HESI/NCLEX QUESTIONS FROM EBOOK

A client has an order for hydromorphone intravenous (IV) push 1 mg every 3 hours. The drug is available as 4 mg/mL per vial. The RN administers _____ mL of hydromorphone for one dose. (Round to the hundredth)

Answer = 0.25

Which adaptation of the environment is most important for the RN to include in the plan of care for a client diagnosed with myxedema? 1. Reduce environmental stimuli. 2. Prevent direct sunlight from entering the room. 3. Maintain a warm room temperature. 4. Minimize exposure to visitors.

Correct Answer: 3 Rationale The RN would maintain a warm room temperature for a client with myxedema because clients may experience cold intolerance, which can lead to myxedema crisis. The other environmental adaptations are not necessary for this client.

A client is receiving an infusion of dobutamine hydrochloride. The order reads: Infuse dobutamine IV at 5 mcg/kg/min available in 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the flow rate in mL/hr. ________________ mL/hr

Calculation: Ordered amount of drug × client's weight × 60 (minutes/hour) ÷ Drug Vehicle (amount of drug available) ANS: 9.75 mL/hr

While the RN is obtaining the health history of a client and reviewing the medical records, which data would alert the RN that the client has an increased risk of developing peptic ulcer disease (PUD)? (Select all that apply.) 1. Excess of gastric acid or a decrease in the natural ability of the GI mucosa to protect itself from acid and pepsin. 2. Invasion of the stomach and/or duodenum by H. pylori. 3. Viral infection, allergies to certain foods, immunological factors, and psychosomatic factors. 4. Taking certain drugs, including corticosteroids and anti-inflammatory medications. 5. Having allergies to foods containing gluten in their ingredients.

Correct Answer(s): 1, 2, 4 Rationale Excess gastric acid production, decreased ability of the GI mucosa to protect itself from acid and pepsin, and invasion of the GI tract with H. pylori are all risk factors for developing PUD. Medications such as corticosteroids and NSAIDs (e.g., aspirin, ibuprofen [Advil], and naproxen [Aleve]) also lead to PUD. Viral infection, food allergies, immunologic factors, and psychosomatic factors do not lead to PUD.

A client diagnosed with Parkinson's disease is prescribed carbidopa-levodopa. Which observation by the RN indicates that the desired effect of the medication is being achieved? 1. Decreased BP. 2. Steady gait. 3. Increased salivation. 4. Increased attention span.

Correct Answer: 2 Rationale Carbidopa-levodopa has a dramatic effect on controlling the symptoms of unsteady or ataxic gait. The other findings do not indicate effective medication therapy with carbidopa-levodopa.

Scenario: The RN is caring for a client admitted with heart failure. The home medication list is obtained. The medication ______(1)_______ is contraindicated for clients with a history of heart failure and can worsen symptoms such as _________(2)__________. Home Med List (Option #1): -Furosemide 40 mg PO Daily -Potassium chloride 20 mEq PO Daily -Pioglitazone 45 mg PO Daily -Enalapril 5 mg PO BID Symptoms (Option #2): -Exertional fatigue -Hypotension -Hyperglycemia -Unusual bleeding

Answer: #1 = Pioglitazone, #2 = exertional fatigue. Rationale: Pioglitazone is a medication used to treat type 2 diabetes and has been known to cause or worsen heart failure. This medication is contraindicated in clients who have heart failure and can lead to worsening symptoms such as exertional fatigue; swelling of the hands, legs, and feet; hypertension; and shortness of breath.

A hospice nurse is admitting a new 68 yr client to the company's services. He is a divorcee with 3 grown daughters who was diagnosed with small cell lung carcinoma over 1 year ago. The client underwent chemotherapy and radiation, but treatment was unsuccessful. Nurse is discussing end-of-life plans with the client and the family. The client wishes to make decisions for care so that the family will not have to when the time comes. Q: The nurse would advise the client complete a(n) _1_ to officially document all wishes for end-of-life care to be implemented once the client is no longer able to make decisions. The client will also be advised to appoint a(n)_2_ to carry out the client's medical wishes. Drop-Down Option 1: Death with Dignity Consent Informed Consent Last Will & Testament Advanced Directive Drop-Down Option 2: Attorney-in-fact Power of Attorney Health Care Proxy Estate Planner

Answer: 1 = Advanced Directive, 2 = Health Care Proxy Rationale 1: An advanced directive is a legal document that details a client's wishes for health care to be instated if/when said client becomes incapacitated or unable to make decisions independently. Death with Dignity Consent is used for physician-assisted suicides in states where this is allowed. Informed consent is required before all invasive procedures but does not pertain to this situation. A last will & testament discusses how a client's possessions will be dispersed but does not address medical issues. Rationale 2: A health care proxy is the appropriate term for the individual who is appointed by a client to make health care decisions for the client if/when the client becomes unable to make decisions for themselves. The proxy should have a detailed understanding of the client's wishes for end-of-life care and should be willing to see that those plans are carried out accordingly. This person is only entitled to make health care decisions and is not involved in financial decisions or estate planning. An attorney-in-fact is a person who assumes responsibility for making financial, legal, and business matter decisions for the client and is another term for someone with general power of attorney. An estate planner helps in designating who will handle a client's assets and responsibilities after death.

Scenario: The RN is caring for a client who has a new prescription for warfarin 2 mg PO daily. The RN is providing medication education for the client and is discussing dietary instructions including foods to avoid while taking this medication. Question: Which vegetable would the RN instruct this client to avoid while taking warfarin? (Select all that apply.) 1. Collard greens 2. Iceberg lettuce 3. Broccoli 4. Brussel sprouts 5. Green beans 6. Spinach 7. Zucchini squash 8. Kale

Answer: 1, 3, 4, 6, 8. Rationale: DARK GREENS: Collard greens, broccoli, brussel sprouts, spinach, and kale are foods that are vitamin K rich and should be avoided while taking warfarin and other anticoagulants. Iceberg lettuce, green beans, and zucchini squash are lower in vitamin K and are good substitutes for these vegetables for a well-balanced diet.

Which finding by the RN indicates an early sign of increased ICP in a client newly diagnosed with a cerebral vascular accident? (Select all that apply.) 1. Alteration in the ability to respond to questions. 2. Alteration in the ability to respond to verbal stimuli. 3. Consensual response of pupils. 4. Heart rate 50, BP 192/60. 5. Drooping of the mouth on one side.

Correct Answer(s): 1, 2 Rationale Confusion and difficulty speaking are early signs of increased ICP. Alteration in the ability to respond to questions and a change in the ability to respond to verbal stimuli are included in these symptoms. Consensual pupil response is a normal reaction. Widening pulse pressure and bradycardia are two components of Cushing's triad, which is a late sign of increased ICP and indicate a life-threatening condition. Drooping of the mouth on one side can indicate a CVA.

The RN is planning a class on stroke prevention for clients with HTN. Which information reflects accurate prevention measures that the clients can undertake? (Select all that apply.) 1. Limit salt intake to 1500 mg/day or less. 2. Eliminate tobacco products. 3. Initiate a program of walking 1 mile per day. 4. Achieve a body mass index (BMI) of 26.2. 5. Schedule routine health assessments biannually

Correct Answer(s): 1, 2, 3 Rationale Limiting salt intake, eliminating tobacco products, and initiating a program of walking every day can help reduce the risk of stroke for at risk clients. A BMI of 26.2 is considered overweight; therefore, the client should attempt to achieve a BMI of less than 25. Clients with HTN should follow up with their care providers more frequently until BP is well controlled.

An older client with a history of hypertension, HF, and sleep apnea is admitted to the acute care unit. Which finding would relate most directly to a diagnosis of acute decompensated HF (ADHF)? (Select all that apply.) 1. Respiratory rate of 25 breaths/min. 2. Orthopnea. 3. S3 heart sound. 4. Dry, nonproductive cough. 5. Heart rate of 69 and irregular.

Correct Answer(s): 1, 2, 3 Rationale Pulmonary edema or ADHF is caused by an abnormal accumulation of fluid in the lung, in both the interstitial and alveolar spaces. It is a severe impairment in the ability of the left side of the heart to maintain cardiac output, thereby causing an engorgement of the pulmonary vascular bed, leading to dyspnea, tachypnea, orthopnea, tachycardia (S3, S4 gallop), and severe coughing productive of frothy and blood-tinged sputum with noisy, wet breath sounds that do not clear with coughing. A dry, nonproductive cough and heart rate of 69 beats/min and irregular are not characteristics of ADHF.

A client is in the oliguric phase of acute kidney injury. Which finding would the RN expect to assess in the client? (Select all that apply.) 1. 390 mL urine output in 24 hours. 2. Potassium of 6.2 mEq/L. 3. Sodium (serum) 155 mEq/L. 4. Metabolic alkalosis. 5. Weight gain.

Correct Answer(s): 1, 2, 5 Rationale 390 mL urine output in 24 hours is a low output. A high potassium level and weight gain are indicative of the oliguric phase of acute kidney injury. Serum sodium of 155 mEq/L and metabolic alkalosis are not expected in this client.

The emergency department RN is assessing a client with a vesicular rash as a result of suspected smallpox exposure. Which transmission precautions would be most appropriate for this client? (Select all that apply.) 1. Airborne. 2. Contact. 3. Aplastic. 4. Droplet. 5. Standard.

Correct Answer(s): 1, 2, 5 Rationale A combination of airborne, contact, and standard precautions is recommended in cases of smallpox exposure. There is no such thing as aplastic precautions. Droplet precautions are not necessary because smallpox is not spread by respiratory droplets from a person talking, coughing, or sneezing.

The RN is assigned to receive a client in the emergency department with suspected anthrax exposure predecontamination. Which transmission precautions would be most appropriate for the client? (Select all that apply.) 1. Airborne. 2. Contact. 3. Aplastic. 4. Droplet. 5. Standard.

Correct Answer(s): 1, 2, 5 Rationale Since this client has not been decontaminated yet, health care providers would observe airborne, contact, and standard precautions. There is no such thing as aplastic precautions. Droplet precautions are not necessary because anthrax is not spread by respiratory droplets from a person talking, coughing, or sneezing.

The RN is reviewing the current medication list of a client, newly diagnosed with type 1 diabetes, who will be prescribed insulin. Which medication would the RN discuss with the health care provider? (Select all that apply.) 1. Prednisone 2. Atenolol 3. Clarithromycin 4. Acetaminophen 5. Ibuprofen 6. Pantoprazole sodium

Correct Answer(s): 1, 2, 6 Rationale Prednisone and pantoprazole sodium can increase blood sugar levels leading to hyperglycemia. Atenolol can mask signs of hypoglycemia. The other medications listed do not have an effect on blood sugar levels.

The charge nurse is planning client assignments for the unit. The collaborative care team consists of a registered nurse (RN), a practical nurse (PN), and an unlicensed assistive personnel (UAP). Which client would be assigned to the RN? (Select all that apply.) 1. A client awaiting a blood transfusion for GI bleeding with a Hgb 7.0 mg/dL (70 g/L). 2. A client with pernicious anemia who is awaiting vitamin B12 injection. 3. A client with resolving sickle cell crisis awaiting IV fluid conversion to saline lock. 4. A client with a pressure ulcer who has been prescribed negative pressure wound (vacuum-assisted closure [VAC]) care. 5. A client who received two blood transfusions yesterday and is awaiting morning care.

Correct Answer(s): 1, 3 Rationale The only client in this list that must be assigned to the RN is the client awaiting a blood transfusion for GI bleeding with a Hgb 7.0 mg/dL (70 g/L). An RN must initiate a blood transfusion and observe the client for S/S of transfusion reaction. A PN can assist with ongoing assessment of the client after the transfusion has been initiated by the RN. A PN can be assigned to administer the B12 injection, converting the Intravenous fluids (IVFs) to a saline lock, and manage the client with the wound VAC. The UAP can provide morning care to the client who had previously received blood transfusions.

A charge nurse is making assignments for five clients. The nursing team has a RN, a PN, and two UAPs. Which client is appropriate to assign to the RN? (Select all that apply.) 1. A client from the previous shift with unstable angina. 2. A client with a stage 3 pressure ulcer who needs a bed bath. 3. A client with an enteral feeding infusing at 30 mL/h. 4. A cardiotomy client who is day 2 postoperative and who has chest tubes. 5. A client with quadriplegia for whom urinary catheterization is prescribed.

Correct Answer(s): 1, 4 Rationale The client with unstable angina and the client with chest tubes need advanced monitoring and assessment that are most appropriate for the RN. The client needing a bed bath can be assigned to the UAP. The client with the enteral feeding and the client needing urinary catheterization could be assigned to the PN.

The RN suspects a postoperative thyroidectomy client may have had an inadvertent removal of the parathyroid when the client begins to experience which symptoms? (Select all that apply.) 1. Hematoma formation. 2. Harsh, vibratory sounds on inspiration. 3. Tingling of lips, hands, and toes. 4. Positive Chvostek's sign. 5. Sensation of fullness at the incision site.

Correct Answer(s): 2, 3, 4 Rationale Removal of the parathyroid during a thyroidectomy can lead to a decrease in serum calcium. Laryngeal stridor may be related to tetany when parathyroid glands are damaged or removed, leading to hypocalcemia. Tingling of toes, fingers, and lips, along with muscular twitching, is a sign of tetany. A positive Chvostek's sign is noted with hypocalcemia. Hematoma formation and sensation of fullness at the incision site are not signs of dysfunctional parathyroid.

A practical nurse (PN) is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observation would the PN immediately report to the RN? (Select all that apply.) 1. The client complains of incisional pain, rating it an 8 on a scale of 0 to 10. 2. The client has had a change in orientation to person but not to time or place. 3. Swelling and redness have developed in the client's lower left leg. 4. The practical nurse (PN) emptied 15 mL of bloody drainage from the Jackson-Pratt drain. 5. The client's last set of vital signs was temperature 37.9°C (100.2°F), pulse 87, respirations 12, blood pressure 108/74, and O2 saturation 93%.

Correct Answer(s): 2, 3, 5 Rationale A change in mental status and swelling/redness to the client's lower left leg could indicate serious postoperative complications and should be reported immediately to the RN. The client's vital signs indicate a low-grade fever that needs to be reported as well. Pain is a concern but can be assessed by the PN. The amount of drainage is small and does not need to be reported to the RN.

The charge nurse is planning client assignments for the shift. The care team includes a RN, a PN, and a UAP. Which client is appropriate to be assigned to the PN? (Select all that apply.) 1. A client scheduled for a STAT x-ray after a fall from a stretcher. 2. A client receiving IV vancomycin through a peripherally inserted catheter (PICC) line. 3. A client with sickle cell crisis who was transferred from the intensive care unit (ICU) to the acute care area and who is receiving hydromorphone via a client-controlled analgesia (PCA) pump. 4. A client with a pressure ulcer who was prescribed negative pressure (wound Vacuum-assisted closure (VAC)) care. 5. A postoperative client who has been prescribed 2 units of packed red blood cells.

Correct Answer(s): 2, 4 Rationale A client receiving IV vancomycin and a client with a wound VAC would be appropriate assignments to give to the PN. The client needing an x-ray can be assigned to the UAP. A client on a PCA of hydromorphone could need more advanced monitoring, which would be more appropriate for the RN. Also, blood transfusions must be initiated and supervised by an RN.

Which assessment finding would the RN recognize as a late sign of increased ICP in a client diagnosed with a CVA or stroke? (Select all that apply.) 1. Alteration in the ability to respond to questions. 2. Irregular breathing with periods of apnea. 3. Consensual response of pupils. 4. Heart rate 50, blood pressure (BP) 192/60. 5. Drooping of the mouth on one side.

Correct Answer(s): 2, 4 Rationale Irregular breathing with periods of apnea is a late sign of increased ICP. A heart rate of 50 beats/min and a BP of 192/60 mm Hg are late signs of increased ICP. The other findings are not late signs of increased ICP.

The RN admits a client with suspected early DIC. Which symptom would indicate early organ ischemia? (Select all that apply.) 1. Slight gingival bleeding. 2. Alterations in mental status. 3. Petechial hemorrhage to chest. 4. Slight decrease in urine output. 5. Bluish discoloration of fingertips.

Correct Answer(s): 2, 4, 5 Rationale Alterations in mental status, slight decrease in urine output, and bluish discoloration of fingertips would indicate early signs of organ ischemia. Gingival bleeding are results of the effects of DIC but are not related to organ ischemia.

The RN is precepting a RN orientee who is caring for a client with a chest tube. The client is 12 hours postoperative from a left partial pneumonectomy. Which assessment finding will the RN advise the orientee to immediately report to the HCP? (Select all that apply.) 1. Pain level of 6 out of 10 on the left side. 2. Tracheal deviation toward the right side. 3. Drainage from the chest tube of 50 mL in the last hour. 4. Oxygen saturation of 90% on 2 L/min. 5. Vigorous bubbling in the water seal chamber.

Correct Answer(s): 2, 4, 5 Rationale The most common cause of tracheal deviation is a pneumothorax. Oxygen saturation should be at least 95%. Bubbling in the suction chamber should be gentle; vigorous bubbling could indicate an air leak. The other answer options do not reflect situations that require the RN to notify the HCP.

The registered nurse (RN) assigns the practical nurse (PN) a client diagnosed with diabetes. Which finding would the RN instruct the PN to report immediately? (Select all that apply.) 1. Fingerstick blood sugar of 247 mg/dL. 2. Cold, clammy skin. 3. Crackles at the end of inspiration. 4. Numbness in the fingertips and toes. 5. Unsteady gait, slurred speech.

Correct Answer(s): 2, 5 Rationale Cold, clammy skin, unsteady gait, and slurred speech are concerning findings and need to be reported immediately to the RN. These indicate a serious change in condition that needs further assessment. The other findings can be expected for a client with this condition or do not require immediate assessment by the RN.

A client is admitted with a diagnosis of Addison's crisis. Which prescription provided by the health care provider (HCP) would the RN question? 1. IV D5NS at 300 mL/hr for 3 hours. 2. Hydrocortisone sodium succinate 100 mg IV push. 3. Potassium 20 mEq in 100 mL saline IV over 60 minutes. 4. 50% dextrose intravenous push.

Correct Answer(s): 3 Rationale Addison's crisis leads to high potassium levels; therefore, the RN would question an order for IV administration of potassium. Administration of dextrose fluids and solutions can help to maintain glucose levels during Addison's crisis. Hydrocortisone must be administered immediately during Addison's crisis.

A client who was recently prescribed metformin hydrochloride calls the clinic to discuss symptoms of bloating, nausea, cramping, and diarrhea. Which instruction would the RN provide the client? (Select all that apply.) 1. Discontinue the medication immediately. 2. Increase fiber and fluids in the diet. 3. Monitor the symptoms. 4. Continue to take the metformin as prescribed. 5. Seek immediate emergency medical care.

Correct Answer(s): 3, 4 Rationale The RN would instruct the client to monitor their symptoms but continue taking the medication as prescribed. These are normal side effects of the medication and should decrease with time. All other instructions are inappropriate.

For which dysrhythmia would the RN implement defibrillation? (Select all that apply.) 1. Asystole. 2. Pulseless electrical activity. 3. Ventricular fibrillation. 4. Pulseless ventricular tachycardia. 5. Ventricular tachycardia. 6. Atrial fibrillation.

Correct Answer(s): 3, 4 Rationale Ventricular fibrillation and pulseless ventricular tachycardia are life-threatening rhythms that require defibrillation. Stable ventricular tachycardia can be treated with medication or cardioversion. The other rhythms do not require defibrillation.

A client diagnosed with advanced cirrhosis of the liver has an acute exacerbation of hepatic encephalopathy. Which type of food would the RN teach the client to limit? (Select all that apply.) 1. Fruits. 2. Vegetables. 3. Red meat. 4. Bread. 5. White meat. 6. Black beans.

Correct Answer(s): 3, 5, 6 Rationale Encourage a well-balanced, moderate-protein (limit protein in hepatic encephalopathy), high-carbohydrate diet with adequate vitamins. This client would need to avoid red meat, white meat, and black beans. Fruits, vegetables, and grains are allowed in the client's diet.

The RN finds a client slumped in a chair. Place the RN's actions in order of priority from first to last for this client. 1. Activate the code team and obtain defibrillator. 2. Assess unresponsiveness. 3. Assess the cardiac rhythm using the "quick-look" paddles. 4. Assess for a carotid pulse. 5. Open airway and give two rescue breaths by bag-valve mask. 6. Move the client to a flat position in bed or on the floor. 7. Begin compressions.

Correct Answer: The order in which actions would be performed according to BCLS guidelines is 2, 4, 1, 6, 7, 5, 3 Rationale First determine the client's level of responsiveness, breathing adequacy and if there is a pulse present. Then initiate a call for help by activating code team. Then move the client to the floor so you can begin high quality chest compressions. You deliver 30 compressions followed by 2 breaths. Once the defibrillator arrives, you will check the rhythm using the quick-look paddles.

The RN is caring for a client who is 24 hours postprocedure for a hemicolectomy with a temporary colostomy placement. The RN assesses the client's stoma, which is dry and dark blue. Which action should the RN take based on this finding? 1. Notify the HCP of the finding. 2. Document the finding in the client record. 3. Replace the pouch system over the stoma. 4. Place petrolatum gauze dressing on the stoma.

Correct Answer: 1 Rationale A normal stoma is pink and moist. A dry, dark red stoma after surgery may indicate infection or other complication such as decreased blood flow. The RN should notify the HCP of the finding immediately. All other interventions do not address the complication noted with the stoma appearance.

The RN provides teaching to a client who is prescribed prednisone 10 mg orally daily. Which statement by the client indicates that further teaching is necessary? 1. "I can take aspirin if I need it for pain." 2. "I need to take medication at the same time daily." 3. "I need to check for bruising on my skin." 4. "If I gain more than 5 lb a week, I will call the HCP."

Correct Answer: 1 Rationale Clients prescribed prednisone need to be aware that using aspirin with steroids can cause bleeding. Clients are expected to gain 1-2 lb, but if a client were to gain 5 lb in a week, the HCP should be notified. The other client statements do not require further teaching.

The RN is caring for a client in shock of unknown etiology and observes the rhythm below on the monitor. Which is the RN's priority intervention? 1. Check for a carotid pulse. 2. Defibrillate the client with 360 joules of energy. 3. Administer an intravenous saline bolus. 4. Give two breaths via Ambu bag.

Correct Answer: 1 Rationale First assess the client by checking for a carotid pulse before performing an intervention. If no pulse is present, then the RN would follow BCLS guidelines. The other nursing interventions are not the priority.

A client with menopause reports that since she stopped hormone replacement therapy (HRT), she has been experiencing increased vaginal discomfort during intercourse. What action would the RN take? 1. Suggest that the client use a vaginal cream or lubricant. 2. Recommend that the client abstain from sexual intercourse. 3. Teach the client Kegel exercises to perform daily. 4. Instruct the client to resume HRT.

Correct Answer: 1 Rationale Lack of estrogen results in vaginal dryness, causing discomfort. Use of a vaginal cream or lubrication will help ease the client's discomfort. The other nursing interventions are not necessary for this client situation.

The RN has just received report on four clients. Which client would the RN assess first? 1. A client with pericarditis with pain relieved by leaning forward. 2. A client with fractured ribs with pain reported at 6/10 on a 1 to 10 scale. 3. A client with stable angina who is awaiting discharge instructions. 4. A client with HF who needs transporting for an echocardiogram.

Correct Answer: 1 Rationale Pain is sometimes alleviated by leaning forward, but it requires further assessment because this also is symptomatic of cardiac tamponade. Pain is to be expected with a rib fractures. A client with stable angina who is awaiting discharge does not require immediate attention. A client with HF who needs transporting for an echocardiogram does not require immediate attention.

The RN assigned to the women's health unit received the morning report. Which client would the RN assess first? 1. A 49-year-old client 1-day postvaginal hysterectomy who is saturating pads every 3 hours. 2. A 34-year-old client postuterine artery embolization who has not voided since her indwelling catheter was removed 4 hours ago. 3. A 52-year-old client who is 2 days postabdominal hysterectomy requesting oral analgesics instead of the client-controlled analgesia (PCA) pump. 4. A 67-year-old client 1-day postanterior and posterior repair who is refusing to ambulate with the unlicensed assistive personnel (UAP).

Correct Answer: 1 Rationale The 49-year-old client 1-day postvaginal hysterectomy who is saturating pads every 3 hours needs to be assessed first. The amount of bleeding the client is experiencing is too high and could indicate postoperative hemorrhage. The other clients are not a priority at this time.

A client who had an abdominal hysterectomy for cervical adenocarcinoma in situ is preparing for discharge. Which recommendation about women's health screening examinations should the RN offer? 1. Continue the annual Pap smear and mammogram, biannual clinical breast examinations, and monthly breast self-examination (BSE). 2. A Pap smear is no longer necessary, but continue the annual mammogram and biannual clinical breast examinations, plus monthly BSE. 3. If the ovaries have been removed, only an annual mammogram and clinical breast examinations are necessary. 4. Annual mammograms are not needed if biannual breast examinations and weekly BSE are performed.

Correct Answer: 1 Rationale The client should continue annual Pap smears, mammogram, and clinical breast examinations and monthly BSE. The other recommendations are not necessary.

After hemodialysis, the RN is evaluating the blood results for a client who has end-stage renal disease. Which value should the RN verify with the laboratory? 1. Elevated serum potassium. 2. Increase in serum calcium. 3. Low hemoglobin. 4. Reduction in serum sodium.

Correct Answer: 1 Rationale The client with end-stage renal disease going through hemodialysis should not experience hyperkalemia. The RN should verify with the laboratory the values that reflect an elevated serum potassium. It is normal for calcium levels to increase during hemodialysis. Anemia is a normal finding in hemodialysis. A drop in serum sodium is normal in hemodialysis.

A client with pneumonia has impending respiratory failure. Which set of ABG values demonstrate acute respiratory failure? 1. pH-7.30 PCO2-52 PO2-56 HCO3-26. 2. pH-7.35 PCO2-44 PO2-86 HCO3-25. 3. pH-7.35 PCO2-62 PO2-66 HCO3-31. 4. pH-7.30 PCO2-39 PO2-88 HCO3-20.

Correct Answer: 1 Rationale The findings for Option A reflect respiratory acidosis, indicating respiratory failure. The PO2 is below normal; the PCO2 is high, indicating retention of acid; and the HCO3 is normal. pH-7.35 PCO2-44 PO2-86 HCO3-25 indicates a normal ABG finding. pH-7.35 PCO2-62 PO2-66 HCO3-31 indicates compensated respiratory acidosis which would not be seen in acute respiratory failure. pH-7.30 PCO2-39 PO2-88 HCO3-20 indicates metabolic acidosis.

A client is receiving pancreatic enzyme replacement therapy for chronic pancreatitis. Which statement by the client indicates a need for more effective teaching? 1. "I will need to mix the enzyme with a protein food." 2. "I will take the enzymes with each meal." 3. "My stools will decrease in number and frequency." 4. "My abdominal pain may lessen."

Correct Answer: 1 Rationale The powder should be mixed with fruit juice or applesauce; avoid mixing with protein foods. Enzymes should be taken with each meal which will decrease the number and frequency of stools and lessen abdominal pain.

A client with a known cardiac history is admitted to the acute care unit with stable angina. At 7:00 a.m., the client had stable vital signs and was on 2 L of oxygen via nasal cannula. At 10:00 a.m., the client reports chest pain of 6 on a scale of 1 to 10, is slightly diaphoretic and pale, has a blood pressure (BP) of 100/52 mm Hg, and has a respiratory rate of 24 breaths/min. Which action should the RN implement first? 1. Apply 4 L of oxygen as ordered. 2. Administer a fluid bolus of 0.9 normal saline. 3. Administer the prescribed opioid for pain control. 4. Obtain a full set of vital signs, including temperature.

Correct Answer: 1 Rationale This is a client with a known cardiac history whose symptoms align with cardiac problems. The client has increased work of breathing with respiratory rate of 24. The priority in this client is to maximize perfusion to the myocardium. The RN should ensure adequate oxygenation before implementing other interventions.

The unlicensed assistive personnel (UAP) reports to the staff RN that a client who had surgery 4 hours ago has had a decrease in blood pressure (BP), from 150/80 to 110/70, in the past hour. The RN advises the UAP to check the client's dressing for excess drainage and report the findings to the RN. Which factor is most important to consider when assessing the legal ramifications of this situation? 1. The parameters of the state's or province's nurse practice act. 2. The need to complete the hospital's adverse occurrence report. 3. Hospital protocol regarding the frequency of vital sign assessment every hour postoperatively. 4. The health care provider's prescription for changing the postoperative dressing.

Correct Answer: 1 Rationale To delegate tasks to UAP, the RN must be knowledgeable regarding the parameters of the state's nurse practice acts. Delegation of an assessment that requires nursing judgment to a UAP is inappropriate. The other answer options do not apply to this scenario.

The RN is orienting a graduate nurse (GN) caring for a client dependent on a ventilator. Which action by the GN demonstrates understanding of VAP care? (Select all that apply.) 1. Administers a proton pump inhibitor as prescribed. 2. Rinses the client's oral cavity with chlorhexidine every 2-4 hours. 3. Elevates the HOB 60 degrees. 4. Implements spontaneous breathing trial. 5. Performs hand hygiene before and after care.

Correct Answer: 1, 2, 4, 5 Rationale VAP prevention guidelines recommend use of routine peptic ulcer prophylaxis such as proton pump inhibitors, oral care per facility protocols which may include chlorhexidine rinses, use of weaning protocols and spontaneous breathing trials, and meticulous hand hygiene before and after care. The HOB should be elevated 30-45 degrees, not 60 degrees.

The RN is administering 0900 medications to three clients on a telemetry unit when the UAP reports that another client is complaining of a sudden onset of substernal discomfort. Which action would the RN take? 1. Ask the UAP to obtain the client's vital signs. 2. Assess the client's discomfort. 3. Advise the client to rest in bed. 4. Observe the client's ECG pattern.

Correct Answer: 2 Rationale A client with a complaint of sudden onset of substernal discomfort must be assessed immediately by the RN. All other interventions listed are inappropriate for this client.

A client is admitted with PUD and GI bleeding. Which risk factor would the RN identify in the client's history? 1. Eats heavily seasoned foods. 2. Uses NSAIDs daily. 3. Consumes alcohol every day. 4. Follows an acid-ash diet.

Correct Answer: 2 Rationale A side effect of frequent use of NSAIDs is gastric irritation and potential for ulceration. Eating heavily seasoned foods does not lead to ulceration. Excessive alcohol consumption can lead to PUD, but a glass of beer/wine a day will not. An acid-ash diet encourages meats, eggs, and cheese, and discourages milk products, fruits and vegetables; it is used to acidify urine and is not a risk factor for gastric ulcer disease.

A client with a 20-year history of type 1 diabetes mellitus is having renal function tests because of recent fatigue, weakness, BUN of 8.5 mmol/L (24 mg/dL), and a serum creatine of 146 mmol/L (1.6 mg/dL). Which additional early symptom of renal insufficiency would the RN expect? 1. Dyspnea. 2. Nocturia. 3. Confusion. 4. Stomatitis.

Correct Answer: 2 Rationale Changes in urine frequency, amount, and nocturia are early symptoms of renal insufficiency. Dyspnea and confusion are late signs of renal dysfunction. Stomatitis is not a symptom of renal insufficiency.

A client with burn injuries has lost a significant amount of body fluid. An IV of Lactated Ringer's solution is infusing at 200 mL/hr, and the client's urine output for the past 8 hours is 400 mL. Which sign or symptom is the highest priority in early distributive shock? 1. A change in BP from 118/60 to 102/68. 2. A change in level of consciousness from awake to restless. 3. A decrease in O2 saturation from 98% to 93%. 4. A decrease in urine output over 8 hours from 400 to 240 mL.

Correct Answer: 2 Rationale In hypovolemic shock, the body conserves fluids, leading to decreased urine output. A key word in this question is "early." All of the other signs and symptoms occur later in the decompensated stage of shock.

The newly licensed RN overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed RN would be implemented first? 1. Monitor the nurses closely for further occurrences. 2. Advise them to cease their communication. 3. Inform the nurse manager of the conversation. 4. Submit an occurrence or variance report.

Correct Answer: 2 Rationale Nurses should not discuss client information in public settings, as it is a violation of Health Insurance Portability and Accountability Act of 1996 (HIPAA). This is a violation of client privacy and confidentiality and should be stopped immediately. All other options should be completed, but advising them to cease their communication should occur first.

A client who had a vaginal hysterectomy the previous day is saturating perineal pads with blood that require frequent changes during the night. Which priority action would the RN take? 1. Provide iron-rich foods on each dietary tray. 2. Monitor the client's vital signs every hour. 3. Administer IV fluids at the prescribed rate. 4. Encourage postoperative leg exercises.

Correct Answer: 2 Rationale The client has experienced excessive bleeding, and the RN would monitor the client's vital signs more closely (every hour). The other nursing interventions are not the priority.

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twins. At shift change, the RN assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which nursing action has the highest priority? 1. Assess the client's temperature. 2. Notify the health care provider. 3. Clean the blood from the incision site. 4. Draw labs for prothrombin time (PT), partial thromboplastin time (PTT), complete blood count (CBC), and fibrinogen.

Correct Answer: 2 Rationale The client is in shock and showing signs of DIC. The client requires immediate attention from the health care provider. The other nursing interventions are not the priority.

After the change of shift report, the RN reviews assignments. Which client would the RN assess first? 1. The elderly client receiving palliative care for heart failure who complains of constipation and nervousness. 2. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting. 3. The middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours. 4. The client who is 2 days postoperative for a thoracotomy and who has chest tubes, is on oxygen at 3 L/min, and has a respiratory rate of 12 breaths/min.

Correct Answer: 2 Rationale The client who is 48 hours postoperative and is complaining of nausea and vomiting would need to be assessed first. These symptoms could be an indication of a paralytic ileus which is a medical emergency and would need to be reported to the HCP immediately. All the other clients are not experiencing symptoms that could be life-threatening and would need to be assessed following this client.

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for pain rating 8/10. The family member requests her father be checked immediately. On arrival to the room, the RN finds the client difficult to arouse, with a respiration rate of 6. Which is the priority nursing action? 1. Elevate the head of the bed. 2. Administer naloxone 0.4 mg IV. 3. Assess breath sounds. 4. Check vital signs and pulse oximetry.

Correct Answer: 2 Rationale The client's respiratory rate is 6. The RN should administer naloxone 0.4 mg IV immediately. One of the side effects of hydromorphone is respiratory depression. The other nursing interventions need to be completed but are not the priority.

A client is admitted with a 2-day history of cough, fever, and fatigue. The medical history is positive for type I diabetes and recent upper respiratory infection (URI). Vital signs are HR 109 beats/min, BP 102/58 mm Hg, respiratory rate 24 breaths/min, temperature 104°F (40°C), and SpO2 92% on 2 L oxygen via nasal cannula. Which prescription has the highest priority in this client's care? 1. Initiate large-bore IV access. 2. Draw two sets of blood cultures. 3. Administer the ordered IV antibiotics. 4. Draw serum lactate and glucose levels.

Correct Answer: 2 Rationale The top priority would be to draw two sets of blood cultures for this client with suspected sepsis. The pathogen needs to be identified to initiate treatment to eradicate the endotoxins. The other nursing interventions are not the priority.

The complete blood count (CBC) results for a client receiving chemotherapy are hemoglobin 85 mmol/L (8.5 g/dL); hematocrit, 32%; WBC count, 6.5 × 109/L (6500 cells/mm3). Which meal choice is best for this client? 1. Grilled chicken, rice, fresh fruit salad, milk. 2. Broiled steak, whole wheat rolls, spinach salad, coffee. 3. Smoked ham, mashed potatoes, applesauce, iced tea. 4. Tuna noodle casserole, garden salad, lemonade.

Correct Answer: 2 Rationale This client has low hemoglobin and low hematocrit, which indicate anemia due to chemotherapy. The client should eat a diet rich in iron. Steak, spinach, and grains are good sources of iron. The other foods are not the highest sources of iron.

An awake, alert client with impending pulmonary edema is brought to the emergency department. The client provides the RN with a copy of a living will that states that "no invasive" medical procedures should be used to "keep her alive." The health care team is questioning whether the client should be intubated. Which information would guide the team's decision? 1. The living will removes the obligation to the client in any medical decision-making. 2. The client is awake and alert, which makes the living will irrelevant and nonbinding. 3. Lifesaving measures do not have to be explained to the client because of the signed living will. 4. The family should be contacted to determine who has durable power of attorney for health care for the client.

Correct Answer: 2 Rationale This client is awake and alert and is capable of making decisions regarding health care procedures at this time. Therefore, the LW has not been activated, and all plans for care should be discussed with the client before intubation takes place. A living will does not remove the client's ability to make medical decisions and all lifesaving procedures should still be explained to the client. The client should be asked if he or she has a durable power of attorney to make medical decisions. After the client has been intubated, they cannot communicate health care decisions.

A client who is 1 day postoperative after a left pneumonectomy is lying on his right side with the HOB elevated 10 degrees. The RN assesses his respiratory rate at 32 breaths/min. In what order would the RN perform the following actions? 1. Elevate the HOB. 2. Assist the client into the supine position. 3. Measure the client's O2 saturation. 4. Administer intravenous (IV) PRN morphine.

Correct Answer: 2,1, 3, 4 Rationale The RN should elevate the HOB and assist the client into a supine position for repositioning and full lung expansion. Then measure the client's O2 saturation. Finally, the RN should administer IM morphine as needed.

Which client would be assigned to a graduate nurse orienting to the neurological unit? 1. A client with a head injury who has a Glasgow Coma Scale of 6. 2. A client who developed autonomic dysreflexia after a T6 spinal cord injury. 3. A client with multiple sclerosis who needs the first dose of interferon. 4. A client diagnosed with Guillain-Barré syndrome.

Correct Answer: 3 Rationale A client with multiple sclerosis who needs the first dose of interferon can be assigned to a graduate nurse who is orienting to the neurological unit. The other clients need more thorough assessment by an experienced nurse.

A client has not had a bowel movement in 2 days and reports this information to the RN. Which intervention would the RN implement first? 1. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. 2. Notify the HCP and request a prescription for a stool softener. 3. Assess the client's medical record to determine his normal bowel pattern. 4. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Correct Answer: 3 Rationale Assessing the normal bowel pattern in a client with possible constipation provides the information to determine an appropriate response to the client's concern. Note that two interventions (A and D) are similar and can be eliminated. Nursing interventions to correct the constipation should be performed before notifying the HCP and requesting medical intervention.

A client who is diagnosed with an obstruction of the common bile duct caused by cholelithiasis passes clay-colored stools containing streaks of fat. Which action would the RN take? 1. Auscultate for diminished bowel sounds. 2. Send a stool specimen to the lab. 3. Document the assessment in the chart. 4. Notify the HCP.

Correct Answer: 3 Rationale Clay-colored stools streaked with fat in the presence of cholelithiasis is an expected finding in blockage of bile duct (stool contains bilirubin). The finding should be documented in the Client chart. The other interventions are not necessary for this client.

In completing a client's perioperative routine, the RN finds that the consent form has not been signed. The client begins to ask more questions about the surgical procedure. Which action would the RN take? 1. Witness the client's signature on the consent form. 2. Answer the client's questions about the surgery. 3. Inform the HCP that the client has questions about the surgery. 4. Reassure the client that the surgeon will answer any questions before the anesthetic is administered.

Correct Answer: 3 Rationale Informed consent must be obtained prior to performing any invasive or surgical procedure. The RN needs to notify the HCP that the client has questions concerning the procedure that must be addressed by the HCP. The consent form cannot be witnessed until all client questions have been clarified to obtain informed consent. It is not the nurse's responsibility to answer the questions. Reassuring the client that the surgeon will answer their questions does not address the issue and therefore should not be stated.

Which assignment should the RN delegate to a UAP in an acute care setting? 1. Checking blood glucose hourly for a client with a continuous insulin drip. 2. Giving PO medications left at the bedside for the client to take after eating. 3. Taking vital signs for an older client with left humeral and left tibial fractures. 4. Replacing a client's pressure ulcer dressing that has been soiled by incontinence.

Correct Answer: 3 Rationale Measuring vital signs on the uninjured arm of an elder client does not require the expertise of the RN to be performed. The other actions are beyond the scope of practice for a UAP and should be completed by the RN.

The charge nurse is making assignments for each of four staff members, including a RN, a licensed practical nurse (PN), and two UAPs. Which task is best to assign to the PN? 1. Maintain a 24-hour urine collection. 2. Wean a client from a mechanical ventilator. 3. Perform sterile wound irrigation. 4. Obtain scheduled vital signs.

Correct Answer: 3 Rationale Performing a sterile wound irrigation is within the scope of practice for the PN and is an appropriate assignment for the charge nurse to make. Maintaining a 24-hour urine collection can be performed by one of the UAPs and the other can gather the scheduled vital signs. A RN should be responsible for weaning a client from a mechanical ventilator.

A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action would the RN take first? 1. Call the HCP. 2. Obtain a bedside pulse oximeter. 3. Raise the head of the bed higher. 4. Assess the client's vital signs.

Correct Answer: 3 Rationale Remember to address ABCs first. The objective is to assist the client in using the accessory muscles of breathing. Raising the head of the bed farther will keep the spine straight, decrease pressure on the diaphragm, relax the abdominal muscle to improve breathing and will assist the client to breathe easier. This intervention addresses breathing, which would be the priority. Although the RN might call the HCP, obtain the pulse oximeter, and assess the client's vital signs, these would not be done first.

The RN is caring for several clients. Which client would the RN assess first? 1. A 20-year-old client whose Glasgow Coma Scale is 8 and unchanged from the last assessment. 2. A 45-year-old client with a left-sided cerebrovascular accident (CVA) who refuses his morning care. 3. A 38-year-old client who is increasingly stuporous after an aneurysm repair. 4. A 29-year-old client post motor vehicle accident (MVA) whose Glasgow Coma Scale was 9 one hour ago and is now 10.

Correct Answer: 3 Rationale The 38-year-old client who is increasingly stuporous after an aneurysm repair is of highest priority and needs to be assessed first. Changes in LOC may be the earliest sign of increasing ICP. The other clients are not as high of a priority.

The RN begins their shift by reviewing the status of their clients. Which client would the RN assess first? 1. The client receiving oxygen per nasal cannula who is dyspneic on mild exertion and has a hemoglobin of 7 g/dL (70 mmol/L). 2. The client receiving IV aminoglycosides per Central Venous Catheter (CVC) who complains of nausea and has a trough level below therapeutic levels. 3. The client with a chest tube that drained 150 mL in the last hour. 4. The client receiving chemotherapy whose temperature is 37.2°C (98.9°F) and who has a white blood cell (WBC) count of 2.5 × 109/L (2500/mm3).

Correct Answer: 3 Rationale The HCP should be notified if chest tube drainage is >100 mL/hr. The first client does not require the RN's immediate attention. The client receiving IV aminoglycosides should be assessed, but this is not the priority client. The client receiving chemotherapy should be assessed, but this is not the priority client.

The RN is preparing for change of shift. Which action by the RN is characteristic of ineffective handoff communication? 1. The RN states to the RN coming on duty, "The client is anxious about complications after surgery. Review the information I provided about how to use an incentive spirometer." 2. The RN refers to the electronic medical record (EMR) to review the client's medication administration record. 3. During rounds, the RN talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client. 4. Before giving a report, the RN performs rounds on assigned clients so that there is less likelihood of interruption during handoff.

Correct Answer: 3 Rationale The RN should not discuss or gossip about a problem with a fellow coworker during shift handoff. This incident should be addressed with the UAP to ensure the incident does not happen again. It is inappropriate to discuss the incident in the shift report and undermine the competency of the UAP. The oncoming RN should be made aware of client concerns and what client teaching has been performed. Using the EMR ensures accurate reporting during handoff communication and is recommended to provide accurate medication administration history information. Reducing the likelihood of interruptions during handoff is an effective communication technique.

A client who is receiving a transfusion of packed red blood cells has an inflamed IV site. Which action would the RN take? 1. Double-check the blood type of the transfusing unit of blood with another nurse. 2. Discontinue the transfusion and send the remaining blood and tubing to the lab. 3. Immediately start a new IV at another site and resume the transfusion at the new site. 4. Continue to monitor the site for signs of infection and notify the HCP.

Correct Answer: 3 Rationale The RN would immediately start a new IV at another site and resume the transfusion at the new site. This is not a sign of a transfusion reaction but rather phlebitis. If the client remains free of S/S of a transfusion reaction, the transfusion should be continued. However, the previous site should be monitored for signs of infection and reported per facility policy. The other interventions should be completed if a transfusion reaction is suspected.

Which nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? 1. Reassure the client that this admission is only for a limited amount of time. 2. Offer the client and family the opportunity to share their feelings about the admission. 3. Determine the behaviors that resulted in the need for admission. 4. Advise the client about the legal rights of all hospitalized clients.

Correct Answer: 3 Rationale Think safety. An involuntary admission is based on the risk for harm to self or others; therefore, assessment of harmful behaviors is the highest priority. The other options are of lesser priority, but will be conducted during the admission process and assessment.

A client recovering from ARDS is awake and alert but has residual fatigue and generalized weakness. The client's current vital signs are HR 83 beats/min, BP 104/64 mm Hg, respiratory rate 25 breaths/min, and SpO2 92% on 2 L/min oxygen via nasal cannula. Which vital sign requires the RN to take action? 1. HR of 83 beats/min. 2. BP of 104/64 mm Hg. 3. Respiratory rate of 25 breaths/min. 4. SpO2 92% of 2 L/min O2 via nasal cannula.

Correct Answer: 3 Rationale This respiratory rate is high, especially for a client on oxygen. The RN should take action on this finding. The other findings do not require immediate nursing attention.

A client, who is HIV positive, asks why it is necessary to have a viral load study performed every 3 to 4 months. Which information would the RN provide? 1. To determine the progression of the disease. 2. To evaluate the ELISA. 3. To monitor the effectiveness of the treatment. 4. To track the effectiveness of the vaccine.

Correct Answer: 3 Rationale Viral load testing directly measures the actual amount of HIV viral RNA particles in blood and is used to monitor the effectiveness of treatment. CD4+ T cells are monitored to determine progression of the disease. The ELISA test confirms a diagnosis of HIV. There is currently no vaccine for HIV.

Which laboratory result for a preoperative client would prompt the RN to contact the health care provider? 1. Platelet count: 151 × 109/L (151,000/mm3). 2. White blood cell (WBC) count: 85 × 109/L (8500/mm3). 3. Serum potassium level: 2.8 mEq/L (mmol/L). 4. Urine specific gravity: 1.031.

Correct Answer: 3 Rationale: The serum potassium level is severely low. Normal potassium level is between 3.6 and 5.2 mEq/L (mmol/L). This electrolyte imbalance can lead to deadly dysrhythmias and must be resolved prior to starting an operative procedure. This requires immediate contact of the health care provider (HCP). The other labs are within normal limits and do not require contact of the HCP.

A client with a history of coronary heart disease was admitted to the acute care unit 2 days ago for management of angina. During the assessment, the client states, "I feel like I have indigestion." In which order would the RN implement care? (Arrange from first action to last.) 1. Notify the rapid response team. 2. Administer PRN nitroglycerin prescription. 3. Assess the pulse, respirations, BP, and oxygen saturation. 4. Document assessment in the electronic medical record. 5. Provide 2 L of oxygen via nasal cannula.

Correct Answer: 3, 5, 2, 1, 4 Rationale For emergency care of the client with chest pain, it is important to quickly gather vital signs, provide O2, administer nitroglycerin, notify the rapid response team, and finally, document: 3, 5, 4, 2, 1, 4.

Which change in the status of a client being treated for increased ICP warrants immediate action by the RN? 1. Urinary output changes from 20 to 50 mL/hr. 2. Arterial PCO2 changes from 40 to 30 mm Hg. 3. Glasgow Coma Scale score changes from 5 to 7. 4. Pulse decreases from 88 to 68 beats/min.

Correct Answer: 4 Rationale A client's pulse that drops from 88 to 68 beats/min is a component of sign of Cushing's triad, which indicates increased ICP.

The RN is assessing clients at the site of a community disaster. Using the color-code system for triage, which client would the RN tag with a red code? 1. A client with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations. 2. A client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18. 3. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene. 4. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32, who is moaning.

Correct Answer: 4 Rationale A red tag would be assigned to the client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32, and who is moaning. The other clients are not the priority in a disaster situation.

The RN enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is most important for the RN to ask the client? 1. "When did the surgeon explain the procedure to you?" 2. "Is any member of your family going to be here during your surgery?" 3. "Have you been instructed in postoperative activities and restrictions?" 4. "Have you received any preoperative pain medication?"

Correct Answer: 4 Rationale Asking the client or knowing if the client has received pain medication prior to signing and witnessing the surgical consent form is essential. Pain medications can alter a client's ability to think clearly and make medical decisions. Consent should be obtained, if possible, before pain medications are administered. The other questions are components of the preoperative checklist and should be reviewed with the client and family prior to the procedure.

A client in shock develops a MAP of 60 mm Hg and a HR of 110 beats/min. Which prescribed intervention would the RN implement first? 1. Increase the rate of O2 flow. 2. Obtain arterial blood gas results. 3. Insert an indwelling urinary catheter. 4. Increase the rate of intravenous (IV) fluids.

Correct Answer: 4 Rationale Nursing interventions to correct shock are focused on correcting decreased tissue perfusion and restoring cardiac output. Increasing the IV fluid rate will help to expand blood volume, which will increase tissue perfusion and cardiac output.

The RN palpates a crackling sensation around the insertion site of a chest tube in a client who has had thoracic surgery. Which action would the RN take? 1. Return the client to surgery. 2. Prepare for insertion of a larger chest tube. 3. Increase the water-seal suction pressure. 4. Continue to monitor the insertion site.

Correct Answer: 4 Rationale Small amounts of subcutaneous emphysema (crackling sensation) after thoracic surgery are common and will be absorbed, causing no problem. The RN should continue to monitor the insertion site for worsening that includes swelling of the neck and chest. Other actions are not indicated at this time.

The charge nurse confronts a staff nurse whose behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states, "Don't blame me; nobody likes this idea." Which is the charge nurse's priority action? 1. Confront the other staff members involved in the change of unit policy. 2. Call a unit meeting to review the reasons the change was made. 3. Develop a written unit policy for the expression of complaints. 4. Encourage the nurse to be accountable for their own behavior.

Correct Answer: 4 Rationale The charge nurse should encourage the staff nurse to be accountable for their own behavior. Displacing blame on other members of the staff is not an appropriate response and should be addressed immediately by the charge nurse. The charge nurse should not confront the other staff members about the policy change. Confrontation should be avoided and a discussion should take place instead. This could be handled in a unit meeting that discusses the reason these changes were made. However, this meeting is not the priority action at this moment. For future occurrences, a written policy for expression of complaints should be developed for the unit or facility.

The RN is assigning rooms for four new clients. Only one private room is available in the oncology unit. Which client would be placed in the private room? 1. The client with ovarian cancer who is receiving chemotherapy. 2. The client with breast cancer who is receiving external beam radiation. 3. The client with prostate cancer who has just had a transurethral resection. 4. The client with cervical cancer who is receiving intracavity radiation.

Correct Answer: 4 Rationale The client receiving intracavity radiation must be place in a private room due to the chance of radiation contamination. All other clients have little to no chance of transmitting radioactive material to other clients.

Which client would the RN assess first? 1. The client diagnosed with hyperthyroidism who is exhibiting exophthalmos. 2. The client diagnosed with type 1 diabetes who has an inflamed foot ulcer. 3. The client with Cushing syndrome exhibiting moon face. 4. The client with Addison disease showing tremors and diaphoresis.

Correct Answer: 4 Rationale The client with Addison disease showing tremors and diaphoresis needs to be assessed first. These can be signs of Addisonian (adrenal) crisis, which can be a potentially fatal condition. All other findings are expected and are not life-threatening.

A family member of a client who is in a Posey vest restraint (SRD) asks why the restraint was applied. Which response would the RN make? 1. The Posey vest restraint was prescribed by the health care provider. 2. There is not enough staff to keep the client safe all the time. 3. The other clients are upset when the client wanders at night. 4. The client's actions place the client at high risk for self-harm.

Correct Answer: 4 Rationale The client's behavior places the client at high risk for self-harm. Restraints may be applied to protect the client from injury after all other measures to protect the client have been attempted. The HCP can prescribe restraints only once all other less restrictive interventions have failed. Staffing issues are not legal indications for restraining a client. Wandering at night and other client concerns are also not reasons for applying restraints.

The RN is preparing to administer a PPD test to a client who is entering nursing school. Which action is the RN's highest priority? 1. Prepare 0.1 mL solution for tuberculin syringe. 2. Assess the skin condition on the forearm. 3. Teach the client about positive findings. 4. Inquire about bacillus Calmette-Guérin (BCG) vaccine history.

Correct Answer: 4 Rationale The highest priority is assessing for a history of BCG vaccine because administering a PPD to a client who has received the vaccine will be positive and result in a large reaction at the site. Those clients will need to have a chest x-ray (CXR) and avoid PPD screening for at least 10 years after administration. The other options are appropriate but not the highest priority.

The charge nurse is making assignments on the renal unit. Which client would the registered nurse (RN) assign to a practical nurse (PN) who is new to the unit? 1. An older client who has thick, dark red drainage in a urinary catheter 1 day after a transurethral prostatic resection. 2. A middle-aged client admitted with a diagnosis of acute renal failure secondary to a reaction to IV pyelogram dye. 3. An older client who has end-stage renal disease and complains of nausea after receiving digoxin. 4. A middle-aged client who receives hemodialysis and has been prescribed epoetin alfa subcutaneous daily.

Correct Answer: 4 Rationale The middle-aged client who receives hemodialysis and has been prescribed epoetin alfa subcutaneous daily can be assigned to the PN. This injection can be administered by the PN. All other clients listed require more advanced assessment by the RN.

A client who has acute renal failure is admitted to the hospital. The client's potassium level is 6.4 mEq/L. Which snack would the RN offer? 1. An orange. 2. A milkshake. 3. Dried fruit and nuts. 4. A gelatin dessert.

Correct Answer: 4 Rationale The normal potassium level for an adult is 3.5 to 5 mEq/L. Therefore, gelatin, which contains no potassium, could be offered. A potassium level of 6.4 mEq/L (hyperkalemia) is life threatening. Milk, oranges, and dried fruits and nuts are potassium-rich foods and should not be offered to the client.

Which situation warrants a variance (incident) report by the RN? 1. A client refuses to take prescribed medication. 2. A client's status improves before completion of the course of medication. 3. A client has an allergic reaction to a prescribed medication. 4. A client received medication prescribed for another client.

Correct Answer: 4 Rationale Variance or incident reports are used for unusual circumstances that require investigation by the facility to prevent further occurrences. A client who receives medication that was prescribed to another client is an example of a medication variance and requires reporting using the facility's incident reporting procedure. This incident should be recorded and investigated to ensure that the occurrence does not reoccur to another client. An incident where a client refuses to take their medications or has status improvement does not require documentation via an incident report but should be documented in the chart. Although an allergic reaction is a concerning incident, this type of reporting is not appropriate. The HCP should be notified of the allergic reaction and the allergy should be noted on the client's chart.

Four clients arrive in the emergency department after an explosion. In which order should they be assessed? All options must be used. 1. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn. 2. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest. 3. A 25-year-old with a superficial burn to the right anterior arm and lateral chest. 4. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion.

Correct Answer: The correct order is 2, 4, 1, 3 Rationale Clients are assessed using the SMART method of triage.