in a dependent position.
• D. Bed rest with the affected extremity elevated.

Correct Answer: D. Bed rest with the affected extremity elevated.

Bed rest is indicated to prevent emboli while the elevation of the affected leg facilitates blood flow by the force of gravity and reduces pain and edema. Elevating the legs can help to instantly relieve pain. A doctor may also instruct a patient to elevate the legs above the heart three or four times a day for about 15 minutes at a time. This can help to reduce swelling. If prolonged standing or sitting is necessary, bending the legs several times will help promote blood circulation.

• Option A: DVT develops as a result of being in a continuous seated prone positioning for 6 hours. Deep vein thrombosis and its sequelae such as PE can be severe or fatal. However, these consequences are preventable. Deep vein thrombosis may arise spontaneously or may be caused by trauma, surgery, or prolonged bed rest.
• Option B: Deep vein thrombosis is a clinical challenge for doctors because it can develop in any section of the venous system; however, it arises most frequently in the deep veins of the leg. There are reports of DVT developing in a fiberglass mold maker after 6 weeks of working in a kneeling position, and in a patient maintaining a prone position after spine surgery with a central venous catheter in place.
• Option C: A surgical operation where the patient is asleep (under general anesthetic) is the most common cause of a DVT. The legs are still when the client is under anesthetic because the muscles in the body are temporarily paralyzed. Blood flow in the leg veins can become very slow, making a clot more likely to occur. Certain types of surgery (particularly operations on the pelvis or legs) increase the risk of DVT even more.

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FNDNRS-07-065

Nurse Sandra had just received a postoperative total hip replacement client from the recovery unit. Which is the best position in which she should place the client?

• A. Side-lying with the affected leg externally rotated.
• B. Side-lying with the affected leg internally rotated.
• C. On the nonoperative side with the legs abducted.
• D. On the nonoperative side with the legs adducted.

Correct Answer: C. On the nonoperative side with the legs abducted.

Abduction is maintained when the client is in a supine position or positioned on the non-operative side. The patient’s leg should be positioned in abduction. This is to prevent dislocation of the prosthesis. It is very crucial that the femoral head component of the acetabular cap is maintained in the correct position. Abduction splints, wedge pillows, and two or three pillows between the legs of the patient will keep the hip in abduction.

• Option A: In cases where the patient needs to be turned, the operative hip must be kept in abduction and the entire length of the leg supported by pillows. The hip of the patient should NOT be flexed more than 45 to 60 degrees.
• Option B: To prevent acute hip flexion, the head of the bed should not be elevated more than 45 degrees. Remind the patient not to sleep on the operated side until this position is cleared with the surgeon.
• Option D: An abduction splint or pillows should be kept between the legs. The patient is encouraged to keep the operative hip in extension when transferring or sitting. The patient is instructed to pivot in the unoperated leg while assisted by the nurse, who protects the operative leg from adduction, flexion, and excessive weight-bearing.

FNDNRS-07-066

A client has just returned to a nursing unit after a cardiac catheterization performed using the femoral artery. The nurse places the client in which position?

• A. Bed rest with head elevation at 30°.
• B. Bed rest with head elevation at 45°.
• C. Bed rest with head elevation at 60°.
• D. Bed rest with head elevation at 90°.

Correct Answer: A. Bed rest with head elevation at 30°.

During cardiac catheterization, if the femoral artery was accessed for the procedure, the client is maintained on bed rest for 4 to 6 hours and the affected extremity is maintained straight and the head is elevated to no more than 30°. Frequent assessment of the extremity for adequate perfusion enables prompt intervention as needed.

• Option B: Guidelines require patient puncture sites to be assessed every thirty minutes for four hours minimum before the patient is allowed off of bed rest. The patient is free to move side to side for their comfort. The head of the bed should be at a maximum thirty-degree tilt. The patient should be allowed to eat and drink right after the procedure if they wish to.
• Option C: Encourage bed rest and keep affected extremity straight or slight bend in the knee (10 degrees) for 6 hours. Bed rest and slight, or no flexion, provide improved circulation and minimizes the risk of further trauma which could promote the formation of a clot.
• Option D: Patients should be kept lying flat for several hours after the procedure so that any serious bleeding can be avoided and that the artery can heal. It is advised that diagnostic catheterization patients are kept on bed rest for four hours, and interventional catheterization patients stay on bed rest for six hours.

FNDNRS-07-067

A nurse is preparing to care for a client who had undergone an above-knee amputation of the right leg. The nurse plans to allow which position for the client in the first 24 hours?

• A. Supine position, with the affected limb flat on the bed.
• B. Supine position, with the affected limb supported with pillows.
• C. Prone position, with the affected limb in a dependent position.
• D. Trendelenburg’s position.

Correct Answer: B. Supine position, with the affected limb supported with pillows.

The amputated limb is usually supported with pillows on the first post-op day to promote venous return and reduce edema. Preventing contractures is very important. A contracture occurs when a joint becomes stuck in one position. If this happens, it may be hard or impossible to straighten the remaining limb and use an artificial leg.

• Option A: Make sure the client puts equal weight on both hips when he sits. Use firm chairs, and sit up straight. The client should keep the remaining limb flat with both legs together while lying on the back. The client should not sit for more than an hour or two. He must stand, or lie on his stomach now and then.
• Option C: If the affected limb is put in a dependent position, edema might occur. Edema in the residual limb is also a common complication after LLA surgery. Controlling the amount of edema post-surgically is vital for promoting wound-healing, pain control, protecting the incision during rehabilitation, and assisting in shaping the stump for prosthetic fitting
• Option D: The main goal of good positioning at any time is to prevent adjacent joint contractures. The patient should be advised on how to position themselves while sitting and lying in the hospital bed or standing to prevent contractures.  Make sure you explain to the patient the dangers of the dependent position (residual limb hanging down) in the early post-op phase as this may increase edema, pain, and healing time.

FNDNRS-07-068

A client is to be on bed rest for 24 hours and the affected extremity is to be kept straight during this time. Which of the following procedures would require a client to do the above?

• A. Varicose vein surgery.
• B. Myelogram.
• C. Abdominal aneurysm resection.
• D. Arterial Vascular Grafting.

Correct Answer: D. Arterial Vascular Grafting.

To promote graft patency after the procedure, bedrest is maintained for the first 24 hours and the affected extremity is kept straight. The pathophysiology of vein graft failure has been attributed to acute thrombosis within the first month, intimal hyperplasia up to 1 year, and atherosclerosis beyond 1 year.

• Option A: After treatment of large varicose veins by any method, a 30- to 40-mm Hg gradient compression stocking is applied, and patients are instructed to maintain or increase their normal activity levels. Most practitioners also recommend the use of gradient compression stockings even after treatment of spider veins and smaller tributary veins.
• Option B: The client may need to sit or lay down for several hours after the procedure to reduce the risk of developing a CSF (cerebral spinal fluid) leak. Most patients are asked to lie down for two hours after the procedure. If the client needs to urinate, he may need to do so in a bedpan or urinal during the time that he needs to stay flat.
• Option C: Avoid strenuous activities that may put stress on the incision, such as bicycle riding, jogging, weight lifting, or aerobic exercise, for 6 weeks or until the doctor says it is okay. For 6 weeks, avoid lifting anything that would make a strain. This may include a child, heavy grocery bags and milk containers, a heavy briefcase or backpack, cat litter or dog food bags, or a vacuum cleaner.

FNDNRS-07-069

Which is the best position for a client with autonomic dysreflexia?

• A. Sim’s Position.
• B. Fowler’s Position.
• C. Semi-Fowler’s Position.
• D. High Fowler’s Position.

Correct Answer: D. High Fowler’s Position.

Autonomic dysreflexia is a condition in which there is a sudden onset of excessively high blood pressure. If it occurs, immediately place the client in a high Fowler’s position to promote adequate ventilation and assist in the prevention of a hypertensive stroke.

• Option A: The Sims position is a standard position in which the patient lies on their left side, with right hip and knees bent. The lower arm is behind the back, the thighs flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the right arm is rested behind the body. This is also known as “lateral” position. This position is often used for rectal or vaginal examination, and treatments.
• Option B: In Fowler’s position, the patient is at an increased risk for air embolism, skin injury from shearing and sliding, and DVT forming in the patient’s lower extremities. In this position, a patient has an increased pressure risk in their scapulae, sacrum, coccyx, ischium, back of knees, and heels.
• Option C: When positioning a patient in Fowler’s position, the surgical staff should minimize the degree of the patient’s head elevation as much as possible and always maintain the head in a neutral position. The patient’s arms should be flexed and secured across the body, the buttocks should be padded, and the knees flexed 30 degrees.

FNDNRS-07-070

A nurse is caring for a client who has returned to the recovery unit following a craniotomy. The nurse can safely place the client in which position?

• A. Trendelenburg position.
• B. Fowler’s position with the head leaning on the left side.
• C. Semi-fowler’s position with the head in a midline position.
• D. Supine position with the neck flexed.

Correct Answer: C. Semi-Fowler’s position with the head in a midline position.

Post-craniotomy clients should be placed in a semi-Fowler’s position and the head is in a midline position to facilitate venous drainage from the head. For nearly all types of craniotomy, the patient is observed for at least the first 24 hours in a neurological intensive care unit (NICU) or general surgical ICU. Basic laboratory tests are sent (complete blood cell count and basic metabolic panel). Neurological examinations are performed by the nursing staff every 1-2 hours and any changes in neurologic status.

• Option A: Placing the client in a Trendelenburg position may increase the swelling of the brain. Frequent neurological checks will be done by the nursing and medical staff to test the brain function and to make sure the body systems are functioning properly after the surgery. The client will be asked to follow a variety of basic commands, such as moving the arms and legs, to assess brain function. 
• Option B: The client’s head must be placed in a midline position to facilitate venous drainage from the head and reduce the swelling. The recovery process will vary depending upon the type of procedure done and the type of anesthesia given. Once the client’s blood pressure, pulse, and breathing are stable and he is alert, he may be taken to the ICU or the hospital room.
• Option D: The head of the bed may be elevated to prevent swelling of the face and head. Some swelling is normal. The client will be encouraged to move around as tolerated while in bed and to get out of bed and walk around, with assistance at first, as his strength improves. A physical therapist (PT) may be asked to evaluate the client’s strength, balance, and mobility, and give him suggestions for exercises to do both in the hospital and at home.

Fundamentals of Nursing NCLEX Practice Questions Quiz #6 | 75 Questions

Apr 30, | Writing

Fundamentals of Nursing NCLEX Practice Questions Quiz #6 | 75 Questions

Questions related to Basic Care and Comfort

FNDNRS-06-001

The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?

• A. Arranging for the wheelchair
• B. Asking her family to visit
• C. Assisting her to sit out of bed in a chair qid
• D. Encouraging the use of an overhead trapeze

Correct Answer: D. Encouraging the use of an overhead trapeze.

Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Facilitates movement during hygiene or skincare and linen changes; reduces the discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed.

• Option A: Sitting in a wheelchair would require too great hip flexion initially. Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures. Reduces the risk of flexion contracture of the hip.
• Option B: Asking her family to visit would not facilitate the resumption of activities. Provide footboard, wrist splints, trochanter, or hand rolls as appropriate. Useful in maintaining a functional position of extremities, hands, and feet, and preventing complications (contractures, foot drop).
• Option C: Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker. Encourage the use of isometric exercises starting with the unaffected limb. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema are present.

FNDNRS-06-002

Which of the following is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?

• A. Measure intake and output
• B. Check albumin level
• C. Monitor glucose levels
• D. Increase enteral feeding

Correct Answer: A. Measure intake and output

It is important to measure intake and output, which should be equal. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance. A urinary catheter is inserted to assess the adequacy of renal perfusion. The kidney requires 20% to 25% of cardiac output; commonly, it’s the first organ to show the effects of impaired perfusion or intravascular volume.

• Option B: Osmotherapy aims to increase the osmolality of the intravascular space, which in turn helps mobilize excess fluid from brain tissue. If ICP increases, mannitol (an osmotic diuretic) may be given to decrease cerebral edema, transiently increase intravascular volume, and improve cerebral blood flow.
• Option C: Low peripheral oxygen saturation values or low arterial blood oxygen values (as shown by arterial blood gas testing) should be avoided. Maintaining adequate brain tissue oxygenation seems to improve patient outcomes.
• Option D: Enteral feedings are hyperosmotic agents pulling fluid from cells into the vascular bed. Initially, a nasogastric or orogastric tube is inserted to decompress the stomach and reduce the aspiration risk. (Typically, the nasal route is avoided as it can obstruct sinus drainage, leading to sinusitis or VAP).

FNDNRS-06-003

The pathological process causing esophageal varices is/are:

• A. Ascites and edema
• B. Systemic hypertension
• C. Portal hypertension
• D. Dilated veins and varicosities

Correct Answer: C. Portal hypertension

Esophageal varices result from increased portal hypertension. In portal hypertension, the liver cannot accept all of the fluid from the portal vein. The excess fluid will backflow to the vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids.

• Option A: Portal hypertension causes portocaval anastomosis to develop to decompress portal circulation. Normal portal pressure is between 5-10 mmHg but in the presence of portal obstruction, the pressure may be as high as 15-20 mmHg. Since the portal venous system has no valves, resistance at any level between the splanchnic vessels and the right side of the heart results in retrograde flow and elevated pressure.
• Option B: Esophageal varices are dilated submucosal distal esophageal veins connecting the portal and systemic circulations. They form due to portal hypertension, which commonly is a result of cirrhosis, resistance to portal blood flow, and increased portal venous blood inflow.
• Option D: Intrahepatic vasoconstriction due to decreased nitric oxide production, and increased release of endothelin-1 (ET-1), angiotensinogen, and eicosanoids. Increased portal flow is caused by hyperdynamic circulation due to splanchnic arterial vasodilation through mediators such as nitric oxide, prostacyclin, and TNF.

FNDNRS-06-004

Which of the following interventions will help lessen the effect of GERD (acid reflux)?

• A. Elevate the head of the bed on 4-6 inch blocks.
• B. Lie down after eating.
• C. Increase fluid intake just before bedtime.
• D. Wear a girdle.

Correct Answer: A. Elevate the head of the bed on 4-6 inch blocks.

Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the esophagus. The fluid does not flow uphill. Instruct to remain in an upright position at least 2 hours after meals; avoiding eating 3 hours before bedtime. Helps control reflux and causes less irritation from reflux action into the esophagus. The other three options all increase fluid backflow into the esophagus through position or increasing abdominal pressure.

• Option B: Avoid placing the patient in a supine position, have the patient sit upright after meals. Supine position after meals can increase regurgitation of acid. Elevate HOB while in bed. To prevent aspiration by preventing the gastric acid to flow back into the esophagus.
• Option C: Instruct patient regarding eating small amounts of bland food followed by a small amount of water. Instruct to remain in an upright position at least 1–2 hours after meals, and to avoid eating within 2–4 hours of bedtime. Gravity helps control reflux and causes less irritation from reflux action into the esophagus.
• Option D: Instruct the patient to avoid bending over, coughing, straining at defecations, and other activities that increase reflux. Promotes comfort by the decrease in intra-abdominal pressure, which reduces the reflux of gastric contents.

FNDNRS-06-005

The main benefit of therapeutic massages is:

• A. To help a person with swollen legs to decrease fluid retention.
• B. To help a person with duodenal ulcers feel better.
• C. To help damaged tissue in a diabetic to heal.
• D. To improve circulation and muscle tone.

Correct Answer: D. To improve circulation and muscle tone.

Particularly in elderly adults, therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. Damaged or strained muscle fibers release inflammatory chemicals to aid the healing process, but these chemicals cause significant pain and discomfort in the process. At least one study, which looked at the effects of massage on postexercise tissue inflammation, suggests that even 10 minutes of massage can reduce signs of inflammation and improve cell processes, thereby promoting healing, with effects lasting several hours after the massage.

• Option A: Massage only the hands, feet, or scalp of patients with sepsis, fever over 100[degrees]F, nausea or vomiting, sickle cell crisis, HIV crisis, a complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia, or meningitis.
• Option B: When patients have fragile skin, or the potential for skin breakdown, apply only light pressure, using enough lotion or oil to minimize friction. For patients with a previous injury, chronic pain, or scar tissue, frequently ask them how the massage feels, and adjust both pressure and massage technique to the patients’ preferences. 
• Option C: A massage is contraindicated in any condition where massage to damaged tissue can dislodge a blood clot. Although massage is associated with few adverse effects, nurses should be careful to avoid areas near open wounds, any stage of pressure ulcer, reddened or swollen areas, rashes, incisions, thromboses, iv lines, drains, shunts, and tubes. 

FNDNRS-06-006

Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)?

• A. Lettuce
• B. Eggs
• C. Chocolate
• D. Butterscotch

Correct Answer: C. Chocolate

Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. Ingesting cocoa can cause a surge of serotonin. This surge can cause the esophageal sphincter to relax and gastric contents to rise. Caffeine and theobromine in chocolate may also trigger acid reflux. All of the other foods do not affect LES pressure.

• Option A: Vegetables are naturally low in fat and sugar, and they help reduce stomach acid. Good options include green beans, broccoli, asparagus, cauliflower, leafy greens, potatoes, and cucumbers.
• Option B: Egg whites are a good option. Stay away from egg yolks, though, which are high in fat and may trigger reflux symptoms. Reflux symptoms may result from stomach acid touching the esophagus and causing irritation and pain.
• Option D: The foods the patient eats affect the amount of acid the stomach produces. Eating the right kinds of food is key to controlling acid reflux or GERD, a severe, chronic form of acid reflux. Sources of healthy fats include avocados, walnuts, flaxseed, olive oil, sesame oil, and sunflower oil. Reduce the intake of saturated fats and trans fats and replace them with these healthier unsaturated fats.

FNDNRS-06-007

Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)?

• A. Withhold medications while the TPN is infusing.
• B. Change TPN solution every 24 hours.
• C. Flush the TPN line with water prior to initiating nutritional support.
• D. Keep the client on complete bed rest during TPN therapy.

Correct Answer: B. Change TPN solution every 24 hours.

TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to the hypertonicity of the solution. Because the central venous catheter needs to remain in place for a long time, a strict sterile technique must be used during the insertion and maintenance of the TPN line. The TPN line should not be used for any other purpose. External tubing should be changed every 24 hours with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 hours using strict sterile techniques.

• Option A: Medication therapy can continue during TPN therapy. Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes, and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.
• Option C: Flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skincare around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates.
• Option D: However, other clinical conditions of the client may affect mobility issues and warrant the client’s being on bed rest. Place the client in a semi-Fowler’s or high-Fowler’s position. Maintaining the head of the bed elevated will promote ease in breathing. This position also allows the pooling of fluid in the bases and for gas exchange to be more available to the lung tissue.

FNDNRS-06-008

Which of the following should be included in a plan of care for a client who is lactose intolerant?

• A. Remove all dairy products from the diet.
• B. Frozen yogurt can be included in the diet.
• C. Drink small amounts of milk on an empty stomach.
• D. Spread out selection of dairy products throughout the day.

Correct Answer: B. Frozen yogurt can be included in the diet.

Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial action, and this action assists in the digestion of lactose. The freezing process further stops bacterial action so that limited lactase activity remains. Some people who are lactose-intolerant can eat some kinds of yogurt without problems, especially yogurt with live cultures.

• Option A: Elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Be sure to get enough calcium in the diet, especially if the client avoids milk products completely. To get enough calcium, the client would need to eat calcium-rich foods as often as someone would drink milk. Calcium is very important because it keeps bones strong and reduces the risk of osteoporosis.
• Option C: Drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods, (especially fat) may decrease transit time and allow for increased lactase activity. Limit the amount of milk and milk products in the diet. Try to drink 1 glass of milk each day. Drink small amounts several times a day. All types of milk contain the same amount of lactose.
  Option D: Although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms. Eat or drink milk and milk products along with other foods. For some people, combining solid food (like cereal) with a dairy product (like milk) can reduce symptoms.

FNDNRS-06-009

Pain tolerance in an elderly patient with cancer would:

• A. Stay the same.
• B. Be lowered.
• C. Be increased.
• D. No effect on pain tolerance.

Correct Answer: B. Be lowered.

There is potential for a lowered pain tolerance to exist with diminished adaptive capacity. For older patients with cancer, unrelieved pain can affect functioning, increase cognitive impairment, and depression, which in turn can influence the severity of pain and make management more challenging. In sum, the literature indicates that cancer pain in advanced disease is multifaceted and can adversely affect the lives of patients and their caregivers. Changes associated with aging have the potential to further impact this experience.

• Option A: Pain continues to be a common and distressing symptom, despite pain management being a central focus of palliative care and guidelines for the management of cancer pain. Estimates suggest that as many as 60% to 80% of individuals with recurrent or metastatic cancer experience pain. Among older patients, cancer pain, similar to other types of pain, tends to go unrecognized and undertreated
• Option C: In older individuals, the higher incidence of comorbidities, age-related declines in functioning, and associated symptoms can further complicate cancer pain and its management. Adding to the complexity is the recognition that the experience of pain is not merely a sensory event, but is multifaceted, comprising sensory, affective, and evaluative components.
• Option D: Indeed, the belief that pain can emanate from both physical sources and nonphysical sources (psychological, spiritual, and interpersonal) is central to the concept of total pain, put forth by Dame Cicely Saunders, founder of the modern hospice. This nonphysical source of pain derives from feelings of helplessness, being dependent on others, and having difficulty in reshaping relationships, and has been described by terminally ill older patients as creating the worst suffering.

FNDNRS-06-010

What is the main advantage of cutaneous stimulation in managing pain?

• A. Costs less.
• B. Restricts movement and decreases.
• C. Gives client control over pain syndrome.
• D. Allows the family to care for the patient at home.

Correct Answer: C. Gives client control over pain syndrome.

Cutaneous stimulation allows the patient to have control over his pain and allows him to be in his own environment. Cutaneous stimulation increases movement and decreases pain. Cutaneous stimulation involves stimulation of nerves via skin contact in an effort to reduce pain impulses to the brain, based on the “gate control” theory of pain. A device used to provide electrocutaneous nerve stimulation was studied for its effect on symptoms of peripheral neuropathy.

• Option A: The potential for TENS associated improvement, combined with reduced medication-related complications and costs, are important points that clinicians should consider when constructing a treatment plan for chronic pain patients. Finally, cost simulation techniques provide a useful tool for assessing outcomes in pain treatment and research.
• Option B: CS effectively reduces pain, heart rate, and blood pressure in ED patients. The intervention of CS has solid utilization potential and could be easily incorporated into standard ED procedure.
• Option D: TENS devices can be purchased over the counter and without medical prescription in the UK. However, a practitioner experienced in TENS principles should supervise patients using TENS for the first time. A point of contact to troubleshoot any problems should also be provided.

FNDNRS-06-011

The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise doing weight-bearing activities.
• B. Exercise to reduce weight.
• C. Avoid exercise activities that increase the risk of fracture.
• D. Exercise to strengthen muscles and thereby protect bones.

Correct Answer: A. Exercise doing weight-bearing activities.

Weight-bearing exercises are beneficial in the treatment of osteoporosis. Although the loss of bone cannot be substantially reversed, it can be greatly reduced if the client includes weight-bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol. 45 minutes to one hour of aerobic activity two to three times per week

• Option B: Resistance training two or three times per week. Each session should include exercises to strengthen the lower limb, trunk, and arm muscles, and each exercise should be performed eight to 10 times
• Option C: Balance exercises need to be at a level that is challenging to balance and should be performed for a few minutes at least twice a week. For safety reasons, always make sure to hold on to something if you overbalance it. People with severe osteoporosis or kyphosis (hunching of the upper back) who are at high risk of bone fractures may find that swimming or water exercise is their preferred activity.
• Option D: Even though walking is a weight-bearing exercise, it does not greatly improve bone health, muscle strength, fitness or balance, unless it is carried out at high intensity such as at a faster pace, for long durations (such as bushwalking), or incorporates challenging terrain such as hills.

FNDNRS-06-012

A client in a long-term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to

• A. Have the client identify coping methods.
• B. Get the description of the location and intensity of the pain.
• C. Accept the client’s report of pain.
• D. Determine the client’s status of pain.

Correct Answer: C. Accept the client’s report of pain.

Although all of the options above are correct, the first and most important piece of information in this client’s pain assessment is what the client is telling you about the pain –“the client’s report.” Pain is the most common complaint seen in a primary care office. There are over 50 million Americans, 20 percent of all patients, that suffer from chronic pain in the United States.

• Option A: Effective treatment modalities for acute, chronic, centralized, or neuropathic are often different. Ten percent of the United States population complain of neuropathic pain. This population may benefit from a serotonin-norepinephrine reuptake inhibitor (SNRI) such as duloxetine, as compared to ibuprofen for an acute injury.
• Option B: To fully assess the location of a patient’s pain, a body diagram map can be completed. Ankle sprains are solitary, acute injuries. Body diagrams may not be necessary in such a case. Localized pain is different from whole body pain. Yet, in a patient with multiple comorbid pain disorders such as fibromyalgia, centralized pain disorder, and rheumatoid arthritis, distinguishing between the numerous locations of a patient’s pain, as well as factoring the radiation of their pain, is difficult.
• Option D: An essential first step in the pain assessment is distinguishing nociceptive pain from neuropathic. Pain characterized as burning, shooting, pins, and needles, or electric shock-like point the differential towards a neuropathic origin of the patient’s pain Sharp or throbbing pain is more likely to be acute nociceptive pain.

FNDNRS-06-013

Which statement best describes the effects of immobility in children?

• A. Immobility prevents the progression of language and fine motor development.
• B. Immobility in children has similar physical effects to those found in adults.
• C. Children are more susceptible to the effects of immobility than are adults.
• D. Children are likely to have prolonged immobility with subsequent complications.

Correct Answer: B. Immobility in children has similar physical effects to those found in adults.

Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.

• Option A: The hazards or complications of immobility, such as skin breakdown, pressure ulcers, contractures, muscular weakness, muscular atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory vital capacity, venous stasis, venous insufficiency, orthostatic hypotension, decreased cardiac reserve, edema, emboli, thrombophlebitis, constipation and the loss of calcium from the bones, are highly costly in terms of health care dollars and in terms of client suffering.
• Option C: Immobility and complete bed rest can lead to life-threatening physical and psychological complications and consequences. Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. Immobility can adversely affect all physiological bodily systems.
• Option D: Children stayed in a cast for a long period, so that the effect of postoperative immobility had negative effects on the physical and psychological wellbeing of children with musculoskeletal injuries. Emphasize the importance of implementing a nursing care program for children in the postoperative period for minimizing the physical and psychological effects of immobility on children with musculoskeletal injuries.

FNDNRS-06-014

After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?

• A. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk.
• B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.
• C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.
• D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.

Correct Answer: D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats. Eat a Mediterranean‐style diet—more bread, fruit, vegetables, and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils (reduces total mortality and the risk of myocardial infarction).

• Option A: Consume at least 7 g of omega‐3 fatty acids per week from 2–4 portions of oily fish per week. If within 3 months of myocardial infarction and they are not achieving this, consider providing at least 1 g daily of omega‐3‐acid ethyl esters treatment licensed for secondary prevention after myocardial infarction for up to 4 years.
• Option B: Choose foods with less sodium and prepare foods with little or no salt. To lower blood pressure, aim to eat no more than 2,300 milligrams of sodium per day. Reducing daily intake to 1,500 mg is desirable because it can lower blood pressure even further.
• Option C: Processed meats, like hot dogs, sausage, and lunch meat, are loaded with sodium and nitrates. This can raise the blood pressure and the risk of another heart attack. High blood pressure is particularly dangerous because there usually aren’t any symptoms.

FNDNRS-06-015

A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest.
• B. An obese client who uses a wheelchair.
• C. An incontinent client who has had 3 diarrhea stools.
• D. An 80-year-old ambulatory diabetic client.

Correct Answer: A. A 79-year-old malnourished client on bed rest.

Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubitus, due in part to poor hydration and inadequate protein intake. Both external and internal factors work simultaneously, forming these ulcers. External factors; pressure, friction, shear force, and moisture and internal factors; fever, malnutrition, anemia, and endothelial dysfunction speed up the process of these lesions.

• Option B: Immobility of as little as two hours in a bedridden patient or patient undergoing surgery is sufficient to create the basis of a decubitus ulcer. The dysfunction of nervous regulatory mechanisms responsible for the regulation of local blood flow is somewhat culpable in the formation of these ulcers. Prolonged pressure on tissues can cause capillary bed occlusion and, thus, low oxygen levels in the area. Over time, the ischemic tissue begins to accumulate toxic metabolites. Subsequently, tissue ulceration and necrosis occur.
• Option C: The development of decubitus ulcers is complex and multifactorial. Loss of sensory perception, locally and general impaired loss of consciousness, along with decreased mobility, are the most important causes that aid in the formation of these ulcers because patients are not aware of discomfort hence do not relieve the pressure.
• Option D: Elderly patients are more prone to sacral decubitus ulcers; two-thirds of ulcers occur in patients who are over 70 years old. There is data that shows 83% of hospitalized patients with ulcers developed them within five days of their hospitalization.

FNDNRS-06-016

Mrs. Kennedy had a CVA (cerebrovascular accident) and has a severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects the correct use of the cane?

• A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg.
• B. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and finally her right leg.
• C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg forward, then moves her left leg forward.
• D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward, then moves her right leg forward.

Correct Answer: A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg

When a person with weakness on one side uses a cane, there should always be two points of contact with the floor. When Mrs. Kennedy. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg.

• Option B: She should not hold the cane with her weak arm. The use of the cane requires arm strength to ensure that the cane provides adequate stability when standing on the weak leg. To go upstairs, use the handrail and step up with the unaffected leg first and follow with the cane and the affected foot together.
• Option C: The cane should be held in the left hand, the hand opposite the affected leg. Hold the cane in the hand of the unaffected side. Move the cane and the affected leg forward at the same time, so that the cane helps take the weight of the weak leg. Then step with the unaffected leg.
• Option D: If Mrs. Kennedy. moved the cane and her strong foot at the same time, she would be left standing on her weak leg at one point. This would be unstable at best; at worst, impossible. To go downstairs, use the handrail and step down with the affected foot and cane together first and follow with the unaffected foot.

FNDNRS-06-017

The nurse is instructing a woman on a low-fat, high-fiber diet. Which of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet?

• A. Tuna salad sandwich on whole wheat bread.
• B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread.
• C. Chef’s salad with hard boiled eggs and fat-free dressing.
• D. Broiled chicken stuffed with chopped apples and walnuts.

Correct Answer: B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread.

This choice shows a low-fat soup (which would have been higher in fat if made with chicken or beef stock) and high-fiber bread and soup contents (both the vegetables and the legumes). Eating a high-fiber diet that is low in fat can help maintain overall health. Fiber-rich foods are naturally low in fat and contain cancer-fighting and heart-healthy properties. While a low-fat diet is good, it is important that the client does not dismiss all fats, however. Eat some foods containing unsaturated fats because they are necessary for an overall healthy diet.

• Option A: Mayonnaise in tuna salad is high in fat. The whole-wheat bread has some fiber. Fiber’s presence in the digestive tract can help reduce the body’s cholesterol absorption. This is especially true if you take statins, which are medications to lower cholesterol, and use fiber supplements like psyllium fiber
• Option C: Salad is high in fiber, but hard-boiled eggs are high in fat. In fact, a single egg contains 212 mg of cholesterol, which is 71% of the recommended daily intake. Plus, 62% of the calories in whole eggs are from fat.
• Option D: There is some fiber in the apples and walnuts. The walnuts are high in fat, as is the chicken. Nuts have a high-fat content, so are high in energy. In most nuts, this is mainly unsaturated fat: either polyunsaturated fats in walnuts and pine nuts or monounsaturated fats in almonds, pistachios, pecans, and hazelnuts, for example. Brazil nuts, cashews, and macadamia nuts are higher in saturated fat.

FNDNRS-06-018

An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?

• A. Stiffness of the right ankle joint.
• B. Soreness of the gums.
• C. Short-term memory loss.
• D. Decreased appetite.

Correct Answer: A. Stiffness of the right ankle joint.

Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy. In the development of joint contractures that result from long-term immobilization, shortening of the joint capsule, synovial adhesions and arthrofibrosis play decisive roles, and may present as a generalized joint stiffness

• Option B: Soreness of the gums is not related to immobility. Brushing too hard, improper flossing techniques, infection, or gum disease can cause sore and sensitive gums. Other causes unrelated to oral hygiene could include a Vitamin K deficiency, hormonal changes during pregnancy, leukemia or blood disorders.
• Option C: Short-term memory loss is not related to immobility. Short-term memory loss is when one forgets things they heard, saw, or did recently. It’s a normal part of getting older for many people. But it can also be a sign of a deeper problem, such as dementia, a brain injury, or a mental health issue.
• Option D: Decreased appetite is unlikely to be related to immobility. People can experience a loss of appetite for a wide range of reasons. Some of these are short-term, including colds, food poisoning, other infections, or the side effects of medication. Others are to do with long-term medical conditions, such as diabetes, cancer, or life-limiting illnesses.

FNDNRS-06-019

An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron-deficiency anemia is suspected, which of the following is the most important information to obtain from the infant’s parents?

• A. Normal dietary intake.
• B. Relevant socio cultural, economic, and educational background of the family.
• C. Any evidence of blood in the stools.
• D. A history of maternal anemia during pregnancy.

Correct Answer: A. Normal dietary intake.

Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 4 to 5 months of infancy iron stores laid down for the baby during pregnancy are adequate. When fetal iron stores are depleted, supplemental dietary iron needs to be supplied to meet the infant’s rapid growth needs. Iron deficiency may occur in the infant who drinks mostly milk, which contains no iron, and does not receive adequate dietary iron or supplemental iron. 

• Option B: Daily dietary intake is much more related to the diagnosis of iron deficiency anemia than is the sociocultural, economic, and educational background of the family. The cause of iron-deficiency anemia varies based on age, gender, and socioeconomic status. Iron deficiency may result from insufficient iron intake, decreased absorption, or blood loss. 
• Option C: Iron deficiency anemia in an infant is very unlikely to be related to gastrointestinal bleeding. In developing countries, a parasitic infestation is also a significant cause of iron-deficiency anemia. Dietary sources of iron are green vegetables, red meat, and iron-fortified milk formulas.
• Option D: Anemia during pregnancy is unlikely to be the cause of the infant’s iron deficiency anemia. Fetal iron stores are drawn from the mother even if she is anemic. In neonates, breastfeeding is protective against iron deficiency due to the higher bioavailability of iron in breast milk compared to cow’s milk; iron deficiency anemia is the most common form of anemia in young children on cow’s milk.

FNDNRS-06-020

A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse?

• A. The client’s dietary habits include foods high in bulk.
• B. The client’s fluid intake is between 2500-3000 ml per day.
• C. The client engages in moderate exercise each day.
• D. The client’s bowel habits were not discussed.

Correct Answer: D. The client’s bowel habits were not discussed.

To assess the client for a bowel training program the factors causing the bowel alteration should be assessed. A routine for bowel elimination should be based on the client’s previous bowel habits and alterations in bowel habits that have occurred because of illness or trauma. 

• Option A: Foods high in bulk are appropriate. Assist the patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetables, whole grains) per day. Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged.
• Option B: The client and the family should assist in the planning of the program which should include foods high in bulk, adequate exercise, and fluid intake of 2500-3000 ml. Encourage the patient to take in fluid 2000 to 3000 mL/day, if not contraindicated medically. Sufficient fluid is needed to keep the fecal mass soft. But take note of some patients or older patients having cardiovascular limitations requiring less fluid intake.
• Option C: Exercise should be a part of a bowel training regimen. Urge the patient for some physical activity and exercise. Consider isometric abdominal and gluteal exercises. Movement promotes peristalsis. Abdominal exercises strengthen abdominal muscles that facilitate defecation.

Question related to Nursing Health Assessment and Pain Management

FNDNRS-06-021

Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?

• A. Alert and oriented to date, time, and place.
• B. Buccal cyanosis and capillary refill greater than 3 seconds.
• C. Clear breath sounds and nonproductive cough.
• D. Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3.

Correct Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds.

Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. As oxygenation and perfusion become impaired, peripheral tissues become cyanotic. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm³ are normal data.

• Option A: Restlessness, irritation, confusion, and somnolence may reflect hypoxemia and decreased cerebral oxygenation and may require further intervention. Check pulse oximetry results with any mental status changes in older adults.
• Option C: Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.
• Option D: Monitor serial chest x-rays, ABGs, pulse oximetry readings. Follows progress and effects and extent of pneumonia. Therapeutic regimen, and may facilitate necessary alterations in therapy. Oxygen saturation should be maintained at 90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue.

FNDNRS-06-022

During the nursing assessment, which data represent information concerning health beliefs?

• A. Family role and relationship patterns.
• B. Educational level and financial status.
• C. Promotive, preventive, and restorative health practices.
• D. Use of prescribed and over-the-counter medications.

Correct Answer: C. Promotive, preventive, and restorative health practices.

The health-beliefs assessment includes expectations of health care; promotive, preventive, and restorative practices, such as breast self-examination, testicular examination, and seat-belt use; and how the client perceives illness. The basic premise of the health belief assessment is that patients have a right to their cultural beliefs, values, and practices, and that these factors should be understood, respected, and considered when giving culturally competent care.

• Option A: Educational level and financial status represent information associated with role and relationship patterns. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual’s unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome.
• Option B: Family role and relationship patterns represent information associated with role and relationship patterns. The nursing assessment includes gathering information concerning the patient’s individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process.
• Option D: The use of medications provides information about the client’s personal habits. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition-appropriate pain scale. The assessment identifies the current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.

FNDNRS-06-023

Nurse Patrick is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history?

• A. The chief complaint
• B. Past health status
• C. History immunizations
• D. Location of an advance directive

Correct Answer: D. Location of an advance directive

Biographic information may include name, address, gender, race, occupation, and location of a living will or durable power of attorney for health care. Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client’s birth date, Social Security number, medical record number, or similar identifying data may be included in the biographic data section. The chief complaint, past health status, and history of immunizations are part of assessing the client’s health and illness patterns.

• Option A: Encourage the client to explain the health problem or symptom in as much detail as possible by focusing on the onset, progression, and duration of the problem; signs and symptoms and related problems; and what the client perceives as causing the problem. The client’s answers to the questions provide the nurse with a great deal of information about the client’s problem and especially how it affects the lifestyle and activities of daily living. This helps the nurse to evaluate the client’s insight into the problem and the client’s plans for managing it.
• Option B: This portion of the health history focuses on questions related to the client’s past, from the earliest beginnings to the present. These questions elicit data related to the client’s strengths and weaknesses in her health history. The client’s strengths may be physical (e.g., optimal body weight), social (e.g., active in community services), emotional (e.g., expresses feeling openly), or spiritual (often turns to faith for support).
• Option C: Information covered in the past health history includes questions about birth, growth, development, childhood diseases, immunizations, allergies, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, painful experiences, and emotional or psychiatric problems.

FNDNRS-06-024

John Joseph was scheduled for a physical assessment. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs?

• A. Dullness
• B. Resonance
• C. Hyperresonance
• D. Tympany

Correct Answer: B. Resonance

Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Since lungs are mostly filled with air that we breathe in, percussion performed over most of the lung area produces a resonant sound, which is a low-pitched, hollow sound. Therefore, any dullness or hyper-resonance is indicative of lung pathology, such as pleural effusion or pneumothorax, respectively.

• Option A: Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation. Once an abnormality is detected, percussion can be used around the area of interest to define the extent of the abnormality. Normal areas of dullness are those overlying the liver and spleen at the anterior bases of the lungs.
• Option C: Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lung. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyper resonance on one side of the chest may indicate a pneumothorax.
• Option D: Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax.

FNDNRS-06-025

Matteo is diagnosed with dehydration and underwent a series of tests. Which laboratory result would warrant immediate intervention by the nurse?

• A. Serum sodium level of 138 mEq/L
• B. Serum potassium level of 3.1 mEq/L
• C. Serum glucose level of 120 mg/dl
• D. Serum creatinine level of 0.6 mg/100 ml

Correct Answer: B. Serum potassium level of 3.1 mEq/L

A normal potassium level is 3.5 to 5.5 mEq/L. Hypokalemia is more prevalent than hyperkalemia, and most cases are mild. Severity is categorized as mild when the serum potassium level is 3 to 3.4 mmol/L, moderate when the serum potassium level is 2.5 to 3 mmol/L, and severe when the serum potassium level is less than 2.5 mmol/L.

• Option A: A normal sodium level is 135 to 145 mEq/L. Among the electrolyte disorders, hyponatremia is the most frequent. Diagnosis is when the serum sodium level is less than 135 mmol/L. Hyponatremia has neurological manifestations. Patients may present with headache, confusion, nausea, deliriums. Hypernatremia presents when the serum sodium levels are greater than145 mmol/L. 
• Option C: A normal non fasting glucose level is 85 to 140 mg/dl. Normal plasma glucose levels are defined as under 100 mg/dL during fasting and less than 140 mg/dL 2-hours postprandial. Additionally, glucose levels in healthy individuals can vary with age. Fasting plasma glucose in adults tends to increase with age starting in the third decade of life but does not increase significantly beyond 60 years of age. Normal HbA1c is lower than 5.7%.
• Option D: A normal creatinine level is 0.2 to 0.8 mg/100 ml. Serum creatinine level for men with normal kidney function is approximately 0.6 to 1.2mg/dL and between 0.5 to 1.1 mg/dL for women. Alteration of serum creatinine values can occur as its generation is subject to influence by muscle function, activity, diet, and health status of the patient. Increased tubular secretion of creatinine in certain patients with dysfunctional kidneys could provide a false negative value. Elevated serum creatinine levels are also present in patients with muscular dystrophy paralysis, anemia, leukemia, and hyperthyroidism. 

FNDNRS-06-026

During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury?

• A. Tipping the client’s head away from the examiner and pulling the ear up and back.
• B. Inserting the otoscope inferiorly into the distal portion of the external canal.
• C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal.
• D. Bracing the examiner’s hand against the client’s head.

Correct Answer: C. Inserting the otoscope superiorly into the proximal two-thirds of the external canal.

In the superior position, the speculum of the otoscope is nearest the tympanic membrane, and the most sensitive portion of the external canal is the proximal two-thirds. It is important to avoid these structures during the examination. The provider should then slowly progress the speculum into the canal until the tympanic membrane becomes visible. The provider should evaluate the health of the tympanic membrane and observe factors such as color, presence of perforation, and a bulging appearance.

• Option A: With the hand that is not holding the otoscope, the provider should grasp and gently pull the patient’s pinna to help straighten the patient’s external auditory canal. This step will facilitate visualization of the tympanic membrane. In a child, the examiner should pull the pinna posteriorly and inferiorly. In an adult, the examiner should pull the pinna posteriorly and superiorly.
• Option B: During the otoscopic examination, the provider utilizes an otoscope, also known as an auriscope, to visualize the ear anatomy. While performing the otoscopic examination, the provider holds the handle of the otoscope and inserts the cone of the otoscope into the patient’s external auditory canal.
• Option D: Providers may have their own preferences regarding how to grasp the otoscope. However, it is generally advisable to hold the otoscope like a pen in between the first and second fingers. The otoscope is usually held in the right hand when evaluating the patient’s right ear and the left hand when assessing the patient’s left ear. The provider should place their free fifth finger of the hand, holding the otoscope against the patient’s cheek to support and brace the hand during the examination.

FNDNRS-06-027

When assessing the lower extremities for arterial function, which intervention should the nurse perform?

• A. Assessing the medial malleoli for pitting edema.
• B. Performing Allen’s test.
• C. Assessing the Homans’ sign.
• D. Palpating the pedal pulses.

Correct Answer: D. Palpating the pedal pulses.

Palpating the client’s pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Finding a pedal pulse is part of the trauma patient assessment and performed before and after lower extremity splint application as well as long backboard immobilization. Assessing a pedal pulse is part of the ongoing assessment for a patient on a backboard or a lower extremity splint.

• Option A: Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. Lower extremity examination should focus on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot. Pitting edema also occurs in the early stages of lymphedema because of an influx of protein-rich fluid into the interstitium, before fibrosis of the subcutaneous tissue; therefore, its presence should not exclude the diagnosis of lymphedema.
• Option B: Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. The Allen test is a first-line standard test used to assess the arterial blood supply of the hand. This test is performed whenever intravascular access to the radial artery is planned or for selecting patients for radial artery harvesting, such as for coronary artery bypass grafting or for forearm flap elevation.
• Option C: Homans’ sign is used to evaluate the possibility of deep vein thrombosis. Homan’s sign test also called dorsiflexion sign test is a physical examination procedure that is used to test for Deep Vein Thrombosis (DVT). A positive Homan’s sign in the presence of other clinical signs may be a quick indicator of DVT.

FNDNRS-06-028

Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves?

• A. Breast
• B. Integumentary
• C. Ophthalmic
• D. Oral

Correct Answer: D. Oral

Gloves should be worn anytime there is a risk of exposure to the client’s blood or body fluids. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. Ophthalmic, breast, or integumentary examinations normally do not involve contact with the client’s body fluids and do not require the nurse to wear gloves for protection. 

• Option A: After completing the visual inspection, the patient should be instructed to lay supine. If a side-specific breast complaint is being evaluated, the examiner should begin his/her exam on the opposite, or “normal” side. As one breast is examined, the other is covered for the patient’s comfort. The patient should place the ipsilateral hand above and/or behind their head to flatten the breast tissue as much as possible. The breast tissue itself is evaluated using a sequence of palpation that allows serial progression from superficial to deeper tissues.
• Option B: A general assessment of the skin begins at the initial contact with the patient and continues throughout the examination. Specific areas of the skin are assessed during the examination of other body systems unless the chief complaint is a dermatologic problem. However, if there are areas of skin breakdown or drainage, gloves should be used.
• Option C: The Royal College of Ophthalmologists have today (26 March 2020) updated their advice on PPE to ophthalmologists and are now recommending that clinicians should wear standard surgical masks when examining or treating patients at the slit lamp. Gowns and gloves are not recommended. They also recommend that plastic breath shields attached to slit lamps provide some protection, but must be disinfected between patients as studies show that the COVID-19 virus is viable for up to 72 hours on plastic surfaces. 

FNDNRS-06-029

Nurse Renner is about to perform Romberg’s test on Pierro. To ensure the latter’s safety, which intervention should nurse Renner implement?

• A. Allowing the client to keep his eyes open.
• B. Having the client hold on to furniture.
• C. Letting the client spread his feet apart.
• D. Standing close to provide support.

Correct Answer: D. Standing close to provide support.

During Romberg’s test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. If the client loses his balance, the nurse standing close to provide support, such as having an arm close around his shoulder, can prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on to a piece of furniture interferes with the proper execution of the test and yields invalid results.

• Option A: The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patient closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.
• Option B: In the Romberg test, the patient stands upright and asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign. The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.
• Option C: The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body. If the clinician observes that the patient is able to stand for long periods of time with the eyes closed, it is evident that the patient’s balance and proprioceptive deficits have decreased.

FNDNRS-06-030

A physical assessment is being performed on patient Geoff by Nurse Tine. During the abdominal examination, Nurse Tine should perform the four physical examination techniques in which sequence?

• A. Auscultation immediately after inspection and then percussion and palpation.
• B. Percussion, followed by inspection, auscultation, and palpation.
• C. Palpation of tender areas first and then inspection, percussion, and auscultation.
• D. Inspection and then palpation, percussion, and auscultation.

Correct Answer: A. Auscultation immediately after the inspection and then percussion and palpation

With an abdominal assessment, auscultation always is performed before percussion and palpation because any abdominal manipulation, such as from palpation or percussion, can alter bowel sounds. Assessing the patient’s abdomen can provide critical information about his internal organs. Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make the findings less accurate.

• Option B: Percussion should never precede inspection or auscultation, and any tender or painful areas should be palpated last. Assess for any visible mass, bulging, or asymmetry. Look for unusual coloring, scars, striae, lesions, petechiae, ecchymoses, spider angiomas, and suspicious-looking moles. Inspect the umbilicus and note any hernias. Look for pulsations. A thin patient may have a pulsation of the aorta in his epigastric area and possibly peristaltic waves.
• Option C: Lightly percuss all four quadrants of the patient’s abdomen. You’ll hear dull sounds over solid structures (such as the liver) and fluid-filled structures (such as a full bladder). Air-filled areas (such as the stomach) produce tympany. Dullness is a normal finding over the liver, but a large, dull area elsewhere may indicate a tumor or mass.
• Option D: Using a light, gentle, dipping motion, palpate for abnormalities, such as muscle guarding, rigidity, or superficial masses. Palpate clockwise, lifting fingers as you move from one location to another. After light palpation of the entire abdomen, place a non-dominant hand on the dominant hand to perform deeper palpation (1½ to 2 inches [3.8 to 5 cm]). However, avoid deep palpation if the patient may have a problem such as splenomegaly, appendicitis, or aneurysm or if palpation is painful for any reason.

FNDNRS-06-031

Which assessment data should the nurse include when obtaining a review of body systems?

• A. Brief statement about what brought the client to the health care provider.
• B. Client complaints of chest pain, dyspnea, or abdominal pain.
• C. Information about the client’s sexual performance and preference.
• D. The client’s name, address, age, and phone number.

Correct Answer: B. Client complaints of chest pain, dyspnea, or abdominal pain.

Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. This portion of the assessment elicits subjective information on the client’s perceptions of major body system functions, including cardiac, respiratory, and abdominal. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts.

• Option A: A brief statement about what brought the client to the health care provider is the chief complaint. The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).
• Option C: Information about the client’s sexual performance and preference addresses past health status. Understanding the client’s current and past health is important and may provide an explanation or rationale for the client’s current health status. Furthermore, these data can provide insight into health promotion needs and co-morbidities. It is helpful to understand the current and past health profiles before assessing other aspects of health, as the information will inform subsequent questions.
• Option D: The client’s name, address, age, and phone number are biographical data. “Introductory information” refers to the demographic and biographic data that you collect from the client. This data provides you with basic characteristics about the client, such as their name, contact information, birthdate and age, gender and preferred pronouns, allergies, languages spoken and preferred language, relationship status, occupation, and resuscitation status.

FNDNRS-06-032

Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?

• A. “What brought you to the clinic today?”
• B. “Would you describe your overall health as good?”
• C. “Do you understand what is happening?”
• D. “Is there anything else you would like to tell me?”

Correct Answer: D. “Is there anything else you would like to tell me?”

By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions.

• Option A: Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. The health history is typically done on admission to the hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).
• Option B: Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012).
• Option C: Asking if the client understands what is happening is a yes-or-no question that can elicit little information. Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history.

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FNDNRS-06-033

For which time period would the nurse notify the health care provider that the client had no bowel sounds?

• A. 2 minutes
• B. 3 minutes
• C. 4 minutes
• D. 5 minutes

Correct Answer: D. 5 minutes

To completely determine that bowel sounds are absent, the nurse must auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive at this conclusion. The first item to listen for is the presence of bowel sounds. To chart an assessment finding of no bowel sounds, the nurse needs to listen over the quadrant for at least five minutes. The nurse should also do the auscultation before palpation and percussion to avoid influencing bowel sounds.

• Option A: In most cases, bowel sounds are present, but the nurse needs to categorize them. She should listen for the intensity of the sound – whether it is soft or strong. The nurse should also listen for frequency. Hypoactive bowel sounds could indicate a problem, so if the nurse is having trouble hearing them, this is significant.
• Option B: Auscultating bowel sounds can allow the nurse to pinpoint areas where an obstruction may have occurred. Finding no bowel sounds can mean an ileus or obstruction above that area of the intestine.
• Option C: Hypoactive bowel sounds are considered as one every three to five minutes, and this can indicate diarrhea, anxiety, or gastroenteritis. Hyperactive bowel sounds are often found before a blockage. It is quite common to find one quadrant with hyperactive bowel sounds and one with none or hypoactive ones

FNDNRS-06-034

Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?

• A. Aortic arch
• B. Pulmonic area
• C. Tricuspid area
• D. Mitral area

Correct Answer: D. Mitral area

The mitral area (also known as the left ventricular area or the apical area), the fifth intercostal space (ICS) at the left midclavicular line, is the best area for auscultating the apical pulse. The apical pulse is auscultated with a stethoscope over the chest where the heart’s mitral valve is best heard. In infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular line. In adults, the apical pulse is located at the fifth intercostal space at the left midclavicular line.

• Option A: The aortic arch is the second ICS to the right of the sternum. Apical pulse rate is indicated during some assessments, such as when conducting a cardiovascular assessment and when a client is taking certain cardiac medications (e.g., digoxin). Sometimes the apical pulse is auscultated pre and post medication administration.
• Option B: The pulmonic area is the second intercostal space to the left of the sternum. It is also a best practice to assess apical pulse in infants and children up to five years of age because radial pulses are difficult to palpate and count in this population. It is typical to assess apical pulses in children younger than eighteen, particularly in hospital environments. Apical pulses may also be taken in obese people because their peripheral pulses are sometimes difficult to palpate.
• Option C: The tricuspid area is the fifth ICS to the left of the sternum. Position the client in a supine (lying flat) or in a seated position. Physically palpate the intercostal spaces to locate the landmark of the apical pulse. Ask the female client to re-position her own breast tissue to auscultate the apical pulse.

FNDNRS-06-035

Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination on a female client?

• A. One half of all breast cancer deaths occur in women ages 35 to 45.
• B. The tail of Spence area must be included in self-examination.
• C. The position of choice for the breast examination is supine.
• D. A pad should be placed under the opposite scapula of the breast being palpated.

Correct Answer: B. The tail of Spence area must be included in self-examination.

The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop breast tumors. This area must also be included in breast self-examination. As the fingers traverse the breasts, they must remain in contact with the skin to avoid missing any tissue plane. Assessment of the inner half of the breasts requires changing to a supine position, removing the hand from the forehead, and placing the inactive arm at a right angle on the examination surface. 

• Option A: One half of all women who die of breast cancer are older than age 65. Breast cancer is the most prevalent malignancy among female populations and is responsible for the second-highest number of cancer-related deaths in American women. The need for early detection has manifested several screening initiatives intent on curtailing morbidity and mortality associated with the disease.
• Option C: The correct position for breast self-examination is not limited to the supine position; the sitting position with hands at sides, above head, and on the hips is also recommended. A visual survey of the breast tissue requires an inspection from three angles, with arms at the side, arms raised above the head while bending forward, and hunched over with the hands placed on the hips. Each of these positions should be observed in a mirror from a direct view, right profile, and left profile.
• Option D: A pad is placed under the ipsilateral (e.g., same side) scapula of the breast being palpated. The middle fingertip pad should be used to perform small circles with light, medium, and deep pressure investigating varying depths of breast tissue. To complete the examination of the breast’s outer half, up and down motions of palpation are performed medially from the axilla to the nipple and vertically from the clavicle to just below the bra line.

FNDNRS-06-036

Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily disfigurement from severe burns over the trunk and arms, is admitted to a pain center. Which evaluation criteria would indicate the client’s successful rehabilitation?

• A. The client remains free of the aftermath phase of the pain experience.
• B. The client experiences decreased frequency of acute pain episodes.
• C. The client continues normal growth and development with intact support systems.
• D. The client develops increased tolerance for severe pain in the future.

Correct Answer: C. The client continues normal growth and development with intact support systems.

Even though the client may experience an aftermath phase, progress is still possible, as is effective rehabilitation. Give positive reinforcement of progress and encourage endeavors toward the attainment of rehabilitation goals. Words of encouragement can support the development of positive coping behaviors.

• Option A: Aftermath reactions may occur but need not interfere with rehabilitation. Encourage family interaction with each other and with the rehabilitation team. To open lines of communication and provide ongoing support for the patient and family.
• Option B: Acute pain is not expected at this stage of recovery. Pain is nearly always present to some degree because of varying severity of tissue involvement and destruction but is usually most severe during dressing changes and debridement.
• Option D: Conditioning probably would produce less pain tolerance. Exercise is generally considered to be a safe and efficacious approach to restoring physiological function in patients with various chronic diseases. However, the inclusion of exercise regimens in the outpatient rehabilitation of patients who have undergone major trauma, such as a large burn, is not common.

FNDNRS-06-037

Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. Which scientific rationale would indicate that she understands the topic?

• A. Pain is an objective sign of a more serious problem.
• B. Pain sensation is affected by a client’s anticipation of pain.
• C. Intractable pain may be relieved by treatment.
• D. Psychological factors rarely contribute to a client’s pain perception.

Correct Answer: B. Pain sensation is affected by a client’s anticipation of pain.

Phases of pain experience include the anticipation of pain. Fear and anxiety affect a person’s response to sensation and typically intensify the pain. Similarly, other factors such as cognitive appraisal of the meaning of the sensation, the emotional and psychophysiological reactions, expectations, and coping skills can all serve as feedback to influence pain perception.

• Option A: Pain is a subjective sensation that cannot be quantified by anyone except the person experiencing it. Pain refers to the product of higher brain center processing; it entails the actual unpleasant emotional and sensory experience generated from nervous signals. Reports of pain are thus not merely a direct output of nociception, they involve interaction with numerous inputs (attention, affective dimensions, autonomic variables, immune variables, and more), and may be considered more accurately from the perspective of a neuromatrix.
• Option C: Intractable pain is moderate to severe pain that cannot be relieved by any known treatment. Intractable pain refers to a type of pain that can’t be controlled with standard medical care. Intractable essentially means difficult to treat or manage. This type of pain isn’t curable, so the focus of treatment is to reduce the discomfort.
• Option D: Psychological factors contribute to a client’s pain perception. In many cases, pain results from emotions, such as hostility, guilt, or depression. There are a number of psychological processes behind pain perception. Attentional orienting to the painful sensation and its source can serve to heighten the painful experience. For instance, patients with somatic preoccupation and hypochondriasis are found to over-attend to bodily sensations, amplifying them as pain.

FNDNRS-06-038

Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let him wash it and apply a small amount of antibacterial ointment and bandage. Then she let him watch TV and eat an apple. This is an example of which type of pain intervention?

• A. Pharmacologic therapy
• B. Environmental alteration
• C. Control and distraction
• D. Cutaneous stimulation

Correct Answer: C. Control and distraction

The mother’s actions are an example of control and distraction. Involving the child in care and providing distraction took his mind off the pain. The brain can only focus its attention in so many areas at one time. Pain sensations compete for attention with all of the other things going on around. Just how much attention the brain gives each thing depends on a number of factors, including how long you have been hurting and the current mood.

• Option A: Pharmacologic agents for pain analgesics — were not used. A wide range of drugs are used to manage pain resulting from inflammation in response to tissue damage, chemical agents/pathogens (nociceptive pain) or nerve damage (neuropathic pain).
• Option B: The home environment was not changed. There has recently been heightened recognition that environmental factors can influence pain. Clinicians involved in delivering multidisciplinary pain programs often structure the social environment of their treatment settings to help promote adaptive responses to pain.
• Option D: Cutaneous stimulation, such as massage, vibration, or pressure, was not used. Cutaneous stimulation involves stimulation of nerves via skin contact in an effort to reduce pain impulses to the brain, based on the “gate control” theory of pain. A device used to provide electrocutaneous nerve stimulation was studied for its effect on symptoms of peripheral neuropathy.

FNDNRS-06-039

Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?

• A. These measures are more effective than analgesics.
• B. These measures decrease input to large fibers.
• C. These measures potentiate the effects of analgesics.
• D. These measures block transmission of type C fiber impulses.

Correct Answer: C. These measures potentiate the effects of analgesics.

Noninvasive measures may result in the release of endogenous molecular neuropeptides with analgesic properties. They potentiate the effect of analgesics. The role of non-pharmacological approaches to pain management is evolving, and some non-pharmacological and complementary therapies have an increasingly important contribution to make to holistic patient care alongside analgesics.

• Option A: No evidence indicates that noninvasive and nonpharmacologic measures are more effective than analgesics in relieving pain. Exercise, multidisciplinary rehabilitation, acupuncture, CBT, mindfulness practices, massage, and mind-body practices most consistently improve function and/or pain beyond the course of therapy for specific chronic pain conditions.
• Option B: Decreased input over large fibers allows more pain impulses to reach the central nervous system. When deciding the most effective non-pharmacological technique, take into consideration the patient’s age, developmental level, medical history and prior experiences, the current degree of pain, and/or anticipated pain. The advantage of non-pharmacological treatments is that they are relatively inexpensive and safe.
• Option D: There is no connection between type C fiber impulses and noninvasive and nonpharmacologic pain-control measures. Non-pharmacological pain therapy refers to interventions that do not involve the use of medications to treat pain. The goals of non-pharmacological interventions are to decrease fear, distress, and anxiety, and reduce pain and provide patients with a sense of control.

FNDNRS-06-040

When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation?

• A. The client distracts himself during pain episodes.
• B. The client denies the existence of any pain.
• C. The client reports no need for family support.
• D. The client reports pain reduction with decreased activity.

Correct Answer: A. The client distracts himself during pain episodes.

Distraction is an appropriate method of reducing pain. This technique involves heightening one’s concentration upon non-painful stimuli to decrease one’s awareness and experience of pain. Drawing the person away from the pain lessens the perception of pain. Examples include reading, watching TV, playing video games, and guided imagery.

• Option B: Denying the existence of any pain is inappropriate and not indicative of coping. It is essential to assist patients to express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Inconsistencies between behavior or appearance and what the patient says about pain relief (or lack of it) may be more a reflection of other methods the patient is using to cope with the pain rather than pain relief itself.
• Option C: Exclusion of family members and other sources of support represents a maladaptive response. Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.
• Option D: Range-of-motion exercises and at least mild activity, not decreased activity, can help reduce pain and are important to prevent complications of immobility. Nonpharmacologic methods in pain management may include physical, cognitive-behavioral strategies, and lifestyle pain management. These methods are used to provide comfort by altering psychological responses to pain.

FNDNRS-06-041

In planning pain reduction interventions, which pain theory provides information most useful to nurses?

• A. Specificity theory
• B. Pattern theory
• C. Gate-control theory
• D. Central-control theory

Correct Answer: D. Central-control theory

No one theory explains all the factors underlying the pain experience, but the central-control theory discusses brain opiates with analgesic properties and how their release can be affected by actions initiated by the client and caregivers. In central-control theory, the master control mechanism directs the muscle movement based on linguistic goals. The gate-control, specificity, and patter theories do not address pain control to the depth included in the central-control theory.

• Option A: Specificity theory is one of the first modern theories for pain. It holds that specific pain receptors transmit signals to a “pain center” in the brain that produces the perception of pain. Von Frey (1895) argued that the body has a separate sensory system for perceiving pain—just as it does for hearing and vision.
• Option B: This theory ignored findings of specialized nerve endings and many of the observations supporting the specificity and/or intensive theories of pain. The theory stated that any somesthetic sensation occurred by a specific and particular pattern of neural firing and that the spatial and temporal profile of firing of the peripheral nerves encoded the stimulus type and intensity.
• Option C: According to his theory, pain stimulation is carried by small, slow fibers that enter the dorsal horn of the spinal cord; then other cells transmit the impulses from the spinal cord up to the brain. These fibers are called T-cells. The T-cells can be located in a specific area of the spinal cord, known as the substantia gelatinosa. These fibers can have an impact on the smaller fibers that carry the pain stimulation.

FNDNRS-06-042

Ryan underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?

• A. Left hip dressing dry and intact.
• B. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute.
• C. Left leg in functional anatomic position.
• D. Left foot cold to touch; no palpable pedal pulse.

Correct Answer: D. Left foot cold to touch; no palpable pedal pulse.

A left foot cold to touch without palpable pedal pulse represents an abnormal finding on neurovascular assessment of the left leg. The client is most likely experiencing some complication from surgery, which requires immediate medical intervention. The nurse should notify the health care provider of these findings.

• Option A: A dry and intact hip dressing is a normal assessment of findings that do not require medical intervention. A dressing is considered INTACT if portions of the white dressing border have lifted from the skin as long as the clear viewing window maintains full contact with the skin. The skin under the viewing window does not appear visibly soiled with exudate or blood. The skin under the viewing window does not appear dampened or moist with sweat, exudate, fluid, or blood.
• Option B: A blood pressure of 114/78 mm Hg and pulse rate of 82 beats per minute are normal assessment findings that do not require medical intervention. The normal range used in an adult is between 60 to 100 beats /minute with rates above 100 beats/minute and rates and below 60 beats per minute, referred to as tachycardia and bradycardia, respectively. The respiratory rate is the number of breaths per minute. The normal breathing rate is about 12 to 20 beats per minute in an average adult.
• Option C: A left foot in functional anatomic position are all normal assessment findings that do not require medical intervention. It functions as a rigid structure for weight-bearing and it can also function as a flexible structure to conform to uneven terrain.

FNDNRS-06-043

Which term would the nurse use to document pain at one site that is perceived in another site?

• A. Referred pain
• B. Phantom pain
• C. Intractable pain
• D. Aftermath of pain

Correct Answer: A. Referred pain

Referred pain is pain occurring at one site that is perceived in another site. Referred pain follows dermatome and nerve root patterns. Referred pain is pain perceived at a location other than the site of the painful stimulus/ origin. It is the result of a network of interconnecting sensory nerves that supply many different tissues. When there is an injury at one site in the network it is possible that when the signal is interpreted in the brain signals are experienced in the surrounding nervous tissue.

• Option B: Phantom pain refers to pain in a part of the body that is no longer there, such as in amputation. Phantom pain is pain that feels like it’s coming from a body part that’s no longer there. Doctors once believed this post-amputation phenomenon was a psychological problem, but experts now recognize that these real sensations originate in the spinal cord and brain.
• Option C: Intractable pain refers to moderate to severe pain that cannot be relieved by any known treatment. Intractable pain refers to a type of pain that can’t be controlled with standard medical care. Intractable essentially means difficult to treat or manage. This type of pain isn’t curable, so the focus of treatment is to reduce the discomfort.
• Option D: Aftermath of pain, a phase of the pain experience and the most neglected phase address the client’s response to the pain experience. The complexity of pain physiology makes some pains more difficult to manage than others. Acute postoperative pain normally responds well to analgesia, but this should be complemented by strategies such as comfortable positioning, distraction, TENS, and reassurance.

FNDNRS-06-044

Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? Select all that apply.

• A. Assessing the client’s bowel sounds.
• B. Taking the client’s blood pressure and apical pulse.
• C. Obtaining a pulse oximeter reading.
• D. Notifying the health care provider.
• E. Determining the last time the client received pain medication.
• F. Encouraging the client to turn, cough, and deep breathe.

Correct Answers: A, B, & E

The nurse must rule out complications prior to administering pain medication, so her interventions would include assessing to make sure the client has bowel sounds and determining if the client is hemorrhaging by checking the client’s blood pressure and pulse. The nurse must also make sure the pain medication is due according to the health care provider’s orders. Obtaining a pulse oximeter reading and turning, coughing, and deep breathing will not help the client’s pain. 

• Option A: Additionally, the nurse should ask the following questions during pain assessment to determine its history: (1) effectiveness of previous pain treatment or management; (2) what medications were taken and when; (3) other medications being taken; (4) allergies or known side effects to medications.
• Option B: Pain should be screened every time vital signs are evaluated. Many health facilities set pain assessment as the “fifth vital sign” and should be added to during routine vital signs assessment.
• Option C: Investigate signs and symptoms related to pain. Bringing attention to associated signs and symptoms may help the nurse in evaluating the pain. In some instances, the existence of pain is disregarded by the patient.
• Option D: There is no need to notify the health care provider in this situation. Some patients may be satisfied when pain is no longer intense; others will demand complete elimination of pain. This influences the perceptions of the effectiveness of the treatment modality and their eagerness to engage in further treatments.
• Option E: Some patients may be hesitant to try the effectiveness of nonpharmacological methods and may be willing to try traditional pharmacological methods (i.e., use of analgesics). A combination of both therapies may be more effective and the nurse has the duty to inform the patient of the different methods to manage pain.
• Option F: Stress correlates to an increase in pain perception by increasing muscle tension and activating the SNS. Eliciting a relaxation response decreases the effects of stress on pain. Examples include directed meditation, music therapy, deep breathing.

FNDNRS-06-045

Albert, who suffered severe burns 6 months ago, is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?

• A. Referring the client for counseling and occupational therapy.
• B. Staying with the client as much as possible and building trust.
• C. Providing cutaneous stimulation and pharmacologic therapy.
• D. Providing distraction and guided imagery techniques.

Correct Answer: A. Referring the client for counseling and occupational therapy

Because it has been 6 months, the client needs professional help to get on with life and handle the limitations imposed by the current problems. Staying with the client, building trust, and providing methods of pain relief, such as cutaneous stimulation, medications, distraction, and guided imagery interventions, would have been more appropriate in earlier stages of postburn injury, when physical pain was most severe and fewer psychological factors needed to be addressed.

• Option B: Explain to the patient what happened. Provide opportunities for questions and give honest answers. Compassionate statements reflecting the reality of the situation can help the patient and SO acknowledge that reality and begin to deal with what has happened.
• Option C: The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of patient addiction or doubts regarding degree of pain experienced are not valid during the emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated.
• Option D: Encourage use of stress management techniques: progressive relaxation, deep breathing, guided imagery, and visualization. Refocuses attention, promotes relaxation, and enhances sense of control, which may reduce pharmacological dependency.

FNDNRS-06-046

Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?

• A. Assessing the client to rule out possible complications secondary to surgery.
• B. Checking the client’s chart to determine when pain medication was last administered.
• C. Explaining to the client that the pain should not be this severe 3 days postoperatively.
• D. Obtaining an order for a stronger pain medication because the client’s pain has increased.

Correct Answer: A. Assessing the client to rule out possible complications secondary to surgery.

The nurse’s immediate action should be to assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. The health care provider ordered the pain medication for routine postoperative pain that is expected after abdominal surgery, not for such complications as hemorrhage, infection, or dehiscence. The nurse should never administer pain medication without assessing the client first. 

• Option B: Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. It is essential to assist patients to express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Inconsistencies between behavior or appearance and what the patient says about pain relief (or lack of it) may be more a reflection of other methods the patient is using to cope with the pain rather than pain relief itself.
• Option C: Pain is subjective, and each person has his own level of pain tolerance. The nurse must always believe the client’s complaint of pain. Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.
• Option D: Obtaining an order for a strong medication may be appropriate after the nurse assesses the client and checks the chart to see whether the current analgesic is infective. The World Health Organization (WHO) in 1986 published guidelines in the logical usage of analgesics to treat cancer using a three-step ladder approach – also known as the analgesic ladder. The analgesic ladder focuses on aligning the proper analgesics with the intensity of pain.

FNDNRS-06-047

Which term refers to the pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity?

• A. Acute pain
• B. Chronic pain
• C. Superficial pain
• D. Deep pain

Correct Answer: D. Deep pain

Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic pain from organs in any body activity. Deep somatic pain originates from structures deeper within the body, such as the joints, bones, tendons, and muscles. Like visceral pain, deep somatic pain is usually dull and aching. Deep somatic pain can either be experienced locally or more generally depending on the degree of trauma.

• Option A: Acute pain is rapid in onset, usually temporary (less than 6 months), and subsides spontaneously. Acute pain is a type of pain that typically lasts less than 3 to 6 months or pain that is directly related to soft tissue damage such as a sprained ankle or a paper cut. Acute pain is of short duration but it gradually resolves as the injured tissues heal.
• Option B: Chronic pain is marked by gradual onset and lengthy duration (more than 6 months). Chronic pain is pain that is ongoing and usually lasts longer than six months. This type of pain can continue even after the injury or illness that caused it has healed or gone away. Pain signals remain active in the nervous system for weeks, months, or years.
• Option C: Superficial pain has an abrupt onset with sharp, stinging quality. Superficial pain arises from nociceptive receptors in the skin and mucous membranes. Superficial somatic pain is the type of pain that happens with common everyday injuries and is characterized as pricking, sharp, burning, or throbbing pain.

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FNDNRS-06-048

A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?

• A. Telling the client to strictly limit the amount of movement of his inflamed joints.
• B. Teaching the client’s family how to transfer the client into a wheelchair.
• C. Teaching the client the proper method for massaging inflamed, sore joints.
• D. Encouraging gentle range-of-motion exercises after administering aspirin and before rising.

Correct Answer: D. Encouraging gentle range-of-motion exercises after administering aspirin and before rising.

Aspirin raises the pain threshold and, although range-of-motion exercises hurt, mild exercise can relieve pain on rising. A tailored program that includes a balance of three types of exercises — range-of-motion, strengthening, and endurance — can relieve the symptoms of arthritis and protect joints from further damage.

• Option A: Strict limitation of motion only increases the client’s pain. The stiffness, pain, and swelling associated with arthritis can severely reduce the range of motion of joints (the distance joints can move in certain directions). Avoiding physical activity because of pain or discomfort also can lead to significant muscle loss and excessive weight pain.
• Option B: Having others transfer the client into a wheelchair does not increase his feelings of dependency. Range-of-motion exercises (also called stretching or flexibility exercises) help maintain normal joint function by increasing and preserving joint mobility and flexibility.
• Option C: Massage increases inflammation and should be avoided with this client. During the course of a range-of-motion exercise program, the joints are stretched progressively farther until normal or near-normal range is achieved and maintained.

FNDNRS-06-049

Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?

• A. Referring the client for hypnosis.
• B. Administering pain medication as prescribed.
• C. Removing all glaring lights and excessive noise.
• D. Using transcutaneous electric nerve stimulation.

Correct Answer: D. Using transcutaneous electric nerve stimulation.

Nonpharmacologic pain relief interventions include cutaneous stimulation, back rubs, biofeedback, acupuncture, transcutaneous electric nerve stimulation, and more. Transcutaneous electrical nerve stimulation (TENS) is a therapy that uses low voltage electrical current to provide pain relief. A TENS unit consists of a battery-powered device that delivers electrical impulses through electrodes placed on the surface of your skin. The electrodes are placed at or near nerves where the pain is located or at trigger points.

• Option A: Hypnosis is considered an alternative therapy. Hypnosis is a set of techniques designed to enhance concentration, minimize one’s usual distractions, and heighten responsiveness to suggestions to alter one’s thoughts, feelings, behavior, or physiological state.
• Option B: Medications are pharmacologic measures. A wide range of drugs are used to manage pain resulting from inflammation in response to tissue damage, chemical agents/pathogens (nociceptive pain) or nerve damage (neuropathic pain).
• Option C: Although removing glaring lights and excessive noise help to reduce or remove noxious stimuli, it is not specific to pain relief. A noxious stimulus is actually, or potentially, damaging to tissue and liable to cause pain, but does not invariably do so. Some noxious stimuli, particularly in the viscera, do not cause nociceptive responses.

FNDNRS-06-050

A 12-year-old student falls off the stairs, grabs his wrist, and cries, “Oh, my wrist! Help! The pain is so sharp, I think I broke it.” Based on this data, the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers?

• A. Type A-delta fibers
• B. Autonomic nerve fibers
• C. Type C fibers
• D. Somatic efferent fibers

Correct Answer: A. Type A-delta fibers

Type A-delta fibers conduct impulses at a very rapid rate and are responsible for transmitting acute sharp pain signals from the peripheral nerves to the spinal cord. Only type A-delta fibers transmit sharp, piercing pain. They respond to stimuli such as cold and pressure, and as nociceptors stimulation of them is interpreted as fast/first pain information.

• Option B: The autonomic system regulates involuntary vital functions and organ control such as breathing. An autonomic nerve pathway involves two nerve cells. One cell is located in the brainstem or spinal cord. It is connected by nerve fibers to the other cell, which is located in a cluster of nerve cells (called an autonomic ganglion). Nerve fibers from these ganglia connect with internal organs.
• Option C: Type C fibers transmit sensory input at a much slower rate and produce a slow, chronic type of pain. The C group fibers are unmyelinated and have a small diameter and low conduction velocity, whereas Groups A and B are myelinated. Group C fibers include postganglionic fibers in the autonomic nervous system (ANS), and nerve fibers at the dorsal roots (IV fiber). These fibers carry sensory information.
• Option D: Somatic efferent fibers affect the voluntary movement of skeletal muscles and joints. General somatic efferent fibers carry motor impulses to somatic skeletal muscles. In the head, the tongue and extraocular muscles are of this type. Cranial nerves III, IV, VI, and XII carry these fibers.

Blood Transfusion NCLEX Practice Quiz (15 Items)

FNDNRS-06-051

Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood transfusion?

• A. Warming the blood prior to transfusion.
• B. Informing the client that the transfusion usually takes 4 to 6 hours.
• C. Documenting blood administration in the client chart.
• D. Instructing the client to report any itching, chest pain, or dyspnea.

Correct Answer: D. Instructing the client to report any itching, headache, or dyspnea.

This will help the nurse take immediate action in case a reaction happens during a transfusion. There are multiple complications of blood transfusions, including infections, hemolytic reactions, allergic reactions, transfusion-related lung injury (TRALI), transfusion-associated circulatory overload, and electrolyte imbalance.

• Option A: There is no evidence that warming blood is beneficial to the patient when transfusion is slow. At transfusion rates of greater than 100 mL/minute, cold blood may be a contributing factor in cardiac arrest. However, keeping the patient warm is probably more important than warming the blood.
• Option B: Transfusion of a unit of blood should be completed within a maximum period of four hours after removal from the blood fridge: discard the unit if this period is exceeded. If blood has been out of the blood bank refrigerator for more than 30 minutes and is not transfused, then the unit must be returned to the laboratory, where it will be disposed of.
• Option C: Documentation related to transfusion therapy should include verification of the prescribed blood product and blood product compatibility; verification of appropriate clinical indication for the transfusion; the date and time of transfusion, type of blood product administered, in addition to the volume, infusion rate, and time of initiation and completion of transfusion;  any medication administered, including premedication (if I.V. drugs are required during transfusion, another I.V. site is required); the patient’s clinical status throughout the transfusion therapy, including patient assessment data such as vital signs and lung sounds; the patient’s response to therapy including any complications or adverse reactions, treatment required, and response to that treatment; and the amount of blood transfused and the return of the unused portion to the blood bank.

FNDNRS-06-052

Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior to the facilitation of the blood transfusion, nurse Paulo priority checks which of the following?

• A. Intake and output
• B. NPO standing order
• C. Vital signs
• D. Skin turgor

Correct Answer: C. Vital signs

The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.

• Option A: Monitoring the intake and output during blood transfusion may be done, but not as often as necessary. Monitoring of intake helps the caregiver to ensure that the patient has a proper intake of fluid and other nutrients. Monitoring of output helps determine whether there is an adequate output of urine as well as normal defecation.
• Option B: A patient on blood transfusion is not placed in an NPO standing order. Current nil per os (NPO) standards promote pre-operative fasting as an approach to reduce the volume and acidity of a patient’s stomach contents to reduce the risks of regurgitation and subsequent pulmonary aspiration. Pre-anesthesia fasting standards apply to any procedure where sedative medications reduce the protective airway reflex that under normal conditions prevent aspiration.
• Option D: Physical findings suggestive of volume depletion include dry mucous membranes, decreased skin turgor, and low jugular venous distention. While the incidence of hypovolemic shock from extracellular fluid loss is difficult to quantify, it is known that hemorrhagic shock is most commonly due to trauma. In one study, 62.2% of massive transfusions at a level 1 trauma center were due to traumatic injury.

FNDNRS-06-053

A client is brought to the emergency department having experienced blood loss due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered. The nurse determines that the reason behind this order is to:

• A. Provide clotting factors and volume expansion.
• B. Increase hemoglobin, hematocrit, and neutrophil levels.
• C. Treat platelet dysfunction.
• D. Treat thrombocytopenia.

Correct Answer: A. Provide clotting factors and volume expansion.

Fresh-frozen plasma may be used to provide clotting factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away. Fresh frozen plasma is the fluid portion of a unit of whole blood frozen in a designated time frame, usually within 8 hours. FFP contains all coagulation factors except platelets.

• Option B: Increasing hemoglobin, hematocrit, and neutrophil levels is not an indication for FFP. FFP corrects coagulopathy by replacing or supplying plasma proteins in patients who are deficient in or have defective plasma proteins. A standard dose of 10 to 20 mL/kg (4 to 6 units in adults) will raise factor levels by approximately 20%.
• Option C: FFP does not contain platelets. Other situations where the administration of FFP cannot be recommended for or against based on systematic review include FFP transfusion at a plasma-to-RBC ratio of 1:3 or more in trauma patients with massive transfusion. Conditions that cause the deficiency of multiple coagulation factors and may require the administration of FFP include liver disease and disseminated intravascular coagulation.
• Option D: Treating thrombocytopenia is incorrect since FFP does not contain any platelet. FFP contains fibrinogen (400 to 900 mg/unit), albumin, protein C, protein S, antithrombin, tissue factor pathway inhibitor. It is free of erythrocytes and leukocytes. FFP provides some volume resuscitation, as each unit contains approximately 250 ml.

FNDNRS-06-054

Nurse Amanda is caring for a client with severe blood loss who is prescribed multiple transfusions of blood. Nurse Amanda obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias?

• A. Cardiac monitor
• B. Blood warmer
• C. ECG machine
• D. Infusion pump

Correct Answer: B. Blood warmer

Rapid transfusion of cool blood puts the client at risk for cardiac dysrhythmias. Modern methods of very rapid transfusion in resuscitation would cause clinically dangerous hypothermia if unmodified, ice-cold blood were to be so transfused. These needs must be reconciled in the interest of adequate patient care–hence the need for blood warming. Countercurrent in-line blood warmers and the method of rapid warm saline admixture can both be used successfully for rapid, massive transfusions.

• Option A: Cardiac monitor is used to assess for any blood transfusion-related complication, but they do not prevent the occurrence of cardiac dysrhythmia. During the blood transfusion process, patients’ vital signs (heart rate, blood pressure, temperature, and respiration rate) should be monitored throughout the procedure and recorded. Follow the organization’s policy on how often the vital signs should be measured.
• Option C: ECG machine is used to assess for any blood transfusion-related complication, but they do not prevent the occurrence of cardiac dysrhythmia. Many severe reactions occur within the first 30 minutes of commencing a transfusion of a blood component unit (SHOT 2008). Close observation during this period is essential.
• Option D: Infusion pump is not beneficial in this case since the infusion must be given rapidly. SHOT 2008 recommends that patients be observed during the subsequent 24 hours because, on occasion, transfusion reactions can occur many hours after transfusion is completed.

FNDNRS-06-055

A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen?

• A. 15 minutes
• B. 30 minutes
• C. 45 minutes
• D. 60 minutes

Correct Answer: A. 15 minutes

Usually, a transfusion reaction occurs within 15 minutes of a transfusion. For each unit of blood transfused, monitor the patient before starting the transfusion (baseline observation; 15 minutes after starting the transfusion; at least every hour during transfusion; and carry out a final set of observations 15 minutes after each unit has been transfused.

• Option B: Staying with the patient for 30 minutes might be too long. Acute reactions may occur in 1% to 2% of transfused patients. Rapid recognition and management of the reaction may save the patient’s life. Once immediate action has been taken, careful and repeated clinical assessment is essential to identify and treat the patient’s problems.
• Option C: 45 minutes of staying and monitoring the patient for transfusion reactions is too long. All suspected acute transfusion reactions should be reported immediately to the blood transfusion center and to the doctor responsible for the patient. With the exception of urticarial allergic reactions and febrile non-hemolytic reactions, all are potentially fatal and require urgent treatment.
• Option D: Most transfusion reactions occur during the first 15 minutes of transfusion. 60 minutes is too long. However, transfusion-transmitted infections are the serious delayed complications of transfusion. Since a delayed transfusion reaction may occur days, weeks, or months after the transfusion, the association with the transfusion may not be recognized.

FNDNRS-06-056

Nurse Rick is administering 2 unit-packed RBCs on a client with low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood?

• A. Microfusion set
• B. Polyvol Pro Burette Set
• C. Photofusion set
• D. Tubing with an in-line filter

Correct Answer: D. Tubing with an in-line filter

The in-line filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused with the client. Use a new, sterile blood administration set containing an integral 170‐200µ filter. Change the set to at least 12‐hourly during a blood transfusion. In a very warm climate, change the set more frequently and usually after every four units of blood, if given within a 12‐hour period.

• Option A: Microinfusion set is incorrect since the tubing that should be used is a macro drip. Use a fresh blood administration set or special platelet transfusion set, primed with saline. All blood components can be slowly infused through small‐bore cannulas or butterfly needles, e.g. 21 to 25 G. For rapid infusion, large‐bore cannulas, e.g. 14 G, are needed.
• Option B: Polyvol Pro Burette set is used for administration of IV medication infusion. The Polymed Polyvol Pro Latex Free Burette Set is a transparent, soft, cylindrical, and calibrated measured volume chamber with a bold marking scale. It has a micro dropper of 60 drops per ml. The burette set comes with a 15 μm fluid filter to reduce particulate matter.
• Option C: Photofusion set is incorrect since blood does not need any protection from light. It protects light-sensitive drugs from UV exposure & its harmful effects. It has a 15-micron fluid filter in the drip chamber

FNDNRS-06-057

To verify the age of blood cells in a blood, the nurse will check which of the following?

• A. Blood type
• B. Blood group
• C. Blood identification number
• D. Blood expiration date

Correct Answer: D. Blood expiration date

The safe storage of blood usually takes 35 days. Examining the expiration date is an important responsibility of a nurse prior to hanging the blood. Once issued by the blood centre, the transfusion of whole blood, red cells, platelet concentrate and thawed fresh frozen plasma should be commenced within 30 minutes of removal from the optimal storage conditions.

• Option A: A 5 mL blood sample should be collected into a dry test tube and then correctly and clearly labeled with the patient’s details, and submitted to the blood center for testing. The taking of a blood sample from the patient needs supervision. If the patient is conscious at the time of taking the sample, ask him/her to identify himself/herself by given name and all other appropriate information.
• Option B: When taking a blood sample for cross match, complete the whole procedure before any other task is undertaken – it is important that there are no interruptions during the process. When correctly performed, compatibility tests will confirm ABO compatibility between component and recipient and will detect the most clinically significant unexpected antibodies.
• Option C: Always take a completed patient documentation label to the issue room of the blood transfusion department when collecting the first unit of blood. Match the details on the blood request form against the blood compatibility label (tag), the bag unit number, and the patient documentation label. When receiving the unit of blood in the clinical area, check that it is the right unit for the right patient.

FNDNRS-06-058

A client has an order to receive one unit of packed RBCs. The nurse makes sure which of the following intravenous solutions to hang with the blood product at the client’s bedside?

• A. 0.9% sodium chloride.
• B. 5% dextrose in 0.9% sodium chloride.
• C. Balanced Multiple Maintenance Solution with 5% Dextrose.
• D. 5% dextrose in 0.45% sodium chloride.

Correct Answer: A. 0.9% sodium chloride.

0.9% sodium chloride is a standard solution used to follow infusion of blood products. Of the various intravenous solutions, only isotonic saline (0.9%) is recommended for use with blood components. Other commonly used intravenous solutions will cause varying degrees of difficulty when mixed with red cells.

• Option B: 5% dextrose in water will hemolyze red cells. Intravenous solutions containing calcium, such as Lactated Ringer’s solution, can cause clots to form in the blood. Prior to blood transfusion, completely flush incompatible intravenous solutions and drugs from the blood administration set with isotonic saline.
• Option C: Normal saline is the only compatible solution to use with the blood or blood component. Crystalloid solutions and medications may cause agglutination and/or hemolysis of the blood or blood components.
• Option D: IV solution containing dextrose in water will hemolyze red cells. Only isotonic, calcium-free IV solutions should be added to, or come in contact with blood products. Calcium may bind with the citrate anticoagulant and promote clotting in the tubing. Excess glucose and/or dextrose causes hemolysis and shortens red cell survival. Studies have shown other IV solutions to be compatible with citrated blood components. However, these solutions should only be considered compatible in situations where the use of 0.9% NaCl would lead to undesirable metabolic abnormalities.

FNDNRS-06-059

Nurse Jay is caring for a client with an ongoing transfusion of packed RBCs when suddenly the client is having difficulty breathing, skin is flushed and having chills. Which action should nurse Jay take first?

• A. Administer oxygen.
• B. Place the client on a droplight.
• C. Check the client’s temperature.
• D. Stop the transfusion.

Correct Answer: D. Stop the transfusion.

The client in this situation is experiencing a transfusion reaction so the priority action of the nurse is to first stop the transfusion. Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion. Send the blood bag and tubing to the blood bank for repeat typing and culture.

• Option A: Place the client in Fowler’s position with shortness of breath and administer O2 therapy. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Obtain a urine specimen and send it to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis.
• Option B: Placing the client under a drop light would not manage his difficulty in breathing. For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen, and aminophylline may be prescribed. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per the physician’s order or protocol.
• Option C: Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.

FNDNRS-06-060

After terminating the transfusion during a reaction, which action should the nurse immediately be taken next? 

• A. Run a solution of 5% dextrose in water.
• B. Run normal saline at a keep-vein-open rate.
• C. Remove the IV line.
• D. Fast drip 200ml normal saline.

Correct Answer: B. Run normal saline at a keep-vein-open rate.

The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. A transfusion reaction evaluation request form typically is used to document signs and symptoms of a suspected reaction so that the blood bank can use this information, in conjunction with laboratory testing, to arrive at a likely diagnosis. The blood bag, along with the infusion set and anything else attached to the set, should be sent with the transfusion reaction evaluation request. 

• Option A: IV solution containing dextrose will hemolyze the red cells. IV solution containing dextrose in water will hemolyze red cells.Only isotonic, calcium-free IV solutions should be added to, or come in contact with blood products. Calcium may bind with the citrate anticoagulant and promote clotting in the tubing. Excess glucose and/or dextrose causes hemolysis and shortens red cell survival. 
• Option C: The nurse will not remove the IV line because then there would be no IV access route. Transfusion reaction treatment varies with the reaction. Diphenhydramine and acetaminophen are some of the most commonly used drugs for treating mild allergic and febrile nonhemolytic reactions. For other reactions, expert consultation should be considered. In cases of acute hemolytic reaction, baseline laboratory tests should be performed and urine should be kept flowing, possibly with alkalinization.
• Option D: Doing a fast drip will potentially lead to congestion and is not done without the physician’s order. Volume overload may require diuretics. TRALI is treated with oxygen and supportive care, which may involve intubation. Bacterial contamination may involve blood pressure support and antibiotics. Because anaphylaxis is treated emergently according to hospital protocol, usually with epinephrine and diphenhydramine, there may not be time for consultation until after the patient is stabilized.

FNDNRS-06-061

A client is receiving a platelet transfusion. The nurse determines that the client is gaining from this therapy if the client exhibits which of the following? 

• A. Less frequent febrile episodes.
• B. Increased level of hematocrit.
• C. Less episodes of bleeding.
• D. Increased level of hemoglobin.

Correct Answer: C. Less episodes of bleeding.

Platelet transfusions may be given to prevent bleeding when the platelet count falls down. In a study of bleeding risks in thrombocytopenic patients, Webert et al. noted that the majority of severe bleeds were preceded by bleeds of lesser severity. Even patients with petechiae (WHO grade 1 bleeding) were 2.5 times more likely to experience clinically significant bleeding on the next day; patients experiencing WHO grade 1 or 2 bleeding were three times more likely to have a severe bleed the next day.

• Option A: A decline in the febrile episode will happen after the transfusion of agranulocytes. Transfusions of granulocytes have a long history of usage in clinical practice to support and treat severe infection in high‐risk groups of patients with neutropenia or neutrophil dysfunction.
• Option B: An increased level of hematocrit occurs after infusion of red blood cells. Blood transfusion is used to treat acute anemia with the goal of increasing blood oxygen-carrying capacity as determined by hematocrit (Hct), and oxygen delivery (DO2).
• Option D: An increased level of hemoglobin will happen after the transfusion of red blood cells. The transfusion of red cell concentrates (RCC) is indicated in order to achieve a fast increase in the supply of oxygen to the tissues, when the concentration of hemoglobin (Hb) is low and/or the oxygen-carrying capacity is reduced, in the presence of inadequate physiological mechanisms of compensation.

FNDNRS-06-062

Nurse Daniel is caring for a client receiving a transfusion of packed red blood cells (PRBCs). The client started to vomit and to be nauseous. Client’s blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client’s temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse understands that the client may be experiencing which of the following?

• A. Circulatory overload
• B. Delayed transfusion reaction
• C. Hypocalcemia
• D. Septicemia

Correct Answer: D. Septicemia

Septicemia happens with the transfusion of blood that is contaminated with microorganisms. Assessment includes the rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and shock. Fever and/or chills are most commonly associated with a febrile, non-hemolytic reaction, however; they can also be the first sign of a more serious acute hemolytic reaction, TRALI, or septic transfusion reaction. If the temperature rises 1 C or higher from the temperature at the start of the transfusion, the transfusion should be stopped.

• Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon auscultation. Dyspnea, or shortness of breath, is a concerning sign that can often be seen with more severe reactions including anaphylaxis, TRALI, and TACO. It can also be seen by itself without accompanying symptoms.
• Option B: Delayed reaction can occur days to years after a transfusion. It causes fever, rashes, mild jaundice, and oliguria or anuria. Typically caused by an anamnestic response to a foreign antigen that the patient was previously exposed to (generally by prior transfusion or pregnancy).
• Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive reflexes, positive Trousseau’s sign, and positive Chovstek’s sign. Hypocalcemia is said to be present when the total serum calcium concentration is less than 8.8 mg/dl. The disorder may be acquired or inherited but its presentation can vary- from asymptomatic to life-threatening. Hypocalcemia is commonly seen in hospitalized patients and for the most part, is mild in nature and only requires supportive treatment.

FNDNRS-06-063

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.8 °F. Which action should the nurse take?

• A. Give an antipyretic and begin the transfusion.
• B. Proceed with the transfusion.
• C. Administer an antihistamine and begin the transfusion.
• D. Delay hanging the blood and inform the physician.

Correct Answer: D. Delay hanging the blood and inform the physician.

If the patient has a temperature higher than 100 ° F, the unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further orders. Fever and/or chills are most commonly associated with a febrile, non-hemolytic reaction, however; they can also be the first sign of a more serious acute hemolytic reaction, TRALI, or septic transfusion reaction.

• Option A: Giving an antipyretic would require a physician’s order. All cases of suspected reactions should prompt immediate discontinuation of the transfusion and notification of the blood bank and treating clinician. A clerical check should be performed by examining the product bag and confirming the patient’s identification. The patient’s vital signs should be monitored and recorded at 15-minute intervals.
• Option C: Administering an antihistamine is incorrect since the administration of the medicine will need the physician’s prescription. Treatment of specific transfusion reactions is most often supportive. For example, antihistamines (such as diphenhydramine) can be given for a mild allergic reaction, or an antipyretic can be given for a nonhemolytic febrile transfusion reaction.
• Option B: The decision to administer the blood is not within the scope of nurse practice. Currently, guidelines for transfusion of red blood cells (RBC), generally follow a restrictive threshold. While there is some variation in the number for the threshold, 7 g/dL is an agreed upon value for asymptomatic healthy patients.

FNDNRS-06-064

A nurse is caring for a client requiring surgery and is ordered to have a standby blood secured if in case a blood transfusion is needed during or after the procedure. The nurse suggests to the client to do which of the following to lessen the risk of possible transfusion reaction? 

• A. Request that any donated blood be screened twice by the blood bank.
• B. Take iron supplements prior to the surgery and eat green leafy vegetables.
• C. Do an autologous blood donation.
• D. Have a family member donate their own blood.

Correct Answer: C. Do an autologous blood donation.

A donation of your own blood is autologous. Doing this will prevent the risk of transfusion reaction. Autologous blood transfusion is the collection of blood from a single patient and retransfusion back to the same patient when required. This is in contrast to allogeneic blood transfusion where blood from unrelated/anonymous donors is transfused to the recipient. The primary driving forces for the use of autologous blood transfusion are to reduce the risk of transmission of infection and to protect an increasingly scarce resource.

• Option A: More recently, concerns have focussed on the blood-borne transmission of variant Creutzfeldt–Jakob disease (vCJD). In 2004, case reports emerged of presumed transmission of vCJD via allogeneic blood transfusion. Unlike hepatitis and HIV, there is no effective screening test and the disease has a variable and often prolonged asymptomatic incubation period.
• Option B: As oral iron supplementation requires a significant amount of time, when the interval before surgery is sufficient (at least 6–8 weeks) and no contraindications are present, supplementation with oral iron and nutritional advice may be appropriate for mild-to-moderate IDA and/or nonanemic ID or insufficient iron stores.
• Option D: Allogeneic donor blood is becoming an increasingly costly and scarce resource. As demand for blood is outstripping donation, there is a real social and economic pressure to increase the proportion of blood transfused by autologous transfusion.

FNDNRS-06-065

A client is receiving a transfusion of one unit of cryoprecipitate. The nurse will review which of the following laboratory studies to assess the effectiveness of the therapy? 

• A. Serum electrolytes
• B. White blood cell count
• C. Coagulation studies
• D. Hematocrit count

Correct Answer: C. Coagulation studies

The evaluation of the effective response of a cryoprecipitate transfusion is assessed by monitoring coagulation studies and fibrinogen levels. Cryoprecipitate Antihemophilic Factor, also called cryo, is a portion of plasma, the liquid part of the blood. Cryo is rich in clotting factors, which are proteins that can reduce blood loss by helping to slow or stop bleeding.

• Option A: Crystalloids are the fluids of choice for most minor procedures. They are sterile aqueous solutions that may contain glucose, various electrolytes, organic salts, and nonionic compounds. Some examples of these solutes are sodium chloride, potassium chloride, sodium bicarbonate, calcium carbonate, sodium acetate, sodium lactate, and sodium gluconate.
• Option B: White blood cells are transfused to treat life-threatening infections in people who have a greatly reduced number of white blood cells or whose white blood cells are functioning abnormally. The use of white blood cell transfusions is rare because improved antibiotics and the use of cytokine growth factors that stimulate people to produce more of their own white blood cells have greatly reduced the need for such transfusions.
• Option D: The average increase in hematocrit per liter of packed red blood cells transfused was 6.4% +/- 4.1%. If 1 “unit” of packed red blood cells is approximately 300 mL, this becomes a change of hematocrit of 1.9% +/- 1.2% per “unit” of blood. The accepted correlation of about 1 “unit” of blood loss per 3% change in hematocrit would be valid for a 500-cc unit, but a typical unit of packed red blood cells is typically 300 cc.

Nutrition NCLEX Practice Quiz (10 items)

FNDNRS-06-066

A nurse is teaching a client with pancreatitis about following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes which food on the item list?

• A. Chocolate milk
• B. Broccoli
• C. Apple
• D. Salmon

Correct Answer: A. Chocolate milk

Chocolate milk is a high-fat food. The pancreas helps with fat digestion, so foods with more fat make the pancreas work harder. Registered dietitian Deborah Gerszberg recommends that people with chronic pancreatitis limit their intake of refined carbohydrates, such as white bread and high sugar foods. Refined carbohydrates can lead to the pancreas releasing large amounts of insulin. Foods that are high in sugar can also raise triglycerides.

• Option B: Vegetables are low in fat because they do not come from animal sources. Vegetables, beans, lentils, and whole grains are beneficial because of their fiber content. Eating more fiber can lower the chances of having gallstones or elevated levels of fats in the blood called triglycerides. Both of those conditions are common causes of acute pancreatitis.
• Option C: Fruits are low in fat because they do not come from animal sources. Fruits are recommended for people with pancreatitis because they tend to be naturally low in fat, which eases the amount of work the pancreas needs to do to aid digestion.
• Option D: Salmon is naturally lower in fat. Many types of fish, such as salmon, lake trout, tuna, and herring, provide healthy omega-3 fat. But avoid fish canned in oil, such as sardines in olive oil. Bake, broil, or grill meats, poultry, or fish instead of frying them in butter or fat.

FNDNRS-06-067

The nurse is giving dietary instructions to a client who is on a vegan diet. The nurse provides dietary teaching focus on foods high in which vitamin that may be lacking in a vegan diet?

• A. Vitamin A
• B. Vitamin D
• C. Vitamin E
• D. Vitamin C

Correct Answer: B. Vitamin D

Deficiencies in vegetarian diets include vitamin B12 which is found in animal products and vitamin D (if limited exposure to sunlight). Vegans and other vegetarians who limit their intake of animal products may be at greater risk of vitamin D deficiency than nonvegetarians because foods providing the highest amount of vitamin D per gram naturally are all from animal sources, and fortification with vitamin D currently occurs in few foods.

• Option A: Plant sources contain vitamin A in the form of carotenoids which have to be converted during digestion into retinol before the body can use it. Carotenoids are the pigments that give plants their green color and some fruits and vegetables their red or orange color.
• Option C: The best way to get the daily requirement of vitamin E is by eating food sources. Vitamin E is found in vegetable oils, nuts, seeds, green leafy vegetables, and fortified breakfast cereals. It is an antioxidant. This means it protects body tissue from damage caused by substances called free radicals. Free radicals can harm cells, tissues, and organs. They are believed to play a role in certain conditions related to aging.
• Option D: Vitamin C can be found in fruits and vegetables, which are eaten by a vegetarian. Humans are unable to synthesize vitamin C, so it is strictly obtained through the dietary intake of fruits and vegetables. Citrus fruits, berries, tomatoes, potatoes, and green leafy vegetables are excellent sources of vitamin C.

FNDNRS-06-068

A nurse is caring for a client with Wernicke-Korsakoff syndrome. The physician asks the nurse to teach the client to consume thiamine-rich food. The nurse instructs the client to increase the intake of which food items?

• A. Chicken
• B. Milk
• C. Beef
• D. Broccoli

Correct Answer: C. Beef

Food sources of thiamin include beef, liver, nuts, oats, oranges, pork, eggs, seeds, legumes, peas, and yeast. In meat, the liver has the highest amount of thiamine. Whereas three ounces of beefsteak gives 7% of the daily value of thiamine, one serving of beef liver will give about 10%. One serving of cooked salmon gives 18% of the daily value of thiamine.

• Option A: Poultry contains niacin. Chicken meat, particularly chicken breast, is an excellent source of protein as well as niacin. A three-ounce serving of skinless breast meat provides 10.3 mg. Niacin is an essential nutrient that we mainly need to get from foods. The body may also convert some tryptophan, one of the body’s amino acids, into a nutrient.
• Option B: Milk contains vitamins A, D, and B2. Milk contains the fat-soluble vitamins A, D, E, and K. The content level of fat-soluble vitamins in dairy products depends on the fat content of the product. Milk contains the water-soluble vitamins thiamin (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), pantothenic acid (vitamin B5), vitamin B6 (pyridoxine), vitamin B12 (cobalamin), vitamin C, and folate. Milk is a good source of thiamin, riboflavin, and vitamin B12.
• Option D: Broccoli contains folic acid, vitamins C, E, and K. Broccoli is a good source of fiber and protein and contains iron, potassium, calcium, selenium, and magnesium as well as the vitamins A, C, E, K, and a good array of B vitamins including folic acid.

FNDNRS-06-069

A client who is recovering from surgery has been ordered a change from a clear liquid diet to a full liquid diet. The nurse would offer which full liquid item to the client?

• A. Popsicle
• B. Carbonated beverages
• C. Gelatin
• D. Custard

Correct Answer: D. Custard

Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding, and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. A full liquid diet is made up only of fluids and foods that are normally liquid and foods that turn to liquid when they are at room temperature, like ice cream.

• Option A: A clear liquid diet is a specific dietary plan that only includes liquids that are fully transparent at room temperature. Some items that may be allowed include water, ice, fruit juices without pulp, sports drinks, carbonated drinks, gelatin, tea, coffee, clear broths, and clear ice pops.
• Option B: Carbonated beverages are part of a clear liquid diet. Items can have color as long as they are transparent. Items such as milk and orange juice are not considered clear liquids because they are not fully transparent and may take more effort for the digestive system to break down, whereas grape juice is allowed (it is pigmented, but fully transparent).
• Option C: Gelatin is a clear liquid diet. The clear liquid diet assists in maintaining hydration, provides electrolytes and calories, and offers some level of satiety when a full diet is not appropriate, but may struggle to provide adequate caloric needs if employed for more than five days.

FNDNRS-06-070

A postoperative client has been placed on a clear liquid diet. The nurse provides the client with which items are allowed to be consumed on this diet?

• A. Vegetable juices
• B. Custard
• C. Sherbet
• D. Bouillon

Correct Answer: D. Bouillon

A clear liquid diet consists of foods that are relatively transparent to light and liquid at room and body temperature. Foods allowed on the clear liquid diet (bouillon, popsicles, plain gelatin, ice chips, sweetened tea or coffee (no creamer), carbonated beverages, and water). The clear liquid diet assists in maintaining hydration, it provides electrolytes and calories, and offers some level of satiety when a full diet is not appropriate, but may struggle to provide adequate caloric needs if employed for more than five days

• Option A: Vegetable juices are part of a full liquid diet. A patient prescribed a full liquid diet follows a specific diet type requiring all liquids and semi-liquids but no forms of solid intake. Unlike a clear liquid diet, which includes only liquids and semi-liquids that are non-opaque, a full liquid diet is more inclusive, as it allows all types of liquids.
• Option B: Custard is a full liquid diet. Patients not ready for a regular diet due to elective or emergent procedures or who experience irregularity in gastrointestinal function, dysphagia, a transition from prolonged fasted periods, etc., are typically placed on a restrictive diet.
• Option C: Sherbet is a full liquid diet. Dietary restrictions can be as restrictive as no food or liquids allowed by mouth, which may increase in a stepwise fashion until reaching regular nutrition. One step in that progression is a full liquid diet.

FNDNRS-06-071

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary instructions if she selects which of the following from her menu?

• A. Nuts and fish.
• B. Oranges and dark green leafy vegetables.
• C. Butter and margarine.
• D. Sugar and candy.

Correct Answer: B. Oranges and dark green leafy vegetables.

Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which enhances iron absorption. A diet plan for anemia needs to include a healthful balance of iron-rich foods, such as leafy vegetables, lean meat, nuts and seeds, and fortified breakfast cereals. It is also crucial to include foods that can improve the body’s absorption of iron and avoid foods that may interfere with this process.

• Option A: Phytates also termed phytic acid is present in legumes, whole grains, nuts, and brown rice. The phytic acid binds with the iron present in the digestive tract and inhibits its absorption. Hence, anemic patients must avoid foods containing phytates.
• Option C: The mineral hinders iron absorption and therefore consuming calcium-containing food products in combination with other iron-rich foods can affect how much iron is being absorbed by the body. Dairy foods like milk, yoghurt, and cheese should be avoided for this reason. Therefore, it is advisable to take calcium-containing foods at different time slots.
• Option D: The effect of the iron-chelating sugars, fructose, glucose and galactose, on iron absorption in rats has been examined. Fructose has an effect in increasing iron absorption. Glucose and galactose have no effect on iron absorption. These findings suggest that the metabolism of fructose is responsible for changing iron absorption in the rat since it is metabolized during its absorption, while glucose and galactose are not.

FNDNRS-06-072

The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?

• A. Mushroom and blueberry.
• B. Beans and bananas.
• C. Fish and tomato juice.
• D. Potato and spinach.

Correct Answer: A. Mushroom and blueberry.

A renal diet is one that is low in sodium, phosphorus, potassium and protein. A renal diet also emphasizes the importance of consuming high-quality protein and usually limiting fluids. Some patients may also need to limit potassium and calcium. Every person’s body is different, and therefore, it is crucial that each patient works with a renal dietitian to come up with a diet that is tailored to the patient’s needs.

• Option B: Bananas are rich in potassium. The kidneys help to keep the right amount of potassium in the body and they expel excess amounts into the urine. When the kidneys fail, they can no longer remove excess potassium, so potassium levels build up in the body.
• Option C: Tomato juice is high in sodium. Too much sodium can be harmful for people with kidney disease because their kidneys cannot adequately eliminate excess sodium and fluid from the body. Processed foods often contain higher levels of sodium due to added salt.
• Option D: Potatoes and spinach are high in potassium. Potassium plays a role in keeping the heartbeat regular and the muscles working correctly. Potassium is also necessary for maintaining fluid and electrolyte balance in the bloodstream. When the kidneys fail, they can no longer remove excess potassium, so potassium levels build up in the body.

FNDNRS-06-073

A client with heart failure has been told to maintain a low sodium diet. A nurse who is teaching this client about foods that are allowed includes which food item in a list provided to the client?

• A. Pretzels
• B. Whole wheat bread
• C. Tomato juice canned
• D. Dried apricot

Correct Answer: D. Dried apricot.

Foods that are lower in sodium include fruits and vegetables like dried apricot. Dried apricots are sodium free. Dried apricots, as part of a low sodium diet, may reduce the risk of high blood pressure. Apricots contain numerous antioxidants, most notably flavonoids. They help protect the body from oxidative stress, which is linked to many chronic diseases.

• Option A: These classic snacks are high in sodium — almost 20 percent of the recommended daily intake is in one serving of pretzels. Too much sodium leads to increased water retention, which can lead to bloating and puffiness, and too much sodium over time can lead to heart disease.
• Option B: Sodium is finding its way into a lot of whole wheat bread brands in amounts that average 240 to 400 mg per slice. If your serving usually contains two slices, the sodium can add up quickly.
• Option C: Many tomato juice products contain added salt — which bumps up the sodium content. For example, a 1.4-cup (340-ml) serving of Campbell’s 100% tomato juice contains 980 mg of sodium — which is 43% of the DV. Research shows that diets high in sodium may contribute to high blood pressure.

FNDNRS-06-074

The nurse is instructing a client with hyperkalemia on the importance of choosing foods low in potassium. The nurse should teach the client to limit which of the following foods?

• A. Grapes
• B. Carrot
• C. Green beans
• D. Lettuce

Correct Answer: B. Carrot

Carrots have 320 mg of potassium per 100 mg serving; green beans give 209 mg of potassium, 194 mg for lettuce, and 191 mg for grapes all in 100 mg serving. Other foods that are low in potassium include: applesauce, blueberries, pineapple, and cabbage. To minimize potassium buildup, a person with chronic kidney disease should stick to a low-potassium diet of between 1,500 and 2,000 milligrams (mg) per day. Limiting phosphorus, sodium, and fluids may also be important for people with kidney dysfunction.

• Option A: Grapes are also rich in potassium, but not as much as in carrots. They’re also a good source of vitamin C, an essential nutrient and powerful antioxidant necessary for connective tissue health. Grapes are high in a number of powerful antioxidant compounds. In fact, over 1,600 beneficial plant compounds have been identified in this fruit.
• Option C: Half a cup of freshly cooked green beans has only 90 milligrams of potassium and 18 milligrams of phosphorus, making them a great vegetable choice for the kidney diet.
• Option D: Lettuce is a popular vegetable and is usually eaten raw in salads. Because CKD patients with hyperkalemia need to limit potassium intake from meals, they are not able to eat large quantities of raw vegetables such as lettuce.

FNDNRS-06-075

A client is recovering from debridement of the right leg. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing? 

• A. Milk
• B. Chicken
• C. Banana
• D. Strawberries

Correct Answer: D. Strawberries

Citrus fruits and juices are especially high in vitamin C. Strawberries are an excellent source of vitamin C and manganese and also contain decent amounts of folate (vitamin B9) and potassium. Strawberries are very rich in antioxidants and plant compounds, which may have benefits for heart health and blood sugar control

• Option A: Dairy products such as milk are high in vitamin B. Milk and other dairy products pack about a third of the daily riboflavin requirement in just 1 cup (240 ml). Milk is also a good source of well-absorbed B12. Like other animal products, milk also is a good source of B12, supplying 18% of the RDI per 1-cup (240-ml) serving.
• Option B: Meats such as chicken are high in vitamin B. Chicken and turkey, especially the white meat portions, are high in B3 and B6. Poultry also supplies smaller amounts of riboflavin, pantothenic acid, and cobalamin. Most of the nutrients are in the meat, not the skin.
• Option C: Bananas are rich in potassium. Bananas are rich in the mineral potassium. Potassium helps maintain fluid levels in the body and regulates the movement of nutrients and waste products in and out of cells. One medium-sized banana contains 422 milligrams (mg) of potassium.