PART 1

42. Which assessment item needs to be documented on a client with restraints ? Select all that apply. One, some, or all responses may be correct. - Pulse near the restrained area - Temperature of the restrained area - Convenience of restraining the client - Skin integrity surrounding the restraint - Behavior leading to the need of the restraint

- Pulse near the restrained area - Temperature of the restrained area - Skin integrity surrounding the restraint - Behavior leading to the need of the restraint

4. A client is hospitalized with dehydration and dysphagia. Which tasks are appropriate to delegate to the licensed practical nurse ( LPN )? Select all that apply. One , some , or all responses may be correct. - Administering medications. - Performing initial swallow screen. (Assessment) - Assisting unlicensed assistive personnel ( UAP ) with ambulating client. - Completing admission skin assessment. (Assessment) - Recording vital signs on electronic health records

- Administering medications. - Assisting unlicensed assistive personnel ( UAP )with ambulating client. - Recording vital signs on electronic health records The LPN is qualified to administer medication, assist UAPs with ambulation, as well as record vital signs on the electronic health records. The swallow screen and skin assessment are both assessments that must be completed by the registered nurse.

37. Which data would the nurse use to determine a client's score on the Braden Scale to predict a client's risk for developing pressure injuries? Select all that apply. One, some, or all responses may be correct . - Age - Anorexia - Hemiplegia - History of diabetes - Urinary incontinence

- Anorexia (Nutrition) - Hemiplegia (Mobility/Movement.) - History of diabetes (sensory perception; compromised feelings/movement and nerves) - Urinary incontinence (moisture) *No age on the Braden Scale*

30. Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply . One, some, or all responses may be correct. - Palpate the chest and back for masses - Question the client about shortness of breath - Check the hematocrit and hemoglobin values - Inspect the skin and nails for integrity and color - Ask the client about color and quantity of sputum

- Question the client about shortness of breath - Ask the client about color and quantity of sputum All other options would give the nurse objective data

18. The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client's plan of care? Select all that apply. One, some, or all responses may be correct. - Ask the client about acceptable level of pain. - Eliminate all activities that precipitate the pain - Administer the pain medications regularly around the clock - Use a different pain scale each time to promote client education - Assess the client's pain every 15 minutes

- Ask the client about acceptable level of pain. - Administer the pain medications regularly around the clock We don't want to eliminate all activities because we want the client to participate. We do not want to use a different pain scale each time because as nurses, we want to promote consistency. Assessing the client's pain every 15 minutes is a little excessive.

45. The client has a vest restraint and bilateral soft wrist restraints. Which actions by the RN is appropriate? - Assess and document the behavior that requires continued used of restraints - Tie the restraint in quick - release knot - Tie the restraints to the side rails - Ask the client if they need to go to the bathroom, and provide ROM exercises every 2 hours - Position the vest restraints so that the straps are crossed in the back

- Assess and document the behavior that requires continued used of restraints - Tie the restraint in quick - release knot - Ask the client if they need to go to the bathroom, and provide ROM exercises every 2 hours *Never tie restraints to side rails*

15. Which clients are using complementary and / or alternative medicine ( CAM ) to treat their symptoms of emotional distress and psychiatric illness? Select all that apply. One , some , or all responses may be correct. - Client practices meditation to reduce anxiety in addition to outpatient counselling. (Allopathic) - Client uses massage, lavender oil, and chamomile to decrease stress and anxiety. (Allopathic) - Client undergoes electroconvulsive therapy and takes an antidepressant medication. (Straight allopathic) - Client takes prescribed antianxiety medication and sees a psychiatrist for psychotherapy. - Client with depression takes an omega - 3 fatty acid supplement and an antidepressant

- Client practices meditation to reduce anxiety in addition to outpatient counselling. - Client uses massage, lavender oil, and chamomile to decrease stress and anxiety. - Client with depression takes an omega - 3 fatty acid supplement and an antidepressant (Allopathic + alternative) Complementary and/or alternative medicine is a mixture of pharmacological and nonpharmacological practices

8. Which points require correction regarding wellness promotion in the older adult? Select all that apply. One, some, or all responses may be correct. - Older adults need to prevent injuries when promoting wellness. - Curing diseases or other illnesses completely is essential to promote wellness in older . adults. - It is important to assess the level of fear of falling and provide support accordingly when caring for older adults. - It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries. - An older adult should live in isolation to prevent stress

- Curing diseases or other illnesses completely is essential to promote wellness in older . adults. - It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries. - An older adult should live in isolation to prevent stress Notice that for the second dash, it has the word completely. Words like relative, absolute, and completely are words that are most likely incorrect in the statement.

Which important point would the nurse keep in mind to promote health when caring for an older adult? Select all that apply. One, some, or all responses may be correct. - Focus on achieving the highest level of health and absence of disease - Encourage regular physical activity and the use of stress - management strategies. - Encourage the client to accept help for carrying out activities of daily living ( ADLs ) - Consider the clients social environment and strength social support to promote health - Assess the client for fear of falling, and provide support by making environmental changes

- Encourage regular physical activity and the use of stress - management strategies. - Consider the clients social environment and strength social support to promote health - Assess the client for fear of falling, and provide support by making environmental changes. Option A is half correct because the nurse wants to achieve the highest level of health, but the nurse does this when the disease is present. Option C would be incorrect because we encourage the client to be as independent as possible.

3. Which statements made by the student nurse indicate the need for further teaching about preparedness when responding to a fire in the health care facility? Select all that apply. One , some , or all responses may be correct. - I will direct the stable clients to walk to safe location on their own. - I will ask ambulatory clients to help push wheelchair clients out of danger. - I will endanger myself while moving and protecting the clients from the fire. - I will continue to provide oxygen to the clients that can breathe on their own. - I will move immobile clients from the fire area in a bed, stretcher, or wheelchair

- I will endanger myself while moving and protecting the clients from the fire. - I will continue to provide oxygen to the clients that can breath on their own. Nurses should never endanger themselves during an event of a fire. Oxygen should also never be delivered during a fire because it can cause an explosion.

24. Which clinical manifestation, commonly associated with pyrexia, would the nurse monitor for in a client who develops pyrexia 3 days after surgery? Select all that apply . One, some, or all responses may be correct. View question - Dyspnea - Chest pain - Tachypnea - Increased pulse rate - Elevated blood pressure

- Increased pulse rate - Tachypnea Increased pulse rate and tachypnea are common symptoms of a fever (increased breathing). During a fever, metabolism is high, and the body needs oxygen. Blood pressure normally drops, but normally does not play a role. Blood pressure only elevates when there is sepsis. Chest pain is not associated, and neither is dyspnea, which is decreased respiration's. Pyrexia = fever

12. Which information would the nurse provide to a student about the primary level of prevention? Select all that apply. One , some , or all responses may be correct . - Known as true prevention. - Applied to clients who are considered physically and emotionally healthy. - Directed toward rehabilitative care rather than diagnosis and treatment. - Activities enable clients to return to a level of health as early as possible. - Include health education programs, immunizations, and physical and nutritional fitness activities

- Known as true prevention. This is because this is the first level, and this is the level where nurses stress the most. - Applied to clients who are considered physically and emotionally healthy. It targets healthy people so that they can remain healthy and enhance their health. - Include health education programs, immunizations, and physical and nutritional fitness activities

When a client has emphysema or COPD, you must supply oxygen that is low and should be no more than how many liters?

2 L

27. Which issue is the main problem for a client who is withdrawn and declines participation in situations that require communication with others? A. Personal identity B. Social interaction C. Sensory perception D. Verbal communication

B. Social interaction

What is the minimum heart rate that a client needs to have in order to be administered to Digoxcin?

60 BPM

19. Which question asked by the nurse is most appropriate to assess the nature of the client's pain? A. Can you describe your pain to me ? B. Is your pain associated with movement. C. Can you rate your pain on a scale of 0 to 10 ? D. Do you notice your pain worsens with activity ?

A. Can you describe your pain to me ? We get the nature of the client's pain by asking them to describe the pain in depth and in their own words. The nurse should not be giving the client words and ideas about their pain, but actually let them state what they are feeling.

Which information would the nurse include when teaching about atenolol prescribed for a client with moderate hypertension? Select all that apply. One, some, or all responses may be correct. A. Change to standing position slowly B. Take the medication before going to bed C. Count the pulse before taking the medication D. Mild weakness and fatigue are common side effect E. It is safe to take over - the - counter ( OTC ) medications

A. Change to standing position slowly To prevent orthostatic hypotension. D. Mild weakness and fatigue are common side effect C. Count the pulse before taking the medication Blood pressure tends to be a little lower at night when the client is not active, so taking the medication in the morning would be more effective.

11. Which are examples of health promotion activities? Select all that apply. One, some, or all responses may be correct. A. Good nutrition. B. Regular exercise C. Physical awareness (participating in activities) D. Immunization against measles E. Education about stress management

A. Good nutrition. B. Regular exercise C. Physical awareness (participating in activities) Nutrition, exercise, and participating in physical activities are beneficial components to health promotion. Education about stress management would not be affective only because the stress seems to have already been embedded within the client, and is more of a way to promote wellness. This would be secondary prevention because the client already has stressors, and the nurse is trying to educate them and prevent the stressors from increasing.

35. Nasogastric ( NG ) tube irrigations are prescribed for a client after abdominal surgery. The nurse instills 30 mL of saline solution, and 10 mL is returned. How would the nurse proceed? A. Record 20 mL as intake B. Increase the amount of suction C. Reposition the NGT D. Irrigate the NGT more frequently

A. Record 20 mL as intake Repositioning the NGT would require an x-ray examination, which would be too much in this situation.

7. Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation ? A. Take pulse apically for a full minute. B. Monitor blood pressure at least every 2 hours. C. Ask client to call for assistance when ambulating. D. Teach client to avoid taking over the counter aspirin

A. Take pulse apically for a full minute. Clients with atrial fibrillation have irregular pulse rates, so taking the pulse apically for a full minute is appropriate. Monitoring blood pressure is incorrect because patients with a-fib may not have any problems with their blood pressure. Option C is invalid because the question has nothing to do with the client's stability status. Phrases like "the client should avoid..." are most likely incorrect. Aspirin should be given since it can prevent clotting.

Where do you access for skin turgor?

Above the clavicles (for the older adult)

Which of the following is traditional and conventional?

Allopathic

refers to a system in which medical doctors and other healthcare professionals (such as nurses, pharmacists, and therapists) treat symptoms and diseases using drugs, radiation, or surgery.

Allopathic medicine

Which of the following medications is a blood pressure medication, also known as a beta blocker? It also drops the client's blood pressure

Atenolol

22. A client reports overwhelming and irresistible attacks of sleep. Which sleep disorder is she or he describing? A. Insomnia B. Narcolepsy C. Sleep terror D. Sleep apnea

B Narcolepsy

14. Which activity by the community nurse is an illness prevention strategy? A. Encourage the client to exercise daily. B. Arranging an immunization program for chickenpox. C. Teaching the community about stress management. D. Teaching the client about maintaining a nutritious diet

B. Arranging an immunization program for chickenpox. Options a and B are more towards health promotion, which is a primary prevention tactic.

21. When taking the history for a client who is being treated for obstructive sleep apnea, which findings would the nurse expect? Select all that apply. One, some, or all responses may be correct. A. Daytime hypoxemia. B. Chronic fatigue. C. Enlarge tonsils D. Subcutaneous emphysema. E. Poor concentration .

B. Chronic fatigue. C. Enlarge tonsils E. Poor concentration Enlarged tonsils come in to play because obstructive sleep apnea obstructs the airway, which enlarges the tonsils, resulting in breathing problems. Daytime hypoxemia would be incorrect because during the day, the client is awake. Hypoxemia normally happens at night time. Emphysema decreases the alveoli, which would be correct, but the subcutaneous aspect makes it incorrect.

28. Which is the highest priority safety assessment the nurse would perform on a client who has received sedative and opioid medications postoperatively? A. Urinary assessment B. Respiratory assessment C. Cardiovascular assessment l D. Neuromuscular assessment

B. Respiratory assessment If you follow the ABC scenario - airway, breathing, circulation - then the respiratory assessment would be the highest priority. Keep in mind that highest priority questions mean that all of the options are correct, but which one is the most important!

17. The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for? A. Pain tolerance. B. Skin turgor. C. Ecchymosis formation. D. Tissue mass

B. Skin turgor.

16. Which culturally based behavior would the nurse expect to observe in an Asian client who has symptoms of anxiety and panic? A. Reluctance to take medications. B. Minimal eye contact. C. Desire to have an Asian nurse. D. Offense at being touch

B. Minimal eye contact. In this culture, Asians find it disrespectful to make eye contact to their superior authority, or persons of a higher status

39. A primary health care provider writes a prescription of ' Restraints PRN ( as needed ) ' for a client who has a history of violent behavior. Which action would the nurse take? A. Ask the health care provider to specify the type of restraint in the prescription B. Notify the provider that PRN prescriptions for restraints are unacceptable C. Implement the restraint prescription when the client begins to act out D. Ensure the entire staff is aware of the prescription for the restraints

B. Notify the provider that PRN prescriptions for restraints are unacceptable *PRN for restraints are unacceptable*

46. A RN is caring for a client with emphysema. What nursing interventions are appropriate? A. Reduce fluid intake to less than 2,500 ml / day B. Teach diaphragmatic , pursed - lip breathing C. Administer low - flow oxygen D. Keep the client in a supine position as much as possible E. Encourage alternating activity with rest periods F. Teach use of postural drainage and chest physiotherapy

B. Teach diaphragmatic , pursed - lip breathing ; controlled breathing C. Administer low - flow oxygen: individuals with COPD or emphysema receive a low supply of oxygen, no more than 2 L. (Needs a prescription) E. Encourage alternating activity with rest periods F. Teach use of postural drainage and chest physiotherapy: good for clearing secretions and allowing better airway for breathing. *Emphysema = breathing problems; COPD.*

9. Which client would have a health promotion nursing diagnosis? A. The client with acute pain due to appendicitis. B. The client who is willing to take a 30 - minute walk daily. C. The older adult client with dementia admitted to the health care facility. D. The client with reduced cognitive ability while recovering from surgery.

B. The client who is willing to take a 30 - minute walk daily. Option B is correct because walking 30 minutes daily is a good way to promote health, and there are no signs of illness or disease present in this patient. Health promotion is normally a primary intervention for clients. Option a, appendicitis, is already an illness. Although it is an acute one, it would be a secondary intervention. Option C, which refers to dementia, shows that the patient is already diagnosed with a disease, so health promotion would not be affective here. Option D would be invalid because there's already an issue with their cognition, so there wouldn't be a way to promote health.

1. A pain scale of 1 to 10 is used by the nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. Which conclusion would the nurse make regarding the client's response to pain medication ? A. The client has a low pain tolerance. B. The medication is not adequately effective. C. The pain medication has sufficiently decreased the pain level D. The client needs more education about the use of the pain scale

B. The medication is not adequately effective

44. The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach? A. To prevent a confused client from pulling out an intravenous ( IV ) line B. To prevent an adult client from getting up at night when there is insufficient staffing on the unit C. To maintain immobilization of the client's leg to prevent dislodging a skin graft D. Keep an older adult client from falling out of bed after a surgical procedure

B. To prevent an adult client from getting up at night when there is insufficient staffing on the unit Insufficient staffing is not something that the client has to suffer from, and the use of the restraints in this scenario would be for convenience.

Medication's that have "pril" are an indication of which of the following?

Blood pressure, but it does not decrease the heart rate as much.

33. During a 12 - hour shift, a client has a 6 - oz ( 180 - mL ) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous ( IV ) fluids equaled the urinary output. Which fluid balance would the nurse record for the 12 - hour period? A. 240 mL B. 340 mL C. 440 mL D. 540 mL

C. 440 mL

31. For a client with difficulty swallowing, the nurse will crush which medication? A. Metoprolol extended release B. Felodipine sustained release C. Acetaminophen extra strength D. Potassium chloride extended release

C. Acetaminophen extra strength Extended release and sustained release medications are the same thing. We do not crush extended release medication because you cannot have all of it at once. Sometimes extended release medications go on for over 12 hours.

13. Which of these measures would the nurse adopt while promoting health among adolescents? Select all that apply. One , some , or all responses may be correct . A. Insist that the adolescent discuss their concerns. B. Have a discussion with the adolescent in front of the family. C. Be sensitive to the emotional cues delivered by the adolescent. D. Tell the clients immediately when a teen discloses their sexual orientation. E. Provide counselling to the adolescent undergoing rehabilitation for substance abuse

C. Be sensitive to the emotional cues delivered by the adolescent. E. Provide counselling to the adolescent undergoing rehabilitation for substance abuse

29. When performing a focused respiratory assessment, which action would the nurse take first? A. Examine for any abnormal respiratory patterns B. Inspect for changes in skin color or temperature C. Check for any evidence of respiratory distress D. Determine the shape and symmetry of the chest

C. Check for any evidence of respiratory distress When the nurse first enters the room, the first thing that she notices is the client's breathing patterns, before anything else. If a client is breathing too rapidly or too slowly, the nurse can spot an issue right away. Check before anything else.

38. A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. Which instruction would the nurse provide to the client to help prevent future hemorrhoidal episodes? A. Exercise to improve circulation B. Eat bland foods and avoid spices C. Consume a high - fiber diet and drink adequate water D. Use laxatives to avoid constipation and use of the valsalva maneuver

C. Consume a high - fiber diet and drink adequate water Fiber helps with bulk and releasing stool

6. Which coworker's statement indicates understanding of content taught by the nurse educator regarding the care of clients with osteoporosis (degrading of a bone overtime)? A. I should teach clients with osteoporosis to avoid milk. B. I should immobilize pain joints during exacerbation of the disease. C. I should encourage the client to ambulate in the sunlight. D. I should teach client to avoid weight - bearing exercises on painful joints

C. I should encourage the client to ambulate in the sunlight. Option C is correct because sunlight promotes vitamin D, which is necessary for bone absorption. Milk helps strengthen the bones, so option A would be incorrect. For option B, you do not want to immobilize the joints, but instead, getting the joints moving during exacerbation is necessary to improve the pain. For option D, we don't want to teach them to avoid weight-bearing exercises because we want them to be able to bear weight on their joints.

40. Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place? A. The restraints will be removed once the client is extubated B. We are required to restrain all clients with breathing tube C. Restraints are a last resort to prevent accidental extubation D. It is routine procedure for us to restrain all intubated clients

C. Restraints are a last resort to prevent accidental extubation *Restraints are always the last resort*

20. Which potassium level would be of greatest concern in a client who is taking furosemide ( Lasix )? A. 5.4 mEq / L B. 6.2 mEq / L C. 4.3 mEq / L D. 3.2 mEq / L

D. 3.2 mEq / L Furosemide makes the client urinate excessively, so a low potassium level would be concerning because they will lose even more potassium. Lasix = potassium wasting

23. Which scenario explained by the registered nurse teaching about factors that influence sleep is an example of a lifestyle factor? A. A client reports trouble falling asleep because of thinking about stress at work B. A client in the intensive care unit has not slept properly because of noises and disturbances. C. A client who has been taking antidepressants reports drowsiness and lack of sleep. D. A client who works rotating overnight shifts reports fatigue and difficulty sleeping through the night

D. A client who works rotating overnight shifts reports fatigue and difficulty sleeping through the night Option D is a lifestyle factor because work is a lifestyle occupation. Option A would be ineffective because since the client is thinking about stress, this would be more of an emotional factor. Option B would be an environmental factor.

5. Which nursing action is appropriate when caring for a client who is legally blind and has been admitted to the hospital for surgery? A. Enter the room while speaking softly. B. Touch the client gently before speaking. C. Hold the client by the elbow while ambulating. D. Keep the furniture in the same location in the room

D. Keep the furniture in the same location in the room. Safe; consistent. Keeping everything in the same location is a good way to prevent any risk for injuries, and a consistent environment is good for the client

26. When a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb ( 2.7 kg ) l, which nursing action has the highest priority? A. Check for lower leg swelling B. Notify the health care provider C. Take the client's pulse D. Listen to the client's breath sounds

D. Listen to the client's breath sounds When a question states highest priority, that means that all of the options are correct. The ABC - airway, breathing, circulation - the breath sounds would be the highest priority. We do this to see if clients have fluid overload, or pulmonary edema, and you would most likely hear crackles during auscultation.

10. Which kind of health service would the nurse offer in a health promotion or primary care program? A. Home care. B. Immunization. C. Sports medicine. D. Nutrition counselling

D. Nutrition counselling This is the most appropriate option because counseling, teaching, etc are beneficial for promoting health. Immunizations are utilized to prevent illness, which would fall underneath secondary prevention. Health promotion = primary prevention Preventing illness = secondary prevention

36. Which action would be the nurse's priority of care for a client with hypothermia? A. Administering electrolytes B. Monitoring body temperature C. Increasing the temperature of the room D. Removing the client from the cold environment

D. Removing the client from the cold environment The highest priority would be to eliminate the problems that are causing the client's condition, which would be the cold environment.

43. Which intervention related to restraint use is appropriate to delegate to unlicensed assistive personnel ( UAP ) ? A. Appropriate use of restraints B. Determination of the need for restraints C. Assessment of the client's behavior D. Routine checks of the client while in restraints

D. Routine checks of the client while in restraints Assessment and determination are done by the registered nurse

41. Which legal implication would the nurse understand about applying restraints to a client? A. The law allows restraining clients until a written prescription is obtained B. A felony charge may be leveled against nurses who use any kinds of restraints C. Nurses are not obligated to report institutions that use restraints unlawfully D. The nurse can be charged with assault and battery for using restraints improperly

D. The nurse can be charged with assault and battery for using restraints improperly Nurses need a prescription before applying a restraint. Felony charges are normally held against charges like murder.

Which of the following drops the heart rate higher than a beta blocker? For example, a client diagnosed with congestive heart failure?

Digoxin

2. Which nursing action occurring within a recently implemented falls reduction program indicates the need for additional staff education ? Select all that apply. One , some , or all responses may be correct. A. Using gait belt for clients transfers and ambulation. B. Placing a bedside commode for a client experiencing incontinence C. Establishing an elimination schedule for clients experiencing confusion. D. Placing a fall pad on the floor by the bed of a client with a high risk for falls. E. Stabilizing a client with hypotension in a standing position for 5 minutes before ambulating

E. Stabilizing a client with hypotension in a standing position for five minutes before ambulating. Nurses do not stabilize in a standing position, we do so well sitting.

Which type of medication/injection is the LPN unable to administer?

Insulin and Heparin

As a nurse, we must ask the client if they need to go to the bathroom, provide ROM exercises every two hours, and check the site every two hours for a patient under which of the following?

Restraints

Which kinds of medications lower respiratory rate?

Sedative and opioid medications

Which of the following restraints is strapped across the front?

Vest restraints

Any medication that ends in "lol" means that...

it is a blood pressure medication, also known as a beta blocker. The heart rate must be greater than 50 in order to administer this medication.