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200 Cards in this Set
- Front
- Back
- 3rd side (hint)
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The nurse returns to the nurse's station after making client roundsand finds four phone messages. Which message should the nurse return FIRST? |
1. A client with hepatitis A who states, "My arms and legs are itching."
2. A client with a cast on the right leg who states, "I have a funny feeling in my right leg." 3. A client with osteomyelitis of the spine who states, "I am so nauseated that I can't eat." 4. A client with arthritis who states, "I am having trouble sleeping at night." |
Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat withcalamine lotion and antihistamines (2) correct—may indicateneurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority |
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Following total hip arthroplasty, an elderly client is ordered to beginambulation with a walker. Which statement by the nurse is correct? |
1. "Sit in a low chair for ease in getting up to use the walker."
2. "Make sure rubber caps are in place on all four legs of the walker." 3. "You will begin weight bearing on the affected hip soon." 4. "Have someone help you tie your shoes before you begin ambulating." 5. "Your walker is the correct height when your elbows bend at a 50° angle." 6. "Always wear non skid footwear when you walk." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° shouldbe avoided to prevent dislocation of prosthesis (2) correct—intact rubbercaps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° shouldbe avoided to prevent dislocation of prosthesis (4) correct—flexionof the hip greater than 90° should be avoided (5) If the walker is the correct height the elbows should be at a 30°angle. (6) correct—Non skipfootwear is a safety consideration and should always be worn with ambulation. |
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The OB client comes to the hospital at term in the early stages of labor.A diagnosis of complete placenta previa is made. It is MOST importantfor the nurse to take which action? |
1. Start an IV of terbutaline and monitor the client's vital signs closely.
2. Prepare the client for an immediate cesarean section. 3. Maintain the client on bed rest until spontaneous vaginal delivery is achieved. 4. Monitor the client's length and duration of contractions. |
Strategy: Answers are both assessments and implementations. Is the assessmentappropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation; terbutaline used to delay delivery in preterm labor (2) correct—implementation;cannot deliver vaginally (3) implementation; cannot deliver vaginally (4) assessment; cannot deliver vaginally, cesarean section must be performed |
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The RN cares for the 4-year-old diagnosed with epiglottitis. Which observationindicates to the nurse that the child is experiencing an early complicationof hypoxemia? |
1. Heart rate of 148 beats per minute (bpm).
2. Bluish discoloration of the skin. 3. Bluish discoloration around the mouth. 4. Throwing toys and kicking the bed. 5. Difficulty swallowing. 6. Nasal flaring with activity. |
Strategy: Determine how each answer choice relates to hypoxemia. (1) correct—heart ratecorrelates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) correct—Irritabilityis an early sign of hypoxemia. temper tantrum like behavior is not expectedin a 4 year old. (5) sign of epiglottitis not hypoxemia (6) correct—Nasal flaringis an early sign of hypoxemia. |
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The RN stabilizes the client with severe multiple trauma injuries froma motor vehicle accident. Which action should the nurse take NEXT? |
1. Limit visiting hours to promote optimal rest.
2. Arrange for clergy to visit with the client and family as requested. 3. Arrange for a psychologist to visit with the family. 4. Arrange for the family to meet with a social worker to discuss financial aid. |
Strategy: All answers are implementations. Determine the outcome ofeach answer. Is it desired? (1) inappropriate (2) correct—providesthe appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation |
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The nursing assistive personnel comes to take the client by wheelchairfor a magnetic resonance imaging (MRI) scan of the head and neck. Which observation,if made by the nurse, requires an intervention? |
1. The client removes her dentures and gives them to her spouse.
2. The client's vital signs are BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C). 3. The client has a nitroglycerine patch on the right chest area. 4. The client has red nail polish on both fingers and toes. |
Strategy: "Requires an intervention" indicates an incorrect action. (1) should be removed before the test (2) results are within normal limits (3) correct—should beremoved before the test; transdermal patch contains heat-conducting aluminizedlayerand burning of skin may occur (4) unnecessary to check capillary refill |
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The neonatal nurse instructs the family of a newborn about an apneamonitor. The nurse is MOST concernedif a family member makes which statement? |
1. "We will be able to leave our baby for brief periods of time."
2. "We plan to sleep by our baby's crib." 3. "We can remove the monitor during our baby's bath." 4. "A family member will closely watch the monitor all the time." |
Strategy: "MOST concerned" indicates that you are looking for an incorrectstatement. (1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct—indicatesa feeling that monitor may not let them know if their infant stops breathing |
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The client has a cast applied for a fracture of the right femur. Threehours later, the client reports feelings of heat and pain under the cast.Which is the MOST appropriate actionfor the nurse to take? |
1. Assess the cast for wet spots, and increase air circulation in the room.
2. Check the circulation in the casted extremity, and change the client's position. 3. Take the client's temperature, and observe for other signs of infection. 4. Medicate the client for pain, and notify the health care provider. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. (1) heat is sign of pressure (2) correct—heat issign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all reports must be investigated; medication would mask signs ofpressure, assessment first step |
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The client is admitted to the hospital with dry mucous membranes anddecreased skin turgor. The client's vital signs are BP 120/70, temperature101°F (38.3°C), pulse 88, respirations 14. Laboratory tests indicatethe serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the healthcare provider to order which IV fluids? |
1. D5NS.
2. 0.45% NaCl. 3. 0.9% NaCl. 4. Lactated Ringer's. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) hypertonic solutions contraindicated in dehydration (2) correct—hypotonicsolution, shifts fluid into intracellular space to correct dehydration (3) isotonic solution, not best with dehydration (4) isotonic solution used to replace electrolytes |
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Which plan is MOST appropriatefor the nurse to use to prepare a 10-year-old for a cardiac catheterization? |
1. Show a videotape specifically prepared for children about cardiac catheterization.
2. Provide the child with a pamphlet about the procedure, and encourage him to read it. 3. Draw a picture of a heart, and explain where the tube will go and what the health care provider will see. 4. Present a puppet show explaining the anatomy and physiology of the heart. |
Strategy: Think about the developmental stage of a 10-year-old. (1) video will provide correct information but is not best preparationfor a school-age child (2) pamphlet will contain correct information but is not best preparationfor a school-age child (3) correct—explainprocedures in simple terms; allow choices when possible (4) more appropriate for a younger child |
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The nurse cares for the client reporting moderate pain. Which nursingaction is MOST important to providethe client with effective pain relief? |
1. Teach the client about the pain.
2. Establish a trusting relationship with the client. 3. Determine how various relaxation techniques affect the pain. 4. Provide alternative measures to relieve pain. |
Strategy: Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct—necessaryto work with client to identify interventions to relieve pain (3) part of the evaluation phase (4) only a portion of interventions used to relieve pain |
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A client diagnosed with a necrotizing spider bite is to perform dressingchanges at home. The nurse determines which statement, if made by the client,indicates a correct understanding of aseptic technique? |
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1. "I need to buy sterile gloves to redress this wound." 2. "I should wash my hands before redressing my wound." 3. "I should keep the wound covered at all times." 4. "I should only use whatever my health care provider orders for the dressing change." 5. "I should make sure someone looks at my wound every dressing change." 6. "I will throw the dressing away in the kitchen garbage wrapped in my glove." |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) sterile gloves are not commonly ordered. There is no informationin the question to suggest this level of dressing (2) correct—indicatesunderstanding of asepsis, hallmark is hand washing (3) is not possible to carry out (4) correct—should useonly the prescribed medications on the wound (5) correct—The woundshould be observed for changes with every dressing change. (6) correct—The dressingshould be discarded after being wrapped in the non sterile glove. |
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An adult client is admitted to an acute locked psychiatric unit onemonth prior to an election. The client requests the opportunity to vote inthe upcoming election. Which response by the nurse is BEST? |
1. "You are not eligible to vote because you are a psychiatric client."
2. "I'll make the appropriate arrangements for you to vote." 3. "You may vote only if you are discharged by Election Day." 4. "I'll contact the Election Board to see if you are registered to vote." |
Strategy: Determine the outcome of each answer choice. (1) psychiatric patients do not forfeit their constitutional rights (2) correct—client canvote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility |
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The nurse administers sublingual nitroglycerin to the client reportingchest pain. Which observation is MOST importantfor the nurse to report to the next shift? |
1. The client indicates the need to use the bathroom.
2. Blood pressure has decreased from 140/80 to 90/60. 3. Respiratory rate has increased from 16 to 24. 4. The client indicates that the chest pain has subsided. |
Strategy: The topic of the question is unstated. Read answer choicesfor clues. (1) not a side effect of this medication (2) correct—hypotensionis significant side effect of nitroglycerin; although effect may be transient,BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome |
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One of the goals the nurse and a client diagnosed with posttraumaticstress disorder (PTSD) mutually agreed upon is that the client will increaseparticipation in out-of-the apartment activities. Which recommendation, ifmade by the nurse, is MOST therapeuticto achieve this goal? |
1. Take a day trip with a friend.
2. Take an 11-minute bus ride alone. 3. Join a support group, and participate in a victim assistance organization. 4. Take a 10-minute walk with the spouse around the block. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) reasonable recommendation to begin using in a systematic desensitizationprogram after the crisis is alleviated (2) reasonable recommendation to begin using in a systematic desensitizationprogram after the crisis is alleviated (3) correct—supportgroups of people who have suffered similar acts of violence can be helpfuland supportive to teach clients how to deal with the traumatizing situationand the emotional aftermath (4) reasonable recommendation to begin using in a systematic desensitizationprogram after the crisis is alleviated |
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The client is scheduled for a traditional abdominal cholecystectomy.Which statement, if made by the nurse to the client the night before surgery,is MOST important? |
1. "It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet."
2. "Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times." 3. "There will be a machine available to you after surgery for you to use to continuously receive pain medication." 4. "You may come back from surgery with a tube in your nose that drains your gallbladder." |
Strategy: All answers are implementations. Determine the outcome ofeach implementation. Is it desired? (1) not most important initially, teaching should be done before discharge (2) correct—should bedone every two hours to prevent respiratory complications, splinting preventsabdominal jarring (3) PCA pumps used postoperative but medication administered intermittently (4) NG tube used to drain stomach, T tube used to drain common bileduct |
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The mother of a 4-year-old boy comes to the prenatal clinic to confirmher second pregnancy. During the initial visit, it is MOST importantfor the nurse to take which action? |
1. Assess the client's feelings about pregnancy, labor, and delivery.
2. Obtain a history of the client's last labor and delivery. 3. Determine how the client's 4-year-old feels about the pregnancy. 4. Identify the client's general health needs. |
Strategy: Think about each answer choice. (1) physical needs take priority (2) physical needs take priority (3) priority is taking care of pregnant client (4) correct—optimalopportunity for preventive health maintenance |
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The nurse prepares the client for a skin biopsy. Which client statementshould the nurse report to the health care provider? |
Select all that apply.
1. "I've been taking aspirin for my sore knees." 2. "Using lotion has helped my dry skin." 3. "I have a tanning appointment tomorrow." 4. "I had a big breakfast this morning." 5. "I have changed my mind about having this done." |
Strategy: Determine how the statements relate to skin biopsy. (1) correct—aspirincompounds can increase bleeding time and should not be taken prior to a surgicalprocedure (2) does not affect the accuracy or results of the biopsy even thoughit is not recommended (3) does not affect the accuracy or results of the biopsy (4) does not affect the accuracy or results of the biopsy (5) correct—The clientis free to change their mind but the health care provider needs to be informed. |
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The nurse cares for the client diagnosed with a perforated bowel secondaryto a bowel obstruction. At the time the diagnosis is made, which should bethe priority in the nursing care plan? |
1. Maintain the client in a supine position.
2. Notify the client's next of kin. 3. Prepare the client for emergency surgery. 4. Remove the nasogastric tube. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct—when thebowel perforates as a result of increased intraluminal pressure within thegut, intestinal contents are released into the peritoneum, leading to peritonitis (4) should not be done |
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The health care provider writes an order for piperacillin 3 g IV q6hfor the adult client. Before administering this drug, the nurse should takewhich action appropriate to this medication? |
Select all that apply.
1. Check for known allergies to medications. 2. Obtain specimen for culture and sensitivity 3. Administer dexamethasone sodium phosphate 2 mg IV stat. 4. Obtain client's current creatinine clearance results. 5. Ensure that the client's respiratory rate is over 12. 6. Check the client's blood pressure both sitting and standing |
Strategy: Answers are a mix of assessments and implementations. Determineif the assessment is necessary in this situation. (1) correct—assessment;piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, shouldnot be administered to clients with known allergies (2) correct—assessment;must be completed prior to starting the antibiotic. (3) implementation; not relevant for administration of this medication (4) correct—assessment;creatinine clearance values necessary to determine appropriate dosage ordered. (5) assessment; not required for this classification of medication. (6) assessment; not required for this classification of medication. |
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The mother brings her 17-month-old son to the well-baby clinic for aroutine checkup. She confides to the nurse that she is concerned because herson sucks his thumb, especially at night when he is put to bed. Which suggestionby the nurse BEST? |
1. "If you want the behavior to stop, put a negative reinforcer, such as red pepper, on his thumb."
2. "Don't intervene at this time. This behavior usually subsides after 24 months of age." 3. "What you are seeing is a common form of self-stimulation. You should discourage this behavior." 4. "This behavior will cause malformation of his teeth. You should wrap his thumb at bedtime." |
Strategy: "BEST" indicates there may be more than one correct response.Remember growth and development concepts. (1) controversial treatment, for an older child (2) correct—normal behavior,peaks at 18–20 months, most prevalent when child is hungry or tired (3) normal behavior in child this age, should not be discouraged (4) malocclusion occurs if thumb sucking persists past 4 years old orwhen permanent teeth erupt |
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The nurse cares for clients in the outpatient clinic. The young adultfemale arrives for help with weight loss. The client’s weight is 257pounds, and the client is 5'7". Which diet choice indicates the MOST appropriate choice for breakfast? |
1. Applesauce, cream of wheat, toast.
2. Scrambled eggs and toast, one slice of bacon. 3. One glass of grapefruit juice. 4. Bagel with two ounces of cream cheese and a banana. |
Strategy: Determine the topic of the question. (1) correct—breakfastwith some substance, won't leave client feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the clientfeeling very hungry before lunch (4) high fat content |
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The toddler admitted with an elevated blood lead level is to be treatedwith intramuscular (IM) injections of calcium disodium edetate and dimercaprol.Which nursing action has the highest PRIORITY? |
1. Keep a tongue blade at the bedside.
2. Encourage the child to participate in play therapy. 3. Apply cool soaks to the injection site. 4. Rotate the injection sites. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) no longer used for seizures, but it is important to have seizureprecautions and emergency respiratory equipment available (2) important to implement, but is not a priority (3) contains incorrect information (4) correct—highestpriority is to prevent tissue damage and promote tissue absorption of themedicine, accomplished through rotation of the injection sites |
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The nurse instructs the client being discharged on tranylcypromine sulfate.The nurse determines further teaching is needed if the client makes whichstatement? |
1. "To celebrate, my wife and I are going out for pepperoni pizza and wine tonight."
2. "I plan to use sunblock at the beach this summer." 3. "When I get home, I am going to start a diet so that I can lose some weight." 4. "Now that I feel so much better, I have more energy." |
Strategy: Determine how each answer choice relates to Tranylcyprominesulfate. (1) correct—Tranylcyprominesulfate is an MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt,beer, wine) to prevent hypertensive crisis (2) sunblock required (3) no contraindication to sensible weight reduction diet (4) expected outcome of antidepressant; takes three to four weeks towork |
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The triage nurse for the women's health center receives 4 phone messages.In which order should the nurse return the phone calls? |
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Strategy: Determine the least stable client and keep prioritizing theclients left. (1) correct—needs tobe evaluated for an ectopic pregnancy; Unstable, Unexpected, Circulatory,Real (2) symptomatic of threatened abortion; Unstable, Unexpected, Circulation,Potential, moderate bleeding (3) symptoms of spontaneous abortion; Unstable, Unexpected, circulation,potential light spotting. (4) expect during first trimester of pregnancy |
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The RN cares for the client just admitted after sustaining a second-degreethermal injury to the right arm. Which observation is MOST importantto report to the health care provider? |
1. Pain around the periphery of the injury.
2. Gastric pH less than 5.0. 3. Increased edema of the right arm. 4. An elevated hematocrit. |
Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct—client isat risk for Curling's ulcer which may develop 24 hours after a severe burninjury; gastric pH acidic (1-5) (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution |
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A college student reports a history of a motor vehicle accident sixmonths ago. The client was minimally injured but a friend was killed. Theclient comes to Student Health Services reporting inability to study or sleep.The client also reports thinking they are "going crazy." Which action by thenurse is MOST important? |
1. Perform a complete physical and social history.
2. Obtain a complete drug and alcohol history, including reports from a drug screen. 3. Review the significant events of the last year. 4. Explore the client's coping methods over the crash and the friend's death. |
Strategy: Determine the outcome of each answer choice. (1) not most important initially (2) not most important initially (3) not most important initially (4) correct—situationalcrisis; priority is to determine how client coped with crisis in the pastand build on client’s coping strategies |
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The RN obtains a urinalysis from the client reporting dysuria, urinaryfrequency, and discomfort in the suprapubic area. After evaluating the results,the nurse should order a repeat urinalysis based on which finding? |
1. Negative glucose.
2. RBCs present. 3. No WBCs or RBCs reported. 4. Specific gravity 1.018. |
Strategy: Determine the significance of each answer choice and how itrelates a bladder infection. (1) glucose increases during the inflammation process; it is not a primarycomponent in determining urinary tract infections (2) not as complete a response as answer choice 3 (3) correct—with theclient's symptoms, WBCs and RBCs should be present; WBCs are a response tothe inflammation process and irritation of the urethra; RBCs are increasedwhen bladder mucosa is irritated and bleeding (4) indicates the concentration of the urine |
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The RN talks to the parents of a 6-month-old. They discuss ways to minimizethe side effects of a DTaP immunization. Which action is important for theRN to discuss? |
1. Give the child an alcohol bath for an elevated temperature.
2. Administer acetaminophen for discomfort. 3. Place a cool cloth on the injection site for 15 minutes. 4. Check the child's temperature every four hours for three days. 5. Wrap and comfort the child for signs of irritability. 6. Administer a salicylate medication for a fever. |
Strategy: Answers are a mix of assessments and implementations. Thisquestion is not a priority, you need to determine if the action is appropriateor not? Determine the outcome of each action. Is it desired? (1) implementation; not recommended for treatment in 6 month old (2) correct—implementation;antipyretics (excluding Salicylates) relieves discomfort (3) correct—implementation;Cool (not cold) is used to decrease pain; should be used for short temporaryintervention (4) assessment; unnecessary unless indicated for another reason (5) correct—Decreasedmoving of the extremity and parental comfort is an appropriate intervention (4) Salicylates are not recommended for children. |
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The clinic nurse observes that a 10-year-old child with leukemia hasa large burn on her arm. The burn appears to be oily. The child tells thenurse that she touched a hot pan, and her mother put cooking fat on it sothat it would not blister. Which action should the nurse take FIRST? |
1. Document the findings in the chart.
2. Call the health care provider immediately to report the injury. 3. Teach the client that oil holds germs and makes infection more likely. 4. Wash the burn with soap and water to remove the oil. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct—becauseleukemic clients are immunosuppressed, they are more susceptible to infections;cooking fat applied to an open wound increases the possibility of infection;burns should be rinsed immediately with tap water to reduce the heat in theburn |
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The nurse instructs a client about how to perform self-monitoring bloodglucose (SMBG) using a blood glucose monitor. Which action, if performed bythe client, indicates to the nurse the need for further teaching? |
1. The client dangles the hand before sticking the finger with the lancet.
2. The client sticks the finger on the side of the distal phalanx. 3. The client touches the strip with a large drop of blood hanging from the fingertip. 4. The client milks the finger after sticking it. |
Strategy: "Further teaching" indicates an incorrect response. (1) helps facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters thereading (4) correct—forces interstitialfluid to mix with capillary blood and dilutes the blood |
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The client is to receive the afternoon dose of nifedipine. The nursenotes this rhythm on the cardiac monitor. |
Which action is MOST appropriate for the nurse to take?
1. Withhold the medication. 2. Check the urinary output. 3. Administer the medication. 4. Increase the potassium intake. |
Strategy: Answers are a mix of assessments and implementations. Is therean appropriate assessment? No. Determine the outcome of the implementations. (1) correct—nifedipineis calcium-channel blocker used as antihypertensive; bradycardia is untowardeffect; withholding medication and checking with the health care provideris appropriate (2) assessment; appropriate nursing action for a client on an antihypertensivethat has diuretic effects because of increased blood flow to the kidney, nota priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive thathas diuretic effects because of increased blood flow to the kidney, not apriority in this instance |
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The multipara client comes to the prenatal clinic during her fifth monthof pregnancy. The client reports that her breasts are sensitive and sore.Which suggestion by the nurse is best? |
Select all that apply.
1. "Apply warm compresses to your breasts, and take two aspirin as needed." 2. "Massage your breasts with lotion in a downward motion." 3. Apply cool compresses to the sides of your breasts." 4. "Take an herbal diuretic once a day." 5. Wear a well fitting supportive bra." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) would increase circulation and increase discomfort (2) not effective in decreasing discomfort (3) correct—during pregnancythere is an increase in lactiferous ducts and lobule-alveolar tissue coolpacks will decrease the discomfort caused by this change (4) medications are to be avoided during pregnancy (5) correct—appropriatesupport of the breast will help decrease the feeling of pulling and the discomfortassociated with that occurrence. |
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The nurse cares for the client diagnosed with hyperparathyroidism. Whichsymptom is most important for thenurse to report to the next shift? |
1. Abdominal discomfort.
2. Hematuria. 3. Muscle weakness. 4. Diaphoresis. |
Strategy: Determine how each answer choice relates to hyperparathyroidism. (1) sign of hyperparathyroidism but does not require reporting (2) correct—hematuriais a sign of urinary tract calculi; 55% of hyperparathyroid clients have urinarytract calculi (3) sign of hyperparathyroidism but does not require reporting (4) sign of hyperparathyroidism but does not require reporting |
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Two days after the client is admitted, the client's sputum culture isreported as positive for tuberculosis. While awaiting orders from the healthcare provider, the nurse should take which action? |
1. Initiate measures to transfer the client to a tuberculosis unit.
2. Institute measures to initiate airborne precautions. 3. Arrange for all of the client's personal effects to be decontaminated. 4. Notify the client's family that they have been exposed to a contagious disease. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the healthcare provider will write appropriate transfer orders (2) correct—clientswith tuberculosis are placed on airborne precautions in the hospital, andthe nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the health care provider's job to tell the family when indicated |
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The nursing assistive personnel(NAP) is assigned to constant observationof a suicidal client. The nurse overhears the NAP talking with the client.Which statement made by the NAP requires IMMEDIATE interventionby the nurse? |
1. "Let's put your clothes in the dresser."
2. "I'll stay in the bathroom with you while you take your shower." 3. "You're going to be moved to a private room later today." 4. "I'll be right back with something for you to eat." |
Strategy: "Require an IMMEDIATE intervention" indicates that somethingis wrong. (1) no reason to intervene (2) appropriate, client is not to be left alone for any reason (3) no reason to intervene (4) correct—client underconstant observation; must not be left alone for any reason |
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The nurse obtains a history from the client just admitted to the unit.The client informs the nurse that any information shared with the nurse duringthe interview is to remain confidential. Which response by the nurse is BEST? |
1. "I'll share any information you give me with staff members only with your approval."
2. "If the information you share is important to your care, I'll need to share it with the staff." 3. "We can keep the information just between the two of us." 4. "I have an obligation to maintain nurse/client confidentiality about anything you tell me." |
Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personneldirectly involved with the client's care (2) correct—the nurseobligated to share client information with personnel directly involved withthe client's care (3) nurse must never agree to keep information confidential withoutknowing the content of the information (4) nurse not obligated to report information that is not relevant tothe client's care or well-being |
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The nurse performs discharge teaching for the client diagnosed withmultiple sclerosis. It is MOST importantfor the nurse to include which instruction? |
Select all that apply.
1. Ambulate as tolerated every day. 2. Avoid overexposure to heat or cold. 3. Perform stretching and strengthening exercises. 4. Participate in social activities. 5. Use cold packs on joints. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—client isencouraged to ambulate as tolerated (2) correct—overexposureto heat or cold may cause damage related to the changes in sensation (3) correct—client isencouraged to participate in an exercise program to include range-of-motion(ROM), stretching, and strengthening exercises (4) correct—client isencouraged to continue usual activities as much as possible, including socialactivities (5) overexposure to heat or cold may cause damage related to the changesin sensation |
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The client diagnosed with lung cancer undergoes a pneumonectomy. Inthe immediate postoperative period, which assessment is MOST important? |
1. Presence of breath sounds bilaterally.
2. Position of the trachea in the sternal notch. 3. Amount and consistency of sputum. 4. Increase in the pulse pressure. |
Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct—positionof the trachea should be evaluated; with a tracheal shift, an increase inpressure could occur on the operative side and could cause pressure againstthe mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation |
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After abdominal surgery, the client is admitted from the recovery roomwith intravenous fluid infusing at 100 ml/hour. One hour later, the nursefinds the clamp wide open and notes that the client has received 850 ml. Thenurse is MOST concerned by whichassessment finding? |
1. A CVP reading of 12 and bradycardia.
2. Tachycardia and hypotension. 3. Dyspnea and oliguria. 4. Rales and tachycardia. |
Strategy: "MOST concerned" indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct—indicatecardiovascular fluid overload |
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The nurse admits the client from the postoperative recovery area afterabdominal exploratory surgery. In which order should the nurse perform theactions? List from first action performedto last action performed. All options must be used. |
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Strategy: Place the actions in order. Consider priority of each action. (1) This is the first action. respiratory assessment is highest priority. (2) 2nd action to perform. assessment of cardiac status is second priority. (3) assessment; dressing should be checked on admission to the roomand frequently for the next several hours (4) 4th action; implementation but priority assessments should be completedfirst (5) 5th action; knowing what occurred in surgery is an action but assessmentand position the client will take priority. (6) 6th action; baseline assessment would be required but much to soonfor infection assessment |
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The client comes to the local outpatient clinic reporting dizzinessand palpitations. The physical exam and laboratory results are normal. Theclient reports the family-owned company is on the verge of bankruptcy. Whichresponse, if made by the nurse to the client, is BEST? |
1. "When did you first notice these symptoms?"
2. "Have you shared this information with anyone?" 3. "Are you concerned about your financial difficulties?" 4. "Would you like to discuss your situation with me?" |
Strategy: "BEST" indicates there may be more than one correct response.Remember therapeutic communication. (1) correct—open-endedquestion, encourages client to discuss when problems occurred (2) yes/no question, nontherapeutic, doesn't encourage discussion ofsymptoms (3) yes/no question, nontherapeutic, too confrontational, does not encouragediscussion (4) yes/no question, nontherapeutic |
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The nurse cares for the client after a radical mastectomy of the rightbreast. Upon return to the unit, which position, if performed by the nurse,is MOST appropriate? |
1. Position the client on the left side with the right arm protected in a sling.
2. Position the client on the right side with the right arm elevated. 3. Position the client in semi-Fowler's position with the right arm elevated. 4. Position the client in the prone position with the right arm elevated. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct—this positionwill facilitate removal of fluid from venous pathways and lymphatic systemthrough gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate |
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The nurse walks into the client's room. The client states, "I just lovehot-blooded redheads." The client pats the bed and says, "Why don't you sitdown here and get off your feet for a while." Which response by the nurseis BEST? |
1. "I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job."
2. "I don't think my spouse would like me doing that." 3. "You must be very lonesome. I'll come back later and spend some time with you." 4. "I bet you flirt with all the nurses like that." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—nurse shouldconfront client about inappropriate sexual behavior (2) should confront the client (3) reinforces inappropriate behavior (4) confront the client about inappropriate and unwanted behavior |
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The nurse answers the phone on the psychiatric unit. The caller identifieshimself as the spouse of a client and inquires about the client's condition.Which response by the nurse is MOST appropriate? |
1. "I cannot deny or confirm any client's presence in this hospital."
2. "Clients are not allowed access to this phone. Please call the number you were given." 3. "I cannot give information over the phone. If you come in, we can discuss her condition." 4. "I will have to ask her if she wishes for me to give out that information." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) confidentiality prohibits a professional from discussing informationabout the client (2) correct— psychiatricclient retains civil rights to communicate with outside world and have reasonableaccess to telephones; unless client opts out of the registry, their locationmay be given out with prearranged codes (3) breaks confidentiality (4) client able to speak for herself |
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Several days after the client's myocardial infarction, the health careprovider places the client on a 2-gm sodium diet. Which selection indicatesto the nurse an understanding of the diet? |
1. Scrambled egg, orange slices, and milk.
2. Instant oatmeal, toast, and orange juice. 3. Poached egg, bacon, and milk. 4. Biscuit, fruit cup, and sausage. |
Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct—all itemsare low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all quick breads are high in sodium, as is sausage |
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The nurse leads a class for expectant mothers. Which comment indicatesto the nurse that the pregnant woman understands the recommended dietary caloricincrease for pregnancy? |
1. "I will need to double my calorie intake because I am now eating for two."
2. "I can add an additional 500 calories by drinking milkshakes." 3. "I need to add 300 calories by increasing my intake of the basic food groups." 4. "I really need to watch my calorie intake so that I will not gain too much weight." |
Strategy: Determine the outcome of each answer choice. Is it desired? (1) common misconception (2) 500 calories is too many calories, and a milkshake is not a goodfood source because of its fat content (3) correct—recommendedto increase calorie intake by 300 for fetal growth, maternal tissues, andthe placenta (4) unsafe for the pregnant client |
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The nurse cares for the 17-year-old married male scheduled for a herniarepair. The nurse administers fentanyl 100 mcg with hydroxyzine pamoate 25mg IM. Thirty minutes later the nurse discovers that the informed consentis unsigned. Which action by the nurse is best? |
1. Cancel the surgery.
2. Ask the client to sign the informed consent. 3. Notify the health care provider. 4. Ask the client's mother to sign the informed consent. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) inappropriate action; should inform health care provider (2) can't sign informed consent if client has been drinking alcoholor has been pre-medicated for surgery (3) correct—health careprovider needs to be informed (4) married minor is considered emancipated; provides own consent fortreatment |
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The nurse instructs a client receiving naproxen 250 mg enteric-coatedtablets PO bid. Which response, if made by the client, indicates that thenurse's instruction about the medication is effective? |
1. "I have a glass of wine with dinner."
2. "I should avoid milk and dairy products when I take this pill." 3. "I should call my health care provider if my stools turn very dark." 4. "I don't like to take pills, so I will crush the pill and add it to some applesauce." |
Strategy: "Teaching is effective" indicates you are looking for a truestatement. (1) alcohol increases risk of gastrointestinal bleeding (2) should be taken with food, milk, or antacid to decrease gastrointestinalupset (3) correct—NSAIDs cancause gastrointestinal bleeding (4) enteric-coated tablet should not be broken |
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The client at 39 weeks gestation in active labor screams, "I have topush, I have to push." The nurse notes that the client is 8 cm dilated. Thenurse should take which action? |
1. Instruct the client to take a deep breath and bear down.
2. Apply gentle but firm pressure to the client's abdomen. 3. Coach the client in relaxation techniques. 4. Tell the client to pant with pursed lips. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period oflabor (4) correct—describestransition phase of labor, breathing technique allows client to control painand urge to push and promotes adequate oxygenation of fetus |
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TThe nurse observes the student nurse perform a wet-to-dry dressingchange on the client's 2-inch incision. In which order should the studentperform the procedure? Place in order from first action to lastaction. All options must be used. |
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Strategy: Think about the process. find the first and the last stepthen insert the steps in the middle. All the steps must be used but all thesteps are not listed. (1) correct—should beremoved dry so that wound debris and necrotic tissue are removed with olddressing (2) The now exposed skin around the wound is cleaned and dried (3) Because this is a wet to dry dressing the 1st clean layer of gauzeis wet then excess liquid is removed by wringing or squeezing. (4) The wet gauze is applied is a single layer. (5) The dry gauze is then applied. |
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The client is presently employed as a night watchman. When the clientcomes to the clinic for a visit, the client reports difficulty sleeping andfatigue. Which response by the nurse is BEST? |
1. "Tell me about your usual sleeping habits."
2. "You probably sleep when you can during your night tour." 3. "This is normal for your age group." 4. "Working the night shift is known to disrupt sleep patterns." |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. (1) correct—assessment;open ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) generalization, closed communication |
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The nurse cares for the client in the emergency room. Before administeringcalcium gluconate 10% 500 mg IV stat, which assessment should the nurse complete FIRST? |
1. Stability of the respiratory system.
2. Adequacy of urine output. 3. Patency of the vein. 4. Availability of magnesium sulfate injection. |
Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct—if injectedinto the extravascular tissues, calcium gluconate can cause a severe chemicalburn (4) irrelevant |
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An 18-month-old is brought by her parent to the well-baby clinic fora routine immunization. Just before the nurse gives the child the injection,the toddler begins to cry. Which comment by the nurse is the MOST appropriate? |
1. "Don't cry. It will be better if you try to behave."
2. "I know you are frightened. It will be over with soon." 3. "A big girl like you shouldn't cry. It's only going to hurt a little." 4. "Please stop crying. There is nothing to be afraid of." |
Strategy: Remember therapeutic communication (1) nontherapeutic; doesn't respond to feeling tone and tells childwhat to do (2) correct—doesn'tminimize child's reaction, responds to feeling tone (3) nontherapeutic; minimizes child's reaction (4) nontherapeutic; minimizes child's reaction, should indicate it isokay to feel afraid |
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The child admitted with failure to thrive has just had a positive sweattest. The nurse anticipates which change in the child's plan of care initially? |
1. Administration of replacement enzymes.
2. Administration of oxygen. 3. A salt-restricted diet. 4. Initiate intravenous therapy. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—sweat testis a positive finding for cystic fibrosis (2) no data in this situation to indicate that the child is having pulmonaryproblems (3) salt is increased in diet (4) no need for IV therapy based on the data in this situation |
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The nurse plans discharge for the client post mild myocardial infarction(MI). The client smokes one pack of cigarettes per day. Which recommendationby the nurse is BEST? |
1. Participate in a program such as nicotine avoidance.
2. Avoid aerobic physical activity. 3. Install a humidifier in the home heating system. 4. Strict adherence to a low-calorie, low-sodium, high-lipid diet. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—smokingis definitely a modifiable risk factor, self-help program can significantlyaid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet |
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The home care nurse visits an infant who had a myelomeningocele repair.The home care nurse determines the parents are accepting of their infant ifwhich finding is observed? |
1. The parents state that the infant will outgrow this problem in time.
2. The parents ask a neighbor to perform bladder expression. 3. The parents measure the head circumference daily. 4. The parents relate that they believe the child will walk in 1 year. |
Strategy: Think about each statement and how it relates to myelomeningocele. (1) child has a chronic problem (2) indicates the parents' lack of interest and inability to care forthe child (3) correct—parents'participation in care may be first sign of acceptance; head circumferencemeasurement is important because of risk of hydrocephalus following surgery;even simple care like bathing child could bring acceptance (4) shows a lack of understanding about myelomeningocele |
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The nurse cares for the client with a Sengstaken-Blakemore tube in place.The nurse enters the room and finds the client in respiratory distress. Whichaction should the nurse take FIRST? |
1. Notify the health care provider immediately to remove the tube.
2. Elevate the head of the bed, and administer oxygen. 3. Cut the balloon ports and remove the tube. 4. Call a code, and begin rescue breathing. |
Strategy: FIRST indicates priority. (1) need to remove tube immediately to provide for airway (2) does not provide a patent airway (3) correct—scissorsalways secured at the bedside; remove tube if observe signs of respiratorydistress or airway obstruction caused by upward displacement of esophagealballoon (4) unnecessary to call code until respiratory arrest occurs, then establisha patent airway first |
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The nurse instructs the prenatal client about the importance of prenatalvitamins. It is MOST important forthe nurse to include which instruction? |
1. "Take prenatal vitamins with orange juice at bedtime."
2. "Take the prenatal vitamins at breakfast with coffee." 3. "Take the prenatal vitamins with milk at lunch." 4. "Take the prenatal vitamins with water at dinner." |
Strategy: "MOST important" indicates discrimination may be requiredto answer the question. (1) correct—taking thevitamins with something acidic increases the absorption of iron; taking themwith food at bedtime decreases the possibility of nausea, as the client willbe asleep (2) not the best way to take prenatal vitamins (3) not the best way to take prenatal vitamins (4) not the best way to take prenatal vitamins |
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The nurse instructs the prenatal client about the importance of risperidone.It is MOST important for the nurseto include which instruction? |
Select all that apply.
1. "I may gain weight when taking this medication." 2. "I should avoid extremes in temperatures." 3. "I can take over-the-counter sedatives if I have trouble sleeping." 4. "I can drink alcohol as long as I drink in moderation." 5. “I will wear long sleeves when I am out in the sun.” 6. “I will change positions slowly.” |
Strategy: “teaching is successful” indicates correct information. (1) correct—causes weightgain (2) correct—drug impairsbody temperature regulation (3) check with health care provider before taking any OTC medication (4) check with health care provider before ingesting alcohol (5) correct—causes photosensitivereactions (6) correct—minimizesorthostatic hypotension |
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The nurse cares for the client diagnosed with bipolar disorder. Theclient refuses to put down the mop that he is swinging to threaten other clientsand staff. What information is MOST important for the nurse to consider beforeadministering a PRN IM dose of lorazepam? |
1. The client is harmful to himself.
2. The client is psychotic. 3. A less restrictive intervention failed. 4. The client is harmful to others. |
Strategy: Think about each answer choice. (1) use the least restrictive interventions in ascending order (2) use the least restrictive interventions in ascending order (3) correct—use theleast restrictive interventions in ascending order (4) use the least restrictive interventions in ascending order |
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The nurse cares for the client with a marked depression of T cells.The nurse should take which action? |
1. Keep a linen hamper immediately outside the room.
2. Restrict eating utensils to spoons made of plastic. 3. Provide masks for anyone entering the room. 4. Remove any standing water left in containers or equipment. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universalguidelines with double biohazard bags (2) universal precautions and client protection may call for plasticutensils but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct—water shouldnot be allowed to stand in containers, such as respiratory or suction equipment,because this could act as a culture medium |
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The health care provider prescribes sucralfate 1 gm PO tid and 2 Magnesiumhydroxide/Aluminum hydroxide tablets tid for the client in the outpatientclinic. The client asks the nurse when to take these medications. Which instructionby the nurse is BEST? |
1. Take the sucralfate and the Magnesium hydroxide/Aluminum hydroxide 1 hour ac.
2. Take the Magnesium hydroxide/Aluminum hydroxide 1 hour ac and the Carafate 1 hour pc. 3. Take the sucralfate and the Magnesium hydroxide/Aluminum hydroxide 2 hours pc and hs. 4. Take the sucralfate 1 hour ac and the Magnesium hydroxide/Aluminum hydroxide 1 hour pc. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) Magnesium hydroxide/Aluminum hydroxide (antacid) decreases bondingto gastrointestinal mucosa, so don't give within 30 minutes of each other (2) sucralfate best results on empty stomach; antacids decrease bondingto gastrointestinal mucosa, so don't give within 30 minutes of each other (3) antacids decrease bonding to gastrointestinal mucosa, so don't givewithin 30 minutes of each other (4) correct—sucralfatehas best results on empty stomach |
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The female client is diagnosed with human papillomavirus (HPV). Whichclient statement, if made to the nurse, illustrates an understanding of thepossible sequelae of this illness? |
1. "I will need to take antibiotics for at least a week."
2. "I will use only prescribed douches to avoid a recurrence." 3. "I will return for a Pap smear in six months." 4. "I will avoid using tampons for eight weeks." |
Strategy: Determine the "hidden meaning" of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct—severalstrains of HPV are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome |
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The client develops severe, crushing chest pain radiating to the leftshoulder and arm. Which medication should the nurse administer? |
1. Diazepam PO.
2. Meperidine IM. 3. Morphine sulfate IV. 4. Clopidrogel |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) not an appropriate medication in this situation; antianxiety medication (2) meperidine is less commonly used because it may induce vomitingand initiate a vagal response (3) correct—morphinesulfate is given to reduce pain, anxiety, and cardiac workload; reduces thepreload and afterload pressures (4) platelet aggregation inhibitor; initial therapy is aspirin |
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The nurse makes a home visit to the client with an abdominal wound.When irrigating the draining wound with a sterile saline solution, which sequenceis MOST appropriate for the nurseto follow? |
1. Pour the solution, wash hands, and remove the soiled dressing.
2. Wash hands, prepare the sterile field, and remove the soiled dressing. 3. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing. 4. Remove the soiled dressing, flush the wound, and wash hands. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) hands should be washed first (2) correct—hand washingshould be done prior to beginning any procedure, especially irrigating a wound (3) using sterile gloves to remove the dressing would contaminate them (4) hands should be washed first |
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The charge nurse reviews care for the client with internal radiation.The charge nurse will intervene if which action is noted? |
Select all that apply.
1. Visitors are limited to 5 hours/day with the client. 2. A male caregiver is assigned to all care. 3. Time in the room is limited for all care providers. 4. Lead-lined apron are worn for all care delivery. 5. Verbal exchanges with the client are done from the doorway. 6. Frequent rest periods are incorporated into clients care. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? We are looking for incorrect statement (1) correct—this isan incorrect statement; all visitors are restricted with regard to the distancethey should be from the client; 3 hours/day is recommended (2) correct—this isan incorrect statement. caregivers are not to be assigned all care not mattertheir gender. (3) this is a correct statement - principles for radiation therapy aretime, distance, shielding; nurse should decrease the time spent in close proximityto the client (4) correct—this isan incorrect statement; appropriate shielding (lead apron) is to be used whenthe nurse has to spend any length of time at a close distance, not just forroutine care (5) this is a correct action. decreases close exposure for the careprovider (6) this is a correct action; radiation implants can cause fatigue,frequent rest periods are appropriate. |
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The nurse prepares the client for a myelogram. It is MOST importantfor the nurse to ask which question? |
1. "Do you have any allergies?"2. "Have you been drinking lots of fluids?"3. "Are you wearing any metal objects?"4. "Are you taking medication?"
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Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct—dye is injectedinto subarachnoid space before an x-ray of spinal cord and vertebral columnto assist in identifying spinal lesions; if client is allergic to dye, thereis a major safety issue (2) important that client drink extra fluids after the test to replacethe CSF lost during test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines,neuroleptics) |
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The nurse cares for the client diagnosed with dementia in a long-termcare facility. Which action by the nurse is BEST? |
1. Encourage the client to verbalize feelings about being placed in a nursing home.
2. Ask the client what favorite pastimes and what type of activities the client used to participate in. 3. Orient the client to the present time and assist the client to be alert and oriented when the family comes to visit. 4. Direct conversation toward assisting the client to reminisce and talk about important past events in life. |
Strategy: The topic of the question is unstated. Read the answer choicesfor clues. (1) may not remember who or where he is (2) not as important as answer choice 4 (3) even with orientation, the client soon forgets (4) correct—geriatricclient should be encouraged to talk about his life and important things inthe past because he has recent memory loss |
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The nurse cares for the client with a nasogastric tube in place afterextensive abdominal surgery. The client reports nausea. The nurse notes theclient’s abdomen is distended and there are no bowel sounds. Which actionshould the nurse take FIRST? |
1. Administer the PRN pain medication and an antiemetic.
2. Irrigate the nasogastric tube with normal saline. 3. Determine if the nasogastric tube is patent and draining. 4. Check the placement of the nasogastric tube by auscultation. |
Strategy: Answers are a mix of assessments and implementations. Is thisa situation that requires assessment? Yes. (1) implementation; may be carried out after the patency of the tubeis determined (2) implementation; patency should be checked first (3) correct—should firstassess if the tube is open and draining to determine if there is a problemwith the nasogastric tube; if it is patent and draining, it does not needto be irrigated (4) assessment; patency should be checked first by aspirating stomachcontents, not by auscultation |
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The nurse cares for the client after a vaginal delivery. Which actionshould be implemented FIRST? |
1. Check the client's lochial flow.
2. Palpate the client's fundus. 3. Monitor the client's pain. 4. Assess the client's level of consciousness. |
Strategy: "FIRST" indicates that this is a priority question. Rememberthe ABCs. (1) correct—complicationof hemorrhage assessed by observing lochial flow (2) done to assist its natural clamping-down action, assessed as firmor boggy (3) must meet physical needs first (4) not first action; hemorrhage most important complication |
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The client diagnosed with a fracture of the left femur is placed inBuck's traction with a 7-lb weight. The nurse notes the client keeps slidingdown in bed. The nurse should take which action? |
1. Elevate the client's left thigh on two pillows.
2. Elevate the foot of the bed on blocks. 3. Raise the knee gatch on the bed 30°. 4. Instruct the client to remain in the middle of the bed. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) will not prevent client from sliding down; may change pull of traction (2) correct—will keepleg straight and counter the pull of the weights (3) will bend the leg and alter the pull of the traction (4) not effective way of preventing the client from sliding down inbed |
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The nurse reviews charts on a medical/surgical unit. The nurse identifieswhich example is a properly recorded client chief complaint in a nursing healthhistory? |
1. "Complains of midepigastric discomfort with flatus after meals."
2. "Area above umbilicus appears to be painful and tender to palpation." 3. "My stomach hurts after dinner every night." 4. "Rebound tenderness present in mid- to upper-abdominal area." |
Strategy: Think about each answer choice. (1) incorrectly stated (2) objective finding (3) correct—chief complaintshould be recorded using the client's own words (4) objective finding |
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The client comes to the nurse's station for their prescribed antipsychoticmedication. The nurse notes that the client has torticollis, an arched back,and rapid movement of the eyes. Which action should the nurse take FIRST? |
1. Determine what other medications the client is taking.
2. Perform a neurological assessment. 3. Administer haloperidol decanoate IM stat. 4. Administer the PRN trihexyphenidyl IM immediately. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require validation? No. Determine the outcome of each implementation. (1) assessment; demonstrating acute extrapyramidal side effects (2) assessment; no validation required (3) haloperidol is antipsychotic, will exacerbate symptoms (4) correct—administerbenztropine or trihexyphenidyl |
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The home health nurse performs a follow-up visit for the elderly clientreceiving isoniazid 200 mg every day for six months. The nurse is MOST concerned if the client makes which statement? |
1. "I have blurred vision at times."
2. "My legs and knees hurt." 3. "My hands and feet tingle." 4. "I think I had a migraine yesterday." |
Strategy: Determine how each answer choice relates to isoniazid. (1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct—may causeperipheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication |
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During the nursing history interview, a preschool client's mother reportsthat the child has frequent bouts of gastroenteritis. It is MOST importantfor the nurse to ask which question? |
1. "Are there other children in the family?"
2. "Does the child attend a day care center?" 3. "Does the child play with neighborhood children?" 4. "Is the child current on his immunizations?" |
Strategy: Determine why the nurse would make the assessment and howit relates to gastroenteritis. (1) does not pose a problem or solution regarding gastroenteritis (2) correct—environmentswith increased numbers of children (day care) more likely to promote infectionsdue to close living conditions and increased likelihood of disease transmission (3) possible source of infection but not as likely as a day care center (4) does not pose a problem or solution regarding gastroenteritis |
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The nurse cares for the young adult client. The client is scheduledfor the first debridement of a deep partial thickness burn of the left arm.It is MOST important for the nurseto take which action? |
1. Assemble all necessary supplies and medications.
2. Plan adequate time for the dressing change and provide emotional support. 3. Prepare the client and family for the pain the client will experience during and after the procedure. 4. Limit visitation prior to the procedure to reduce stress. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) appropriate but is not a high priority (2) correct—planningfor burn wound treatment should include organizing and planning to spend timenot only on the mechanics of the procedure but also on providing the emotionalsupport necessary for the client (3) appropriate but is not a high priority (4) appropriate but is not a high priority |
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The nurse cares for the client diagnosed with hypovolemia. Which observationshould the nurse identify as the desired response to fluid replacement? |
1. Urine output 160 ml/8 h.
2. Hgb 11 g/L (6.8mmol/L), Hct 33% (0.33 vol frac). 3. Arterial pH 7.34. 4. CVP reading of 8 cm of water pressure. |
Strategy: Determine the significance of each answer choice and how itrelates to hypovolemia. (1) indicates a hypovolemic state (2) indicates a hypervolemic state (3) indicates acidosis (4) correct—normal rangefor CVP is 3–12 cm water pressure; reading of 8 cm water pressure indicatesa desired response to fluid replacement |
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The nurse prepares the client for a lumbar puncture. It is importantthat the nurse makes which statement? |
Select all that apply.
1. "Don't worry because a general anesthetic will be used." 2. "You can't drink fluids for eight hours before the test. 3. "You will remain flat in bed for eight hours after the test." 4. "A compression bandage will be in place for 10 hours after the test." 5. "You may feel discomfort in your leg when the needle is inserted." 6. "You can have analgesics after the procedure if you have a headache." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) general anesthetic is not used (2) fluids are not restricted before the test (3) correct—to preventa post-lumbar puncture headache, client should remain flat in bed for eighthours after the test (4) inappropriate for this procedure (5) correct—nerve endingsmay be touched when performing the procedure. (6) correct—headachesor discomfort may be experienced after the procedure sans pain control canbe provided by analgesics. |
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The emergency room nurse cares for the client demonstrating the followingsymptoms: elevated vital signs, hallucinations, and aggressive behavior. Theclient's friend tells the nurse that the client used hallucinogenic drugs.The nurse should take which action? |
1. Place the client in full restraints.
2. Decrease environmental stimulation. 3. Call the security guards. 4. Administer a PRN dose of chlorpromazine (Thorazine). |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) unnecessary at this time (2) correct—symptomswill subside with time and decreased stimulation (3) unnecessary at this time (4) inappropriate |
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The nurse sees the client with a 25-year history of alcohol abuse inthe outpatient clinic. The client is being treated for chronic cirrhosis.Which symptom suggests to the nurse that the client is in the early stagesof hepatic encephalopathy? |
Select all that apply.
1. The client has a distended abdomen and protruding umbilicus. 2. The client has difficulty describing what he does at work. 3. The client states difficulty sleeping through the night. 4. The client's exhibits asterixis when hands are assessed. 5. The client sleeps 10-12 hours through the day. 6. The client's spouse notes a change in the client's handwriting. |
Strategy: Determine how each answer choice relates to hepatic encephalopathy. (1) ascites is symptom of cirrhosis (2) correct—impairedthought processes is early symptom (3) correct—insomniaand sleep disturbances are signs of grade 0 (4) flapping of the hands after extension is grade 3 and above; is latesymptom (5) lethargy and extended sleep patterns are signs of grade 3; latesigns (6) correct—Writingchanges and hand tremors are grade 0; early signs |
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A 32-year-old multipara is seen in the prenatal clinic. The nurse notesthe client is in her fifth month of pregnancy and has a weight gain of 14lb. The history indicates that prenatally the client was of average heightand weight. The nurse knows which process is the MOST likely? |
1. The client has gained too much weight, and her diet should be re-evaluated.
2. The client has not gained enough weight, and her diet should be re-evaluated. 3. The weight gain is appropriate, and she should continue on her present diet. 4. The weight gain indicates that she may have difficulties later in pregnancy. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) excessive weight gain is >6.6 lb (3 kg)/month (2) inadequate weight gain is <2.2 lb (1 kg)/month (3) correct—weight gain2–5 lb (2.5 kg) first trimester,0.66–1.1 lb (0.5 kg) weekly insecond and third trimester (4) not substantiated by information presented in question |
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The nurse cares for the client currently hospitalized with chronic kidneydisease. The client has 3+ pitting edema of the lower extremities. Which nursingobservation indicates a therapeutic response to therapy for the edema? |
Select all that apply.
1. Serum potassium 4.0 mEq/L (4.0 mmol/L). 2. Plasma glucose 140 mg/dL (7.8 mmol/L). 3. Increased specific gravity of the urine. 4. Weight loss of 5 lb over last two days. 5. Decrease in calf circumference by 2 cm. |
Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to losesome edema fluid (4) correct—edema isa result of sodium and fluid retention; weight loss should occur if therapyis effective (5) correct—edema isa result of sodium and fluid retention; decrease in peripheral circumferenceshould occur if therapy is effective |
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The nurse cares for clients on the surgical floor and has just receivedreport from the previous shift. In which order should the nurse assess theclients? Place the answers in order of priority.All options must be used. |
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Strategy: All the clients are unstable use ABCs and real vs potential (1) See first; Unstable, unexpected, real problem peritonitis, shouldbe assessed for further symptoms of infection (2) See second, Unstable, expected, respiratory, resolution (3) See third; Unstable, expected, circulation, potential (4) See last; Unstable, expected, potential |
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Which behavior by the client should the nurse record to indicate thatthe client is experiencing hallucinations? |
1. The client sits immobilized for long periods of time.
2. The client turns and tilts his head as if talking to someone. 3. The client expresses the belief that the health care provider is out to get him. 4. The client wrings his hands and paces constantly. |
Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct—hallucinationsare sensory perceptions for which there is no external stimulus; this optiondescribes client behavior that would be observed when the client is respondingto voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety |
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The adult client comes to the AIDS clinic for treatment of large, painful,purplish-brown open areas on his right arm and back. The nurse should instructthe client to take which action? |
1. Clean the area carefully with soap and warm water every day, and cover them with a sterile dressing.
2. Soak in a warm tub twice a day, and rub the areas with a washcloth before covering them. 3. Shower daily using a mild antimicrobial soap from a pump dispenser, and leave the lesions uncovered. 4. Clean the lesions twice a day with a diluted solution of povidone-iodine, and leave them open to the air. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—open Kaposi'ssarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infectionbut should be covered because of open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma |
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The nurse knows that which assessment is BEST toindicate relief from abdominal pain for a child who received morphine 1 hourago? |
1. The child states that pain has gone away.
2. The child's heart rate has changed from 80 to 95. 3. The child sleeps except when receiving nursing care. 4. Results from the incentive spirometer have improved. |
Strategy: Think about what the words mean. (1) contains correct information but is not a priority; child coulddeny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct—when painis decreased, child will be better able to breathe deeply and improve theoutcome of use of the incentive spirometer |
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The nurse cares for clients in an acute care facility. The nurse identifieswhich client as a likely candidate for developing acute kidney injury? |
1. A young client with recent ileostomy due to ulcerative colitis.
2. A middle-aged client with elevated temperature and chronic pancreatitis. 3. A teenager in hypovolemic shock following a crushing injury to the chest. 4. Child with compound fracture of the right femur and massive laceration of the left arm. |
Strategy: Determine how each answer choice relates to acute kidney injury. (1) usually ileostomy clients do not experience severe hypovolemia,which would lead to kidney injury problems (2) this type of infection and inflammation does not lead to acute kidneyinjury (3) correct—common causeof acute kidney injury is kidney ischemia precipitated by hypovolemia or heartfailure (4) femoral fractures are more likely to lead to fat embolism than acutekidney injury |
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The nurse prepares an older client for discharge after treatment fordehydration. Which statement, if made by the client to the nurse, indicatesthat further teaching is needed? |
1. "I should weigh myself daily."
2. "I should drink fluids throughout the day." 3. "I can use a measuring cup to find out how much I drink during the day." 4. "I should let my health care provider know if I get dizzy when I change positions." |
Strategy: Determine how each answer choice relates to dehydration. Becareful, this is a negative question. (1) correct—only indicatesoverhydration, not response to dehydration (2) helps prevent recurrence of dehydration, should force fluids to3,000 ml/day (3) good indication of total intake (4) indicates postural hypotension resulting from volume deficit |
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The client is diagnosed with metastatic cancer with a poor prognosis.Recently, the client reports increased pain, is less communicative, very irritable,and anorexic. Which nursing goal should be a priority at this time? |
1. Encourage client to talk about the possibility of dying.
2. Provide pain assessment and effective pain management. 3. Manage nutrition and hydration. 4. Verify that the health care provider has discussed the prognosis with the family. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) will be difficult if client's pain is not adequately controlled (2) correct—comprehensiveand regular pain assessment/management is necessary to facilitate client'sability to maintain comfort, which may enable him to verbalize his feelings (3) important but will be difficult if client's pain is not adequatelycontrolled (4) not highest priority |
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The adult client with a nasogastric tube has an order for acetaminophen650 mg PRN for a temperature greater than 101°F (38.3°C). The nurseshould take action when administering this medication? |
1. The tablets should be swallowed carefully with sips of water.
2. The medication should be withheld until the nasogastric tube is removed. 3. Placement of the nasogastric tube should be checked prior to giving the medication. 4. Powdered medication should be used and mixed with water to form a solution. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) client is NPO, so nothing should be administered orally (2) medication should not be withheld (3) correct—liquid acetaminophenmay be administered via the nasogastric tube after tube placement has beenchecked; tube placement should be checked before anything is instilled (4) acetaminophen does not come powdered |
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The nurse assesses the infant with a repair of a cleft lip and palate.The respiratory assessment reveals that the infant has upper airway congestionand slightly labored respirations. Which nursing action is MOST appropriate? |
1. Elevate the head of the bed.
2. Suction the infant's mouth and nose. 3. Position the infant on one side. 4. Administer oxygen until breathing is easier. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) will not promote adequate drainage from the upper airways (2) contraindicated based on the infant's operative site (3) correct—will facilitatedrainage of mucus from upper airway and will promote adjustment to breathingthrough the nose (4) does not relieve the congestion |
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The nurse cares for the client following a cardiac catheterization.Two hours after the procedure, the nurse checks the client's insertion sitein the antecubital space. The client reports the hand is numb. The nurse shouldtake which action? |
1. Change the position of the client's hand.
2. Check the client's grip strength in both hands. 3. Notify the health care provider. 4. Instruct the client to exercise the fingers. |
Strategy: Answers are a mix of assessments and implementations. Doesthe assessment answer validate what is going on? No. Determine the outcomeof each answer choice. (1) assumes that numbness is related to positioning of hand, not circulatorychanges (2) part of assessment but doesn't indicate status of circulation (3) correct—absent orweak pulse or numbness could indicate problem with circulation, anticoagulantsand vasodilators may be ordered (4) assumes that numbness is related to immobility of fingers, not circulatorychanges |
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The client, gravida 2/para 1, is admitted for induction of labor withoxytocin. It is MOST important forthe nurse to take which action? |
1. Mix oxytocin in D5W, begin at 5 mg/ml as primary IV to gravity flow.
2. Decrease the rate/flow of oxytocin if the fetal heart rate is below 150. 3. Piggyback the oxytocin into the mainline IV, and maintain the flow by gravity. 4. Start an IV line, and piggyback the oxytocin with an infusion pump. |
Strategy: The topic of the question is unstated. Read the answer choicesfor clues. (1) oxytocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct—oxytocinshould always be a secondary infusion controlled by an IV pump |
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A client is admitted with a diagnosis of urinary tract calculi and isexperiencing severe pain. Fentanyl 100 mcg IV is given prior to the changeof shift. Which symptom is most important for the nurse to report to the nextshift? |
1. Nausea with a small amount of vomitus.
2. Pain of 5 on a scale of 1 to 10. 3. Change in the location and character of pain. 4. No known drug allergies. |
Strategy: Determine how each answer choice relates to urinary tractcalculi. (1) often accompanies pain but is not most important to report to nextshift (2) important but not the highest priority (3) correct—locationof the pain depends on location of urinary tract calculus; character of painchanges depending on location or movement of stone (4) important but not the highest priority |
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The nurse plans discharge for a group of clients. The nurse identifieswhich clients require a referral for home care? |
Select all that apply.
1. A postoperative appendectomy client who reports incisional pain. 2. A newly diagnosed diabetic client who has a vision impairment. 3. A postoperative cholecystectomy that requires steps to get into their apartment. 4. A client with congestive heart failure who underwent diuresis in the hospital. 5. An elderly client with a new right hip replacement who lives with a daughter. |
Strategy: Determine the the need for follow up care. (1) expected outcome, treat with analgesics (2) correct—Follow upon medication administration and ability for self care at home. (3) teach client to limit trips up and down and take stairs slowly (4) correct—assess fordecreased circulating volume, hypotension, tachycardia, monitor for signsand symptoms of hypokalemia (5) correct—the clientwill need assessment in the home for self care; family can help but not fullcare. |
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The nurse plans care for the client hospitalized with bipolar disorder.While the client is in the manic phase, the nursing plan should include whichintervention? |
Select all that apply.
1. Explain procedures in depth. 2. Distract the client with light physical activities 3. Isolate the client until manic phase is resolved 4. Concisely remind the client about the rules. 5. Provide prn medication for all inappropriate behaviors. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) will not be effective in changing behaviors, requires an attentivelistener (2) correct—client experienceshyperactivity, poor concentration, and distractibility ; redirect into activitythat promotes nourishment; are light activity (3) isolation not required, would increase anxiety and hostility (4) correct—clear conciseinformation is appropriate (5) prn medication is a last result and used when physical harm is anticipated. |
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The nurse supervises the staff caring for clients on the medical/surgicalunit. The nurse observes the student nurse enter wearing a gown, gloves, anda mask. The nurse determines that the precautions are correct if the studentnurse is caring for which client? |
1. An infant diagnosed with respiratory syncytial virus.
2. A young child with a wound infected with S. aureus. 3. A teenager diagnosed with toxic shock syndrome. 4. A teenager diagnosed with rubella (German measles). |
Strategy: Determine the precautions required for each disease. (1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct—dropletprecautions used for organisms that can be transmitted by face-to-face contact,door may remain open |
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The health care provider orders metronidazole 250 mg PO tid for sevendays for a client. The nurse instructs the client about the medication. Whichstatement, if made by the client to the nurse, indicates teaching is effective? |
1. "I should take this medication between meals to increase absorption."
2. "I shouldn't drink alcohol while I am taking this medication." 3. "If I experience a metallic taste in my mouth while taking this medication, I should notify my health care provider." 4. "I should avoid strong sunlight while I am taking this medication." |
Strategy: "Teaching is effective" indicates a correct statement. (1) given with meals to decrease gastrointestinal upset (2) correct—causes metronidazole-likereaction of nausea and vomiting, headache, cramps, flushing (3) frequently seen, not a problem (4) sensitivity to sun not seen with this medication |
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The nurse supervises a student nurse obtaining an infant's vital signs.Which action should the student nurse complete FIRST? |
1. Obtain the infant’s temperature.
2. Count respirations for 15 seconds and multiply the number by 4. 3. Count respirations for a minute prior to arousing the infant. 4. Use a stethoscope with a 1.5-inch diaphragm to count the apical pulse. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) count respirations for 1 full minute before taking temperature (2) should count for a full minute (3) correct—respirationsshould be counted for 1 full minute prior to arousing the infant with a temperatureprobe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluationof respirations |
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The nurse determines teaching is effective if the parents of the 4-year-oldchild diagnosed with sickle cell anemia makes which statement? |
Select all that apply.
1. "When my daughter reports pain, I use cold compresses." 2. "I try to keep my daughter away from people with infections." 3. "I sometimes have to give my daughter some of her morphine for pain." 4. "I encourage my daughter to drink a lot of water." 5. "I love to watch my daughter play hard through a whole soccer game." |
Strategy: "Effective teaching" indicates correct knowledge. (1) cold will cause vasoconstriction limiting blood flow (2) correct— importantfor a sickle cell client to prevent sickling crisis (3) correct—reflectsappropriate use of medication to decrease the client's pain (4) correct—importantfor a sickle cell client to prevent sickling crisis (5) frequent rest periods are necessary to prevent deoxygenation withcan precipitate a crisis. |
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An 8-year-old boy falls off the swings at school and hits his head.He is examined by the health care provider at an urgent care center. The clientis diagnosed with a minor head injury, and sent home. Which statement, ifmade by the mother to the nurse, requires further teaching by the nurse? |
1. "He should avoid blowing his nose or cleaning his ears for two days."
2. "I should wake him every three hours tonight and tomorrow night to check him." 3. "I can give him acetaminophen every four hours if he reports a headache." 4. "He will be well enough to play in his soccer game tomorrow." |
Strategy: "Further teaching" indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every threeto four hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct—no strenuousactivity for 48 hours |
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The client receives digoxin 0.25 mg PO qd and furosemide 40 mg PO bid.The client calls the health care provider (HCP) reporting mild diarrhea. TheHCP prescribes bismuth subsalicylate 60 mg after each bowel movement for twodays and instructs the client to call back if symptoms don't subside. Theclient asks the office nurse if there should be any changes to the medicationschedule. The nurse should instruct the client to take which action? |
1. Continue the medication schedule.
2. Wait 1 hour before taking the scheduled medications if the bismuth subsalicylate is taken. 3. Hold the scheduled medications until the diarrhea subsides. 4. Take the digoxin but hold the furosemide if the client takes the bismuth subsalicylate. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) PO meds would be absorbed by bismuth subsalicylate, not by stomach (2) correct—bismuthsubsalicylate absorbs PO meds, separate administration of other meds (3) other meds should be given later (4) both meds should be given later |
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The client comes to the outpatient psychiatric clinic for treatmentof a fear of heights. The nurse identifies which action is the best plan ofcare to meet the needs of this client INITIALLY? |
1. Point out to the client the secondary gain that results from her behavior.
2. Demonstrate to the client the irrational nature of these fears. 3. Encourage the client to rely on significant others for support. 4. Allow the client to avoid the situations that are anxiety provoking. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) secondary gain (attention and assistance received) is not the motivationof a phobic client, remain nonjudgmental (2) ineffective in relieving behavior, may increase anxiety and feelingsof guilt (3) should encourage client to remain independent (4) correct—phobia isfixed channel for discharge of tension from unconscious conflict |
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Which finding indicates to the nurse that the client's Salem sump tube(nasogastric) is functioning effectively? |
1. Fluctuation of the fluid level in the water seal chamber.
2. Active bubbling in the suction bottle. 3. The presence of a hissing sound from the blue lumen tube. 4. A pressure of 25 mm Hg in the esophageal balloon. |
Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct—hissingsound is indicative that air is freely exiting the airway, purpose is to providecontinuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube |
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A client in labor is receiving magnesium sulfate IV. Which assessmentis MOST important to give during the report to the nurses on the next shift? |
1. Respiratory rate changed from 13/minute to 15/minute.
2. Increase in anxiety and hyperactivity. 3. Presence of nausea and refusal to take clear liquids. 4. Urine output decreased from 60 ml/h to 25 ml/h. |
Strategy: Determine how each answer choice relates to magnesium sulfate. (1) not a concern because the respirations are increasing (2) not relevant to the medication (3) not relevant to the medication (4) correct—magnesiumsulfate is a central nervous system depressant; side effect is oliguria |
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The client is seen in the clinic reporting back pain. The nurse discussesand demonstrates how to perform activities of daily living to decrease theincidence of back pain. Which action, if performed by the client, indicatesto the nurse that further teaching is needed? |
Select all that apply.
1. The client bends over to put on and tie her tennis shoes. 2. The client stands on her toes to place a box on the top shelf of a closet. 3. The client sits in a recliner with her feet elevated to watch TV. 4. The client stands with her feet close together and shifts her weight between her feet. 5. The client squats to pick up a spoon on the floor. 6. The client places their right leg on top of the left while reading. |
Strategy: “Teaching is required” indicates an incorrectstatement. (1) correct—causes stresson lumbar region of back (2) correct—causes stresson lower spine (3) provides lumbar flexion, decreasing pressure on lower spine (4) correct—should havefeet apart for wide base of support (5) Decreases stress on the lower back (6) correct—Turns thelower spine causing stress. |
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Which action, if performed by the nurse, is considered negligence? |
1. Obtain a Guthrie blood test on a 4-day-old infant.
2. Massage lotion on the abdomen of a 3-year-old diagnosed with Wilms' tumor. 3. Instruct a 5-year-old asthmatic to blow on a pinwheel. 4. Play kickball with a 10-year-old with juvenile arthritis (JA). |
Strategy: "Is considered negligence" indicates an incorrect action. (1) obtain after ingestion of protein, no later than seven days afterdelivery (2) correct—manipulationof mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise |
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At an inpatient psychiatric unit, a client insists on staying in theroom and repeatedly comments to the nurse, "Special agents are here. Maybeyou are one." Which response, if made by the nurse, is BEST? |
1. "You can trust me. There are no agents here."
2. "You must feel afraid if you believe that, but there are no agents here." 3. "No one here will hurt you. They are here to help you." 4. "Agents? Tell me more about what you mean." |
Strategy: Remember therapeutic communication. (1) nontherapeutic; fails to respond to feeling tone, trust builds throughinteractions (2) correct—client experiencingdelusion (persistent false belief), responds to feeling tone, acknowledgesthat client believes it to be true, represents reality (3) statement of reassurance but denies acceptance of client's feelings (4) should not encourage client to explain delusions, would serve toreinforce them |
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The postoperative client returns to the assigned room from the surgicalrecovery area. The client is sleeping, and the nurse notes that the clientis disoriented when aroused. Which action, if taken by the nurse, is BEST? |
1. Place the call bell within the client's reach.
2. Stay with the client until he is totally oriented. 3. Restrain all four extremities until the client is oriented. 4. Elevate the side rails until the client is fully awake. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) not the safety action (2) unnecessary to stay with the client, especially while he is sleeping (3) restraints are unnecessary at this time (4) correct—side railsshould always be elevated for any disoriented client |
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The nurse cares for the client with deep partial thickness and fullthickness burns. The client receives morphine sulfate 15 mg IV. The nursenotes a decrease in bowel sounds and slight abdominal distention. Which action,if taken by the nurse, is BEST? |
1. Recommend that the morphine dose be decreased.
2. Withhold the pain medication. 3. Administer the medication by another route. 4. Explore alternative pain management techniques. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) could indicate a possible impending ileus; this option is not ideal (2) inappropriate (3) inappropriate (4) correct—morphineis drug of choice for burn pain management; when side effect becomes apparent,exploration of alternative pain management techniques such as visualizationbecomes important |
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The visiting nurse evaluates the progress of the client recently diagnosedwith type 1 diabetes. As part of the treatment plan, the client receives HumulinN 32 units and Humulin R 8 units each morning. Which action, if performedby the client while preparing the morning insulin injection, requires an interventionby the nurse? |
1. After drawing up 8 units of Humulin R, the client adds Humulin N to the syringe for a total of 40 units.
2. The client draws up 32 units of the clear insulin followed by 8 units of cloudy insulin for a total of 40 units. 3. Initially, the client injects air into the Humulin N vial without drawing up any insulin. 4. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) clear insulin always drawn up first (2) correct—HumulinR is clear and drawn up first, only 8 units are ordered; Humulin N is cloudy (3) allows you to withdraw medication later (4) allows you to withdraw medication later |
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The visiting nurse evaluates the progress of the client recently diagnosedwith type 1 diabetes. As part of the treatment plan, the client receives HumulinN 32 units and Humulin R 8 units each morning. Which action, if performedby the client while preparing the morning insulin injection, requires an interventionby the nurse? |
Select all that apply.
1. After drawing up 8 units of Humulin R, the client adds Humulin N to the syringe for a total of 40 units. 2. The client draws up 32 units of the Humulin N insulin first. 3. The client injects air into the Humulin N vial then draws up 32 units. 4. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn. 5. After drawing up the Humulin N the client injects air into the Humulin R vial. 6. The client cleans the vials with a new alcohol wipe. |
Strategy: Requires an intervention indicates an incorrect action. Determinethe outcome of each answer choice. Is it correct? (1) clear insulin always drawn up first; this is a correct action (2) correct—HumulinR is clear and drawn up first, only 8 units are ordered; Humulin N is cloudy (3) correct—After injectingair the client should withdraw the syringe to inject air in tot he other vial. (4) allows you to withdraw medication later (5) correct—air is injectedbefore withdrawing the other insulin. (6) This is a correct action. |
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The clinic nurse obtains a throat culture from the client diagnosedwith pharyngitis. It is MOST important for the nurse to take which action? |
1. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
2. Obtain a sputum container for the client to use. 3. Irrigate with warm saline, and then swab the pharynx. 4. Hyperextend the client's head and neck for the procedure. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—tonsillarand pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended |
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A mother brings her 7-year-old daughter to the outpatient clinic fora routine check-up. The girl weighs 50.25 lb (22.85 kg) and is 48 inches (121.7cm) tall. The nurse notes that the child has gained 2.5 lb and grown 3 inchesin the past year. Which of the following responses by the nurse is BEST? |
1. "Your daughter's height and weight are within normal limits."
2. "Your daughter's height is normal, but she needs to gain some weight." 3. "Your daughter's height is normal, but she needs to lose some weight." 4. "Your daughter's weight is normal, but she is shorter than normal." |
Strategy: "BEST" indicates discrimination is required. The topic ofthe question is unstated. Read answer choice to obtain clues. (1) correct—betweenages 6–12, children grow about 2 inches (5 cm)/year and gain 4.5–6.5lb (2–3kg)/year; at age 7 average 39–66.5 lb (17.7–30 kg)and 44–51 inches (111.8–129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits |
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During the first 24 hours after parenteral nutrition (PN) therapy isstarted, the nurse should take which action? |
1. Monitor vital signs every two hours.
2. Determine urinalysis results. 3. Evaluate blood glucose levels. 4. Compare weight with the previous readings. |
Strategy: Determine how each assessment relates to PN. (1) not necessary to do every 2 hours; every 4 hours is appropriateaction (2) important but not the priority (3) correct— parenteralnutrition (PN), or hyperalimentation, has a high glucose content; importantto monitor glucose levels (4) appropriate but not a priority |
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The nurse cares for the elderly client recovering from a fractured pelvis.The client's activity order reads: "ambulate with walker bid." After the nurseimplements the order, which charting entry is BEST? |
1. "Client ambulated well with walker. States has no stiffness or pain. Did not appear fatigued."
2. "Ambulated without difficulty for 20 minutes. Vital signs remained stable. Color good." 3. "Walked full length of hall with walker. No difficulty with balance. Using walker correctly." 4. "Client ambulated 60 ft independently with walker. Gait steady. Respirations 14 and unlabored." |
Strategy: Think about what the words means in each answer. (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objectiveinformation (4) correct—gives objectiveinformation |
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A client is brought into the emergency room for treatment of a suspecteddrug overdose. The client appears to be highly agitated, fearful, and maybe hallucinating. Which action should the nurse take FIRST? |
1. Offer immediate support from family and friends who accompanied her.
2. Greet the client with a warm, friendly approach. 3. Place the client in a quiet, darkened room. 4. Make an immediate referral to a social service agency. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) inappropriate at this time because the client is not in contactwith reality (2) may agitate the client further (3) correct—sensorystimulation would only increase agitation and could potentially lead to aggressivebehavior and injury (4) not the priority at this time |
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The nurse receives a phone call from the nursing assistive personnelwho states that her 5-year-old child has developed chickenpox. It would be MOST important for the nurse to ask whichquestion? |
1. "Have your other children had chickenpox?"
2. "Does your child have a temperature?" 3. "Have you had the chickenpox?" 4. "Do you have someone to watch your child?" |
Strategy: "MOST important" indicates there may be more than one answerthat you would like to select. Remember, you can only ask one question. (1) chickenpox spread by direct contact, airborne route; not the mostimportant question (2) fever, malaise, and anorexia occur during first 24 hours; treatwith Tylenol (3) correct—need toascertain if staff has had the disease; if not, VZIG can be given; excludefrom client care from the 10th day after first exposure through the 21st day(28th day if VZIG given) after last exposure (4) important information, but assessing staff is most important |
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Butorphanol tartrate 1 mg IM is ordered for the woman 1 day postpartum.Which action is MOST important for the nurse to take after administering themedication? |
1. Observe the woman for sedation.
2. Monitor the vital signs. 3. Assess for visual disturbances. 4. Evaluate fluid status. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—Guthrieblood test evaluates neonate for phenylketonuria (PKU); Lofenalac formulais low in phenylalanine but contains minerals and vitamins to provide a balancednutritional formula (2) fat source found in some formulas (3) important but is not as high a priority as answer choice 1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD) |
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The nurse knows that which action would be a priority for the infantwith a positive PKU blood test? |
1. Place the infant on Lofenalac formula.
2. Administer medium-chain triglyceride (MCT) oil with each feeding. 3. Provide genetic counseling for the family. 4. Place the infant on Lorenzo's Oil treatments. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—Guthrieblood test evaluates neonate for phenylketonuria (PKU); Lofenalac formulais low in phenylalanine but contains minerals and vitamins to provide a balancednutritional formula (2) fat source found in some formulas (3) important but is not as high a priority as answer choice 1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD) |
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The nurse conducts preoperative teaching with the family of a clientscheduled for a total laryngectomy. Which statement, if made by the family,indicates to the nurse a need for further teaching? |
Select all that apply.
1. "We will need to learn other ways to communicate with each other." 2. "My husband will require a feeding tube for several months." 3. "My father will require a special kind of tube in his neck for his airway." 4. "Dad may develop some difficulty with taste and smell after the surgery." 5. “Dad is looking forward to learning how to laugh using tracheoesophageal puncture.” 6. “We will encourage Dad to cough and deep breathe after surgery.” |
Strategy: "Further teaching is necessary" indicates incorrect responses. (1) will communicate in writing initially, then by artificial larynxor esophageal speech (2) correct—requiresnutritional support for 10 days until wound heals, then gradually resumesoral intake (3) will require laryngectomy tube to prevent scar tissue contracture (4) common with total laryngectomy (5) correct—will notbe able to sing, whistle, or laugh using laryngeal communication (6) appropriate action |
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The nurse sees a client in the emergency department in severe emotionaldistress. The client’s respirations are 42/minute, and the blood gasesreveal a pH of 7.5 and a PaCO2 of 34. Initially, thenurse should take which action? |
1. Instruct the client to breathe into a paper bag.
2. Start an IV of D5W. 3. Administer oxygen. 4. Place the client’s head between his knees. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—becauseof hyperventilation, client is in alkalosis; having him rebreathe his owncarbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint |
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The nurse cares for the client twenty-four hours after abdominal surgery.Which action is a PRIORITY for thenurse to prevent complications of flatulence? |
1. Encourage the client to drink carbonated beverages daily.
2. Instruct the client to turn from side to side. 3. Encourage the client to do leg exercises in bed. 4. Assist the client to walk in the hall every two hours. |
Strategy: Answers are all implementations. Determine the outcome ofeach answer choice. Is it desired? (1) increasing carbonated beverages will increase flatus (2) will prevent postoperative complications but not flatulence (3) does not address flatulence (4) correct—will increaseperistalsis, decreasing the development of flatus |
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The nurse cares for the client in the outpatient clinic. The clientis seen for treatment of hypertension. The client expresses concern to thenurse that the spouse has been unemployed for more than six months. The clientis afraid that soon they will be unable to pay their rent. Which responseby the nurse is BEST? |
1. "These things always have a way of working themselves out."
2. "It's important for your health that you not worry too much." 3. "You're worried that you won't be able to pay the rent?" 4. "A social worker might be able to help you with this problem." |
Strategy: "BEST" indicates discrimination is required to answer thequestion. Remember therapeutic communication. (1) minimizes client's concerns (2) minimizes client's concerns and places pressure on client to avoidfeelings (3) correct—reflectiveresponse, would encourage discussion of feelings and concerns (4) passing the buck, nontherapeutic |
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The nurse obtains a nursing history from a teenaged client. The clientstates that she drinks "lots" of fluids and still feels thirsty. It is MOST important for the nurse to ask whichquestion? |
1. "Has your weight recently changed?"
2. "What medications do you take?" 3. "Do you have any allergies to food or medication?" 4. "How often do you menstruate?" |
Strategy: Determine how each answer choice relates to the symptoms. (1) correct—excessivethirst and weight loss are two notable symptoms of type 1 diabetes (2) medication can cause thirst; more important to ask about changesin weight (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information |
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The nurse cares for the client after delivery of a 7 lb 10 oz baby boy.The client has decided to bottle-feed her infant. The nurse should encouragethe client to take which action? |
Select all that apply.
1. Use acetaminophen po as directed. 2. Apply cool packs around the outside of each breast. 3. Massage the breasts. 4. Wear a well-supportive bra 24 hours a day. 5. Use the manual breast pump to relieve pressure. 6. Be patient, the milk will resolve in 5-7 days. |
Strategy: encouraged actions are correct actions. Determine the outcomeof each answer choice. Is it desired? (1) correct—will decreasediscomfort and encourage the client to follow treatment plan. (2) correct—will decreasemilk production (3) may be taut due to engorgement; massage would be painful and unnecessary,will encourage milk flow (4) correct—will helpminimize discomfort during period of engorgement; will decrease let down effect (5) will scourge and continue milk production. (6) correct—patienceis required for the natural process to occur. Engorgement usually resolveson it's own in 5-7 days. |
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The client reports chronic constipation to the nurse. The nurse in thehealth care clinic should advise the client to take which action? |
Select all that apply.
1. Reduce intake of highly seasoned foods and fats. 2. Drink 1,000 ml of fluids daily. 3. Increase intake of cereals, fresh fruits, and vegetables. 4. Ask the health care provider to prescribe bisacodyl 5 mg enteric-coated tablets daily. 5. Plan the day to be home around the usual time of defecation. 6. Establish daily exercise pattern. |
Strategy: Recommended action will be correct actions. Determine theoutcome of each answer choice. Is it desired? (1) unnecessary, no effect on constipation (2) normal intake 1,500–2,000 ml, reduced intake causes constipation (3) correct—bulk-formingfoods help with constipation (4) passing the buck, laxatives are a last resort (5) correct—establishinga particular time in the home helps establish bowel routine decreasing constipation. (6) correct—Exerciseaccumulates bowel function decreasing constipation. |
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The nurse cares for clients in the post-anesthesia care unit (PACU).In which order will the nurse assess the clients? Place the answers in order ofpriority. All answers must be used. |
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Strategy: All clients are unstable because they are in the PACU. UseABCs the real vs potential (1) unexpected outcome, airway issue and real. Most unstable. see first. (2) unexpected, breathing issue, real; see second. (3) expected outcome airway location, potential see third. (4) expected finding, circulation/GI, potential. see last. |
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The client admitted with metastatic cancer has received chemotherapyfor three months. Lab values include RBC 3.8 million/mm3 (3.8x1012/L),WBC 3,000/mm3 (3.0 x109/L),Hgb 9.3 g/dL (5.8 mmol/L), platelets 50,000/mm3 (50x 109/L). The nurse expects the client to exhibitwhich symptom? |
1. BP 120/70, pulse 100, respirations 22.
2. Ankle edema and ascites. 3. Flushed face and light stools. 4. Nausea, anorexia, and vomiting. |
Strategy: Determine how each answer choice relates to the situation. (1) correct—increasedpulse and respirations are caused by decreased oxygenation of tissues; normalrespiratory rate 12 - 20 per minute; normal pulse 10 to 100 beats per minute (2) no information to suggest this is provided in the question (3) will be pale due to anemia (4) not related to information provided in the question |
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A health care provider writes an order for an HIV-positive infant toreceive IPV immunization. Which nursing action is most appropriate? |
1. Wear gloves and a gown when administering the immunization.
2. Administer the immunization. 3. Contact the health care provider for clarification of the order. 4. Determine if child has a history of seizures. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) standard precautions required (2) correct—inactivatedpolio (IPV) appropriate; contraindications include anaphylactic reaction toneomycin, streptomycin, or polymyxin B (3) no reason to discuss with health care provider (4) if child had seizure within three days of DTP, evaluate whetherrisks of giving immunization outweigh the benefits |
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The nurse cares for a client receiving amphotericin B 1 mg in 250 mlof D5W IV over a 2-hour period. The nurse is MOST concernedif which is observed? |
1. Blood urea nitrogen (BUN) 7.2 mg/dL (2.6 mmol/L), creatinine 0.9 mg/dL (79.6 mcmol/L).
2. Blood pressure 90/60, reports fever and chills. 3. Reports burning on urination, thirst, and dizziness. 4. Aspartate aminotransferase (AST) 12 U/L, alanine aminotransferase (ALT) 14 U/L, total bilirubin 0.4 mg/dL (6.8 µmol/L). |
Strategy: "MOST concerned" indicates an untoward effect of the medication. (1) normal results, causes renal toxicity, BUN and creatinine wouldbe elevated (2) correct—monitorvital signs every 30 minutes (3) not a side effect fo the medication (4) check liver function studies weekly, notify health care providerif elevated |
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A staff member informs the nurse that the staff member’s 6-year-oldchild has head lice. It is MOST important for the nurse to take which action? |
1. Inspect the staff member's head for louse and nits.
2. Inform the staff member that he cannot care for clients until further notice. 3. Request that the staff member contact his health care provider. 4. Instruct the staff member about how to use Kwell. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. Is there an appropriate assessment?Yes. (1) correct—observefor movement (louse) or small whitish oval specks that adhere to the hairshaft (nits); treat with gamma-benzene hexachloride (Kwell) (2) confirm the presence of lice before excluding from duty; if licepresent, exclude from client care until appropriate treatment has been receivedand shown to be effective (3) should assess first (4) should assess first, apply shampoo to dry hair and work into latherfor four to five minutes |
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A client who attends an outpatient clinic is taking chlorpromazine hydrochloride100 mg tid. The client reports to the nurse that he is sleeping through theday. Which action by the nurse is MOST appropriate? |
1. Contact the health care provider to change the dose to 100 mg BID.
2. Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs. 3. Instruct the man to take frequent naps during the day. 4. Encourage the man to be more active during the day. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) 300–400 mg/day is needed to treat psychosis (2) correct—will reducedaytime sedation (3) won't decrease sedation from medication (4) won't decrease sedation from medication |
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Which is a priority nursing goal in the plan of care for a client diagnosedwith paralysis due to stroke? |
1. Maintain adduction of the affected shoulder.
2. Prevent flexion of the affected extremities. 3. Observe active range of motion (ROM) daily to all extremities. 4. Maintain external rotation of the affected hip. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) to prevent deformities, the nurse needs to prevent adduction ofthe affected shoulder (2) correct—flexor musclesare stronger than extensor muscles (3) client will be unable to perform active ROM, will need assistancefrom nurse (4) to prevent deformities, the nurse needs to prevent external rotationof the hip joint, prevent foot drop (plantar flexion), and place the handin slight supination so that the fingers are barely flexed |
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The health care provider orders an arterial blood gas (ABG) for a clientreceiving oxygen at 6 L/minute. Which information concerning the client isMOST important for the nurse to document on the lab slip that accompaniesthe blood sample? |
1. The client's position in bed and the respiratory rate.
2. The site used to obtain the blood specimen. 3. The use of supplemental oxygen. 4. The client's diagnosis and blood type. |
Strategy: Think about each answer choice and how it relates to bloodgases. (1) unnecessary to document positioning (2) unnecessary to document site used (3) correct—necessaryfor accurate test results (4) unnecessary to document blood type, should document diagnosis |
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Which statement, if made by the parents of a 9-year-old client withan ostomy, indicates to the nurse that the parents are providing quality homecare? |
1. "We change the bag at least once a week, and we carefully inspect the stoma at that time."
2. "We change the bag every day so that we can inspect the stoma and the skin." 3. "We encourage our daughter to watch TV while we change her ostomy bag." 4. "We only have to change the ostomy bag every 10 days." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—ostomy bagsshould be changed at least once a week; good time for stoma to be closelyinspected (2) bag should be changed at least once a week or when seal around stomais loose or leaking (3) does not encourage client participation or foster independence (4) bag should be changed more often |
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The nurse cares for a client after a bronchoscopy. The nurse is MOST concerned if which finding was observed? |
1. Depressed gag reflex.
2. Sputum streaked with blood. 3. Tachypnea. 4. Complaints of a sore throat. |
Strategy: "MOST concerned" indicates a complication. (1) would cause a complication if client is given fluids before thegag reflex has returned (2) common for a few days after a biopsy (3) correct—client shouldbe assessed for symptoms of respiratory distress from swelling due to theprocedure; signs of respiratory distress include tachypnea, tachycardia, respiratorystridor, and retractions (4) expected after this procedure |
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The nurse cares for the 8-month-old client. Which observation tellsthe nurse the client is in pain? |
Select all that apply.
1. Decreased pulse rate. 2. Increased fluid intake. 3. Decreased respiratory rate. 4. Rubbing a body part and crying. 5. Eyes closed tightly. 6. Pushes away painful nurses hands. |
Strategy: Think about each assessment. (1) pulse rate would increase (2) nonspecific regarding pain (3) does not reflect pain (4) correct—becausean infant cannot talk, nurse needs to be aware of nonverbal signs of pain,such as rubbing the ear because of an earache (5) correct—Facial expressionare used by the young infant. brows lowered and mouth opened are others (6) This is something a young child would do not a 8 month old. |
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The client is placed on cephalexin monohydrate prophylactically aftersurgery. Which foods should the nurse encourage? |
Select all that apply.
1. Bran cereals. 2. Egg whites. 3. Yogurt. 4. Fish. 5. Acidophilus milk. |
Strategy: The topic of the question unstated. Read the answer choicesfor clues. (1) unnecessary to encourage (2) unnecessary to encourage (3) correct—this foodwill help maintain normal intestinal flora, which may be altered by the cephalexin (4) unnecessary to encourage (5) correct—this foodwill help maintain normal intestinal flora, which may be altered by the cephalexin |
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The home care nurse is scheduling clients for the day. Which clientshould the nurse visit FIRST? |
1. A primigravida client, 10 days postpartum, is anxious about caring for her newborn.
2. A middle-aged client, six days postoperative, reports pain in the midsternal incision. 3. A client with AIDS who had a chest tube removed yesterday and reports crackling under his skin. 4. A client receiving amiloride hydrochloride who reports dizziness when arising in the morning. |
Strategy: Identify the least stable client by eliminating the more stableclients. (1) psychosocial need, physical issues take priority (2) complaints require follow-up, but not the most unstable client (3) correct—describessubcutaneous emphysema, which is indication of pneumothorax; observe clientfor respiratory distress, contact health care provider (4) postural hypotension a side effect of diuretic therapy, change positionslowly |
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The nurse enters the room of a client and finds that the tracheostomytube inserted two days ago has been accidentally dislodged. The nurse shouldtake which action? |
1. Immediately replace the tracheostomy tube.
2. Suction the client's airway using sterile technique. 3. Provide oxygen at 8 L/minute per mask over the stoma. 4. Check for bilateral breath sounds immediately. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require validation? No. Determine the outcome of the implementations.Remember ABCs. (1) correct—implementation;will secure the airway (2) implementation; will not provide for open airway (3) implementation; will not help with open airway (4) assessment; should be done after tracheostomy tube is replaced |
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The nurse performs the physical examination on the newborn. Which nursingassessments should be reported to the health care provider? |
Select all that apply.
1. Head circumference of 40 cm. 2. Chest circumference of 32 cm. 3. Circumoral cyanosis 4. Heart rate 160. 5. Respirations 80. 6. Edema of the scalp |
Strategy: Determine if the assessment is abnormal. (1) correct—averagecircumference of the head for a neonate ranges from 32–36 cm; increasein size may indicate hydrocephaly or increased intracranial pressure (2) normal newborn assessment (3) correct—cyanosisof the mucous membranes may be an indication of hypoxia. (4) normal newborn assessment (5) correct—Normal respiratoryrates are between 30-60 bpm (6) normal finding due to delivery. |
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The nurse cares for the client receiving dopamine hydrochloride at 4mcg/kg/minute. The nurse determines the client weighs 64 kg. The nurse usesa dopamine mixture of 1.6mg/mL. The nurse should set the IV pump at whichrate? |
1 |
First determine the required mcg/kg/min 64kg × 4 mcg/kg/min = 256 mcg/min Next determine how many mcg/mL are in the premixed IV solution. 1.6 mg/ml × 1000 = 1600mcg/mL 1600 mcg/1 mL = 256 mcg/X X = 0.16 mL/min 0.16 mL/min × 60 minutes = 9.6 mL/hour or 10 mL/hr |
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Which action, if performed by the nurse, is considered negligence? |
1. The nurse performs range-of-motion (ROM) exercises for a client with deep partial thickness and full thickness burns of the chest.
2. The nurse sits with a client who suffers from depression while he eats his lunch. 3. The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide PO at 7:45 AM. 4. The nurse instructs a 15-year-old girl who is sexually active about different types of contraceptives without consulting her parents. |
Strategy: "Negligence" indicates an incorrect action. (1) minimizes muscle atrophy (2) promotes eating, offer more frequent feedings of favorite foods (3) correct—delay inmedication may cause difficulty in swallowing, might have difficulty takingmedication (4) minor can request birth control without the parent's consent |
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The nurse cares for an elderly client following a right total hip replacement.The nurse's notes indicate that since the surgery, the client has become disorientedand confused at night. One evening as the nurse prepares the client for sleep,the client glances to his left and says, "Oh, you think so?" and starts tolaugh. Which response by the nurse is the BEST? |
1. "Do you hear voices talking to you?"
2. "Tell me why you are laughing so I can laugh too." 3. "What is it that you find amusing?" 4. "I notice you're laughing." |
Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspecta hallucination (3) confrontation would block communication (4) correct—reflectswhat behavior nurse is observing; offers client opportunity to communicate |
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A client is scheduled for a cardiac catheterization at 0800. The client’slaboratory work was completed five days ago, and the results include K+ 3.0mEq/L (3.0 mmol/L), Na+ 148 mEq/L (148 mmol/L),glucose 178 mg/dL (9.9mmol/L). The client reports of muscle weakness and cramps.Which action by the nurse is BEST? |
1. Administer the 0700 dose of spironolactone.
2. Encourage eating bananas for breakfast. 3. Obtain stat K+ level. 4. Call for 12-lead EKG. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) spironolactone is potassium-sparing diuretic and is an oral medication,client is NPO for procedure (2) is not feasible prior to the cardiac cath because the client isNPO (3) correct—signs andsymptoms are indicative of hypokalemia; stat serum K+ levelis needed to confirm the K+ level prior to goingfor cardiac catheterization (4) is unnecessary at this time |
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A client has a chest tube inserted for treatment of a hemothorax. Whichfinding indicates to the nurse that there is a problem with the effectivefunctioning of the chest tube? |
1. Fifteen centimeters of water is present in the suction control chamber.
2. Constant bubbling is observed in the water seal chamber. 3. Two centimeters of water is present in the water seal chamber. 4. Clots of blood are observed in the collection chamber. |
Strategy: Think about each answer choice. (1) appropriate, regulates the amount of suction delivered to the client (2) correct—would indicatean air leak, would not allow negative pressure to be re-established and wouldhinder complete resolution of the pneumothorax (3) appropriate, provides for a water seal (4) would be an expected finding |
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The nurse’s assessment of a disoriented male client reveals thatthe client has a self-care deficit (feeding). Which finding indicates to thenurse that the client has made a positive response to the plan of care? |
1. Client explains the relationship between weight loss and change in mental status.
2. Client identifies the basic four food groups. 3. Client states that he needs to drink more water. 4. Client feeds self when the nurse stays with him and cues him. |
Strategy: Determine the outcome of each answer choice. (1) not realistic in a client who is disoriented (2) not realistic in a client who is disoriented (3) not realistic in a client who is disoriented (4) correct—disorientedclient who is not able to be an independent self-care agent will need cueingfrom the nurse to accomplish self-feeding |
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The nurse instructs the client with newly diagnosed type 1 diabetesabout proper foot care. Which statement, if made by the client to the nurse,indicates that further teaching is necessary? |
Select all that apply.
1. "I should cut my toenails straight across." 2. "I love to go barefoot." 3. "I should inspect my feet once a week." 4. "I should bathe my feet daily in warm water." 5. "I can keep using my heating pad on my feet." 6. "I am going to buy some warm socks." |
Strategy: "Further teaching" indicates an incorrect response. (1) prevents ingrown nails (2) correct—feet shouldbe protected by footwear (3) correct—should inspectfeet daily for blisters, sores, ingrown nails, and cuts (4) proper care (5) correct—extremesof temperature are dangerous for the diabetic foot. (6) Keeping the feet warm is a correct action. |
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The labor and delivery nurse begins the admission procedure for a clientwho is at 38 weeks’ gestation and is diagnosed with gestational hypertension.Which is the priority nursing action? |
1. Start an IV.
2. Obtain the vital signs. 3. Administer magnesium sulfate. 4. Notify the lab to draw blood. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. Is there an appropriate assessment?Yes. (1) implementation; not a priority action (2) correct—assessment;important to do a baseline assessment in order to successfully evaluate thetreatment (3) implementation; not a priority action (4) implementation; not a priority action |
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An elderly client is oriented during the day but becomes disorientedduring the evening. Which nursing action is MOSTappropriate? |
1. Place a large clock where the client can see it.
2. Place a vest restraint on the client during the evening. 3. Encourage the client to take a nap during the afternoon. 4. Install nightlights in client's room and bathroom. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) will provide visual cues, but safety is more important (2) should be applied as a last resort (3) disorientation due to cognitive dysfunction (4) correct—adequatelighting will help ensure safety |
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The nurse cares for clients in the diabetic clinic. In which order shouldthe nurse see the clients? Place the answers in order of priority.All answers must be used. |
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Strategy: Determine the least stable client then keep finding the leaststable. (1) See first- Unstable, unexpected, Circulatory. Real, indicates diabeticketoacidosis; treat with normal saline and regular insulin (2) See second: Unstable, unexpected, Glucose Real; suggestive of hyperglycemia;should assess blood sugar (3) See third, Stable, expected, real: suggestive of intermittent claudication;not an emergency situation (4) See last; psychosocial; ; physical takes priority |
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A client is admitted with the following symptoms: dependent pittingedema, abdominal distention, and a recent 10-lb weight gain. The client receives80 mg of furosemide. Which nursing observation is MOST importantto report to the next shift? |
1. Reports of nausea and vomiting.
2. Urine output of 200 ml in two hours. 3. Quiet and withdrawn behavior after lunch. 4. Blood pressure changes from 160/90 to 150/90. |
Strategy: The topic of the question is unstated. Read the answers forclues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct—furosemideis diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss but is not a priority overanswer choice 2 |
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A 3-year-old boy was shown to have delays on the Denver DevelopmentScreening Test (DDST). The mother asks the nurse, "Does this mean my childis going to be slow?" Which response by the nurse is BEST? |
1. "Maybe he is just having a bad day. I'm sure he will do much better next time."
2. "The test indicated a delay, and we will have to investigate to learn more." 3. "What are your thoughts about how your child performed on the test?" 4. "The results may not be accurate. Let's set up a time to retest your child." |
Strategy: "BEST" indicates that discrimination is required. The topicof the questions is unstated. Determine topic by reading the answer choices. (1) nontherapeutic; false reassurance (2) factual but closed communication (3) correct—open ended,encourages discussion (4) doesn't encourage discussion of concerns |
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At 11:00 the client returned to the nursing unit from the postanesthesiacare unit (PACU) following a bowel resection. At 12:00 the client reportspain. The health care provider ordered fentanyl 100 mcg IV q 3-4 hours. Thechart indicates that the client was given fentanyl 100 mcg IV at 09:15. Whichaction by the nurse is most appropriate? |
1. Ask the health care provider if the dosage of fentanyl can be increased.
2. Give the client fentanyl 50 mcg IV now. 3. Inform the client the next dose of fentanyl will be given at 13:00. 4. Give the client fentanyl 100 mcg IV now. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) no reason to call the health care provider (2) can't change amount of medication ordered by health care provider (3) medication is ordered every three to four hours, should not waitif client needs medication after three hours (4) correct—give clientthe medication as ordered |
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The clinic nurse is giving instructions to the family of a school-agedchild diagnosed two weeks ago with hepatitis A. The family asks if the childcan return to school. Which response by the nurse is BEST? |
1. "You must isolate your child at home for two more weeks."
2. "Why don't you speak with the health care provider about this matter?" 3. "Your child may return to school this week." 4. "Your child may return to school in two weeks but cannot participate in sports." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) communicable for two to three weeks before onset of jaundice andabout 1 week after onset of jaundice (2) passing the buck (3) correct—type A hepatitisis not infectious within a week or so after the onset of jaundice; child canreturn to school (4) can return to school, activity at that time depends on the child'senergy level |
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Which finding indicates to the nurse that a client experiencing alcoholwithdrawal is in need of more sedation to control the severity of withdrawalsymptoms? |
1. Increasing lethargy.
2. Uncoordinated motor movements. 3. Elevated pulse rate. 4. Improved orientation to time and place. |
Strategy: Determine the significance of each answer choice and how itrelates to alcohol withdrawal. (1) would indicate a need for less sedation and a thorough physicalassessment (2) suggests neurological trauma or damage (3) correct—pulse rateis a good indicator of client's progress through withdrawal, increasinglyelevated pulse signals impending alcohol withdrawal delirium, requiring moresedation (4) suggests that the client is improving and will subsequently requireless sedation |
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A client developed diabetes insipidus following a craniotomy. The nurseprovides discharge instructions for the client and spouse. Which statement,if made by the client, indicates to the nurse that further teaching is needed? |
1. "I should keep a daily record of my fluid intake and how much I go to the bathroom."
2. "I should call my health care provider if I seem thirsty a lot and my urine specific gravity is less than 1.005." 3. "I should weigh myself every day and drink less fluid if I gain more than 5 lb over a week." 4. "I will need to take the nose spray medication for the rest of my life." |
Strategy: "Further teaching" indicates an incorrect response. (1) disorder or water metabolism caused by deficiency of ADH (antidiuretichormone) by pituitary gland, symptoms are increased urinary output (4–30L/24 hours), dilute urine with specific gravity less than 1.005 (2) normal specific gravity 1.010–1.030 (3) correct—weight gainshould be reported to health care provider, may need medication adjusted (4) desmopressin (DDAVP) nasally or SQ required for remainder of life |
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During the physical assessment, the nurse determines the need to performthe bulge test. Which statement, if made by the nurse, is BEST? |
1. "Please lie down and extend your legs."
2. "Please bend over and touch your toes." 3. "Please hold both hands behind your back." 4. "Please bend your elbow." |
Strategy: Think about each answer choice. (1) correct—bulge testconfirms presence of fluid in the knee; client's leg should be extended andsupported on the bed (2) observing curve of spine; scoliosis will cause lateral curve inthe spine (3) unrelated to knee examination (4) tests articulation of elbow |
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The nurse performs a routine IV tubing change on a client with a centralline. Fifteen minutes later, the nurse re-enters the client's room to findthe client cyanotic, short of breath, and reporting of pain. The client'svital signs are BP 84/62, pulse 112, respirations 18. What is the FIRSTaction the nurse should take? |
1. Call the health care provider to report the client's symptoms.
2. Lower the head of the bed and place the client on the left side. 3. Place the client in high Fowler's position. 4. Start oxygen at 4 L/minute via nasal cannula. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) second action, first should respond to potential problem of emboli (2) correct—air willrise to right atrium, minimizes chance of air bubbles entering pulmonary circulation (3) never done with shock, trapped air could travel to pulmonary circulation (4) not first action |
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Which should be the nursing priority for an infant admitted to the pediatricunit with possible Haemophilus influenzae meningitis? |
1. Encourage intake of oral fluids to prevent dehydration.
2. Restrain the child appropriately to maintain the integrity of the IV site. 3. Place the child on droplet precautions. 4. Encourage the parents to hold and rock the infant to promote comfort. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) fluid requirements are determined by child's hydration status; fluidsare usually limited to prevent cerebral edema (2) not a priority (3) correct—to preventspread of infection, child is placed on droplet precautions for at least 24hours after implementation of antibiotic therapy (4) would cause discomfort to infant's head |
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The nurse cares for a client who has overdosed on a large quantity ofdiazepam. Which nursing action should take priority during the first severaldays of this client's inpatient treatment? |
1. Complete a full psychiatric assessment.
2. Contact client's family to involve them in treatment. 3. Observe and record vital signs frequently, including neurological symptoms. 4. Determine whether this client may need long-term therapy after this hospitalization. |
Strategy: Think "Maslow". (1) psychosocial, can be done after the client has been medically stabilized (2) psychosocial, can be done after the client has been medically stabilized (3) correct—physical,because of potentially life-threatening complications of depressant overdosesuch as respiratory failure, pulmonary edema, and seizures, nurse's priorityis observation and documentation of vital signs (4) psychosocial, can be done after the client has been medically stabilized |
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During the second session of individual therapy, a client sits quietlywith arms folded and eyes cast down. Which statement by the nurse is BEST? |
1. "What is the weather like outside?"
2. "Do you not want to talk with me today?" 3. "Are you cold sitting here?" 4. "You seem to be feeling sad today." |
Strategy: "BEST" indicates that this is a priority question. Remembertherapeutic communication. (1) is used to get client comfortable but would not help focus on whatis important (2) focusing on client's difficulty speaking may make him defensiveand block communication (3) concrete questions will encourage client to give yes/no answers,factual answers may block communication of feelings (4) correct—reflectionallows client to verbalize feelings |
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The nurse performs in-service education about the use of the defibrillator.It is MOST important for the nurseto make which statement? |
1. "Do not touch the bed when using the defibrillator."
2. "Check the defibrillator every 24 hours." 3. "Do not leave the defibrillator plugged in." 4. "Do not place the paddles over the electrodes." |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—is a priorityto prevent accidental countershock (2) equipment should be checked every eight hours (3) equipment should remain plugged in at all times (4) is not a priority; although this should not occur, it can be safelydone |
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A 4-year-old comes to the outpatient clinic for a routine exam. Thechild’s mother is concerned because the child often talks to an "imaginarybest friend." The nurse should advise the mother to take which action? |
1. Insist the child play more often with other children.
2. Tell her child that this friend is not a real person. 3. Allow the child to engage in imaginary play. 4. Encourage the child to explain the friend to her. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) doesn't recognize play with imaginary friends as normal developmentalstate (2) may create anxiety in child (3) correct—normal for4- to 6-year-old children (4) may create anxiety in child |
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The nurse cares for a client diagnosed with hyperthyroidism. Which action,if taken by the nurse, is BEST? |
1. Provide the client with extra blankets.
2. Instill artificial tears PRN. 3. Offer the client reading material. 4. Offer frequent low-calorie snacks. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct—clientswith hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmicdrops on a regular basis (3) should provide a calm, restful environment with low levels of sensorystimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie |
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The nurse has just received report from the previous shift. Which clientshould the nurse see FIRST? |
1. An elderly woman, eight hours postoperative, following an open-reduction and internal fixation of the right hip.
2. An elderly man admitted four hours ago with status asthmaticus. 3. A middle-aged man admitted two days ago with pneumonia that has a temperature of 101.2°F (38.4°C). 4. A middle-aged woman who suffered a myocardial infarction (MI) three days ago. |
Strategy: Determine the least stable client. (1) leg needs to be abducted at all times, ice to operative site, turnclient as ordered (2) correct—life-threateningcondition which can last longer than 24 hours, constantly monitor client (3) requires follow-up, assess breath sounds (4) monitor vital signs, I and O, teach to modify lifestyle (stop smoking,reduce stress, modify intake of calories, fat, and salt) |
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In planning care for a client with signs of increased intracranial pressure(ICP), the nurse should include which implementation? |
1. Encourage coughing and deep breathing to prevent pneumonia.
2. Suction the airway every two hours to remove secretions. 3. Position the client in the prone position to promote venous return. 4. Determine cough reflex and ability to swallow prior to administering PO fluids. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15–30° to promote venousdrainage (4) correct—assessment,cough or gag reflex and the swallowing reflex may be affected by the increasedpressure; increases the incidence of aspiration |
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While doing a physical examination of a 1-year-old child, which assessmentshould be completed by the nurse LAST? |
1. Examine infant’s ears.
2. Auscultate the breath sounds. 3. Auscultate the apical heart rate. 4. Evaluate motor functions. |
Strategy: Picture the situation. (1) correct—all invasiveprocedures (eyes, ears, mouth) should be done last, so as not to alter cardiopulmonaryassessment of the child (2) auscultate while child is quiet (3) auscultate heart, lungs, abdomen, and then palpate and percuss (4) elicit reflexes as body part examined |
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A client returns from surgery with a Jackson-Pratt drain in place. Thenurse observes a student nurse perform a dressing change for the client. Whichactivity, if performed by the student nurse, requires an intervention by thenurse? |
1. Documents the amount and character of the drainage in the client's chart.
2. Attaches the drain to the top sheet on the bed. 3. Empties the reservoir of the drain. 4. Records the amount of drainage on the output sheet. |
Strategy: "Require an intervention" indicates an incorrect response. (1) drains used to prevent wound infections and abscess formation (2) correct—drain shouldbe attached to client's gown or pajamas, never to the sheet or mattress (3) Jackson-Pratt drain is a self-contained suction device that is emptiedas needed (4) important to monitor output |
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An unaccompanied client at 24 weeks’ gestation is admitted tothe nursing unit with vaginal bleeding. Which comment, if made by the client,indicates to the nurse the need to assess the adequacy of the client's emotionalsupport? |
1. "My husband will be so angry with me if I lose this baby."
2. "I'm afraid I am going to lose my baby." 3. "I can't stay here. I don't have any insurance." 4. "I feel so guilty. I didn't want to get pregnant." |
Strategy: Think about what the words mean. (1) correct—client'sconcern about her husband's feelings indicates that he may not be able tosupport her emotionally at this time (2) reflects a reality-based concern (3) indicates an economic concern (4) indicates client needs to talk about her current feelings; doesnot give any indication of level of emotional support |
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When the nurse assesses the incision of a client two days after surgery,a shiny, pink, open area is noted with the underlying bowel visible. Whichaction should the nurse take FIRST? |
1. Cover the open area with sterile gauze soaked in normal saline.
2. Reapply a sterile dressing after cleaning the incision with hydrogen peroxide. 3. Pack the opened area with sterile 0.75-inch gauze soaked in normal saline. 4. Apply Neosporin ointment and cover the incision with Tegaderm dressing. |
Strategy: All answers are implementation. Determine the outcome of eachanswer. Is it desired? (1) correct—eviscerationis treated immediately by application of sterile gauze soaked in sterile normalsaline, followed by notification of health care provider (2) wounds are not cleansed with peroxide (3) there is not an order to pack the wound (4) not a sterile procedure |
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The nurse cares for a newborn to be discharged in the morning. The nurseshould instruct the child's mother to perform which action? |
1. Apply a sterile gauze dressing with petroleum jelly to the cord.
2. Position the diaper over the umbilicus to keep it dry. 3. Clean the cord several times a day, and expose it to air frequently. 4. Apply erythromycin ointment to the cord several times a day. |
Strategy: The topic of the question is unstated. Read the answer choicesfor clues. (1) appropriate for circumcision (2) will keep the area moist; the diaper should be placed below theumbilicus (3) correct—encouragesdrying and helps prevent infection (4) antibiotic ointment is unnecessary |
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A client is transferred from a nursing home to the hospital with anindwelling urinary catheter. The urine appears cloudy and foul-smelling. Whichnursing measure is MOST appropriate? |
1. Clean the urinary meatus every other day.
2. Encourage the client to increase fluid intake. 3. Empty the drainage bag every two to four hours. 4. Irrigate the Foley catheter every eight hours. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) does not address the problem of the client's urine, should not beperformed (2) correct—increasingintake of fluids is an appropriate independent nursing action that facilitatesremoval of concentrated urine (3) does not address the problem of the client's urine, should not beperformed (4) could increase the chance of developing an infection |
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The nurse has just returned to the desk and has four phone messagesto return. Which message should the nurse return FIRST? |
1. A man with swelling of his left wrist following a fall from a ladder two hours ago.
2. A woman who had a cholecystectomy one week ago and now reports of redness and tenderness at the incision site. 3. A mother of a child reports that her son's lips are swollen following a fire ant bite. 4. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101°F (38.4°C). |
Strategy: Remember the ABCs. (1) wrist needs to be x-rayed, not a priority (2) indicates infection, treated with antibiotic (3) correct—potentialanaphylactic reaction, administer epinephrine, corticosteroids; treat forshock (4) indicates infection, treat with antibiotic |
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The nurse cares for a client diagnosed with pneumonia. Which observationindicates a therapeutic response to the treatment? |
1. Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough.
2. Cough, productive of thick, green sputum, client reports feeling tired. 3. Respirations at 20 with moderate amount of thin, white sputum, denies dyspnea. 4. White cell count of 10,000 mm3, urine output at 40 ml/hour, decreasing amount of sputum. |
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When preparing discharge plans for a client being treated for syphilis,it is MOST important for the communityhealth nurse to include which information? |
1. Have sexual activity with one partner.
2. The practice of safe sex. 3. Information about Planned Parenthood. 4. Signs of a secondary infection. |
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The clinic nurse receives a call from the parent of a 12-year-old childreceiving albuterol. The parent states the child is irritable and reports,"I can feel my heart pounding." Which response by the nurse is MOST appropriate? |
1. Instruct the parent to decrease external stimuli in the child's room.
2. Ask the parent to administer an ordered analgesic. 3. Ask the parent how long the child has been taking the medication. 4. Explain to the parent that this is expected. |
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The nurse is informed that there will be two new admissions to the unit.One of the new admissions is diagnosed with pneumonia, and the other new clientis diagnosed with AIDS. Which assignment is MOST appropriate? |
1. Assign both clients to one room with one nurse caring for both patients.
2. Place both clients in the same room, and assign the care to two different nurses. 3. Assign each client to a private room, and assign both clients to one nurse. 4. Place each client in a private room, and assign each client to a different nurse. |
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The nurse counsels a client who has been abusing alcohol and other drugsfor 6 years. The nursing diagnosis is ineffective individual coping. Whichnursing action should take priority during the working stage of the nurse/clientrelationship? |
1. Observe the client every half hour to determine the extent of drug-seeking behavior.
2. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition. 3. Help the client obtain a sponsor through a 12-step group in the client's local area. 4. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options. |
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The nurse supervises care of a client with a stage III pressure ulcerof the sacrum with foul-smelling, purulent drainage. The nurse should intervenein which situation? |
1. The LPN/LVN enters the room wearing a gown and gloves.
2. The nursing assistive personnel enters the room wearing a mask. 3. The client's family brings the client a milkshake. 4. The staff lifts the client to reposition him. |
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A client develops orthopnea, dyspnea, and basilar crackles. Which actionis MOST appropriate for this client? |
1. Elevate the legs to promote venous return.2. Decrease the IV fluids, and notify the healthcare provider.3. Orient the client to time, place, and situation.4. Prevent complications of immobility.
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The nurse care for a client in labor. Upon returning to the room thenurse notes this pattern on the fetal monitor.
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Which action should the nurse take FIRST?
1. Turn the mother on her right side, increase the intravenous flow rate, and call the health care provider. 2. Turn the mother on her left side, administer oxygen by nasal cannula, and start an IV. 3. Call the health care provider, and make preparations for an immediate emergency cesarean section. 4. Position the mother in Trendelenburg's position, administer oxygen, and force fluids. |
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After the client has returned to the floor from thyroidectomy surgery,it is MOST important for the nurseto take which action? |
1. Monitor vital signs every four hours.
2. Observe for frequent swallowing. 3. Monitor for signs of respiratory distress every hour. 4. Position the client in the supine position. |
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The nurse cares for clients on the psychiatric unit. Suddenly, a maleclient's behavior begins to escalate into aggressive behavior. It is MOST important for the nurse to take whichaction? |
1. Utilize an organized team to place the client in seclusion.
2. Leave the client alone in his room to identify feelings of anger. 3. Redirect the client to a quiet activity to divert his attention and not disturb the other clients. 4. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger. |
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The nurse instructs the parents of the child diagnosed with celiac disease.The nurse determines teaching is effective when the parents make which statement? Select all that apply. |
1. "My child's diet should be high in calories."
2. "I will make sure I serve my child foods high in protein." 3. "I will make a nice oatmeal breakfast twice a week." 4. "I will pack raw carrots or celery for snack every day." 5. "I will use wheat bread for sandwiches" |
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The nurse reviews health care provider’s orders. The nurse determineswhich order warrants further clarification? |
1. Administer haloperidol 5 mg.
2. Instruct client to use incentive spirometer q 1 hour while awake. 3. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/hour. 4. CBC with differential and platelets at 0800. |
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In developing discharge plans for the family of the client diagnosedwith stage four Parkinson's disease, the nurse should include activity? |
1. Ambulate twice daily.
2. ROM exercise to all extremities four times a day. 3. Include activities such as knitting and putting puzzles together. 4. Encourage and provide writing materials. |
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A client is admitted with abdominal pain and nausea. The health careprovider orders stool for guaiac times three days. The nurse asks the nursingassistive personnel (NAP) to obtain the stool specimen. Which statement, ifmade by the NAP, requires an intervention by the nurse? |
1. "I'll remind the client to use the bedpan instead of the bathroom toilet."
2. "I'll use a tongue blade to collect a small amount of stool in a clean container." 3. "I'll get a couple of specimens this afternoon because the client is having loose stools." 4. "I'll ask the client if he has ingested any red meat recently." |
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The home care nurse visits a client receiving levothyroxine sodium 0.1mg PO daily. Which finding indicates to the nurse that the client is gettingfavorable results from the medication? |
1. Decreased blood pressure.
2. Increased urine output. 3. Decreased pulse rate. 4. Increased respiratory rate. |
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A 24-year-old woman at 30 weeks’ gestation is seen in the outpatientclinic for a routine visit. The nurse is MOST concernedif the client makes which statement? |
1. "During the day I seem to get hot flashes and chills."
2. "I am having some trouble with constipation and hemorrhoids." 3. "At the end of the day I have leg cramps." 4. "When I put my hand on my abdomen, I can feel it tense and relax." |
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The nurse prepares an older client for an intravenous pyelogram (IVP).Which information is MOST importantfor the nurse to obtain before the procedure? |
1. The date of the client's last EKG.
2. The time of the client's last meal. 3. A list of the client's allergies. 4. A list of the medications the client takes at home. |
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A client receives heparin via continuous IV infusion for managementof venous thromboembolism (VTE). The partial thromboplastin time (PTT) is1.5 times greater than normal. Which action by the nurse is MOST appropriate? |
1. Discontinue the heparin infusion.
2. Check the International Normalized Ratio (INR) results. 3. Check the prothrombin time (PT) results. 4. Continue to monitor the client. |
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The home care nurse is visiting an elderly client with osteoarthritis.It is MOST important for the nurseto include which instruction? |
1. "Swimming is the only helpful exercise for osteoarthritis."
2. "Warm-up exercises should be done prior to exercising." 3. "Exercises should be done routinely, even if severe joint pain occurs." 4. "Isometric exercises are most helpful to prevent contractures." |
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The nurse observes a new graduate nurse palpating the uterine contractionsof a primipara in active labor. Which action, if taken by the new graduatenurse, is appropriate? |
1. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen.
2. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly. 3. The graduate nurse places one hand on the abdomen over the fundus, and with the fingertips, presses gently. 4. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly. |
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The nurse is assigned to a team with another registered nurse and anLPN. Which clients should the nurse assign to the LPN? |
1. A 67-year-old man who is NPO and scheduled for a transurethral resection of the prostate (TURP) in three hours.
2. A 53-year-old woman with an IV of 0.9% NaCl at 100 ml/hour who had a lumbar laminectomy two days ago. 3. A 40-year-old woman with a Hemovac drain and a large surgical dressing from a mastectomy two days ago and who is showing signs of depression. 4. A 27-year-old woman scheduled for discharge later today after receiving chemotherapy through a portacath for treatment of leukemia. |
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The nurse cares for the client with rheumatoid arthritis. The nurseprepares for the client to be discharged. The nurse knows that for the clientto manage at home alone the client needs to be able to perform which activity? |
Select all that apply.
1. Climb up stairs. 2. Lace shoes. 3. Comb hair. 4. Walk without assistance. 5. Brush teeth 6. Eat independently |
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A nurse was sued for malpractice but is proved innocent. Which factfrom the case was decisive in determining the outcome? |
1. Negligence was implied.
2. The suit was filed under the law of negligent tort. 3. No harm was actually suffered by the client. 4. The nurse failed to give competent care. |
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The nurse performs discharge teaching for a client receiving fluticasoneby inhalation. Which statement by the client indicates that the teaching wassuccessful? |
1. "I will use fluticasone when I feel an asthma attack beginning."
2. "I use my albuterol inhaler after I inhale the fluticasone." 3. "The medication will prevent infection in my leg." 4. "I will rinse my mouth every time after I inhale the fluticasone." |
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