Henson Test 4
A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?
Diminished awareness of body position and balance
A nurse is performing a focused assessment to an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system?
Increased curvature of the thoracic spine
A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?
Slide board
A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?
The use of ergonomics increases job satisfactions
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? a) record the time and length of the seizure b) restrain the client's extremities c) place the client in the prone position d) monitor the client's hemoglobin level
a) record the time and length of the seizure
A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin, Which of the following actions should the nurse take? a) rinse the client's skin with water b) remove the client's clothing by pulling it over their head c) dispose of the client's clothing in a single biohazard bag d) prepare to administer potassium iodide to the client
a) rinse the client's skin with water
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? Select all that apply a) the client's full name b) the client's DOB c) the client's telephone number d) the client's diagnosis e) the client's room number
a) the client's full name b) the client's DOB c) the client's telephone number
A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? Select all that apply a) the date the med was mixed b) the client's age c) the client's room number d) the dose of the mixed med e) the time the medication was mixed
a) the date the med was mixed d) the dose of the mixed med e) the time the medication was mixed
a nurse holds a single state nursing license and is preparing to move to another state. for the nurse to apply for reciprocity, which of the following actions should the nurse take? (select all that apply) a. present a current and valid nursing license b. submit an application c. pay the fees for a new license d. retake the nclex exam e. reapply for specialty nursing certifications held in their previous home state
a, b, c a. present a current and valid nursing license b. submit an application c. pay the fees for a new license
a graduate nurse is offered a position in the emergency department upon the granting of initial licensure. which of the following information should the graduate nurse identify as a requirement during the initial licensure process? a. verification of graduation b. criminal background check in certain states c. passing score on nclex exam d. submitting continuing education hours within the application e. self-disclosure of any substance use in the past 5 years
a, b, c, e a. verification of graduation b. criminal background check in certain states c. passing score on nclex exam e. self-disclosure of any substance use in the past 5 years
a nurse is educating a group of nurses about the nurse practice act (NPA). which of the following statements should the nurse include (select all that apply) a. the NPA contains current laws and regulations for nursing practice b. the NPA is the same for all states c. the NPA contains standards and scope of practice d. the federal government enforces the NPA for each state e. the nurse is responsible to know the current roles and responsibilities as defined by the NPA
a, c, e a. the NPA contains current laws and regulations for nursing practice c. the NPA contains standards and scope of practice e. the nurse is responsible to know the current roles and responsibilities as defined by the NPA
A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicated an understanding of the teaching? a) the nurse plugs in a sequential compression device with wet hands b) the nurse holds onto the plug to unplug a client's electronic bp machine c) the nurse rolls the client's bed over an electrical cord d) the nurse uses an extension cord to plug in a client's smart infusion pump
b) the nurse holds onto the plug to unplug a client's electronic bp machine
A nurse is caring for a client who states, "My doctor said I should have and EMG (electromyograph). What is that?" Which fo the following responses should the nurse make? a. "It is a test that determines if there is a loss of the ability to smell." b. "It is a test that measures the response of the eardrum to various sounds." c. "It is a test that determines if there is nerve damage affecting a muscle." d. "It is a test that is performed to diagnose damage to the retina of the eye."
c. "It is a test that determines if there is nerve damage affecting a muscle."
A nurse is performing the role of case manager for a client. Which of the following actions demonstrates this nursing role? - coordinating & overseeing the care the client is receiving - helping to develop nursing knowledge for clinical interventions - providing knowledgeable & compassionate care to promote health & address illness - instructing the client on specialized topics such as diabetes care
coordinating & overseeing the care the client is receiving
A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? a) extinguish the fire b) close the windows in the client's room c) close the client's door d) activate the fire alarm
d) activate the fire alarm
A nurse is assisting with teaching about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? a) legitimate absenteeism b) strict adherence to facility policies c) consistent adequate work performance d) frequent reports of not being treated fairly
d) frequent reports of not being treated fairly
a nurse is planning to implement the Transforming Care at the Bedside plan on a med-surg unit. Which of the following interventions should the nurse include in the plan? a) require nurses to spend 50% of their time at the bedside of the clients b) perform change-of-shift report at the nurses' station c) complete the client rounds every 4 hours d) use a standardized communication tool
d) use a standardized communication tool
a newly licensed nurse is reviewing the standards of care when performing client care. which of the following describes a standard of care? a. explanatory statements that describe the competent level of care for all nurses to follow in practice b. a component of the nursing scope of practice that specifies the competent level of behavior expected in one professional role c. part of the nursing scope of practice that specifies the nurses role in alleviating client suffering and promoting client healing d. the level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience
d. the level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience
A nurse educator is planning a presentation for nurses about the opioid epidemic. Which of the following is a strategy promoted by the U.S. Department of Health and Human Services to address this epidemic? - continue to evaluate to determine if the use of opioids improves on its own - educate nurses and other health care personnel about naloxone - keep the issue private to avoid embarrassment - reduce efforts to explore alternative pain management practices until the opioid epidemic is over
educate nurses and other health care personnel about naloxone
A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?
Mechanical lift
A nurse is caring for a client who reports experiencing chills ad not well. The nurse informs the client that they will need to have their temp taken to monitor the manifestations. Which of the following terms describes that the nurse's action is grounded in research? - evidence based practice - competencies - lifelong learing - change agent
evidence based practice
A nurse who completed their shift realized they forgot to take a client's vital signs as frequently as prescribed. Which of the following actions should the nurse take to uphold the American Nurses Associations Code of Ethics for nurses w/ interpretive statements? - take the clients vital signs now & document them as being completed 8 hr earlier - document vital signs that are the same as those obtained - make reminder note to be more diligent next day - report this omission to charge nurse and the nurse on the next shift
report this omission to charge nurse and the nurse on the next shift
A nurse is discussing culturally competent care w/ another nurse. Which of the following statements should the nurse include? -"use a medical interpreter for a client who does not speak the same language" - "provide the client w/ information in print only so they can have it as a resource" - "provide standard educational materials to all clients for continuity" - "limit communication with the client if there is a language barrier"
"use a medical interpreter for a client who does not speak the same language"
A nurse is caring for a client who tells the nurse they want to quit smoking. The nurse provides the client with information about smoking cessation and other ways to improve their health. Which of the following nursing roles is the nurse demonstrating? (Select all that apply) - advocate - collaborator - change manager - health promotor - nurse educator
- health promotor - nurse educator
A nurse is explaining to a newly licensed nurse that caring for clients involves lifelong learning by the nurse. The nurse should include which of the following as examples of learning opportunities for nurses? (select all that apply). - nursing blogs or opinions - online continuing education journal articles - nursing skill refresher opportunities - continuing education presentations - participating in healthcare research
- online continuing education journal articles - nursing skill refresher opportunities - continuing education presentations - participating in healthcare research
A nurse is reviewing the contributions made by various nursing organizations that have impacted the nursing profession. The nurse should identify that which of the following are contributions made by the American Nurses Association (ANA)? (select all that apply). - providing a definition of nursing - lobbying for whistle blower protection - providing objective data to improve the health of society - providing all RN's w/ competency expectations - providing the nursing magazine imprint
- providing a definition of nursing - lobbying for whistle blower protection - providing all RN's w/ competency expectations
A nurse is reinforcing teaching with a newly licensed nurse about using the nursing process when caring for a client who has an acid-base imbalance. The nurse should include that the stages of the nursing process should be performed in what order? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Data Collection 2. Evaluation 3. Implementation 4. Planning
1,4,3,2
A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?
1. A stable center of gravity increases stability and balance 2. A wide base lowers the center of gravity 3. Proper body alignment involves tightening the abdomen
A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?
1. Stand as close to the object as possible 2. Keep abdominal muscles contracted and lower the back straight 3. Look straight ahead with shoulders raised up 4. Bend hips slightly and squat 5. Push up from the knees when lifting the object
A nurse is preparing to administer 1,950 mL of 0.45% sodium chloride IV to infuse over 13 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
150 mL/hr Rationale: 1950mL/13hr = 150mL/hr
A nurse is preparing to administer 4,200 mL of intravenous fluids to a client to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
175 mL/hr Rationale: 4200mL/24hr = 175mL/hr
A nurse is reviewing the contributions of various nursing organizations that provide support in caring for clients. The nurse should identify that which of the following agencies provides The Nursing Scope and Standards of Practice? - American Nurses Association (ANA) - American Academy of Nursing - National StudentNurses Association (NSNA) - National Academy of Medicine
American Nurses Association (ANA)
A nurse manager is providing education to a group of newly licensed nurses about various nursing organizations. Which of the following information should the nurse manager include? - American Nurses Associations The code of ethics -National Academy of Medicine - American Academy of Nursing - National Student Nurses Association
American Nurses Associations The code of ethics
A nurse in a long term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?
Atrophy
A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?
Damage into the skin layer
A nurse is caring for a client who had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?
Deep vein thrombosis
A nurse is reviewing historical nursing data & how it has impacted nursing care. The nurse should identify that which of the following nurse pioneers is credited w/ first using evidence based practice in caring for clients? - Clara Barton - Dorthea Dix - Eddie Bernice Johnson - Florence Nightingale
Florence Nightingale
A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?
Foot drop
A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?
Fowler's
A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?
Kyphosis is a rounded upper back with the pelvis tilted forward
A nurse is preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics?
Looking at the client face-to-face when transferring the client
A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?
Muscles
A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?
Muscles assist with thermoregulation in the body
A nurse is reviewing the Institute of Medicine (IOM) Future of Nursing report to better understand proposed educational requirements of nurses. Which of the following organizations is responsible for publishing this report? - American Nurses Association - National Academy of Medicine - State Board of Nursing - American Association of Colleges of Nursing
National Academy of Medicine
A nursing student expresses a desire to become more involved w/ the nursing profession on a national level. Which of the following organizations should the student join? - National League for Nursing - National Student Nurses' Association - National Academy of Medicine - International Council of Nurses
National Student Nurses' Association
A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?
Occupational Therapist
A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?
Prone
A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?
Remind the client to use incentive spirometer
A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?
Tendons connect muscle to bone
A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at a Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?
Sit on the edge of the bed for 1 min
A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?
The client has the crutches resting 5 cm (2 in) below their axilla
A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?
The contraction of a muscle results in flexion of a joint
A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?
The top of the walker should be at the level of your wrist
A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?
Toileting
A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? Select all that apply a) a client's visitor falls in the hallway b) a nurse forgets their computer password c) a client develops an unexpected reaction to a medication d) a client's dentures are lost e) an antibiotic was administered to a client 30 min after the scheduled time
a) a client's visitor falls in the hallway c) a client develops an unexpected reaction to a medication d) a client's dentures are lost
A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include which of the following? Select all that apply a) blood transfusion incompatibility b) wrong-site surgery c) ineffective insulin usage d) dysphagia following a stroke e) dehydration due to diarrhea
a) blood transfusion incompatibility b) wrong-site surgery c) ineffective insulin usage
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? Select all that apply a) fall history b) medical diagnosis c) use of assistive devices d) mental status e) do-not-resuscitate status
a) fall history b) medical diagnosis c) use of assistive devices d) mental status
A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? Select all that apply a) locks the brakes on the client's bed b) checks the max weight on the lift before using it c) places the client on the edge of the sling d) uses the lift without assistance from another team member e) performs a safety check before lifting the client
a) locks the brakes on the client's bed b) checks the max weight on the lift before using it e) performs a safety check before lifting the client
A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? a) near-miss event b) client safety event c) adverse event d) sentinel event
a) near-miss event
A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? Select all that apply a) place the client on round-the-clock surveillance b) remove the objects from the room that the client could use to arm themselves c) search items brought into the client's room by visitors d) refrain from asking the client if they intend to harm themselves e) screen the client for suicide ideation
a) place the client on round-the-clock surveillance b) remove the objects from the room that the client could use to arm themselves c) search items brought into the client's room by visitors e) screen the client for suicide ideation
A nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make? a. "You can receive a blood donation from donors with type O- and type O+ blood." b. "You can receive a blood donation from donors with type B- and type A+ blood." c. "You can receive a blood donation from donors with type B- and type AB+ blood." d. "You can receive a blood donation from donors with type AB- and type A- blood."
a. "You can receive a blood donation from donors with type O- and type O+ blood." Rationale: Clients who have type O+ blood can only receive blood from donors who have type O- or O+ blood.
A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100 mL/hr. Which of the following amounts represents the client's intake over the last 4 hr? a. 1,120 mL b. 720 mL c. 480 mL d. 580 mL
a. 1,120 mL Rationale: 480mL + 240mL +4hr (100mL/hr) = 1120mL
A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia? a. A client who has vomited four times during the last 8 hr. b. A client who requested an extra breakfast tray to eat. c. A client who can ambulate without assistance. d. A client who reports extreme thirst.
a. A client who has vomited four times during the last 8 hr. Rationale: Nausea & vomiting are early manifestations of hypomagnesemia. Other manifestations of hypomagnesemia include decreased appetite & weakness which could make it difficult to ambulate. Extreme thirst is a manifestation of hypernatremia
A charge nurse is discussing hearing test with a newly licensed nurse. Which of the following information should the charge nurse include? a. The audiometer test measures the brain's electrical activity in response to sounds. b. A tuning fork is placed against the client's mastoid bone during the Rinne test. c. The otoacoustic stimulation (OAE) test is the most commonly performed hearing test. d. Small electrodes are placed behind the client's ears during an electromyography test.
a. A tuning fork is placed against the client's mastoid bone during the Rinne test.
A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? SATA a. A walking cane b. Area rugs c. A walker d. Audio materials e. A magnifying glass
a. A walking cane c. A walker
A nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what blood types can receive their blood donation. Which of the following responses should the nurse make? (Select all that apply.) a. A+ b. B+ c. O+ d. AB- e. AB+ f. A-
a. A+ d. AB- e. AB+ f. A-
A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions? a. Availability of aids to enhance vision b. Antibiotic therapy c. Risks associated with the loss of peripheral vision d. Treatment options
a. Availability of aids to enhance vision
A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II? a. Check the client's visual acuity using a Snellen chart b. Have the client identify a specific smell. c. Whisper on one of the client's ear while occluding the other. d. Observe for facial symmetry while the client smiles.
a. Check the client's visual acuity using a Snellen chart
A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? (Select all that apply.) a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid d. Eating watermelon daily e. Eating cucumbers with each meal
a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid Rationale: The nurse should identify that an older adult client who has decreased kidney function, decreased thirst response, decreased total body fluid is at risk for dehydration
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? SATA a. Difficulty maintaining attention b. Aphasia c. Agitation d. Alertness e. Hallucinations f. Rambling speech
a. Difficulty maintaining attention c. Agitation e. Hallucinations f. Rambling speech
A nurse is reviewing arterial blood gas (ABG) values for a client who is experiencing metabolic acidosis. Which of the following ABG values should the nurse expect? (Select all that apply.) a. HCO3- 19 mEq/L b. pH 7.29 c. PaCO2 49 mm Hg d. pH 7.49 e. PaCO2 35 mm Hg
a. HCO3- 19 mEq/L b. pH 7.29 e. PaCO2 35 mm Hg
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client? a. Increase the carbon dioxide level. b. Increase the respiratory rate. c. Increase the bicarbonate level. d. Increase the pH level.
a. Increase the carbon dioxide level
A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? SATA a. Inspect the feet every day. b. Wear closed-toe shoes. c. Install smoke detectors in the home. d. Manage glucose levels. e. Encourage the client to take their time when speaking.
a. Inspect the feet every day. b. Wear closed-toe shoes. d. Manage glucose levels.
A nurse is proving care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client? a. Keep the client's environment free from clutter. b. Offer opportunities for the client to get exercise. c. Prevent the client's social isolation. d. Provide nutritional education to the client.
a. Keep the client's environment free from clutter.
A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? SATA a. Loop diuretics b. Benzodiazepines c. NSAIDS d. Antihistamines e. Aminoglycoside antibiotics
a. Loop diuretics c. NSAIDS e. Aminoglycoside antibiotics
A nurse on a pediatric floor is reinforcing teaching with a newly licensed nurse about IV therapy. Which of the following information should the nurse include? a. Perform range of motion exercises on the extremity containing the IV site. b. Shave the client's hair if the IV is to be placed in the scalp. c. IV sites can be placed in the lower extremities up to the age of 2 years. d. Monitor the IV site, tubing, and connections every 4 hr.
a. Perform range of motion exercises on the extremity containing the IV site.
A nurse is caring for a middle-adult client who asks about expected age-related changes. Which fo the following sensory changes should the nurse include as age-related change? a. Presbyopia b. Diplopia c. Myopia d. Astigmatism
a. Presbyopia
a newly licensed nurse is reviewing information about the national council of state board of nursing (NCSBN) transition to practice (TTP) program. which of the following factors should the nurse expect? a. TTP programs increase job retention b. TTP programs decrease the ability to provide safe client care c. TTP programs increase stress in the workplace d. TTP programs decrease competency
a. TTP programs increase job retention
A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? (Select all that apply.) a. The client states their muscle spasms are absent. b. The client reports a headache. c. The client denies being confused. d. The client reports being nauseated. e. The client reports feeling tired.
a. The client states their muscle spasms are absent. c. The client denies being confused. Rationale: The absence of muscle spasms & client reporting that they are not confused is an indication of adequate sodium levels
A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse selects 0.45% sodium chloride to use to prime the tubing. b. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion. c. The nurse uses tubing with a filter for the blood transfusion. d. The nurse discards the tubing after the first unit of blood is completed.
a. The nurse selects 0.45% sodium chloride to use to prime the tubing. Rationale: The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride to use to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administration
A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? SATA a. Trauma to the outer ear b. Damage to inner ear structures c. Inflammation d. Down syndrome e. Cerumen buildup f. Otitis media
a. Trauma to the outer ear c. Inflammation e. Cerumen buildup f. Otitis media
a nurse is teaching a group of nurses and asks which of the national league of nursing (NLN) integrating competencies is defined as having respect for diversity, holistic care, client-centered approach, and client advocacy. which of the following competencies does this describe? a. human flourishing b. nursing judgment c. patient-centered care d. spirit of inquiry
a. human flourishing
a newly licensed nurse is reviewing electronic information about the nclex exam from the national council of state boards of nursing (NCSBN) website. which of the following information should the nurse identify as passing criteria for the nclex computerized adaptive test (CAT)? a. the computer will stop giving items using the 95% confidence interval rule b. the board of nursing for each state determines the passing grade for the nclex exam c. the candidate receives the maximum number of items available d. the candidate runs out of time before answering the maximum number of items
a. the computer will stop giving items using the 95% confidence interval rule
A nurse is talking w/ a client who arrived at the clinic over an hour ago and states, "doesn't anyone care that I am sick? Why do I have to wait so long?" The nurse listens to the needs of the client. In which of the following roles is the nurse performing? - educator - case manager - advocate - leader
advocate
A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? Select all that apply a) influenza infection b) catheter-associated urinary tract infection c) Mycobacterium tuberculosis infection d) central line-associated bloodstream infection e) surgical site infection
b) catheter-associated urinary tract infection d) central line-associated bloodstream infection e) surgical site infection
A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? a) tie the restraints to the siderails on the client's bed b) remove the restraints with each vital sign check c) use the square knot to secure the restraints d) make sure one finger can fit under the restraints
b) remove the restraints with each vital sign check
A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? a) an extension cord is secured under a rug b) the edges of stairs are marked with brightly colored tape c) a toaster is plugged in when not in use d) the water heater is set to 55 degrees C
b) the edges of stairs are marked with brightly colored tape
A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make? a. "SPD occurs when a client's brain is unable to process rapidly occurring multiple stimuli." b. "SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin." c. "A client is diagnosed with SPD if they experience significant decrease in stimuli." d. "A client who has SPD has a deficit in the function of one or more of their five senses."
b. "SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."
A nurse is reviewing the process of how a refraction assessment is preformed with a client. Which of the following statements should the nurse make? a. "This test is performed using the Snellen chart." b. "This test is performed using lenses of various prescription strengths." c. "This test is performed by injecting dye into a vein." d. "This test is performed by measuring the amount of pressure inside the eyes."
b. "This test is performed using lenses of various prescription strengths."
A nurse is caring for a client who is scheduled for an otoacoustic emission (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make? a. "You will have small electrodes placed on your scalp during the test." b. "You will have a small probe placed in your ear canal during the test." c. "You will have dye injected through an IV during the test." d. "You will have photographs taken using a special camera during the test."
b. "You will have a small probe placed in your ear canal during the test."
A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate? a. 3% sodium chloride solution b. 0.9% sodium chloride solution c. 0.45% sodium chloride solution d. Dextrose 10% in water
b. 0.9% sodium chloride solution Rationale: A 0.9% sodium chloride solution is isotonic & is used for hydration needs such as from vomiting, diarrhea, hemorrhage & shock. 3% sodium chloride solution is hypertonic & is used for emergent replacement solutes experiencing manifestations of hyponatremia. 0.45% sodium chloride solution is hypotonic & is used to treat hypernatremia & DKA. Dextrose 10% in water is hypertonic & is used to treat hypoglycemia
A nurse is assisting in the care of a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first? a. Initiate continuous cardiac monitoring. b. Elevate the head of the client's bed. c. Instruct the client to deep breathe and cough. d. Initiate continuous SpO2 monitoring.
b. Elevate the head of the client's bed Rationale: The 1st action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the HOB. Placing the client in a Fowler's or semi-Fowler's position will promote effective breathing & chest expansion
A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? SATA a. Provide the client with large print materials. b. Ensure the client wears their hearing aids. c. Use a sign language interpreter. d. Communicate using paper and pen. e. Face the client when speaking.
b. Ensure the client wears their hearing aids. c. Use a sign language interpreter. d. Communicate using paper and pen. e. Face the client when speaking.
A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes? a. Decreased sense of touch b. Hearing loss c. Impaired ability to smell d. Reduced taste
b. Hearing loss
A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor? a. The need for multiple IV sticks b. Infection at the access site c. Dehydration d. Infiltration
b. Infection at the access site Rationale: The nurse should monitor the client who has a PICC for complications, such as infection at the access site & blood clots. It is important for the nurse to use aseptic technique when accessing & flushing the PICC line & during dressing change
A nurse is reviewing laboratory results for a client and notes the following arterial blood gas (ABG) values: pH 7.31, PaCO2 49 mm Hg, and HCO3- 25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis
b. Respiratory acidosis
A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following decreases with age? SATA a. Sweet b. Sour c. Spicy d. Bitter e. Salty f. Savory
b. Sour d. Bitter e. Salty
A nurse is collecting data from a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following reports from the client is an indication that they may have a fluid or electrolyte imbalance? a. The client reports working in a warehouse in 21.1° C (70° F) temperature. b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. c. The client reports that their provider decreased their diuretic dose. d. The client reports they had a 24-hr intestinal virus 2 weeks ago.
b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. Rationale: The nurse should identify that working outside in high temperature for an extended period can cause profuse sweating & lead to a fluid & electrolyte imbalance
a nurse is providing education to a group of newly licensed nurses regarding the development of an identity as a nurse as well as the behavioral characteristics associated with nursing. which of the following components of practice addresses the identity and characteristics of nursing? a. standard to plan nursing care b. standards of professional performance c. standards of care d. clinical practice guidelines
b. standards of professional performance
a nurse receives a license renewal notification from the board of nursing. the nurse should identify that a license renewal requires the disclosure of which of the following? a. medical history b. substance abuse within the last 5 years c. certificates received d. current salary
b. substance abuse within the last 5 years
a nurse resides in a state that has recently enacted the nurse licensure compact (NLC). which of the following information should the nurse identify as part of the NLC? a. the NLC requires a nurse to obtain a license for each state in which they wish to practice b. the NLC allows a nurse to practice across state lines with one license c. the NLC allows a nurse to have a suspended license while practicing under a multistate license d. the NLC is not a good option for telehealth
b. the NLC allows a nurse to practice across state lines with one license
A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for a fire to occur? Select all that apply a) CO2 b) Nitrogen c) cooking oil d) oxygen e) heat
c) cooking oil d) oxygen e) heat
A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? a) wipe down the client's bedside table with an antiseptic wipe b) conduct informal audits of medical records to identify the number of healthcare-associated infections c) perform hand hygiene d) instruct the client on ways to reduce the risk for infection
c) perform hand hygiene
A nurse is planning to use the identify, situation, background, assessment, recommendation, read-back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? a) the client's admitting diagnosis b) the client's medical history c) the client's lab test results d) the client's response to treatment
c) the client's lab test results
a nurse is reviewing the licensing laws in their state of residence. which of the following statements should the nurse use to define licensure? a. "licensure increases state revenue" b. "licensure limits the number of practicing nurses" c. "licensure protects the health and welfare of the public" d. "licensure protects a nurse from a malpractice lawsuit"
c. "licensure protects the health and welfare of the public"
A nurse is assisting in the care for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the #20-gauge being replaced. Which of the following gauge catheters should the nurse recommend using? a. #16-gauge b. #18-gauge c. #22-gauge d. #14-gauge
c. #22-gauge Rationale: As the gauge # increases, the actual catheter size decreases
A nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan for the blood to infuse over which of the following lengths of time? a. 1 hr b. 2 hr c. 4 hr d. 6 hr
c. 4 hr Rationale: The transfusion should be administered slowly (max time of 4hrs) to avoid increasing the workload of the heart
A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following informations should the nurse include? a. An electromyography (EMG) test is performed by placing small electrodes on the scalp. b. A fluorescein angiography test diagnoses dysfunction of the cochlea. c. A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles. d. An Amsler grid test is performed by looking at the internal eye using a slit lamp.
c. A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.
A nurse is caring for a client who has the following arterial blood gas (ABG) values: pH 7.44, PaCO2 37 mm Hg, and HCO3- 24 mEq/L. The nurse should identify that these values are an indication of which of the following? a. Metabolic acidosis b. Respiratory acidosis c. Acid-base balance d. Respiratory alkalosis
c. Acid-base balance Rationale: The nurse should identify that this client's ABG values are within the expected reference range
A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? SATA a. Speaks in soft tones b. Reports ringing in the ears c. Asks for questions to be repeated d. Withdraws from social activities e. Reports feeling dizzy at times f. Describes sounds as being muffled
c. Asks for questions to be repeated d. Withdraws from social activities f. Describes sounds as being muffled
A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process? a. Planning b. Data collection c. Evaluation d. Implementation
c. Evaluation Rationale: Reviewing the client's ABG values is part of the evaluation stage of the nursing process
A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider? a. Potassium 4.5 mEq/L b. Sodium 138 mEq/L c. Magnesium 3 mEq/L d. Calcium 10 mg/dL
c. Magnesium 3 mEq/L Rationale: A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1 mEq/L
A nurse is reviewing the arterial blood gas (ABG) values for a client and notes the following results: pH 7.49, PaCO2 39 mm Hg, and HCO3- 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis
c. Metabolic alkalosis
A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation? a. Sensory deprivation is commonly experienced by clients who are in the ICU. b. Sensory deprivation can cause tactile stimuli to feel painful. c. Risk factors for sensory deprivation include experiencing total vision or hearing loss. d. Sensory deprivation occurs most often in children who have developmental disorders.
c. Risk factors for sensory deprivation include experiencing total vision or hearing loss.
A nurse is assisting in the care of a client who has a prescription to receive one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take? a. Return the blood unit as it is not compatible with the client's blood type. b. Stay with the client for 15 min prior to starting the blood transfusion. c. Verify the unit of blood with another nurse. d. Prime the blood tubing with 0.45% sodium chloride.
c. Verify the unit of blood with another nurse. Rationale: The unit of blood is compatible with the client's blood type. However, the nurse should ensure that the blood unit had been verified by 2 nurses before initiating the transfusion
a nurse is providing client care using the nursing process. the nurse should identify that which of the following standards or guidelines includes this criterion? a. standards of care b. clinical practice guidelines c. standards of practice d. standard to plan nursing care
c. standards of practice
A nurse is reviewing the health history of a client during a routine office visit. Which of the following observations by the nurse is an example of the client demonstrating health literacy? - client states they want to improve their current knowledge about their health - client asks for information that will help them improve their eating habits - client states they understand their health care information and treatment - client requests a meeting w/ nurse, physical therapist and provier
client states they understand their health care information and treatment
A newly licensed nurse is reviewing Benner's Novice to Expert Model for nursing competence. At which of the following stages does the nurse first develop the ability to prioritize tasks by drawing on experience? - advanced beginner - proficient -competent - novice
competent
The nurse is reviewing the medical record of a client who reports recent insomnia. The nurse should identify which of the following conditions as a risk factor for developing insomnia? a. Gastroesophageal reflux disease b. Herniated lumbar disc c. Wernicke's aphasia d. Alzheimer's disease
d. Alzheimer's disease
A nurse is assisting an RN who is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take? a. Apply a cold compress to the selected IV site. b. Ask the client to hold the extremity up prior to searching for an IV site. c. Ask the client to spread the fingers of the selected extremity. d. Apply a blood pressure cuff set to 30 mm Hg.
d. Apply a blood pressure cuff set to 30 mm Hg Rationale: Instead of using a tourniquet, the nurse should apply a BP cuff set to 30 mm Hg prior to starting an IV for this client. This will help protect the client's extremity from bruising & bleeding
A nurse is collecting data on a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications? a. Phlebitis b. Extravasation c. Air embolism d. Circulatory overload
d. Circulatory overload Rationale: The nurse should identify that a client who has been receiving IV therapy & whose daily weight has increased is at risk for circulatory overload. Other indications of circulatory overload include tachycardia, increased BP, edema, cough & tachypnea
A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? a. Dry mucous membranes b. Decreased urine output c. Report of thirst d. Decrease in level of consciousness
d. Decrease in level of consciousness Rationale: This is an indication that the hypovolemia has progressed to a critical level & requires immediate interventions Dry mucous membranes, decreased urine output, report of thirst are non-urgent because it is an early & expected finding of hypovolemia
A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia? a. Rapid-onset memory loss b. Hyperglycemia c. Hypervigilance d. Difficulty problem solving
d. Difficulty problem solving
A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments? a Diabetic retinopathy b. Macular degeneration c. Cataract d. Glaucoma
d. Glaucoma
A nurse is reviewing a client's latest arterial blood gas (ABG) report. Which of the following values should the nurse identify as the priority to report to the provider? a. pH 7.37 b. PaCO2 43 mm Hg c. HCO3- 27 mEq/L d. PaO2 76 mm Hg
d. PaO2 76 mm Hg Rationale: This value is below the expected reference range of 80 to 100 mm Hg & could be an indication the client is decompensating
A nurse has completed collecting data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next? a. Implementation b. Re-collection of data c. Evaluation d. Planning
d. Planning Rationale: After assessing & analyzing data for a client who has an acid base imbalance, the nurse should move into the planning stage of the nursing process & establish goals & outcomes for the client
A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII? a. Monitor for symmetry when the client shrugs their shoulders. b. Ask the client to identify a smell in each nostril. c. Have the client stick out their tongue. d. Whisper something in one ear while occluding the other ear.
d. Whisper something in one ear while occluding the other ear.
a nurse is reviewing the scope of nursing practice. which of the following is the purpose of the nursing scope of practice? a. provides recommendations for nursing practice b. provides competencies for the nurse to achieve before receiving initial licensure c. serves as a contractual document between the nurse and their employer d. specifies the actions a nurse can perform
d. specifies the actions a nurse can perform
a nurse is delivering client care in partnership with multidisciplinary members of the healthcare team. this is an example of which of the following QSEN competencies? a. safety b. patient-centered care c. quality improvement d. teamwork and collaboration
d. teamwork and collaboration
A nurse is describing to another nurse how to use social media in client care. Which of the following examples should the nurse include as an acceptable use of social media? - posting a comment on social media about facility staffing shortage - reviewing the use of a fitness application w/ a client - accepting a social media friend request from a client - sharing client information w/ a coworker in a private social media message
reviewing the use of a fitness application w/ a client
A nurse is caring for a client who asks about healthy choices to lose weight. The nurse shares information from Healthy People 2030 to address the client's questions. Which of the following describes the Healthy People Initiative? - program for health care practitioners to get healthy - social media platform for nurses - set of objectives for improving the health of Americans - rehabilitation program for clients who have substance use disorders
set of objectives for improving the health of Americans
A nurse has accepted a position at a hospital in the state where they live. The nurse should identify that which of the following regulates the nurse's actions when they begin working? - American Nurses Association (ANA) code of ethics for nurses with interpretive statements - state nurse practice act - national student nurses association (NSNA) - national league for nursing
state nurse practice act
A nurse in a long-term care facility took a picture of a client and posted it on the internet. This action by the nurse is an example of which of the following? - serving as an advocate for the client - violating the code of ethics for nurses - participating in the Healthy People 2030 - demonstrating collaboration
violating the code of ethics for nurses
