Q Review 1
When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? 1. Nervousness 2. Weight gain 3. Exophthalmos 4. Loss of appetite 5. Constipation 6. Hot and sweating
1,3,6
Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough
4. Whooping cough
Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener. 2. Increase intake of fruit in the diet. 3. Monitor elimination habits for the next week. 4. Rest after each meal.
2
The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority? 1. Check blood glucose level. 2. Assess for proper shoe size. 3. Examine the client's feet for signs of injury. 4. Test sensory perception in the client's feet.
3. Examine the client's feet for signs of injury.
After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action? 1. Leave the client lying with the unaffected ear facing up. 2. Place a cotton ball firmly into the affected ear for 15 minutes. 3. Pull the pinna of the ear down and back. 4. Gently massage the tragus of the ear.
4. Gently massage the tragus of the ear.
A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? 1. Are you feeling afraid now? 2. I am here with you. 3. Let's discuss something else. 4. You know that is not true.
1. Are you feeling afraid now?
A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? 1. Blood cultures times two 2. Ceftriaxone 250 mg IV every 12 hours 3. Start IV & monitor site. 4. 1/2 normal saline at 40 mL/hr
1. Blood cultures times two
A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? 1. Checking your vital signs frequently. 2. Examining the dressing for bleeding. 3. Listening to and percussing your lungs. 4. Positioning you with your affected lung down. 5. Palpating around the incision site for air under the skin.
1,2,3,5
In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? You answered this question Correctly 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 6. Obtain assistance from other nurses or nurse assistants as needed.
1,2,3,6
A nurse assesses the 5 minute Apgar on a term, newborn infant. Based on the Apgar score, what should be the nurse's priority intervention? 1. Continue Apgar scoring every five minutes until 20 minutes of life. 2. Transfer newborn to the neonatal intensive care unit ASAP. 3. Administer "blow-by" oxygen while suctioning. 4. Perform cardiopulmonary resuscitation.
3. Administer "blow-by" oxygen while suctioning.
Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider? 1. Parent states infant tastes salty. 2. Frequent coughing with thick, blood-streaked sputum. 3. Foul-smelling, greasy stools. 4. Able to hold head upright without head wobbling. 5. No weight gain since last check-up.
1,2,3,5
A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? 1. Accepts the treatment of the nurse and think that it is appropriate. 2. Takes offense to the abrupt nature of the treatment. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient.
2. Takes offense to the abrupt nature of the treatment. The family is likely to be offended by the abrupt manner of the nurse. The Hispanic culture is present time oriented and desire attention and interaction. It would not be relevant that the nurse may be busy. To overlook this cultural variation is rude and does not treat the mother with dignity.
what is The normal CVP reading
is 2-6 mm Hg.
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Confusion and disorientation. 2. Scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.
2
A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? 1. Medium rare steak, potato salad, peas and coffee 2. Ham sandwich, chips, fruit salad and juice 3. Broiled white fish, baked potato, mixed salad and tea 4. Baked chicken, vegetable medley, rice and milk
3. Correct: Fish is allowed if it has fins and scales. Shellfish is not kosher. Pasta, potatoes, salads and tea are allowed. 1. Incorrect: Although steak is allowed, all traces of blood must be gone. 2. Incorrect: No pork products are allowed, so no bacon, ham, or sausage. 4. Incorrect: Milk is not allowed at the same time as meat. There should be at least three hours separating the two.
What should the nurse include when educating a client about the use of nitroglycerin sublingual. 1. Do not swallow nitroglycerin. 2. Keep the medication is a moist, warm place. 3. The medication may burn when taken. 4. Sit or lie down when taking this medication. 5. The most common side effect is vomiting.
1 3 4
As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number.
Calculate BMI by dividing weight in pounds by height in inches squared and multiplying by a conversion factor of 703. 5'5" = 65" [180 pounds ÷ (65)2 ] x 703 = [180 pounds ÷ 4225] x 703 = 0.04260355 x 703 = 29.95 or 30
A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? 1. Depersonalization 2. Echopraxia 3. Neologism 4. Concrete thinking
1. Depersonalization
The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which sign or symptom would cause the greatest concern? 1. Nasal congestion 2. Hiccups 3. Blood glucose of 150 4. Muscle spasms
4. Muscle spasms
What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? 1. Jogging 2. Volleyball 3. Tennis 4. Bicycle riding 5. Swimming
4. Bicycle riding 5. Swimming
Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client?
case manager
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? You answered this question Incorrectly 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain
1., 2., 3., 4. & 6. Correct: Infections may cause color changes, drainage, odor, fever, & increased pain. Bleeding is a sign of hemorrhage, trauma, anemia or other blood disorders but not infection.
The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? 1. Endotracheal tube (ET) 2. Head tilt-chin lift maneuver 3. Oropharyngeal airway 4. Jaw thrust maneuver
4. Correct: This is a trauma client that could possibly have a C-spine injury. The jaw thrust maneuver will open the client's airway without manipulating the client's C-spine.
A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? 1. Firm, nodular liver 2. Ascites 3. Increased serum albumin levels 4. Increased ALT and AST levels 5. Lowered ammonia levels 6. Bleeding from the GI tract
1,2,4,6
The primary healthcare provider (PHP)has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's best first action? 1. Administer the injection. 2. Take vital signs. 3. Question prescription with primary healthcare provider. 4. Notify the nursing supervisor
3
What side effects would the nurse expect to find in a client who has received too much levothyroxine? 1. Angina 2. Bradycardia 3. Hypotension 4. Heat intolerance 5. Tremors
1,4,5
The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected? 1. Abrupt onset of dyspnea, fever. 2. Small papule on skin resembling an insect bite. 3. Pustular vesicles on skin. 4. Fatigue.
1. Abrupt onset of dyspnea, fever.
the nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent? 1. A bruit is heard with a stethoscope. 2. A thrill is felt on palpation. 3. There is a blood return on the venous side of the shunt. 4. Urine output greater than 30 mL/hr. 5. There is a strong radial pulse in the arm with the AV shunt.
1. A bruit is heard with a stethoscope. 2. A thrill is felt on palpation.
A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? 1. Administer the digoxin. 2. Hold the digoxin. 3. Notify the primary healthcare provider. 4. Repeat the digoxin level.
1. Administer the digoxin. This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL.
What symptoms does the nurse expect to see in a client with bulimia nervosa? You answered this question Correctly 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise
2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain
A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation? 1. Calcium supplement 2. Ferrous sulfate 3. Folic acid 4. Cetirizine
2. Ferrous sulfate
The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? 1. My weight may decrease while taking this drug. 2. I may expect increased sweating while taking this drug. 3. I may actually feel more depressed while taking this medication. 4. I should feel better within a couple of days after beginning the medication.
2. I may expect increased sweating while taking this drug.
The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container
2. In a chemotherapy sharps container
The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body? 1. Lowers the blood glucose 2. Provides more energy 3. Increases insulin need 4. Reverses complications of diabetes 5. Increases the workload of the liver
1 2
Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? 1. 10 year old paraplegic in for bowel training. 2. 2 year old with asthma newly admitted with dehydration. 3. 3 month old admitted with possible septicemia. 4. 7 year old in Buck's traction for a femur fracture. 5. 10 year old transferred from ICU yesterday with a head injury.
1, 4
Which nurse is providing cost effective care to a client? 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves.
1,2,3,4 5-needs sterile gloves
The nurse is planning to teach a group of assisted living residents about tuberculosis (TB) infection. What should the nurse include? 1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 4. Obtain a yearly chest x-ray. 5. Proper disposal of tissues.
1,2,3,5
The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.
1,2,4
Which intervention should the nurse initiate for a client post liver biopsy? 1. Apply direct pressure to site immediately after needle is removed. 2. Assess puncture site every 15 minutes for 1 hour. 3. Position client on left side. 4. Keep client NPO for 24 hours. 5. Advise client that pain may occur in right shoulder as the anesthetic wears off.
1,2,5
The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion? 1. "Please tell me how I can best help you control your pain." 2. "It is my job to teach you how to deal with your pain." 3. "I will be teaching you how to use guided imagery to decrease your pain." 4. "Your primary healthcare provider has prescribed pain medication for your pain. I will teach you about this medication."
1. "Please tell me how I can best help you control your pain."
A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse? 1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed."
1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. "
The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? 1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 2. "I have been gaining a lot of weight lately." 3. "My stools are darker. Sometimes they are even black." 4. "When I start hurting, it helps if I drink milk or have a small snack."
1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt."
The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? 1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.
1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends.
Which client should the charge nurse assign to a new RN? 1. Child needing pre-operative medication prior to reduction of a fracture. 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago.
1. Child needing pre-operative medication prior to reduction of a fracture.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? 1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash.
1. Correct. The client usually experiences dramatic improvement within 24 hours after beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of NSAIDs, in fact, most NSAIDs are also antipyretics and would prevent fever.
The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement? 1. I will wear long sleeves and a hat when I go for my afternoon walks. 2. I will limit my alcohol intake to one glass of red wine with supper. 3. I need to limit my fluid intake in order to avoid fluid retention. 4. I need to maintain a high calorie diet and eat 6-8 small meals a day.
1. I will wear long sleeves and a hat when I go for my afternoon walks.
Which action, if done by a nurse, needs to be interrupted by the charge nurse? 1. Mixes diazepam and hydromorphone in one syringe. 2. Administers diazepam before meals. 3. Raises side rails after administering hydromorphone. 4. Instructs client to call for assistance getting out of bed after administration of diazepam.
1. Mixes diazepam and hydromorphone in one syringe. Diazepam cannot be mixed with any other medication
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.
1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery.
job of these hormones 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG)
1. Progesterone causes amenorrhea. 2. Estrogen renders the female genital tract suitable for fertilization. causes stuffiness 3. This stimulates the growth of the graafian follicle in the ovary. 4. This is the hormone present in urine for pregnancy test
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.
1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate.
What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? 1. Suggest client eat several small meals a day, with the largest at breakfast. 2. Recommend eating meals in a semi-recumbent position. 3. Administer metoclopramide 1 hour after meals. 4. Avoid fruit juices and carbonated beverages.
1. Suggest client eat several small meals a day, with the largest at breakfast. Large meals are difficult to manage when the client is anorexic and has loss of appetite, as is usually the case with Hepatitis B. Anorexia may also worsen during the day, making intake of food difficult later in the day.
A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? 1. Use simple words. 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-ended questions to ask what is wrong.
1. Use simple words.
A client has just delivered a newborn. Based on the primary healthcare provider's notation, what prescriptions does the nurse anticipate administering to the mother? Exhibit Healthy male (21 inches long, 7 pounds) delivered to 22 y/o female Para 1 Gravida 1. Client is Rh negative and the newborn is Rh positive. Rubella titer less than 1:8. Hepatitis B status negative. Tetanus toxoid 2 years ago 1. Measles, mumps and rubella (MMR) vaccine 2. Hepatitis A vaccine 3. Hepatitis B immune globulin 4. RH0(D) immune globulin 5. Tetanus toxoid
1., & 4. Correct: A client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine, or measles, mumps and rubella vaccine (MMR) during the postpartum period to protect a subsequent fetus from malformations. Clients should not get pregnant for 4 weeks following the vaccination. All Rh negative moms who have Rh positive newborns must be given RH0(D) immune globulin IM within 72 hours of newborn being born to suppress antibody formation in the mother.
A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement? 1. Monitor stools for occult blood. 2. Place on fall prevention. 3. Place client in protective isolation. 4. Restrict venipunctures. 5. Limit visitors.
1., 2., & 4. Correct: A normal platelet count ranges from 150,000-400,000 mm3. This is a low platelet count, so interventions should focus on bleeding precautions. The white cell count (WBC) is normal (5,000-10,000 cells/mcL). Bleeding precautions would include monitoring for bleeding, such as monitoring stools for occult blood. The client is at risk for injury, so fall prevention is needed. Since the client will bleed more easily, restrict venipunctures.
The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective? 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia
1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety.
Three hours after delivery of a client's newborn, the nurse assesses for bladder distention. What signs would the nurse note if the client's bladder is distended? 1. Fundus 3 cm above umbilicus 2. Excessive lochia 3. Voids 200 mL every 2 hours 4. Fundus in abdominal midline 5. Tenderness above symphysis pubis
1., 2., & 5. Correct: Monitor client for signs of distended bladder, such as fundal height above the umbilicus or baseline level, and/or fundus displaced from midline over to the side. Bladder bulges above the symphysis pubis, excessive lochia, tenderness over the bladder area, frequent voiding of less than 150 mL (indicative of urinary retention with overflow) are also sign of distended bladder.
Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Help position a client for a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen.
1., 2., 3., & 5. Correct: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client has difficulty swallowing and is at risk for choking making the client unstable. Therefore, the nurse should not allow the UAP to feed this client.
A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? 1. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses' reasons for not using pain level scale. 6. Disciplines offenses through unpaid time off.
1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill before, but have not practiced the skill on a regular basis, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Counseling the nurses when pain level scale is not utilized may improve understanding and performance. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance. 6. Incorrect: Quality improvement looks at improving processes and does not use intimidation and punishment to improve quality care.
he nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises
1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT).
The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase? 1. On-going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 3. Discontinue programmatic exercise plan. 4. Relapse prevention plan. 5. Continued peer support.
1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase.
A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
1., 3, & 5. Correct: These are written correctly with complete, concise and objective information for each statement pertaining to the client. 2. Incorrect: "Appears" is a subjective word. Remember to use objective words. Pain should be assessed in an objective manner, such as by using a pain scale that is appropriate for the client's age and communication abilities. If the client were unable to respond to a pain scale assessment, the nurse would need to describe objectively the behavior of concern; for instance, the nurse could document "client moaning, guarding abdominal area with both hands, and knees pulled towards chest". 4. Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect dosage. Likewise, always lead a decimal point with a zero (0.5).
Which task would be appropriate for the charge nurse to assign to a LPN/VN? 1. Collect data on a new client admit. 2. Administer morphine IVP to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
1., 3., 4., & 5. Correct: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN also. A LPN/VN can monitor the PCA pain medication but cannot initiate or administer the medication. 2. Incorrect: Administering morphine IVP is out of the scope of practice for the LPN/VN since it is a complex, high risk IV push medication and has the potential to depress the client's respiratory rate.
Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? 1. "I will read labels to be sure there is no hidden alcohol in food." 2. "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." 3. "I can call the clinic or my sponsor whenever I feel tempted to drink alcohol." 4. "Even one glass of alcohol can cause me to start drinking regularly again.
2
The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? 1. Cottage cheese 2. Salami 3. Baked chicken 4. Potatoes
2 2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis.
The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? 1. Family members are responsible for preventing future suicidal attempts. 2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes.
2,3,4,5
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.
2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery. razors cause micro abrasions
A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? 1. Maintain continuous cardiac monitoring. 2. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn. 3. Provide alprazolam 0.25 mg PO PRN. 4. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr.
2. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn.
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? 1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red blood cells for anemia.
2. Client diagnosed with seizure disorder.
A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? 1. Prolonged bleeding time 2. Elevated reticulocyte count 3. Decreased platelet count 4. Elevated bands
2. Elevated reticulocyte count
A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? 1. Directly observe the client at least every 4 hours. 2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. 5. Discourage client's expression of negative feelings.
2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client.
A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? 1. Yes, I believe that God will heal you. 2. Many people of faith believe that one way God works to heal is through medication. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the medication?
2. Many people of faith believe that one way God works to heal is through medication.
The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? 1. Document the medication with times and doses to be given, then administer the medication as ordered. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 5. Call the pharmacy to see if the medication needs to be changed.
2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record.
A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? 1. Send the client to the waiting room. 2. Place the client in a negative pressure room. 3. Put a surgical mask on the client. 4. Initiate contact precautions.
2. Place the client in a negative pressure room. The client may have smallpox, which is very contagious. Smallpox can also be used as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure.
The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? You answered this question Incorrectly 1. Apply gauze padding beneath the tubing. 2. Use petroleum jelly on the nares and cheeks. 3. Provide mouth and nose care every 4 hours as needed. 4. Place the oxygen tubing above the ears.
2. Use petroleum jelly on the nares and cheeks. Petroleum jelly is a combustible substance. It should not be used with oxygen therapy.
The nurse is caring for a client prescribed vancomycin for Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. What nursing intervention is appropriate? 1. Provide the client food or a snack to take with the medication 2. Verify that the client's BUN and creatinine are within normal range 3. Administer an antiemetic prior to vancomycin administration 4. Request the placement of a PICC line for IV administration
2. Verify that the client's BUN and creatinine are within normal range
The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client? 1. Place the finger at heart level when making the stick. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level when making the stick.
2. Warm the finger prior to the stick.
The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? 1. Educating the client regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.
2., 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain. All of these provide comfort, are non-invasive, and show the client that the nurse cares.
A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs further instruction? 1. "I will not alter the height of my crutches." 2. "My body weight should be supported at the hand grips with my elbows flexed at 30 degrees." 3. "When I rise from a chair, I should position my crutches on my unaffected side." 4. "I will not lean on my crutches while standing."
3
What should the nurse include when teaching a client in renal failure about peritoneal dialysis? 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.
3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 ml at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal). 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately.
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?"
3. "Come to the clinic now so that we can help you."
An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? 1. "I'm going to miss having my evening glass of wine now." 2. "I told my daughter to buy spinach for me. I'll have to eat more servings now." 3. "I will have to watch my intake of salads, something that I really love." 4. "I am going to begin eating more fish and pork and leave beef alone now."
3. "I will have to watch my intake of salads, something that I really love."
When caring for young adult clients, which developmental tasks would the nurse expect to see? 1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. 5. Developing sense of fulfillment by volunteering in the community.
3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect: Parenting is a primary task of middle adulthood. This is the middle adulthood stage of Generativity versus Stagnation, where each adult must find some way to satisfy and support the next generation. 2. Incorrect: During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity versus Despair, where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to support others.
Which client should the nurse, working the Emergency Department (ED), see first? 1. Client diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who has a non-productive cough. 2. Client who is a diabetic and has an infected sore on the foot. 3. Client with adrenal insufficiency who feels weak. 4. Client with a fracture of the forearm that has been placed in a splint.
3. Client with adrenal insufficiency who feels weak.
A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider? 1. Blood pressure 136/84 2. Report of nausea 3. Anxiety 4. Urinary output at 50 mL/hour
3. Correct: Anxiety, restlessness, or a sense of apprehension is often the first sign/symptoms of acute pulmonary edema.
A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning? 1. Ask the family to restrict the client to the first floor. 2. Instruct the client on home safety issues. 3. Notify social services to arrange a home visit. 4. Discuss cast care with client and family
3. Correct: The nurse is aware that a spiral fracture is caused by a twisting or jerking motion, in this case, of the forearm. While a fall could cause many injuries, contusions of the face combined with a spiral forearm, are indicative of abuse. The priority is to alert social services to follow-up with this client and family in the home setting, to determine the severity of the situation and possible interventions for the client's well-being.
One week ago a client was involved in a motor vehicle crash and was brought to the Emergency Department. The client received two sutures to the forehead and was sent home. Today, the client's spouse notes the client "acts drunk" and cannot control the right foot and arm. Based on this data, what should the nurse suspect? 1. Meningitis 2. Transient ischemic attack 3. Subdural hematoma 4. Meniere's disease
3. Correct: Yes, subacute subdural hematoma is a head injury with slow venous bleed. The body does not have symptoms until compensation is exhausted.
A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 1. Administer the medication as prescribed. 2. Obtain pre-filled syringes from the pharmacy. 3. Discuss client rights with the primary healthcare provider. 4. Tell the client what has been prescribed.
3. Discuss client rights with the primary healthcare provider.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.
3. Read about formalin on the Material Safety Data Sheet (MSDS).
A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? 1. Your head is turned to the side as if you are listening to voices. 2. I don't hear anyone but you speaking. 3. Tell me what the voices are saying to you. 4. Let's talk about your anxiety right now.
3. Tell me what the voices are saying to you.
An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? 1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should be used on all clients." 4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn."
4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn."
The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse best meet the religious dietary needs for this client? 1. Allow the client to select whatever is acceptable from a regular meal tray. 2. Review the client's admission data to determine any dietary restrictions. 3. Call the dietician to discuss special dietary needs with the client's spouse. 4. Ask the client about dietary preferences needed to meet religious guidelines.
4. Ask the client about dietary preferences needed to meet religious guidelines.
What task by the RN should be performed first? 1. Changing a burn dressing that is scheduled every four hours. 2. Administering scheduled IV antibiotic. 3. Teaching a new diagnosed diabetic about diet and exercise. 4. Assessing a newly admitted client.
4. Assessing a newly admitted client.
A home health nurse visits a recently discharged client with right-sided paresis due to a stroke. The nurse discovers that the spouse has been feeding the client. What action should the nurse take? 1. Instruct the spouse to require the client to feed independently. 2. Suggest the spouse hire an aide to feed and bathe the client. 3. Advise the spouse to consider an extended care facility for the client. 4. Determine why the spouse is not encouraging self-care by the client.
4. Correct: Because family members are important in promoting client self-care and preventing further illness, it is important to include family members in the teaching plan for the client. In a family support model, the goal is client self-care activities through formal and informal support systems.
What instruction is most important to include when teaching a child how to self administer a combined dose of isophane suspension and regular insulin subcutaneously? 1. Alternate the injection sites from one body area to another with each dose. 2. Draw up the isophane suspension insulin first and then regular insulin into the same insulin syringe. 3. Massage the injection site after the medication is injected. 4. Insulin syringes should be stored at room temperature.
4. Correct: Insulin syringes and needles should be stored at room temperature. The potential benefits or risks of refrigerating the syringe are unknown. 1. Incorrect: Insulin injection sites are rotated, but within a chosen site e.g., the abdomen. Once all the sites in that area are used, then another area of the body is selected e.g., the arm. 2. Incorrect: As a rule, remember clear before cloudy; that is, draw up the regular (clear) insulin first, and then draw up the long acting insulin, isophane suspension (cloudy). 3. Incorrect: Gently blot any blood with a gauze pad. Do not massage the site. Massaging or rubbing the site will alter the rate of absorption of the medication.
The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? 1. Calmly sit with the client and have the client repeat the room number at frequent intervals. 2. Have the client remain in the room so the client can become familiar with it. 3. Place a sign on the client's door that clearly has the client's name so the client can identify it. 4. Hang a familiar object on the door to enhance room recognition.
4. Hang a familiar object on the door to enhance room recognition.
During shift change the night charge nurse reports to the day charge nurse that the client admitted with an ingestion of unknown drugs, was physically restrained last night at 10:00 pm. The client was incoherent, combative, and attempting to leave the facility. No family members were present. The night charge nurse noted that there was no primary healthcare provider prescription for the restraints. On last assessment 30 minutes ago, the client was still combative. What is the best action by the day shift charge nurse? You answered this question Correctly 1. Since the client is still combative, continue the restraints. 2. Remove restraints until the primary healthcare provider writes the prescription. 3. Assign an unlicensed assistive personnel (UAP) to check on the client periodically. 4. Obtain a prescription from the primary healthcare provider on rounds this shift.
4. Obtain a prescription from the primary healthcare provider on rounds this shift. Since the restraints are still needed and 24 hours have not passed, it would be acceptable to wait until the primary healthcare provider makes rounds. A prescription for physical restraints must be written within a 24 hour period. Generally, restraints are not used past a 24 hour period. The prescription for the restraint should include why the client requires physical restraints and a time period for using them and no more than 24 hours.
A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? 1. Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Pre-term labor client with twins at 28 weeks gestation.
4. Pre-term labor client with twins at 28 weeks gestation. both need to be kept unstimulated bc early labor
After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first? 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.
4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing. Crust forming on the Steinmann pins should be removed from the pin insertion site, however, this client would not be given priority over the client with dehydration.
The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene? 1. TPN has been hanging for 12 hours 2. Central venous catheter's dressing is clean and dry 3. TPN fluid is room temperature when beginning administration 4. TPN appears oily in consistency
4. TPN appears oily in consistency ten can infuse for 24 hrs
These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first? 1. The client whose blood pressure is 40 palpable, heart rate 30, and respirations 6. 2. The comatose client with fixed and dilated pupils. 3. The unresponsive client with an open head fracture and visible white matter. 4. The client with a sucking chest wound and tension pneumothorax.
4. The client with a sucking chest wound and tension pneumothorax.
A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. Close the door to the client's room. Obtain the fire extinguisher. Remove the client from the room. Extinguish the fire. Activate the fire alarm.
Remember RACE: Rescue the client; activate the alarm; contain the fire in the client's room; extinguish the fire. This standard process ensures safety for the client first and then the remaining people in the facility next. remove pt activate alarm close door obtain extinguisher extinguish fire