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At 0100 on a male client's second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement? A.Leave the room and close the door to the client's room B.Assess the appearance of the client's surgical dressing C.Bring the client a prescribed PRN sedative-hypnotic D.Discuss symptoms of sleep deprivation with the client

22. A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only]

4 tablets

A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only]

4 tabs

Dosage question: the doctor ordered 45mg. On hand is 30mg/ml. How many mls will you give?

45/30== 1.5 ml

1) A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.

14) The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin

19) An obese male client discusses with the LPN/LVN his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

2) When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the LPN implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

23) Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

24) The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.

30) A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

31) A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the LPN/LVN take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.

36) Which snack food is best for the LPN/LVN to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

40) After completing an assessment and determining that a client has a problem, which action should the LPN/LVN perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

5) While instructing a male client's wife in the performance of passive rangeof-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

A client is 2 days post op from a thoracic surgery and is complaining of incisional pain. The client last received pain medicine 2 hours ago. He is rating his pain a 5 on a scale of 1-10. After calling the provider, what is the nurses next action? A.instruct the clients to use guided imagery and slow rhythmic breathing B.provide at least 20 mins of back massage and gentle effleurage C.Encourage the client to watch TV D.Place a hot water circulation device, such as an Aqua K pad, to operative site

A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? A. Access for side effects of the medication. B. Document the client's responses. complete a C.Medication error report. D.Determine if the pain was relieved.

The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement? A.Communicate the colleague's actions to the unit charge nurse B.Send an email to facility administration reporting the action C.Write an anonymous complaint to a professional website D.Post a comment about the action on a staff discussion board

The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? a. Instruct the client to repeat the medication plan b. Encourage client to take a PRN antianxiety drug c. Provide written instructions that are easy to follow d. Include a family member in the teaching session

The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. Which action should the nurse implement? a. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows b. Ensure that the UAP has placed pillows effectively to protect the client c. Ask the UAP to use some pillows to prop the client in a side-lying position d. Assume responsibility for placing the pillows while the UAP complete another task

The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? A.Remove identifying information of the clients who participated B.Recall that authored content may be legally discoverable C.Share material from credible, peer reviewed sources only D.Respect all copyright laws when adding website content

To prepare a client for the potential side effects of a newly prescribed medication, what action should the nurse implement? A.Assess the client for health alterations that may be impacted by the effects of the medication B.Teach the client how to administer the medication to promote the best absorption C.Administer a half dose and observe the client for side effects before administering a full dosage D.Encourage the client to drink plenty of fluids to promote effective drug distribution

When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? a. Position the client supine for a few minutes b. Assist the client to stand at the bedside c. apply the blood pressure cuff securely d. record the client's pulse rate and rhythm

While suctioning a client's nasopharynx the nurse observes that the client's oxygen saturation remains at 94% which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? a. Complete the intermittent suction of the nasopharynx. b. Reposition the pulse oximeter clip to obtain a new reading. c. Stop suctioning until the pulse oximeter reading is above 95%. d. Apply an oxygen mask over the client's nose and mouth

A 24hr urine collection is in progress. The pt tells the nurse that the last voiding was accidentally flushed instead of saved in the container. What intervention should the nurse initiate? A. Discard the urine and start another 24hr period B. Notify the charge nurse of the problem C. Notify the healthcare provider of the situation D. Add another hour to the urine collection period

A. Discard the urine and start another 24hr period**

The nurse is planing a weight reduction program to be implemented to a community health center. Which goal is best for clients who are approx fifteen percent over their ideal weight and wish to participate in the weight loss program? Explain why A. Fat intake between 20-20 percent of total daily intake B. Caloric intake between 800-1000 kcal per day C. Maintain cholesterol level of between 225- 240 D. A 3-5 lb weight loss per week

A. Fat intake between 20-20 percent of total daily intake**

A young male pt with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the pt has a good prognosis and refuses to write a DNR prescription. What action should the nurse take? A. Initiate an ethics committee review of the case B. Ensure resuscitation equipment is available C. Ask the family to review options with pt

A. Initiate an ethics committee review of the case**

2. The nurse has been alerted by the EMR when scanning the dispensed medication that the dosage is two times higher than the prescribed dose. The nurse should: A. Report mismatch of prescription and available dosages B. Withhold medication until exact dose is available C. Ask pharmacy if another dose can be dispensed D. Calculate dose on hand to match the prescribed dose

Ans: D

20. UAP is not fitted for a respirator mask and requests to be re-assigned from a client with droplet precautions. The charge nurse should: A. Before changing assignments, check to see which nurses are fitted for the respirators B. Send UAD to get fitted for the respirator immediately so that she can return to take care of the patient C. Tell the UAP that she can wear a standard mask during vitals and use a respirator mask for other tasks D. Tell the UAP that a standard face mask is sufficient

Ans: D

28. What to assess first for a client with cyanosis A. Temperature B. Heart rate C. Blood pressure D. Respiratory rate

Ans: D

3. A patient diagnosed with small bowel obstruction refuses surgery. The nurse should: A. Assess client needs for antiemetics and pain medications B. Prepare nasogastric tube compress C. Sent patient to CT abdominal scan D. Notify HCP that patient refuses surgery

Ans: D

31. HCP tells the nurse that he will be prescribing a placebo to a client. The nurse should: A. Inform the nurse supervisor and refuse to administer placebo B. Administer the placebo to the client C. Inform the patient that he will be receiving a placebo D. Discuss ethical concerns with HCP

Ans: D

6. IM ventrogluteal landmark A. Upper outer quadrant of buttock B. Deltoid C. Knee and greater trochanter D. Greater trochanter and anterior superior iliac spine

Ans: D

9. A post-op patient is grimacing when moving from bed to chair but denies pain. What should the nurse do next? A. Administer pain medication PRN B. Review his pain medications that are prescribed C. Monitor patient's nonverbal actions D. Ask what is making him grimace

Ans: D

53. What is the most important thing to assess prior to applying a heating pad?

Ans: Degree of neurosensory impairment

49. A post-op client has concerns with using his bedpan. He is prescribed activity from bed to chair at least 3 times a day.

Ans: Encourage client to use bedside commode

50. A nurse is providing passive ROM pronation and supination on an adolescent. What should the nurse do next? [Picture of adolescent hand on nurse's hand in pronation).

Ans: Turn hand so palm faces up

54) Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

6) What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure

7) The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

A cerebrovascular accident is placed on a ventilator. The client's daughter arrives with a durable power of attorney, and a living will that indicates the...extraordinary life saving measures. What action should the nurse take? a. Refer to the risk manager b. Notify the healthcare provider c. Discontinue the ventilator d. Review the medical record

A female client's significant other has been at her bedside providing reassurances and support for the past 3days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? A.Obtain a perception from the healthcare provider regarding visitation privileges B.Request a consultation with the ethics committee for resolution of the situation C.Encourage the client to speak with her husband regarding his disruptive behavior D.Communicate the client's wishes to all members of the multidisciplinary team

A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? A. Answer the client's specific questions with a short understandable explanation B. Postpone the procedure until the client understands the risks and benefits C. Call the client's next of kin and ask them to provide verbal consent D. Page the healthcare provider to return and provide additional explanation

During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this statement? a. Provide information about the hours and location of the chapel b. Document the statement of the client's spiritual assessment c. Invite the client to a healing service for people of all religions d. Offer to contact a spiritual advisor of the client's choice

Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action? a. Ask the family to wait in the cafeteria when the next of kin makes the necessary arrangements b. Provide space and privacy for the family to share their concerns about the client's discharge c. Ask the social worker to encourage the family to clear the hallway d. Explain to the family the client's need for privacy so that she can make independent decisions

The nurse attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading? a. BP 142/88 mmHg b. 2+ edema of fingers and hands c. Radial pulse volume is +3 d. Capillary refill time is 2 seconds

The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first? a. Apply the restraints to maintain the client's safety. b. Reassess the client to determine the need for continuing restraints. c. Document the time the family left and continue to monitor the client. d. Call the healthcare provider for a new prescription.

The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client... the client's gag reflex. Which action should the nurse include? A. Offer smalls sips of water through a straw B. Place tongue blade on back half of tongue C. Use a penlight to observe back of oral cavity D. Auscultate breath sounds after client swallows

The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states "clean the wound and then apply collagenase." collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? a. Lightly coat the wound with povidone-iodine solution b. Irrigate the wound with sterile normal saline c. Flush the wound with sterile hydrogen peroxide d. Remove the eschar with a wet-to-dry dressing

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? A. Tilt the pelvis forwards and backwards B. Bend the arm by flexing the ulnar to the humerus C. Turn the head to the right and left D. Extend the arm at the ice and rotate in circles

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take? A. Remove the basin of water from the client's bed immediately B.Remind the UAP to dry between the client's toes completely C.Advise the UAP that this procedure is damaging to the skin D.Add skin cream to the basin of water while the foot is soaking

The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL, for the previous 6 hour shift. Which intervention should the nurse implement first? a. Check the drainage tubing for a kink b. Review the intake and output record c. Notify the healthcare provider d. Give the client 8 oz of water to drink

To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? A. Ventrogluteal B. outer upper quadrant of the buttock. C.Two inches below the acromion process D.Vastus lateralis

Which assessment data reflects the need for the nurses to include the problem, "Risk for falls" in a client's plan of care? a. Recent serum hemoglobin level of 16g/dL b. Opioid analgesic received one hour ago c. Stooped posture with a steady gait d. Expressed feelings of depression

To access the quality of an adult client's pain, what approach should the nurse use? A. Provide a numeric pain scale B. Ask the pt to describe pain C. Identify effective pain relief measures D. Observe body language and movement

B. Ask the pt to describe pain ***

The electronic mediation system alerts the nurse that the medication dose scanned is two times higher than the dose prescribes. What action should the nurse implement? A. Withhold meds, until exact dose is available B. Convert the dose on hand to match the prescribed dose C. Ask the pharmacist if another dose can be dispensed D. Report a mismatch of prescribed and available doses

B. Convert the dose on hand to match the prescribed dose

The nurse is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the nurse include in the assessment? a. Provider an interpreter to convey the meaning of words and messages in translation b. Commend the client for her patience after a long wait in the admission process c. Arrange for the hospital chaplain to visit the client during her hospital stay d. Rely on cultural norms as the basis for providing nursing care for this client

The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include... A. Notify the OR staff of the client's confusion B. Have the client sign a new surgical permit C. Add the additional information to the permit D. Inform the surgeon about the client's concern

The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precaution? a. Remove needle before discarding used syringes b. Wear gloves to dispose of the needle and syringe c. Done a face mask before administering the medication d. Washes hands before handling the needle and syringe

The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. A. Administer nasal oxygen at a rate of 5 L/min B. Help the client to lie back down in the bed C. Quickly pivot the client to the chair and elevate the legs D. Check the client's blood pressure and pulse deficit

What instruction should the nurse provide for an UAP caring for a client with MRSA who has a prescription for contact precautions? a. Do not allow visitors until precautions are discontinued b. Wear sterile gloves when handling the client's body fluid c. Have the client wear a mask whenever someone enters the room d. Don a gown and gloves when entering the return

When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which? A.Hyperphosphatemia B.Hypocalcemia C.Hypermagnesemia D.Hypokalemia

When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take a. divert the client's attention b. Call for additional help from staff c. Document the planned action d. Re-assess the client situation

When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse take first? A.Determine pulse pressure B.Auscultate heart sounds C.Measure oxygen saturation D.Check for neck vein distention

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? A.Monitor daily urine output volume B.Drink plenty of water whenever thirsty C.Use salt tablets for sodium content D.Review food labels for sodium contents

Pt with vaginal bleeding after unprotected sex. What is the most appropriate action for the nurse to take?

Educate about safe sex.

20. To prepare a client for the potential side effects of a newly prescribed medication, what action should the nurse implement? a. Assess the client for health alterations that may be impacted by the effects of the medication b. Teach the client how to administer the medication to promote the best absorption c. Administer a half dose and observe the client for side effects before administering a full dosage d. Encourage the client to drink plenty of fluids to promote effective drug distribution

a. Assess the client for health alterations that may be impacted by the effects of the medication

8. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement? a. Communicate the colleague's actions to the unit charge nurse b. Send an email to facility administration reporting the action c. Write an anonymous complaint to a professional website d. Post a comment about the action on a staff discussion board

a. Communicate the colleague's actions to the unit charge nurse

39. While suctioning a client's nasopharynx the nurse observes that the client's oxygen saturation remains at 94% which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? a. Complete the intermittent suction of the nasopharynx. b. Reposition the pulse oximeter clip to obtain a new reading. c. Stop suctioning until the pulse oximeter reading is above 95%. d. Apply an oxygen mask over the client's nose and mouth

a. Complete the intermittent suction of the nasopharynx.

When providing health teaching to elderly clients, what action in most important for nurse to implement? A. Underline key words on the written info B. Use everyday language when explaining issues C. Speak loudly and face client D. Provide a very well lit meeting space

B. Use everyday language when explaining issues***

The computer documentation system shuts down while the nurse is entering pt's physical assessment data. What should the nurse do first? A. Print electronic medical record from backup server B. Wait for notification services department of the situation C. Notify info services department of the situation D. Identify info as late as last entry in the record

B. Wait for notification services department of the situation***

10) The LPN is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.

12) An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

16) A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the LPN/LVN to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

21) The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the LPN/LVN plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets

25) The LPN prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

26) Which action is most important for the LPN/LVN to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

37) The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

41) An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred

42) A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.

46) Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

47) The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the LPN/LVN take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

52) When conducting an admission assessment, the LPN should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

After assessing a pt, the nurse identifies 3 nursing problems. When developing the pt's plan of care, which action should the nurse take next? A. Cluster supportive client data B. Identify client care interventions C. Prioritize the identified nursing diagnoses D. Collaborate w/ client to establish goals

C. Prioritize the identified nursing diagnoses**

The nurse prepares to administer ear drops to an adolescent client. What should nurse do next? A. Place drops in the ear canal B. Apply gentle pressure to ear tragus C. Pull ear auricle downward D. Move dropper closer to ear canal

C. Pull ear auricle downward**

The nurse measures the pt's Bp and notes that it is significantly higher than the previous reading. What should the nurse do next? A. Assign the UAP to recheck bp in hr B. Ask another nurse to assist in assessing an apical-radial pulse deficit C. Retake the pt's Bp in opposite arm D. Determine the pt's activity and feelings prior to bp measurement E. Immediately take 2 more readings on the same arm

C. Retake the pt's Bp in opposite arm** D. Determine the pt's activity and feelings prior to bp measurement**

29. What should the nurse implement when inserting an indwelling catheter to an uncircumcised male. A. Clean meatus before retracting the foreskin B. Advance catheter before inflating balloon C. Sterile field should be even between nurse's hips D. Wipe the meatus back and forth

Ans: B

32. Proper method of wound care A. Cleaning outwards to inward B. Cleaning inward to outward C. Cleaning back and forth D. Wiping sterile cotton swab twice

Ans: B

35. A client with a new exercise regimen states that it still takes him an hour to fall asleep. The nurse should: A. Tell the client that it usually takes a few weeks for the body to regulate a new exercise regimen B. Ask client to describe his exercise regimen

Ans: B

39. Intervention for skin turgor in aging client: A. Bathe daily with mild soap and water B. Apply lubricating lotion to skin

Ans: B

40. A mother requests to see her 18 year-old lab results. What is the nurse's best response? A. I will give you the results when it is back. B. I can only give the results to your son. He is an adult. C. The healthcare provider will give you the results.

Ans: B

43. A client is on a full liquid diet for "Volume deficit related to less than required oral intake." What should the nurse give to the client? A. Beef or chicken broth B. Ensure C. Low-fat milk D. Apple or grapefruit juice

Ans: B

5. An elderly patient returns to the clinic for chronic pain management. He is prescribed MS Contin PO Q12H. He states that he only takes it when the pain is so severe that he can't sleep. A. Long time use of opioids may cause drug addiction B. Take medication Q12H as prescribed C. Teach alternative methods for pain management D. Continue taking MS Contin for severe pain.

Ans: B

51. Active ROM of hinge joints A. Extend arm at side and rotate in circles B. Flexing ulnar to humerus C. Rotating hips

Ans: B

52. Priority assessment for client with 2.9 serum potassium level. A. Deep tendon reflexes B. Heart rate and rhythm

Ans: B

41. What should the nurse do when interviewing a client about sexual and reproductive matters?

Ans: Begin with less sensitive topic

21. Patient complains that he hates how his boss orders him around and how he doesn't listen to his ideas. What is the nurse's best response? A. "I'm sure that it will get better with time." B. "It must be difficult for you to work in a place that makes you feel so bad." C. "How do you feel when your boss doesn't listen to you?" D. "You should change how you interact with your boss."

Ans: C

30. A nurse notices a fire in the bathroom of an empty room and reports the location of the fire immediately. What should the nurse do next? A. Close the door to all the client's rooms in the hallway B. Evacuate clients in the rooms close to the fire C. Shut the door to the bathroom and the empty room D. Obtain fire extinguisher on the unit

Ans: C

33. A nurse walks into a client's room to see him coughing non-productively into his upper sleeve. The nurse should: A. Obtain face masks for all staff entering client's room B. Teach client how to cough into his hands C. Provide tissues for the client to cough into

Ans: C

38. A confused elderly patient is having trouble sleeping and is often found wandering the halls. The nurse should: A. Administer PRN sedative B. Have client's room door open slightly C. Provide back rub before bed D. Apply soft wrist restraints to prevent wandering

Ans: C

46. A client on nasal cannula 3L/min has O2 saturation of 91%. A. Apply lubricant to the tubing B. Discontinue nasal cannula use C. Put padding around NC tubing D. Decrease oxygen to 1L/min

Ans: C

47. Which factor is most important when selecting blood pressure cuff? A. Limited ROM B. 89 year-old C. BMI of 15 D. Female

Ans: C

54. The family of a confused client remove her restraints and left. What should nurse do? A. Call HCP for renewal order of restraints B. Continue to monitor client C. Reassess need to continue restraints D. Reapply the restraints

Ans: C

7. A client with a nasogastric tube is receiving low intermittent suction and is complaining of dry mouth. What should the nurse implement? A. Tell the client that the mucosa must stay dry to prevent aspiration B. Turn off suction so that the client can rinse his mouth with cold water C. Provide oral sponge toothettes so the client can clean and moisten his mouth D. Instill 50 mL of normal saline and clamp

Ans: C

1. Older female client can't sleep at night. Nurse recommends SATA A. Take afternoon nap B. Ask HCP for prescription of mild sedative at bedtime C. Establish regular time for getting up and going to bed D. Drink whiskey, water and honey before bed E. Avoid drinking caffeine before bedtime

Ans: C, E

48. Which client has the highest risk of nosocomial infection?

Ans: Cancer patient receiving immunosuppressed medication

10. A client is on a mechanical soft diet and is constipated. He requests for prune juice. The nurse should: A. Restrict fluid B. Initiate bowel training protocol C. Advance to regular diet D. Offer to warm up the prune juice

Ans: D

11. The nurse is assessing a client's ability to perform activities of daily living (ADL) safely. The client has steady gait and is able to ambulate from the door to the bed with full ROM. The nurse should: A. Teach the client to take shorter strides for better balance B. Record client's ability to perform ADL safely C. Initiate fall risk protocol D. Determine client's activity tolerance

Ans: D

12. A patient is demonstrating diaphragmatic breathing by holding her abdomen while inhaling and removing her hands during exhalation. A. The demonstration was successful B. The hands do not need be on the abdomen, but the demonstration was still correct C. Keep light pressure on abdomen and cough after inspiration D. Expand abdomen during inspiration and let the abdomen sink during exhalation

Ans: D

14. The computer system shuts down while the nurse was inputting client data. What should the nurse do next? A. Print EMR from backup server B. Wait for notification that the EMR is rebooted C. Identify information as late entry D. Notify IT

Ans: D

18. Which related data should be obtained if a client is wheezing? A. Radiates to other parts of the body B. Heart sounds C. Body temperature D. Precipitating factors

Ans: D

reassess the client to determine the need for continuing restraints

A significant other has been providing support to a pt as desired by the pt. The estranged spouse comes days later and request that the significant other be not allowed to visit. What should the nurse do?

Communicate the pt's desire to health team. The pt's wishes are priority unless the spouse has power of attorney.

A 54 yo male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is most appropriate for the wife?

refer her to support group for family members of those dying of cancer

rely on cultural norms as the basis for providing nursing care for this client

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the clients foot in a basin of warm water placed on the bed. What action should the nurse take?

remind the UAP to dry between the clients toes completely

The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease. Which action should the nurse implement to protect client privacy?

remove identifying information of the clients who participated

request a consultation with the ethics committee for solution of the situation

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

review food labels for sodium content

The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL, for the previous 6 hour shift. Which intervention should the nurse implement first?

review the intake and output record

send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client

The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description warrants additional follow up by the nurse? (select all that applies).

solid with streaks brown liquid multiple hard pellets tarry appearance

teach coping strategies to use wheen feeling stressed

A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?

the ability to perform ADLs

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

the nurse has limited ability to observe nonverbal communication while entering the assessment electronically

The nurse assesses a client who has a nasal cannula delivering oxygen at 2L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?

top of the ear around the nostrils over the checks

he nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precaution?

wash hands before handling the needle and syringe

29. The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required , round to the nearest tenth)

0.8

The nurse retrieves hydromorphine 4mg/mL from from the Pyxis meditation for a client who is receiving hydromorphone 3mg IM 6 hours PRN severe pain. How many mL should the nurse administer?

0.8

.The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required , round to the nearest tenth)

0.8 ml

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct Answer: A

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml.

(B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct Answer: B

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. Correct Answer: B

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

(C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem. Correct Answer: C

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.

(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client. Correct Answer: D

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. Correct Answer: D

Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.

15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B). Correct Answer: B

8) A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The LPN plans to administer the IVPB dose over 20 minutes. For how many ml/ hr should the infusion pump be set to deliver the secondary infusion?

150

When giving meds, what do you do?

2 different pt identification

The nurse attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

2+ edema of fingers and hands

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated. Correct Answer: B

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.

A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred. Correct Answer: D

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.

A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Correct Answer: B

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.

A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care. Correct Answer: C

6. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? select all that apply A. Tops of the ear B. Bridge of the nose C. Around the nostrils D. Over the cheeks E. Across the forehead

A, C, D

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? A. Tops of the ear B. Bridge of the nose C. Around the nostrils D.Over the cheeks E. Across the forehead

A,C,D

A male client presents to the clinics stating that he has a high stress job and is having difficulty falling asleep at night. .The client reports having a constant headache and is seeking medication to help the sleep. Which intervention should the nurse implement? a. Determine the client's sleep and activity pattern b. Obtain prescription for client to take when stressed c. Refer client for a sleep study and neurological follow-up d. Teach coping strategies to use when feeling stressed

When evaluating the effective of a clients nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A.determine if the expected outcomes were realistic B. obtain current clients date to compare with expected outcomes C. Modify the nursing interventions to achieve the clients goal D. Review related professional standard of care

During transfer to med unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraint s for pt's upper and lower extremities. Which intervention is most important for the nurse to implement on admission? A. Determine baseline neuro status B. Admin an IV anxiolytic med C. Assess peripheral ox sat D. Schedule a sitter around the clock

A. Determine baseline neuro status

A male client presents to clinic stating that he has high stress job and is having difficulty falling asleep at night. Client complains of constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? A. Determine the client's sleep and activity pattern B. Teaching coping strategies to use when feeling stressed C. Refer to client for sleep study and neuro follow up D. obtain prescription for client to take when stressed

A. Determine the client's sleep and activity pattern**

A male pt with limited mobility is discharged w home health service. When the home health nurse arrives, the client asks what he can do for the swelling in his leg. Which actin should the nurse implement? A. Instruct pt to flex both of his feet several times a day** B. Explain the need to keep the head of bed elevated C. Advise the pt to dangle feet during meals and before bedtime D. Encourage the pt to take short walks around the block

A. Instruct pt to flex both of his feet several times a day**

Two nurses assess the pt for a pulse deficit and count an apical pulse of 72bpm and a radial pulse of 88bpm. What action should the nurses take? A. Obtain a second pulse deficit reading B. Report the results to the healthcare provider C. Measure the pt's bp D. Document a pulse deficit of 16 bpm

A. Obtain a second pulse deficit reading

After reviewing the admission assessment of a pt with chronic pain, which interventions should the nurse include in the pt's plan of care? (Select all that apply) A. Provide comfort measures such as topical warm application and tactile massage B. Encourage increased fluid intake and measure urinary output q8 hour C. Implement a 24h schedule of routine administration of prescribed analgesic D. Determine client's subjective measure of pain using a numerical pain scale E. Assist the client ambulated as much as possible during waking hrs

A. Provide comfort measures such as topical warm application and tactile massage*** C. Implement a 24h schedule of routine administration of prescribed analgesic*** D. Determine client's subjective measure of pain using a numerical pain scale***

The healthcare provider prescribes bladder irrigation to nation patience of a pt's indwelling urinary catheter. Which interventions should the nurse implement? A. Use sterile syringe to irrigate the normal saline 20 ml B. Use infusion pump to slowly irrigate the indwelling catheter C. Clamp the catheter for 30 mins prior to irrigating with No D. Power flush with NS 60 ml to remove the mucous membrane

A. Use sterile syringe to irrigate the normal saline 20 ml

The nurse prepares to irrigate the ear of an adult client. The client is positioned w/ the head titled slightly toward the affected side and the emesis basin under the ear. What action should the nurse take next? A. confirm the temperature of the irrigation solution B. reposition the client so affected ear is upward C. direct the flow of the solution toward ear canal D. place emesis basin within reach of the pt

A. confirm the temperature of the irrigation solution

The unlicensed assistive personnel describes the appearance of the bowel moments of several clients. Which description warrants additional follow up by nurse? Solid with red streak Brown liquids Multiple hard pellets Formed but soft Tarry Appearance

ABCE

Which pt do you see first?

ABCs—

A terminal ill pt becomes angry. What should the nurse do?

Acknowledge his feeling

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private.

Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings. Correct Answer: C

A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide? a. Surgery removes the disk and is the only treatment that can totally resolve the pain b. The medication regimen you previously used should be re-evaluated for dose adjustment c. Massage and hot pack treatments are less invasive and can provide temporary relief d. Acupuncture is a complementary therapy that is often effective for management of pain

Acupuncturecomplementary therapy that is often effective for management of pain

26. Which outcome is appropriate for the planning stage? A. The client will adhere to medication after discharge B. The client will successfully demonstrate dressing change within 2 days of hospitalization C. The nurse will assess the patient every 2 hours

Ans: B

Pt going home with low Na diet? What should you tell pt?

Advise the pt to check food labels

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Correct Answer: D

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (D). Correct Answer: A

15. The student nurse assesses an adult client's TM by pulling the ear up and back. The preceptor: A. Provides positive reinforcement to the student nurse for using correct technique B. Tells the student nurse that the ear should be pulled down

Ans: A

27. Which is the most appropriate method to teach young adults? A. Simulation activities B. Positive reinforcement C. Physical demonstrations D. Verbal analogies

Ans: A

34. A client has concerns and fears about his new temporary pacemaker. The nurse should: A. Encourage discussion about concerns and fears B. Use simple terms how pacemaker functions C. Offer reassurance that pacemaker his temporary D. Reminds him that the pacemaker will be monitored at all times

Ans: A

4. What is the most important factor for obesity referral? A. BMI >35 B. Client expressed desire to lose 50 pounds C. Body weight is 10% over ideal weight D. Daily calorie intake is 3,500

Ans: A

42. What should be monitored when assessing for water intoxication? A. Serum sodium levels B. Serum potassium levels C. Creatine

Ans: A

44. What is the purpose of logrolling? A. Maintain straight spinal alignment B. Rolling has less friction than pulling C. Safer for multiple nurses to move client

Ans: A

45. A client with heart failure states that she does not want heroic measures performed if cardiac arrests. A. Discuss what heroic measures mean to her B. Obtain DNR order

Ans: A

8. A client who is 12 days post op complains of thoracic incisional pain 2 hours after he received his pain medication. The HCP has been called. What should the nurse do next? A. Guided imagery and deep breathing B. Turn on a T.V. show and music for distraction C. Put a hot device on the area D. Provide a 20 minute back massage

Ans: A

55. Hospice SATA A. Provides comfort and dignity B. Can be at home C. Living will not active in hospice D. Services can be initiated before discharge E. Family members can be involved in care

Ans: A, B, D, E

13. Highest priority? A. Impaired bed mobility B. Fluid volume deficit C. Bowel incontinence D. Caregiver role strain

Ans: B

16. How should the nurse instruct the mother of an adolescent with Diabetes Type 1 to inject insulin? [Picture of injection at deltoid] A. Correct her to the proper injection site B. Instruct mother how to insert needle with dart-like motion

Ans: B

19. Picture of a nurse about to open an ampule. What should the nurse do next? A. Clean neck of ampule with alcohol B. Position gauze around neck of ampule C. Apply clean gloves before breaking the ampule open D. Snap neck away from hands

Ans: B

22. A Native American client complains of abdominal cramping and nausea. What is the most important factor to assess? A. Family decision-making regarding health B. Recent use of home remedies and herbs C. Employment status

Ans: B

23. A patient with a latex allergy needs a dressing change. The nurse notices redness on the skin around the draining wound. The nurse should: A. Obtain sample from draining wound B. Replace dressing with cotton gauze and silk tape C. Measure ankle to brachial index D. Administer antibiotics

Ans: B

24. A nurse is educating a client on 24-hour urine test. The client states that the first void is in the urinal. A. Add the urine from the urinal to the collection container B. Start collecting with next void C. Start collecting the next day D. Check urine for sediments

Ans: B

25. A Muslim female comes to the clinic for an initial assessment A. Obtain most of her history from her family members B. Determine what the client consider to be her ethnicity

Ans: B

5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend? A. Plan low carbohydrate and high protein meals B. Engage in strenuous activity for an hour daily C. Keep a record of food and drinks consumed daily D. Participated in a group exercise class 3 times a week

C. Keep a record of food and drinks consumed daily

A pt's pulse increases 20bpm, but is within normal range. What do you do?

Assess for physical changes

19. While changing a client's post operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take? A. Force oral fluids B. Request a nutrition consult C. Initiate contact precautions D. Limit visitors to immediate family only

C. Initiate contact precautions

Two pt request pain meds at the same time. What is the best action for the nurse to implement?

Ask each pt to rate their pain

51) The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

53) A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.

13) A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.

17) A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the LPN advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner

18) A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

20) The LPN is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.

22) The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml

27) A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the LPN/LVN to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

28) An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

29) A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

3) The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.

32) A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?

43) When evaluating a client's plan of care, the LPN determines that a desired outcome was not achieved. Which action will the LPN implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

44) The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min

45) Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the LPN/LVN plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.

48) When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.

49) In developing a plan of care for a client with dementia, the LPN/LVN should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.

50) An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.

The grandmother of a young male adult admitted to the psych unit yesterday requests info about her grandson's treatment plan. Before answering the family member's question, what action should the nurse take? A. Ask the pt if he wants this info shared with his grandmother B. Ensure that the signed release of info includes the grandmother C. Consult w/ healthcare provider before sharing the info D. Reassure the grandmother by providing a honest response

B. Ensure that the signed release of info includes the grandmother

The nurse is supervising a UAP who is providing care for a pt w/ watery diarrhea caused by c. Diff. The UAP applies gloves and a gown before entering the pt's room carrying a fresh potted plant given to pt. What nurse action is the highest priority A. Asks the UAP to get a stool sample asap B. Explain the need to remove both gown and gloves C. Remind UAP to keep pt's water pitcher filled D. Determine whether UAP plans to discard the plant

B. Explain the need to remove both gown and gloves**

2. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client...the client's gag reflex. Which action should the nurse include? A. Offer smalls sips of water through a straw B. Place tongue blade on back half of tongue C. Use a penlight to observe back of oral cavity D. Auscultate breath sounds after client swallows

B. Place tongue blade on back half of tongue

A confused elderly male is having trouble sleeping at night and is sometimes found wondering the the hallway. What nursing intervention should the nurse implement first? A. Apply wrist restraints to prevent wandering B. Provide back rub at bedtime C. Leave door to his room slightly open D. Administer a PRN sedative prescription

B. Provide back rub at bedtime**

Nurse finds a confused pt wandering in the hallway during the night. What actions should the nurse implement? (Select all that apply) A. Close pt's door B. Raise the side rails of bed C. Orient the pt to her surroundings D. Escort her back to room E. Secure bed alarm on mattress

B. Raise the side rails of bed**** D. Escort her back to room**** E. Secure bed alarm on mattress****

A female pt who is 1 day post mastectomy is crying when the nurse enters the room. What action should the nurse take? A. Remain quietly by the door until the pt stops crying B. Stay w the pt in silence while touching forearm C. Ask the client if she would like er clergy notified D. Tell pt it is normal to cry after surgery

B. Stay w the pt in silence while touching forearm**

A male pt w/ chronic debilitating heart disease asks the nurse to help him die because he believes that he will be better off dead rather than living under the current circumstances. The nurse supports the pt and considers providing the family w/ a dose of medications that can result in pt's death. If the nurse acts on this intention, what is the most likely consequence? A. The nurse's actions will be rewarded by supporters of the right-to-die B. The nurse will be prosecuted for the murder of the pt C. The pt's family will defeat the nurse who acted w/ empathy D. The employing agency will be held legally responsible for the death

B. The nurse will be prosecuted for the murder of the pt**

What info is most important for the nurse to consider when preparing to transfer a pt from bed to chair? A. Whether the pt is wearing antiembolism stockings B. The pt's ability to bear weight on lower extremities C. The presence and volume of the pt's pedal pulse D. How long the client is prescribed to remain out of bed

B. The pt's ability to bear weight on lower extremities

A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment...she has not yet been fitted for a particulate filter mask.Which action should the nurse take? a. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care b. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client c. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client d. Before changing assignments, determine which staff members have fitted particulate filter masks

B.Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client

What assessment does finding place a client at risk for problems associated with impaired skin integrity? a. Scattered macula of the face b. Capillary refill 5 seconds c. Smooth nail texture d. Absence of skin tenting

B.capillary refill 5 seconds

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D). Correct Answer: A

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.

Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Correct Answer: B

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement. Correct Answer: C

After giving an enema to mobile, the pt tells you that she doesn't believe she can hold the fluid all the way to the bathroom. What should you do next?

Bring a bedside commode

55) At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? a. Document the client's circadian rhythms b. Assess for flushed, warm skin regularly c. Measure temperature at regular intervals d. Vary sites for temperature measurement

A client who has a body mass index of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend? A.Plan low carbohydrate and high protein meals B.Engage in strenuous activity for an hour daily C.Keep a record of food and drinks consumed daily D.Participated in a group exercise class 3 times a week

A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care? a. Amount of support provided by family members b. Measurement of pain using a scale of 0 to 10 c. The ability to perform ADLs d. Nonverbal behaviors exhibited when pain occurs

A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that the chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? a. Evaluate the stool samples for presence of blood b. Assess for the presence of an impaction c. Determine what home remedies were used d. Obtain list of prescribed home medication

A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved. a.Number of staff induced injury b.Client satisfaction survey c.Health care-associated infection rate. d.Rate of needle-stick injuries by nurse.

The nurse explains to an older adult make the procedure for collecting 24-hr urine specimen for creatinine clearance. A. Assess the client for confusion and reteach the procedure B. Check the urine for color and texture C. Empty the urinal contents into the 24-hour collection container D. Discard the contents of the urinal

While changing a client's post operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take? A.Force oral fluids B.Request a nutrition consult C.Initiate contact precautions D.Limit visitors to immediate family only

While interviewing a client the nurse records the assessment in the electronic health record. Which statement is more accurate regarding electronic documentation during an interview? A.the clients comfort level us increases when the nurse breaks eye contact to type notes into the record B.the interview process is enhanced with electronic documentation and allows the client to speak at a normal pace C.the nurse has limited ability to observe nonverbal communication while entering the assessment electronically D.completing the electronic record during an interview is a legal obligation of the examine nurse

The home health nurse visits a client who has serum sodium level of 123. To explore possible ecologists for this value, what question should the nurse ask the client? A. "How frequent do you eat processed or canned food" B " do you drink or eat dairy products at each meal? C. " How much water and ice chips do you have each day" D. "What amount of daily meals contained fresh vegetables"

C. " How much water and ice chips do you have each day"

Two days after surgery a male pt experiences incisional pain while dangling his feet at the bedside and he refueled to ambulated as prescribed. The nurse establishes a problem, which outcome statement is best for the nurses to include in this pt's plan of care? Pt will A. Show evidence of incision healing B. Avoid pain-caused activity C. Ambulate without discomfort D. Take analgesics as prescribed

C. Ambulate without discomfort

3. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. A. Assess the client for confusion and reteach the procedure B. Check the urine for color and texture C. Empty the urinal contents into the 24-hour collection container D. Discard the contents of the urinal

C. Empty the urinal contents into the 24-hour collection container

The nurses is assessing the pt with COPD. The pulse ox alarm is flashing without displaying a percentage of oxygen. What action should the nurse implement? A. Prepare equipment to assist w/ intubation B. Assess lung sounds and capillary refill C. Exchange pulse ox for another monitor D. Discontinue pulse ox readings

C. Exchange pulse ox for another monitor

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.

Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first. Correct Answer: B

Clear liquid diet

Carbonated drinks, gelatin, tea, water, coffee, and ice chips

Restraint was applied to pt's hand after he/she removed IV line and NG tube. What action should you take next?

Check capillary refill

Pt has elevated blood pressure, WNL, what should the nurse do next?

Check emotional states, or ask pt if an activity has been performed.

In what manner should nurse clean a wound?

Circular motion—inner to outer

The restroom of an unoccupied room is on fire the nurse has already alarmed the situation. What should she do next?

Close the door to the restroom and leave the room

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.

Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice. Correct Answer: D

Spo2 was 94% before suctioning. During suctioning the spo2 remains at 94%. What should the nurse do next?

Continue intermittent suctioning

A pt with limited mobility, what do you instruct him to do to avoid DVT?

Contract and relax let muscles several times a day

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D). Correct Answer: C

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat. Correct Answer: D

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes. Correct Answer: C

A pt wearing a nasal cannula has redness in his cheek bones. What should the nurse do?

Cover the nasal cannula with pads

11) The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

15) The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

33) During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

34) Which intervention is most important for the LPN/LVN to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

35) A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match

38) Which nutritional assessment data should the LPN/LVN collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference

39) An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the LPN/LVN implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

4) A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300

9) Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.

A 54 year old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most A.Ask her how she would like to participate in the client's care B.Provide the wife with information about hospice C.Encourage the wife to visit after painful treatments are completed D.Refer her to support group for family members of those dying of cancer

An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? A.Establish a toileting schedule to decrease episodes of incontinence B.Complete a functional assessment of the client's self-care abilities C.Apply a barrier ointment to intact areas that may be exposed to moisture D.Determine the size and depth of skin breakdown over the sacral area

53. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. A. Administer nasal oxygen at a rate of 5 L/min B. Help the client to lie back down in the bed C. Quickly pivot the client to the chair and elevate the legs D. Check the client's blood pressure and pulse deficit

D. Check the client's blood pressure and pulse deficit

While suctioning a client's nasopharnx, the nurse observes that the pt's oxygen sat remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? A. Stop suctioning until pulse ox reading is above 95% B. Apply xylene mask over the pt's nose and mouth C. Reposition the pulse ox clip to obtain new reading D. Complete the intermittent suction of nasopharynx

D. Complete the intermittent suction of nasopharynx

A client in the outpatient clinic complains of experiencing hard, infrequent stools. Which instruction should the nurse provide this client? A. "Walk around the block or further everyday" B. Take an over the counter laxative every morning C. Try using over the counter enemas when needed D. Drink 6-8 large glasses if water daily

D. Drink 6-8 large glasses if water daily***

A client is discharged for a long-term facility w/ an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the pt's risk for infection related to catheter? A. Secure the drainage bag a bladder level during transport B. Administer a pen antipyretic if a fever develops C. Flush the catheter daily with sterile saline D. Encourage increased intake of oral fluids

D. Encourage increased intake of oral fluids

52. The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include... A. Notify the OR staff of the client's confusion B. Have the client sign a new surgical permit C. Add the additional information to the permit D. Inform the surgeon about the client's concern

D. Inform the surgeon about the client's concern

The home care nurse has identified the problem "risk for hopelessness" for a male pt who is terminally ill w/ a life expectancy of several days. Which instruction should the nurse provide the pt's spouse? A. Offer meals prepared w pt's favorite food at frequent, regular intervals B. Help save pt''s energy by making as many decision of him as possible C. Maintain cheerful and calm appearance while spending time w/ pt D. Listen for changes in what the client hopes for and try to help meet his goals

D. Listen for changes in what the client hopes for and try to help meet his goals***

The nurse reviews discharge instructions for a male pt with obstructive sleep apnea syndrome (OSAS). The client tells the nurses that he like to drink a glass of wine before going to bed. How should the nurse respond? A. Advise the pt to switch to non-alcoholic beverage such as a cola drink B. Confirm that a glass of wine at bedtime can help promote relaxation and sleep C. Suggest having wine w/ dinner so its consumed 3hours before bedtime D. Offer to contact healthcare provider about a prescription for a sleeping aid

D. Offer to contact healthcare provider about a prescription for a sleeping aid***

The nurse noted that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? A. Temp B. Pulse C. BP D. RR

D. RR

4. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most A. Ask her how she would like to participate in the client's care B. Provide the wife with information about hospice C. Encourage the wife to visit after painful treatments are completed D. Refer her to support group for family members of those dying of cancer

D. Refer her to support group for family members of those dying of cancer

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurse implement? a. Explain the respiratory problems that can occur with morphine use. b. Teach family how to evaluate the effectiveness of analgesics. c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump. d. Provide client with a schedule of around-the-clock prescribed analgesic use.

D. provide client with schedule of around the clock prescribed analgesic

UAP has lowered the head of the bed to change the lines for a client who is bedless. Which observation...most immediate intervention by the nurse? a. A feeding is infusing at 40 mL/hr through an enteral feeding tube b. The urine meter attached to the urinary drainage bag is completely full c. There is a large dependent loop in the client's urinary drainage tubing d. Purulent drainage is present around the insertion site of the feeding tube

D. purulent drainage is present around the insertion site of the feeding tube

The healthcare provider prescribes hydroxyzine (vistaril) 35mg IM for client who is vomiting. The availed drug is labeled 50mg/mL. How many mL should the nurse administer?

D/HxV= 35/50= 0.7 mL

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Correct Answer: D

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.

Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain). Correct Answer: A

When teaching a pt how to administer eye drops, what should the nurse include?

Do not let bottle touch the eye

The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated. Correct Answer: B

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome. Correct Answer: B

Pt incontinent for feces and with diarrhea? What is most appropriate nursing Dx?

Fluid volume deficit—

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.

Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary. Correct Answer: A

Muslim pt who is ESL becomes agitated everyday before being transported for his dialysis?

Get interpreter to find reason behind behavior. Before implementation—assess!!!

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Correct Answer: C

Durable power of attorney

Has control of pt's choices

You see a pt having trouble feeding himself. What is wrong with him?

He has problems with his fine motor skill

A pt seated on the char starts having a seizure. What is the best action to take?

Help the pt to the floor

13. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? a. Access for side effects of the medication. b. Document the client's responses. c. complete a medication error report. d. Determine if the pain was relieved

a. Access for side effects of the medication.

When taking a palpable pressure the nurse stops feeling the pulse at 90mm hg. What should the nurse do next?

Inflate cuff to 120 mm hg

While documenting the results of a health assessment the system shuts down on the nurse. What should the nurse do next?

Inform the service department.

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.

Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority. Correct Answer: C

A wound care pt, with stage 3 ulcer with eschar, with an order to put cream on wind. What should nurse do first?

Irrigate with normal saline before applying cream

When inserting catheter into uncircumcised pt. What should the nurse do?

Keep inserting cath and then inflate balloon

For pt trying to lose weight. What do you advise them?

Limit fat intake 20-30% of daily intake

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.

Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase. Correct Answer: C

A pt with COPD tells the nurse that she feels better when seated upright. What should the nurse tell the UAP to do when taking care of this pt?

Lower the bed to working level. Prevents injury to worker and pt

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification. Correct Answer: B

10. The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? a. Remove identifying information of the clients who participated b. Recall that authored content may be legally discoverable c. Share material from credible, peer reviewed sources only d. Respect all copyright laws when adding website content

a. Remove identifying information of the clients who participated

Pt wearing a diaper and with a pressure ulcer

Measure and document size

What assessment finding places a client at risk for problems associated with impaired skin integrity?

capillary refill 5 seconds

An UAP has been assigned to care for pt in droplet isolation. UAP has not been fitted for a mask. What does the nurse do?

Nothing. A regular surgical mask is adequate for care.

Pt on ventilator and power of attorney ask nurse to take off ventilator. What should nurse do?

Notify the physician. Not in nurse's scope of practice.

Physician order the nurse to obtain a blood occult specimen. The pt stool was soft and yellow. What should nurse do?

Obtain blood occult specimen

When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse take first?

check for neck vein distention

A pt with terminal lung cancer is concerned about pain. What should the nurse do?

Offer around the clock pain meds

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct Answer: B

A pt with severe obstructive apnea is receiving an opioid. What should the nurse do before leaving the room?

Place continuous positive airway pressure therapy. CPAP

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D). Correct Answer: B

When palpating pt's dorsal pedis pulse the nurse can't feel it. What should the nurse do next?

Release some of the pressure

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.

Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. Correct Answer: B

What should be transported out of pt's room that has MRSA in a biohazard bag?

Sputum sample

check the clients blood pressure and pulse deficit

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium. Correct Answer: C

After obtaining a clean catch urine sample, what info would prompt the nurse to repeat the test?

Small colony of organisms are present

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.

Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed. Correct Answer: D

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation. Correct Answer: C

After knee surgery, a pt complains of not being able to sleep because of pain. What should the nurse do?

Teach pt about the PCA pump. Where they can control what meds the take and lessen the pain

Pt on air mattress without sheets and has not been turned the whole night? What do you tell the family members?

Tell the family the air mattress is sufficient enough

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.

The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C). Correct Answer: C

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.

The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer. Correct Answer: B

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.

The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C). Correct Answer: D

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.

The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Correct Answer: B

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration. Correct Answer: B

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.

The client should be positioned in a semi-sitting or Fowler's (B) position during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often referred to as a PEG tube, is inserted directly into the stomach through an incision in the abdomen and is used when long-term tube feedings are needed. In (A and/or C) positions, the client would be lying on his abdomen and on the tubing. In (D), the client would be lying flat on his back which would increase the chance of aspiration. Correct Answer: B

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.

The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is related to allergens (D), and the client should be instructed to stay indoors when the pollen count is high. Correct Answer: A

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort, and provide calories and protein. (C) does not provide any nutritional value. (B and D) require energy to chew and are more difficult to swallow than pudding. Correct Answer: A

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy. Correct Answer: B

The nurse in the emergency department observes a colleague viewing the electronic health record of a client who holds an elected position in the community. The client is not a part of the colleagues assignment. Which action should the nurse implement?

communicate the colleagues action to the unit. charge nurse

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.

The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct Answer: A

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.

The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D). Correct Answer: C

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.

The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of sensory and motor functions. Correct Answer: C

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.

The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D). Correct Answer: C

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D). Correct Answer: B

A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?

The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150

complete the intermittent suction of the nasopharynx

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Correct Answer: C

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.

The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Correct Answer: A

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). Correct Answer: B

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A). Correct Answer: A

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented. Correct Answer: D

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D). Correct Answer: A

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.

The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured. Correct Answer: A

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Correct Answer: A

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.

Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D). Correct Answer: B

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D

Why do you log roll?

To keep spine straight

After plugging the oxygen pipe into the wall outlet you hear a whooshing sound. What do you do?

Unplug and replug

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. Correct Answer: D

When pt does not understand the teaching, what do you do?

Use analogy to help pt understand materials

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.

Using ratio and proportion: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Correct Answer: A

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B

The nurse is preparing to assist a newly admitted client with person hygiene measures. The client... the client's gag reflex. Which action should the nurse include?

place tongue blade on back half of tongue

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?

Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference. Correct Answer: B

The UAP is caring for a client with hepatitis. What should nurse tell UAP?

Wear gloves when bathing pt

When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?

position the client supine for a few minutes

34. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? a. Determine if the expected outcomes were realistic b. Obtain current client data to compare with expected outcomes c. Modify the nursing interventions to achieve the client's goals d. Review related professional standards of care

a. Determine if the expected outcomes were realistic

37. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? a. Instruct the client to repeat the medication plan b. Encourage client to take a PRN antianxiety drug c. Provide written instructions that are easy to follow d. Include a family member in the teaching session

a. Instruct the client to repeat the medication plan

28. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? a. Position the client supine for a few minutes b. Assist the client to stand at the bedside c. Apply the blood pressure cuff securely d. Record the client's pulse rate and rhythm

a. Position the client supine for a few minutes

A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

postpone the procedure until the client understands the risks and benefits

30. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description warrants additional follow up by the nurse? (select all that applies). a. Solid with red streaks. b. Brown liquid. c. Multiple hard pellets. d. Formed but soft. e. Tarry appearance.

a. Solid with red streaks. b. Brown liquid. c. Multiple hard pellets. e. Tarry appearance.

21. A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action? a. instruct the client to use guided imagery and slow rhythmic breathing b. Provide at least 20 minutes of back massage and gentle effleurage c. Encourage the client to watch TV. d. Place a hot water circulation device, such as an Aqua K pad, to operative site

a. instruct the client to use guided imagery and slow rhythmic breathing

access for side effects of the medication

A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

acupuncture is a complementary therapy that is often effective for management of pain

To prepare a client for the potential side effects of a newly prescribed medication, what action should the nurse implement?

assess the client for health alterations that may be impacted by the effects of the medication

assume responsibility for placing the pillows while the UAP completes another task

35. The nurse attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading? a. BP 142/88 mmHg b. 2+ edema of fingers and hands c. Radial pulse volume is +3 d. Capillary refill time is 2 seconds

b. 2+ edema of fingers and hands

33. What assessment finding places a client at risk for problems associated with impaired skin integrity? a. Scattered macula of the face b. Capillary refill 5 seconds c. Smooth nail texture d. Absence of skin tenting

b. Capillary refill 5 seconds

51. During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this statement? a. Provide information about the hours and location of the chapel b. Document the statement of the client's spiritual assessment c. Invite the client to a healing service for people of all religions d. Offer to contact a spiritual advisor of the client's choice

b. Document the statement of the client's spiritual assessment

provide client with a schedule of around-the-clock prescribed analgesic use

26. The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states "clean the wound and then apply collagenase." collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? a. Lightly coat the wound with povidone-iodine solution b. Irrigate the wound with sterile normal saline c. Flush the wound with sterile hydrogen peroxide d. Remove the eschar with a wet-to-dry dressing

b. Irrigate the wound with sterile normal saline

44. A cerebrovascular accident is placed on a ventilator. The client's daughter arrives with a durable power of attorney, and a living will that indicates the...extraordinary life saving measures. What action should the nurse take? a. Refer to the risk manager b. Notify the healthcare provider c. Discontinue the ventilator d. Review the medical record

b. Notify the healthcare provider

48. Which assessment data reflects the need for the nurses to include the problem, "Risk for falls" in a client's plan of care? a. Recent serum hemoglobin level of 16g/dL b. Opioid analgesic received one hour ago c. Stooped posture with a steady gait d. Expressed feelings of depression

b. Opioid analgesic received one hour ago

11. A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? a. Answer the client's specific questions with a short understandable explanation b. Postpone the procedure until the client understands the risks and benefits c. Call the client's next of kin and ask them to provide verbal consent d. Page the healthcare provider to return and provide additional explanation

b. Postpone the procedure until the client understands the risks and benefits

45. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action? a. Ask the family to wait in the cafeteria when the next of kin makes the necessary arrangements b. Provide space and privacy for the family to share their concerns about the client's discharge c. Ask the social worker to encourage the family to clear the hallway d. Explain to the family the client's need for privacy so that she can make independent decisions

b. Provide space and privacy for the family to share their concerns about the client's discharge

36. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first? a. Apply the restraints to maintain the client's safety. b. Reassess the client to determine the need for continuing restraints. c. Document the time the family left and continue to monitor the client. d. Call the healthcare provider for a new prescription.

b. Reassess the client to determine the need for continuing restraints.

7. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take? a. Remove the basin of water from the client's bed immediately b. Remind the UAP to dry between the client's toes completely c. Advise the UAP that this procedure is damaging to the skin d. Add skin cream to the basin of water while the foot is soaking

b. Remind the UAP to dry between the client's toes completely

15. A female client's significant other has been at her bedside providing reassurances and support for the past 3days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? a. Obtain a perception from the healthcare provider regarding visitation privileges b. Request a consultation with the ethics committee for resolution of the situation c. Encourage the client to speak with her husband regarding his disruptive behavior d. Communicate the client's wishes to all members of the multidisciplinary team

b. Request a consultation with the ethics committee for resolution of the situation

49. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL, for the previous 6 hour shift. Which intervention should the nurse implement first? a. Check the drainage tubing for a kink b. Review the intake and output record c. Notify the healthcare provider d. Give the client 8 oz of water to drink

b. Review the intake and output record

31. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment...she has not yet been fitted for a particulate filter mask. Which action should the nurse take? a. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care b. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client c. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client d. Before changing assignments, determine which staff members have fitted particulate filter masks

b. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client

12. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? a. Tilt the pelvis forwards and backwards b. bend the arm by flexing the ulnar to the humerus c. Turn the head to the right and left d. Extend the arm at the ide and rotate in circles

b. bend the arm by flexing the ulnar to the humerus

17. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? a. Ventrogluteal b. outer upper quadrant of the buttock c. Two inches below the acromion process d. Vastus lateralis

b. outer upper quadrant of the buttock

The nurse is teaching a client how to do active range of motion exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

bend the arm by flexing the ulnar to the humerus

At 0100 on a male clients second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

bring the client a prescribed PRN sedative-hypnotic

9. At 0100 on a male client's second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement? a. Leave the room and close the door to the client's room b. Assess the appearance of the client's surgical dressing c. Bring the client a prescribed PRN sedative-hypnotic d. Discuss symptoms of sleep deprivation with the client

c. Bring the client a prescribed PRN sedative-hypnotic

47. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that the chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? a. Evaluate the stool samples for presence of blood b. Assess for the presence of an impaction c. Determine what home remedies were used d. Obtain list of prescribed home medication

c. Determine what home remedies were used

1. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved. a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infection rate. d. Rate of needle-stick injuries by nurse

c. Health care-associated infection rate.

Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

provide space and privacy for the family to share their concerns about the clients discharge

UAP has lowered the head of the bed to change the lines for a client who is bedless. Which observation...most immediate intervention by the nurse? a

purulent drainage is present around the insertion site of the feeding tube

27. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? a. Document the client's circadian rhythms b. Assess for flushed, warm skin regularly c. Measure temperature at regular intervals d. Vary sites for temperature measurement

c. Measure temperature at regular intervals

46. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care? a. Amount of support provided by family members b. Measurement of pain using a scale of 0 to 10 c. The ability to perform ADLs d. Nonverbal behaviors exhibited when pain occurs

c. The ability to perform ADLs

24. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? a. The client's comfort level is increased when the nurse breaks eye contact to type notes into the record b. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace c. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically d. Completing the electronic record during an interview is a legal obligation of the examining nurse

c. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically

25. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide? a. Surgery removes the disk and is the only treatment that can totally resolve the pain b. The medication regimen you previously used should be re-evaluated for dose adjustment c. Massage and hot pack treatments are less invasive and can provide temporary relief d. Acupuncture is a complementary therapy that is often effective for management of pain

d. Acupuncture is a complementary therapy that is often effective for management of pain

43. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. Which action should the nurse implement? a. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows b. Ensure that the UAP has placed pillows effectively to protect the client c. Ask the UAP to use some pillows to prop the client in a side-lying position d. Assume responsibility for placing the pillows while the UAP complete another task

d. Assume responsibility for placing the pillows while the UAP complete another task

16. When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse take first? a. Determine pulse pressure b. Auscultate heart sounds c. Measure oxygen saturation d. Check for neck vein distention

d. Check for neck vein distention

23. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? a. Establish a toileting schedule to decrease episodes of incontinence b. Complete a functional assessment of the client's self-care abilities c. Apply a barrier ointment to intact areas that may be exposed to moisture d. Determine the size and depth of skin breakdown over the sacral area

d. Determine the size and depth of skin breakdown over the sacral area

38. What instruction should the nurse provide for an UAP caring for a client with MRSA who has a prescription for contact precautions? a. Do not allow visitors until precautions are discontinued b. Wear sterile gloves when handling the client's body fluid c. Have the client wear a mask whenever someone enters the room d. Don a gown and gloves when entering the room

d. Don a gown and gloves when entering the room

14. When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which? a. Hyperphosphatemia b. Hypocalcemia c. Hypermagnesemia d. Hypokalemia

d. Hypokalemia

When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take

re-assess the client situation

32. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurse implement? a. Explain the respiratory problems that can occur with morphine use. b. Teach family how to evaluate the effectiveness of analgesics. c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump. d. Provide client with a schedule of around-the-clock prescribed analgesic use.

d. Provide client with a schedule of around-the-clock prescribed analgesic use.

40. UAP has lowered the head of the bed to change the lines for a client who is bedless. Which observation...most immediate intervention by the nurse? a. A feeding is infusing at 40 mL/hr through an enteral feeding tube b. The urine meter attached to the urinary drainage bag is completely full c. There is a large dependent loop in the client's urinary drainage tubing d. Purulent drainage is present around the insertion site of the feeding tube

d. Purulent drainage is present around the insertion site of the feeding tube

54. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take a. divert the client's attention b. Call for additional help from staff c. Document the planned action d. Re-assess the client situation

d. Re-assess the client situation

50. The nurse is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the nurse include in the assessment? a. Provider an interpreter to convey the meaning of words and messages in translation b. Commend the client for her patience after a long wait in the admission process c. Arrange for the hospital chaplain to visit the client during her hospital stay d. Rely on cultural norms as the basis for providing nursing care for this client

d. Rely on cultural norms as the basis for providing nursing care for this client

18. Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? a. Monitor daily urine output volume b. Drink plenty of water whenever thirsty c. Use salt tablets for sodium content d. Review food labels for sodium content

d. Review food labels for sodium content

41. A male client presents to the clinics stating that he has a high stress job and is having difficulty falling asleep at night. .The client reports having a constant headache and is seeking medication to help the sleep. Which intervention should the nurse implement? a. Determine the client's sleep and activity pattern b. Obtain prescription for client to take when stressed c. Refer client for a sleep study and neurological follow-up d. Teach coping strategies to use when feeling stressed

d. Teach coping strategies to use when feeling stressed

42. The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precaution? a. Remove needle before discarding used syringes b. Wear gloves to dispose of the needle and syringe c. Done a face mask before administering the medication d. Washes hands before handling the needle and syringe

d. Washes hands before handling the needle and syringe

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

determine if the expected outcomes were realistic

determine the size and depth of skin breakdown over the sacral area

determine what home remedies were used

During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this statement?

document the statement of clients spirtiual assessment

What instruction should the nurse provide for an UAP caring for a client with MRSA who has a prescription for contact precautions?

don a gown and gloves when entering the return

The nurse explains to an older adult male the procedure for collecting a 24-hr urine specimen for creatinine clearance.

empty the urinal contents into the 24-hr collection container

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B

A policy required the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?

health care-associated infection rate

When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the clients laboratory values to validate the existence of which?

hypokalemia

The father of an 11 year old boy....

inform the father that it is important to let the son that nocturnal emissions are normal

The father of an 11-year-old boy...

inform the father that it is important to let the son that nocturnal emissions are normal

The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include...

inform the surgeon about the clients concern

initiate contact precautions

instruct the client to repeat the medication plan

A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action?

instruct the client to use guided imageryand slow rhythmic breathing

irrigate the wound with sterile normal saline

A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend?

keep a record of food and drinks consumed daily

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

measure temperature at regular intervals

notify the healthcare provider

Which assessment data reflects the need for the nurses to include the problem, "Risk for falls" in a client's plan of care?

opioid analgesic received one hour ago

To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?

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