nclex practice test
A client comes to the emergency department with crushing substernal chest pain. Which interventions should the nurse complete? Select all that apply. 1. Administer morphine 2. Check blood pressure and heart rate 3. Draw blood specimen 4. Obtain a 12-lead ECG 5. Position client in the supine position
1,2,3,4 The nurse needs to quickly identify the signs and symptoms of myocardial infarction (eg, chest pain, diaphoresis, dyspnea, anxiety) and initiate interventions to preserve cardiac muscle. The nurse also recognizes that female and older clients may have nonspecific symptoms (eg, fatigue, indigestion, shortness of breath). The following are initial interventions in the emergency management of chest pain: Assess airway, breathing, circulation (ABCs) (eg, vital signs, heart and lung sounds), and pain (eg, PQRST method) (Option 2) Obtain diagnostics (eg, 12-lead ECG, cardiac markers, electrolytes, chest x-ray) (Options 3 and 4) Apply oxygen if required (eg, SpO2 <90%, dyspnea) Insert 2 large-bore IV lines and administer prescribed medications (eg, nitroglycerin, aspirin, morphine) (Option 1) Initiate continuous cardiac monitoring Prepare client for additional therapy (eg, percutaneous coronary intervention, thrombolytics)
A client is at 28 weeks gestation with suspected preeclampsia. Which are potential signs/symptoms related to this syndrome? Select all that apply. 1. 2+ pitting pedal edema 2. 300 mg/24 hr (0.3 g/day) protein in urine 3. Frequent urination 4. Headache and blurry vision 5. Hemoglobin 10 g/dL (100 g/L)
1,2,4 Preeclampsia is defined as new-onset hypertension (≥140/90 mm Hg) plus proteinuria and/or signs of end-organ damage after 20 weeks gestation. Although edema is not a diagnostic criterion for preeclampsia, it is a common manifestation of the disease process.
A nurse is teaching an inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the teaching? Select all that apply. 1. Administer scheduled anticoagulants 2. Apply sequential compression devices 3. Elevate the legs with pillows behind the knees 4. Have clients ambulate regularly as tolerated 5. Instruct clients to point and flex the feet in bed
1,2,4,5 Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). Hospitalized clients tend to have multiple risk factors for VTE, including venous stasis from prolonged immobility and endothelial damage from surgeries or IV catheter placement. VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1) Application of compression devices or antiembolism stockings to limit venous stasis (Option 2) Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5)
The nurse is caring for an older adult client with advanced dementia, confusion, and a history of falls. Which of the following interventions are appropriate to promote client safety? Select all that apply. 1. Activate the bed alarm before leaving the room 2. Keep the lights dim to create a calm environment 3. Place a bedside commode next to the bed 4. Place the client in a room close to the nurses' station 5. Request a prescription for a vest or belt restraint
1,3, 4
The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply. 1. Instructs client that stockings will be worn only at night 2. Measures circumference of both calves at the widest point 3. Rolls down any excess length at the top of the stocking 4. Selects a size larger to avoid friction against a leg laceration 5. Smoothes out any wrinkles or creases in the stocking
1. Instructs client that stockings will be worn only at night 3. Rolls down any excess length at the top of the stocking 4. Selects a size larger to avoid friction against a leg laceration
The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client with a right-sided ischemic stroke who is confused and is repeatedly getting out of bed without assistance [58%] 2. Client with an asthma exacerbation who was administered albuterol 15 minutes ago and has a heart rate of 110/min [15%] 3. Client with diabetes who has a blood glucose of 290 mg/dL (16.1 mmol/L) and has a scheduled dose of insulin aspart due [9%] 4. Client with obstructive sleep apnea who is 12 hours postoperative and maintaining an oxygen saturation of 92% on room air [16%]
1. Clients who have suffered a stroke can experience cognitive dysfunction (eg, confusion) and hemiplegia, resulting in a high risk for injury (eg, falls). The nurse should ensure that safety precautions (eg, bed alarm, nonslip socks) are in place. Additional Information Management of Care NCSBN Client Need
A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond? 1.Allow the spouse into the room and provide a chair 2. Call the chaplain to sit with the spouse outside the room 3. Have the unit secretary escort the spouse to the waiting room 4. Tell the spouse that the resuscitation is too graphic to be witnessed
1. allow the spouse into the room and provide a chair
The nurse prepares to administer potassium chloride to a client through a peripherally inserted IV line. What are the appropriate nursing interventions related to administration of this medication? Select all that apply. 1. Administer as IV bolus 2. Assess IV site frequently 3. Assess renal function laboratory results and urine output 4. Place client on cardiac monitor 5. Verify that IV pump infusion is not >10 mEq/hr (10 mmol/hr)
2, 3 4 5
A nurse hears various alarms sounding from different client rooms. Which alarm will the nurse address first? 1. Distal occlusion alarm on an infusion pump infusing heparin [3%] 2. Low-pressure limit alarm on a ventilator [55%] 3. Monitor alarm for a low respiratory rate of 11 breaths/min [38%] 4. Occlusion alarm on a continuous enteral feeding pump [1%]
2. A low-pressure limit alarm on the ventilator is triggered when the amount of positive pressure necessary to deliver a breath to the client is decreased. A decrease in resistance to airflow occurs due to complications that arise in the client (eg, loss of airway), artificial airway (eg, cuff leak), and/or ventilator system (eg, tubing disconnect). All of these conditions impair airway and ventilation; therefore, addressing this alarm is the highest p
The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? 1. "I lost my imipramine prescription. Could I have a refill?" 2. "I plan to attend my granddaughter's graduation next month." 3. "I seem to have a lot more energy since I started therapy." 4. "I will sign a 'no-suicide' contract at today's appointment."
2. I plan to aattend my granddaughters graduation next month
A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1. Client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest [8%] 2. Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain [73%] 3. Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) [3%] 4. Client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft [14%]
2. client 3 hours post coronary artery stent placement via femoral approach reporting back pain
The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. 1. "Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel." 2. "Having a routine for bowel movements is important, but I should not wait if I feel the urge." 3. "I can use an over-the-counter laxative every other day if needed." 4. "I should try to eat more fruits and vegetables every day." 5. "Increasing my daily exercise level may help keep my bowel movements regular."
2. having a routine for bowel movements is important but i should not wait if i feel the urg 4. I should try to eat more fruits and veggies every day 5.increasing daily exercise level may help keep bowel movements regular
A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A bystander brings the automated external defibrillator (AED). The nurse notes that the victim is wet, lying in a small pool of water, and wearing a transdermal medication patch on the upper right chest. What is the most appropriate action at this time? 1. Do not use the AED and continue CPR until paramedics arrive [27%] 2. Move the client away from the pool of water before applying AED pads [26%] 3. Remove the transdermal patch and wipe the chest dry before using the AED [42%] 4. Wipe the chest dry and apply the AED pads over the transdermal patch [4%]
3
tpa to disolve blood clots must be given within how many hours
3 to 4.5 hours frm onset
A nurse in the cardiac intensive care unit assesses a client with diabetes who had a percutaneous coronary intervention with stent placement via the left femoral artery 3 hours ago. Which assessment finding requires priority notification of the health care provider? 1. 1+ palpable pedal pulses bilaterally [18%] 2. 2-cm area of ecchymosis in the left groin [32%] 3. Angina rated as 4 on pain scale of 0-10 [38%] 4. Blood glucose of 220 mg/dL (12.2 mmol/L) [10%]
3.
An older adult client takes multiple prescription medications plus several over-the-counter medications. Which intervention by the clinic nurse is most important in reducing the risk for drug interactions? 1. Assist client with making a list of all medications, doses, and times to be taken [34%] 2. Encourage client to obtain all prescription medications from the same pharmacy [14%] 3. Have client bring all medications taken regularly or occasionally to each appointment [39%] 4. Instruct client to use a pill organizer to separate pills by day and time [11%]
3. Polypharmacy and the physiologic changes associated with aging place older adults at an increased risk of adverse drug events. Decreased renal and hepatic function causes increased drug half-life and impaired drug clearance, potentially resulting in toxicity and adverse events. Clients may see different health care providers and receive multiple prescriptions for different health problems (polypharmacy). Clients should be encouraged to bring all medications (ie, prescription, over-the-counter [OTC], herbal supplements) they take regularly and occasionally to each appointment so that potential drug interactions can be evaluated (Option 3).
The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? 1.Call for help to initiate cardiopulmonary resuscitation 2. Call the health care provider to confirm the DNR status 3. Explain the client's wishes to the client's child 4. Offer to call the hospital chaplain to provide support
3. explain the wishes to the clients child
The nurse on the antepartum unit is performing shift assessments of several pregnant clients. Which client assessment is the priority to report to the health care provider? 1. Client with gestational diabetes mellitus reporting dysuria [2%] 2. Client with hyperemesis gravidarum with a blood pressure of 90/48 mm Hg [42%] 3. Client with oligohydramnios and a reactive fetal nonstress test [7%] 4. Client with preeclampsia with 3+ reflexes and 2 beats of clonus [47%]
4 Clients with preeclampsia are at risk for developing preeclampsia-associated seizure activity (eg, eclampsia) as a result of increased central nervous system irritability. The presence of neurologic manifestations (eg, hyperreflexia, clonus) may indicate worsening preeclampsia and can precede seizure activity (Option 4). This client is at the most immediate risk of harm and is the priority to report to the health care provider.
The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider? 1. HCO3− of 35 mEq/L (35 mmol/L) [12%] 2. Hemoglobin of 19 g/dL (190 g/L) [3%] 3. PaCO2 of 67 mm Hg (8.91 kPa) [33%] 4. PaO2 of 52 mm Hg (6.92 kPa) [50%]
4.
after listening to the parents reports and seeing the following pediatric clients, the nurse knows that which clent demonstrates signs of abuse that may need reporting 1. 1 year old with dyspnea, drooling, and a swollen tongue after eating part of houseplant 2. 2 year old who is crying and has large foregead hemotoma after falling out of a chair 3. 3 year old with second degree burns afte rpulling hot tea off table 4. 5 yr old whose xray recelas 2 humerus fractures after falling from tree
4. 5 year old whose x ray reveal humurus fractures rationale: the nurse should be aware of signs of abuse including repeated injuries in caried stages of healing, shaken baby syndrome,
how long can blood products be left in room beforetransfusion
<30 mins
A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion? 1. Administering high-flow IV fluids [72%] 2. Applying oxygen via nasal cannula [17%] 3. Maintaining strict bed rest [3%] 4. Transfusing packed red blood cells [6%]
administering high IV flow Iv fluids
list 5 characteristics of infective endocarditis
fever myalgia chills joint pain anorexia petechia
what is a stage 5 pressure ulcer
unstageable, full thickness, ucer base covered by slough and or eschar that needs removal to stage
When caring for a client with ulcerative colitis, which nursing activities are appropriate for the registered nurse to delegate to the licensed practical nurse? Select all that apply. 1. Administer a blood transfusion 2. Administer a prescribed suppository 3. Discuss dietary modifications with the dietitian 4. Monitor for a change in bowel sounds 5. Remind the client to track daily weights
2,4,5 lpns can MONITOR AND REINFORCE
During the discharge process, the nurse observes a new parent placing a newborn into a car seat in the vehicle. Which action by the parent requires the nurse to intervene? 1. Anchors the car seat in the center of the vehicle's back seat [34%] 2. Dresses the newborn in a sleep sack before securing the harness [47%] 3. Keeps the car seat at a 45-degree angle [9%] 4. Uses a car seat that faces the rear of the vehicle [7%]
2.
The charge nurse is making client assignments for the oncoming shift. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant? 1. Client receiving brachytherapy for endometrial cancer [28%] 2. Client with an infected surgical wound positive for methicillin-resistant Staphylococcus aureus [44%] 3. Client with a herpes zoster rash on the face and scalp [18%] 4. Client with pneumonia who recently traveled to a region with the Zika virus [7%]
2.
The registered nurse supervises a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP) caring for clients receiving brachytherapy. Which action would require the nurse to intervene? 1. LPN who reinforces the purpose of prescribed bed rest for a client with a radium implant for cervical cancer [2%] 2. LPN who, when caring for a client with a radium implant, turns away from the client while wearing a lead apron [45%] 3. UAP who changes the bed linens of a client with a radium implant and leaves the removed linens in the room [14%] 4. UAP who empties the urinal of a client with implanted radioactive seeds for prostate cancer into the toilet [38%]
2.
While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action? 1. Assess respiratory rate and breath sounds to ensure ventilation is occurring [26%] 2. Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen [58%] 3. Immediately alert the health care provider and prepare for reintubation [10%] 4. Initiate a code blue to prepare for potential cardiac arrest due to hypoxemia [3%]
2.
The nurse conducts a developmental assessment of a 4-year-old child. Which of the following tasks does the nurse anticipate that the child will perform successfully? Select all that apply. 1. Draw a circle 2. Jump rope with both feet 3. Sit quietly for 30 minutes 4. Use a spoon and fork 5. Walk up and down stairs
1 4 5 Preschool-age children begin to master more gross motor activities while rapidly increasing their fine motor abilities. The preschooler age 4 should have the fine motor skills to manipulate small tools (eg, scissors, pencil) and therefore be able to draw simple shapes (eg, circle, square) and perform more self-care activities (eg, eating with a spoon and fork) (Options 1 and 4). The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Option 5).
The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply. 1. Encourage intake of at least 2 L of clear fluids per day to prevent constipation 2. Ensure that the weights hang freely and do not touch the ground 3. Monitor for erythema, drainage, swelling, and malodor at the pin insertion sites 4. Perform frequent neurovascular checks on the affected extremity for the first 24 hours 5. Remove the weights for 10 minutes every 2 hours to prevent muscle spasm
1,2,3,4 When caring for clients in skeletal traction, the nurse should encourage increased fluid intake, ensure that pulley weights hang freely, inspect pin sites for signs of infection, and perform frequent neurovascular checks on the affected extremity. Additional Information Basic Care and Comfort NCSBN Client Need
The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter.
hand hygiene apply sterile gloves and place drape down use non dominant hand to grasp penis use dominat hand to clean use dominant hand to insert advance catheter and inflate balloon
retroperitoneal hemmorage signs (list 4)
hypotension, back pain, flank ecchymosis, hematoma formation, diminished pulses
name 6 things PVC can be caused by
hypoxia electrolyte imbalance emotional stress stimulants fever exercise
does lithium decrease or increase serum glucose levels
increase. monitor blood levels
percutaneous coronary intervention what is it and what is a risk
nonsurgical procedure that uses a catheter to place small structure called a stent to open ip blood vessels a risk is retroperitoneal hemmoragge
The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply. 1. "I have switched from coffee to decaffeinated herbal tea in the mornings." 2. "I plan to join a smoking-cessation program." 3. "I prefer to eat three large meals a day and avoid snacking." 4. "I prop myself up on a couple of pillows when I go to sleep." 5. "I will switch to low-fat dairy products and avoid high-fat foods."
1,2,4,5 Lifestyle and dietary measures that may help prevent GERD and associated symptoms include: Weight loss because excessive abdominal fat may increase gastric pressure Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1 and 5) Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated (Option 4) Discontinuing the use of tobacco products (Option 2) Refraining from eating at bedtime and/or lying down immediately after eating
A 2-month-old infant is admitted with respiratory syncytial virus and bronchiolitis. Which interventions would the nurse anticipate? Select all that apply. 1. Administer antipyretics 2. Initiate IV fluids 3. Keep the head of the bed flat 4. Maintain isolation precautions 5. Suction as needed
1,2,4,5 Respiratory syncytial virus (RSV) is a common cause of respiratory tract infection and bronchiolitis in infants and children, occurring primarily during the winter. It affects the ciliated cells of the respiratory tract, causing bronchiolar swelling and excessive mucus production. RSV in infants causes rhinorrhea, fever, cough, lethargy, irritability, and poor feeding. Severe RSV infection also causes tachypnea, dyspnea, and poor air exchange. Interventions are supportive, including: Providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway (Option 5) Elevating the head of the bed to improve diaphragmatic expansion and promote secretion clearance (Option 3) Administering antipyretics to reduce fever and provide comfort (Option 1) Initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake (Option 2)
A new nurse is providing hospice care for a terminally ill client who reports dyspnea. Which intervention would cause the charge nurse to intervene? 1. Administering oxygen via a nonrebreather mask [40%] 2. Administering prescribed morphine PRN [32%] 3. Providing a portable fan to improve air flow in the room [22%] 4. Providing relaxation strategies such as music and guided imagery [4%]
1 Dyspnea (air hunger) is a common symptom in terminally ill clients. Dyspnea is subjective, and management depends on the client's clinical condition and reported symptoms. Initial interventions focus on decreasing respiratory effort and the perception of dyspnea, as well as relieving anxiety. Interventions for hospice clients include the following: Administering opioids (eg, morphine, fentanyl), which are prescribed to relieve dyspnea (Option 2) Providing low-flow oxygen by nasal cannula, which may provide psychological comfort and ease feelings of apprehension Allowing frequent periods of rest to minimize exhaustion and dyspnea Administering anxiolytics (eg, lorazepam) for anxiety associated with dyspnea Placing a fan in the room to improve airflow near the client, which decreases the perception of dyspnea (Option 3) Assisting with relaxation strategies (eg, music, guided imagery) (Option 4)
While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? 1. Activate the hospital emergency response system [2%] 2. Apply supplemental oxygen and quickly transport to the new unit [4%] 3. Check the client's respiratory pattern and effort and oxygen saturation [18%] 4. Firmly cover the insertion site with the palm of a clean, gloved hand [74%]
4. firmly cover the insertion site cover with petroleum gauze. oxygen is given after covered
A nurse reviews the plan of care for a client who has increased intracranial pressure. Which nursing actions should be included? Select all that apply. 1. Administer a stool softener 2. Dim lights when not providing care 3. Elevate head on several pillows 4. Maintain body in midline position 5. Only perform oral suctioning when necessary
1,2.4.5 For clients with increased intracranial pressure (ICP), the goal is to reduce ICP while managing the client's basic needs; however, many nursing activities increase client ICP. Nursing interventions to decrease ICP include: Position head of bed to 30 degrees to promote venous return from the head, which will decrease cerebral edema. Elevating the head >30 degrees decreases blood pressure, which can decrease cerebral perfusion pressure (CPP); therefore, position the client to balance ICP and CPP. Keep head and body midline and avoid extreme hip or neck flexion as this impedes venous drainage (Option 4). Administer stool softeners to prevent straining to defecate (Option 1). Straining and coughing increase intrathoracic and intraabdominal pressure, which increase ICP. Keep the client in a calm environment with minimal noise and disturbances (eg, dim lights, limit visitors) (Option 2). Suction only when needed to maintain airway and for no longer than 10 seconds per suctioning pass (Option 5). Reduce metabolic demands (eg, pain, seizures, hypoxia, fever). Treat fever aggressively (eg, acetaminophen) but avoid shivering.
The nurse administers an intermittent bolus enteral feeding to a client via nasogastric tube. Which actions by the nurse are appropriate? Select all that apply. 1. Aspirate and discard 50 mL of gastric residual prior to feeding 2. Assess the tube placement marking at the naris insertion site 3. Auscultate the client's bowel sounds prior to feeding 4. Keep the client's head of the bed elevated at 45 degrees 5. Slow the feeding rate if the client develops abdominal cramping
2. Assess the tube placement marking at the naris insertion site 3. Auscultate the client's bowel sounds prior to feeding 4. Keep the client's head of the bed elevated at 45 degrees 5. Slow the feeding rate if the client develops abdominal cramping
The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? 1. "If the family is not in complete agreement about organ donation, we won't be able to proceed." [9%] 2. "Once the body is dressed, there is no evidence of organ removal. An open casket will be fine." [69%] 3. "Some organ procurement leaves evidence on the body. You may want to consider a closed casket." [9%] 4. "Your family member consented to be an organ donor. You should really honor this wish." [12%]
2. once body is dressed there no evidence of organ removal
shallow open area with clean dark pink wound bed about 1 cm in diameter. surrounded area is slightly hard and warm to touch with erthmea what stage is this?
stAGE 2 rationale: stage 2 is a shallow open ulcer with red pink wound. possible intact or ruptired blister
The nurse is caring for an African American client with disseminated intravascular coagulation. Which locations are best to assess for the presence of petechiae? 1. Buccal mucosae and conjunctivae of the eyes [46%] 2. Nail beds of the fingers and toes [6%] 3. Palms of the hands and soles of the feet [37%] 4. Skin over the sacrum and behind the heels [9%]
1. Petechiae are reddish or purple pinpoints on the skin that occur due to bleeding from capillaries. Petechiae usually occur due to blood vessel injury or bleeding disorders (eg, thrombocytopenia, disseminated intravascular coagulation). Petechiae and similar skin conditions are often challenging to detect in dark-skinned clients as dark pigmentation makes it difficult to assess skin color changes. In dark-skinned clients, petechiae can best be assessed in the conjunctivae of the eyes and the buccal mucosae. (Option 2) The nail bed of the finger is the best location to assess dark-skinned clients for cyanosis, a blue discoloration that may occur with hypoxemia (ie, decreased blood oxygen). Petechiae generally do not occur in the nail bed.
The nurse receives handoff of care report on four clients. Which client should the nurse assess first? The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls [73%] 2. Client who had an exploratory laparoscopy 2 hours ago and has absent bowel sounds and is reporting nausea [9%] 3. Client with diabetes mellitus who has a foot ulcer and is reporting feeling pins and needles in the lower legs [9%] 4. Client with Parkinson disease who has tremors while resting and developed black-colored urine after taking carbidopa/levodopa [7%]
1. client who had emergency appendectomy 48 hours ago who hears waves and sees fish swiiming thugh walls rationale:hallucination is a serious safety risk. hallucinations without psychiatic illness may indicate withdrawal.
The nurse is caring for a pediatric client with osteomyelitis. Prior to the nurse administering IV antibiotics, the client's parent states, "We don't believe in antibiotics. Healing comes from within, and medications are toxic to that process." What is the nurse's priority response? 1. "Please tell me how medications are toxic to the healing process." [7%] 2. "Please tell me your understanding of your child's condition." [41%] 3. "What type of healing practices would you prefer for your child?" [36%] 4. "Without this medication, your child can get worse and could die." [14%]
2 IV antibiotics are necessary for treating osteomyelitis (infection of the bone), and without them, the client is at risk for potentially life-threatening complications (eg, sepsis). Parental refusal of necessary medication for a minor creates an ethical dilemma. The nurse's first response should be assessment of a parental knowledge deficit regarding the client's condition. The nurse should ask open-ended questions, allowing the parent to demonstrate knowledge. With education and proper understanding of the condition, the parent may consent to the necessary treatment (Option 2).
A nurse is caring for a client with unstable angina. After 5 minutes on a nitroglycerin IV infusion, the client reports relief of chest pain but a new dull, throbbing headache. What is the appropriate nursing action? 1. Decrease the infusion rate and reassess the client's report of pain [23%] 2. Document the finding and administer prescribed acetaminophen [57%] 3. Notify the health care provider and request a CT scan of the head [3%] 4. Stop the infusion immediately and notify the health care provider [15%]
2. Nitroglycerin is an antianginal medication that causes potent vasodilation (coronary and systemic) and is used in the treatment of acute coronary syndrome (eg, unstable angina, myocardial infarction). IV nitroglycerin administration requires continuous cardiac monitoring and frequent blood pressure assessment (eg, every 15 minutes for the first hour). Headache is an expected side effect from vasodilation of cranial vessels and should decrease with continuing nitroglycerin therapy. As long as the client does not have severe hypotension (eg, systemic blood pressure <90 mm Hg), the finding can be documented and the headache can be treated with aspirin or acetaminophen.
A nurse is caring for a client who had a transurethral resection of the prostate and is receiving continuous bladder irrigation by gravity. Which tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Calculating the difference between irrigant intake and total drainage output A nurse is caring for a client who had a transurethral resection of the prostate and is receiving continuous bladder irrigation by gravity. Which tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Calculating the difference between irrigant intake and total drainage output 2. Cleaning around the catheter insertion site daily 3. Immediately notifying the nurse if the client reports pain 4. Increasing the irrigation rate when the urine becomes more red than pink 5. Measuring the total volume of output in the drainage collection bag
2. Cleaning around the catheter insertion site daily 3. Immediately notifying the nurse if the client reports pain 5. Measuring the total volume of output in the drainage collection bag
The nurse auscultates the lung sounds of a client with shortness of breath. Then, the nurse notifies the health care provider about the adventitious sounds heard. Which medication prescription should the nurse anticipate? Listen to the audio clip. (Headphones are required for best audio quality.) 1. Albuterol [29%] 2. Bumetanide [44%] 3. Guaifenesin [16%] 4. Methylprednisolone [9%]
2. Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excretion by the kidneys (Option 2).
The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan? 1. Black beans and rice, sliced tomatoes, half a cantaloupe [11%] 2. Grilled chicken sandwich on white bread, applesauce [58%] 3. Hamburger patty on whole wheat bun, carrot sticks, chocolate pudding [15%] 4. Poached salmon, green peas, baked potato, strawberries [14%]
2. Educational objective:The kidneys' ability to excrete potassium is compromised in clients with end-stage renal disease. These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels (3.5-5.0 mEq/L [3.5-5.0 mmol/L]).
The nurse is performing a medication reconciliation during a clinic visit with a client recently prescribed lithium. Which of the client's home medications is the priority to clarify with the health care provider? 1. Acetaminophen [6%] 2. Hydrochlorothiazide [55%] 3. Metformin [10%] 4. Sulfadiazine [27%]
2. Lithium is a mood stabilizer most often used to treat bipolar affective disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]) that should be closely monitored; it also has the potential for many drug interactions. Several medications can cause increased lithium levels, including thiazide diuretics (eg, hydrochlorothiazide), nonsteroidal anti-inflammatory drugs, and antidepressants. Thiazide diuretics have demonstrated the greatest potential to increase lithium concentrations, with a possible 25%-40% increase in concentrations (Option 2). The nurse should assess the client for signs and symptoms of lithium toxicity and report the findings to the health care provider. The client should bring all prescription and over-the-counter medications to each office visit to perform a medication reconciliation and reduce the risks associated with polypharmacy.
The primary nurse is preparing a client with atrial fibrillation for scheduled cardioversion. What action by the primary nurse requires the charge nurse to intervene? 1. Assembles equipment and obtains a prescription for preprocedural IV sedation [11%] 2. Ensures that defibrillator is programmed as prescribed and synchronize function is off [67%] 3. Uses clippers to remove the client's chest hair prior to placing defibrillation pads [18%] 4. Verifies that the client has provided informed consent and that documentation is signed [2%]
2. ensures defibrillator is porgrammed as prescribed and synchronize function is off
The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching? 1. "A bite block will be placed in the client's mouth to prevent injuries to the tongue and teeth." [21%] 2. "Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document." [63%] 3. "The client should have had nothing to eat or drink for at least 6-8 hours prior to the procedure." [5%] 4. "The client will receive a muscle relaxant and short-acting anesthetic before the current is delivered." [9%]
2.' Electroconvulsive therapy is a procedure that induces a brief seizure to treat clients with mood disorders or schizophrenia. Informed consent must be obtained from the client prior to the procedure unless the client has been deemed legally incompetent or meets other standards for incompetency (eg, inebriation). Prior to ECT, clients should be NPO for 6-8 hours and receive both a short-acting anesthesia and a muscle relaxant as well as a bite block. Additional Information Management of Care NCSBN Client Need
A pregnant client at 38 weeks gestation is admitted to the labor and delivery unit reporting contractions, severe abdominal pain, and dark vaginal bleeding. What is the nurse's priority action? 1. Initiate large-bore (18-gauge) peripheral IV line [19%] 2. Notify operating room staff of emergency cesarean birth [17%] 3. Palpate abdomen and apply fetal heart rate monitor [55%] 4. Perform vaginal examination to assess cervical dilation [7%]
3. Placental abruption (abruptio placentae) occurs when the placenta prematurely detaches from the uterine wall. This life-threatening complication can interrupt fetal oxygen supply and cause maternal hemorrhage. Associated symptoms may include frequent contractions, abdominal pain, dark red vaginal bleeding, uterine tenderness, and elevated uterine resting tone. Priorities include assessment of maternal vital signs, palpation of the abdomen/uterus, and continuous fetal heart rate monitoring (Option 3). If monitoring indicates fetal distress and/or maternal hemodynamic compromise, the health care team will prepare for emergency cesarean birth. -ASSESS THEN DO LARGE BORE
The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, "My client is constantly requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority at this time? 1. Document the incident in the nurse's employee file and review it with the unit manager [8%] 2. Follow institutional protocol for filing an incident or variance report [30%] 3. Instruct the nurse to notify the health care provider about the lack of pain relief [52%] 4. Report the incident to the hospital's ethics committee for evaluation [8%]
3.
A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? 1. Dons a mask with eye shield before irrigating a draining wound for a client on standard precautions [7%] 2. Places a "soap and water only" sign on the door of a client with Clostridium difficile [12%] 3. Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client with HIV [55%] 4. Wears an N95 respirator before entering the room of a client with active varicella-zoster [23%]
3. The best way for health care workers to protect themselves against possible HIV infection is to consistently follow standard (universal) precautions with all clients, regardless of HIV status. HIV is spread when nonintact skin comes into contact with infected blood, breast milk, semen, and vaginal secretions. No extra precautions are needed for routine care of clients with HIV as the virus is not spread through casual contact, droplets, or aerosolized particles. Some experienced nurses hold to the common misconception that "double-gloving" reduces the risk of contracting HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Opti
The nurse cares for a client with an established ascending colostomy. Which statement made by the client indicates that further teaching is required? 1. "I always try to drink 3 liters of water each day." [14%] 2. "I avoid eating beans, onions, broccoli, and cauliflower." [9%] 3. "I change the appliance and bag every other day." [64%] 4. "I empty the bag when it is about one-third full." [11%]
3. Educational objective:Peristomal skin irritation is prevented by ensuring that ostomy appliances fit closely around the stoma and that the appliance is changed every 5-10 days. The ostomy bag is emptied when one-third full. The client with a colostomy is encouraged to drink plenty of fluids and decrease intake of gas-forming foods. Additional Information Physiological Adaptation NCSBN Client Need
Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first?Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first? 1. Child who is unable to eat or drink without vomiting [13%] 2. Child with a recently placed tympanostomy tube that has fallen out [5%] 3. Child with bruising behind the ears after a football injury [68%] 4. Child with increased pain at skeletal pin insertion sites on the leg [11%]
3. child with bruising beind ears after fotball injury rationale: this may indicate a basilar skull fracture this requires immediate cervical spine immobilizaation, neurologic assessment, and ab supports
The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate? 1. Client with blood loss anemia and client with intractable diarrhea [11%] 2. Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting [6%] 3. Client who had a bowel resection 1 day ago and client with asthma exacerbation [80%] 4. Client who had a total hip arthroplasty 2 days ago and client with influenza [1%]
3. client who had a bowel resection 1 day ago and client with asthma exacerbation rationale: when making room assignment it is important to remember that a client with an active or suspected infection should not be paired with client with fresh surgical wound or is immunocomprimised. a client with ASHTMAS DOES NOT HAVE AN INFECTION
There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? 1. Client who has partial-thickness burns on both hands [4%] 2. Client who is screaming and has a left lower arm laceration [3%] 3. Client with a broken, protruding right tibia and gray, pulseless foot [73%] 4. Client with a gaping head wound and Glasgow Coma Scale score of 3 [19%]
3. client with a broken protruding right tibia and gray pulseless foot rationale: glasgow scale of 3 would be expectant
A nurse receives change-of-shift report on 4 clients. Which client should the nurse assess first? A nurse receives change-of-shift report on 4 clients. Which client should the nurse assess first? 1. Client who experienced a transient ischemic attack 2 days ago and is due to receive scheduled aspirin [9%] 2. Client who had a subdural hemorrhage 36 hours ago and is requesting a breakfast tray [6%] 3. Client with a bowel resection receiving total parenteral nutrition who had 4,800 mL of urine output during the last shift [67%] 4. Client with a stroke receiving tissue plasminogen activator whose Glasgow Coma Scale changed from 9 to 13 [16%]
3. client with a bwel resection receiving tpn signs of hyperglycemia include pollydipsia polyuria
The nurse is planning care for a client with bipolar disorder and acute mania who is being admitted involuntarily after attempting to run across a five-lane highway. Which intervention is the priority to include in the care plan? 1. Assist the client with dressing by giving instructions one at a time [4%] 2. Collaborate with unit staff to set consistent limits on manipulative behaviors [30%] 3. Offer high-calorie snacks the client can eat while on the move and during tasks [63%] 4. Secure the client's credit cards to prevent compulsive spending and bankruptcy [2%]
3. offer high calorie snack
The nurse is preparing to teach a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include?The nurse is preparing to teach a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? 1. Discuss the need for increasing dietary iron intake [18%] 2. Provide education on the benefits of breastfeeding [0%] 3. Stress the importance of consistent prenatal care [69%] 4. Teach the signs and symptoms of preeclampsia [11%]
3. stress importance of consistent prenatal care
The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. 1. 0.3 mg of nitroglycerin sublingual PRN [5%] 2. 10 mg of ezetimibe PO once daily [31%] 3. 20 mg of lisinopril PO once daily [4%] 4. 200 mg of celecoxib PO once daily [58%]
4.
The nurse accidentally administers orally dissolving mirtazapine through a client's percutaneous endoscopic gastrostomy tube instead of the prescribed sublingual route. After assessing the client for adverse reactions, what is the nurse's priority action? 1. Disclose the medication error to the client [5%] 2. Document the error on an incident report [12%] 3. Inform the nurse manager about the error [20%] 4. Notify the prescribing health care provider [61%]
4. . After an error, the nurse should first assess and stabilize the client, then immediately inform the health care provider. After implementing new prescriptions, the nurse should notify both the client and nurse manager about the error and complete an incident report.
A client is receiving packed red blood cells intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin amphotericin B IVPB. What is the nurse's best action? 1. Administer amphotericin B through the unused lumen of the PICC line [18%] 2. Insert a peripheral IV line to begin infusion of amphotericin B [19%] 3. Interrupt the blood transfusion to infuse amphotericin B, then resume after infusion [0%] 4. Wait 1 hour after transfusion finishes before administering amphotericin B [60%]
4. At least one hour should be allowed between completion of a blood transfusion and administration of amphotericin B. The adverse effects of a transfusion-related reaction and an adverse reaction from amphotericin B are similar, and the observation time allows the nurse to distinguish the triggering event if symptoms develop.
When the nurse provides education about starting risperidone, which statement by the client's caregiver indicates a need for further teaching? 1. "I will call the clinic if the client has a fever or muscle stiffness." [4%] 2. "I will remind the client to move slowly and not stand up too quickly." [3%] 3. "I won't worry if the client sleeps more often when taking this medicine." [25%] 4. "It is normal for the client to become shaky and restless when agitated." [66%]
4. Atypical (second-generation) antipsychotic medications (eg, risperidone, quetiapine, olanzapine) treat symptoms of schizophrenia. Major side effects include extrapyramidal symptoms, neuroleptic malignant syndrome, anticholinergic effects, orthostatic hypotension, and sedation. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need
The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first? 1. Client who had a colonoscopy with polypectomy who reports abdominal cramping and a small amount of rectal bleeding [9%] 2. Client who had a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement [23%] 3. Client who underwent laparoscopic inguinal hernia repair yesterday who reports difficulty urinating [21%] 4. Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 F (38.3 C) [45%]
4. Arteriovenous (AV) graft placement involves surgical connection of an artery and a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection of an AV graft may cause thrombosis, graft failure, or systemic infection. Fever in a postoperative client may indicate infection of the graft site, which warrants immediate notification of the health care provider (HCP); this client may require antibiotics and surgical removal of the graft (Option 4).
The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. 1. 0.3 mg of nitroglycerin sublingual PRN [5%] 2. 10 mg of ezetimibe PO once daily [31%] 3. 20 mg of lisinopril PO once daily [4%] 4. 200 mg of celecoxib PO once daily [58%]
4. NSAIDs (eg, naproxen, ibuprofen, celecoxib) are used for their analgesic, antipyretic, and anti-inflammatory properties. However, they increase the risk of thrombotic events (eg, myocardial infarction [MI], stroke),
A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thrombolytic therapy due to which reason? 1. Client had gallbladder surgery 2 months ago [11%] 2. Client has experienced loss of the gag reflex [2%] 3. Client has platelet count of 130,000/mm3 [130 × 109/L] [27%] 4. Client has symptoms that started 12 hours earlier [58%]
4. Thrombolytic therapy (tissue plasminogen activator) is used to treat and dissolve blood clots in clients with ischemic stroke. This therapy should be administered within 3-4.5 hours of when the client was last "normal." Contraindications include thrombocytopenia (platelet count <100,000/mm3 [100 × 109/L]), coagulation disorders, and major surgery within the past 14 days.
The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first? 1.Administer ondansetron 4 mg IV push PRN for nausea or vomiting 2. Document the occurrence and notify the hospital's epidemiology team 3. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV 4. Obtain blood cultures and discontinue the central venous catheter
4. obtain blood cultures and discontinue the CVS rationale: when caring for client with signs of Central line infection the nurse should obtain blood clutlresnd remove the device before beginning antibiotic therapy
the nurse is reviewing the medical history of a client who has sustained a right tibia fibula fracture from a fall the nurse identifies which as most likely to hinder healing 1. bmi of 29.5 2. family histry of osteoporosis 3. history of a daily glass of wine 4. peripheral arterial disease
4. peripheral arterial disease rationale: peripheral artey diseas has decreased perfusion to the extremeties due to atheroslerotic changes
The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? 1. Contact the client's family and ask them to bring prepared food from home 2. Inform the client that tube feedings will be initiated if the client refuses to eat 3. Offer to taste the client's food and drinks while the client observes 4. Provide the client food in unopened single-serving packages
4. provide the client food in unopened single serving packages rationale: nursees caring for clients who have paranoid delusions must work to build a trusting realtionship.
