A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal AV fistula in the RA. Which intervention should the nurse implement in caring for the client? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and three each shift
e. Placing a pressure dressing over the site after each dialysis treatment
f. Administering IV fluids through the venous site of the AV fistula as needed
A, B, C, D
A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg
D, E
A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a cardiac monitor. The nurse is monitoring the client’s cardiac rhythm and nots ventricular fibrillation. Which nursing intervention should the nurse take first?
a. Calling the rapid response team
b. Preparing the client for cardioversion
c. Asking the client to bear down and cough
d. Preparing to administer diltiazem
A
The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI. VF makes the patient feel faint, then loses consciousness and becomes pulseless and apneic (BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias.
A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to prevent this complication?
a. Keeping the fan running in the client’s room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories
B
The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize these risks.
A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to prevent sweating
d. I have to check the pin sites everyday and watch for signs of infection
C
Cleanse the skin under the wool liner each day to prevent rashes and soars.
A nurse is caring for a client with increased intracranial pressure. In which position should the nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees
D
Proper positioning promotes venous drainage from the cranium to minimize ICP.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first?
a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture
B
CSF contains glucose not protein.
A nurse is caring for a client who has just undergone cardioversion. Which intervention is the nurse’s priority after this procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medications
d. Monitoring the client’s LOC
A
ABC’s of nursing. All other choices are correct, but not priority.
A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1c) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. Which is the best response for the nurse to provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at risk for hypoglycemia
d Determine whether the prescribed insulin dosage is correct
B
A nurse caring for a client with acquired immunodeficiency syndrome is monitoring the client for signs of complications. Which of the following would cause the nurse to suspect infection with Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus
B, D, E
A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is important to report back to the clinic as scheduled for which follow-up diagnostic?
a. Blood glucose checks
b. Blood pressure checks
c. Complete blood counts (CBC)
d. Electrocradiographic studies
C
Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB infection, an area of induration 6 mm wide developed. The client asks the nurse what this result means. Which is the best response?
a. We’ll have to repeat the test because the result was inconclusive
b. The swollen area is small, so that means your test result is negative
c. You’ve been exposed to TB so you will need to have a chest x-ray
d. You need to get started on medication right away because you have TB
B
Indurations less than 10 mm (non-immunocompromised) and 5 mm (immunocompromised) is considered a negative result after 48-72 hrs. Results greater indicate exposure and possible TB infection. Morse testing (x-ray) will be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L. Which acid base balance disturbance does the nurse identify from these results?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
D
RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis is HCO3- is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26 mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right leg. Which of the following interventions of the nurse immediately implement?
a. Elevating the foot of the bed 6 inches
b. Placing ice packs on and under the right leg
c. Documenting the need for hourly calf measurements
d. Performing the need for hourly calf measurements
A
DVT treatment includes bed rest, leg elevation, and application of warm, moist heat. Elevation decreases the venous pressure with relieves edema and pain. ROM cause cause the thrombus to mobilize to the lungs causing PEs.
A nurse provides instruction to a client with COPD about home oxygen therapy. Which statement made by the client indicates need for further instruction?
a. I should limit activity as much as possible
b. If I have trouble breathing, I need to call the doctor
c. I need to drink lots of fluids to keep my mucus thin
d. I can apply petroleum jelly to my nose if the oxygen dries it out
e. I should wear a scarf over my nose and mouth in cold weather
f. If I get a flu shot, I do not have to worry about being around people with colds
A, D, F
A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which signs or symptoms would prompt the nurse to notify the primary health care provider immediately?
a. Disorientation to date
b. Pupils equal and reactive at 4 mm
c. Mild headache relieved by acetaminophen with codeine
d. Pain with forward flexion of the neck onto the chest
D
A complication of cranial surgery is meningitis.
A man calls the clinic and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first take which action?
a. Place a cool compress on the sting site
b. Apply an antipruritic lotion to the sting site
c. Apply a topical corticosteroid to the sting site
d. Take an oral antihistamine such as diphenhydramine (Benadryl)
A
A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should take which action first?
a. Ask the client to sign a no-harm contract
b. Ask the client to report any suicidal thoughts immediately
c. Place the client under suicide precautions with 15-minute checks
d. Check the dressings that were placed over the client’s wrists in the emergency department
D
First assess the physical state of the patient for safety then implement precautions.
A nurse is preparing to administer digoxin to a client with heart failure. When assessing the client, the nurse notes an apical pulse rate of 58 beats/min. Also, the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings?
a. Contact the primary health care provider
b. Administer an as-needed antiemetic
c. Check the most recent digoxin level
d. Administer the digoxin with an antacid
C
A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears stridor when auscultating over the trachea. On the basis of this finding, which is the priority nursing action?
a. Assess the client’s pulse oximetry Incorrect
b. Place the client in a supine position
c. Contact the primary health care provider
d. Administer a nebulizer treatment with the use of a bronchodilator
C
Stridor indication there is an obstruction and the HCP should be notified immediately. The patient should be placed in high Fowlers and pulse oximetry can be completed by is not the priority.
A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 a.m. At 11 a.m. the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately takes which action?
a. Contacts the physician
b. Gives the child milk to drink
c. Arranges to have the child’s lunch tray delivered early
d. Prepares to administer intravenous 5% dextrose solution
B
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. Which is the first action on the part of the nurse?
a. Calling the physician
b. Inserting an oral airway
c. Turning the client on her side
d. Noting the time of the seizure
C
A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication?
3
The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn’s thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication
A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of (2.164 mmol/L)35 mg/dL. The nurse would take which action first?
Ask the mother to breastfeed the newborn
Bottle-feed the newborn with diluted glucose
Start an intravenous line for the administration of glucose
Ask the laboratory to perform a blood glucose test immediately
D
Normal newborn levels are 40 mg/dL or greater. Glucose levels of less than (2.22-2.298 mmol/L))40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain.
A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which actions should the nurse perform? Select all that apply.
Placing the woman in knee-chest position
Administering oxygen at 2 to 4 L/min by nasal cannula
Administering terbutaline to stop contractions
With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part
Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution
A, C, D
Oxygen should be administered at 8-10 L/min via face mask
A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the primary health care provider. Which statement by the mother indicates the need for further instruction?
“I’ll call the doctor if she gets dizzy and acts sick.”
“I’ll call the doctor if she has severe stomach cramps.”
“I’ll call the doctor if her temperature is 102°F (38.9°C) or higher.”
“I’ll call the physician if she goes longer than 6 hours without urinating.”
C
Call doctor at temperature above 100.
A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of which other issue?
Refusal to suck
Frequent diarrhea
Recurrent otitis media
Inability to pass stools
C
Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER.
A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which diagnostic test will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find?
Throat culture
Blood urea nitrogen (BUN)
Antistreptolysin (ASO) titer
White blood cell (WBC) count
C
In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs which complication?
Anemia
Renal failure
Thrombus formation
Gastrointestinal disturbances
C
Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. These vascular changes, along with the increase in platelets that occurs as part of the disease, can cause thrombus formation, myocardial infarction, and death in some children.
A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse realizes the mother understands the instructions if the mother states she will increase which food in the child’s diet?
Milk
Cheese
Orange juice
Cream of Wheat
D
A nurse provides home care instructions to an adolescent with sickle cell disease about measures to prevent vaso-occlusive crisis. The nurse should emphasize which priority instruction?
Restrict fluid intake
Contact your primary health care provider if you have a fever.
Take acetylsalicylic acid (aspirin) immediately if a fever develops
Be sure to spend plenty of time in the fresh air and sun each day
B
Fevers can initiate a vaso-occlusive crisis. Others should also be avoided.
A primary health care provider prescribes morphine sulfate, 2.5 mg intravenously stat, for a client with terminal cancer. The medication ampule reads, “Morphine sulfate 10 mg/mL.” How many milliliters of medication does the nurse prepare to administer the correct dose? Please enter the number only.
0.25
A nurse is caring for the client who is in bed and begins to exhibit seizure activity. Which actions does the nurse implement to care for the client? Select all that apply.
Observing and timing the seizure
Loosening any restrictive clothing
Turning the client’s head to the side
Removing the pads on the side rails
Inserting an airway into the client’s mouth
Removing objects that might injure the client from the vicinity
A, B, C, F
The nurse is participating in a facility’s planning committee to deal with possible bioterrorism threats. The nurse should recommend implementing which infection control measures to be used for clients in whom smallpox is diagnosed? Select all that apply.
Enteric
Droplet
Contact
Standard
Protective isolation
B, C, D
Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented when the client is neutropenic and needs to be protected from infection.
A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should take which action immediately?
Stop the oxytocin infusion
Check the client’s blood pressure
Contact the primary health care provider
Place the client in a side-lying position
A
An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse takes which priority action?
Notifying the police department
Obtaining psychiatric help for the caregiver
Contacting adult protective services to investigate the situation
Telling the caregiver that he or she is not allowed to care for the client
C
A nurse responds to an external disaster in a large city involving an explosion at a shopping mall. Numerous victims require treatment. Which victim will the nurse attend to first?
A victim with multiple bruises who is alert and oriented
A victim who has sustained multiple lacerations with minor bleeding
A victim who is alert and wandering around yelling that he cannot see
A victim with a crush injury to the abdomen who has no pulse or blood pressure
C
The victim who must be treated immediately because of the threat to life, limb, or vision is categorized as emergent and is the priority.
A nurse stops at the scene of an automobile accident. One of the victims is sitting in the driver’s seat, complaining of severe muscle spasms in the neck area. The nurse must take which action first?
Stabilize the neck area
Firmly massage the neck area
Assist the victim out of the automobile and lay the victim on the ground
Tell the victim that the nurse is leaving to call an ambulance but will be right back
A
A nurse assesses the chest tube drainage system of a client who has undergone thoracic surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, which would the nurse check first?
The chest tube connection sites
For bubbling in the suction-control chamber
The amount of drainage in the collection chamber
The amount of suction being applied to the chest tube system
A
A nurse on the day shift is assigned to care for four clients. In which order will the nurse assess the clients after receiving report from the night shift.
A client scheduled for an electrocardiogram (ECG) at 11 a.m.
A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 a.m.
A client who has undergone above-the-knee amputation who is scheduled for discharge home
A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam and phenytoin
D
As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately take which action first?
Call the physician
Turn the client to the side
Restrain the client’s limbs
Insert an airway in the client’s mouth
B
A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately take which action?
Reinsert the chest tube
Turn the client onto his back
Contact the primary health care provider
Apply pressure over the chest tube insertion site
D
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next?
Calling a code
Administering an inhaled bronchodilator
Connecting oxygen to the suction catheter
Encouraging the client to take deep breaths
C
The inability to remove a suction catheter is a critical situation. This finding, along with the client’s symptoms presented in the question, indicates bronchospasm and bronchoconstriction. The nurse must immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter, because the client is at risk for hypoxia.
A client with skeletal traction applied to the right leg complains of severe pain in the leg. The nurse realigns the client’s position, but this intervention does not relieve the pain. Which action would the nurse take next?
Providing pin care
Calling the primary health care provider
Removing some of the traction weights
Medicating the client with the prescribed analgesic
B
The nurse realigns the client and, if this is ineffective, calls the primary health care provider. The nurse never removes traction weights unless this is specifically prescribed by the primary health care provider. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain.
A nurse is preparing client assignments for the day. Which assignments would be appropriate for a registered nurse who is pregnant? Select all that apply.
A client with active herpes virus lesions in the perianal area
A client who requires frequent abdominal wound irrigations
A client with a solid sealed implanted radiation source who is restricted to bed rest
A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions
A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning
B, D, E
A female client is examined in the clinic, and gonorrhea is diagnosed. The nurse provides information to the client about the disease and provides which information?
Condoms will not help prevent transmission of the infection
Healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities
It is not necessary for sexual partners to be examined, because the disease is not highly communicable
Treatment includes the administration of an antibiotic, but it is not necessary for sexual partners to be treated
B
A nurse on the day shift receives the client assignment for the day. In which order will the nurse assess the assigned clients?
A client who was admitted during the night because of congestive heart failure
A client who has been fitted with a closed chest tube drainage system
A client with a nasogastric tube who underwent bowel resection 2 days ago
A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m.
A client who was admitted during the night because of congestive heart failure
A client who has been fitted with a closed chest tube drainage system
A client with a nasogastric tube who underwent bowel resection 2 days ago
A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m.
The nurse is observing a new nurse employee perform an otoscopic examination of an adult client. The nurse determines the new nurse employee understands the procedure if the new nurse employee takes which action?
Uses a small speculum to decrease the discomfort
Pulls the pinna up and back before inserting the speculum
Tilts the client’s head forward before inserting the speculum
Pulls the earlobe down and back before inserting the speculum
B
Old= up
Young= down
A primigravida is admitted to the labor unit. During assessment, the client’s membranes rupture spontaneously. What is the priority nursing action?
Checking the amniotic fluid
Checking the fetal heart rate
Assessing the contraction pattern
Preparing for immediate delivery
B
When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord.
A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client?
Fundal assessment
Monitoring of urine output
Frequent assessment of lochia
Inclusion of iron in every meal
C
A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse realizes the patient understands patient teaching if the patient makes which statement?
“I may need to get a therapeutic abortion.”
“I will need an immunization against rubella immediately.”
“Immunization against rubella is required after delivery.”
“Antibiotics will be prescribed to prevent the infection.”
C
MMR vaccines are contraindicated in pregnancy
A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the umbilicus and displaced from the midline. What should the nurse do first?
Massage the fundus
Help the client void
Document the findings
Help the client ambulate
B
A distended bladder can cause the fundus to deviate from midline
A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which pieces of information should the nurse give to the client? Select all that apply.
An internal fetal monitor is attached.
The client will walk on a treadmill until contractions begin.
A positive test result indicates a need for further evaluation.
Special body movements will be performed to stimulate contractions.
The client may be asked to massage one or both nipples to stimulate uterine contractions.
C, E
he fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either with the administration of a dilute dose of oxytocin (Pitocin) or by having the mother stimulate the nipples until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are taken, and the client is monitored closely if increasing doses of oxytocin are given. A positive contraction stress test result indicates that the fetus may be compromised and requires continued monitoring and further evaluation. A negative result indicates fetal well-being.
A nurse provides information to a pregnant client about foods that are high in iron. Which food, suggested by the client after this discussion, indicates that the client requires further instruction?
Spinach
Tomatoes
Lima beans
Whole-grain bread
B
A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client’s temperature: 100.8°F (38.2°C). Which of the following actions on the part of the nurse is appropriate?
Documenting the temperature
Retaking the temperature rectally
Notifying the primary health care provider
Informing the client that a temperature of 100.8°F is normal during pregnancy
C
A client who is 8 weeks pregnant reads her electronic medical record via a patient portal. She contacts the clinic and asks the nurse to explain a “positive Hegar sign.” Which is the best answer for the nurse to provide?
“You are able to feel fetal movement.”
“A soft blowing sound can be heard with a stethoscope.”
“The lower part of your uterus is softer than when you are not pregnant.”
“You are experiencing irregular painless contractions during the pregnancy.”
C
Softening and compressibility of the lower uterine segment, occurring around the sixth week of pregnancy, is called the Hegar sign.
A nurse has provided dietary instructions to a pregnant client with diabetes mellitus. Which patient statement indicates the patient understands the teaching?
“I should increase my fat intake to ensure that the baby gains weight.”
“I’ll need to start a high-protein, high-fat diet to help control the blood glucose level.”
“I should add extra glucose to the diet because additional calories are needed during pregnancy.”
“I will need to increase fiber in the diet to help control the blood glucose level and prevent constipation.”
D
A nurse is performing an initial assessment of a pregnant adolescent client with diabetes mellitus. The client says to the nurse, “I’ve stopped my insulin and cut back on my food.” Which client concern does the nurse recognize as the priority?
Concern about nutritional deficiency
Concern about getting stretch marks
Concern about being able to care for the infant
Concern about what her friends might think about her wearing maternity clothes
A
A nurse is monitoring a client in precipitous labor. The nurse would contact the primary health care provider on noting which concern?
Fetal descent of 1 cm/hr
A reassuring fetal monitoring pattern
Cervical dilation of 2 to 4 cm/hr during the active phase
Shortening periods of uterine relaxation between contractions
D
A pregnant client complains of heartburn, and the nurse provides instruction regarding measures to alleviate the problem. The nurse tells the client to take which action?
Lie down right after meals
Take antacids as often as necessary
Eat three meals a day and avoid eating between meals
Sleep with an extra pillow under the head and shoulders
D
A nurse provides instructions to a pregnant woman about foods that contain calcium. The nurse realizes the client understands instructions if the client selects which products? Select all that apply.
Cheese
Yogurt
Spinach
Sardines
Shellfish
A, B, D
A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate?
Administering the vaccine
Contacting the primary health care provider
Asking the laboratory to repeat the CD4+ test
Informing the child’s mother that the vaccine must not be administered at this time
A
The normal CD4+ count is 500 to 1600 cells/mm3. Because this child’s CD4+ count is 1000 cells/mm3, the nurse would administer the vaccine.
A client in a manic state emerges from her room wearing provocative clothing and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. Which is the priority nursing action?
Ask the client to go to her room and to change her clothes
Tell the client firmly that burlesque shows are not allowed in the nursing unit
Tell the client that her bathroom privileges are being suspended because of her behavior
Quietly and firmly assist the client to her room and help her dress in appropriate clothes
D
A client who has just received a diagnosis of asthma says to the nurse, “This is just another nail in my coffin.” Which response by the nurse is therapeutic?
“Do you think that having asthma will kill you?”
“You seem very distressed at learning that you have asthma.”
“I’m not going to work with you if you can’t view this as a challenge rather than a ‘nail in your coffin.'”
“Asthma is a very treatable condition, but it’s important to learn how to properly administer your medications. Let’s practice with your inhalant.”
B
During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which statement by the nurse is appropriate?
“You seem upset. Would you rather be alone?”
“You’re crying. Tell me more about how you are feeling.”
“Your surgeon is the best and has done many of these operations.”
“Crying before a serious operation is common, but everything will be okay.”
B
A client hospitalized on a mental health unit with schizophrenia tells the nurse, “The voices in my head say that I’m worthless and that I don’t deserve to be alive.” What is the nurse’s priority concern for this client?
Ineffective coping skills
Perceptual disturbances
Chronic low self-esteem
Risk for self-directed violence
D
A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault. The client says to the nurse, “It still doesn’t seem real.” The nurse is considering requesting a referral to a mental health professional because which defense mechanism has been used for an extensive period of time?
Denial
Projection
Rationalization
Intellectualization
A
A nurse completes an initial assessment of a client admitted to the mental health unit. Which assessment finding is the priority concern?
Bruises on the client’s neck
The client’s report of not sleeping well
The client’s report of suicidal thoughts
The spouse’s statement “I don’t approve of this treatment.”
C
A client who is delusional says to the nurse, “Terrorists have been sent here to kill me.” How should the nurse respond to the client?
“No one is going to kill you.”
“Your medication is making you feel like this.”
“Are you worried that people are trying to hurt you?”
“What makes you think that terrorists were sent to hurt you?”
C
A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client?
“Leave the room.”
“Go to the nurses’ station until our group therapy session is finished.”
“I will recommend that group therapy be eliminated from your treatment plan.”
“Thank you for your comments. Now, try to stop talking and listen to the others.”
D
A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by providing which explanation?
The pain is a normal, temporary condition
The pain occurs because nerves have been cut
This pain will go away once a prosthesis is used
Pain medication may be needed for life to alleviate the discomfort
A
Phantom limb pain is a temporary condition that some people who undergo amputation experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child should be reassured that the condition is normal.
A woman whose husband died 2 months ago says to the visiting nurse, “My daughter came over yesterday to help me move my husband’s things out of our bedroom, and I was so angry with her for moving his belongings from where he always kept them. She doesn’t know how much I’m hurting.” Which statement by the nurse would be therapeutic?
“I know just how you feel, because I lost my husband last summer.”
“It’s OK to grieve and be angry with your daughter and anyone else for a time.”
“You need to focus on the many good years you enjoyed together and move on.”
“I know it’s a troubling time for you, but try to focus on your children and grandchildren.”
B
The mother of 6-year-old twins says to the nurse, “My mother-in-law doesn’t think that the twins should come to the funeral service for their grandfather. What do you advise?” Which response by the nurse would be therapeutic?
“What do you and your husband believe is the right thing for your children?”
“By all means have them attend. Keeping them home will only prolong their grief. “
“I agree with your mother-in-law. Just tell your children that their grandfather is in heaven.”
“It’s a difficult decision, but given their young age, maybe it would be best to keep them home from the wake and just let them attend the funeral.”
A
The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client’s cardiac monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
The nurse should suspect
Your Answer: hypokalemiaCorrect Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect Answer: flattened T waves and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client’s vital signs and cardiac status for signs of hypokalemia. The nurse should also check the client’s most recent serum potassium level and then contact the primary health care provider to report the findings and obtain prescriptions to treat the hypokalemic state.
The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to this personal item? Click to highlight the correct answer from the options provided.
The nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
Rationale:Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body because of client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of such an item and its removal because it may have cultural or spiritual significance. If so, the nurse should ask the client if the item can be either removed temporarily or placed on another part of the body during the procedure if appropriate.
While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: “I have changed my mind. I don’t want this surgery.” Click to highlight the correct answer from the options provided.
The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
✓Discuss the client’s concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
✓Further questions or concerns should be determined and addressed.
Ethical considerations are important for a client undergoing surgery.
The nursing scope of practice places limitations on how the nurse can respond.
Rationale:If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client’s request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would then withhold further surgical preparation and contact the surgeon to report the client’s request so that the surgeon can discuss the consequences of not having the surgery with the client. Further assessment and follow-up related to the client’s request need to be done. It is the client’s right to refuse treatment; however, further investigation is needed so the interventions can be tailored to specific needs.
The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program?For each action, click to specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
Non-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problem
Contraindicated: an action that could harm the client and should not be taken
Collect identifying patient information
Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance improvement, focuses on processes or systems that significantly contribute to client safety and effective client care outcomes; criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. If the nurse notes a particular problem, such as an increase in the number of intravenous (IV) site infections, the nurse should collect data about the problem. This should include information such as the primary and secondary diagnoses of the clients developing the infection, the type of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse should examine evidence-based practice protocols to identify the best practices for care to IV sites to prevent infection. These practices can then be implemented and followed by evaluation of results based on the evidence-based practice protocols used. Collecting identifying client information is contraindicated because of confidentiality and is unnecessary in this quality improvement effort. Noting the mental status of the clients can be done but is not likely to address the problem. Noting the types of medications being infused can also be done, but will not address the problem of IV site infection. Although it is helpful to know the expected duration of the IV site, this information does not change infection control practices in managing the IV site and is therefore considered a non-essential action.
The nurse performs an Allen’s test on a client scheduled for an arterial blood gas draw from the radial artery. On release of pressure from the ulnar artery, color in the hand returns after 20 seconds. How should the nurse interpret the finding? Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
The test result is
Your Answer: Abnormal Correct Answer: Abnormal
because
Your Answer: The time for color to return is prolonge Correct Answer: The time for color to return is prolonged
Rationale:Failure to determine the presence of adequate collateral circulation before drawing an arterial blood gas specimen could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Another site needs to be selected for the arterial puncture, and the primary health care provider needs to be notified of the finding.
The nurse has just received a client from the postanesthesia care unit (PACU) and is monitoring the client’s vital signs. Click to highlight the current finding(s) that would be essential to follow up on. Highlight only finding(s) that require follow-up. To deselect a finding, click the finding again.
30 min ago:
BP= 142/78
HR= 98
RR= 14
Temp= 37.2 C
O2 sat= 95% 3L NC
Current:
BP= 95/54 (F/U correct)
HR= 118 (F/U correct)
RR= 18
Temp= 36.8 C
O2 sat= 91% 3L NC (F/U correct)
Rationale:Some of the client’s vital signs are showing a significant change, particularly the blood pressure, heart rate, and oxygen saturation levels. The nurse should first compare the current vital signs to the set of baseline vital signs obtained when the client arrived to the unit. This provides information about how much of a change has occurred in these parameters. The nurse should quickly consider the following when determining the next action: (1) What is the client’s condition? Is the client responding to stimuli? (2) Does the oxygen saturation increase if the client deep breathes? (3) Is the equipment working properly? (4) Is the correct equipment being used? (5) Is there a condition or procedure in the client’s history that can be attributed to this change? (6) Are there environmental factors that could influence the change in the client’s vital signs? (7) Does this change in the client necessitate contacting the surgeon? Given the significant changes from the baseline vital signs, and after checking the client and equipment to ensure it is working properly, the nurse should then determine that it is necessary to contact the surgeon to inform him or her of this change, especially considering that the client recently had surgery and there is a potential for bleeding. The nurse should determine if there is any sign of bleeding such as drainage on the dressing, bloody output in a surgical drain, or swelling in the surgical area suggestive of hematoma. The charge nurse should also be informed of the change in client status.
A client has been diagnosed with chronic kidney disease. The nurse anticipates specific dietary prescriptions due to the risks associated with chronic kidney disease. Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
The nurse should note the client is
Your Answer: On a fluid restriction
Correct Answer: On a fluid restriction
because
Your Answer: Of the risk of hypervolemia
Correct Answer: of the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: Chew gum
Correct Answer: Chew gum
because
Your Answer: it doesn’t contribute to hypervolemia
Correct Answer: it doesn’t contribute to hypervolemia
Rationale:The client with chronic kidney disease may be placed on fluid restriction because of decreased renal function and glomerular filtration rate, resulting in fluid volume excess. To allow the kidneys to rest, decreased fluid consumption may be indicated. When a client is placed on this restriction, increased thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to promote adherence to the fluid restriction. These measures include chewing gum or sucking hard candy, freezing fluids so they take longer to consume, adding lemon juice to allowed water to make it more refreshing, and gargling with refrigerated mouthwash.
A client with a peripherally inserted central catheter (PICC) in the right upper extremity suddenly exhibits chest pain, dyspnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC line. What should the nurse do?For each action, click to specify whether the action would be:Indicated: an action that the nurse should take to resolve the problemNon-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problemContraindicated: an action that could harm the client and should not be taken
Action
Assess for fever
Non-essential
Assess for chest pain
Indicated
Assess for cyanosis
Indicated
Turn the client to the left side
Indicated
Position the client so the feet are lower than the head
Contraindicated
Administer oxygen
Indicated
Place the client on continuous vital sign monitoring
Indicated
Notify the primary health care provider
Indicated
Rationale:When a client has any type of central venous catheter, there is a risk for breaking of the catheter, dislodgement of a thrombus, or entry of air into the circulation, all of which can lead to an embolism. Signs and symptoms that this complication is occurring include sudden chest pain, dyspnea, tachypnea, hypoxia, cyanosis, hypotension, and tachycardia, and the nurse would assess for these findings. If this occurs, the nurse should clamp the catheter, place the client on the left side with the head lower than the feet (not the feet lower than the head) to trap the embolism in the right atrium of the heart, administer oxygen, and notify the primary health care provider. Continuous vital sign monitoring should also be done to note for changes in the client’s condition. There is no reason for assessing for a fever at this time.
The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has never received a blood transfusion. The nurse suspects a transfusion reaction based on clinical presentation. Based on this scenario, select the initial clinical findings for each suspected condition
Acute hemolytic reaction
1
Allergic reaction
3-4-5
Fluid volume overload
2
Back pain(1)
Difficulty breathing(2)
Rash(3)
Urticaria(4)
Pruritis(5)
Rationale:There are different types of blood transfusion reactions, including fluid volume overload, allergic reaction, and acute hemolytic reaction. In general, signs of an immediate transfusion reaction include the following: chills and diaphoresis; muscle aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse; dyspnea, cough, or wheezing; pallor and cyanosis; apprehension; tingling and numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. An acute hemolytic reaction is usually characterized by back pain initially. An allergic reaction is manifested by rash, urticarial, and pruritis as initial signs. Fluid volume overload often is noted by difficulty breathing in the early phase.
The nurse is assessing an infant with clubfoot who is in a cast. The nurse notes the following clinical findings on assessment.Vital signs:
Blood pressure 90/60 mm Hg
Heart rate 112 beats per minute
Respirations 24 breaths per minute
Oxygen saturation 98% on room air
Temperature 36.4° C (97.5° F)
Musculoskeletal findings : Tissue distal to the cast is pale and edematous.The infant shows signs of pain with passive movement.
Which actions should the nurse take? Select all that apply.
1.Notify the surgeon
2.Administer topical pain medication
3.Administer anticoagulant medication
4.Contact the physical therapy department
5.Assess distal pulses on bilateral extremities
1 & 5
Rationale:Compartment syndrome is a condition in which pressure increases in a confined anatomical space, leading to decreased blood flow, ischemia, and dysfunction of these tissues. This complication can occur with casts. Signs of this complication include unrelieved or increased pain in the limb; pale, dusky, or edematous tissue distal to the involved area; pain with passive movement; loss of sensation (paresthesia); and pulselessness (a late sign). In this scenario, the nurse should assess the distal pulses on bilateral extremities. Noting a difference between the 2 extremities is helpful in determining the presence of compartment syndrome. The nurse should contact the surgeon immediately if signs of neurovascular impairment are noted in a child with a cast or brace because of the risk of tissue ischemia and necrosis. Administering topical pain medication is not helpful because of the severity of the pain, and relief of the pressure is the priority and ultimately will relieve the pain. Administering anticoagulant medication does not address the problem of the pressure from the tight compartment. Contacting the physical therapy department is unnecessary and does not help to address this complication.
The nurse is working in a long-term care facility that has a “no restraint policy.” An assigned client is disoriented and unsteady and continually attempts to climb out of bed. Which interventions and supporting rationales are appropriate in this scenario? Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
The nurse should
Your Answer: Implement other safety strategies
Correct Answer: Implement other safety strategies
due to
Your Answer: The risk for further injury with restraints
Correct Answer: The risk for further injury with restraints
Type in 3 safety strategies the nurse should implement:
Any 3 of the following would be correct:
Orienting the client and family to the surroundings
Explaining all procedures
Encouraging family and friends to stay
Assigning confused or disoriented clients to a room near the nurses’ station
Providing appropriate stimuli to the client
Maintaining toileting routines
Eliminating bothersome treatments
Using relaxation techniques
Instituting an ambulation schedule
Rationale:Many facilities implement a “no restraint policy,” which requires health care workers to implement other safety strategies for clients who pose a risk for falls. These strategies include orienting the client and family to the surroundings; explaining all procedures and treatments to the client and family; encouraging family and friends to stay with the client as appropriate and using sitters for clients who need supervision; assigning confused and disoriented clients to rooms near the nurses’ station; providing appropriate visual and auditory stimuli to the client, such as a night-light, clock, calendar, television, or radio; maintaining toileting routines; eliminating bothersome treatments, such as tube feedings, as soon as possible; evaluating all medications that the client is receiving; using relaxation techniques with the client; and instituting exercise and ambulation schedules as the client’s condition allows. Some agencies are instituting certain policies, such as hourly rounding, to ensure client safety. With hourly rounding, nurses and assistive personnel are required to check the client to address the 5 Ps—problem, pain, positioning, potty, and possessions—every hour. This helps to eliminate the need to call for assistance and ensures that the client’s basic needs are being met in a timely manner.
The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. In considering the child’s developmental stage, the nurse should determine that this is an expected finding. Using Freud’s psychosexual stages of development, identify the behaviors associated with the various stages that can be taught to the mother to alleviate her concerns. Select the behaviors that associate with Freud’s psychosexual stages of development.
Oral
Correct Answer:4. Mouth-sucking and swallowing
Anal
Correct Answer:3. Withholding or expelling feces
Phallic
Correct Answer:1. Masturbation
Latent
Correct Answer:5. Little to no sexual motivation present
Genital
Correct Answer:2. Sexual intercourse
Rationale:According to Freud’s psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining genitalia, masturbating, and expressing interest in sexual concerns. The oral phase is associated with mouth-sucking and swallowing, the anal with withholding or expelling feces, the latent with little to no sexual motivation, and genital with sexual intercourse. The nurse should alleviate the mother’s concern by telling the mother that this behavior is normal.
A pregnant client with diabetes mellitus asks the nurse about insulin needs during pregnancy. What information should the nurse provide to the client? Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
Pregnancy places demands on
Correct Answer: Carbohydrate…
metabolism and causes insulin requirements to change.
Maternal
Correct Answer: Glucose…
crosses the placenta, but
Correct Answer: Insulin
does not….
During the
Correct Answer: First…
trimester, maternal insulin needs decrease.
During the
Correct Answer: Second…
and
Correct Answer: Third…
trimesters, increases in placental hormones cause an insulin-
Correct Answer: Resistant…
state, requiring a(n)
Correct Answer: Increase…
in the client’s insulin dose.
Due to the fact that the fetus produces its own
Correct Answer: Insulin…
and pulls
Correct Answer: Glucose…
from the mother, the mother is predisposed to
Correct Answer: Hypoglycemic
reactions.
Rationale:The nurse should begin by explaining to the client that pregnancy places demands on carbohydrate metabolism and causes insulin requirements to change. The nurse should inform the client that maternal glucose crosses the placenta, but insulin does not. During the first trimester, maternal insulin needs decrease. During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the client’s insulin dose. After placental delivery, placental hormone levels abruptly decrease and insulin requirements decrease. In addition, the fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions.
The nurse is caring for a pregnant client in labor at 33 weeks’ gestation, who experiences premature rupture of the membranes (PROM).Progress Notes:
1400 The nurse was notified regarding the lecithin/sphingomyelin (L/S) ratio of 1.5:11430 Fetal heart rate 134 beats per minute with variability
What actions should the nurse take?For each action, click to specify whether the action would be:Indicated: an action that the nurse should take to resolve the problem Non-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problem Contraindicated: an action that could harm the client and should not be taken
Imminent delivery
3
Administration of corticosteroids
1
Hospitalization
1
Cesarean section on a specified date
2
Administration of magnesium sulfate
2
Administration of broad-spectrum antibiotics
1
Routine prenatal care
3
Indicated(1)
Non-essential(2)
Contraindicated(3)
Rationale:Management of PROM is done on an individualized basis, depending on certain risk factors. Labor and birth may be actively pursued if the PROM occurred between 34 and 36 weeks’ gestation, as well as for women with PROM at 32 to 33 weeks’ gestation if fetal lung maturity can be documented. PROM before 32 weeks’ gestation is usually managed conservatively with hospitalization to prolong the pregnancy. Considering the progress for the infant in this scenario, the infant’s lungs are considered to be mature when the L/S ratio reaches 2:1. A ratio of 1.5:1 is low and indicates that if the infant were born now, he or she may be at risk for complications related to lung immaturity. A fetal heart rate of 134 beats per minute is considered normal at this gestational age. Because of these reasons, imminent delivery would be considered contraindicated because the infant’s lungs need to mature, and fetal well-being is noted on interpretation of the fetal monitor. Administration of corticosteroids would be indicated to promote fetal lung maturity in the event of imminent delivery due to other complications arising, such as intrauterine infection or umbilical cord compression as a result of PROM. Hospitalization, or daily monitoring, is indicated to monitor for these complications. A cesarean section scheduled for a specific date is non-essential, as this mother may still be able to have a vaginal delivery unless there are other indications for a cesarean section. Administration of magnesium sulfate is non-essential and is usually reserved for PROM before 32 weeks’ gestation who are thought to be at imminent risk for giving birth prematurely. Administration of broad-spectrum antibiotics is indicated and has been shown to significantly increase the time between membrane rupture and birth, reduce infections, decrease the need for infant oxygen and surfactant therapy, as well as reduce the risk for intraventricular hemorrhage in the infant. Routine prenatal care is contraindicated as this mother and infant require daily monitoring at a minimum.
The nurse is caring for a client in the office setting who gave birth to a healthy infant 18 days ago by cesarean section after she had a prolonged labor and required artificial rupture of the membranes.
Time: 1000
Vital signs:
Blood pressure 108/74 mm Hg
Heart rate 112 beats per minute
Respirations 18 breaths per minute
Oxygen saturation 98% on room air
Temperature 101.2° F (38.4° C)
Additional Assessment Findings:Reports fatigue, chills, nausea, and pelvic pain
Tenderness noted on palpation of the abdomen and profuse lochia noted
Which actions should the nurse take? Select all that apply.
1.Encourage increased water intake
2.Encourage hot tub use for comfort measures
3.Discuss a home exercise program with the client
4.Obtain a prescription for blood and urine cultures
5.Discuss initiating antibiotics with the obstetrician/gynecologist
6.Obtain a prescription for a complete blood count with differential
1 4 5 6
Rationale:A temperature of 100.4° F (38° C) is normal during the first 24 hours postpartum because of dehydration; a temperature of 100.4° F (38° C) or greater after 24 hours postpartum indicates infection. Therefore, if the temperature is 101.2° F (38.4° C) 18 days postpartum, the nurse should report the finding to the obstetrician/gynecologist. The likely diagnosis in this case is endometritis, which usually begins as a localized infection at the placental site, which can spread to the entire endometrium. Risk factors for this client include giving birth by cesarean section after a prolonged labor and artificial rupture of the membranes. The client should be encouraged to increase hydration, rest, and use pain relief measures. Although comfort measures such as rest, cool compresses, warm blankets, perineal care, and sitz baths may be helpful, sitting in a hot tub has the potential to worsen the infection. At this time, the client should be encouraged to rest rather than engage in a home exercise program. Blood cultures, urine cultures, intracervical or intrauterine cultures, complete blood count with differential, and sedimentation rate are helpful in diagnosing the problem. Management of this problem consists of intravenous broad-spectrum antibiotic therapy and supportive care.
The nurse is performing an initial assessment on a newborn and notes that the newborn is experiencing slight tremors.Time: 0730Vital signs:
Blood pressure64/41 mm HgHeart rate142 beats per minuteRespirations50 breaths per minuteOxygen saturation98% on room airTemperature36.4° C (97.5° F)
Which actions should the nurse take? Select all that apply.
1.Check the newborn’s stool
2.Check the newborn’s weight 3.Check the newborn’s glucose level
4.Check the newborn’s calcium level
5.Check the newborn for responsiveness
3 4 5
Rationale:Noting that the newborn’s vital signs are normal, the nurse should consider some of the common causes of tremors in a newborn, as opposed to an infectious process. A tremor is noted to be repetitive movements of both hands with or without movement of the legs or jaw 2 to 5 times per second lasting more than 10 minutes. Slight tremors noted in the newborn may be a common finding but could also be a sign of hypoglycemia, hypocalcemia, or drug withdrawal. It can also be a sign of neurological damage, so this possibility should be addressed, although most tremors have no pathological significance. The nurse should determine the presence of tremors so that treatment can be initiated immediately. This finding should also be reported to the primary health care provider immediately. Checking the newborn’s glucose level, calcium level, and level of responsiveness will provide information directly related to the potential cause of the tremors. The newborn’s stool and weight patterns are not directly related to the tremors.
A 4-year-old child admitted 1 day ago to the pediatric unit is suspected of having periorbital cellulitis of the right eye with associated impetigo. Which of the current findings would be essential to follow up on?Click to highlight the current finding(s) that would be essential to follow up on. Highlight only finding(s) that require follow-up. To deselect a finding, click the finding again.
ParameterCurrent8 hours ago24 hours agoBlood pressure92/64 mm Hg98/70 mm Hg99/70 mm HgPulse✓126 beats per minute120 beats per minute116 beats per minuteRespirations18 breaths per minute20 breaths per minute18 breaths per minuteOral temperature✓38.4° C (101.2° F)37.8° C (100° F)37.6° C (99.9° F)
Laboratory testCurrent24 hours agoWhite blood cell✓18,400/mm3 (18.4 x 103/uL)15,200/mm3 (15.2 x 103/uL)Hemoglobin15.2 g/dL (152 mmol/L)15.0 g/dL (150 mmol/L)Hematocrit38% (0.38)39% (0.39)
Cranial nerve testCurrent24 hours agoCranial nerve II20/20 left eye20/20 both eyes✓20/40 right eyeCranial nerve IIIExtraocular movements intact,Extraocular movements intact, no nystagmus✓pain associated with movements in right eye
2 4 5 9 11
Rationale:Periorbital cellulitis is an acute infection characterized by pain, erythema, and edema of the anterior eyelid and tissue surrounding the eye. The risk with periorbital cellulitis is that it can progress to orbital cellulitis and can threaten vision. Antibiotics should be prescribed, and intravenous antibiotics may be required depending on the clinical findings. If bacteremia is suspected, a complete blood count may be done, and vital signs will be monitored closely. Physical assessment should focus on visual acuity and extraocular movements. An increase in pulse rate, increase in temperature, increased white blood cell count, decreased visual acuity, and increased pain on extraocular movements in the affected eye are all findings that constitute a worsening of the condition and should be followed up on promptly to preserve vision.
The nurse caring for a child with a diagnosis of leukemia receives a report from the laboratory indicating that the white blood cell count is 2000/mm3 (2.0 × 109/L) and the absolute neutrophil count (ANC) is 40% (0.40). Vital signs are unchanged from baseline and the child denies pain. The nurse determines that further actions are needed to care for this client based on this information. Fill in the correct missing information by selecting from the lists of options in the drop-down menus.
ActionSupporting findingRationale
Your Answer:1. Private roomCorrect Answer:1. Private room
ANC less than 50% (0.50)Severe infection risk is presentAlcohol-based hand rub or hand washing
Your Answer:2. ANC less than 50% (0.50)Correct Answer:2. ANC less than 50% (0.50)
Severe infection risk is presentKeep fresh flowers out of the roomANC less than 50% (0.50)
Your Answer:1. Can harbor bacteriaCorrect Answer:1. Can harbor bacteria
1 2 1
Rationale:A white blood cell count of 2000/mm3 (2.0 × 109/L) and an absolute neutrophil count of 40% (0.40) are indicative of a neutropenic state, and the child should be placed on neutropenic precautions. The absolute neutrophil count (ANC) is the standard of care in determining whether a child is in a neutropenic state and the need for protective isolation and other hygienic measures. If the ANC is less than 50% (0.50), a severe infection risk is present. Interventions include a private room; good hand-washing technique or use of an alcohol-based hand rub before entering the child’s room and before touching the client or any belongings; ensuring that the child’s room and bathroom are cleaned a minimum of once per day; limiting the number of people entering the child’s room (no sick persons should enter the room); using strict aseptic technique for all invasive procedures; keeping fresh flowers and potted plants out of the room; and implementing a low-bacteria diet (no fresh fruits or vegetables or undercooked meats).
A child suddenly vomits. The nurse takes the following actions to ensure safety. Select the Rationale for each Nursing Action.
Nursing ActionsRationalPosition the child upright or on the side.Your Answer:1. This allows the child to maintain a patent airway.Correct Answer:1. This allows the child to maintain a patent airway.Perform oral suctioning.Your Answer:1. This allows the child to maintain a patent airway.Correct Answer:1. This allows the child to maintain a patent airway.Assess the character and amount of vomitus.Your Answer:3. This will provide information about possible causes of the vomiting episode.Correct Answer:3. This will provide information about possible causes of the vomiting episode.Assess the force of the vomiting.Your Answer:3. This will provide information about possible causes of the vomiting episode.Correct Answer:3. This will provide information about possible causes of the vomiting episode.Monitor intake and output and vital signs.Your Answer:2. This will be helpful in monitoring for complications of the vomiting episode.Correct Answer:2. This will be helpful in monitoring for complications of the vomiting episode.
Rationale:If a child suddenly vomits, the nurse must maintain a patent airway. The child should be positioned upright or on the side to prevent aspiration. Suctioning equipment should be obtained, kept at the bedside, and used if needed to assist in maintaining a patent airway. The nurse should check the character and amount of the vomitus as this will provide information about possible causes of the vomiting episode. The force of the vomiting should be assessed because projectile vomiting may indicate pyloric stenosis or increased intracranial pressure, which are possible causes. The nurse should also monitor intake and output and vital signs to monitor for the complication of dehydration.
The nurse is caring for an infant who underwent surgical repair of hypospadias. The infant weighs 4.5 kg.Progress Notes:1000: Urinary output 5 mL since 09001100 Urinary output 4.5 mL1200 Urinary output 4.2 mL1300: Urinary output 3.0 mL1400: No urinary outputWhat actions should the nurse take?For each action, click to specify whether the action would be:Indicated: an action that the nurse should take to resolve the problemNon-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problemContraindicated: an action that could harm the client and should not be taken
Action
Indicated(1) Non-essential(2) Contraindicated(3)
Increase the rate of intravenous fluids.IndicatedNon-essentialContraindicatedFlush the intravenous line.IndicatedNon-essentialContraindicatedIncrease the number of feedings.IndicatedNon-essentialContraindicatedPerform an abdominal assessment.IndicatedNon-essentialContraindicatedPerform perineal hygiene.IndicatedNon-essentialContraindicatedContact the surgeon.IndicatedNon-essentialContraindicated
3 2 3 1 2 1
Rationale:Following surgical repair for hypospadias, there is a risk for kinks in the urinary diversion or stent placed during the procedure, as well as an obstruction caused by sediment. To detect this complication, the urinary output is monitored closely. The nurse should perform an abdominal assessment to assess for bladder distention and notify the surgeon if there is no urinary output for 1 hour because these findings may indicate this complication. Increasing the rate of intravenous fluids and increasing the number of feedings are contraindicated because these actions could result in producing more urine, which could worsen the bladder distention and potentially lead to perforation. In addition, these actions do not address the problem of urinary obstruction and also should not be performed without a prescription. Flushing the intravenous line and performing perineal hygiene are non-essential and will not address the problem although it would not cause harm.
The charge nurse is preparing to make room assignments for the 8 clients below. What room assignments would result in a safe assignment for each client? Select an appropriate room and bed for each client. A maximum of two clients may occupy each room. Some clients may require a private room based on their diagnosis or current condition.
(DELETE SELECT)
8-year-old female with confirmed respiratory syncytial virusSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)205 (Private)11-year-old male with sickle cell anemia in sickle cell crisisSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)203-B5-year-old female admitted for new-onset seizures scheduled for an electroencephalogramSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)202-A18-year-old female admitted for drug overdose who is on a legal hold because of a suicide attemptSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)201 (Private)10-year-old male awaiting a surgical consult for fractured humerusSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)204-B17-year-old male, status post laparoscopic cholecystectomySelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)204-A7-year-old female admitted for complaints of abdominal pain awaiting surgical consult for suspected appendicitisSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)203-A18-year-old male admitted for observation following a head injury
Rationale:In considering room assignments, the charge nurse needs to consider the gender of the clients as well as their diagnosis or current condition. It is also helpful to consider the age of the clients because when clients are assigned to semiprivate rooms, it is better if they are also close in age. The 8-year-old female with confirmed respiratory syncytial virus should be in 1 of the 2 private rooms because she requires droplet isolation and contact precautions. The 18-year-old female admitted for drug overdose who is on a legal hold should also be in a private room because she will require one-to-one monitoring and suicide precautions. The 10-year-old male awaiting surgical consult for a fractured humerus and the 11-year-old male with sickle cell anemia in sickle cell crisis can be safely placed in the same room. The 5-year-old female admitted for new-onset seizures scheduled for an electroencephalogram and the 7-year-old female admitted for complaints of abdominal pain awaiting surgical consult for suspected appendicitis can be safely roomed together. The 17-year-old male, status post laparoscopic cholecystectomy and the 18-year-old male admitted for observation following a head injury can be safely placed in the same room.
The nurse is admitting a 42-year-old female client who is alone to the hospital unit with delirium. The nurse is reconciling the client’s medications and finds a handwritten list of home medications in the client’s wallet. The nurse transcribes the information that is available. Fill in the correct missing information by selecting from the lists of options in the drop-down menus.
MedicationDose, Route, FrequencyDrug ClassIndication
Your Answer:1. HydrochlorothiazideCorrect Answer:1. Hydrochlorothiazide
25 mg by mouth dailyThiazide diureticPrimary hypertensionBupropion ER150 mg by mouth twice dailyNorepinephrine-dopamine reuptake inhibitor
Your Answer:4. DepressionCorrect Answer:4. Depression
Norgestimate/ethinyl estradiol1 tab by mouth dailyHormonal contraceptive
Your Answer:3. Prevention of pregnancyCorrect Answer:3. Prevention of pregnancy
Alprazolam0.5 mg by mouth twice daily as needed
Your Answer:1. BenzodiazepinesCorrect Answer:1. Benzodiazepines
Generalized anxiety
Rationale:Hydrochlorothiazide is a thiazide diuretic used to treat primary hypertension. Bupropion is a norepinephrine-dopamine reuptake inhibitor and is used to treat depression. Norgestimate/ethinyl estradiol is a hormonal contraceptive and is used to prevent pregnancy. Alprazolam is a benzodiazepine and is used on an as needed basis for the management of generalized anxiety.
The nurse is performing an assessment on a 64-year-old African American client admitted with flank pain who has a history of type 2 diabetes mellitus, hypertension, and polycystic ovarian syndrome. The nurse notes the following clinical findings on assessment.Vital signs:
Blood pressure142/84 mm HgHeart rate90 beats per minute (bpm)Respirations18 breaths per minute (bpm)Oxygen saturation98% on room airTemperature98.9° F (37.2° C)
Laboratory test results:
Serum glucose226 mg/dL (12.6 mmol/L)Serum potassium3.9 mEq/L (3.9 mmol/L)Serum creatinine2.2 mg/dL (194.3 mcmol/L)Hemoglobin, glycosylated (HbA1c)10.8%Serum lactic acid level25.2 mcg/dL (2.8 mmol/L)Urine glucosePositiveUrine ketonesNegativeUrine bilirubinNegativeUrine pH5.6 (5.6)Urine proteinModerateUrine specific gravity1.032 (1.032)Urine bacteriaMany
Laboratory Physical assessment findings:
NeurologicalPERRLA (Pupils equal, round, reactive to light and accommodation)RespiratoryClear to auscultation bilaterallyCardiovascularS1, S2, no S3, S4, no murmurs, rubs, gallopsGastrointestinalBS (bowel sounds) normoactive in all 4 quadrants, soft, nontender, nondistended to palpationGenitourinaryNo suprapubic tenderness, no bladder distention; costovertebral angle tenderness noted bilaterally
Which actions should the nurse take? Select all that apply.
1.
Initiate a referral for nephrology
2.
Administer an as needed antianxiety medication
3.
Assess for neurological changes in the extremities
4.
Assess for a history of bacterial infections and antibiotic use
5.
Discuss with the primary health care provider about initiating a dietician referral
6.
Collaborate with the primary health care provider on prescribing further laboratory testing
1 3 4 5 6
Rationale:Given the client’s present and past medical history, as well as other clinical findings, it is appropriate to initiate a referral to nephrology. The client’s creatinine level is elevated, and there are abnormal findings on the urinalysis, including urine glucose, protein, and bacteria. The client also has flank pain. The client may be experiencing complications of type 2 diabetes mellitus and also is likely experiencing a urinary tract infection. The client is also showing signs of an ascending urinary tract infection, and septicemia should be a concern. Assessing for neurological changes in the extremities is an appropriate action as this is a common complication of poorly controlled diabetes mellitus (serum glucose of 226 mg/dL [12.6 mmol/L] and HbA1c is 10.8%). Assessing for a history of bacterial infections and antibiotic use is appropriate because this, along with a consistently elevated blood glucose level, predisposes the client to further bacterial infections such as urinary tract infection. A dietician referral would be appropriate for this client given the fact that her diabetes is poorly controlled as evidenced by the blood glucose level and HbA1c level. Further laboratory testing is likely indicated, specifically blood and urine cultures, to determine the extent of the disease and to guide further interventions in the care of this client.
A client who is bedbound and incontinent has been diagnosed with heart failure exacerbation. The nurse anticipates specific prescriptions due to the risks associated with heart failure. Fill in the correct missing information by choosing from the lists of options in the drop-down menus.
The nurse should note the client is
Your Answer: On a fluid restrictionCorrect Answer: On a fluid restriction
because
Your Answer: of the risk of hypervolemiaCorrect Answer: of the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: use lemon swabsCorrect Answer: use lemon swabs
because
Your Answer: it doesn’t contribute to hypervolemiaCorrect Answer: it doesn’t contribute to hypervolemia
The nurse notes that in order to effectively monitor diuretic therapy, a prescription for
Your Answer: an indwelling urinary catheterCorrect Answer: an indwelling urinary catheter
should be anticipated because
Your Answer: it allows for monitoring of a therapeutic effectCorrect Answer: it allows for monitoring of a therapeutic effect
Rationale:The client with heart failure exacerbation may be placed on fluid restriction because of altered cardiac output and overall cardiac function, resulting in fluid volume excess. To allow the heart to rest, decreased fluid consumption may be indicated. When a client is placed on this restriction, increased thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to promote adherence to the fluid restriction. These measures include chewing gum or sucking hard candy, using lemon swabs, freezing fluids so they take longer to consume, adding lemon juice to water to make it more refreshing, and gargling with refrigerated mouthwash. The client with heart failure exacerbation will likely be on diuretic therapy to manage the fluid volume excess. To effectively monitor for a therapeutic effect, the nurse should anticipate a prescription for an indwelling urinary catheter if the client is incontinent because the excess fluid is excreted by way of the kidneys in the form of urinary output. An increase in urinary output should occur if the diuretics are having a therapeutic effect, so strict intake and output monitoring is required in this scenario.
A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse?
1Write down potential solutions to the problems today by shift’s end
2Add this concern to the agenda of the next unit meeting
3Assure the staff nurse that the complaint will be investigated
4Explore for further identification about the nature of the problem
4 Explore for further identification about the nature of the problem
The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?
1″Ovulation, or midcycle is the best time to detect changes.”
2″Do the exam at the same time every month.”
3″Right after the period, when your breasts are less tender.”
4″The first of every month, because it will be easiest to remember.”
3
The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present?
1An open wound on the heel with minimal discomfort
2Occasional hiccups and sneezing
3Sustained insomnia and daytime fatigue
4Persistent dryness and itching of the perineal area
1An open wound on the heel with minimal discomfort-
A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman’s needs?
- 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear
- Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine
- 3 oz. chicken, one-half cup of corn, lettuce salad, small banana
- Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries
- Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries –
A nurse is taking a health history from parents of a child admitted with possible Reye’s syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye’s syndrome?
- Varicella
- Meningitis
- Hepatitis
- Rubeola
- Varicella –
A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: “I wonder if he has any idea how ridiculous he looks – he’s a grown man!” The nurse’s comment is an example of what type of attitude?
- Prejudice
- Ethnocentrism
- Discrimination
- Stereotyping
- Prejudice-
A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student’s question, what information should the nurse emphasize?
- Increased competition between health care insurers
- Increase in health care spending that’s growing faster than the economy
- Increase in the population who have health insurance
- Increase in spending for end-of-life treatment
2
A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child?
- Maintain hydration and encourage fluids
- Implement droplet precautions
- Monitor respiratory rate and oxygen saturation
- Anti- infective therapy
2
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse?
1Complaints for the feeling of pulling on the urinary catheter
2Light, pink to clear urine
3Occasional suprapubic cramping
4Minimal drainage into the urinary collection bag
4Minimal drainage into the urinary collection bag
A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time?
1Risk for fluid volume deficit
2Risk for excessive bleeding
3Risk for infection –
4Altered tissue perfusion
3
A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?
1Hypothermia
2Nausea and vomiting
3Hypoventilation
4Bradycardia
2
A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure?
1Place the hands or a folded blanket under the head of the child
2Provide privacy as much as possible to minimize frightening the other children
3Move any chairs or desks at least three feet away from the child
4Note the sequence of movements with the time lapse of the event
1Place the hands or a folded blanket under the head of the child –
A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client?
1Droplet
2Contact
3Standard
4Airborne
4
A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)?
1″I have active tuberculosis.”
2″I have been exposed to mycobacterium tuberculosis.”
3″I have never been infected with mycobacterium tuberculosis.”
4″I have never had tuberculosis.”
2
A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment?
1Wheezes
2Friction rubs
3Rhonchi
4Diminished sounds
3
A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, “I am a government official and spies are following me.” Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?
1Listen quietly without comment
2Ask for further information on the spies
3Confront the client about the delusions
4Contact security for potential safety concerns
1Listen quietly without comment –
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?
1Less jaundice
2Increased appetite
3Decreased lethargy
4Less edema
3
The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications?
1Employer policy and procedures manuals
2Nursing faculty from a local nursing program
3The nurse practice act of the state in which the practice takes place
4American Nurses Association (ANA) professional standards
3
The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?
1Dry off infant with a warm blanket or towel
2Apply identification bracelets
3Assign the one-minute APGAR score
4Obtain vital signs
1Dry off infant with a warm blanket or towel –
The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed?
1″I will make an effort to talk with someone about my feelings if I start to feel overwhelmed.”
2″It’s common for women with postpartum depression to have delusions about the infant.”
3″Women with postpartum depression have feelings of guilt and worthlessness.”
4″I may experience postpartum depression up to a year after delivery.”
2
The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included?
1Diarrhea, dry mouth, weight loss, reduced libido
2Tachycardia, blurred vision, hypotension, anorexia
3Orthostatic hypotension, vertigo, reactions to tyramine, nausea
4Photosensitivity, seizures, edema, hyperglycemia
1Diarrhea, dry mouth, weight loss, reduced libido
A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin?
1Use the pulse reading from the electronic blood pressure device
2Take a radial pulse, counting for a full 60 seconds
3Check for a pulse deficit at least twice with another nurse
4Assess the apical pulse, counting for a full 60 seconds
4Assess the apical pulse, counting for a full 60 seconds –
A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client’s refusal of the medication?
1″You need to take your medicine. This is how you get better.”
2″What is it about the medicine that you don’t like?”
3″I can see that you are uncomfortable right now; let’s talk about it tomorrow.”
4″If you refuse your medicine, tell me how do you think you will get better?”
2
A parent expresses frustration and anger about the toddler constantly saying “no” and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need?
1Self-esteem
2Initiative
3Independence
4Trust
3
The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function?
1Squeeze the trapezius muscle firmly
2Lift the client’s arm and observe for pronation and drift
3Apply finger tip pressure for 10 seconds
4Rub the sternum with the knuckles
1Squeeze the trapezius muscle firmly –
A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?
1Discontinue breastfeeding during treatment
2Rotate the neonate to treat all of his/her skin
3Restrict holding the newborn during treatment
4Provide more frequent feedings
4Provide more frequent feedings-
A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, “You think you’re so perfect, pure and good.” How should the nurse respond?
1″You seem to be in a bad mood.”
2″Perfect? I don’t quite understand.”
3″You sound angry right now.”
4″That explains why you’ve been staring at me.”
3
The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day?
1It can cause severe headaches
2It may no longer work as well
3It will cause profound hypotensive effects
4it will irritate the skin
2
A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?
1Compare daily infant weights
2Monitor the infant’s urine output
3Ensure appropriate fluid intake
4Maintain accurate intake and output
2
A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point?
1They can expect the child will be mentally retarded
2Administration of a thyroid hormone will prevent problems
3This rare condition is hereditary
4Physical growth and development will be delayed
2
A child is admitted to the hospital for emergency surgery. The child’s parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about?
1Perfumed soap
2Shellfish
3Balloons
4Mold
3
A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action?
1Assist the woman to empty her bladder
2Monitor the pulse and blood pressure
3Call the registered nurse (RN) immediately
4Check lochia for color and amount
1Assist the woman to empty her bladder –
The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider?
1Diminish destructive behavior through peer pressure
2Plan strict schedules with defined expectations
3Punish inappropriate behavior as it occurs
4Achieve a client’s therapeutic goals
4Achieve a client’s therapeutic goals –
A client tells a nurse, “I have something very important to tell you if you promise not to tell anyone.” Which statement by the nurse would be the most appropriate response?
1″That depends on what you tell me.”
2″I must report everything to the treatment team.”
3″All right, I promise.”
4″I can’t make such a promise.”
4″I can’t make such a promise.” –
A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment?
1″I know I must avoid crowds.”
2″I will report any bruises or bleeding.”
3″I plan to use an electric razor for shaving.”
4″I will keep all laboratory appointments.”
1″I know I must avoid crowds.” –
The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene?
1Validate the client’s advance directive
2Participate with the compressions or breathing as requested by the first nurse
3Bring the code cart –
4Relieve the first nurse on the scene and continue single person CPR
3
The nurse and client are discussing the client’s progress toward understanding the client’s behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship?
1Termination
2Working –
3Orientation
4Pre-interaction
2
The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers?
1Ambulatory client who had three incontinent diarrhea stools in the past 24 hours
2Ambulatory older adult diagnosed with type 2 diabetes for the past 20 years
3Obese client who uses a wheelchair throughout the facility
4Malnourished older adult client who is on bed rest
4
A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client’s status?
1Glasgow Coma Scale 13, no ventilator required
2Glasgow Coma Scale 8, respirations regular –
3Appears to be sleeping, vital signs stable
4Comatose, breathing unlabored; is resting
2
A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time?
1Notify the health care provider of the client’s failure to follow the prescribed diet
2Make a referral to Meal-on-Wheels for delivery of one meal three times a week
3Discuss the diet with the client to learn the reasons for not following the diet –
4Recommend a release from home health care related to noncompliance
3
A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance?
1Trends in daily weights –
2Skin turgor over at least two areas of the body
3Changes in mucous membrane moistness
4Difference between intake and output
1Trends in daily weights –
The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse?
1Hematemesis –
2Pink-tinged saliva
3Serosanguinous drainage from the IV site
4Slight rust-colored urine
1Hematemesis –
The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse?
1Check the distal circulation of the casted extremity
2Obtain the pulse oximetry reading
3Measure the client’s blood pressure in the supine and Fowler’s positions
4Check the orientation to time, place and person
2
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube?
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shift
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate –
3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate –
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shifto the G-tube
4Measure the length of tubing from the insertion site each shift
The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition?
1Pronounced wheezes
2Pain on deep inspiration
3Sudden back pain
4Sudden dyspnea
4
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure?
1The surgical repair of a diseased coronary artery
2An noninvasive radiographic examination of the heart
3A process to compress arterial plaque to improve blood flow
4The placement of an automatic internal cardiac defibrillator
3
A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child’s birth, which of these responses might the nurse expect from the grandparents?
1Anger
2Disbelief
3Depression
4Frustration
2
The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU?
1An ICU nurse and intensivist remotely monitor ICU clients around the clock
2An ICU nurse is on-call to answer questions when needed
3Clients can ask the intensivist for a second opinion
4Less staff is needed on site when a remote eICU is available
1
A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result?
1Provide a well-balanced nutritional intake
2Promote healing and strengthen the immune system
3Spare protein catabolism to meet metabolic and healing needs
4 stimulate increased peristalsis and nutrient absorption
3
A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse?
1″Use this medication at bedtime to promote rest.”
2″Notify the health care provider if your canister lasts only two weeks.”
3″Inhale this medication after other asthma sprays.”
4″Discontinue the inhaler if you are dizzy.”
2
An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client’s condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate?
1Notify the attending physician
2Consult the charge nurse and prepare to transfer the client to an intensive care unit
3Call the rapid response team
4Contact the family member indicated in the admission forms
1
The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care?
1Safety
2Elimination
3Rest
4Nutrition
1
A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance?
1Iron
2Calcium
3Vitamin E
4Vitamin K
4
The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase?
1The client revitalizes a relationship with the family to help in coping with a child’s death
2The client recognizes feelings and expresses them appropriately
3The client expresses a desire to be mothered and pampered
4The client recognizes regression as a part of a defense mechanism
2
During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately.
During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately.
An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client’s behalf
A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion?
1Proximity to emergency services
2Number of children in the home
3Knowledge level of the parents
4Age of children in the home
4
When reviewing the medication lithium with a client, the client asks, “How long will it take before I can feel the effects of the medication?” Which response by the nurse is the best?
1″About two weeks”
2″One month”
3″Immediately”
4″Several days”
1
A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy?
1Ambulate the client within four hours after procedure
2Change the dressing when it becomes saturated
3Monitor vital signs using post-op protocols
4Maintain client on NPO status for 24 hours
3
The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client’s T-tube to be?
1Dark brown
2Green
3Yellowish-brown
4Orange
3
A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.)
Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects.
The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time?
1Prior to going to sleep at night
2After each fecal elimination
3At the same time each day
4When it is one-third to one-half full
4
A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test?
1″Be sure to eat a fat-free diet until the test, and drink lots of water.”
2″Stay at the laboratory so that two blood samples can be drawn an hour apart.”
3″Do not eat or drink anything but water for 12 hours before the blood test.”
4″Have the blood drawn within two hours of eating breakfast.”
3
The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent?
1Restricted physical activity
2Separation from family
3Altered body image
4Unrelieved pain
3
In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect?
1Retained placenta
2Clotting disorder
3Vaginal lacerations
4Uterine atony
3
A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus?
1High-protein diet
2Fluid intake of at least 3000 mL/day
3Acetaminophen for inflammation
4Hot compresses to affected joints
2
A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client?
1Weigh the child twice per shift
2Relieve boredom through physical activity
3Institute seizure precautions
4Encourage the child to eat protein-rich foods
3
A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age?
1Riding a tricycle
2Tying shoelaces
3Jumping rope
4Playing hopscotch
1
The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect?
1Jaundice
2Peripheral edema
3Buffalo hump
4Increased muscle mass
3
A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach?
1Commenting “I believe you know better than to eat with your hands.”
2Removing the food and stating “You can’t have any more food until you use the spoon.”
3Jokingly stating “Well, I guess fingers sometimes work better than spoons.”
4Placing the spoon in the client’s hand and stating “Use the spoon to eat your food.”
4
The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication?
1Monitor serum electrolytes and creatinine
2Measure apical pulse prior to administration
3Maintain accurate intake and output ratios
4Monitor blood pressure every 4 hours
2
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse?
1Arrange to change client-care assignments
2Discuss with the parent the appropriate use of “time-out”
3Explain to the mother that the child needs extra attention
4Explain to the parent that this behavior is expected
4
The mother of a hospitalized 2 year-old child asks a nurse’s advice about the child’s screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach?
1Explain that this behavior will stop with in a few days
2Suggest that the mother “sneak out” of the child’s room when the child is asleep
3Request for the mother to remain with the child at all times
4Help the mother understand that this is a normal response to hospitalization
4
A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube?
1Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding
2Adequately flushing the tube with water before and after use
3Completely crushing all medications prior to administration
4Squeezing the tube to dislodge obstructions
2
A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display?
1Pull up to stand
2Use a spoon
3Say two words
4Sit without support
4
A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy?
1Heat intolerance
2Diarrhea
3Tachycardia
4Lethargy
4
The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse?
1Jaundice
2Anorexia
3Hematemesis
4Ascites
3
A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose?
1Foster independence with better communication
2Protect the ego and diminish anxiety
3Eliminate anxiety and apprehension
4Avoid conflict and unpleasant consequences
2
A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always “scratching his bottom” and is “extremely irritable.” Based on this information, which health issue would the nurse assess for initially?
1Pinworm
2Scabies
3Ringworm
4Allergies
1
The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse?
1Administer PRN pain medication as ordered
2Determine the origin of the pain
3Draw blood for for troponin/CK and CBC per standing orders
4Order ECG per standing orders
1
The client is diagnosed with Parkinson’s disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention?
1Allow the client the time needed to dress
2Encourage the client to dress more quickly
3Ask family members to dress the client
4Demonstrate methods on how to dress more quickly
1
A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse’s explanation should include which of these comments?
1″It tells us how far along your pregnancy is.”
2″It can help identify potential neurological defects.”
3″The results help determine if the baby is growing normally.”
4″The placental exchange of oxygen is measured.”
2
A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization?
1Protection from harm to self and others
2Return to independent functioning
3Elimination of negative findings
4Reorientation to reality
1
A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take?
1Drink small amounts of liquids frequently
2Eat the evening meal within two hours of going to sleep
3Sleep with head propped on several pillows
4Take a proton pump inhibitor either before or after eating
3
A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)?
1Lifts head from the prone position
2Rolls from abdomen to back
3Falls forward when sitting
4Responds to parents’ voices
3
A nurse is monitoring the client’s initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)?
1Paresthesia and muscle cramping
2Mild dysphagia and hoarseness
3Headache and nausea
4Irritability and insomnia
1
An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus?
1Muscle weakness
2Respiratory function
3Bladder control
4Peripheral sensation
2
There’s a new order to apply one-inch of nitroglycerin paste to the client’s chest every 12 hours, but the medication is not in the automatic medication dispensing system’s drawer for this client. What should the nurse do next?
1Use another client’s nitroglycerin paste until pharmacy sends a tube for this client
2Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart
3Call the pharmacy to send up a tube of nitroglycerin paste
4Call the prescriber and ask to substitute a different formulation of nitroglycerin
3
A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents?
1Report a persistent cough to the health care provider
2The child can return to school in four days
3Administer chewable medication for pain
4The child may gargle as necessary for discomfort
1
An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client’s medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider?
1Diltiazem (Cardizem)
2Digoxin (Lanoxin)
3Nitroglycerine ointment
4Metoprolol tartrate (Toprol XL)
2
A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse?
1″Smoking will decrease the circulation to my leg”
2″Coughing and deep breathing are important for a few weeks.”
3″I will put my right leg through a full range of motion.”
4″I might feel a throbbing pain in my right leg.”
3
The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority?
1The cast material should be dipped several times into warm water
2The cast should be uncovered until it dries
3The casted extremity should be placed on a supporting surface
4The wet cast should be handled with the palms of hands for 48 to 72 hours
4
The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first?
1Reposition the tube
2Increase the amount of suction
3Gently irrigate the tube with sterile normal saline
4Notify the surgeon
3
A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse?
1Reassure the child that the surgery will go fine with no problems
2Provide privacy with encouragement to work through feelings
3Distract the child with a choice of activities to do while waiting for surgery
4Make arrangements for friends to visit as soon as possible
2
A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use?
1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus
2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape
3Open the bottom of the pouch to allow the flatus to be expelled
4Assist the client to ambulate to reduce the flatus in the pouch
3
A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period?
1Manage postoperative pain
2Maintain fluid and electrolyte balance
3Control bladder spasms with PRN medication
4Ambulate the client within a few hours after surgery
1
The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, “This is not my baby, and I do not want it.” How should the nurse respond?
1″What a beautiful baby! The baby’s eyes are just like yours.”
2″This is a common occurrence after birth. Let’s talk about how to accept the baby.”
3″You seem upset, tell me about how you are feeling”?
4″Many women have postpartum blues and need some time to love the baby.”
3
The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse?
1″Do your eyes appear bloodshot and is there any itching?”
2″Tell me about your prescription for digoxin. Are you still taking the medication?”
3″Call back in a week and schedule an appointment if your symptoms don’t improve.”
4″Is there anyone else at home who has the same symptoms?”
2
A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics?
1Meticulous attention to hygiene, grooming
2Anxiety, hostility
3Psychomotor retardation, agitation
4Guilt, indecisiveness
3
A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate?
1Behavior consistent with hyperactivity
2Slow heart rate when sleeping
3Pale mucosa inside the mouth
4High hemoglobin level
3
The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective?
1Assist the client to analyze the meaning of behaviors
2Remind the client frequently to interact with other clients
3Offer the client frequent opportunities to interact with the nurse
4Initiate client interactions with one or two other clients
3
A female client admitted for a breast biopsy says tearfully to a nurse, “If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.” What would be the most appropriate response to this statement?
1″Are you questioning the depth of your relationship?”
2″Why are you concerned that you will be rejected?”
3″You sound worried that the surgery might change your relationship with your partner.”
4″I’m sure your companion will understand.”
3
The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis?
1Peak air flow volume
2Respiratory rate
3Pulse oximetry
4Skin color
1
The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.)
Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day.
A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care?
1Activity intolerance related to an imbalance of oxygen supply and demand
2Imbalanced nutrition related to poor appetite
3Risk for impaired skin integrity related to dependent edema
4Constipation related to reduced activity level
1
The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred?
1Performance on written tests
2Completion of a mailed survey
3Responses to verbal questions
4Reported behavioral changes
4
The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.)
may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If “skin glue” is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it’s best to stick to non-greasy, non-spicy foods for a few days.
The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis?
1Turn, cough and breathe deeply
2Ambulate client within 12 hours
3Maintain adequate hydration
4Splint incision when moving or coughing
1
A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care?
1Assist the parents to plan quiet play activities with the toddler at home
2Stress to the parents that they will need relief care givers
3Instruct the parents for them and the toddler to avoid contact with persons with infection
4Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class
4
A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client?
1Simple face mask
2Partial rebreather mask
3Venturi mask
4Non-rebreather mask
4
A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding?
1Cannot ride a bicycle
2Cannot catch a ball
3Cannot skip on alternate feet
4Cannot stand on one foot
4
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client?
1″Hello. My name is Elaine Jones and I am your nurse for today.”
2″Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
3″How are you today? Remember, you’re in the hospital. I will be your nurse all day. My name is Elaine Jones.”
4″Good morning. I am Elaine Jones, your nurse. Do you remember where you are?”
2
A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client?
1Double glove when in contact with feces or emesis
2Wash hands thoroughly before and after any client contact
3Wear gloves when disposing of contaminated linens
4Use gloves when in contact with body secretions
2
A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents?
1Turn the baby every two hours using the abduction stabilizer bar
2Check frequently for swelling in the baby’s feet
3Gently rub the skin with a cotton swab to relieve itching
4Place favorite books and push-pull toys in the crib
2
A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization?
1Localized tenderness at the injection site
2Tympanic temperature of 104 F (40 C)
3Some irritability and fussiness
4Swelling at the injection site
2
A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.)
Correct Response
Assess vital signs and neurological function
Assess the airway
Prepare for CT imaging of the head
Assess the wound for presence of drainage or bruising on the head
A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, “Don’t waste good food on me. I’m dying from this disease I have.” Which response by the nurse would be the best?
1″None of the laboratory reports show that you have any physical disease.”
2″Try to eat a little bit. Breakfast is the most important meal of the day.”
3″I know you believe that you have an incurable disease.”
4″What has your primary health care provider told you?”
3
The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus?
1Achieve harmony
2Respect life in old age
3Maintain energy balance
4Restore yin and yang
4
The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet?
1A gluten-free diet, avoiding foods that contain wheat, rye and barley
2Balanced, high calorie diet with extra fat, salt, protein and calcium
3Foods low in sodium, potassium and phosphorus
4Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group
2
The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents?
1Progressive failure to adapt to peer pressure
2Reunion wish or a fantasy of some sort
3Feelings of anger or hostility toward others
4Feelings of alienation or isolation from peers
4
When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time?
1Ask the family members to call you when they notice the spot getting larger
2Record the findings in the nurse’s notes
3Outline the spot with a pen and note the time and date on the cast
4Report the finding to the registered nurse (RN) charge nurse
3
The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child’s ability to understand the information at this stage of development?
1Makes simple association of ideas
2Bases conclusions on abstract thinking
I3nterprets events from own perspective
4Thinks logically to organize facts
4
The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing?
1Open the airway and deliver two breaths followed by 30 compressions
2Provide continuous chest compressions until someone comes with the crash cart
3Provide a cycle of 30 compressions followed by two breaths
4Provide 15 compressions and then pause while someone delivers one “breath” using an ambu bag
3
A nurse is discussing with a group of parents when they can begin teaching their preschool children about injury prevention. Which approach should the nurse reinforce?
1Discuss the consequences of not wearing protective devices
2Protect their preschooler from outside influences
3Set good examples themselves through their actions
4Make sure their preschooler understands all the safety rules
3
The nurse is caring for a postmature infant in the newborn nursery. What factor should the nurse recognize as being the primary reason associated with complications of being post-term?
1Depletion of subcutaneous fat
2Progressive placental insufficiency
3Excessive fetal weight
4Low blood sugar levels
2
The registered nurse (RN) has initiated the administration of an intravenous vesicant chemotherapeutic agent to a client. Which finding during the care by a practical nurse (PN) would require the PN to immediately notify the RN?
1A rash on the client’s extremities
2Complaints of pain at the infusion site
3Stomatitis lesions in the mouth
4Severe nausea and vomiting
2
A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses his fears related to the prognosis. Which statement should be the initial response by a nurse?
1″Self-examination needs to be continued in order to prevent and detect recurrences.”
2″Chemotherapy is most likely to be started right away.”
3″Adoption may be a consideration if you want children.”
4″Testicular cancer has a very high cure rate with early diagnosis and treatment.”
4
A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate?
1Dry, nonproductive cough
2Poor appetite
3Frequent urinary infections
4Ribbon-like stools
1
The nurse is caring for a client who is diagnosed with chronic renal failure with hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client’s behavior?
1Low potassium level
2Elevated blood urea nitrogen (BUN)
3Low calcium level
4Metabolic alkalosis
2
The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.)
a false positive test and should be avoided for at least 3 days before the fecal occult blood test;
Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result.
A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse?
1Suggest to elevate the arm higher than heart level
2Ask if numbness is present in the fingers and if the client can move the fingers
3Have the client make an appointment with the surgeon for the next day
4Approve the application of a cool cloth to the fingers of the affected arm
2
The client is seen in the emergency one day after falling in his bathroom at home. The client reports having “a few drinks” prior to the fall. Which finding requires the nurse’s immediate attention?
1Bruise behind one ear
2Blurred vision
3Nausea and vomiting
4Headache
1
Diagnosed with heart failure, the client had an implantable cardioverter-defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort?
1Encouraging the client to sit upright in bed
2Confirming advanced directives and plans for resuscitation
3Deactivating the implantable cardioverter-defibrillator (ICD)
4Assisting the client to eat several small meals
3
The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce?
1Take on an empty stomach
2Take with milk, two hours after meals
3Take with calcium
4Take after meals
1
A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit?
1Plan another pregnancy as soon as possible
2Seek causes of the death for prevention purposes
3Focus on the other healthy children at home
4Discuss feelings with support persons and each other
4
A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information?
1″The therapy can be discontinued when the spots disappear.”
2″I will boil the nipples and pacifiers for 20 minutes.”
3″Expressed breast milk should be used immediately or frozen.”
4″Nystatin should be given four times a day after my baby eats.”
1
The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially?
1Place the bed in the low position
2Instruct the client to remain in bed
3Place the call bell within reach
4Have the client empty the bladder
4
The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes?
1Being a picky eater
2Weight gain
3Bedwetting
4Oily and acne-prone skin
3
An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first?
1Review the client’s pattern of weight gain over the past year
2Encourage her to talk about her self-image
3Give her several pamphlets on postpartum nutrition
4Ask the mother to record her diet for the next few weeks
2
A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire’s disease. Which finding would require the nurse’s immediate attention?
1Dry mouth with frequent requests for water
2Abdominal gas pains that are severe and disappear suddenly
3 Increased use of accessory muscles of breathing
4Difficulty sleeping due to leg cramps
3
Legionnaire’s disease is a type of acute bacterial pneumonia. Increased use of accessory breathing muscles and labored breathing are indicators of respiratory distress and should be reported immediately.
The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)?
1Record and report the client’s intake and output.
2Inspect and report peripheral IV site status.
3Palpate for edema in the lower extremities.
4Evaluate understanding of prescribed medications.
1
A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take?
1Discuss with the client to find out about the preferred herbal preparation
2Explain the importance of the medication to the client
3Contact the client’s health care provider about the refusal
4Report the behavior to the charge nurse
1
The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next?
1Close all doors in the area.
2Find the fire extinguisher.
3Remove oxygen devices.
4Begin evacuating the clients.
1
The licensed practical nurse (LPN) is caring for a client with an order that reads, “morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain.” There are no other licensed persons working that shift. Which action should the nurse take?
1Give the medication orally and follow-up with the health care provider.
2Hold the medication and contact the health care provider.
3Administer the prescribed dose as ordered.
4Check with the pharmacist to verify the order.
2
The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.)
“Have you thought about what you want done as your disease progresses?”
“What does your family know about your condition and prognosis?”
“Have you discussed your wishes regarding resuscitation with your health care provider?”
A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan?
1Set daily goals with the establishment of priorities
2Complete each task before beginning another activity
3Ask for additional assistance when necessary to complete tasks
4Keep a time log for what was done during the hours worked
4
A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client’s health care provider?
1″When I emptied my urine catheter drainage bag it looked like rusty-colored water.”
2″I just didn’t sleep well the last few nights. I keep having sad thoughts running through my mind.”
3″I really don’t want home-delivered meals any longer. I am just not hungry.”
4″My neighbors just don’t visit me anymore since I came home from the hospital.”
1
The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase?
1Selection of interventions that are measurable and achievable
2Achievement or status of progress related to prior goals
3Identification of any findings of physical and psychosocial stressors
4Establishment of goals to ensure continuity of care
2
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?
1Clinical specialty certification by an accredited organization
2Complete and accurate documentation of assessments and interventions
3Sworn statement that health care provider orders were followed
4Above-average performance reviews prepared by nurse manager
2
The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report?
1The client with asthma who is scheduled for a chest X-ray prior to discharge
2The client with peptic ulcer disease who has been vomiting most of the night
3The client with chronic kidney disease who completed peritoneal dialysis two hours ago
4The client with pancreatitis who reports pain at a level of eight out of 10
2
The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP’s complaints. What is the best action by the nurse?
1Notify the chief of the medical staff about the HCP’s breach of professional conduct.
2Encourage the UAP to directly confront the HCP about the unprofessional behavior.
3Complete an incident report describing the HCP’s unprofessional behavior.
4Walk up to the HCP and quietly state, “This unacceptable behavior has to stop.”
2
Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management?
1Case management strategies focus mainly on the client’s needs after discharge.
2Case management is a collaborative process designed to meet complex client needs.
3Physicians are responsible and accountable for client outcomes.
4The interdisciplinary team makes all the decisions for the client and family.
2
During the management of a client’s pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client’s pain?
1Cultural sensitivity is fundamental to client-centered pain management.
2Clients have the right to have their pain managed promptly.
3Nurses should not judge a client’s pain based on the nurse’s values.
4The client’s self-report of pain is the most important consideration.
4
A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)?
1Provide instruction to the client for ambulation with the orthotic.
2Monitor the client’s response to moving with the orthotic.
3Check the client’s skin for any redness or irritation from the orthotic.
4Assist with transferring the client from the bed to the chair.
4
Upon completing a review of a 27-year-old client’s admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take?
1Lecture the client on the importance of having advance directives.
2Inform the charge nurse to offer information about advance directives.
3Advance directives are not appropriate for this client due to the client’s age.
4Refer this issue to the client’s health care provider.
2
The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person?
1Physical therapist
2Pharmacist
3Physical therapist
4Occupational therapist
4
Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work.
A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client?
1The psychiatrist will need to grant permission to discuss the client’s medications.
2All clients have a right to be informed about their prescribed medications
3A decision to reinforce or not reinforce information about medications should be made by the nurse alone.
4It is too dangerous for clients who are diagnosed with schizophrenia to know about their medications.
2
The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take?
1Report this request immediately to the nurse manager.
2Review the client’s medication administration record (MAR) for past wastes.
3Ask the nurse’s client if they witnessed the waste of the partial dose.
4Confront the nurse about suspected narcotics diversion.
1
A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client’s mental status and adjustment. What should the nurse do next to respond to this request?
1Go ahead and provide the information, since the client is ready for discharge.
2Inform the caller that this kind of information is never given over the telephone.
3Refer the social worker to the health care provider to obtain the requested information.
4Verify that the client’s medical record includes the client’s written consent to release information.
4
During a discussion about a living will, the client’s son states, “I do not understand the need for a living will.” What is the best response by the nurse?
1″Health care decisions can be made based on the client’s wishes.”
2″Specific instructions are listed for specific diseases.”
3″A designated family member can make all decisions.”
4″Do not resuscitate (DNR) orders are automatic under these conditions.”
1
The client requests not to be interrupted before 10 am because it interferes with the client’s time to meditate. What action shall the nurse take first?
1Document the client’s request in the medical record.
2Meet with the client to formulate a mutually agreeable schedule.
3Notify the dietary department about the client’s request.
4Adjust administration times for prescribed medications.
2
A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate?
1″Have the client lift and move the walker out to arm’s length, then walk into the walker.”
2″If the client becomes dizzy while walking, ask the client to stop and take 10 fast, deep breaths.”
3″As you assist the client to the chair, let me know if the client uses the quad cane correctly.”
4″Stand on the client’s strong side when you assist the client to the bathroom.”
1
The person assisting the client to ambulate should walk on the client’s weak side, NOT STRONG, side.
The nurse is reviewing information about the health care organization’s efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting?
1Perform actions based on reactive problem solving.
2Create a flow chart of department or staff interactions.
3Conduct chart audits for common error discovery.
4Improve the quality of care in a proactive manner.
4
The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)?
1Check sensation in the extremities
2Observe for mental status changes every four hours
3Reinforce findings of hypoglycemia when the client asks
4Measure blood pressure, pulse and respirations
4
When walking past a client’s room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse?
1″I’ll come back and make the bed after I go to the lab.”
2″If we work together we can get all of the client care completed.”
3″Since I am late for lunch, would you perform my client’s blood glucose test?”
4″This client seems confused, we need to watch the client closely.”
3
The nurse has been assigned to four clients. Which client should the nurse see first?
1The client with a history of coronary artery disease (CAD) reporting dyspnea, nausea and unusual discomfort in the upper back
2The client diagnosed with peripheral artery disease (PAD) who reports cramp-like pains in both calf muscles following physical therapy
3The client with a history of heart failure (HF) who reports going to the bathroom “too much” after taking a diuretic
4The client diagnosed with hypertension whose last recorded blood pressure (BP) was 180/90 after returning from the radiology department
1
The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept?
1A trauma victim with multiple lacerations requiring complex dressings
2An older adult client diagnosed with cystitis who has an indwelling urethral catheter
3A confused client whose family complains about the nursing care given after the client’s surgery
4A client, admitted for a possible stroke, with unstable neurological findings
2
A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client?
1Include a family member and direct comments to that person
2Talk to the interpreter in advance and leave the client and interpreter alone for discussion
3Speak directly to the interpreter while asking questions
4Face the client while asking questions as the interpreter translates the information
4
The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child’s parents?
1Use gentle cleansers to protect jaundiced child’s skin from breakdown.
2Child can return to daycare two days after starting antibiotic treatment.
3Keep child on bedrest for several weeks before gradually resuming activity.
4Wash hands thoroughly with soap and warm water after contact with the child.
4
The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment.
A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints? (Select all that apply.)
To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never “as needed.” An order must be written by a provider for each restraint episode. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client’s permanent medical record. It is a legal requirement to notify the client’s advocate or a relative if requested by the client.
The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include?
1Empty the child’s mouth of any poisonous substance still present.
2Give the child a glass of milk to drink to neutralize the poisonous substance.
3Induce vomiting if the child is suspected of swallowing something poisonous.
4Start treatment before calling the Poison Control Center
1
The nurse is stuck in the hand by an exposed needle that was accidentally left in the client’s bed. What action should the nurse take first?
1Contact employee or occupational health services.
2Look up the policy and procedure on needlestick injury.
3Immediately wash hands vigorously with soap and warm water.
4Notify the nursing supervisor and complete an incident report.
3
The nurse is reviewing the documentation of a client’s care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take?
Mark the entry as “mistaken entry-wrong patient.”
Enter the time the error was discovered.
The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client?
“Please tell me your full name and date of birth.”
“Do you have any questions about the colonoscopy?”
“Describe what the health care provider told you about a colonoscopy.”
An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce?
1No solid food may be eaten for six hours after ingestion.
2Urine and saliva will be radioactive for 24 hours after ingestion.
3Wash laundry separately and rinse twice in hot water.
4Wait for 48 hours to have grandchildren visit at home.
2
The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is:
1To ensure that treatment compliance will be monitored
2To trace and screen recent contacts the client had
3To maintain important disease outbreak statistics
4To track the incidence of tuberculosis cases
2
The parent of a toddler who is being treated for suspected poisoning asks, “Why is activated charcoal used?” What is the best response by the nurse?
1″When the poison is absorbed into the blood stream, the activated charcoal will neutralize it.”
2″Activated charcoal binds with the poison to limit absorption in the digestive tract.”
3″Activated charcoal causes vomiting, which will eliminate the poison from the body.”
4″The activated charcoal will protect the kidneys from any long-lasting damage.”
2
The parents of a toddler ask, “How long will our child have to sit in a car seat when riding in a car?” What would be the best response by the nurse?
1″Until the child is able to sit in a booster seat.”
2″Until the child weighs 40 pounds.”
3″Until the child outgrows the car seat.”
4″Until the child is 50 inches tall.”
3
The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client with a diagnosis of schizophrenia. Which of the following behaviors justify use of this chemical restraint?
The client is verbalizing a plan to harm another client.
The client is expressing paranoid delusions.
The client is experiencing command hallucinations.
A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.)
frequency and amount used
color of bowel movements
bruising
The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention?
1Increasing physical exercise
2Smoking cessation
3Stress management
4Weight reduction
2
The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure?
1Schedule regular visits to monitor wound healing.
2Involve the client in making decisions.
3Evaluate the client’s understanding of appropriate foot care.
4Arrange for referral to a diabetic educator.
2
The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy?
1Viewing the fetus as a separate and unique being.
2Accepting the loss of physical intimacy.
3Resolving any fears related to giving birth.
4Accepting physical changes related to pregnancy.
4
A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client’s health needs?
1Identify community resources.
2Assist with meal planning.
3Evaluate the home for safety hazards.
4Identify the client’s learning needs.
4
During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform?
1Sits without support
2Uses pincer grasp
3Says several words
4Drinks from a cup
1
The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months.
A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first?
1Ask the client to state his date of birth.
2Confirm that the client’s hearing is intact.
3Observe the client while performing an activity.
4Ask the client to name the current U.S. president.
2
During the physical inspection of a client, the nurse notes a pulsating mass in the client’s periumbilical area. Which action should the nurse take next?
1Measure the length of the mass.
2Auscultate the area.
3Palpate the area.
4Percuss the area.
2
A client has a family history of coronary artery disease (CAD). Which of the following findings should be of concern to the nurse?
1Low density lipoprotein (LDL) cholesterol level of 80 mg/dL
2Blood pressure of 154/78
3Serum creatinine of 0.4 mg/dL
4A glycosylated hemoglobin (Hb A1C) level of 4.8%
2
Which of the following actions performed by the nurse indicates that additional education on ergonomic principles is needed to reduce the risk of injury?
1Flex the knees and knee close to an object, before lifting it from the floor.
2Use arm and leg strength to assist in repositioning a client in bed.
3Push a bed down the hall, instead of pulling it during transport.
4Bend and twist at the waist when assisting a client in transferring to the chair.
4
A client with a back injury asks the nurse how chiropractic manipulation works. What is the nurse’s best response?
1Electrical energy fields
2Spinal column manipulation
3Mind-body balance
4Exercise of joints
2
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) and a significant family history of coronary artery disease. Which of the following prescriptions by the health care provider would treat a major modifiable risk factor of coronary artery disease?
1Atorvastatin
2Prednisone
3Albuterol
4Fluticasone/salmeterol
1
Atorvastatin is an HMG-CoA reductase inhibitor, more widely known as a statin, and it is a medication used to treat hyperlipidemia. Statins reduce LDL levels, reduce triglycerides and increase HDL levels. Hyperlipidemia is a major modifiable risk factor of coronary artery disease.
A 20-year-old male client who has a profuse, purulent urethral discharge with painful urination is seen at a community health clinic. Which information will be most important for the nurse to obtain?
1Sexual orientation
2Recent sexual contacts
3Immunization history
4Contraceptive preference
2
The nurse recognizes that which finding indicates a child has attained the developmental stage of concrete operations, according to Piaget?
1The child makes the moral judgment that “stealing is wrong.”
2The child explores the environment with the use of sight and movement.
3The child thinks in mental images or word pictures.
4The child reasons that homework is time-consuming but necessary.
1
After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased client prior to moving the body. What would be the most appropriate response by the nurse?
1″I will have to check on hospital regulations and policies.”
2″These procedures have to be carried out by our staff.”
3″Is there anything you need from me to perform the bath?”
4″A ritual bath will have to wait until after postmortem care.”
3
A nurse is working to establish a therapeutic relationship with a client. Which action would support the nurse’s goal?
1Establish trust and rapport with the client.
2Identify with what the client is feeling.
3Praise the client for appropriate behavior.
4Advise the client on problem-solving techniques.
1
The client diagnosed with paranoid-type schizophrenia is sitting alone, intently staring at and watching other clients and staff members. The client becomes hostile when approached with medication and claims that the medication controls the mind. What type of symptom(s) does the nurse recognize that this client is exhibiting?
1Antisocial behavior
2Negative symptoms
3Positive symptoms
4Inappropriate affect
3
Symptoms of schizophrenia are commonly described as positive or negative. Positive symptoms are behaviors and experiences present in a person with schizophrenia that would not be present in a person without the illness. These are sometimes described as features that are “added” by the illness. In contrast, negative symptoms are those that reflect a decrease in normal functions, or abilities that have been “taken away.” Positive symptoms of schizophrenia include delusions, hallucinations, hyper vigilance and disorganized thinking.
The nurse is providing care for a client who has been diagnosed with terminal cancer. The nurse notes that the client’s wife is not visiting very often. When she does visit the client, she only stays for a brief time, stands in the corner and does not approach the client during interactions. Which of the grieving processes is the client’s wife most likely experiencing?
1Disenfranchised grief
2Anticipatory grief
3Perceived loss
4Death anxiety
2
anticipatory grief is the family member becomes distant and detached from the client and the client feels isolated and alone. Death anxiety is worry or fear related to dying that may be seen with a grieving child. Disenfranchised grief is when the individual cannot acknowledge the loss, perhaps because of an unrecognized loss, such as an abortion or a suicide. Perceived loss is a loss that cannot be verified by others such as a loss of self-esteem or a loss of control.
The nurse is caring for a postpartum Latina client who keeps declining the hospital food because it is “cold.” What action should the nurse take initially?
1Send the food to be reheated.
2Encourage the client to eat for strength.
3Ask the client what foods are acceptable.
4Consult with the dietitian as soon as possible.
3
An adolescent client is paralyzed from the waist down after being involved in a motor vehicle accident. Which client statement would indicate to the nurse that the client is using repression as an ego defense mechanism?
1″It’s all the other driver’s fault! They were driving too fast.”
2″I don’t remember anything about what happened to me.”
3″My parents are heartbroken about my situation.”
4″I know that I will walk again one day.”
2
Repression is the unconscious and involuntary forgetting of painful events, ideas and conflicts.
The nurse is working with a couple who is experiencing intense anxiety after their home was completely destroyed by a fire. The nurse should implement which initial intervention?
1Suggest finding an apartment with a sprinkler system.
2Explore the couple’s feelings of grief and loss.
3Determine what community housing resources are available.
4Provide a brochure on relaxation and stress relief.
3
The couple has experienced a crisis, i.e., sudden loss event that has resulted in disequilibrium. The most important initial crisis intervention focuses on identifying resources and obtaining assistance for housing and other immediate needs.
The nurse is evaluating a client who is being physically abused by the client’s domestic partner. The client states, “I need a little time away.” Which is the most likely response from the partner for which the nurse should prepare the client?
1Fear of rejection, resulting in increased rage toward the client
2Relief over a separation as a way to have some personal time
3Acceptance and understanding that the relationship is in trouble
4A new commitment to seek counseling to assist with problems
1
A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve hours after admission the client becomes diaphoretic, tremulous and irritable, and the client’s pulse and blood pressure are elevated. The client states to the nurse, “I have to get out of here.” What is the most likely cause for the client’s symptoms and behavior?
1Dissatisfaction with hospital care
2Anxiety related to being hospitalized
33hock related to the injuries
4Early stage of alcohol withdrawal
4
signs and symptoms of alcohol withdrawal, such as sweating, tremors, hyperactivity, hypertension and tachycardia. The client most likely wants to leave the hospital to obtain alcohol. The client must be monitored very closely for progression to more severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs).
A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse?
1″Duloxetine is used to treat depression but can also be used to lower blood sugar levels.”
2″Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes.”
3″Duloxetine is not prescribed for either depression or diabetes.”
4″Duloxetine is used to treat diabetes but can also be used to treat depression.”
2
Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy.
The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? (Select all that apply.)
obstructive sleep apnea
gallstones
coronary artery disease
breast cancer
HYPERTHYROIDISM IS NOT ASSOCIATED WITH BEING OVERWEIGHT OR BMI
The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, “I just drink occasionally. I don’t know why my wife and the judge think that I need to be in an alcohol treatment program.” Which of the following behaviors are consistent with SUD? (Select all that apply.)
Prone to act impulsively
Insecurity in relationships
Craving and inability to abstain from alcohol
The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)?
1Chest pain, nausea, diaphoresis and tachycardia
2Nausea, vomiting, bloody stools and hypotension
3Headache, blurred vision, garbled speech and hypertension
4Excitability, disorientation, tremors and tachycardia
4
A couple that recently immigrated to the United States tells the nurse about their concern that hospital staff is giving their child the “evil eye.” What should the nurse communicate to the other personnel who are involved in the care of this family?
1Touch the child after or while looking at the child.
2Avoid touching or looking at the child.
3Look only at the parents and not the child.
4Instruct the parents to remain outside of the room.
1
an “evil eye” is cast by looking at a person without touching them or while the person is unaware. The evil eye is believed to cause misfortune or injury. The spell is broken by touching the child while looking at them or assessing them.
The nurse is caring for a client diagnosed with end-stage heart failure (HF). The family members are distressed about the client’s impending death. Which action should the nurse take initially?
1Explain the stages of death and dying to the family.
2Recommend an easy-to-read book on grief.
3Ask about the family’s religious affiliation and practices.
4Explore the family’s past patterns for dealing with death.
4
A nurse is caring for a client who is being treated for major depression. During which time period is the client most likely to be at the highest risk for attempting suicide?
1 1 to 2 weeks after initiating antidepressant medication.
26 to 12 months after discharge from the hospital.
3Around the time of the client’s birthday.
4While under one-on-one observation in the hospital.
1
A client diagnosed with schizophrenia first speaks animatedly to another client, with exaggerated clarity of pronunciation. The nurse then observes the client turning abruptly away, mumbling to themselves and speaking to the wall. Which priority goal/outcome should the nurse select for the client’s plan of care?
1Client will express feelings appropriately through verbal interactions.
2Client will accurately interpret events and other’s behaviors.
3Client will engage in meaningful and understandable verbal communication.
4Client will demonstrate improved social relationships.
3
The nurse is working in an inpatient psychiatric setting and understands that touching clients should be limited to a quick handshake for which reason?
1Touching a client, other than a handshake, can set off a violent episode.
2Refraining from touching signals the termination of the nurse-client relationship.
3A handshake allows the use of therapeutic touch while maintaining boundaries.
4A handshake will not be misinterpreted as an invitation to more sexual behavior.
3
The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder (OCD). Which behavior should the nurse expect to see with this diagnosis?
1The client is seen washing her hands every 15 minutes.
2The client exhibits repetitive, involuntary movements.
3The client verbalizes suspicions about thefts on the unit.
4The client prefers to interact with female staff members.
1
OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions).
The nurse is caring for a client who has an alcohol use disorder (AUD). The client states that the client’s dysfunctional family caused the addiction. Which response by the nurse would best help the client accept responsibility for their own behavior?
1″It was your choice to drink, so you need to take responsibility.”
2″It is wrong for you to blame your problems on your family.”
3″Yes, I can understand that families can be tough to deal with.”
4″The lab report showed a high blood alcohol level when you were admitted.”
4
A nurse is collecting data on a client believed to be in an abusive relationship. Which client statement is most indicative that this individual is experiencing intimate partner abuse?
1″I must have done something to deserve this.”
2″No one else in my family has been treated like this.”
3″I have only been in this relationship for two months.”
4″I will keep praying that things will get better.”
1
A home health nurse is caring for a client diagnosed with late-stage, Lewy body dementia (LBD). The nurse is meeting with the client’s family to discuss options for care of the client. What is the initial question the nurse should ask to assist the family with their decision-making process?
1″What is your opinion of nursing homes or assisted living facilities?”
2″Is your parent currently taking over-the-counter (OTC) or prescription medications?”
3″Are you able to assist with the care of your parent in any manner?”
4″What type of assistance does your parent require?”
4
The nurse is caring for a client with paraplegia due to a spinal cord injury at the T-7 level. Which nursing intervention should be a priority for this client?
1Obtain a pressure-reducing mattress for the client’s bed.
2Observe the client performing self-catheterization correctly.
3Consult with the discharge planner about equipment the client’s needs at home.
4Encourage the client to increase intake of fluids and high-fiber foods.
1
The nurse is evaluating the plan of care for a client with osteoporosis. What type of activity should the nurse reinforce for this client?
1Enroll in a kickboxing class twice a week.
2Walk for 30 minutes, 3 to 5 times a week.
3Participate in swimming lessons three times a week.
4Go jogging 5 to 7 times a week.
2
Teach the client (or reinforce teaching) that walking for 30 minutes, 3 to 5 times a week, is the single most effective exercise for osteoporosis prevention.
The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child?
1A cup of cereal
2A slice of wheat bread
3A cup of yogurt
4An oatmeal cookie
3
A client is on NPO status and has a nasogastric (NG) tube in place, connected to low-intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client?
1Allow the client to melt ice chips in their mouth.
2Provide oral care at least every 2 to 4 hours.
3Swab the client’s mouth, using glycerin swabs.
4Provide the client mints to freshen their breath.
2
The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective?
1Elastic, nontenting skin turgor
2Moist oral mucus membranes
3Urine output of 35 mL per hour
4No reports of thirst
3
The goal is to maintain an hourly urine output of 0.5 mL/hour (about 30 mL/hour) for the average adult.
Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)?
1The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection.
2The nurse calls the health care provider (HCP) to request the removal of the indwelling urinary catheter for a two days postoperative client.
3The nurse cleanses hands with soap and water for 60 seconds after caring for a client with Clostridium difficile (C. difficile) infection.
4The nurse wears a gown and gloves when providing perineal care to a client with Vancomycin-resistant Enterococci (VRE) infection.
1
A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client?
1Instruct the client to tilt their head back while swallowing.
2Position the client in an upright position while they are eating.
3Assist the client to drink through a straw.
4Instruct the client to use sips of water to help wash down food.
2
A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first?
1Ask the client about pain.
2Orient the client to the unit.
3Review the postoperative orders.
4Take the client’s vital signs.
4
The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching?
Bowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client’s normal bowel elimination time—inserting it just prior to bedtime will disturb the client’s sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate.
An obese client tells the nurse, “I just started a diet and I am eating no more than 800 calories a day.” What information should the nurse reinforce with the client?
1Very low-calorie diets often have severe and irreversible side effects.
2Very low-calorie diets are adequate if balanced with fruits and vegetables.
3Very low-calorie diets are intended for short-term use only.
4Very low-calorie diets are appropriate for long-term weight management.
3
A 2-year-old child is brought to the pediatrician’s office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents?
1Keep the child fasting, give them nothing to eat, and return the next day.
2Give the child only clear liquids and gelatin for 24 hours.
3Continue a regular diet and add electrolyte replacement drinks.
4Give the child bananas, apples, rice and toast as tolerated.
3
The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client’s comfort?
1Encourage visits from family and friends.
2Keep conversations short.
3Increase the client’s oral fluid intake.
4Monitor vital signs frequently.
2
An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action?
1Severe abdominal pain
2A bladder ultrasound value of 900 mL
3A heart rate of 110 bpm
4A blood pressure of 180/105
2
The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider?
1Serum creatinine level of 2.8 mg/dL
2Blood glucose level of 146 mg/dL
3Serum potassium level of 5.0 mEq/L
4Serum hemoglobin level of 15.7 g/dL
1
normal range of 0.5 to 1.2 mg/dL in adults. Dehydration can contribute to impaired renal function. A creatinine level of 2.8 mg/dL is significantly elevated and indicative of renal impairment. Therefore, the creatinine value is the most important result
The nurse is evaluating a client who has been diagnosed with heart failure (HF) to gauge their understanding of the required diet modifications. Which menu items selected by the client indicate to the nurse that the client understood the teaching?
1Cheeseburger and baked potato chips
2Grilled cheese sandwich with a glass of skim milk
3Leftover turkey on a sandwich and fresh pineapple
4Vegetable pizza and ice cream
3
Clients with HF should adhere to a low-sodium diet to prevent fluid volume excess. A sodium-restricted diet should consist of less than 2 grams of sodium per day. (A regular diet should include 4 to 6 grams of sodium per day.)
The nurse receives an order to give a client iron by deep injection. What does the nurse understand about the reason for using this method of administration?
1Provides more even distribution of the drug
2Prevents the medication from tissue irritation
3Ensures that the entire dose of medication is given
4Enhances absorption of the medication
2
Deep injection, or Z-track, is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue.
A client has been taking alprazolam for three days. For which expected effect of the medication should the nurse evaluate the client?
1The client reports feeling less depressed.
2The client reports sleeping through the night.
3The client denies having auditory hallucinations.
4The client denies having suicide ideation.
2
Antianxiety medications or anxiolytics, such as alprazolam, a benzodiazepine, work quickly. They produce sedative effects and reduce anxiety through effects on the limbic system, a neuronal network associated with emotionality. They also promote sleep through effects on cortical areas and on the brain’s sleep-wakefulness “clock.”
At 9 am, the nurse administers 10 units of insulin aspart subcutaneously to a client with a blood sugar of 322 mg/dL. At approximately what time should the nurse expect the insulin to peak?
1At noon
2At 9:30 am
3At 10:00 am
4This insulin does not peak because it acts over 24 hours.
1
Insulin aspart is an analog of human insulin with a rapid onset (10 to 20 minutes) and short duration (3 to 5 hours).
injections should be given 5 to 15 minutes before meals.
A nurse notes an abrupt onset of confusion in an 85-year-old client. Which newly prescribed medication most likely caused this change in the client’s mental status?
1Diphenhydramine
2Metoprolol
3Warfarin
4Pantoprazole
1
An older adult client is to receive intravenous (IV) gentamicin for urosepsis. Before administering the medication, for which finding should the nurse notify the health care provider (HCP)?
1The client has a history of retinopathy.
2The client has a history of chronic kidney disease.
3The client has a history of acid reflux disease.
4The client has a history of urinary retention.
2
they are excreted by glomerular filtration. Aminoglycosides are nephrotoxic and requires close monitoring of renal function. A client with chronic kidney disease should not receive this medication.
The nurse in a long-term care facility is preparing to administer medications. Which physiological changes does the nurse know will affect medication pharmacokinetics in older adults?
1Due to an increase in glomerular filtration rates, medications are excreted more rapidly.
2Due to a decrease in gastric emptying, higher medication doses are prescribed.
3Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exist.
4Due to an increase in metabolism, medications are prescribed more frequently.
3
The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administration?
1Use an oral syringe to administer the medication, alternating with a pacifier.
2Mix the liquid medication with a full bottle of formula.
3Give half the dose now and the remaining amount in an hour.
4Ask the health care provider (HCP) to switch the medication to an injection.
1
A client is admitted with deep vein thrombosis (DVT). The health care provider (HCP) orders the immediate administration of an intravenous bolus of heparin sodium 200 units/kg . The client weighs 187 lbs. How many mL should the nurse draw up from the supplied 10 mL vial that contains 5,000 units per mL? Do not round.
3.4
The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse’s instructions regarding the medication?
1″I can stop taking the medication at any time.”
2″It is safe to take extra doses if my pain becomes worse.”
3″The medication might cause me to have insomnia.”
4″My doctor prescribed it for the pain in my legs.”
4
The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a new written order for a pain medication. The health care provider (HCP) wrote, “Give APAP every six hours as needed for pain.” Which parts of the medication order should the nurse clarify before administering the medication?
route
drug name
dosage
The nurse administers a medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? (Select all that apply.)
Notify health care provider
Complete an incident report
Monitor the client for adverse effects
Document the error in the medical record
A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client?
1Diffuse rash
2Constipation
3Wheezing
4Hyperglycemia
2
A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which statement by the nurse about this medication is correct?
1″You can stop the medication after five days.”
2″Be sure to take the medication with food.”
3″Drink at least eight glasses of water a day.”
4″It is safe to take with oral contraceptives.”
3
Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring.
The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management?
1Relief of pain will be achieved quickly.
2Pain therapy is based on the client’s report of pain.
3High doses of opioid analgesics will be required.
4The client will most likely become addicted.
2
The nurse is discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client?
1″Notify your health care provider if your stools appear tarry or black.”
2″You should massage the injection site for better absorption.”
3″An intravenous (IV) catheter will be placed to administer the medication.”
4″You must have your partial thromboplastin time (PTT) checked weekly.”
1
As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP
A client who has been diagnosed with Raynaud’s disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client?
1Decreased urine output
2Facial flushing
3Cyanosis of the lips
4Increased pain in fingers
2
Nifedipine is a calcium channel blocker (CCB) used in the treatment of Raynaud’s disease and hypertension by producing vasodilation. As a result of this vasodilating effect, facial flushing can occur.
A postoperative client has a prescription for acetaminophen with codeine for pain relief. The nurse understands which action to be the primary purpose of this drug combination?
1Faster onset of action
2Minimized side effects
3Enhanced pain relief
4Prevents tolerance
A client diagnosed with tuberculosis is prescribed rifampin and isoniazid. Which information should the nurse include when reinforcing information about these medications?
1″You may have occasional problems sleeping.”
2″You can take the medication with food.”
3″You may notice an orange-red color to your urine.”
4″You may experience an increase in appetite.”
3
The nurse is reinforcing medication interactions with a client who is taking warfarin. Which over-the-counter (OTC) medication should the nurse remind the client to avoid?
1Naproxen
2Diphenhydramine
3Acetaminophen
4Pantoprazole
1
Naproxen can prolong bleeding time and should therefore be avoided by clients who take anticoagulants.
The nurse is preparing to administer an antibiotic intramuscularly (IM) to a 2-year-old child. The total volume of the injection is 2 mL. What is the best approach for the nurse to take when administering this medication?
1Call the provider and request a smaller dose.
2Split the medication into two separate injections.
3Substitute an oral form of the medication.
4Inject the medication in the deltoid muscle.
2
The nurse is reinforcing teaching for a client with chronic kidney disease about the prescribed aluminum hydroxide. Which is the best statement by the nurse about this medication?
1″It reduces potassium levels.”
2″It increases urine output.”
3″It controls stomach acid secretions.”
4″It decreases phosphate levels.”
4
Phosphates tend to accumulate in the client with chronic kidney disease due to decreased filtration capacity of the kidneys. Antacids that contain aluminum such as aluminum hydroxide (Amphojel) are commonly used to lower phosphate levels.
A client has a new prescription for sertraline, a selective serotonin reuptake inhibitor (SSRI) antidepressant. After reviewing the client’s medical record, which data is the nurse most concerned about?
1History of an eating disorder
2Current prescription for phenelzine
3History of premenstrual dysphoric disorder
4Current prescription for alprazolam
2
Phenelzine is a monoamine oxidase inhibitor (MAOI) antidepressant. Combining MAOIs with SSRIs and other serotonergic drugs poses a risk of serotonin syndrome.
The client is discharged from the hospital with a new prescription for furosemide. During a follow-up visit one week later, the nurse notes the following findings. Which finding is most important to report to the health care provider?
1Increased urine production
2Occasional lightheadedness
3Muscle cramps
4Constipation
3
Furosemide is a loop (potassium-wasting) diuretic. It can cause dehydration and hypokalemia, which can result in muscle cramps. This is the most important finding.
The nurse is reviewing prescribed medications with a client. Which information should the nurse reinforce about captopril?
1Avoid using salt substitutes.
2Avoid green leafy vegetables.
3Restrict fluids to 1000 mL/day.
4Take the medication with meals.
1
Captopril is an angiotensin converting enzyme (ACE) inhibitor. It reduces aldosterone secretion, thereby reducing sodium and water retention. Captopril is used to treat hypertension and heart failure. Because it can cause an accumulation of serum potassium (i.e., hyperkalemia), clients should avoid the use of salt substitutes, which often contain potassium instead of sodium chloride.
A nurse administers cimetidine to a 75-year-old client diagnosed with a gastric ulcer. The nurse should monitor the client for which adverse reaction?
1Hearing loss
2Mental status change
3Constipation
4Increased liver enzymes
2
Cimetidine is a histamine H2-receptor antagonist used to treat gastric ulcers. It has been found to cause confusion in susceptible clients, such as the elderly and debilitated clients. Clients over age 50 or who are severely ill may become temporarily confused while taking H2 blockers, especially cimetidine.
A client at risk for a stroke has been prescribed clopidogrel. Which information is most important for the nurse to reinforce with the client?
1″You must take the medication on an empty stomach.”
2″If you miss a dose, take a double dose the next day.”
3″You must have your lab tests checked weekly.”
4″You must stop the medication a week before your surgery.”
4
Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is taken for secondary prevention of myocardial infarction, ischemic stroke and other vascular events. Clopidogrel prevents platelet aggregation. Like all other antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel should be discontinued 5 to 7 days before elective surgery.
The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly-diagnosed with asthma. The client asks, “how will I know the canister is empty?” What is the best response by the nurse?
1″Drop the canister in water to observe if it floats.”
2″Contact your pharmacy to find out when to obtain a refill.”
3″Count the number of doses as the inhaler is used.”
4″Shake the canister and listen for any fluid movement.”
3
A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the client for which potential adverse drug effect?
1Pulmonary hypertension
2Acute arterial occlusion
3Cardiac dysrhythmias
4Acute kidney injury
3
Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial contractility. By increasing contractile force, digoxin can increase cardiac output in clients with heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia. Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity, leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept within normal range (3.5 to 5 mEq/L) while taking digoxin.
The nurse in an ambulatory clinic is speaking with the parents of a 2-year-old child diagnosed with acute otitis media. Which information is most important for the nurse to include in the instructions to the parents?
1The child must complete the entire course of the prescribed antibiotic.
2The child may be given a decongestant to relieve pressure on the tympanic membrane.
3The child should return to the clinic to evaluate effectiveness of the treatment.
4The child may be given acetaminophen or ibuprofen drops for pain.
1
The nurse is reinforcing teaching about levothyroxine for a client newly-diagnosed with hypothyroidism. Which information should the nurse make sure to reinforce about this medication?
1The medication may decrease the client’s energy level.
2The medication will decrease the client’s heart rate.
3The medication should be taken in the morning.
4The medication must be stored in a dark container.
3
A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. Levothyroxine will cause an increase in the client’s energy level and heart rate.
A client received hydromorphone orally one hour ago. When the nurse enters the client’s room, the client is unresponsive to verbal stimuli and has a respiratory rate of six. Which action should the nurse take next?
1Prepare for endotracheal intubation.
2Administer supplemental oxygen.
3Begin cardiopulmonary resuscitation.
4Prepare to administer naloxone.
4
A client has been prescribed alendronate for osteoporosis. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.)
Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same time.
The nurse observes a new nurse administering a rectal suppository to a client. Which actions are appropriate for the new nurse to implement? (Select all that apply.)
The nurse pushes the suppository in, up to the second knuckle.
The nurse applies water-soluble lubricant to the suppository.
The nurse places the client on the left side during insertion.
After 10 minutes, the nurse turns the client to the right side.
A nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect?
1Level of consciousness (LOC)
2Amount of intravenous fluid infused
3Pulse and blood pressure
4Injuries to the extremities
1
The nurse is preparing a client for an intravenous pyelogram (IVP) test. What information is most important for the nurse to obtain prior to the procedure?
1Time of the client’s last meal
2History of allergies
3Amount of urine output
4BUN and creatinine level
2
An older adult client, diagnosed with active pulmonary tuberculosis, has difficulty in coughing up secretions for a sputum specimen. Which nursing intervention would be most helpful for this client?
1Encourage client to ambulate frequently.
2Spray the oropharynx with saline.
3Administer a nebulizer treatment.
4Push fluids for the next eight hours.
3
A client is receiving heparin and warfarin after total hip replacement surgery. Lab results show an international normalized ratio (INR) of 5.5. Which priority action should the nurse take?
1Hold the next dose of warfarin.
2Monitor for bruising or bleeding.
3Notify the health care provider (HCP).
4Administer protamine sulfate.
3
The therapeutic range for INR is 2 to 3, therefore a client with a 5.5 INR is at a high risk for bleeding and the nurse should notify the HCP immediately.
A nurse is caring for a 2-year-old child who underwent a tonsillectomy at 8:00 am. At 11:00 am, the child has a temperature of 98.2⁰ F (36.7⁰ C). At 1:00 pm, the child’s parent reports to the nurse that the child feels very warm to touch. What should the nurse do first?
1Reassure the parent that this is normal.
2Take the child’s temperature.
3Offer the child cold oral fluids.
4Administer prescribed acetaminophen.
2
The nurse is caring for a 60-year-old female client scheduled for abdominal surgery. Which factor in the client’s history indicates that the client is at an increased risk for deep vein thrombosis (DVT) in the postoperative period?
1Past hypersensitivity to heparin
2Family history of uterine cancer
3Estrogen replacement therapy for the past three years
4History of acute hepatitis A
3
The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, increasing the risk for development of a DVT.
The nurse is caring for a client receiving mechanical ventilation. The nurse understands which are the possible causes for a high-pressure alarm? (Select all that apply.)
Kinked tubing, secretions and/or bronchospasms cause obstruction to airflow from the ventilator, creating high pressure in the ventilator circuit and setting off the high-pressure alarm.
The nurse is reviewing the medical record of a client on the medical surgical unit and notes a positive result of the stool for occult blood (OB) test. The nurse recognizes which risk factors for this result? (Select all that apply.)
Drugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen (Aleve). Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to GI bleeding. Factors that may cause a false positive result include bleeding gums following a dental procedure and the ingestion of red meats within three days before testing because red meats contain animal hemoglobin.
A client is scheduled for a computerized tomography (CT) scan of the abdomen with contrast. What action should the nurse take before sending the client to the imaging department?
1Insert a temporary urinary catheter.
2Confirm that a signed consent is in the chart.
3Keep the client on bedrest.
4Hold all of the client’s medications.
2
An 80-year-old client with type 2 diabetes mellitus is admitted to the emergency department with worsening confusion and decreased level of consciousness. Which of these findings is most important for the nurse to report to the health care provider?
1Blood glucose of 380 mg/dL
2Arterial blood pH of 7.36
3Urine output greater than 100 mL/hour
4Serum osmolarity of 355 mOsm/L
4
The nurse is monitoring a 45-year-old client who just underwent a cardioversion for dysrhythmias. The client’s respirations are 12 per minute. Which action should the nurse take next?
1Measure the client’s oxygen saturation.
2Ask another nurse to verify the respiratory rate.
3Notify the health care provider (HCP).
4Continue to monitor the client.
4
Normal respirations range from 12 to 20 per minute; respirations of eight or less per minute would be a cause for concern.
The nurse is preparing a client for an intravenous pyelogram (IVP) test. Which intervention should the nurse plan to implement?
1Limit client’s fluid intake to 400 mL prior to the test.
2Inform client that no special preparation is necessary.
3Instruct client to maintain a regular diet until the test.
4Administer a laxative the evening before the test.
4
It is important for the large intestine to be clear of stool to allow full visualization of the kidney, bladder and ureters.
The nurse is preparing to suction a client’s tracheostomy. What action should the nurse take to prevent hypoxia during the procedure?
1Explain procedure to client.
2Monitor heart rate during suctioning.
3Use sterile technique.
4Provide preoxygenation to the client.
4
The nurse is caring for a comatose client. To prevent keratitis, moisturizing ointment should be prescribed for which body site?
1Lower eyelids
2External ear canal
3Fingernails and toenails
4Perianal area
1
Unconscious or comatose clients are often unable to close their eyes or do not have a functioning blink reflex. When the eye remains open for a prolonged time, the cornea will dry out, causing irritation or ulceration.
The nurse is in the process of inserting a urinary catheter in an adult female client. The nurse advances the catheter approximately 2 to 3 inches (5 to 7 cm), but no urine return is seen. What should the nurse do next?
1Inflate the catheter balloon.
2Advance the catheter a few more inches.
3Withdraw the catheter and try again.
4Notify the health care provider (HCP).
2
A child diagnosed with thalassemia has received several blood transfusions during the past three days. What lab value is the priority for the nurse to monitor with this client?
1Hemoglobin level
2Platelet count
3Blood urea nitrogen level
4Neutrophil percentage
1
A normal hemoglobin range for children is approximately 11 to 13 gm/dL. Thalassemia, also called Cooley’s anemia, is a genetic defect that causes anemia, i.e., a condition in which the blood contains below-normal hemoglobin levels. Hemoglobin is the oxygen-carrying protein component of the red blood cell (RBC).
The nurse initiates continuous enteral feeding at 8 am at 50 mL/hour for a client with malnutrition. It is now noon. What priority action should the nurse take at this time?
1Flush the feeding tube with 100 mL of water.
2Assess bowel sounds and gastric pH.
3Measure the gastric residual volume.
4Keep head of bed elevated at least 30 degrees.
3
A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which action included in the TEE orders should the nurse implement first?
1Place the client on NPO status.
2Administer O2 per nasal cannula.
3Start a peripheral IV line.
4Give midazolam (Versed) 1 mg IV push.
1
A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding that started several hours ago. The nurse should prepare the client for what procedure?
1Pelvic exam
2Abdominal ultrasound
3Nonstress test
4Caesarean section
2
A client has been taking isoniazid (INH) and rifampin for several months. Which laboratory test should the nurse monitor with this client?
1Creatinine clearance
2Cardiac enzymes
3Liver enzymes
4Sputum culture
3
INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid can cause hepatocellular injury
A male client underwent a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He received 1000 mL of intravenous (IV) fluids. Which action should the nurse implement to help this client urinate?
1Have the client drink several glasses of water.
2Insert a urinary catheter.
3Assist the client to stand to void.
4Obtain a bladder ultrasound.
3
The nurse is caring for a client who had a closed reduction of a fractured right wrist, followed by the application of a cast about 12 hours ago. Which finding requires the nurse’s immediate attention?
1Serum calcium level of 6.8 mg/dL
2Numbness in the right hand
3Reported pain level of six on a numeric pain scale
4Edema and swelling of the right hand
2
A nurse is caring for a client who had a cholecystectomy with common bile duct exploration and placement of a T-tube 24 hours ago. The nurse observes large amounts of bilious drainage from the T-tube. Which action should the nurse take?
1Administer pain medication.
2Clamp the T-tube for two hours.
3Continue to monitor the drainage.
4Lower the head of the bed.
3
A client is admitted to the hospital with endocarditis. The nurse understands that which risk factors can lead to the development of endocarditis? (Select all that apply.)
Oral abscess with tooth extraction
History of aortic valve replacement
Placement of an arteriovenous fistula for hemodialysis
Placement of a central venous access device
The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery disease due to atherosclerosis. Which factors most likely contributed to the development of this disease? (Select all that apply.)
Mother died of a myocardial infarction
Low-density lipoprotein (LDL) level of 149 mg/dL
History of diabetes mellitus
Used to smoke 40 packs per year until one year ago
The target LDL level for a client is less than 100 mg/dL.
The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration. Which observation by the nurse would indicate that the dehydration is improving?
1The client has normoactive bowel sounds.
2The client voided 300 mL of urine in the past two hours.
3The client denies any nausea or vomiting.
4The client reports the passing of flatus.
2
A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client’s plan of care?
1Maintain the client on bedrest.
2Administer a stool softener daily.
3Implement seizure precautions.
4Discuss the client’s wishes for organ donation.
A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client’s plan of care?
1Maintain the client on bedrest.
2Administer a stool softener daily.
3Implement seizure precautions.
4Discuss the client’s wishes for organ donation.
2
To avoid a vasovagal response (i.e., the slowing of the heart rate caused by bearing down when trying to defecate) and the risk for another syncopal episode, it is important to ensure that the client’s bowel movements are soft and easily expelled. The client should also be instructed to avoid holding their breath or bearing down (Valsalva maneuver).
A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension orally. Which instruction would be most appropriate for the nurse to give to the client regarding this medication?
1″You should use a straw when taking this medication.”
2’Taking this medication will turn your urine dark orange in color.”
3″Diarrhea is a common side effect when taking this medication.”
4″You should take the medication with food to enhance absorption.”
1
Because liquid iron can stain the teeth, the most appropriate instruction is to use a straw
The nurse is caring for a client with severe iron deficiency anemia. Which interventions should the nurse include in the client’s plan of care? (Select all that apply.)
Instruct assistive personnel to allow the client to rest during care activities.
Monitor the client for palpitations and orthostatic hypotension.
Review the client’s medical record for NSAID use.
Encourage the client to eat more green leafy vegetables and beans.
Monitor the client’s stool for color, consistency and frequency.
The nurse is caring for a client with a diagnosis of pericarditis. The unlicensed assistive person reports to the nurse that the client’s last set of vital signs were blood pressure of 84/40 mm Hg, respiratory rate of 28 breaths/minute, heart rate of 112 and the client seemed short of breath. The nurse examines the client and also notes the presence of jugular vein distention. What should the nurse do next?
1Administer the prescribed metoprolol.
2Notify the health care provider.
3Place the client on nothing by mouth status.
4Obtain a 12-lead electrocardiogram.
2
risk for cardiac tamponade due to jugular vein distention
The nurse in the outpatient clinic is reviewing the medical record of a client diagnosed with Raynaud’s disease. What information from the client’s health history would support this diagnosis? (Select all that apply.)
The client works in an office setting as a typist.
The client smokes two packs of cigarettes per day.
Warfarin is listed on the medication reconciliation form.
The client complains of brittle fingernails that break easily.
Fingers become cyanotic when exposed to cold objects.
A client is admitted to the cardiology unit for treatment for recurrent supraventricular tachycardia. Which observation by the nurse would best indicate that the client’s condition can be considered hemodynamically stable?
1The client denies any chest pain and capillary refill is less than three seconds.
2The client’s blood pressure is 88/40 mm Hg.
3The client’s pulse oximeter reads 91% on three liters nasal cannula.
4The client’s cardiac monitor shows a heart rate of 170 beats per minute.
1
A client with a history of chronic alcohol use disorder is admitted to the inpatient unit with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse implement first?
1Assess the client’s deep tendon reflexes.
2Order the client a meal with foods high in magnesium.
3Obtain the client’s heart rate and oxygen saturation.
4Place the client on fall risk and seizure precautions.
3
The nurse administered furosemide to a client with acute pulmonary edema. Which observation by the nurse would indicate that the client is experiencing an adverse side effect of the medication?
1The client exhibits exertional dyspnea with walking.
2The client reports muscle cramps in both legs.
3The client’s blood pressure is 104/60 mm Hg.
4The client’s weight decreased by 2 lbs. in two days.
2
Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia, an adverse drug effect of furosemide because this is a potassium wasting diuretic
The nurse is reviewing the plan of care for a client with peripheral artery disease who has a history of leg pain with walking. Which interventions should the nurse include in the client’s plan of care? (Select all that apply).
Enroll the client in an exercise program that involves low-impact activities.
Assist the client in selecting food items that are low in saturated fats and cholesterol.
Reinforce teaching on the importance of not walking without shoes on.
Assist the client in enrolling in a smoking cessation program.
The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of choice for pain management with this client?
1Meperidine
2Ibuprofen
3Acetaminophen
4Hydromorphone
4
The nurse is planning care for a client newly diagnosed with essential hypertension. Which interventions should the nurse include in the client’s plan of care? (Select all that apply.)
Encourage the client to take daily, 30-minute walks.
Explain the negative effects of hypertension on
Evaluate the client’s understanding of a low-sodium diet.
Evaluate the client’s ability to take their own blood pressure.
The nurse is assisting in developing a plan of care for a client who is on complete bedrest due to a spinal cord injury. Which intervention is most important for the nurse to include?
1Apply pneumatic compression devices to both legs.
2Turn and reposition the client every shift.
3Insert an indwelling urinary catheter.
4Administer a daily enema.
1
The nurse is reinforcing teaching for a client who was newly diagnosed with asthma. Clients with asthma should demonstrate understanding of which of the following? (Select all that apply.)
Clients must understand the use of medications including quick-relief (rescue) and long-acting (maintenance) therapies. Clients use the peak flow meter to assess effectiveness of medication or breathing status. An acute attack can be a medical emergency and knowing where and how to seek medical care is important. Certain conditions (triggers) can exacerbate an attack and should be avoided.
A client is seen at the primary care clinic for allergic rhinitis. Which clinical manifestations should the nurse expect with this diagnosis? (Select all that apply.)
Common symptoms of allergic rhinitis are due primarily to the release of immune mediators such as histamine, prostaglandins, eosinophils and cytokines. This leads to sneezing, runny nose with clear discharge, nasal congestion and an increased eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client’s sense of smell can be altered.
The nurse is caring for a client with a dry chest tube drainage system due to a left tension pneumothorax. Two hours ago, the health care provider (HCP) changed the chest tube prescription to water seal only. When entering the client’s room, the nurse finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2) of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe. What action should the nurse take first?
1Apply oxygen via nasal cannula
2Document all interventions in the client’s medical record
3Notify the appropriate HCP
4Request a chest X-ray
1
The nurse is planning care for a client admitted to the hospital with influenza. Which interventions should the nurse include in the client’s plan of care? (Select all that apply.)
Antiviral agents, such as oseltamivir, are used to shorten the course and reduce symptoms of the flu. Droplet transmission-based precautions are indicated to prevent the spread of the flu. To avoid further transmission of the illness, visitors with signs/symptoms of a respiratory illness should not be permitted on the unit. It is important to ensure that clients understand how to prevent transmission of infections such as the flu through proper hand hygiene and cough etiquette.
A client has been diagnosed with emphysema. Which intervention should the nurse implement when caring for this client?
1Inquire if the client has a power of attorney for health care.
2Reassure the client that the lung damage is usually reversible.
3Schedule a lung cancer screening for the client.
4Assist the client with enrolling in a smoking cessation program.
4
A nurse is administering the influenza vaccine in an occupational health clinic. Within 10 minutes of giving the vaccine to a middle-aged adult male, the man reports having itchy and watery eyes, feeling anxious and short of breath. What should the nurse do first?
1Administer SQ epinephrine.
2Maintain the airway.
3Take the client’s vital signs.
4Apply oxygen.
1
The nurse is evaluating whether teaching a client with dysphagia about preventing aspiration was effective. Which action by the client indicates that additional teaching is required?
1The client is sitting in a chair during meals.
2The client uses a straw to drink.
3The client tucks in the chin while swallowing.
4The client alternates solids with liquids.
2
The nurse is assisting with discharging a client from the hospital who was admitted for acute exacerbation of chronic obstructive pulmonary disease. Which statement by the client indicates that teaching was effective?
1″I will make sure to get the pneumonia vaccine every October.”
2″I will eat foods low in calories and protein.”
3″I will switch from regular to electronic cigarettes.”
4″I will use my spacer each time I use my inhaler.”
4
The home health nurse is reviewing information with a client who is being treated for pulmonary tuberculosis. Which statement by the nurse is correct?
1″You should not leave your home until your cough is completely gone.”
2″Your family members should get the tuberculosis vaccine.”
3″You can stop the medications once your symptoms have resolved.”
4″You should avoid public transportation and crowds in enclosed areas.”
4
The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reviews the client’s medical record and notes which risk factors? (Select all that apply.)
It is primarily caused by cigarette smoking. Other risk factors include genetics, asthma and exposure to occupational chemicals and air pollution.
ALL HISTORY OF
The nurse in the pediatric clinic is caring for an acutely ill, 10-year-old child. Which assessment finding would require immediate intervention by the nurse?
1Slow, irregular respirations
2Temperature of 101.3° F (38.5° C)
3Rapid, bounding pulse
4Profuse diaphoresis
1
The nurse is preparing a client for a pulmonary CT angiogram with contrast to rule out a pulmonary embolism. For which laboratory result should the nurse notify the health care provider immediately?
1D-dimer level of 1.2 mcg/mL
2Serum creatinine level of 2.8 mg/dL
3Arterial blood gas PaO2 level of 80 mm Hg
4Serum troponin level of 0.1 mg/mL
2
The client’s creatinine level is significantly elevated (normal creatinine level is 0.8 to 1.2 mg/dL), placing the client at risk for dye-induced renal failure and the nurse should notify the health care provider of this lab result immediately.
The nurse in the primary health care provider’s office is reviewing the medical record of a client with idiopathic pulmonary arterial hypertension. The nurse should expect which potential clinical manifestations with this disease? (Select all that apply.)
Classic symptoms include: exertional dyspnea and chest pain, fatigue, right-sided heart failure (cor pulmonale) due to the increased workload of the right ventricle and abnormal heart sounds, such as an S3.
The home health nurse is reviewing the medical record of a client with closed-angle glaucoma in both eyes. Which statement by the client would support this diagnosis?
1″I have specks floating in my eyes.”
2″I have to turn my head to see around the room.”
3″I can’t see out of my left eye.”
4″I have constant blurred vision.”
2
Which action should the nurse take before communicating with a client diagnosed with presbycusis?
1Check the client for cerumen impaction.
2Ask for permission to turn off the television.
3Request a medical translator.
4Wait until family members have left.
2
The nurse is planning care for a client diagnosed with Guillain-Barré syndrome. Which problem should the nurse identify as a priority?
1Difficulty breathing
2Altered bowel elimination
3Partial or total immobility
4Nutritional deficits
1
The nurse is providing care to an 80-year-old client with the diagnosis of advanced Parkinson’s disease. The nurse should know that the greatest risk to the client is related to which finding?
1Difficulties with reading and seeing at night
2Extreme weakness in the lower extremities
3Drooling and coughing when eating
4Dizziness and syncopal episodes
3
The home health nurse is reviewing the plan of care for a client experiencing acute attacks of Ménière’s disease. What is the priority intervention for this client?
1Instruct the client not to drive a motor vehicle.
2Provide assistance with bathing and dressing.
3Communicate clearly and use visual aids.
4Encourage bland foods and noncarbonated fluids.
1
The nurse on the inpatient unit is expecting the admission of a client with a new onset of seizures and instructs the unlicensed assistive person (UAP) to prepare the client’s room. Which piece of equipment should the UAP make sure to place in the room?
1Soft wrist restraints
2An oral airway
3A bedside commode
4Pads to be placed over the bed’s side rails
4
The nurse is reinforcing discharge instructions for a client after cataract surgery of the left eye. Which statements by the client indicate an understanding of the instructions? (Select all that apply.)
“I will follow the instructions for the eye drops.”
“I will call the surgeon if the pain is intense.”
“I will not rub, press on or scratch my eye.”
The nurse is providing care for a 40-year-old client suspected of having Guillain-Barré syndrome. Which intervention should the nurse plan for?
1Genetic testing of the client’s children
2A bone marrow biopsy
3Administration of immunoglobulins
4Implementation of airborne precautions
3
Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early phase. They are believed to interfere with antigen presentation and help to modulate the body’s immune response.
The nurse in the neurology office is reviewing information about levetiracetam with a 30-year-old female client with a history of seizures. Which instruction about the medication should the nurse make sure to include?
1″You might experience irregular menses and intermittent bleeding.”
2″Call the office immediately if you feel like hurting or killing yourself.”
3″You should stay away from large crowds and sick children.”
4″You should avoid becoming pregnant while taking this medication.”
2
Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the significant side effects is behavioral changes and suicidal ideations.
The nurse is performing a home visit for an older adult client with Alzheimer’s disease. Which of the following observations should be a priority for the nurse to address?
1Good lighting in the stairwell
2Throw rugs on the kitchen floor
3Lamps plugged directly into wall outlets
4Handrails in the bathtub
2
The nurse is collecting data from a college student who comes to the health clinic with symptoms of meningitis. The student resides in the school dormitory. What is the priority action the nurse should take?
1Perform a focused neurological assessment.
2Administer acetaminophen for the headache.
3Alert the college’s administration and dormitory staff.
4Obtain the client’s immunization history.
3
The clinic nurse is following up with a client who was seen a few days ago for trigeminal neuralgia. Which action by the client indicates an understanding of how to manage the condition?
1Takes an analgesic after performing household chores.
2Keeps the environment at a moderate temperature and free from drafts.
3Eats a bowl of hot, steaming soup every day for lunch.
4Performs vigorous brushing of teeth twice per day.
2
Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe, brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can reduce the risk of triggering an acute attack.
The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson’s disease. Which interventions should the nurse make sure to include for this client? (Select all that apply.)
Set-up a bladder training program for the client.
Encourage participation in speech therapy.
Use cognitive strategies to enhance the client’s memory.
Provide assistance with ambulation.
The nurse is reviewing the plan of care for a 30-year-old client newly diagnosed with multiple sclerosis. Which interventions should the nurse include for this client? (Select all that apply.)
Instruct the client on how to self-catheterize as needed.
Review methods to prevent and treat constipation.
Encourage participation in physical and occupational therapy.
Encourage participation in vocational rehabilitation.
Encourage independence in personal care and bathing.
Review methods to prevent and treat constipation.
Encourage participation in physical and occupational therapy.
Encourage participation in vocational rehabilitation.
Encourage independence in personal care and bathing.
The nurse is caring for a client who has a history of peptic ulcer disease. The nurse notes the abdomen is rigid and the client complains of severe pain with palpation. What is the priority action by the nurse?
1Record the findings in the client’s record.
2Ask the client about dietary habits.
3Notify the health care provider of the findings.
4Review the client’s record for NSAID use.
3
The nurse is caring for a client who is suffering from an exacerbation of ulcerative colitis. Which manifestations would the nurse expect to see with this client? (Select all that apply.)
Fever of 104° F (40° C)
Crackles in the lower lung fields
Mucous noted in the stool
Frequent bloody stools
Abdominal pain relieved by defecation
mucous, bloody, abdominal pain
The nurse is caring for a client who had a small bowel resection two days ago. The client reports that the pain has significantly increased over the last two hours and does not get better after receiving an analgesic. Which additional findings are indicative of a postoperative complication the client might be experiencing? (Select all that apply.)
Tenderness at the incision site
Taut, distended abdomen
Hyperactive bowel sounds
Serosanguineous fluid in the surgical drain
Nausea and vomiting
Taut, distended abdomen
Hyperactive bowel sounds
nausea and vomiting
The nurse in the primary care office is reviewing after-visit instructions with a client who was recently diagnosed with gastroesophageal reflux disease (GERD). Which action should the client implement to decrease the symptoms associated with GERD?
1Increase oral fluid intake to 4 liters a day.
2Avoid caffeinated and carbonated beverages.
3Eliminate dairy products from the diet.
4Limit foods high in fiber.
2
The home health nurse is caring for a client who underwent a partial gastrectomy due to gastric cancer several months ago. Which finding would indicate that the client is suffering from pernicious anemia? (Select all that apply.)
The client’s sclerae are icteric.
The client reports numbness and tingling in the feet.
The client is experiencing urinary retention.
The client’s tongue is shiny and beefy-red.
The client is exhibiting alopecia.
The client’s sclerae are icteric.
The client reports numbness and tingling in the feet
tongue shiny and beefy-red
The nurse is educating a group of individuals about how to prevent hepatitis B and C. Which statement by the nurse would best describe prevention of these two diseases?
1″You can eat fresh fruit picked from the tree without the need to wash.”
2″You should use protection when engaging in sexual intercourse.”
3″You should talk to your health care provider when traveling internationally.”
4″You can receive a yearly vaccination to prevent the diseases.”
2
The nurse at the outpatient surgery center is speaking with a client who is scheduled for a colonoscopy the next morning. Which information about the procedure should the nurse make sure to include? (Select all that apply.)
“You will have an intravenous catheter inserted prior to the procedure.”
“You will be required to lay still for 6 to 8 hours after the procedure.”
“You should only consume clear liquids for the next 12 to 24 hours.”
“Remember to stop eating any food six hours before you come to the center.”
“Make sure to drink the entire bowel preparation liquid.”
“You will have an intravenous catheter inserted prior to the procedure.”
“You should only consume clear liquids for the next 12 to 24 hours.”
“Remember to stop eating any food six hours before you come to the center.”
“Make sure to drink the entire bowel preparation liquid.”
A client is being admitted to the hospital with complaints of bloody stools for several days. Which interventions should the nurse expect to be prescribed for this client? (Select all that apply.)
Administration of pantoprazole
Collection of a stool sample for occult blood testing
Discontinuation of all NSAID medications
The nurse is reinforcing teaching with a client regarding their diagnosis of hepatic encephalopathy. Which statement by the client indicates that additional teaching is needed?
1″I will brush my teeth with a soft toothbrush to avoid bleeding gums.”
2″I will eat enough protein and calories to stay healthy.”
3″I will stop taking ibuprofen for my knee and back pain.”
4″I will stop taking my lactulose when I have more than one loose stool.”
4
The nurse is assisting with meal planning for a client with cholelithiasis. Which food items would be most appropriate for this client? (Select all that apply.)
The most common cause of gallbladder disease is from stones that block the biliary ducts. Other causes are due to inflammation, infection, tumors or decreased blood flow due to damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and limit their intake of fried and processed foods such as breakfast cereals, lunch meats and microwavable meals.
The nurse is assigned to care for a client with end-stage liver failure and portal hypertension. Which clinical manifestations would the nurse expect to see with these conditions? (Select all that apply.)
Diminished pedal pulses
Shortness of breath
Increased weight gain
Increased abdominal girth
Elevated serum albumin level
Shortness of breath
Increased weight gain
Increased abdominal girth
Which discharge instruction should the nurse make sure to include for a client with chronic pancreatitis?
1″Make sure to eat a low-fat, high-fiber diet.”
2″Try to reduce smoking cigarettes to half a pack per day.”
3″Limit alcohol intake to one drink a day.”
4″Take the prescribed pancreatic enzymes on an empty stomach.”
1
The nurse is assisting in developing as plan of care for a postoperative client following a radical left mastectomy. Which nursing problem should be the priority for this client?
1Risk of infection of the surgical site
2Anxiety related to the cancer diagnosis
3Acute pain related to the surgery
4Impaired left arm circulation (lymphedema)
3
The nurse is evaluating a client’s understanding of appropriate dietary choices with chronic kidney disease. Which food choices by the client indicate an understanding of the teaching? (Select all that apply.)
Fresh apples
Baked chicken
Unsalted pretzels
Slice of cheese
Orange juice
Baked potato
Fresh apples
Baked chicken
Unsalted pretzels
A client with chronic kidney disease (CKD) must limit intake of potassium, sodium, phosphorus and protein. In CKD, the kidneys are unable to adequately excrete these components. Foods low in potassium include: apples, grapes, lettuce and cauliflower. Foods high in potassium include: bananas, oranges, potatoes and spinach. Foods low in phosphorus include: chicken, shrimp, crab and rice. Foods high in phosphorus include: organ meats, salmon, scallops, nuts and cheese.
A client comes to the community health clinic with symptoms of gonorrhea. Which intervention should the nurse implement first?
1Discuss the risk of infertility with the client.
2Collect a urethral swab from the client.
3Instruct the client to notify past sexual partners.
4Obtain information about the client’s recent sexual encounters.
4
The nurse is assisting with developing a plan of care for a client with benign prostatic hyperplasia. Which nursing interventions should the nurse include for this client? (Select all that apply.)
Limit caffeinated and alcoholic beverages.
Calculate accurate intake and output.
Void every 1 to 2 hours to empty the bladder.
Catheterize as needed for post-void residual urine.
Monitor for bladder distention.
limit caffeine
catheterize as needed
monitor
The nurse is reviewing the medical record of a client admitted with acute kidney injury. Which findings would support this diagnosis? (Select all that apply.)
Proteinuria
Hypokalemia
Elevated creatinine level
Decreased glomerular filtration rate
Hematuria
Decreased blood area nitrogen
proteinuria
elevated creatinine
decreased function
hematuria
A nurse is caring for a client with continuous bladder irrigation (CBI), following a transurethral resection of the prostate. Which finding would indicate the need for the nurse to increase the flow of the CBI?
1Bladder spasms
2Pain at the catheter insertion site
3Temperature of 99.8° F
4Blood clots in the catheter tubing
4
A 68-year-old, postmenopausal, female client has been prescribed tamoxifen for breast cancer with bone metastases. The nurse should reinforce teaching about which potential adverse drug effect?
1Stroke-like symptoms
2Seizures
3Symptoms of hypocalcemia
4Insomnia
1
Tamoxifen is an antineoplastic drug, commonly prescribed for clients with breast cancer or for clients who are at high risk for developing breast cancer. The most common adverse drug effects (ADEs) are hot flashes, fluid retention, vaginal discharge, nausea, vomiting and menstrual irregularities. In women with bone metastases, tamoxifen may cause transient hypercalcemia. Because of its estrogen agonist actions, tamoxifen poses a small risk of thromboembolic events, including deep vein thrombosis, pulmonary embolism and stroke.
The school nurse is teaching a group of teenagers about the prevention of sexually transmitted infections (STIs). Which statement by one of the students indicates an understanding of the teaching?
1″Wearing a condom will eliminate any risk of contracting an STI.”
2″There are vaccines available that will prevent the majority of STIs.”
3″Being on birth control will prevent getting an STI.”
4″Having multiple sexual partners puts me at a higher risk for an STI.”
4
The nurse is reinforcing teaching with a client who has recurrent kidney stones. Which statement by the client would indicate that further teaching is needed?
1″I will follow a low-calcium diet and avoid dairy products.”
2″I will contact my health care provider if I am having difficulty urinating.”
3″I will monitor the color of my urine.”
4″I will make sure I drink plenty of water throughout the day.”
1
A client with benign prostatic hypertrophy has been prescribed tamsulosin. Which statement by the nurse describes how this medication works?
1″This drug will eliminate your nocturia.”
2″This medication will improve the flow of urine.”
3″Your libido will increase with this medication.”
4″This medication will shrink your enlarged prostate gland.”
2
The nurse in the outpatient clinic is assisting in the admission of a client scheduled for a prostatectomy this morning. Which statement by the client should be of greatest concern to the nurse?
1″I am feeling nervous about the procedure.”
2″I have not had anything to eat since 9:00 pm last night.”
3″I have had an allergic reaction to an antibiotic before.”
4″I have not had to urinate since yesterday evening.”
4
The nurse is reviewing the electronic medical record of a client diagnosed with endometriosis. The nurse should expect which findings with this diagnosis? (Select all that apply.)
The following findings that would indicate the client has endometriosis are pain with menstruation (dysmenorrhea), pain with intercourse (dyspareunia), excessive bleeding, and infertility. The client may also complain of pelvic and/or back pain, along with pain during bowel movements.
The nurse in the emergency department is admitting a client with a reduced level of consciousness due to severe hypothyroidism. Which interventions should the nurse implement first?
1Implement warming blankets as indicated.
2Orient the patient to person, time and place.
3Monitor O2 saturation and provide supplemental oxygen.
4Administer propranolol as prescribed.
3
The nurse is caring for a client who has type I diabetes mellitus. Upon entering the room, the nurse notes the client has rapid, deep respirations, and is lethargic and difficult to arouse. What should the nurse do first?
1Check the client’s blood sugar.
2Administer glucagon per protocol.
3Review the client’s insulin pump settings.
4Review when the last dose of insulin was given.
1
The nurse in the primary health care provider’s office is speaking with a 40-year-old male client whose most recent hemoglobin A1C level was 9%. The client states that he is motivated to make lifestyle changes to better manage his disease. What interventions should the nurse recommend for this client? (Select all that apply.)
Eliminate all consumption of alcohol.
Minimize intake of caffeinated beverages.
Schedule an appointment with a registered dietitian.
Start a weight loss program until BMI is below 25.
Check the blood sugar several times a day, ideally before eating.
Engage in regular physical activity, such as walking.
Schedule an appointment with a registered dietitian.
Start a weight loss program until BMI is below 25.
Check the blood sugar several times a day, ideally before eating.
Engage in regular physical activity, such as walking.
The nurse is reinforcing education for a client with type 2 diabetes mellitus who is being discharged home. Which statement by the client would require clarification from the nurse?
1″At home, I should check my blood sugar before meals and at bedtime.”
2″It is important to increase my physical activity gradually.”
3″I will make sure to have an eye exam every five years.”
4″When I administer my insulin, I will rotate injection sites.”
3
Eye exams should be performed annually for diabetic clients due to the risk of diabetic retinopathy.
The nurse is caring for a client who has suspected Cushing’s disease. The nurse should monitor for which potential symptoms? (Select all that apply.)
Large fat pads on the back and shoulders
History of pathologic fractures
Tachycardia and panic attacks
Changes in visual acuity
Polyuria and polydipsia
Large fat pads on the back and shoulders
History of pathologic fractures
Cushing’s disease occurs when there is an excess amount of cortisol. The nurse must understand that glucocorticoids, including cortisol, regulate metabolism and immune function, and play a role in the regulation and distribution of serum calcium levels. Therefore, deposition of fat pads on the back and shoulders, as well as fractures secondary to osteoporosis, are signs and symptoms of Cushing’s disease that the nurse should be able to recognize.
The nurse is caring for a client who was admitted for hyperglycemic hyperosmolar state (HHS). Which clinical finding would support this diagnosis?
1Blood sugar > 600 mg/dL
2Positive urine ketones
3Deep, rapid breathing pattern
4Serum pH level < 7.35
1
A client diagnosed with hypoparathyroidism would be most likely to display which of the following symptoms?
1Pruritus
2Flank pain
3Decreased reflexes
4Polydipsia
1
The nurse is caring for a client with diabetes who was admitted for intractable vomiting. The nurse notes that the client’s skin is cool to the touch, and the fingerstick blood sugar result is 55 mg/dL. What intervention should the nurse implement first?
1Administer glucagon.
2Recheck the blood sugar in 15 minutes.
3Offer the client a warm blanket.
4Administer an antiemetic.
1
The nurse is reviewing the plan of care for a client with acute adrenocortical insufficiency. Which intervention should be a priority for this client?
1Administration of potassium supplements
2Electrocardiogram monitoring
3Implementation of a low-sodium diet
4Administration of insulin
2
The nurse understands that the prescribed levothyroxine is effective when the client with hypothyroidism makes which statement?
1″I still feel lethargic and fatigued.”
2″I have been having daily, formed bowel movements.”
3″I have to change my sheets in the morning because I sweat a lot at night.”
4″I was reprimanded at work after becoming angry with my boss.”
2
The nurse is caring for a client who presents with polyuria, polydipsia and a urine specific gravity of 1.002. The nurse suspects that the client is experiencing diabetes insipidus. Which risk factors would support this diagnosis? (Select all that apply.)
Recent neurologic injury
Current use of lithium
History of recent surgery
History of radiation treatment
History of pulmonary disease
Recent neurologic injury
Current use of lithium
History of recent surgery
History of radiation treatment
The nurse is planning care for a client admitted with uncontrolled hyperglycemia. Which activities can the nurse delegate to the unlicensed assistive person (UAP)? (Select all that apply.)
Soak the client’s feet in warm water prior to performing nail care.
Administer insulin, but do not aspirate for blood prior to injecting.
Report any skin lesions or breakdown to the nurse.
Cut the client’s toenails short and trim the corners with cuticle scissors.
Apply moisturizing cream between the client’s toes.
After bathing, ensure that the client’s skin is completely dry.
Check the client’s blood sugar before meals and at bedtime.
Report any skin lesions or breakdown to the nurse.
After bathing, ensure that the client’s skin is completely dry.
Check the client’s blood sugar before meals and at bedtime.
The nurse is caring for a client who has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions are appropriate for this client? (Select all that apply.)
Monitoring of intake and output
Administration of a loop diuretic
Implementation of a fluid restriction
Implementation of a low-sodium diet
Administration of vasopressin
Monitoring of intake and output
Administration of a loop diuretic
Implementation of a fluid restriction
The nurse is caring for a client who has been diagnosed with Cushing syndrome. Which medication most likely contributed to this condition?
Pantoprazole
Prednisone
Paroxetine
Pravastatin
prednisone
The nurse is reviewing the medical record of a client with diabetes who was admitted for a surgical site infection. Which findings should the nurse report to the health care provider? (Select all that apply.)
In reviewing the lab values, the nurse should notify the HCP of the positive glucose in urine (normally, glucose is not seen in urine), A1C of 8% (desired range for a client with diabetes is 7% or less), and the serum glucose level of 220 mg/dL, which is higher than the normal range of 70 to 110 mg/dL. These abnormal lab results indicate that the client’s diabetes is not managed well and most likely contributed to the client developing an infection.
The nurse is reviewing the medical record of a client who has been diagnosed with osteoporosis. The nurse identifies which risk factors for this condition? (Select all that apply.)
The client takes 10 mg of prednisone daily.
The client performs weight-bearing exercises six days a week.
The client weighs 200 lbs. (90.7 kg) with a height of 5 feet 2 inches (157 cm).
The client is a 75-year-old Caucasian female.
The client has a 30 pack per year smoking history.
Osteoporosis is the loss of bone density that leads to weakness of the bone. Risk factors for osteoporosis include being a postmenopausal woman (lack of estrogen), smoking, thin stature, steroid use, lack of weight-bearing exercise, such as prolonged immobility or a sedentary lifestyle, and ethnicity.
prednison
75
30pack
The nurse in the outpatient clinic is following up on a client with a fractured arm. The client’s arm was placed in a cast four hours ago. The client states, “my fingers are tingling and feel cold.” Which action should the nurse take first?
1Apply an ice pack to the cast to reduce swelling.
2Elevate the client’s arm above the level of the heart.
3Check the capillary refill in the client’s fingers.
4Notify the health care provider.
3
A client has received instructions for the management of osteoarthritis. Which statement by the client would indicate a need for additional teaching?
1″Early surgical intervention is the preferred treatment.”
2″Gradual weight loss may help my pain.”
3″It is important for me to balance my exercise and rest periods.”
4″I will avoid driving after I have taken cyclobenzaprine.”
1
The nurse is reviewing the medical record of a client who has been diagnosed with systemic lupus erythematous (SLE). The nurse would expect which findings associated with this disease? (Select all that apply.)
Generalized weakness
Reports of pain in the hands and knees
A recent ten pound weight gain
A temperature of 100.6° F (38° C)
Polydipsia for the last month
A red, raised rash on the face
generalized weakness
reports of pain
temperature of 100.6
red, raised rash
A client who has osteoarthritis, affecting both knees, is reporting constant pain at a level of 4 on a 0 to 10 scale. Which nonpharmacological intervention should the nurse implement for this client to help alleviate the pain?
1Position the client with the knee joints in a flexed position.
2Provide opportunity for the client to participate in hydrotherapy.
3Collaborate with physical therapy for paraffin dips to the knees.
4Place the client on strict bedrest with bathroom privileges only.
2
Soaking in a hot bathtub or doing hydrotherapy with physical therapy provides warmth that will decrease pain. The buoyancy of the client’s body in water decreases weight on the joints, which will also decrease pain.
The nurse in the urgent care clinic is reinforcing teaching for a client who is being discharged with a new cast on the left arm due to a spiral fracture. Which statement indicates that the client correctly understands how to care for the cast?
1″I will avoid using ice the first 24 hours that my cast is on.”
2″A moderate amount of daily drainage from my cast is expected.”
3″I will notify my health care provider if my hand becomes pale.”
4″I should be able to fit three fingers between the cast and my skin.”
3
The nurse is assisting in the admission of a 73-year-old client who has a fractured right hip. Which interventions should the nurse include in the client’s plan of care? (Select all that apply.)
Ask about the client’s pain level with every set of vital signs.
Perform daily circulation, motion and sensation checks on the client’s right leg.
Palpate the client’s bilateral pedal pulses every four hours.
Place the client on continuous pulse oximetry.
Reposition the client every hour to prevent skin breakdown.
The client with a hip fracture is at risk for impaired perfusion to the affected extremity. Monitoring bilateral pedal pulses allows the nurse to compare the pulse strength in the injured site with that in the non-injured site. A decrease in the injured leg could signal a decrease in circulation that would require immediate intervention. A fat embolism is also a risk with a hip fracture and continuous pulse oximetry would allow the nurse to identify hypoxia quickly which could be associated with a fat embolism. Clients with a hip fracture usually experience great pain and assessing pain with each set of vital signs is key to effective pain management. Circulation, motion and sensation checks should be completed at least every four hours, not daily.
The nurse is assisting in the preoperative plan of care for an older adult client who will be undergoing a total hip arthroplasty. To improve the client’s postoperative course, which interventions should the nurse plan for? (Select all that apply.)
Preoperative pain control with naproxen
Instruction on plantar and dorsiflexion exercises
Administration of subcutaneous warfarin
The use of assistive devices for ambulation
Application of sequential compression devices
Due to the client’s age and the surgical procedure, the client is at risk for a venous thromboembolism. The nurse should include the use of sequential compression devices to decrease venous stasis along with providing instruction on plantar and dorsiflexion exercises. Warfarin is administered orally; it does not come in an injectable form. The client will most likely need assistive devices initially for safe ambulation postoperatively. Preoperatively, the nurse should not use naproxen to control pain because it is a nonsteroidal anti-inflammatory drug (NSAID) and can increase the risk of bleeding during surgery.
The nurse is caring for a client who is experiencing an acute gout attack. Which action should the nurse implement?
1Monitor liver enzymes.
2Provide a high-protein diet.
3Restrict sodium intake.
4Administer indomethacin.
4
the nurse should administer a non-steroidal anti-inflammatory medication such as indomethacin to help decrease pain and inflammation.
The nurse is reinforcing teaching regarding the use of methotrexate with a female client who has systemic lupus erythematosus. Which statement by the client indicates an understanding of the teaching?
1″I should not use contraception that contains estrogen.”
2″I will avoid interacting with people in large crowds.”
3″Lab work won’t be necessary while I take this medication.”
4″I will not take any vitamin that contains folic acid.”
2
Methotrexate is an immunosuppressant medication that is used to treat systemic lupus erythematosus (SLE). Due to immunosuppression, clients taking methotrexate should avoid large crowds of people to prevent becoming ill. Methotrexate should be taken with folic acid to decrease gastrointestinal and hepatic toxicity. Clients who are taking this medication should have a complete blood count test done regularly to monitor for decreased white blood cells and platelets, which can indicate bone marrow suppression. Methotrexate is teratogenic, therefore, pregnancy should be avoided while taking this medication.
The nurse is caring for a client with osteoporosis who has been prescribed alendronate. When providing care, which intervention would be a priority?
1Notify the health care provider if the client reports jaw pain.
2Monitor the client’s serum calcium levels.
3Encourage the client to increase their intake of vitamin D.
4Administer the alendronate 30 to 60 minutes before the client eats.
1
The office nurse is discussing how to prevent an acute gouty attack with a client who has gout. Which actions should the nurse recommend to the client? (Select all that apply.)
Limit their intake of shellfish and red meats.
Take the prescribed prednisone regularly.
Limit their consumption of alcohol.
Implement stress reduction techniques.
limit shellfish/meat intake
limit consumption of alcohol
stress reduction techniques
The nurse observes an unlicensed assistive person (UAP) providing care to a client who had a total hip arthroplasty 24 hours ago. Which action by the UAP would require the nurse to intervene immediately?
1Placing non-slip foot wear on the client prior to ambulation.
2Placing a raised toilet seat in the client’s bathroom.
3Standing by the client’s non-operative side during ambulation.
4Reminding the client not to cross their legs.
3
When assisting the client during ambulation following a total hip arthroplasty, the UAP should stand on the operative side (i.e., the side of the surgery) to help provide support to the client because that is the client’s weaker side.
The home health care nurse is caring for a client who has epilepsy. While the nurse is providing care, the client has a seizure. Which intervention would be most appropriate to prevent an injury to the client?
1Loosening clothing around the waist
2Asking the client to state where they are
3Lowering the client to the ground
4Placing a pillow under the client’s head
3
The nurse is participating in a disaster simulation that involves a school bus accident. The nurse is assigned to care for the following four clients in a rural hospital’s emergency department. Which client should the nurse see first?
1The client with a penetrating abdominal wound
2The client with multiple facial abrasions
3The client with an open humerus fracture
4The client with a third degree burn to the arm
1
A client with a known large abdominal aortic aneurysm develops a sudden change in level of consciousness and tachycardia. The client’s blood pressure is 72/48. What should the nurse do first?
1Activate the hospital’s emergency response team.
2Page the client’s health care provider.
3Conduct a complete head-to-toe physical assessment.
4Obtain a 12-lead electrocardiogram.
1
The nurse is caring for a client with a medical history of peripheral artery disease, hypertension and smoking. The client reports severe pain in the right lower leg that started very suddenly and did not get better after receiving an analgesic. What action should the nurse take first?
1Check the client’s pedal pulse.
2Offer the client an ice pack for the pain.
3Administer an additional dose of the analgesic.
4Notify the health care provider.
1
A client presents to the emergency department with a prolonged asthma attack that did not resolve after the client used a metered-dosed inhaler at home. Which medication should the nurse plan to administer first for this client?
1Oral prednisone
2Fluticasone inhaler
3Intravenous azithromycin
4Nebulized albuterol
4
The nurse on a postpartum nursing unit is receiving report about a client who had a normal spontaneous vaginal delivery the night before. The client has been passing golf ball-sized clots on her peri-pad for the last few hours. The client’s most recent blood pressure is 88/56, and her heart rate is 118. The nurse enters the client’s room and notices blood oozing from her intravenous insertion site. Which action should the nurse take first?
1Notify the client’s health care provider.
2Palpate and massage the client’s uterus.
3Perform peri-care and change the client’s peri-pad.
4Encourage breastfeeding to promote uterine contractions.
1
The nurse is beginning a shift caring for a group of adult clients on a neurological unit in an acute care hospital. Which client should the nurse see first?
1A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64
2A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home
3A client admitted with hepatic encephalopathy who has an elevated ammonia level
4A client admitted with a transient ischemic attack, who has a bubble study echocardiogram ordered
2
The nurse is reviewing vital signs documented in the electronic health record for a group of clients. Based on this data, which client should the nurse see first?
1A client diagnosed with heart failure who has a SpO2 of 82%.
2A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88.
3A client diagnosed with infective endocarditis who has a temperature of 101.8 °F (39° C).
4A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute.
1
The off-duty nurse witnesses a motor vehicle accident and is concerned that the driver of the automobile may be injured. What should the nurse do first?
1Consider scene safety to prevent further injury.
2Check the driver’s respiratory rate.
3Check the driver’s pulse.
4Minimize movement of the driver’s cervical spine.
1
The nurse is talking with a client during a home health visit. The client states, “my right arm and right leg are beginning to feel heavy.” The nurse notices the client is having trouble speaking and has stopped moving the right side of their face. What action the nurse should take first?
1Take the client’s vital signs.
2Document the onset of symptoms in the medical record.
3Call 911.
4Ask the client if they have a headache.
3
An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first?
1Obtain a STAT 12-lead electrocardiogram.
2Obtain a STAT electroencephalogram.
3Administer levetiracetam intravenously.
4Administer lorazepam intravenously.
4
The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What diagnostic test would the nurse expect to be performed first?
1Echocardiogram
2Computerized tomography scan
3Arterial blood gas
4Chest X-ray
2
The off-duty nurse is helping to administer first aid following a mass casualty incident in the community. Emergency medical personnel at the scene have started to triage victims, using a common, color-tagging system. Which tag color usually indicates the highest priority for a victim to receive care?
1Green
2Red
3Yellow
4Black
2
The nurse in a long-term care facility is caring for an 89-year-old client with atrial fibrillation and a history of multiple falls. The client’s medications include amiodarone, atorvastatin, baby aspirin and metoprolol. Which new finding should be of greatest concern to the nurse?
1Heart rate of 106
2Bibasilar crackles
3Right-sided facial droop
4SpO2 of 89% on room air
3
A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor and an increase in swelling of the anterior neck area. What should the nurse do first?
1Activate the hospital’s emergency or rapid response system.
2Check the client’s blood pressure and heart rate.
3Ask the charge nurse to come see the client immediately.
4Place a heart monitor on the client and observe for dysrhythmias.
1
The nurse is reviewing discharge instructions with a client who has been prescribed ciprofloxacin following a minor burn injury. Which statement by the client requires additional teaching?
1″I can take ibuprofen for the pain related to this burn.”
2″After healing, I should have no scarring from this burn.”
3″I will not take ciprofloxacin prior to sun exposure.”
4″I will protect my skin from the sun with sunscreen and clothing.”
3
The nurse in the primary care office is speaking with a client who has contact dermatitis on both hands. The client wants to know how to manage the condition. Which interventions should the nurse recommend to the client? (Select all that apply.)
Rubbing the area can alleviate symptoms.
Applying a cold pack to the area can help.
Avoid heat that can exacerbate symptoms.
Corticosteroid cream is acceptable to use.
Frequent handwashing is important.
Using soap without fragrance is recommended.
avoid heat
corticosteroid acceptable to use
use soap without fragrance
Exposure to heat or cold may cause or exacerbate contact dermatitis. Rubbing the area may also exacerbate or spread symptoms. While washing hands after exposure to possible irritants is recommended, frequent handwashing is not. Soap with fragrance is an external irritant and may exacerbate symptoms, so fragrance-free soap is recommended. A barrier cream containing a corticosteroid is the most frequently prescribed topical ointment.
The home health nurse is visiting a client who has peripheral artery disease. It is winter time and cold outside. While observing the client getting dressed, which clothing choice by the client should the nurse question?
1Two pairs of cotton socks
2A fleece hat with ear protection
3Wind-protecting pants and jacket
4A polyester fleece inner layer
1
A client is in the rehabilitation phase after suffering severe facial burns. Which behavior by the client best indicates that the client is coping effectively with the injury?
1The client appears cheerful when the spouse visits.
2The client asks for information about a support group for burn survivors.
3The client is looking forward to attending their high school reunion.
4The client plans to work from home after discharge from the facility.
3
The nurse is caring for a client who suffered second-degree burns over 50% of their body. The nurse understands that which medication is used for the prevention of stress ulcers for this client?
1Pantoprazole 40 mg IV daily
2Furosemide 40 mg IV daily
3Ibuprofen 400 mg PO every eight hours
4Bumetanide 2 mg PO every six hours
1
Curling’s ulcers generally manifest themselves as gastric bleeding and are prevented by administering proton-pump inhibitors, such as pantoprazole.
The home health nurse is visiting an older adult client who recently moved to this community from a much colder climate. The nurse provides the client with instructions on how to prevent a heat stroke. Which statement by the client indicates that additional teaching is needed?
1″I will not take my diuretic on days that I exercise.”
2″I will increase my fluid intake if I develop cramps when exercising.”
3″I will wear loose clothing and a hat when I walk my dog.”
4″I will take my morning jog early in the morning when it is cool outside.”
1
A client has received instructions about the management of their chronic dermatitis. Which action by the client indicates an understanding of the instructions?
1The client applies topical corticosteroids as prescribed.
2The client applies warm compresses to relieve itching.
3The client avoids use of antihistamines when a flare-up occurs.
4The client avoids itching and scratching the affected area.
4
The nurse in a long-term care facility is reviewing the medical record of a newly admitted client. Which of the following factors put the client at an increased risk for developing a pressure ulcer? (Select all that apply.)
The client has a history of exercise-induced asthma.
The client has diabetes mellitus.
The client has a body mass index (BMI) of 30
The client is receiving an immunosuppressant drug for rheumatoid arthritis.
The client is alert and oriented to person, place, time and situation.
The client has diabetes mellitus.
Correct!
The client has a body mass index (BMI) of 30.
Correct!
The client is receiving an immunosuppressant drug for rheumatoid arthritis.
The nurse in a long-term care facility is observing the certified nursing assistant (CNA) change a soiled incontinence brief on a client with incontinence-associated dermatitis (IAD). Which actions by the CNA would require the nurse to intervene?
1Positions the client in a side-lying position.
2Places an absorbent dressing pad over the wound.
3Applies a thin layer of barrier cream to the perineum.
4Cleanses the perineal area with toilet tissue.
4
The nurse in a long-term care facility is reviewing the plan of care for a client with quadriplegia. Which risk assessment scale should be included for this particular client?
1The Hamilton scale
2The Braden scale
3The Wong-Baker scale
4The Hendrich scale
2
The Braden scale is used for predicting pressure ulcer risk, and should be included in this client’s plan of care. The Hendrich scale is used for fall risk. The Wong-Baker scale uses visual faces to assess pain. The Hamilton scale is used to rate anxiety
A client presents at an urgent care center after burning their hand while cooking. The client’s burn wound has an intact skin surface, with redness and blistering that covers their posterior hand. How should the nurse describe this wound when documenting in the client’s medical record?
1A superficial-thickness wound
2A partial-thickness wound
3A deep full-thickness wound
4A full-thickness-wound
2
The wound described here is a partial-thickness wound. It involves the entire epidermis and varying depths of the dermis. These wounds are red, moist and blanch when pressure is applied.
The nurse is caring for a client with a large wound. In order to promote healing. What is the most appropriate meal selection for this client?
1Turkey, spinach and orange juice
2Green salad, apple and ice cream
3Pasta, broccoli and fat free milk
4Chicken breast, potatoes and gelatin
1
Protein, vitamins A and C and zinc promote wound healing and immune system functioning.
A client has herpes simplex I with visible cold sores on the lips. Which intervention is most important for the client to implement to prevent spreading the infection?
1Take antiviral medication as prescribed.
2Wash hands frequently.
3Avoid sharing towels.
4Do not scratch the affected area.
3
The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST?
- A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worthlessness.
- A patient indicates an intent to kill himself and says he has access to a gun.
- A patient had a miscarriage last evening and is experiencing anger and resentment.
- A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.
Strategy: “FIRST” indicates priority.
1) need to assess physical needs and examine patient; second patient to see
2) CORRECT— patient is at risk for self-harm; client has intent and a way to carry out threat
3) allow client to verbalize feelings
4) allow client to verbalize feelings
The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions?
- Time the frequency of the contractions.
- Assess the type of vaginal discharge.
- Monitor the strength of the contractions.
- Observe the perineum.
Strategy: Assess before implementing.
1) priority is assessing if baby is crowning
2) priority is assessing if baby is crowning
3) labor is not the priority; nurse should determine if the birth is imminent
4) CORRECT— baby will descend into birth canal and may crown, major responsibility in second state of labor; support infant’s head; apply slight pressure to control delivery
The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST?
- Contact the nursing supervisor.
- Tell the emergency management team they will have to re-route 25 victims.
- Activate the hospital’s disaster plan.
- Inform the emergency department nurses they must work overtime.
Strategy: “FIRST” indicates priority.
1) CORRECT— nurse must follow chain of command
2) not the nurse’s responsibility
3) must notify immediate supervisor about the call; disaster plans are hospital policies that detail how nurses are to perform duties
4) not the responsibility or role of the nurse
As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?”
- “This medication helps me with my depression.”
- “I will notify my physician if I show signs of hyperactivity and mania.”
- “I will see improvement in my symptoms in 1 to 4 weeks.”
- “If I experience a fever I will take Tylenol.”
Strategy: “Further teaching is necessary” indicates incorrect information.
1) Celexa is a selective serotonin reuptake inhibitor (SSRI) used to treat depression
2) side effects: mania, hypomania, insomnia, impotence, headache, and dry mouth
3) true statement
4) correct— should notify physician immediately to assess for serotonin syndrome, which is a rare, life threatening event caused by SSRIs; symptoms include abdominal pain, fever, sweating, tachycardia, hypertension, delirium, myoclonus, irritability, and mood changes; may result in death
The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST?
- A client diagnosed with COPD with an PaO 2 of 70%.
- A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured.
- A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement.
- A client 10 hours postop after a right mastectomy complaining of wet sheets under her back.
Strategy: “FIRST” indicates priority.
1) oxygenation considered “normal to good” for client with COPD; stable client
2) physical needs take priority
3) requires preop injection; all other preparation should be completed; stable client
4) CORRECT— may indicate hemorrhage from operative site; unstable client
The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child?
- Guacamole with pita bread, lettuce, tomato juice.
- Poached halibut, brown rice, carrots, peach cobbler.
- Scrambled eggs, whole wheat toast, grapes, skim milk.
- Baked chicken leg, mashed potatoes, spinach, milkshake.
Strategy: “Teaching is effective” indicates correct information.
1) if a person has a latex allergy, there is cross-reaction to tomatoes and avocados
2) peach is a cross-reactive food with latex
3) grapes are cross-reactive with latex
4) CORRECT— this meal does not have any cross-reactive foods with latex; foods to avoid include apricots, cherries, grapes, kiwis, passion fruit, bananas, avocados, chestnuts, tomatoes, and peaches
The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children?
- A child just returned from a 2-week trip to Europe.
- A child recently moved to an apartment because the family lost their home.
- A child with a new nanny who just emigrated from Latin America.
- A child who weighed 4 lb, 10 oz at birth.
Strategy: All answers are assessments. Determine how they relate to risk factors for tuberculosis.
1) tuberculosis is endemic to Asia, Middle East, Africa, Latin America, and Caribbean; consider screening if child has traveled to an endemic region
2) the homeless and impoverished are at risk for developing tuberculosis
3) CORRECT— children traveling to endemic areas or who have prolonged, close contact with indigenous persons should undergo immediate skin testing
4) no reasons to undergo immediate screening
The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the nurse to take which of the following actions?
- Obtain vital signs.
- Identify the source of the bleeding.
- Elevate the head of the bed 30°.
- Administer 0.9% NaCl IV.
Strategy: Assess before implementing.
1) assessment; more important to determine the source of bleeding
2) CORRECT— assessment first step; initial priority to identify and then apply direct pressure and elevate affected area if possible
3) intervention; elevate the extremities
4) intervention; 1-2 liter bolus of isotonic fluids (lactated Ringer or 0.9% NaCl) will be given
During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse’s excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate?
- “I want to see both of you in my office right away.”
- “Would you please lower your voices and finish the report.”
- “I want the two of you to stop yelling and work this problem out.”
- “Both of you are good nurses and are under a lot of stress right now.”
Strategy: Determine the outcome of each response. Is it appropriate?
1) confrontation is not the appropriate conflict management approach when emotions are high
2) CORRECT— forcing is the most appropriate conflict management technique; enables nurses to exchange information; client care takes priority over interpersonal conflict
3). need cooling-off period before issues can be discussed; communicating about patient care takes priority
4) “don’t worry” response; may make the nurses feel better but does not address the immediate task of completing the report
A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following?
- Slowed pulse and reduced blood pressure.
- Constipation and decreased bowel sounds.
- Palpitations and nervousness.
- Difficulty voiding and oliguria.
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) causes rapid pulse and dysrhythmias; decrease intake of colas, coffee, and chocolate because they contain xanthine
2) causes diarrhea, nausea, and vomiting; administer with food or full glass of water
3) CORRECT— effects of aminophylline include nervousness, nausea, dizziness, tachycardia, seizures
4) medication has no effect on the kidneys; encourage intake of 2,000 cc per day to decrease viscosity of airway secretions
The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The nurse identifies that which of the following BEST measures the overall therapeutic response to management of the diabetes?
- Glycosylated hemoglobin (HbA 1 c) 5% of total Hb.
- Fasting blood sugar 128 mg/dL.
- Blood pressure 130/82.
- Serum amylase 100 Somogyi U/dL.
Strategy: Think about each answer.
1) CORRECT— indicates overall glucose control for the previous 120 days; normal is 4.5-7.6% of total hemoglobin
2) normal fasting is 60-110 mg/dL; HbA 1 c more accurate indicator of glucose control
3) evaluates response to antihypertensive medication
4) elevated in acute pancreatitis; normal is 60-160 Somogyi U/dL
The nurse cares for a client in labor. The client’s examination reveals that the cervix is 5 cm dilated and 100% effaced and the fetal head is at -1. The membranes rupture and the nurse notes clear fluid. Which of the following actions should the nurse take FIRST?
- Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes.
- Prepare for delivery and notify the care provider.
- Apply an electronic fetal monitor and start an IV.
- Encourage the client to void every 1-2 hours and take her temperature every hour.
Strategy: “FIRST” indicates priority.
1) do not ambulate the client; head is too high, may cause cord to prolapse
2) too early to set up for delivery, has approximately 2-3 remaining hours of labor; sterile equipment should be opened for no more than 1 hour
3) no indication that the client is in trouble
4) CORRECT— facilitates descent of the fetal head; temperature evaluation is necessary because of ruptured membranes
The nurse cares for a client receiving a heparin drip via an infusion pump. The physician orders warfarin (Coumadin) 5 mg PO. Which of the following actions should the nurse take NEXT?
- Administer medication as ordered.
- Notify the physician.
- Check the most recent serum partial prothrombin levels.
- Assess client for signs/symptoms of bleeding.
Strategy: “NEXT” indicates priority
1) CORRECT— warfarin interferes with the hepatic synthesis of vitamin K-dependent clotting factors; oral anticoagulant therapy should be instituted 4 to 5 days before discontinuing the heparin therapy
2) no reason to notify the physician
3) partial thromboplastin time used to monitor effectiveness of heparin; therapeutic level is 1.5 to 2.5 times the control
4) warfarin takes 3 to 5 days to reach peak levels
The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia nervosa. The nurse identifies that which of the following activities is MOST appropriate for this client?
- Making jewelry with the occupational therapist.
- Exercising in the physical therapy department.
- Assisting the dietician to plan the week’s menus.
- Reading teen magazines with other patients her age
Strategy: Determine the outcome of each answer.
1) CORRECT— one of the goals for a client with anorexia is to achieve a sense of self-worth and self-acceptance that is not based on appearance; this activity will promote socialization and increase self-esteem
2) goal is for client to achieve 85-95% of ideal body weight; may be able to exercise after short term goals are met
3) meal planning is a part of self-care activities, but more important for client to achieve a sense of self-worth
4) can read magazines in the presence of others without interacting
A mother reports to the clinic nurse that her daughter developed a large welt, red rash, and shortness of breath after being stung by a bee. The mother asks the nurse, “What should I do if she gets stung again?” Which of the following responses by the nurse is BEST?
- “Make a paste of baking soda and water and apply it to the sting.”
- “Remove the stinger and immediately apply ice to the site.”
- “Give 12.5 mg of Benadryl by mouth.”
- “Administer 0.3 mg of epinephrine subcutaneously.”
Strategy: Determine the outcome of each answer. Is it desired?
1) treatment for sting in persons not allergic to bee stings; treats local reaction
2) not appropriate for this child because she has demonstrated hypersensitivity to bee sting; if no previous hypersensitivity; initial action is to remove stinger as quickly as possible to decrease the amount of venom injected into wound, wash with soap and water, apply cool compress
3) will not work fast enough to prevent anaphylactic reaction
4) CORRECT— child who has demonstrated previous hypersensitivity should have an EpiPen available; instruct child to wear medical identification bracelet
The nurse counsels the mother of a child diagnosed with impetigo. The nurse notes that the infection has not improved and learns the mother has not been caring for the child’s skin because it “takes too much time.” It is MOST important for the nurse to assess for which of the following?
- White patches on buccal mucosa.
- Hearing loss.
- Respiratory wheezing.
- Periorbital edema.
Strategy: What indicates a complication?
1) describes Candida , a fungal infection
2) not caused by impetigo
3) not caused by impetigo
4) CORRECT— impetigo is caused by Staphylococcus and Streptococcus ; untreated, can cause acute glomerulonephritis; periorbital edema indicates poststreptococcal glomerulonephritis
The nurse on a college campus is informed by the microbiology department that they accidentally received a shipment of highly toxic, contagious bacteria. Which of the following actions should the nurse take FIRST?
- Determine if there are adequate supplies of antibiotics and antipyretics.
- Order necessary equipment and supplies.
- Contact the Red Cross.
- Identify who was exposed to the shipme
Strategy: “FIRST” indicates priority.
1) may be required, but not the first action; affected people will most likely be treated in a treatment facility
2) more important to determine who was exposed to the bacteria
3) if exposure is widespread, they may send health care providers; determine scope of problem first
4) CORRECT— assess before implementing; after determining who has been exposed, appropriate treatment can be instituted
The nurse administers promethazine (Phenergan) 25 mg IM to a client complaining of nausea and vomiting. After receiving the medication, the client complains of dizziness when standing up. Which of the following actions should the nurse take FIRST?
- Notify physician.
- Monitor severity of symptoms.
- Instruct client to ask for assistance before ambulating.
- Assess client’s hydration status.
Strategy: Complete assessment before implementing
1) complete assessment before contacting physician
2) is complaining of orthostatic hypotension; determine if fluid volume deficit contributing to dizziness
3) appropriate action, but nurse should first complete assessment
4) CORRECT— side effects include anorexia, dry mouth and eyes, constipation, orthostatic hypotension; client is at risk for fluid volume deficit due to vomiting, which exacerbates the orthostatic hypotension
The nurse in the outpatient clinic has four unscheduled clients waiting to see the physician. Which of the following clients should the nurse see FIRST?
- A client complaining of a sore throat and nasal drainage.
- A client with a history of kidney stones complaining of severe flank pain.
- A client complaining of redness and pain in his left great toe.
- A client receiving digoxin (Lanoxin) complaining of nausea and vomiting.
Strategy: “FIRST” indicates priority
1) symptoms consistent with viral rhinitis; encourage to gargle with salt water and increase fluid intake
2) second client that should be seen; administer opioid analgesics to prevent shock and syncope
3) indications of acute gout; attack subsides spontaneously in 3 to 4 days; administer colchicine (Colsalide) and NSAIDS
4) CORRECT— early effects of digitalis toxicity; hold medication and monitor client’s symptoms
The nurse cares for a client diagnosed with a recurrence of colon cancer. The client tells the nurse that she is dreading taking chemotherapy again. Which of the following responses by the nurse is MOST appropriate?
- “There are web sites that provide information about chemotherapy.”
- “Have you discussed this with your physician?”
- “I can give you a handout about how to treat the side effects of chemotherapy.”
- “What are your concerns about taking chemotherapy?”
Strategy: Assessment before implementation
1) assumes that client needs more information about chemotherapy; nurse should respond to client’s concerns
2) don’t pass the buck; responding to client’s concerns is a nursing responsibility
3) assess before implementing
4) CORRECT— think about the nursing process when selecting answers; allows nurse to gather data about what is concerning the client
The nurse in the outpatient clinic receives a call from a client who has been receiving continuous ambulatory peritoneal dialysis (CAPD) for 1 year. The client states that he infused 2 L of dialysate and 1200 cc returned. Which of the following statements by the nurse is BEST?
- “Record the difference as intake.”
- “When was your last bowel movement?”
- “Are you having shoulder pain?”
- “Increase your fluid intake.”
Strategy: Determine if it is appropriate to assess or implement.
1) the difference between inflow and outflow is counted as intake; ensure that all fluid has drained from the peritoneal cavity; change positions or ask client to walk around
2) CORRECT— full colon can create outflow problems; ensure that bowel evacuation has occurred
3) referred shoulder pain may be caused by rapid infusion of dialysate; instruct to decrease infusion rate; this client is having an outflow problem
4) will not affect outflow
The nurse evaluates assignments on the unit. The nurse determines that assignments are appropriate if the LPN/LVN is assigned to which client?
- A client with type 1 diabetes scheduled for discharge.
- A client newly admitted to the unit with chest pain.
- A client receiving chemotherapy.
- A client diagnosed with myasthenia gravis.
Strategy: Assign stable clients with expected outcomes.
1) requires teaching; LPN/LVN can reinforce teaching but cannot perform initial teaching
2) is not a stable client with an expected outcome; requires assessment
3) is not a stable client with an expected outcome; requires assessment
4) CORRECT— no indication that client is not stable; myasthenia gravis is deficiency of acetylcholine at myoneural junction; symptoms include muscular weakness produced by repeated movements that soon disappear following rest
An elderly client is brought to the emergency department complaining of acute back pain. The client denies any chronic illness, allergies, or previous hospitalizations. Which of the following is the BEST initial response for the nurse to make to this client?
- “We’ll get this pain under control in no time.”
- “Are you sure you’ve never been in the hospital?”
- “Did you fall, lift something heavy, or turn the wrong way?”
- “On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing.”
Strategy: “BEST” indicates priority.
1) false reassurance; nurse should complete assessment
2) confrontational response; pain assessment is priority
3) should first assess intensity of pain as well as location
4) CORRECT— assessment, is objective and clear, and responds directly to client’s complaint; gives information for further intervention
A nurse observes a student nurse administer carvedilol (Coreg) to an elderly patient. The patient refuses medication, saying, “Go away. It makes me dizzy.” The nurse should intervene if the student nurse states which of the following?
- “If you don’t take this medication, you will be restrained.”
- “This medication will help control your blood pressure.”
- “Side effects of this medication make some patients feel uncomfortable.”
- “When do you notice the dizziness?”
Strategy: “nurse should intervene” indicates something is wrong.
1) CORRECT— inappropriate action; client has the right to refuse medication; restraining client is an example of battery
2) Coreg is a nonselective beta-blocker used to treat hypertension and heart failure
3) side effects include dizziness, fatigue, weakness, orthostatic hypotension; instruct client to change positions slowly
4) allows nurse to teach about medication
The nurse cares for clients in the emergency department (ED). An 82-year-old client comes to the ED complaining of muscle weakness and drowsiness. The nurse notes decreased deep tendon reflexes and hypotension. Which of the following actions should the nurse take FIRST?
- Escort the client to an emergency room unit.
- Ask the client if he has been taking antacids.
- Assess for Chvostek’s sign.
- Measure client’s intake and output
Strategy: “FIRST” indicates priority
1) delegate to other personnel
2) CORRECT— increased intake of magnesium-containing antacids and laxatives can cause hypermagnesemia (> 2.5 mEq/L); depresses CNS and cardiac impulse transmission; discontinue oral Mg, support ventilation, administer loop diuretics or IV calcium, teach about OTC drugs that contain Mg
3) seen with hypocalcemia; tap face just below and anterior to the ear to trigger facial twitching on that side of face
4) renal insufficiency can cause decreased excretion of magnesium; not appropriate for this setting
A tornado has just leveled a large housing division near the hospital, and a disaster alarm has been declared at the hospital. The nurse caring for clients on the maternal-child unit considers which of the following clients appropriate for discharge within the next hour?
Select all that apply.
- A multipara client who delivered over an intact perineum 12 hours ago.
- A postpartum client with an infection who has been on antibiotics for the past 24 hours.
- A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting.
- A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL.
- A client at 34 weeks’ gestation diagnosed with generalized edema and complaints of epigastric pain.
- A 2-day-old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-streptococcus (GBS).
Strategy: Determine the most stable clients.
1) CORRECT— stable patient
2) do not know if antibiotics are effective or the current WBC count
3) requires frequent assessment of hydration status and blood glucose levels
4) CORRECT— phototherapy considered for the infant with total serum bilirubin of greater than 15 mg/dL at 72 hours of age
5) epigastric pain indicates pending eclampsia
6) CORRECT— group B streptococcal (GBS) disease causes sepsis; because mother received intrapartum prophylaxis, infant has 1-in-4,000 chance of developing sepsis due to GBS
The nurse cares for a client following a scleral buckling. Which of the following nursing actions is MOST important?
- Remove all reading material.
- Assess for nausea.
- Assess drainage from affected eye.
- Irrigate affected eye every 3 hours.
Strategy: “MOST important” indicates priority.
1) scleral buckling compresses the sclera to repair a detached retina; should take precautions to prevent moving eyes rapidly
2) CORRECT— nausea and vomiting increase intraocular pressure and could cause damage to the area repaired
3) wear eye shield; avoid sneezing, coughing, straining at stool
4) do not irrigate
The nurse supervises care for a patient admitted to the psychiatric unit with a diagnosis of bipolar disorder: manic phase. A student nurse plans activities for the patient. The nurse should intervene if the student nurse chooses which of the following activities?
- Volleyball.
- Painting.
- Walking.
- Dancing.
Strategy: “Nurse should intervene” indicates an incorrect action.
1) CORRECT— avoid competitive games because they increase agitation; assign to a single room away from activity; keep noise level low and lighting soft
2) appropriate activity; will not provoke or over-stimulate client
3) appropriate activity; activity that uses large movements until acute mania subsides
4) appropriate activity; provides structure and safety in the milieu
The nurse on the medical/surgical unit is approached by an LPN/LVN from a different team. The LPN/LVN expresses concern because one of her patients is diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at 2 L/min. Which of the following statements by the nurse is MOST appropriate?
- “I will assess the patient for oxygen toxicity.”
- “Are you concerned about the oxygen or the new graduate’s competency?”
- “Please tell me more about your concerns.”
- “Leave the oxygen in place.”
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) client is assigned to another nurse; usurps assigned nurse’s authority
2) yes/no question; nontherapeutic; should allow LPN/LVN to express her concerns
3) CORRECT— open-ended statement; therapeutic; allows the LPN/LVN to express specific concerns and enables the nurse to further assess
4) not enough information to make a judgment; assess before implementing
The nurse cares for an infant diagnosed with congenital heart disease. The nurse notes that the infant becomes easily fatigued during feedings and the infant’s pulse and respirations increase. The nurse should take which action?
- Feed the infant soon after awakening.
- Change the infant’s diaper before feeding.
- Increase the caloric content of the feeding to 30 kcal/oz.
- Mix rice cereal in the formula.
Strategy: Determine the outcome of each answer. Is it desired?
1) CORRECT— infant feeds better if well rested; offer small, frequent feeding every 3 hours; enlarge hole in nipple
2) will not affect infant’s intake; pin diaper loosely to promote maximum chest expansion
3) allows infant to take in more calories in a smaller quantity; to prevent diarrhea, increase the calories by 2 kcal/oz/day; formulas provide 20 kcal/oz
4) infant would have to expend more energy to eat
The nurse instructs a client who is scheduled for a 24-hour creatinine clearance test. Which statement, if made by the client to the nurse, indicates further teaching is required?
- “I will eat a high-protein meal before the test begins.”
- “I will use the specimen collection time to catch up on my reading.”
- “I will drink as much fluid as I want before and during the test.”
- “I will save all of my urine during the 24 hours and keep it in the refrigerator.”
Strategy: “Further teaching is necessary” indicates incorrect information.
1) CORRECT— high-protein diet before the test may increase creatinine clearance and affect the accuracy of the test
2) appropriate action; avoid strenuous physical activity, will increase creatinine excretion and compromise the accuracy of the test
3) appropriate action
4) appropriate action; bottle should contain a preservative
The nurse prepares to admit a 6-month-old diagnosed with rotavirus, severe diarrhea, and dehydration. The nurse should place the infant in which of the following rooms?
- In a semiprivate room with a 2-year-old in traction due to a fracture.
- In a semiprivate room with a 9-month-old admitted for a shunt revision.
- In a private room that is close to the nurse’s station.
- In any private room that is available.
Strategy: Think about the outcome of each answer.
1) a diapered or incontinent client diagnosed with rotavirus requires contact precautions for the duration of the illness; is a significant nosocomial pathogen
2) requires a private room; do not place a client with an infection in a room with a client who does not have an infection
3) CORRECT— rotavirus is spread by fecal-oral route and requires contact precautions if client is diapered or incontinent
4) due to severe nature of the symptoms requiring hospitalization, infant requires close observation for changes in condition
A patient returns from surgery for a total replacement of the right hip with a large surgical dressing and a Jackson-Pratt drain. Which of the following, if observed by the nurse 2 hours after surgery, necessitates calling the physician?
- There is a small amount of bloody drainage on the surgical dressing.
- The patient complains of increased hip pain.
- A harsh, hollow sound is auscultated over the trachea.
- The patient’s blood pressure is 136/86.
Strategy: “necessitates calling the physician” indicates a complication.
1) expected outcome, complications of total hip replacement include dislocation of prosthesis, excessive wound drainage, thromboembolism, and infection
2) CORRECT— indicates dislocation of prosthesis; other indications include shortening of affected leg, leg rotation, soft popping sound heard when affected leg is moved; maintain abduction, use wedge pillow, avoid stopping, do not sleep on operated side until directed to do so, flex hip only 1/4 circle, never cross legs, avoid position of flexion during sexual activity, walking is excellent exercise, avoid overexertion; in 3 months will be able to resume ADLs, except strenuous sports
3) describes normal breathing sounds
4) within normal limits
An older client is placed in balanced suspension traction for a compound fracture of the femur. The client reports, “My hands, feet, and nose feel cold. Which action should the nurse take FIRST?
- Provide the client with more blankets.
- Assess for dependent edema.
- Assess that client is exhaling when moving in bed.
- Increase the temperature of the room.
Strategy: Determine if it is time to assess or implement.
1) treats a symptom, not the cause of the problem
2) CORRECT— because of recumbent position, cardiac workload increases; if heart is unable to handle increased workload, peripheral areas of body will be colder; more important to assess cardiovascular status; edema caused by heart’s inability to handle increased workload; assess sacrum, legs, and feet; also assess peripheral pulses
3) Valsalva maneuver increases workload on heart; to prevent, teach immobilized clients about exhaling when moving about in bed; should first assess client complaints
4) assess the client; cold extremities may indicate heart is not able to tolerate increased workload
The nurse cares for a client at term in labor. The client’s blood pressure is 182/88 and fetal heart rate (FHR) is 132-134 with minimal beat-to-beat variability. Her bloody show is dark red and there is more bleeding than anticipated. Her abdomen is firm between contractions and she complains of back pain. The nurse understands that the client is at risk for which of the following?
- Placenta previa.
- Abruptio placenta.
- Miscarriage.
- Imminent delivery.
Strategy: Think about each answer.
1) placenta is implanted near or over the cervical os; symptoms include painless, sudden, profuse bleeding in third trimester
2) CORRECT— premature separation of placenta; painful vaginal bleeding, abdomen is tender, painful, tense, possible fetal distress; prepare for immediate delivery
3) occurs before 20-24 weeks of pregnancy; indications are persistent uterine bleeding and cramp-like pain
4) symptoms are classic signs of abruption
The nurse cares for an older client diagnosed with terminal lung cancer. When told about the diagnosis, the client becomes very angry. He curses, throws objects, and hits the nurse tech and LPN/LVN when they attempted provide care for him. It is MOST important for the nurse to take which of the following actions?
- Inform client that injury or risk of injury to staff is not acceptable.
- Send the staff out of the room.
- Administer prescribed antianxiety with full glass of water.
- Report signs/symptoms to physician immediately.
Strategy: “FIRST” indicates priority
1) CORRECT— set limits on client’s behavior; staff has the right to work in a safe environment
2) gives client the power; speak calmly to client, help to verbalize feelings, use nonthreatening body language
3) nurse should use least restrictive interventions to assist the client to regain control
4) passing the buck; it is the nurse’s responsibility to care for the client
The nurse, caring for clients in the outpatient clinic, performs a chart review for clients who are receiving medication. The nurse determines that which of the following clients is at risk to develop problems with hearing?
- A client receiving spironolactone (Aldactone) and cefaclor (Ceclor).
- A client receiving metformin (Glucophage) and alendronate (Fosamax).
- A client receiving paroxetine (Paxil) and cholestyramine (Questran).
- A client receiving furosemide (Lasix) and indomethacin (Indocin).
Strategy: Think about each answer.
1) Aldactone is a potassium-sparing diuretic and Ceclor is a second-generation cephalosporin; neither drug is ototoxic
2) Glucophage is an oral hypoglycemic and Fosamax is a bone resorption inhibitor; neither is ototoxic
3) Paxil is a selective serotonin reuptake inhibitor (SSRI) and Questran is an antihyperlipidemic agent; neither is ototoxic
4) CORRECT— Lasix is a loop diuretic and is ototoxic, especially when given with other ototoxic drugs; Indocin is a NSAID and is also ototoxic
The nurse in the pediatric clinic receives a phone call from the mother of a 3-year-old child. The mother reports that her child has been complaining of a sore throat, has a temperature of 102°F (39°C), and he has suddenly begun drooling. Which of the following suggestions should the nurse make FIRST?
- “Place a cold water vaporizer in your child’s room.”
- “Take your child to the emergency department immediately.”
- “Look into your child’s throat and tell me what you see.”
- “Frequently offer your child oral fluids.”
Strategy: “FIRST” indicates priority.
1) appropriate action if the child has croup
2) CORRECT— symptoms indicate acute epiglottitis which can be life threatening; drooling occurs because of difficulty swallowing; child may become apprehensive or anxious; transport to hospital sitting in the parent’s lap to reduce stress
3) do not inspect the throat unless immediate intubation can be performed if needed
4) transport to the hospital
The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two days after admission, the client begins complaining of severe nausea. Which of the following actions should the nurse take FIRST?
- Determine the client’s most recent fasting serum glucose level.
- Perform a comprehensive client assessment.
- Ask the client if she is pregnant.
- Administer an antiemetic.
Strategy: “FIRST” indicates priority.
1) no relationship between diabetes and nausea; last glucose reading does not give the nurse information about client’s current condition
2) CORRECT— nausea not usually associated with diabetes; assess before implementing
3) nurse is making assumptions based on client’s age; should perform a comprehensive assessment
4) assess before implementing
A new registered nurse asks the assigned nurse mentor to check on 4 clients who are receiving oxygen therapy. It is MOST important for the nurse mentor to ask the nurse which of the following questions?
- “Which client should I see first?”
- “Have you completed your assessment?”
- “What are your specific concerns?”
- “Don’t you think you should be able to care for the clients?”
Strategy: “MOST important” indicates discrimination may be required to answer the question.
1) nurse mentor should find out about the nurse’s specific concerns
2) yes/no question; doesn’t allow nurse mentor to assess the nurse’s needs
3) CORRECT— clarifies the nurse’s concerns and will help the new nurse become a safe practitioner
4) yes/no question; nontherapeutic; does not allow nurse mentor to assess new nurse’s concerns
The nurse cares for a client receiving chlordiazepoxide (Librium). It is MOST important for the nurse to observe for which of the following?
- Skeletal muscle spasms and insomnia.
- Anorexia and dry mouth.
- Diarrhea and euphoria.
- Drowsiness and confusion
Strategy: Think about each answer.
1) dystonia is side effect of antipsychotics; insomnia caused by SSRIs
2) Ritalin causes anorexia; dry mouth is side effect of tricyclic antidepressants
3) not caused by Librium
4) CORRECT— antianxiety and sedative/hypnotic used to treat anxiety and alcohol withdrawal; causes drowsiness and sedation; use caution when driving or operating equipment; confusion may indicate immediate n
Following the administration of morphine sulfate for an adult client, the nurse expects to observe which finding?
- The client states they feel better.
- The client is talking with visitors.
- The client appears to be physically relaxed.
- The client is no longer crying or moaning.
Strategy: Think about how each answer relates to pain.
1) client may express pain relief, but in reality may still be experiencing pain
2) client may still be in pain
3) CORRECT— nonverbal cues are the best indication of pain relief
4) not best indication of relief of pain
After being admitted for management of a cervical spine injury, a client in a rehabilitation center reports a severe headache. Which of the following actions should the nurse take FIRST?
- Administer an analgesic medication
- Ask the client to rank the pain from 1 to 10.
- Ask the client if he is worried about something.
- Place the client in a sitting position.
Strategy: “FIRST” indicates priority.
1) priority is to decrease blood pressure
2) cervical spine injury and severe headache should clue nurse that client is possibly in imminent danger
3) assess for physical causes before psychosocial causes
4) CORRECT— pounding headache and profuse sweating are indications of autonomic hyperreflexia; place in a sitting position immediately to decrease blood pressure and reduce risk of cerebral hemorrhage
The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?
- A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago.
- A client diagnosed with right-sided heart failure and glaucoma.
- A client diagnosed with chronic obstructive pulmonary disease and psoriasis.
- A client diagnosed with rheumatoid arthritis and malnutrition.
Strategy: Determine the most unstable client.
1) CORRECT— both diseases are in the dynamic phase and require close monitoring; most unstable client
2) client should be seen second
3) two chronic illnesses
4) client more stable than #1
The nurse cares for a 4-year-old on the pediatric unit. The child is unable to go to sleep while in the hospital. It is MOST important for the nurse to take which of the following actions?
- Turn out the light and close the door.
- Encourage the child to exercise during the evening.
- Identify the child’s home bedtime ritual.
- Ask the child’s siblings to visit during the evening.
Strategy: Assess before implementing
1) will increase the child’s fears; preschoolers fear injury, mutilation, and punishment
2) will not promote sleep
3) CORRECT— preschoolers require bedtime rituals that should be followed in hospital; nurse should assess before implementing
4) will be comforting to child, but to promote sleep it is more important to determine bedtime routine
The nurse prepares an elderly client newly diagnosed with type 1 diabetes for discharge. The client is alert and oriented and lives alone in her home. It is MOST important for the nurse to assess for which of the following?
- Client’s vision and manual dexterity.
- Client’s understanding of diabetes.
- Client’s need for visits from the home care nurse.
- Client’s ability to perform blood glucose monitoring.
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) CORRECT— client must have the visual acuity and manual dexterity to draw up and administer insulin
2) it is important that the client understands diabetes, but priority is assessing client’s ability to manage insulin administration
3) may be necessary
4) important, but first assess the client’s vision and manual dexterity
The nursing assistive personnel inform the nurse that the elderly client admitted following a hemorrhagic stroke ate half of the food on the tray. The food left on the tray looked as if someone had drawn a straight line down the center of the plate and eaten the food only to one side of the line. Which instruction by the nurse is MOSTimportant?
- “Rotate the plate so that the food is on the other side.”
- “Offer him a snack later in the day.”
- “Ask the client’s family to assist him with the next meal.”
- “Which foods did he omit?”
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) CORRECT— indicates homonymous hemianopsia (loss of half of the visual field); client neglects one side of body; instruct client to turn head in direction of visual loss
2) food pattern on plate indicates loss of visual field
3) passing the buck
4) situation does not require further assessment
The nurse evaluates care for a client who demonstrates manipulative behavior. The nurse should intervene if which of the following is observed?
- The staff discusses with the client the consequences of his manipulative behavior.
- The staff establishes limits on the client’s manipulative behavior.
- The staff clarifies the consequences of the client’s manipulative behavior.
- The staff decreases the demands on the client.
Strategy: “nurse should intervene” indicates something is wrong.
1) appropriate that the staff help to client learn to see the consequences of his behavior
2) appropriate; staff should communicate clearly defined expectations and carry out limit-setting
3) appropriate behavior
4) CORRECT— fosters a sense of entitlement
The nurse in the pediatric clinic performs a well-child assessment on a 20-month-old. The child’s mother tells the nurse that she is earning extra money by growing houseplants in her home. Which of the following responses by the nurse is MOST appropriate?
- “How did you get into that business?”
- “What a great opportunity.”
- “You should not have plants in your home.”
- “Where do you keep the plants?”
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) encourages the mother to talk about her interests but does not address safety issue of toddler
2) closed response; does not give client opportunity to respond
3) not all plants are toxic; nurse is expressing an opinion without completing the assessment
4) CORRECT— toddlers explore by putting things in their mouth; all potentially toxic agents should be placed out of reach of the toddler; nurse should assess the type of plants in the home and the location of the plants
The nurse performs discharge teaching for a client diagnosed with gastroesophageal reflux disease (GERD). The nurse determines that teaching is successful if the client selects which of the following menus?
- Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello, and cola.
- Cheddar cheese omelet, spinach salad, chocolate brownie, and milk.
- Broiled chicken, cream of broccoli soup, rice pudding, and apple juice.
- Baked salmon with lemon butter, baked potato, mint chocolate chip ice cream, and lemonade.
Strategy: “Teaching is successful” indicates correct information.
1) oil dressing high in fat, tomato exacerbates GERD, as do carbonated beverages
2) fatty foods and chocolate exacerbate GERD
3) CORRECT— menu low in fat and contains non-acidic foods
4) lemonade and mint exacerbate GERD
What condition is commonly associated with PICA?
Anemia is common with PICA
T/F
NSAIDS can worsen asthma symptoms
TRUE
Fexofenadine
antihistamine
Hodgkin’s lymphoma
What are typical signs and symptoms of this disease?
chronic malignant disease of the lymph nodes
affects the lympathic system
S/S include:
Sweats
Painless Enlarged lymph nodes
Fever
Fatigue
How should a nurse provide care for a patient with schizophrenia and persecutory delusions?
Focus on reality and verbally reinforce it
Focus on the clients feeling secondary to the delusions (this is an example of empathy, and therapeutic communication)
What are interventions to help reduce viscosity of mucus?
-Increase fluids
-Cool mist humidifier
-Guaifensein (expectorant)
-Huff coughing – abdominal breathing with a huff, and expiratory cough technique
What GI condition is associated with olive shaped mass?
Pyloric stenosis
What is botulinum toxin type A
What should you closely monitor while using this drug?
Botox – a neuromuscular transmission used by inhibiting acetylcholine(excite) release from nerve endings. RELAXATION of skeletal and smooth muscles.
Used to treating wrinkles, blepharospasm (eye twitching), and cervical dystonia
What are some examples of SSRIs?
What are they and what is a common adverse effect of there use?
How long does it take for this medication to take effect?
Sertraline, Escitalopram
(-etine, -opram)
Selective Serotonin Re-uptake Inhibitors
Used to treat Depression and Anxiety
Side effect:
Sexual dysfunction which is usually under reported
WEIGHT GAIN (eat a health diet and regular exercise)
It will take about 4-6 weeks to take effect
Allopurinol (Zyloprim)
What does this medication treat?
What symptom of the medication can lead to higher complication? What is the complication?
Gout, Anti-gout medication
Used to decrease/prevent levels of Uric Acid
Takes with full glass of water to prevents complications with kidneys and nausea.
COMPLICATION:
Rash – which can indicate a hypersensitivity and develop to Stevens Johnsons Syndrome
Dabigatran (Pradaxa)
What condition is this used for? Why?
Where should you keep these pills?
Anticoagulant, Direct Thrombin Inhibitor
Commonly used for patients with A-Fib and Flutter
Do not crush or open pills.
KEEP THIS MEDICATION IN ITS ORIGINAL CONTAINER/BOX.
What is Trazadone?
What is this used for?
What are the common adverse effects of this medication?
A serotonin modulator
Used to treat Major depressive Disorders
Also blocks alpha and H1 receptors leading to ORTHOSTATIC HYPOTENSION, and SEDATION
What is priapism?
Is it painful?
A prolonged and painful erection
What is tissue plasminogen activator (tPA)
When should it be administered within? (hours)
What is it contraindicated with
Dissolve clots and restore perfusion
ADMINISTER within 3 to 4 hours
Contraindicated in patients with recent surgeries (2 weeks)
How are thyroid medications best absorbed?
What time of the day should they be taken?
Are they safe to take during pregnancy?
On an empty stomach
Best taken in the morning because they increase metabolism and energy
Safe during pregnancy
Steven Johnson Syndrome (SJS)
How does it appear on the skin?
Severe blistering of the skin, with mucous membrane involvement and fever
Can be FATAL
Begins with flu like symptoms, painful and purple/red rash.
Resembles 3rd degree burns.
Cyclosporine
What is it used for to prevent?
Immunosuppressant
Suppresses the immune system to prevent WBC from getting rid of a organ transplant
Tetracycline/Doxycycline // Sulfa Drugs
What are common complications with these type of drugs
Sulfa Drugs:
Tetracyclines
Antibiotics
Complication:
Sun Burn
What insulin is the ONLY insulin administered IV Push?
Regular Insulin
What is the correct administration route for NPH insulin?
Subcutaneous
Digoxin (Lanoxin)
What should be monitored while on this medication?
What the symptoms of Digoxin toxicity
cardiac glycoside
Be sure to monitor patients HR
Toxicity:
Visual symptoms
Gastrointestinal (N/V)
Neurologic manifestions
Positive Inotropic Effects (increase Cardiac Output)
and
Negative Chronotropic Effects (Decrease Heart Rate)
What can colorless nasal drainage indicate?
CSF
A complication
T/F
Any drug order-dose takes priority
TRUE
What can a new painful skin rash indicate?
Steven Johnsons Syndrome
Can be FATAL
What is the action of Sucralfate?
how should it be taken?
An oral medication that forms a protective layer in the gastrointestinal mucosa that provides a physical barrier against stomach acids and enzymes
TAKE ON A EMPTY STOMACH w water
Other meds should be taken 1 or 2 hours before or after this med!
Glyburide
What is this medication used for?
What common symptom is associated with his medication?
Diabeta
Used to treat diabetes mellitus.
Can cause severe hypoglycemia especially in children
How should patients be roomed together?
Patients with the same organism should be roomed together
Life before limb
prioritize interventions for a client in shock over interventions for a client who has a localized limb injury
Pulsatile Mass
Strong pulse of midline abdomen, possible aortic aneurysm
Phenytoin
What is this med used for?
What is the therapeutic range for this medication?
What are symptoms of toxicity?
Dilantin/Anticonvulsant
Used to treat tonic-clonic seizures
Range: 10 -20
Toxicity:
Horizontal Nystagmus
Gait unsteadiness
Hyperosmolar Hyperglycemic Syndrome (HHS)
a serious complication usually associated with type 2 diabetes
What does green amniotic fluid indicate?
fetus has passed meconium in utero
characteristic of DKA
Type 1 diabetes
Younger age
More rapid onset o hyperglycemia
Hyperventilation
Abdominal pain
Glucose 250-500
Bicarb <18
Elevated anion gap
KETONES
serum osm <320
characteristic of hyperosmolar hyperglycemia
Type 2 diabetes
Older age
Altered mental status
Gradual onset of hyperglycemia
Hyperventilation
glucose >600
BECAUSE people with type 2 can develop some insulin, the symptoms occur gradually
Metronidazole (Flagyl)
What condition is this medication usually used for?
antibiotic
Used for C.diff
What are nonselective beta blockers?
What can these medications effect?
Propranolol
Nadolol
Timolol
This medication has beta 2 blocking effect that results in bronchial smooth muscle constriction
After how many hours can a nurse consider a patient stabilized enough to eat after having a stroke?
48 hours
Addison’s disease – what does this effect
What are the treatments for this disease?
occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone
Treatment includes:
Life long hormone replacement
Increase salt intake
Monitoring ortho BP
What is a sentinel event?
What is a near miss event?
Sentinel
Unanticipated, preventable errors that cause significant harm or death
Near-miss
Medical errors that are identified before reaching the clients and does not cause harm
What are 4 interventions that are important to monitor with HELLP?
Preparing the client for birth
Magnesium sulfate
Deep tendon reflexes
Monitoring clotting factors
What is DIC?
How would this be treated?
disseminated intravascular coagulation
A BLOOD CLOTTING disease that can turn into uncontrolled bleeding
this results from abnormal activation of clotting cascade followed by consumption of clotting factors and platlets
Treatment:
replacement of clotting factors
blood
platlets
Parovirus B19, what is another name for this condition
What kind of precautions are needed for this disease
Is this disease fatal to pregnant women?
fifth disease; erythema infectious
TORCH
Transmitted from person to person contact, RESPIRATORY secretions
Droplet precautions
Parovirus is infectious to the fetus, can cause abnormalities
What is postpartum psychosis?
How long after birth, can this condition occur?
syndrome occurring after childbirth characterized by severe depression, manic episodes, hallucinations, and/or delusions
Begins usually after 2 weeks of birth
Who/what role is legally appointment to be the primary decision maker for a patient?
What is the role of a __?
Health care proxy
the role is to make decisions for a client who is unable to do so.
They should have good understanding of the the clients wishes and be emotionally capable of fulfilling the role
What task are delegated to an RA?
Clinical assessment
Initial client education
Discharge education
Clinical judgment
Initiating blood transfusion
What task are delegated to an LPN?
Monitoring RN findings
Reinforcing education
Routine procedures
Most medication admin
Ostomy care
Tube patency and enteral feedng
Specific assessments
What task are delegated to a UAP?
Activities of daily living
Hygiene
Linene changes
Routine, stable vital signs
Documenting I&O
Positioning
ROM
Apply protective ointment
Occupational therapy
v.
Physical therapy
Above the waist
v
Below the waist
T/F – Food decreases the absorption of iron supplements
TRUE
gullian-barre syndrome
ascending symmetric muscle paralysis and areflexia (no reflexes), watch for respiratory problems.
Usually occurs after a respiratory or GI infections that triggers this immune response
testicular torsion
How is this condition usually treated?
twisting of the spermatic cord
AND
testicular ischemia and necrosis from inadequate blood supply
Treatment:
Surgery
Removal of the testes
what medication is used to treat C.diff?
Metronidazole (Flagyl)
Carboxyhemoglobin
Carbon monoxide bound with hemoglobin’
Normal is < less than 5% in nonsmokers
slightly over 10% in smokers
What are the signs of compartment syndrome?
the 6 Ps
Pain
Pallor
Pulselessness
Paresthesias
Poikilotherma
Paralysis
recumbent position
lying down in any position
Where should the nurse auscultate for heart murmers?
Aortic point
Nifedipine (Procardia)
calcium channel blocker
Lowers blood pressure
Hodgkin’s lymphoma
What is used to treat this condition?
A form of cancer characterized by abnormal growth of lymphocytes
Treatment:
chemotherapy and external bean radiation therapy.
Peak flow meter
How do you use it?
a handheld device often used to test those with asthma to measure how quickly the patient can expel air
exhale a complete breath as quickly as possible
Pathological Jaundice of the Newborn
Jaundice manifests within the first 24 hours.
Always investigate causes and notify the MD.
What complication is common with elevated levels of serum bilirubin level
Be aware of permanent neurological damage
Oxybutynin
What should be avoided with this medication
Ditropan (anticholinergic)
Used to treat overreactive bladder
Be cautious in hot weather and during physical activity
osteomalacia
abnormal softening of bones in adults
this occurs when the body is unable to use calcium and phosphorus for bone calcification due to vitamin D deficiency
What is a common bleeding complication associated with hip fractures.
Hemorrhage!!
Bone fragments and sever the veins or arteries in the pelvis
Conversion Disorder (Functional Neurological Symptom Disorder)
What should the nurse do for this patient?
presence of neurological symptoms brought on by psychological stress, without clear physical cause
The nurse should validate the clients feelings and educate the using therapeutic communication
what does the loss of hair on legs indicate?
Poor Perfusion
What is the number one cause of Epiglottis in children?
How is it preventable?
Haemophilus Influenza B (HiB)
Preventable through vaccination at 2 to 4 months visits.
Patients with acute pancreatitis are a risk for what complication?
As evidence by what symptoms?
What type of bowel movement is commonly associated with this condition?
Pancreatic abscess development
Evidenced by increase temperature and increased abdominal pain
Fatty, yellow, fouls smelling stools
(Steatorrhea)
Correct sequence of assessing a patient, from least to most invasive
Supine position
Inspection
Auscultation
Percussion
Palpation
Palpation last because it can induce pain
What oxygen saturation is concerning for a patient with status asthmatics
Less than 92%
What are teratogens?
What are the drugs harmful to fetuses?
substances that cause birth defects
Phenytoin
Lithium
Valproate
Isotretinoin (BLACK BOX) – acne
Methotrexate
ACE inhibitors // ARBs
Warfarin
Doxycycline (sulfa)
What’s methotrexate?
Anti-cancer medication
Used to slow cancer cells
Which precaution is recommended for C.diff?
Contact precautions
Single use gown
Single client room
Clean gloves
hand hygiene soap/H2o
What is required for airborne precautions?
Surgical Mask
How is HIV transmitted
Contact with bodily fluids such as:
Semen
Vaginal secretions
Breast Milk
What is metoclopramide?
What adverse effect/condition is this associated with?
What are common symptoms of this condition?
Antiemetic
used to treat delayed gastric emptying, and GERD
Tardive Dyskinesia
Protruding or twisting tongue
Lip smaking
puffing cheeks
involuntary movement
What is the 9th cranial nerve?
Glossopharyngeal
What is a sausage shaped mass associated with?
Besides red feces, how else does the stool appear
Intussusception – a type of bowel obstruction with telescoping of a proximal segment of the intestine into an adjacent distal segment
COMPROMISES CIRULATION
Appears as a red, jelly like stool
Bilious vomiting may occur
What is Metabolic syndrome
presence of more than 3 metabolic health factors that increase risk for stroke, diabetes mellitus and cardiovascular disease
INCLUDING:
HIGH BP
LOW HDL
Abdominal obesity
HIGH Trigylerides
HIGH fasting glucose
Signs of a heart attack in patients with type 2 diabetes
They are traditional signs such as:
Nausea
Vomiting
Belching
Indigestion
Diaphoresis
Dizziness
Fatigue
How long before a surgery is the nurse to discontinue antiplatlet medication
5 to 7 days before the surgery
Biphosphonates
alendronate
inhibit osteoclast to allow bone mineralization to occur more quickly
what should be included in a diabetics diet?
High fiber
Low sodium
Low glycemic index
Does T3/T4 or TSH determine hypo/hyper thyroidism?
Look at the levels of T3/T4
What is the best indicator of improve nutrition and response to treatment of malnuttirion?
Weight gain
What is the antidote to BENZOS
Flumazenil
What is the normal amount of drainage from a chest tube after an hour of placement?
Less than 100ml/hr
Kawasaki disease
Inflammation that occurs in the arterial walls. Mostly common in CHILDHOOD
Includes:
Joint pain
Fever
STRAWBERRY tounge
Rash
Cardiac involvement
Acute Rheumatic Fever (ARF)
Inflammatory condition that occurs after STREP group A infection
(untreated)
LIFE LONG TREATMENT
Includes:
Joint pain
Fever
STRAWBERRY tounge
Rash
Cardiac involvement
Lyme disease
Bacterial infection that occurs after A BITE
Includes:
BULLS EYE
Flu like symptoms
fever
joint pain
What is used to increase neurologic function after cardiac arrest?
Therapeutic hypothermia
How often do you assess a patients weaning readiness on a ventilator?
Daily
Which side should a cane be held on when ambulating?
On the stronger side
What is a Nitrazine PH test?
What does the color Yellow vs Blue mean?
Its a strip test that help determine between amniotic fluid (alkaline) and normal vaginal fluids or urine (acidic)
Yellow, olive, green color means the membrane is intact
Blueish color suggest rupture of membrane
What is the function of a cervical cerclage?
When can you place this in patients? what term gestation?
It is placed to prevent preterm labor
This can be placed 12-14 weeks gestation
T/F
As long as you swap disposable equipment with alcohol you can use it within patient rooms
FASLE
Disposable or single use equipment should not be shared at all
What is the sound upon auscultation of a patent ductus arteriosus?
Loud machine like murmor
Isotreninoin use
Used for cystic acne!
Also a BLACK BOX medication
Mot safe during pregnancy
What IV site is at least risk of infections?
What CVC location is at most risk of infection and why?
Dorsum of the hand
Femoral line because it can easily be contaminated with urine or feces
What medications should be avoided with patients with asthma?
Why?
Ibuprofen and Aspirin
These can cause bronchspams
Benzotropine
What is this medication used to treat?
Anticholinergic
Its used to treat parkinsons disease
AND
Extrapyramidal symptoms (EPS)