kap kat 1b

The nurse manager reviews the importance of using best evidence when planning client care during a nursing staff meeting. Which nursing staff response indicates additional information is required regarding evidence-based practice? (Select all that apply.) 1. "I'm glad that standardized care plans are gone." 2. "Care plans now will be customized and useful." 3. "I always liked research and now we can do it with our clients." 4. "A software program to help search for information will be helpful." 5. "Now we know that interventions for care will work for our clients."

1) CORRECT - A misconception about evidence-based practice is that it is another name for standardized care. 3) CORRECT - Evidence-based practice is not conducting research, but rather using the best evidence substantiated by research for client care.

The nurse provides care for a client recovering from surgery to repair retinal detachment. Which nursing intervention is important for this client? 1. Maintain eye shield or patch. 2. Encourage deep breathing. 3. Monitor for hemorrhage. 4. Assist with activities of daily living. 5. Teach symptoms of retinal detachment.

1) CORRECT - An eye patch or shield is applied to protect the eye and prevent any further detachment. 3) CORRECT - Hemorrhage is a risk post-operatively. 4) CORRECT - Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living. The client needs the nurse's assistance with these activities. 5) CORRECT - Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment.

The nurse provides care for a client diagnosed with diabetic ketoacidosis. Which nursing diagnosis will the nurse include in the plan of care for this client? (Select all that apply.) 1. Anxiety related to loss of control and inability to manage diabetes. 2. Risk for fluid volume excess related to anuria. 3. Deficient knowledge related to diabetes management. 4. Risk for electrolyte imbalance related to fluid shifts. 5. Risk for falls related to mental status changes.

1) CORRECT - Anxiety related to loss of control and inability to manage diabetes would be appropriate for the client diagnosed with diabetic ketoacidosis. 3) CORRECT - The client diagnosed with diabetic ketoacidosis may have deficient knowledge related to diabetes management that led to the complication. 4) CORRECT - The client with diabetic ketoacidosis is a risk for electrolyte imbalance related to fluid loss and shifts. 5) CORRECT - A client with diabetic ketoacidosis is at risk for falls secondary to mental status changes that may occur.

The nurse prepares teaching for a client prescribed alendronate sodium. Which information will the nurse include in this teaching? (Select all that apply.) 1. "Take this medication with at least 8 ounces of water." 2. "Take this medication while ingesting the first bite of food in the morning." 3. "Wait 30 minutes after eating before taking this medication." 4. "Sit upright for at least 30 minutes after taking the medication." 5. "Take this medication 30 minutes before food or other medications."

1) CORRECT - Bisphosphonate alendronate sodium is given as treatment for osteoporosis. The medication should be taken with at least 8 ounces of water. 4) CORRECT - Alendronate sodium can cause esophageal irritation and erosion. Because of this, the client should be instructed to sit upright for at least 30 minutes after taking. 5) CORRECT - Alendronate sodium is to be taken on an empty stomach. Once taken, the client should wait 30 minutes before eating so as not to interrupt the absorption of the medication from the gastrointestinal tract.

The nurse observes a client's cardiac rhythm change from sinus rhythm to ventricular fibrillation. Which action does the nurse take next? 1. Begin cardiopulmonary resuscitation. 2. Administer prescribed intravenous amiodarone. 3. Palpate for a femoral pulse. 4. Prepare for defibrillation.

1) CORRECT - Cardiopulmonary resuscitation should be started while preparing for defibrillation.

The nurse works in a psychiatric facility that applies behavioral therapy. Which group of clients benefits most from this method? 1. Children in general. 2. Delinquent adolescents. 3. Mentally challenged adults. 4. Socially isolated persons.

1) CORRECT - Children respond especially well to behavioral therapy that uses a reward system, such as sticker charts, and lists of responsibilities that can be checked off. These strategies help reinforce appropriate behaviors.

The nurse provides teaching for a client who takes an alpha-adrenergic blocker to treat benign prostatic hyperplasia (BPH). Which client statement indicates to the nurse that the teaching is successful? 1. "I will avoid tasks that require me to be alert." 2. "I will take my medication as soon as I wake up." 3. "I will take my medication with food or milk." 4. "I will take my medication with a liquid antacid."

1) CORRECT - Common side effects of an alpha-adrenergic blocker include dizziness and drowsiness. The client should void tasks requiring alertness (driving, operating machinery) until effects of medication are known.

After being notified that a client is seeking legal counsel about care received while hospitalized, the nurse manager investigates a staff nurse's performance regarding the client's care. Which nursing action will concern the nurse manager? (Select all that apply.) 1. The nurse mailed prescriptions to the client after discharge. 2. The nurse consulted the wound care nurse for the client's area of skin breakdown. 3. The nurse found a referral for home care with laboratory results faxed after the client was discharge. 4. The nurse delegated sterile wound care to nursing assistive personnel (NAP). 5. The nurse administered an oral pain medication when an intramuscular dose was prescribed.

1) CORRECT - Discharging a client without prescribed medications could be viewed as negligence or a breach of duty. 3) CORRECT - Finding a home care referral with laboratory results faxed after discharge could be viewed as negligence or breach of duty. 4) CORRECT - Delegating care to someone that is beyond their scope of practice is negligence. 5) CORRECT -Altering a medication prescription is malpractice since it is beyond the nurse's scope of practice.

A client with heart failure is prescribed furosemide. Which observation best indicates to the nurse that this medication is effective? 1. Ankle edema is +1. 2. Urine output 45 mL/hr. 3. Crackles bilateral lung bases. 4. Blood pressure 158/88 mm Hg.

1) CORRECT - Furosemide is used in the treatment of edema associated with heart failure. Ankle edema noted at +1 indicates that this medication has been effective.

The health care provider prescribes erythromycin eye ointment for a full-term newborn. Which nursing action is appropriate when administering this medication? (Select all that apply.) 1. Wear disposable gloves while administering the medication. 2. Hold the ointment tube in a vertical position to prevent injury. 3. Apply ointment from the outer canthus to the inner canthus. 4. Apply ointment to the lower conjunctival sac of each eye. 5. Rinse each eye with sterile saline after administering the ointment.

1) CORRECT - Gloves should be worn when providing newborn care. 4) CORRECT - The ointment should be applied to the lower conjunctival sac.

The nurse suctions a newborn using a bulb syringe. Which nursing action is appropriate? (Select all that apply.) 1. Place the newborn supine with head turned to the side. 2. Compress the bulb before inserting the bulb tip into the mouth. 3. Gently insert the bulb tip toward the back of the throat. 4. Release the bulb quickly to get as many secretions as possible. 5. Suction the nose after the mouth is suctioned, if necessary.

1) CORRECT - It is best to position an infant on the back with the head to either side. 2) CORRECT - Compress the bulb before inserting the bulb tip into the infant's mouth. 5) CORRECT - Suction the nose gently, only if necessary, as suctioning can be traumatic to nasal tissues.

A client in the postanesthesia care unit (PACU) reports nausea to the nurse. Which prescribed medication will the nurse give intravenously for this client's problem? (Select all that apply.) 1. Metoclopramide. 2. Promethazine. 3. Ondansetron. 4. Aluminum hydroxide 5. Sucralfate.

1) CORRECT - Metoclopramide, an antiemetic and gastrointestinal stimulant, can be given intravenously to treat nausea. 2) CORRECT - Promethazine, an antiemetic, can be given intravenously (with extreme caution and according to facility protocol) to treat nausea. If extravasation occurs, tissue necrosis is a risk. 3) CORRECT - Ondansetron, an antiemetic, can be given intravenously to treat nausea.

The nurse teaches the client about sickle cell disease. Which statement by the client indicates to the nurse that the client needs further teaching? (Select all that apply.) 1. "I know I need to smoke cigarettes less often." 2. "Taking "the pill" will keep me from getting pregnant." 3. "Drinking water often throughout the day will take effort." 4. "Hiking every Sunday is my favorite physical activity." 5. "I've already told my new dentist I have sickle cell disease."

1) CORRECT - The client needs to completely stop using tobacco in any form in order to help prevent sickle cell crisis. 2) CORRECT - Oral contraceptives will prevent pregnancy but also increase the risk of blood clots. The client is already at high risk for blood clots due to sickle cell disease. 3) The client has identified that drinking lots of water is necessary and that it will be a struggle. 4) CORRECT - Strenuous activity, high altitudes, and dehydrating circumstances should be avoided. If the client wants to continue this activity, there needs to be plan to prevent sickle cell crisis.

The nurse learns that victims of a chemical plant disaster will need to be admitted; however, the unit is filled to capacity. Which client will the nurse identify to discharge in order to make room for the new admissions? (Select all that apply.) 1. Client recovering from appendectomy 36 hours ago. 2. Client being treated for exacerbation of multiple sclerosis. 3. Client with a urinary tract infection awaiting blood culture results. 4. Client with hypokalemia and multifocal premature ventricular contractions. 5. Client with new onset of abdominal distention, nausea, and distant bowel sounds.

1) CORRECT - The client who had an appendectomy 36 hours ago is most likely ambulatory and can be safely discharged after receiving specific instructions to report signs of infection or wound dehiscence. 2) CORRECT - The client with an exacerbation of multiple sclerosis is being treated and could safely be discharged with specific instructions regarding the reporting of new symptoms or adverse effects of medications. 3) CORRECT - The client with a urinary tract infection awaiting blood culture results can be safely discharged after receiving instructions on the self-administration of antibiotics and new symptoms to report.

The nurse provides care to a client with liver failure. Which medication route will the nurse use to avoid the first-pass effect with this client? (Select all that apply.) 1. Inhaler. 2. Oral. 3. Intramuscular. 4. Sublingual. 5. Transdermal.

1) CORRECT - The nasal route will bypass the liver. 3) CORRECT - The intramuscular route will bypass the liver. 4) CORRECT - The sublingual route will bypass the liver. 5) CORRECT - The transdermal route will bypass the liver.

The nurse receives a verbal prescription from a health care provider during a client emergency. Which action does the nurse take to ensure client safety? (Select all that apply.) 1. Record the prescription in the client's medical record. 2. Read back the prescription to verify the accuracy of the prescription. 3. Date and time the prescription that was issued during the emergency. 4. Record the health care provider's prescriber number. 5. Document the nurse's own name and license number.

1) CORRECT - The nurse should first record the prescription in the client's medical record. 2) CORRECT- After writing down the prescription in the client's medical record, the nurse should read back the prescription to verify the accuracy of the prescription. 3) CORRECT - After writing down the prescription in the client's medical record and reading back the prescription to verify its accuracy, the nurse should record the date and time the prescription was issued.

The nurse performs teaching for a client diagnosed with Crohn disease. Which statement made by the client would cause the nurse to provide additional instruction? (Select all that apply.) 1. "I need to consume a low-calorie, high-protein, low-residue diet." 2. "I will take a cathartic each morning before breakfast." 3. "I take supplemental vitamin therapy and iron replacement pills." 4. "It may be necessary to have nutrition delivered intravenously." 5. "If I watch my diet, I can expect to achieve a cure from this condition."

1) CORRECT - The response does not reflect the correct understanding of a recommended diet for Crohn disease. The client will need a high calorie intake in addition to the high protein and low residue. 2) CORRECT - A cathartic will stimulate defecation and is not desired because the client has Crohn disease. Diarrhea is a clinical manifestation of Crohn disease. 5) CORRECT - A client can expect to put the Crohn disease into remission, but a cure is not achieved. There is usually frequent exacerbations, treatment, and then periods of remission.

The nurse provides care to an older adult client in the hospital. Which factor increases this client's risk of falling? (Select all that apply.) 1. Glare from bright lights. 2. Hypertension. 3. Obesity. 4. Medication interactions. 5. Previous falls.

1) CORRECT - Vision changes associated with aging can be exacerbated by the glare from bright hospital lights. This can cause difficulty differentiating things that can create tripping hazards. 4) CORRECT - Medication interactions can cause drowsiness, decreased coordination, and orthostatic hypotension, which increase the risk of falling. 5) CORRECT - Previous falls can lead to fear and a loss of confidence when walking.

The nurse notes that the high-pressure alarm is sounding on a client being mechanically ventilated. Which occurrence results in the activation of this alarm? (Select all that apply.) 1. Increased bronchial secretions. 2. A kink in the tubing. 3. Acute bronchospasm. 4. The client biting the endotracheal tube. 5. Disconnected ventilator tubing.

1) CORRECT — An increased amount of secretions or a mucus plug in the airways can trigger the high-pressure alarm. 2) CORRECT — An obstruction of the tubing, such as a kink, can trigger the high-pressure alarm. 3) CORRECT — A decrease in airway size related to wheezing or bronchospasm can trigger the high-pressure alarm. 4) CORRECT — Coughing, gagging, or biting on the oral endotracheal tube can trigger the high-pressure alarm.

The health care provider prescribes peripheral intravenous (IV) fluid for a client diagnosed with pneumonia. Which action will the nurse take when inserting the IV catheter? (Select all that apply.) 1. Perform hand hygiene before inserting the catheter. 2. Verify the prescription for IV therapy. 3. Prepare the site with chlorhexidine and wipe it dry with a sterile gauze pad. 4. Cover the insertion site with a sterile occlusive dressing. 5. Stabilize with an armboard if in an area of flexion such as the elbow.

1) CORRECT — Hand hygiene should be performed before inserting the catheter to reduce the risk for vascular catheter-associated infections. 2) CORRECT — The health care provider's prescription should be verified before beginning the therapy. 4) CORRECT — The insertion site should be covered with a sterile occlusive dressing to prevent contamination and subsequent vascular catheter-associated infection. 5) CORRECT — A joint stabilization device should be applied to an area of flexion to prevent injury.

The nurse provides care for a school-age child. The nurse receives an intramuscular antibiotic prescription for the child. Which step does the nurse take first? 1. Advocate for selection of an alternate administration route. 2. Confirm the child's identity using at least two client identifiers. 3. Administer a topical anesthetic to the administration site. 4. Disinfect the injection site with an antiseptic and allow to dry.

1) CORRECT — Most medications can be prescribed by an alternative route. Maintaining the principles of atraumatic care, the nurse should advocate for the child to see whether the medication can be administered by an alternate route.

The nurse provides care for client with a pulmonary artery catheter (Swan-Ganz). Which parameter does the nurse monitor to evaluate whether interventions to decrease afterload were effective? 1. Systemic vascular resistance (SVR). 2. Central venous pressure (CVP). 3. Cardiac output (CO). 4. Pulmonary artery occlusion pressure (PAOP).

1) CORRECT — SVR best reflects afterload (vascular resistance).

After being told the diagnosis of terminal cancer, a client says "Why is God doing this to me?" Which nursing diagnosis does the nurse include in the plan of care for this client? 1. Spiritual distress. 2. Ineffective coping. 3. Anticipatory grieving. 4. Readiness for enhanced spiritual well-being.

1) CORRECT — The client's questions about actions that might have angered God to cause the illness indicate a conflict with spirituality.

A client returns to the care area after an esophagectomy. Which intervention will the nurse make a priority? 1. Turning, deep breathing, and coughing every 1 to 2 hours. 2. Positioning the client in semi-Fowler or high-Fowler. 3. Monitoring heart rhythm for arrhythmias and changes in rate. 4. Evaluating nasogastric tube drainage for character and color.

1) CORRECT — Turning, deep breathing, and coughing prevent pulmonary secretions from accumulating and helps prevent postoperative respiratory complications.

The nurse is teaching a client who has undergone a cataract extraction with intraocular implant. Which instruction does the nurse include in the discharge teaching? (Select all that apply.) 1. Avoid activities that require bending over. 2. Place an eye shield on the surgical eye at bedtime. 3. Avoid lifting anything over 5 pounds. 4. Contact the surgeon if eye scratchiness occurs. 5. Take acetaminophen for minor eye discomfort.

1) CORRECT- Activities such as bending over increase intraocular pressure. These place strain on the suture line. 2) CORRECT- Placing an eye shield over the operative eye at bedtime protects the eye from injury during sleep. 3) CORRECT- Lifting weights over 5 pounds increases intraocular pressure and puts strain on the suture line. 5) CORRECT- After eye surgery, mild eye discomfort may occur in the operative eye. It is usually relieved by mild analgesics

The infection control nurse supervises care for a client diagnosed with a Clostridium difficile (C.Diff). Which action, if observed by the infection control nurse, necessitates intervention? (Select all that apply.) 1. Implementing droplet precautions while caring for the client. 2. Cleansing equipment with alcohol wipes. 3. Using hand sanitizer after providing client care. 4. Allowing the client to eat in the hospital cafeteria. 5. Leaving the client's door open after staff members exit the room.

1) CORRECT- The infection control nurse should intervene. The client should be placed under contact precautions and staff should enter client's room wearing gown and gloves to provide barrier to prevent transmission of spores. Droplet precautions are not necessary for this client. 2) CORRECT- The infection control nurse should intervene. C.diff spores are resistant to alcohol; therefore, a bleach-based cleaning product should be used when disinfecting the surface areas used for clients who are diagnosed with C.diff. 3) CORRECT- The infection control nurse should intervene. Hands should be cleansed with soap and water after providing client care. Alcohol hand gels are ineffective against Clostridium difficile spores. 4) CORRECT- The infection control nurse should intervene. The client should not go to common areas, such as the cafeteria or gift shop. However, client can go to other areas of the hospital for treatments and tests.

The nurse provides care for a client with a serum sodium level of 119 mEq/L (119 mmol/L). Which action will the nurse take? (Select all that apply.) 1. Obtain an order for nothing by mouth status. 2. Monitor for neurological changes. 3. Teach about a fluid restriction. 4. Anticipate a prescription for hypertonic saline. 5. Assess for signs of fluid overload.

2) CORRECT - A critically low sodium can lead to seizures or coma. 3) CORRECT - A fluid restriction of 800 to 1,000 mL per day is standard with syndrome of inappropriate antidiuretic hormone. It depends on how low the sodium level is. 4) CORRECT - If the sodium level is critically low, hypertonic saline solution (3%) may be given. 5) CORRECT- Water retention in syndrome of inappropriate antidiuretic hormone can lead to fluid overload.

The nurse finds a client lying on the floor. The client is unresponsive with agonal, gasping respirations and no palpable pulse. Which action is appropriate for the nurse to take? (Select all that apply.) 1. Administer synchronized cardioversion. 2. Begin cycles of 30 chest compressions and two breaths. 3. Call for nearby help. 4. Check the client's heart rhythm. 5. Activate the emergency response system using a mobile device.

2) CORRECT - According to the American Heart Association guidelines, the nurse should call for nearby help, activate the emergency response system using a mobile device, send someone for a defibrillator or automated external defibrillator, and begin cycles of 30 chest compressions and two breaths. 3) CORRECT - According to the American Heart Association guidelines, the nurse should call for nearby help, activate the emergency response system using a mobile device, send someone for a defibrillator or automated external defibrillator, and begin cycles of 30 chest compressions and two breaths. 4) CORRECT - According to the American Heart Association guidelines, the nurse should call for nearby help, activate the emergency response system using a mobile device, send someone for a defibrillator or automated external defibrillator, and begin cycles of 30 chest compressions and two breaths. When the defibrillator arrives, the nurse should check the heart rhythm, and deliver a shock if a shockable rhythm is present. 5) CORRECT - According to the American Heart Association guidelines, the nurse should call for nearby help, activate the emergency response system using a mobile device, send someone for a defibrillator or automated external defibrillator, and begin cycles of 30 chest compressions and two breaths.

The nurse suspects that a client has problem with cranial nerve V. Which action will the nurse perform to support this clinical determination? 1. Shine a penlight into the right eye. 2. Touch the cornea with a cotton wisp. 3. Touch the uvula with a tongue depressor. 4. Apply a tuning fork to the top of the head.

2) CORRECT - An absent corneal reflex may be associated with a malfunctioning trigeminal nerve or cranial nerve V.

The nurse provides care for a client diagnosed with inflamed pruritic dermatitis. Which dressing is appropriate for the nurse to use for this client's condition? 1. Sterile dry gauze dressing. 2. Cool tap water dressing. 3. Warm sterile saline dressing. 4. Warm acetic acid dressing.

2) CORRECT - Dressings used to treat pruritic lesions should be cool to promote vasoconstriction and to have an anti-inflammatory effect.

The nurse prepares teaching materials to review chest physiotherapy with the parents of a pediatric client diagnosed with cystic fibrosis (CF). Which observation indicates to the nurse that additional teaching is needed? (Select all that apply.) 1. Blood pressure 110/68 mm Hg. 2. Pulse oximetry 88% on room air. 3. Respiratory rate 24 breaths/min. 4. Ecchymosis over the back and lateral chest. 5. Complaint of pain with deep inspiration.

2) CORRECT - Hypoxemia is an adverse effect of incorrectly performed chest physiotherapy. 4) CORRECT - Bruising is an adverse effect of incorrectly performed chest physiotherapy. It indicates cupping is too forceful or incorrectly done. 5) CORRECT - Pain is an adverse effect of incorrectly performed chest physiotherapy.

The nurse asks the nursing assistive personnel (NAP) to obtain vital signs on five clients and then asks the LPN/LVN to administer medications on the same clients. Which nursing model of care is the nurse implementing? 1. Primary. 2. Functional. 3. Team. 4. Case method.

2) CORRECT - In the functional nursing model, care is partitioned and assigned to a staff member with the appropriate skills.

The nurse receives a call at the clinic from the parent of a young infant who has a severe diaper rash. Which advice does the nurse provide to the parent? 1. Wash the infant's bottom with soap and water at each diaper change. 2. Leave the diaper off while the infant sleeps. 3. Use baby wipes at each diaper change. 4. Use cloth diapers instead of disposable diapers.

2) CORRECT - Leaving the diaper off while the infant sleeps helps to promote air circulation to the area to improve the condition.

The nurse provides care for a client who receives metoprolol. The nurse will assess the client for which adverse effect? (Select all that apply.) 1. Tachycardia. 2. Bronchospasm. 3. Hyperglycemia. 4. Hypotension. 5. Fatigue.

2) CORRECT - Metoprolol is a cardioselective beta-adrenergic receptor blocker, so it may affect the beta-adrenergic receptors in the bronchioles and cause bronchospasm. 4) CORRECT - Metoprolol blocks beta-adrenergic sympathetic stimulation to the heart, thereby reducing heart rate, slowing conduction, and reducing blood pressure; hypotension may result. 5) CORRECT - Fatigue may result with metoprolol therapy as blood pressure and heart rate decrease.

While comparing a client's medication administration record (MAR) against the health care provider's prescriptions, the nurse notes that the MAR lists metoprolol succinate but metoprolol tartrate is in the precription. Which action will the nurse take next? 1. Administer the medication. 2. Notify the pharmacist. 3. Call the health care provider. 4. Ask the client which type of metoprolol is taken at home.

2) CORRECT - Since the prescription states metoprolol tartrate, the pharmacy should be contacted to find out why metoprolol succinate is on the MAR.

The nurse provides care to a client who experienced a stroke 1 day ago. Which action does the nurse safely delegate to the nursing assistive personnel (NAP)? 1. Monitor neurologic status using the Glasgow Coma Scale. 2. Check and document oxygen saturation every 1 to 2 hours. 3. Complete morning bath, change linen, and perform range of motion by 1000 hours. 4. Notify the health care provider about the need for assistive walking device.

2) CORRECT - The NAP can measure and document oxygen saturation.

A client sues the nurse and the hospital for malpractice. Which resource will the nurse refer to determine if the client's suit is legitimate? 1. Medical record. 2. Standards of care. 3. American Nurses Association Code of Ethics. 4. The Joint Commission standards.

2) CORRECT - The first step in proving malpractice is to determine if negligence occurred. Negligence is defined as conduct that deviates from what another person would do in a similar situation. Standards of care are used to determine if the nurse was negligent when providing care.

The nurse prepares a quality improvement project to reduce the incidence of hospital-acquired infections (HAIs) when bathing clients. Which intervention is most important for the nurse to include in this project? 1. Avoid reusing basins when bathing clients. 2. Use chlorhexidine as part of bathing agent. 3. Remind clients to wash hands after bathing. 4. Re-educate nursing personnel about bathing.

2) CORRECT - The use of chlorhexidine as part of the bathing agent has been shown to reduce the risk of spreading microorganisms.

The nurse notes that a client exhibits changes in mental status at 0300. The client also experiences a decrease in oxygenation, requiring the nurse to place oxygen at 2 L/min via nasal cannula on the client. Which action should the nurse take next? 1. Continue to monitor the client until the health care provider comes in. 2. Contact the health care provider and explain the client's situation. 3. Wait until 0400 or 0500 before calling the health care provider. 4. Notify the rapid response team of the client's change in status.

2) CORRECT - These changes could indicate a serious health event and should be addressed immediately.

The charge nurse assigns several clients to a novice nurse who is fresh off unit orientation. Which client will the charge nurse assign the novice nurse to provide care during this shift? (Select all that apply.) 1. A client on airborne precautions for newly diagnosed tuberculosis (TB). 2. A client diagnosed with chronic obstructive pulmonary disease (COPD) discharging tomorrow. 3. A client diagnosed with acute pneumonia on a bilevel positive airway pressure (BiPAP) machine. 4. A client status postoperative for a vaginal hysterectomy done earlier in the day. 5. A toddler diagnosed with respiratory syncytial virus (RSV) admitted an hour ago.

2) CORRECT — A client diagnosed with COPD who is discharging tomorrow is a stable client and can be assigned to the new nurse. 4) CORRECT — A client who had a vaginal hysterectomy done earlier in the day is a stable client and can be assigned to the new nurse.

A client admitted to the unit 8 hours ago states to the nurse, "This hospital is dirty! There are bugs are crawling on the walls." On which substance use will the nurse focus when assessing this client? 1. Heroin. 2. Alcohol (ETOH). 3. Crack cocaine. 4. Phencyclidine piperidine (PCP).

2) CORRECT — A major withdrawal symptom of ETOH use is visual hallucinations.

The nurse provides care to a 10-month-old infant. For which statement made by the parent will the nurse intervene? (Select all that apply.) 1. "My child has a two-word vocabulary." 2. "My child gained 1 ounce this week." 3. "My child cannot walk unless I hold under the arms." 4. "My child cries and spreads the arms in and out when I bump the crib." 5. "My child's soft spot on top of the head is still open."

2) CORRECT — An average weight gain of 4 oz. per week is expected between 6 and 12 months of age. 4) CORRECT — The Moro reflex should disappear after 3 to 4 months of age.

The nurse provides care for a client in the second trimester of pregnancy. Which finding does the nurse attribute to the normal increase in blood volume during pregnancy? 1. Increase in the respiratory rate. 2. Elevation in heart rate of 15 beats per minute (bpm). 3. Increase in blood pressure of 20 points. 4. Decrease in mean arterial pressure (MAP).

2) CORRECT — Cardiac output increases as more blood is pumped from the heart with each contraction and the pulse increases by 10 to 15 bpm.

The nurse provides care for a young school-age child who is injured. The client requires sutures. Which strategy does the nurse use to prepare the child for the suturing procedure? (Select all that apply.) 1. Explain the procedure thoroughly and use correct terms. 2. Involve the child in distraction such as music or a game. 3. Ask the parents to leave the room until the procedure is done. 4. Restrain the child to prevent movement during procedure. 5. Use guided imagery that involves a previous enjoyable event.

2) CORRECT — Distraction is a proven pain management technique for this age child. 5) CORRECT — Distraction techniques are useful for a young school-age child during a painful procedure.

The nurse provides care for a client diagnosed with new onset atrial fibrillation. The client's health care provider prescribes a transesophageal echocardiogram (TEE). What reason will the nurse give to the client as the primary reason for performing a TEE? 1. To measure the cardiac index. 2. To rule out thrombus in the heart. 3. To estimate the ejection fraction. 4. To observe ventricular wall motion.

2) CORRECT — In clients with atrial fibrillation, a TEE is done to rule out blood clots in the heart chambers, especially if the client is being considered for cardioversion.

A client experiencing severe abdominal pain tells the nurse that pulling the knees up to the chest relieves the discomfort. Which health problem will the nurse suspect this client is experiencing? 1. Peritonitis. 2. Pancreatitis. 3. Gastric ulcer. 4. Appendicitis.

2) CORRECT — In pancreatitis, the client can obtain relief by assuming the fetal position or drawing the knees up to the chest and flexing the spine

The nurse prepares to document care given to clients. Which areas will the nurse include in complete and accurate documentation? (Select all that apply.) 1. Subjective nursing observations. 2. Client symptoms and response to treatments. 3. Nursing care given. 4. Explanation of a medication error. 5. Medications and treatments.

2) CORRECT — Objective assessment of client's symptoms and response to treatment should be documented. 3) CORRECT — An objective description of nursing care and a client's response are appropriate to document. 5) CORRECT — The nurse would document medications and treatments given following appropriate and clear medical orders.

The nurse provides pain management teaching to an older adult client diagnosed with osteoarthritis (OA). Which medication does the nurse discuss as the initial treatment of choice for OA pain? 1. Morphine. 2. Acetaminophen. 3. Ibuprofen. 4. Cyclobenzaprine.

2) CORRECT — The primary pain med of choice in osteoarthritis is acetaminophen.

The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1. Asking if the client understands the instruction. 2. Demonstrating the procedure and having the client return the demonstration. 3. Asking an interpreter to replay the instructions to the client. 4. Writing out the instructions and having a family member read them to the client.

2) CORRECT — When the client can repeat the action that was taught by the nurse, that best ensures that the client can perform wound care correctly at home.

The nurse provides care for a client on mechanical ventilation. The nurse notes that the high-pressure alarm was triggered. Which nursing action is appropriate? (Select all that apply.) 1. Call the rapid response team. 2. Determine the need for sedation. 3. Call the health care provider. 4. Assess the need for suctioning. 5. Assess for disconnected tubing.

2) CORRECT- Agitation or pain can trigger a high-pressure alarm; therefore, the nurse assesses the client to determine sedation or pain medication needs. 4) CORRECT - Respiratory secretions require higher ventilator pressure to deliver the breath and will trigger a high-pressure alarm.

The nurse provides care to a newborn in the delivery room. Which intervention does the nurse implement to prevent the newborn from experiencing radiant heat loss? 1. Drying the newborn's skin immediately after birth. 2. Putting the unclothed newborn against the mother's skin. 3. Keeping the incubator away from windows and outside walls. 4. Placing the newborn under a radiant warmer.

3) CORRECT - Keeping the incubator away from windows helps prevent radiant heat loss.

A newly admitted client is prescribed a medication to be given every 6 hours, starting at 0600 hours. However, the medication arrived from the pharmacy at 0745 hours. Which action will the nurse take next? 1. Plan to administer the next dose at 1200 hours. 2. Notify the health care provider. 3. Give the next dose at 1400. 4. Report the late medication as a medication error.

3) CORRECT - Since the first dose was given at 0745 hours, the next dose at 1400 hours would be appropriate.

A client experiences wide QRS complexes on telemetry, numbness of the feet, and tingling of both hands. Which medication will the nurse question before administering to this client? 1. Diltiazem. 2. Furosemide. 3. Spironolactone. 4. Metoprolol tartrate.

3) CORRECT - Spironolactone is a potassium-sparing diuretic. The client is demonstrating manifestations of hyperkalemia. The nurse should question providing the next dose of spironolacton

The charge nurse notes that a client is seen in the emergency department (ED) for the third time in 5 weeks. The client has a history of a chronic respiratory disorder and diabetes mellitus. The client's record lists multiple home addresses and no family. The client indicates a lack of employment. Which referral is most appropriate for this client? 1. Hospital social worker. 2. Community housing. 3. Case manager. 4. County welfare program.

3) CORRECT - The case manager is the best referral because this person works in collaboration with other departments and community agencies to take care of the client's multiple needs.

The nurse prepares to leave the room after irrigating the infected wound of a client in contact transmission-based precautions. Which personal protective equipment item does the nurse remove next after taking off the contaminated gloves? 1. Mask. 2. Gown. 3. Eye goggles. 4. Foot covering.

3) CORRECT - The eye goggles are removed after removing the gloves and before removing the gown.

The nurse provides care for a client diagnosed with leukemia. The nurse notes the client has vomited a large amount of bloody emesis. Which action should the nurse take first? 1. Measure the vomitus before dumping it. 2. Assess the client's last platelet count. 3. Notify the health care provider. 4. Complete a head to toe assessment.

3) CORRECT - The health care provider needs to be made aware to determine the next step for this client.

The nurse notes that four clients have returned from surgery within the last 24 hours. Which client is at the highest risk for developing a post-operative infection? 1. A school-age client recovering from a tonsillectomy. 2. An adolescent client who had an unruptured appendectomy. 3. An older adult client with gastric tube placement. 4. A middle-age client with a coronary artery by-pass graft.

3) CORRECT - The older adult client has three risk factors. These risk factors are recent surgery, age, and compromised nutritional status. This client is at the greatest risk for a post-operative infection

The nurse provides care for a client who is on hourly intake and output. In the past hour, the nurse notes the client has had 100 milliliters (mL) of intravenous (IV) fluid, 4 oz of jello, 3 oz of chicken broth, and 1 oz of ice cream. Which amount does the nurse record for the client's oral intake? 1. 90 mL. 2. 210 mL. 3. 240 mL. 4. 340 mL.

3) CORRECT - The oral intake is 120 mL (4 oz) + 90 mL (3 oz) + 30 mL (1 oz) = 240 mL (8 oz). The IV fluid is not counted in oral intake.

The nurse delegates client care to an LPN/LVN and a nursing assistive personnel (NAP). Which client care assignment is inappropriate? 1. Assist with a bed bath for the client on the first day after surgery for a mitral valve replacement (MVR) by the NAP. 2. Reinforce diet teaching to a client with hyperglycemia by the LPN/LVN. 3. Feed a thickened liquid diet to a client 2 days after a cerebral vascular accident (CVA) by the NAP. 4. Ambulate a client in the hall for the second day after surgery by the LPN/LVN.

3) CORRECT - This task is not within the scope of practice for the NAP. The client is at high risk for choking. The nurse must assess the client's ability to swallow and any change in the client's status. The nurse must be ready to respond if the client chokes.

The nurse provides care for an infant who has a fractured femur. Which statement regarding pain in an infant is accurate? (Select all that apply.) 1. Infants cannot feel pain. 2. Infants cannot express pain. 3. Infants have the same sensitivity to pain as older children. 4. Pain scales do not work well with infants. 5. Absorption of pain medication is faster in an infant than an adult.

3) CORRECT — Infants have the same sensitivity to pain as older children. 5) CORRECT — Absorption of medications is quicker in an infant than an adult.

The nurse manager evaluates staff for understanding of standard precautions when caring for clients with acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV). Which behavior indicates to the nurse manager that the staff understands standard precautions? (Select all that apply.) 1. Nursing assistive personnel (NAP) receiving chemotherapy refuses to care for a client with Kaposi sarcoma. 2. Laboratory technician performs a venipuncture and places the needle on a table while labeling the specimen tube. 3. Health care provider uses a personal stethoscope to assess a client with HIV and fever. 4. Nurse applies a mask and protective eyewear before providing tracheostomy care. 5. Nurse who is pregnant wears gloves and a gown to clean stool from a client who is incontinent for diarrhea.

3) CORRECT — It is unlikely the client with HIV and a fever will transmit an illness to someone with an intact immune system. Standard precautions are required for all clients, regardless of diagnosis. 4) CORRECT — When suctioning a tracheostomy, staff are likely to come into contact with sputum that can transmit HIV/AIDS. Contact transmission precautions are needed. 5) CORRECT — A client with incontinent stools always requires gloves and a gown, even if the feces is not bloody. Contact transmission precautions are required for all clients with incontinent stools, regardless of diagnosis.

The nurse teaches a group of clients about prenatal care. Which client statement requires further teaching? 1. "I avoid changing my cat's litter box." 2. "I drink eight glasses of water each day." 3. "I put my legs up on a pillow when I lie on my back." 4. "I continue exercising until I become short of breath."

3) CORRECT — Lying on your back may result in supine hypotension syndrome as the heavy uterus compresses the inferior vena cava, reducing blood returned to heart. This may also reduce circulation to the placenta due to increased pressure on the client's aorta, resulting in fetal hypoxia.

Which client does the nurse monitor for a heart block after a myocardial infarction (MI)? 1. A client with a non-ST elevation MI. 2. A client with a septal wall MI. 3. A client with an inferior wall MI. 4. A client with a subendocardial wall MI.

3) CORRECT — The SA node is supplied by the right coronary artery, is located in the inferior wall, and is the type of infarct to SA node that leads to heart blocks and the related bradyarrhythmia.

A client receiving an enema reports cramping and discomfort when the nurse releases the clamp and places the container 12 inches above the client's hip level. Which action will the nurse take next? 1. Instruct the client to take deep breaths. 2. Discontinue the enema. 3. Clamp the tubing 4. Lower the enema bag below the level of the hips.

3) CORRECT — The nurse should clamp the tubing first to see if the cramping resolves.

The nurse provides care for a client diagnosed with major head trauma. The nurse prepares to administer the client's bolus enteral feeding. Which prescription will the nurse implement before beginning the feeding? 1. Monitor blood glucose levels. 2. Increase the enteral feeding. 3. Measure intake and output. 4. Monitor the client's albumin

3) CORRECT — This is an important assessment of fluid balance. Enteral feedings are hyperosmotic agents that pull fluid from cells into the vascular bed. Water given before feeding, as necessary, will prevent a hyperosmotic diuresis and correct any fluid imbalance.

The infection control nurse observes the care of several staff nurses. Which action made by the staff nurse requires the infection control nurse to intervene? 1. Placing a disposable mask on a client diagnosed with tuberculosis, who is being transported to nuclear medicine. 2. Leaving a stethoscope in the room of a client who is on contact precautions. 3. Allowing a family member to bring flowers into the room of a client diagnosed with a vancomycin-resistant Enterococcus (VRE) wound infection. 4. Wearing a disposable mask when changing the dressing of a client diagnosed with a methicillin-resistant Staphy

4) CORRECT - A mask is not need, as MRSA is transmitted by contact. This action would require the infection control nurse to intervene.

The nurse reviews the care needs for assigned clients. Which client will the nurse assess first? 1. Client with ulcerative colitis who reports rectal bleeding. 2. Client with an acute kidney injury with a urine output of 100 mL over the past 6 hours. 3. Client with angina pectoris who reports a headache after receiving a dose of prescribed nitroglycerin. 4. Client with a radioactive implant for cervical cancer who is in the bathroom.

4) CORRECT - The client with a radioactive implant is restricted to bedrest during the treatment session. Excessive movement in bed is restricted to prevent dislodgment of the radioactive source. This is the priority assessment.

The nurse asks a nursing assistive personnel (NAP) for the temperature obtained on a client prior to hanging a blood product. Which right of delegation does the nurse follow in this situation? 1. Right task. 2. Right circumstance. 3. Right communication. 4. Right evaluation.

4) CORRECT - The nurse is following up with the NAP to ensure the NAP completed the task. The scenario indicates the nurse was providing right supervision/evaluation.

The nurse provides care for a pediatric client suspected of having the respiratory syncytial virus (RSV). Which transmission-based precaution does the nurse initiate once influenza and adenovirus are ruled out for this client? 1. Airborne precautions. 2. Droplet precautions. 3. Reverse precautions. 4. Contact precautions.

4) CORRECT - The nurse should continue contact precautions for clients suspected of having RSV once influenza and adenovirus are ruled out. Contact precautions are implemented for diseases that clients can transmit via microorganisms in bodily fluids or inanimate objects.

The partner of a recently deceased client feels uncomfortable and leaves the room when the nurse escorts the family in to view the body. Which type of grief is the partner at risk for developing? 1. Delayed. 2. Inhibited. 3. Complicated. 4. Disenfranchised.

4) CORRECT — Disenfranchised grief occurs when a person cannot acknowledge grief to others because the loss is not socially recognized.

The nurse assesses an older client for substance abuse. Which medications does the nurse specifically ask if the client uses? 1. Sedatives-hypnotics. 2. Stimulants. 3. Opioids. 4. Over-the-counter medications.

4) CORRECT — Older adults specifically have the highest use of over-the-counter medications.

The nurse receives report on a client who was confused overnight and is scheduled for surgery later in the morning. The nurse asks the off-going nurse if the preoperative checklist and informed consent are complete. The off-going nurse replies, "I did the checklist. Since he doesn't have any family, the client 'made a mark' on the signature line of the consent". Which action does the nurse take first? 1. Continue to prepare the client for surgery. 2. Contact the health care provider (HCP). 3. Ask the client if the purpose of the surgery is understood. 4. Contact the nurse manager.

4) CORRECT — The nurse manager needs to be contacted first, and then the health care provider needs to be notified.

The nurse provides care for a client receiving total parenteral nutrition (TPN). Which nursing diagnosis is the priority when planning care for this client? 1. Risk for aspiration. 2. Electrolyte imbalance. 3. Impaired body image. 4. Risk for Infection.

4) CORRECT — The use of a central line and the high glucose content of TPN make the risk for infection a priority nursing diagnosis.

The nurse assesses an adolescent client diagnosed with an eating disorder. Which finding indicates to the nurse that the client has anorexia nervosa? (Select all that apply.) 1. Diarrhea. 2. Sensitivity to heat. 3. Coarse hair covering most of the body. 4. Amenorrhea. 5. Muscle weakness.

4) CORRECT— A client who has anorexia nervosa is likely to have amenorrhea, due to loss of body fat, which affects the body's ability to ovulate and menstruate. 5) CORRECT — A client who has anorexia nervosa is likely to have fluid and electrolyte imbalances, one of which is hypokalemia. This electrolyte imbalance occurs due to decreased potassium intake and renal loss of potassium. A client who has hypokalemia is likely to have muscle weakness, cardiac dysrhythmias, and renal failure.

The nurse provides care for a client diagnosed with idiopathic thrombocytopenic purpura (ITP). The client receives treatment with medication and several platelet transfusions. The client's platelet count remains low. Which treatment does the nurse anticipate the health care provider (HCP) will prescribe next? 1. A splenectomy. 2. A fresh frozen plasma (FFP) transfusion. 3. A packed red blood cell (PRBC) transfusion. 4. An update of the client's immunizations.

A) CORRECT - Due to the client not responding to treatment or medications for the diagnosed IFP, a splenectomy may be needed.