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Q Review 1

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A 35 year old client asks a clinic nurse how to find out if the client is overweight or obese. The client weighs 135 pounds and is 5 feet 2 inches tall. What should the nurse educate the client about? You answered this question Correctly 1. Calculating body mass index 2. Measuring abdominal circumference 3. Determining lean body mass 4. Finding the nearest hydrostatic testing location

1. Calculating body mass index

A pregnant client who had been on a magnesium drip for severe pregnancy induced hypertension (PIH) has had an emergency cesarean section at 35 weeks. The nursery nurse should anticipate what findings in the newborn related to the magnesium therapy? 1. Hypotension 2. Hypoglycemia 3. Hyperreflexia 4. Flaccid muscle tone 5. Respiratory depression

1. Hypotension 4. Flaccid muscle tone 5. Respiratory depression

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin

1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM

A nurse has taught a group of teenage girls about breast self-awareness. Which statements by the teens would indicate to the nurse that teaching was effective? 1. "I should have a clinical breast exam every 5 years starting at the age of 18." 2. "Doing a monthly breast self-exam will help me learn what is normal for me." 3. "It is only important to know my maternal health history." 4. "Signs I should not ignore include dimpling of the skin, and nipple discharge." 5. "Self-breast exam should be done a few days before my menstrual cycle begins."

2. "Doing a monthly breast self-exam will help me learn what is normal for me." 4. "Signs I should not ignore include dimpling of the skin, and nipple discharge."

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam.

The primary healthcare provider's prescription for a client instructs the nurse to give digoxin 0.125 mg intravenously as a one-time dose. The available medication is in a concentration of 0.25 mg/2 mL. How many milliliters should the nurse give? Round answer using one decimal point.

1 mL

When making assignments for an LPN on the Labor and Delivery unit, the charge nurse is aware the most appropriate clients should meet what criteria? 1. Clients requiring close monitoring. 2. Post-vaginal delivery clients only. 3. Clients with a predictable outcome. 4. Non-routine clients in early labor.

3. Clients with a predictable outcome.

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? You answered this question Correctly 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

3. Invite staff to contribute ideas on scheduling changes.

The nurse is reviewing morning laboratory results on four clients. Which lab finding should the nurse report to the primary healthcare provider immediately? Exhibit You answered this question Correctly 1. aPTT 2. WBC 3. Sed rate 4. K+

4. K+

The nurse is monitoring care provided to clients by a newly hired unlicensed assistive personnel (UAP). Which action by the UAP would require the nurse to intervene? 1. Uses a gait belt when ambulating a client with right sided weakness. 2. Repositions a client in bed using a lift sheet. 3. Disconnects nasogastric (NG) tube from suction to allow ambulation to toilet. 4. Massages a surgical client's calf after reports of leg cramping.

4. Massages a surgical client's calf after reports of leg cramping.

The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene? 1. Lifting the affected leg with the palms of the hands 2. Covering the affected leg with a blanket to avoid chills 3. Placing plastic over the entire cast prior to bathing 4. Elevating the casted leg on two pillows

2. Covering the affected leg with a blanket to avoid chills

What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia? Select all that apply 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

A client who is sitting in a chair begins to have a tonic-clonic seizure. In what order should the nurse intervene? You answered this question Incorrectly The Correct Order Ease client to the floor. Position client on side. Push aside any furniture. Administer prescribed antiepileptic medication.

correct order listed

A client who is ventilator dependent is scheduled to be discharged home. What is the most critical assessment for the nurse case manager to make? 1. Financial stability for home health care. 2. Long-term home care needs. 3. Safe home environment. 4. Home medical equipment needed.

3. Safe home environment.

68-year-old client with a history of angina presents to the emergency department (ED) reporting flu like symptoms progressively worsening over the past 24 hours.What action is most important for the nurse to initiate? Exhibit You answered this question Incorrectly 1. Administer acetamenophen. 2. Initiate IV of Normal Saline at 250 mL/hour. 3. Notify radiology and lab of diagnostic test prescriptions. 4. Discuss IV prescription with primary healthcare provider.

4. Discuss IV prescription with primary healthcare provider.

Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? 1. Soaking the dentures in hot water 2. Donning gloves and using a gauze pad to grasp and remove dentures 3. Moistening the dentures prior to inserting them 4. Wrapping the dentures in tissue while the client sleeps 5. Placing a washcloth in the bathroom sink prior to cleaning.

1. Soaking the dentures in hot water 4. Wrapping the dentures in tissue while the client sleeps

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. Client's tracheostomy needs to be suctioned. The water seal chamber is empty in a client's closed chest drainage unit. UAP reports a heart rate of 40/min in a client. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria.

correct order

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? You answered this question Incorrectly 1. Blank affect. 2. Decreased ability to swing arms. 3. Waddling gait. 4. Walking on toes. 5. Pill-rolling tremor. 6. Stiff muscles.

1. Blank affect. 2. Decreased ability to swing arms. 5. Pill-rolling tremor. 6. Stiff muscles.

A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? You answered this question Correctly 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair.

3. Slides walker slowly forward when walking across the room.

A concerned mother is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

3. baseball

An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What is the priority nursing intervention at this time? 1. Hide the client's clothes so that he cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.

4. Determine why the client wants to leave

What electrolyte imbalance should the nurse monitor for in a client diagnosed with hyperosmolar hyperglycemic state (HHS)? 1. Hypocalcemia 2. Hypermagnesemia 3. Hyperkalemia 4. Hyponatremia

4. Hyponatermia

A premature HIV+ infant has been admitted to the Pediatric Unit with a new diagnosis of cytomegalovirus (CMV). The charge nurse is aware the most appropriate staff to assign to this client is what individual? 1. A new nurse orienting to the unit. 2. A pediatric nurse six months pregnant. 3. An LPN with an exacerbation of eczema. 4. An experienced UAP with no health issues.

1. A new nurse orienting to the unit.

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? You answered this question Incorrectly 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin

1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM

A hospitalized client reports needing scented candles to aid sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? Select all that apply 1. Use an electric potpourri burner. 2. Place dry potpourri in nightstand. 3. Bring in live flowers to keep in room. 4. Spray scented air freshener frequently. 5. Dab scented oil on corner of the sheets.

2. Place dry potpourri in nightstand. 5. Dab scented oil on corner of the sheets.

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Deep tendon reflexes of plus three. 2. Urine output of 80 mL over four hours. 3. Respiratory rate of 24 breaths/minute. 4. Severe headache with blurred vision.

2. Urine output of 80 mL over four hours

What task would be most appropriate to assign to the UAP when caring for a client with ulcerative colitis? 1. Sharing successful anxiety reduction measures. 2. Encouraging the client to express concerns about an ileostomy. 3. Reminding the client to avoid cold foods and smoking. 4. Explaining the rationale for needing a low residue diet.

3. Reminding the client to avoid cold foods and smoking.

Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? 1. Give parent a small dog for company and comfort. 2. Reset the water heater to 125 degrees Fahrenheit (51.67 degree Celsius) to prevent burns. 3. Place mirrors in multiple locations so parent sees images of self. 4. Make floors and walls different colors.

4. Make floors and walls different colors

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

1. 3+ pedal edema 4. Purse-lip breathing 5. Pale nail beds

The nurse is reinforcing the dietary discharge instruction for a client prescribed warfarin. Which food choices should be avoided on the warfarin dietary instruction plan? Select all that apply 1. Corn 2. Carrot 3. Spinach 4. Broccoli 5. Watermelon

3. Spinach 4. Broccoli

A client performed a home pregnancy test and received a positive result. She arrives at the clinic for her first prenatal visit. She reports to the nurse that her last menstrual cycle was December 26, 2019. Based on the Naegele's Rule, when is the estimated date of confinement (EDC)? 1. September 3, 2020 2. September 26, 2020 3. October 2, 2020 4. October 3, 2020

4. October 3, 2020

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? You answered this question Correctly 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

1. Pesticide exposure

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? Select all that apply 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon

1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese

4. Make floors and walls different colors.

The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 20 gtt/mL. How many drops per minute should the nurse administer? Round answer to the nearest whole number.

42 drops

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? You answered this question Incorrectly 1. Spinach 2. Raspberries 3. Almonds 4. 100% bran cereal 5. Bananas 6. Raisins

5. Bananas 6. Raisins

The client diagnosed with active tuberculosis has been prescribed isoniazid 300 mg by mouth every day. What should the nurse teach this client? 1. "Notify your healthcare provider if your urine turns dark." 2. "Your healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "You should avoid eating aged cheeses and smoked fish." 4. "Eat foods such as tuna twice a week." 5. "Rise slowly from lying to sitting, or sitting to standing."

1. "Notify your healthcare provider if your urine turns dark." 2. "Your healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "You should avoid eating aged cheeses and smoked fish." 5. "Rise slowly from lying to sitting, or sitting to standing."

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

1. Administer 100% oxygen per mask

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? 1. Consult with the primary healthcare provider. 2. Assess the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

1. Consult with the primary healthcare provider. 2. Assess the client. 5. Utilize a pain scale to determine level of pain.

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? 1. Stands straight with feet together. 2. Asks client to lift head off the bed. 3. Pulls draw sheet with both hands. 4. Faces slightly towards head of bed.

1. Stands straight with feet together.

A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? 1. Apply occlusive dressing to chest. 2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen. 5. Position client on right side.

2. Initiate large gauge IV line 3. Prepare for chest tube placement 4. Administer high flow oxygen

What should the nurse emphasize when teaching clients how to decrease the risk of chronic obstructive pulmonary disease? You answered this question Correctly 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals. 5. Get a yearly influenza and pneumococcal vaccination.

3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals.

A client who had a triple lumen catheter placed in the right subclavian vein 30 minutes ago reports chest discomfort and shortness of breath. The assessment reveals BP 92/58, HR 104, Resp 28, and unequal breath sounds over lung fields. What problem should the nurse suspect this client is exhibiting? 1. Myocardial infarction 2. Atelectasis 3. Pneumothorax 4. Pneumonia

3. Pneumothorax

What task would be most appropriate to assign to the UAP when caring for a client with ulcerative colitis? You answered this question Incorrectly 1. Sharing successful anxiety reduction measures. 2. Encouraging the client to express concerns about an ileostomy. 3. Reminding the client to avoid cold foods and smoking. 4. Explaining the rationale for needing a low residue diet.

3. Reminding the client to avoid cold foods and smoking.

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? You answered this question Correctly 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

3. Restrict any visitors with visible illnesses.

3. Spinach 4. Broccoli

A nurse has arrived late to work twice in the last week. What should be the nurse manager's first action? 1. Confront the nurse with the consequences of tardiness. 2. Ask the nurse to consent to a drug screening test. 3. Document the tardiness in the nurse's record. 4. Ask the nurse the reason for being tardy.

4. Ask the nurse the reason for being tardy.

The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Which response by the LPN is appropriate in response to the inappropriate delegation? 1. Notify the primary healthcare provider. 2. Refuse the delegated intervention. 3. Discuss the assignment with another LPN. 4. Ask the charge nurse to evaluate the intervention.

2. Refuse the delegated intervention

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"

4. "What worries you most about getting out of bed?"

What should the nurse include in the teaching plan for a client receiving external beam radiation? 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment.

1. Small marks will be placed on the skin to mark the treatment area 3. The radiation therapist can see, hear, and talk with you at all times during treatment

The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Which response by the LPN is appropriate in response to the inappropriate delegation? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Refuse the delegated intervention. 3. Discuss the assignment with another LPN. 4. Ask the charge nurse to evaluate the intervention.

2. Refuse the delegated intervention.

Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake

3. Chicken leg, corn on the cob, apple

Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

1. Six year old who ingested diluted bleach.

The nurse walks into a client's room and finds the client exposed while the unlicensed assistive personnel (UAP) is giving the bath. After covering the client with a sheet, what should the nurse do first? Exhibit You answered this question Incorrectly 1. Tell the UAP to keep the client covered at all times. 2. Talk with the UAP about providing appropriate care for all clients. 3. Provide teaching to the UAP about privacy for clients. 4. Use the call light to ask for additional assistance in the room.

1. Tell the UAP to keep the client covered at all times.

A client diagnosed with primary pulmonary hypertension is admitted to the hospital. What does the nurse expect the client to mention when reviewing the client's current treatment regimen? Select all that apply 1. Aminoglycosides 2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators

2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators

Which nursing intervention represents secondary prevention level? 1. Teaching the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.

2. Providing care for abused women in a shelter.

Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distension in the client who had a indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.

3. Prepare a sitz bath for a postpartum client.

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

3. Prevent respiratory complications

A client is prescribed 2 grams of levodopa daily. Available forms of this drug include tablets of 500 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

4 tablets

The nurse has been talking with a depressed client at an outpatient clinic. When asked how the client feels to live alone, the client simply stares straight ahead. How should the nurse respond? 1. Ask, "Why won't you answer me?" 2. Leave the client alone for awhile. 3. Tell a joke to lighten the mood. 4. Use therapeutic silence.

4. Use therapeutic silence.

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? Select all that apply 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist

The nurse recognizes which manifestations as signs of community-acquired pneumonia? Select all that apply 1. Cough 2. Decreased respiratory rate 3. Fever 4. Myalgia 5. Pleuritic chest pain

1. Cough 3. Fever 4. Myalgia 5. Pleuritic chest pain

A client has been admitted with a stroke on the left side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? You answered this question Correctly 1. Right sided hemiplegia 2. Impaired judgment 3. Depression 4. Impaired language comprehension 5. Impulsiveness 6. Impaired speech

1. Right sided hemiplegia 3. Depression 4. Impaired language comprehension 6. Impaired speech

What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? You answered this question Correctly 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches

3. Paresthesia 5. Hypotonia 6. Muscle aches

Which activity by the unlicensed assisted personnel (UAP) assisting a client with Parkinson's disease would require intervention by the nurse? 1. Assisting the client with ambulating to the bathroom and back to bed 2. Reminding the client not to look down while walking 3. Performing bathing and oral care for the client 4. Encouraging the client to feed self

3. Performing bathing and oral care for the client

The nurse is preparing to administer subcutaneous injection. Place an X over the correct syringe position for this injection.

45 degree angle

A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."

1. "What do you think you should do?"

The family of an elderly woman is concerned that their mother is not getting restful sleep. As a result, the family members' sleep is disturbed. Which questions would be important for the nurse to ask? Select all that apply 1. Has there been any change in your mother's state of health? 2. Can family members take naps during the day? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels? 5. Can the family take turns in managing the mother's sleep problems?

1. Has there been any change in your mother's state of health? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels?

A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? 1. "Can you prove what the nurses are stealing?" 2. "No nurse working here would steal." 3. "You must have misunderstood what you were seeing." 4. "Tell me more about what you saw."

4. Tell me more about what you saw

An elderly client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the low dose regimen with regular insulin every 6 hours. The 2400 hours glucose level is 252 mg/dL. How much regular insulin should the nurse give the client at this time?

The nurse is sharing best practice for preventing pressure injuries in clients. What should the nurse include? 1. Use moisturizer daily on dry skin. 2. Massage reddened skin areas. 3. Prevent shearing by maintaining the head of bed at 45 degrees or higher. 4. Place rubber ring (donut) under client's sacral area. 5. Position client at 30 degree tilt when placed on side.

1. Use moisturizer daily on dry skin. 5. Position client at 30 degree tilt when placed on side.

The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? You answered this question Incorrectly 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

1. Age over 65 years. 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2. Avoid eating raw fruits and vegetables.

What clients could safely be delegated to the LPN/VN? Select all that apply 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

A child has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? Select all that apply 1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 3. Administer aspirin for fever. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.

1. Apply calamine lotion to affected areas several times a day 2. Provide cool baths with baking soda 4. Do not allow visitors who have never had varicella 5. Keep fingernails trimmed short

When assessing for the development of an infection following the application of a plaster cast to the leg, the nurse should teach the client to observe for the presence of which sign of infection? 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

1. Hot spots

Which vaccines would a nurse participating at a health fair encourage a 65 year-old adult to receive? 1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine 6. Measles, mumps, and rubella (MMR)

1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? You answered this question Incorrectly 1. Nonmaleficence 2. Beneficence 3. Justice 4. Fidelity

1. Nonmaleficence

The nurse is presenting discharge instructions, including dietary restrictions, to a client newly diagnosed with Cushing's disease. The nurse knows the teaching has been successful when the client chooses what selections? Select all that apply 1. Broiled cod, baked potato and steamed broccoli 2. Sliced ham with mashed potatoes and gravy 3. Beef taco with refried beans and guacamole 4. Lean cheeseburger with fries and fruit cocktail 5. Braised chicken with kale and navy bean salad

1. broiled cod, baked potato, and steamed broccoli 5. Braised chicken with kale and navy bean salad

The nurse manager is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position. 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.

2. The client who is confused and wanders about the unit.

A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.

3. Wipe up spilled coffee in the family waiting room.

Which teaching points should the nurse include when preparing the school-age child for heart surgery? Select all that apply 1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 3. Explain that an endotracheal tube will be needed. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

A client admitted for debridement of a leg wound has been diagnosed with vancomycin-resistant enterococci (VRE). What is the nurse's priority action? 1. Place with another client in contact isolation for methicillin-resistant staphylococcus aureus (MRSA). 2. Move the client to a private room with contact precautions. 3. Alert staff to use masks, goggles and gown to provide care. 4. Notify family members to gown and glove before entering room.

2. Move the client to a private room with contact precautions.

A client has delivered a set of premature twins. The neonatal intensive care unit (NICU) notifies the charge nurse on the postpartum floor the death of one infant is expected within the hour. What is the priority action by the charge nurse? 1. Sit quietly with client and allow expression of feelings. 2. Instruct UAP to take mother to the NICU immediately. 3. Request hospital clergy to visit the mother right away. 4. Notify father of the baby about the current situation.

2. Instruct UAP to take mother to the NICU immediately.

A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to obtain clients vital signs and a weight. 2. Assign an LPN/VN to perform the initial nursing history and physical assessment. 3. Have an LPN/VN perform collect data on the client and report results to RN. 4. Inform one of the RNs that a new client is on the floor and that a nursing history should be completed as soon as possible.

3. Have an LPN/VN perform collect data on the client and report results to RN.

A client, who arrives at the emergency department, reports flashes of light. What problem does the nurse suspect? 1. Cataract 2. Open angle glaucoma 3. Macular degeneration 4. Retinal detachment

4. Retinal detachment

The client with bi-polar disorder is parading around the common areas of the psychiatric unit in a sexually suggestive manner. The client then sits on the lap of one of the young male clients. What should the nurse do? 1. Tell the client that the behavior is inappropriate. 2. Accompany the client to the TV room on the unit. 3. Allow the male client to handle the situation. 4. Continue with the unit routine.

2. Accompany the client to the TV room on the unit.

How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? 1. 3 mL syringe with 23 gauge, 1" needle for IM injection 2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. 3. Prime intranasal spray for administration. 4. Tuberculin (TB) syringe with 28 gauge, 3/8" needle for intradermal injection.

2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection.

The nurse is evaluating a client for compliance to the prescribed diabetic program by checking recent lab results. Based on the lab data, what should the nurse conclude regarding the client? Exhibit You answered this question Correctly 1. At risk for developing hypoglycemia. 2. Demonstrating good control of blood glucose. 3. At risk for developing Somogyi phenomenon. 4. Demonstrating signs of insulin resistance.

2. Demonstrating good control of blood glucose.

A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement? 1. "My spouse can verbalize all the steps in order." 2. "I have attended all the sessions on ostomy care." 3. "I can do the irrigation if I refer to the instructions." 4. "I don't need to irrigate if the ostomy is making stool."

3. "I can do the irrigation if I refer to the instructions"

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN/VN to the floor. Which clients would be appropriate assignments for the LPN/VN? 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions.

1. A client with COPD complaining of shortness of breath on exertion. 3. A client receiving heparin injections for deep vein thrombosis. 5. A client receiving a blood transfusion that requires monitoring.

The homecare nurse is visiting a newly diagnosed diabetic being treated for a small left foot wound. What is the nurse's priority assessment on this first home visit? 1. Determine stage and drainage of foot wound. 2. Assess the client's ability to prepare and administer insulin. 3. Check home environment for potential hazards. 4. Assess client's knowledge of signs of hypoglycemia.

3. Check home environment for potential hazards

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? You answered this question Correctly 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

4. "You can refuse to be part of the students' study."

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the nurse privately in person. 4. Discuss suspicions with unit nurse manager.

4. Discuss suspicions with unit nurse manager.

A homecare nurse is visiting a client with advanced Alzheimer's disease living in the home of a daughter. The household includes two adults and three adolescents with extremely busy schedules. The daughter admits to feeling overwhelmed but is fearful of placing the client into a permanent care facility. What interventions by the nurse would be most helpful for the family at this time? You answered this question Correctly 1. Call Adult Protective Services and ask for recommendations. 2. Request the primary healthcare provider to order placement. 3. Provide the family with brochures from various nursing homes. 4. Encourage family to join a local Alzheimer's Support Group. 5. Talk with daughter regarding fears or concerns about placement.

4. Encourage family to join a local Alzheimer's Support Group. 5. Talk with daughter regarding fears or concerns about placement.

A mass casualty disaster has occurred and clients are being received at the emergency department. In what order should the nurse assess these clients? Sort from highest priority to lowest priority. Client with blunt trauma to the spine that is unable to move extremities. Client with an open chest wound that is beginning to show signs of tracheal deviation. Client with traumatic amputations with agonal respirations. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding.

open chest wound blunt trauma 4 inch agonal respirations

A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4. Keep affected extremity immobilized for 6 hours.

A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority? 1. Psychoses 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm

4. Laryngospasm

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns.

3. Assess current pain level and medicate.

Which client is at the greatest risk for developing pancreatic cancer? 1. 70 year old obese client who smokes one pack of cigarettes a day 2. 64 year old client who had gallbladder surgery less than 5 years ago 3. 58 year old client with Chron's Disease 4. 52 year old client whose mother died from pancreatic cancer

1. 70 year old obese client who smokes one pack of cigarettes a day

Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs

1. Bathe the client. 3. Listen to the client reminisce. 5. Weigh the client. 6. Take vital signs

The nurse is reviewing some clients' prescriptions. Which prescription should the nurse question and have corrected? 1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO4 at 3g/hr IV 4. Risperidone .5mg PO daily 5. Dexlansoprazole 30 mg PO daily

1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO4 at 3g/hr IV 4. Risperidone .5mg PO daily

An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Discontinue G-tube feeding 3. Administer oxygen 4. Obtain blood work for troponin level

1. Initiate seizure precautions

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? Select all that apply 1. Wear comfortable, low-heeled shoes. 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

1. Wear comfortable, low-heeled shoes. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

A client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the high dose regimen with regular insulin AC & HS. How much insulin should the nurse administer at 2100 hours? 1/19 @ 0730 368 mg/dL High dose regimen 16 units regular insulin 1/19 @ 1130 256 mg/dL High dose regimen 12 units regular insulin 1/19 @ 1700 164 mg/dL High dose regimen 4 units regular insulin 1/19 @ 2100 248 mg/dL ?

The emergency department nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first? You answered this question Correctly 1. 12 year old reporting a severe headache 2. 6 month old with respiratory rate of 68/min while sleeping 3. 2 year old with a broken arm who is crying and appears in pain 4. 8 year old with cellulitis of the left leg and an elevated body temperature

2. 6 month old with respiratory rate of 68/min while sleeping

The nurse has been assigned four clients. Who should the nurse see first? You answered this question Correctly 1. A client with diabetes admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain.

2. A client with epilepsy reporting an odd smell in the room.

The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.

2. A nurse discusses client's prognosis with family.

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? You answered this question Correctly 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks

2. Ask the dietician to visit the client and discuss food preferences.

Four clients arrive at the emergency department. Which client should the nurse triage as the highest priority for care? 1. Adult with severe upper gastric pain. 2. Child with stridor and excessive drooling. 3. Adult with an open fracture to the right radius. 4. Child with fever of 103ºF (39.44 °C) and blood streaked sputum.

2. Child with stridor and excessive drooling.

A nurse, who has been assigned to the Emergency Response Team, is beginning to work on the agency's disaster response plan. What would be the nurse's role in this disaster response plan? 1. Perform duties specific to the area of expertise only. 2. Identify the individual in charge of a given client area. 3. Remain alert to potential security issues. 4. Consider ethical conflicts that may impact care. 5. Provide emotional support and make referrals to mental health resources

2. Identify the individual in charge of a given client area. 3. Remain alert to potential security issues. 4. Consider ethical conflicts that may impact care. 5. Provide emotional support and make referrals to mental health resources

Which finding in fetal heart rate during a non-stress test would indicate to the nurse that a potential problem for the fetus may exist? 1. Increases 30 beats per minute for 20 seconds with fetal movement. 2. Increases 8 beats per minute for 10 seconds with fetal movement. 3. Remains unchanged with maternal movement. 4. Increases 5 beats per minute for 30 seconds with maternal movement.

2. Increases 8 beats per minute for 10 seconds with fetal movement.

A newly hired nurse from South America is being oriented to a medical-surgical unit. The hospital recently changed to a digital computer system, including laptop stations in client rooms for documentation. The new nurse resists using the system, indicating the process is "too advanced to learn". What is the most appropriate action by the charge nurse? 1. Report the nurse's refusal to the supervisor for disciplinary action. 2. Have the new nurse shadow staff to observe the computer process. 3. Arrange for nurse to receive special training by education department. 4. Assign only personal care to the nurse until able to use the new system.

3. Arrange for nurse to receive special training by education department.

The nurse is reinforcing proper use of the walker with partial weight-bearing to a client with a total hip arthroplasty. Which action would indicate to the nurse that the client is using the walker correctly? 1. Leaning over the walker. 2. Using a walker with 4 wheels. 3. Elbows positioned at 30 degrees. 4. Lifts the walker when climbing steps.

3. Elbows positioned at 30 degrees.

A client is transported to the emergency department by the police following a sexual assault. What is the nurse's priority intervention? 1. Instruct the client to remove all of her clothes so they can be bagged as evidence. 2. Ask the client to describe what happened . 3. Tell the client she is safe here. 4. Perform a rape kit in order to preserve the evidence .

3. Tell the client she is safe here.

The nurse is caring for four clients. Which client should the nurse see first? You answered this question Correctly 1. The client hospitalized with dehydration related to diarrhea. 2. The seizure client who is currently in the postictal phase. 3. The post-op client who received Morphine 4 mg IV 15 minutes ago. 4. The client who is due pre-op medication now.

3. The post-op client who received Morphine 4 mg IV 15 minutes ago.

A client asks, "I would like to view my medical records." Which response made by the nurse is most appropriate? 1. You will first need to contact your primary healthcare provider. 2. You may view your electronic health records on a weekly basis. 3. You have the right to view the medical records that pertain to your care. 4. You want to view your medical records?

3. You have the right to view the medical records that pertain to your care.

Which client in the emergency department should the nurse identify as being the highest priority? 1. Client with emphysema reporting shortness of breath. 2. Client with a cut on the left calf with moderate bleeding. 3. Client with onset of confusion 1 hour prior to arrival. 4. Client with facial swelling and rash after taking azithromycin.

4. Client with facial swelling and rash after taking azithromycin.

A newly married wife tells the nurse, "I told my husband that I may not know how to cook, but I can sure do the dishes!" Which defense mechanism is the client displaying? 1. Projection 2. Displacement 3. Sublimation 4. Compensation

4. Compensation

A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take? 1. Ask primary healthcare provider for an oral antiemetic. 2. Give ondansetron IVPB with the chemotherapy. 3. Wait until chemotherapy is complete to infuse ondansetron. 4. Stop chemotherapy temporarily and flush line to give ondansetron.

4. Stop chemotherapy temporarily and flush line to give ondansetron.

Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

The nurse is caring for a client with questionable loss of consciousness in the emergency department following a motor vehicle crash. Which action should the nurse take first? You answered this question Correctly 1. Assess airway patency, breathing, and circulation. 2. Assess level of consciousness and movement. 3. Cover wounds with a sterile dressing. 4. Maintain cervical spine immobilization.

1. Assess airway patency, breathing, and circulation.

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? You answered this question Correctly 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

1. 1 mm of Hg

A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse would teach the client that the insulin should start to lower the blood sugar within how many minutes? 1. 15 2. 30 3. 45 4. 90

1. 15

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

1. 3+ pedal edema 4. Purse-lip breathing 5. Pale nail beds

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? You answered this question Correctly 1. A private room on the gynocological unit. 2. A private room on the postpartum unit. 3. Discharge her home as soon as her condition is stable. 4. Room her with another client with a pregnancy loss.

1. A private room on the gynocological unit.

The nurse is caring for a client with cirrhosis of the liver. Which assessment finding would suggest to the nurse that the client is developing hepatic encephalopathy? Select all that apply 1. Asterixis 2. Musty breath odor 3. Aphasia 4. Blood tinged sputum 5. Kussmaul respirations

1. Asterixis 2. Must breath odor

What discharge teaching should the nurse include to the parent of an adolescent who has a mild concussion? Select all that apply 1. Concussion symptoms may last anywhere from hours and days to weeks and months. 2. Return to the emergency department for worsening headache. 3. Monitor for increased intracranial pressure. 4. Avoid physical activities until released from care. 5. Awaken the client every two hours.

1. Concussion symptoms may last anywhere from hours and days to weeks and months. 2. Return to the emergency department for worsening headache. 4. Avoid physical activities until released from care. 5. Awaken the client every two hours.

A client who was diagnosed with amyotropic lateral sclerosis (ALS) has been immobile for 2 weeks. Which of the nursing interventions would the nurse implement? Select all that apply 1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. 5. Encourage a fluid intake of 1500 mL/24 hours.

1. Explore diversional activities 2. Perform range of motion exercises 3. Maintain the feet in dorsiflexion changes 4. Assess pressure points for skin changes

A client has been admitted with a diagnosis of pneumocystis carinii pneumonia (PCP). What initial assessment findings would the nurse expect? (Select All That Apply). Select all that apply 1. Fever 2. Night sweats 3. Hemoptysis 4. Dry cough 5. Dyspnea

1. Fever 4. Dry cough 5. Dyspnea

The nurse is caring for a client admitted with heart failure. Which prescriptions would necessitate that the nurse seek clarification from the primary healthcare provider? Select all that apply 1. Furosemide 20.0 mg p.o. daily 2. Rosuvastatin 5 mg p.o hs 3. Digoxin 0.125 mg IVP every 8 hours for three doses 4. Folic acid 1 mg daily 5. Heparin 1000 IU subcutaneously daily

1. Furosemide 20.0 mg p.o. daily 4. Folic acid 1 mg daily 5. Heparin 1000 IU subcutaneously daily

1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO4 at 3g/hr IV 4. Risperidone .5mg PO daily

The nurse is developing a teaching plan for a female client who is taking one of the thiazolidinediones for the treatment of type 2 diabetes. What instruction should be included in the teaching plan? 1. Make sure that you use effective contraception while taking this drug. 2. The drug may lead to weight loss. 3. Therapeutic effect is reached within one to two weeks. 4. Therapeutic effect is reached within one month.

1. Make sure that you use effective contraception while taking this drug.

A pediatric nurse is providing anticipatory guidance to a group of parents who have children nearing the age of 1 year old. What milestones should the nurse teach the parents to expect to see in their 1 year old child? Select all that apply 1. Gets to a standing position without help. 2. Puts out arm or leg to help with dressing. 3. Able to say several single words. 4. Pulls toys while walking. 5. Builds a tower of 4 blocks.

1. Gets to a standing position without help. 2. Puts out arm or leg to help with dressing.

A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? You answered this question Correctly 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Client report of abdominal pain

1. Dry mucous membranes 2. Fruity-smelling breath 4. Glycosuria 5. Client report of abdominal pain

A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.

1. Meet with the family member and the RN to discuss the disagreement.

A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first? You answered this question Correctly 1. Go to the client to assess for signs and symptoms of decreased cardiac output. 2. Call the primary healthcare provider to report that the client had an episode of VF so medication adjustments can be made. 3. Notify the "on call" person in the cath lab to re-charge the ICD in the event that the client has a recurrence. 4. Document the incident on the code report form and follow up regularly.

1. Go to the client to assess for signs and symptoms of decreased cardiac output.

What strategies for smoking prevention could the school nurse recommend to the community task force? 1. Have a "Pledge Campaign" asking students not to use tobacco. 2. Include effects of smoking in health classes. 3. Enlist help from celebrities who are against smoking. 4. Conduct a "Don't Smoke" poster contest aimed at seventh graders. 5. Start a smoking cessation class for students who currently smoke.

1. Have a "Pledge Campaign" asking students not to use tobacco 2. Include effects of smoking in health classes 3. Enlist help from celebrities who are against smoking 4. Conduct a "Don't Smoke" poster contest aimed at seventh graders

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance would be the nurse's priority concern? 1. Hypomagnesemia 2. Hyponatremia 3. Hyperkalemia 4. Hypercalcemia

1. Hypomagnesemia

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus.

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbant position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

A client on a surgical unit frequently quarrels with the staff. Which nursing intervention should the charge nurse implement? 1. Involve the client in their plan of care. 2. Delegate 2 nurses to work with the client. 3. Accept the client's behavior as confrontational. 4. Encourage the client to be more cooperative.

1. Involve the client in their plan of care.

Which male client condition in the after-hours clinic should the nurse assess first? You answered this question Correctly 1. Scrotal pain and edema. 2. Erection lasting for 2 hours. 3. Inability to void with a history of benign prostatic hyperplasia (BPH). 4. Purulent drainage from the penis.

1. Scrotal pain and edema.

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? You answered this question Correctly 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage

1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform

The out patient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first? 1. The client awaiting repair of hiatal hernia reporting chest pain. 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client with an inguinal hernia repair reporting skin irritation. 4. The client awaiting a hemorrhoidectomy reporting rectal bleeding.

1. The client awaiting repair of hiatal hernia reporting chest pain.

In what order should the emergency department triage nurse send these clients to a room for treatment? Place in priority order. You answered this question Incorrectly The Correct Order Client who has multiple injuries from a motor vehicle accident. Elderly client who fell and fractured the left femoral neck. Client reporting epigastric pain and nausea after eating. Female client stating she has been raped.

correct order

In what order should the nurse assess assigned clients following shift report? Place in priority order. You answered this question Correctly The Correct Order Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Client one day post splenectomy. Client diagnosed with cancer who is crying and states, "I am not ready to die". Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk.

correct order

An 18 month old is admitted to the unit with a diagnosis of pertussis. The mother asks the nurse, "How did my child get this disease? I didn't think anyone got that anymore." What is the appropriate response by the nurse? 1. "Pertussis is a common childhood disease since there is no vaccine." 2. "Since not all children are immunized against pertussis, the disease has reemerged." 3. "Your baby got this disease because you didn't have your child immunized." 4. "Since your child is already sick, let's just focus on getting well."

2. "Since not all children are immunized against pertussis, the disease has reemerged."

A client has been admitted with a diagnosis of sepsis and two sets of blood cultures have been ordered. When the nurse explains the procedure, the client asks the purpose of drawing blood from two different veins at two different times. What is the best response by the nurse? 1. "If we don't get enough blood the first time, we can obtain more." 2. "We want to be sure to get samples of all organisms in your blood." 3. "We have to be certain none of the samples have been contaminated." 4. "It's important not to get too much blood from the arm all at once."

2. "We want to be sure to get samples of all organisms in your blood."

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? You answered this question Incorrectly 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Using alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2. Instituting contact precautions for all who enter the client's room 4. Dedicating equipment for use only in the client's room.

A client is curious about visible appearance changes related to menopause. What menopausal changes, in general, would the nurse explain to the client? 1. Bone loss and fractures. 2. Loss of muscle mass. 3. Improved skin turgor and elasticity. 4. A reduction in waist size.

2. Loss of muscle mass.

Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older client

2. Measuring intake and output 5. Performing oral hygiene for an older client

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? You answered this question Correctly 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Provide positive feedback to the UAP.

Which task would be appropriate for the nurse to assign the unlicensed assistive personnel (UAP)? You answered this question Correctly 1. Assess any pressure ulcers noted on clients. 2. Report if any client indicates pain. 3. Monitor amount of chest tube drainage. 4. Demonstrate coughing and deep breathing exercises to post-op clients.

2. Report if any client indicates pain.

Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery and what the alternative treatments are." What should the nurse do first? You answered this question Correctly 1. Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider. 2. Reinforce that it is not unusual for clients to have questions about surgery. 3. Inform the primary healthcare provider that the client has concerns about the surgery. 4. Use open ended questions to explore client's concerns.

3. Inform the primary healthcare provider that the client has concerns about the surgery.

A client arrives at the emergency room with active gastrointestinal bleeding. What is the most important nursing action? 1. Treat the cause of the bleeding. 2. Record the amount of blood loss. 3. Initiate an intravenous access line. 4. Prepare client for stat endoscopy.

3. Initiate an intravenous access line

A client arrives at the emergency room with active gastrointestinal bleeding. What is the most important nursing action? You answered this question Correctly 1. Treat the cause of the bleeding. 2. Record the amount of blood loss. 3. Initiate an intravenous access line. 4. Prepare client for stat endoscopy.

3. Initiate an intravenous access line.

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

3. Invite staff to contribute ideas on scheduling changes.

How should the nurse document the cardiac rhythm on a client admitted with a diagnosis of syncope? 1. Atrial flutter 2. First degree atrioventricular (AV) block 3. Normal sinus rhythm (NSR) 4. Sinus arrhythmia

3. Normal sinus rhythm (NSR)

While suctioning a client's endotracheal (ET) tube, the nurse notes that the client's heart rate has gone from 78 to 44. The nurse stops suctioning the ET tube. What is the nurse's best action? 1. Deflate the ET tube cuff. 2. Have the client cough several times in a row. 3. Oxygenate the client with 100% oxygen. 4. Notify the primary healthcare provider.

3. Oxygenate the client with 100% oxygen

A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair.

3. Slides walker slowly forward when walking across the room.

A client diagnosed with Addison's disease has been prescribed prednisolone. Which statement by the client indicates that the client's medication instructions for prednisolone have been effective? 1. "I should avoid foods high in protein." 2. "I will take prednisolone in the morning." 3. "I need to schedule an eye examination every 2 years." 4. "Infections will be reduced while taking prednisolone."

2. "I will take prednisolone in the morning."

The nurse is providing care to a client who is post laparoscopic cholecystectomy. Which finding would be of concern? You answered this question Incorrectly 1. Right upper quadrant abdominal discomfort 2. Clay colored stool 3. Light yellow urine 4. Pruritus 5. Icteric sclera

2. Clay colored stool 4. Pruritus 5. Icteric sclera

2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam.

Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? Select all that apply 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 6. Clubbing of fingernails

A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? Select all that apply 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast

2. Grilled cheese with tomatoes 5. Chicken sandwich on wheat toast

A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? 1. Apply ice pack to needle site. 2. Hold pressure on needle site for at least 5 minutes. 3. Observe needle insertion site every 2 hours. 4. Advise client to avoid activities that may result in trauma to the site for 48 hours.

2. Hold pressure on needle site for at least 5 minutes.

What developmental milestone does the nurse expect to see in a two month old baby? Select all that apply 1. Responds to own name. 2. Holds head up. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Turns head towards sound. 6. Reaches for toy with one hand.

2. Holds head up 5. Turns head towards sounds

A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? You answered this question Correctly 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia

2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 6. Hyperphosphatemia

A nurse is caring for a client injured in a motor vehicle accident while driving intoxicated. After hearing that someone was critically injured because of the accident, the client mumbles, "But I only had just a few drinks". What is the most therapeutic statement the nurse could make to the client? 1. "If you only had a few drinks, how did you wreck?" 2. "What do you mean by 'just a few drinks'?" 3. "Tell me what you remember about the accident." 4. "You were driving when the accident happened."

3. Tell me what you remember about the accident

Which assessment finding by the nurse is likely to indicate an increased level of stress in a client? 1. Weight at normal level. 2. Daily experience of headaches and other body aches. 3. Use of the problem solving method to handle daily annoyances. 4. Reports of increased creativity in the job situation.

2. Daily experience of headaches and other body aches.

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

2. Discuss the issue with the leader of the "best practices" committee.

Which nursing interventions will help to prevent a contracture post-operatively in a client with a below the knee amputation? 1. Keep the residual limb elevated on a pillow at all times 2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day 4. Keep head of bed elevated with knees up. 5. Apply anti-embolism stockings to the unaffected leg

2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day

A client who is of the Jehovah's Witness faith presents to the emergency department following a traffic accident. The primary healthcare provider orders a type and cross-match for this client. It is determined that the client will benefit from two units of blood. What should the nurse do? 1. Prepare the client for the administration of blood. 2. Explain to the primary healthcare provider that the client's faith prohibits blood transfusions. 3. Explain to the client that the blood transfusions are needed for return to health. 4. Try to convince the client to accept the transfusions.

2. Explain to the primary healthcare provider that the client's faith prohibits blood transfusions.

Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? Select all that apply 1. Child dying with leukemia who has been on the hematology/oncology unit for two weeks. 2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 4. New admit scheduled for bone marrow transplant. 5. Child diagnosed with leukemia admitted for stomatitis.

2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 5. Child diagnosed with leukemia admitted for stomatitis.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Check client's bony prominences for redness. 2. Monitor client need for suctioning hourly. 3. Explain how to collect 24 hour urine to client. 4. Take a tympanic temperature on client every two hours. 5. Perform postural drainage and chest physiotherapy on client. 6. Report client's pulse oximetry reading every hour.

4. Take a tympanic temperature on client every two hours. 6. Report client's pulse oximetry reading every hour.

The nurse is passing morning medication on a busy medical-surgical unit and has been delayed in completing rounds. When re-evaluating how to distribute the remaining scheduled medications, which client would the nurse consider at greatest risk if medications are late? 1. The client with congestive heart failure receiving digoxin. 2. The client with epilepsy scheduled to receive phenytoin. 3. The client with myasthenia gravis on pyridostigmine. 4. The client with hypertension due for daily nifedipine.

3. The client with myasthenia gravis on pyridostigmine.

The nurse is preparing to educate a client about human papillomavirus (HPV). What information should the nurse include? 1. There is no vaccine to prevent HPV. 2. HPV is the cause of most ovarian cancers. 3. The only way to prevent HPV is refraining from any genital contact with another. 4. HPV is cured by removal of genital warts.

3. The only way to prevent HPV is refraining from any genital contact with another.

The nurse is caring for four clients. Which client should the nurse see first? 1. The client hospitalized with dehydration related to diarrhea. 2. The seizure client who is currently in the postictal phase. 3. The post-op client who received Morphine 4 mg IV 15 minutes ago. 4. The client who is due pre-op medication now.

3. The post-op client who received Morphine 4 mg IV 15 minutes ago.

The community health nurse plans to educate a client diagnosed with tuberculosis (TB) how to avoid spreading the disease to others. What should the nurse include when educating this client? 1. Wear a N95 respirator when around family at home. 2. Have adult family members get the TB vaccine. 3. Complete TB medication regimen. 4. Live at a sanatorium until cured of TB.

3. Complete TB medication regimen

The community health nurse plans to educate a client diagnosed with tuberculosis (TB) how to avoid spreading the disease to others. What should the nurse include when educating this client? You answered this question Incorrectly 1. Wear a N95 respirator when around family at home. 2. Have adult family members get the TB vaccine. 3. Complete TB medication regimen. 4. Live at a sanatorium until cured of TB.

3. Complete TB medication regimen.

A home care nurse is assessing a client with a forearm cast recently applied for a displaced radial fracture. What client comment should the nurse consider the priority concern? 1. "The cast feels tight on my arm." 2. "There is an odd smell inside my cast." 3. "I can't open up my fingers this morning." 4. "The pain medicine is not relieving my pain."

3. "I can't open up my fingers this morning."

3. "Tell me what you remember about the accident."

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better."

3. "Unexpected changes can be difficult to accept."

What should the nurse tell a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors."

3. "We need to let your primary health care provider know because it may indicate a problem."

The client, who recently started college, tells the nurse, "I am having trouble studying for my tests. Every time I try to study, my mind begins to wander." What is the nurse's best response? 1. "Stop making excuses and make a study schedule you will follow." 2. "I wouldn't worry. You are smart enough to pass college." 3. "You are having difficulty concentrating?" 4. "What do you mean you can't study?"

3. "You are having difficulty concentrating?"

A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 1. Apply oxygen by mask at 1 liter. 2. Prepare for emergency intubation. 3. Continue monitoring every 15 minutes. 4. Notify the primary healthcare provider stat.

3. Continue monitoring every 15 minutes.

The nurse is assessing a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time? 1. Blood glucose level 2. Ankles for edema 3. Twenty-four hour diet recall 4. Confirmation of last menstrual period

3. Twenty-four hour diet recall

The nurse has received the change-of-shift report. What client should the nurse assess first? You answered this question Correctly 1. A client with fibromyalgia reporting generalized pain of 7 out of 10. 2. A client diagnosed with rheumatoid arthritis needing discharge teaching. 3. A client with a fractured right humerus who reports the cast is too tight. 4. A client with an above the knee amputation reporting phantom pain.

3. A client with a fractured right humerus who reports the cast is too tight.

A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.

3. Absolute neutrophil count of 400/mm3 in a child with fever.

A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological

3. Airway

3. Arrange for nurse to receive special training by education department.

A newly hired nurse from South America is being oriented to a medical-surgical unit. The hospital recently changed to a digital computer system, including laptop stations in client rooms for documentation. The new nurse resists using the system, indicating the process is "too advanced to learn". What is the most appropriate action by the charge nurse? You answered this question Incorrectly 1. Report the nurse's refusal to the supervisor for disciplinary action. 2. Have the new nurse shadow staff to observe the computer process. 3. Arrange for nurse to receive special training by education department. 4. Assign only personal care to the nurse until able to use the new system.

3. Arrange for nurse to receive special training by education department.

The nurse is teaching a pregnant teenage client about resources available through the health department. The client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say? 1. What does the baby's father think about an abortion? 2. I know this is a difficult decision. 3. What are your thoughts about abortion? 4. There are many options other than abortion.

3. What are your thoughts about abortion?

A nurse is to administer a time release capsule to a client who has difficulty swallowing. Which intervention would be the best course of action for the nurse to take? 1. Open the capsule and sprinkle it on applesauce. 2. Melt the capsule in juice or water. 3. Call the primary healthcare provider to change the order. 4. Break the capsule in half using a pill splitter.

3. Call the primary healthcare provider to change the order.

Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response? 1. Elevate the head of the client's bed. 2. Start giving the client 8 ounces of oral fluid per hour. 3. Check circulation and take the vital signs of the client. 4. Continue monitoring, because this is an expected finding.

3. Check circulation and take the vital signs of the client.

What information should the nurse include when providing community teaching on burn prevention strategies? Select all that apply 1. Have chimney professionally inspected every 5 years. 2. Microwave a baby bottle rather than heating on the stove. 3. Clean the lint trap on the clothes dryer after each use. 4. Keep anything that can burn at least 3 feet (0.91 meters) away from space heaters. 5. Hold a hot beverage or hold a child, not both at the same time. 6. Home hot water heater should be set at a maximum of 120°F (48.8°C).

3. Clean the lint trap on the clothes dryer after each use. 4. Keep anything that can burn at least 3 feet (0.91 meters) away from space heaters. 5. Hold a hot beverage or hold a child, not both at the same time. 6. Home hot water heater should be set at a maximum of 120°F (48.8°C).

Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans

3. Yogurt

While preparing an information sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.

4. Clean the bathroom and kitchen with warm water and bleach

A child weighing 75 lbs. (34.1 kg) is admitted to the unit with a diagnosis of bacterial meningitis. The child has been started on an IV of D5 NS at 100 mL per hour and IV antibiotic therapy has been initiated. Which assessment finding would need to be reported immediately to the healthcare provider? 1. Urinary output of 28 mL/hr. 2. Change in the level of consciousness. 3. Temperature of 101.2 degrees F (38.4 degrees C). 4. Increase of 5 mm Hg in systolic BP from baseline. 5. Sodium level of 130 mEq/L (130 mmol/L).

1,2,5

A tour bus is involved in an accident, sending several clients to the emergency room for treatment. An unconscious client with multiple internal injuries requires immediate surgery. When itemizing the client's belongings, the nurse finds a wallet containing four thousand dollars. What is the appropriate method for the nurse to secure the money? You answered this question Correctly 1. Place wallet inside client's pants and then in belongings bag. 2. Secure the money in an envelope in the E.R. narcotics drawer. 3. Sign money over to the hospital CEO until client is discharged. 4. Tally cash with 2nd nurse, document and lock in hospital safe.

4. Tally cash with 2nd nurse, document and lock in hospital safe.

A home health nurse is planning home safety education for a client and spouse. Which actions should be included to promote fire safety in the home setting? You answered this question Correctly 1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and a place where all family members will meet.

1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 5. Have a planned route of exit and a place where all family members will meet.

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? You answered this question Incorrectly 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.

3. Rate the client's pain using the pain scale used in the ED.

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client.

3. Research established protocols utilized by emergency groups 4. Discuss best communication methods with client and family

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container

The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.

1. Call the supervisor and inform of the possibility of contamination in the surrounding space 3. Call personnel trained in containment and decontamination immediately

The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? You answered this question Correctly 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.

1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 3. Call personnel trained in containment and decontamination immediately.

The nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The high-pressure alarm begins sounding. What actions should the nurse initiate? 1. Check to see if client is biting ET tube. 2. Examine tubing for presence of water. 3. Inspect for any loose connections. 4. Reduce the amount of PEEP used. 5. Assess client's need for suctioning.

1. Check to see if client is biting ET tube 2. Examine tubing for presence of water 5. Assess client's need for suctioning

A client has been admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis. The primary healthcare provider writes prescriptions based on the lab values. The nurse would monitor the effectiveness of medications by observing for what specific neurologic changes in the client? Labs: Sodium - 129 meq/dl Potassium - 3.0 meq/L Albumin - 2.0 gm/dl Ammonia - 80 mcg/dl Bilirubin - 2.0 gm/dl BUN - 32mg/dl Creatinine - 2.0 mg/dl BP - 100/60 pulse - 110 RR - 28 Meds: Furosemide (Lasix) 60 mg IV Every 12 hours Lactulose 30 mg by mouth Every 4 hours K-Dur40 meq by mouth Twice daily Albumin 25%100 mL IV Twice daily 1. Increased urination and improved memory. 2. Increased blood pressure and lower pulse. 3. Frequent diarrhea with orientation x three. 4. Clear speech and +2 pitting edema to BLE.

3. Frequent diarrhea with orientation x three.

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Chronic fatigue syndrome who has had no relief of fatigue.

All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? You answered this question Correctly 1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour. 2. One hour postpartum client with a continuous trickle of vaginal bleeding. 3. 2 hours postpartum client reporting intense perineal pain. 4. Client at 36 weeks gestation with a blood pressure of 148/92.

1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour.

A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? 1. Rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures. 2. Rubella is the most common cause of meningitis and acquired deafness. 3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect. 4. Rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis or meningitis and can lead to death.

3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect.

Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Which client can be assigned to the LPN? 1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 3. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 4. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

Which client would be appropriate for the RN to assign to the LPN? Select all that apply 1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client one day post kidney transplant. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis.

1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which finding would indicate the need to increase the irrigation rate? 1. Clots in urine 2. Unable to palpate bladder 3. Slightly pink tinged urine 4. No report of bladder spasms

1. Clots in urine

The nurse is caring for a client post hysterectomy. Based on data obtained from the nurse's notes, what should be the nurse's initial response? 0900: Client received to post-anesthesia unit after hysterectomy. Easily aroused. BP 128/72, respirations 18, heart rate 90, skin warm and dry. 1100: Lethargic, Vital signs are BP 100/68, respirations 24, heart rate 102, skin cool and moist. 1. Retake the vital signs. 2. Administer the ordered dopamine to maintain a blood pressure of 110 systolic. 3. Increase the IV rate of the lactated ringer's solution. 4. Raise the head of the bed to 30 degrees.

3. Increase the IV rate of the lactated ringer's solution.

The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care? You answered this question Correctly 1. Identify a new goal for the client since this one has not been achieved. 2. Consider new nursing interventions for achievement of the goal if the condition still warrants it. 3. Determine that the nursing interventions were performed as planned. 4. Allow more time for achievement of the goal.

3. Determine that the nursing interventions were performed as planned.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

3. Disconnect client's nasogastric (NG) tube suction to allow ambulation.

The nurse manager is presenting a seminar on HIPAA regulations to a group of newly hired graduates. When discussing the most common cause of violating client privacy, the nurse knows teaching was successful when the graduates select what situation? 1. Failure to cover client fully during a bed bath. 2. Leaving chart open in full view when at the desk. 3. Discussing client with staff not providing direct care. 4. Healthcare provider not pulling curtain to talk to client.

3. Discussing client with staff not providing direct care.

4 tabs

A client arrives at the emergency room with 20% partial thickness burns to bilateral lower extremities following a grass fire. Prior to the arrival of the ambulance, friends had soaked the client's legs in cold water for pain relief. The client is now requesting more cold water on legs because of intense pain. What statement by the nurse would be mostaccurate? 1. "I can soak some towels in water to place on your legs." 2. "I will call the doctor to ask for an order to use wet gauze." 3. "I need to finish my nursing assessment first before treatment." 4. "I must cover your legs with dry gauze to prevent complications."

4. "I must cover your legs with dry gauze to prevent complications."

A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease? 1. "I can be treated and then no one else is at risk." 2. "Using condoms will keep my sex partner from acquiring the disease." 3. "If I have no sores, I am not contagious to anyone." 4. "My sex partner should be tested because we have not always used condoms."

4. "My sex partner should be tested because we have not always used condoms."

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? 1. "The medication permits safe breastfeeding after delivery." 2. "It protects you against other infections during pregnancy." 3. "This drug prevents transmission of HIV to your partner." 4. "ZDV decreases the chance the baby will contract HIV."

4. "ZDV decreases the chance the baby will contract HIV."

An unresponsive client with a respiratory rate of 14/min arrives at the emergency department after attempting suicide in a running car with the garage door closed. What action should the nurse perform FIRST? 1. Connect to an O2 saturation monitor. 2. Hyperventilate with an ambu bag. 3. Notify the xray department for a ventilation/perfusion scan of the lungs. 4. Administer 100% O2 per nonrebreather mask.

4. Administer 100% O2 per nonrebreather mask.

The morning assessment of a client admitted with congestive heart failure reveals a weight gain of 2.5 pounds (1.14 kg) since the previous day, crackles in lung fields bilaterally, dyspnea, sacral edema, and bounding peripheral pulses. Which prescription by the healthcare provider should be the nurse's priority? 1. Maintain accurate intake and output. 2. Restrict sodium in the diet. 3. Limit fluids to 1500 mL per day. 4. Administer furosemide 40 mg IV push.

4. Administer furosemide 40 mg IV push.

During evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be delegated to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider 4. Begin oxygenating the client.

4. Beging oxygenating the client

The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. What action should the nurse implement first to ensure client safety? 1. Take report on the most critical clients first. 2. Encourage the staff to help each other. 3. Assign one additional client to each nurse. 4. Call the nursing supervisor to request additional staff immediately.

4. Call the nursing supervisor to request additional staff immediately.

The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? 1. Keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 93%. 2. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. 3. Let the client sleep until he has rested, then discuss abuse potential of narcotics. 4. Call the primary healthcare provider and report client assessment findings.

4. Call the primary healthcare provider and report client assessment findings

Which client with a heat-related illness should the emergency room nurse provide attention to first? You answered this question Correctly 1. Elderly person with reports of dizziness and syncope following working in the yard in the sun for several hours. 2. Football player who was at summer practice and developed severe leg cramps, nausea, tachycardia, and diaphoresis. 3. Low income individual who reports that the power has been turned off and has not had air conditioning for several days and who is experiencing increased respiratory rate, fatigue, extreme diaphoresis, and hypotension. 4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? 1. Restricting oral fluids until the gag reflex has returned. 2. Encouraging early ambulation and deep breathing exercises. 3. Discontinuing medicines following percutaneous intervention. 4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.

4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.

Which finding should take priority when the nurse is assessing the skin of a client diagnosed with diabetes? 1. Vitiligo of the chest. 2. Scleroderma to scapula and posterior neck region. 3. Redness of face and upper chest. 4. Small abrasion on great toe.

4. Small abrasion on great toe.

What should the summer camp nurse include when teaching a group of adolescents about West Nile Virus? 1. Antiviral medications are used to treat West Nile Virus. 2. Using insect repellent containing diethyltoluamide (DEET) will kill the virus when a mosquito makes skin contact. 3. Nothing can be done to prevent West Nile Virus. 4. Symptoms of West Nile Virus include headache, fever, and fatigue

4. Symptoms of West Nile Virus include headache, fever, and fatigue

4. Take a tympanic temperature on client every two hours. 6. Report client's pulse oximetry reading every hour.

How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

An injured client brought to the emergency room by ambulance insists on leaving before being seen by the primary healthcare provider. What is the nurse's priority action? 1. Explain potential risks of leaving without proper care. 2. Insist the client sign "Against Medical Advice" form. 3. Calmly convince client to wait for needed treatment. 4. Notify primary healthcare provider immediately.

4. Notify primary healthcare provider immediately.

What discharge instructions should the nurse provide to the parents of a child diagnosed with sickle cell anemia? Select all that apply 1. Provide high-calorie, low protein diet. 2. Inheritance is by autosomal dominate genes. 3. Restrict all activities for 3 months. 4. Deferasirox helps prevent liver damage from iron deposits. 5. Avoid high altitudes.

4. Deferasirox helps prevent liver damage from iron deposits. 5. Avoid high altitudes.

Immediately following the birth of an infant, what is the nurse's priority action when caring for the newborn? 1. Examine the infant and take a set of vitals. 2. Confirm identification and apply arm band. 3. Instill silver nitrate solution into both eyes. 4. Dry infant and place in warm environment.

4. Dry infant and place in warm environment.

An unlicensed assistive personal (UAP) has been floated to the emergency department (ED) because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the charge nurse could assign? 1. Clean and restock exam rooms after client discharge. 2. Follow another UAP who has worked there previously. 3. Sit at the reception desk and answer incoming calls. 4. Escort clients from the ED to other areas for tests.

4. Escort clients from the ED to other areas for tests.

A nurse has been assigned to care for five clients. In what order should the nurse assess these clients after shift report? Place in priority order from highest to lowest priority. Client hospitalized to rule out abdominal aortic aneurysm who is reporting deep, aching pain in the flank area. Client whose BP is reported by the UAP to be 200/102 at present. Client diagnosed with an arterial ulcer to the right leg who reports pain of 8/10. Client with Buerger's disease reporting numbness, tingling and cold in toes. Client diagnosed with peripheral vascular disease requesting information on smoking cessation.

Correct Order

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority.

Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report.

In what order should the nurse assess assigned clients following shift report? Place in priority order.

elderly client admitted 30 minutes ago with reports of constipation for four days. client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. client diagnosed with Crohn's disease who had three semi-formed stools over the past shift.

While in the emergency department, a 68 year old client being treated for flu symptoms, became symptomatic with an episode of atrial tachycardia which was successfully treated with cardioversion. After stabilization, the client was admitted to the telemetry unit with a diagnosis of the flu, and a history of angina. Primary healthcare provider prescriptions were received. What is most important for the nurse to ensure prior to administering Peramivir? 1. Creatinine clearance is greater than 50 mL/min. 2. Pulse greater than 70 beats/min. 3. Cardiac rhythm showing normal sinus rhythm. 4. Oral temperature less than 101° F (38.3° C)

1. Creatinine clearance is greater than 50 mL/min.

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? Select all that apply 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

1. Diabetes mellitus 2. Hypertension 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

A client diagnosed with confusion and dehydration is admitted to the medical unit. The RN is working with an LPN and an unlicensed assistive personnel (UAP). Which tasks would be best for the RN to assign to the LPN? 1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family 3. Maintain fluids at bedside 4. Assess I & O for adequate fluid replacement 5. Obtain daily weights

1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family

A client diagnosed with confusion and dehydration is admitted to the medical unit. The RN is working with an LPN and an unlicensed assistive personnel (UAP). Which tasks would be best for the RN to assign to the LPN? You answered this question Correctly 1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family 3. Maintain fluids at bedside 4. Assess I & O for adequate fluid replacement 5. Obtain daily weights

1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1. Monitor for contractures. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 6. Refer to physical therapist.

A nurse is planning to conduct primary prevention classes in a local community. Which initiatives should the nurse include? 1. Parenting classes for first time parents 2. Healthy diet classes for school-age children 3. Breast self-examination classes 4. Cardiac rehabilitation classes 5. Community exercise classes to promote weight loss

1. Parenting classes for first time parents 2. Healthy diet classes for school-age children 5. Community exercise classes to promote weight loss

The nurse is caring for a client admitted with a diagnosis of pheochromocytoma. What sign/symptom does the nurse expect during an acute episode? 1. Profuse sweating 2. Hypertension 3. Hypoglycemia 4. Tachycardia 5. Palpitations

1. Profuse sweating 2. Hypertension 4. Tachycardia 5. Palpitations

A client has been admitted with a stroke on the left side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? Select all that apply 1. Right sided hemiplegia 2. Impaired judgment 3. Depression 4. Impaired language comprehension 5. Impulsiveness 6. Impaired speech

1. Right sided hemiplegia 3. Depression 4. Impaired language comprehension 6. Impaired speech

A non-English speaking client arrives in the emergency room with a 2 inch head laceration. The nurse attempts to complete the assessment but is unable to understand information provided by client or family. The facility interpreter lives several hours away; however, a UAP is available and willing to help translate. The nurse should be mostconcerned about what situation? You answered this question Incorrectly 1. The UAP is not trained to interpret medical terminology for a client. 2. The facility translator is best qualified, but waiting causes delay of treatment. 3. Obtaining consent through an unofficial interpreter is not considered legal. 4. The UAP is not providing direct care, which violates HIPAA privacy regulations.

1. The UAP is not trained to interpret medical terminology for a client.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.

1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction.

The primary healthcare provider has prescribed KCL 20 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.

12.5

The nurse is providing medication teaching to a client starting psyllium. What comment by the client indicates the teaching has been successful? 1. "I should take this medication just before bedtime." 2. "I need to drink large amounts of water with this drug." 3. "I might need to take as many as six doses every day." 4. "I should not eat or drink for two hours after the pill."

2. "I need to drink large amounts of water with this drug."

The nurse is caring for a client taking lithium. Which comment by the client indicates lack of understanding of the therapeutic regimen? 1. "I must keep my sodium intake steady over time. " 2. "If I miss a dose of lithium, I should make it up with the next dose." 3. "I must check with my primary healthcare provider before changing my diet for weight loss." 4. "I must keep my exercise routine the same or discuss with my primary healthcare provider. "

2. "If I miss a dose of lithium, I should make it up with the next dose."

A client hospitalized with a deep vein thrombosis (DVT) is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the best explanation for the nurse to provide to the client? 1. "The medicine might make your blood much too thin." 2. "It helps us monitor and adjust the dose to work better." 3. "It is required for anyone getting heparin intravenously." 4. "The test results tell us whether the treatment is working."

2. "It helps us monitor and adjust the dose to work better."

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? You answered this question Correctly 1. Consult with the primary healthcare provider. 2. Assess the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

2. Assess the client. 5. Utilize a pain scale to determine level of pain.

A child diagnosed with gastroenteritis is being given fluids in the emergency room for severe dehydration. Prior to discharge, the nurse instructs the mother how to prepare a BRATT diet. The nurse knows the teaching was successful when the mother selects what foods for the child? Select all that apply 1. Raisins 2. Bananas 3. Apples 4. Toast 5. Rice 6. Tea

2. Bananas 4. Toast 5. Rice 6. Tea

2. Providing care for abused women in a shelter

What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury? You answered this question Correctly 1. Increased pulse 2. Rhinorrhea 3. BP 150/60 4. Papilledema 5. Projectile vomiting

2. Rhinorrhea 3. BP 150/60 4. Papilledema 5. Projectile vomiting

A primagravida asks the nurse about the purpose of the RhoGam injection. What would be the best explanation by the nurse? 1. RhoGam changes the RH positive fetus to Rh negative. 2. RhoGam prevents the mother from forming Rh antibodies. 3. RhoGam inhibits Rh antibodies in the newborn infant. 4. RhoGam destroys antibodies in the RH positive mother.

2. RhoGam prevents the mother from forming Rh antibodies.

Who often performs the responsibilities of a case manager? 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel

2. Social worker 4. Nurse

A client who has had a stroke presents with lethargy, facial droop, and slurred speech. The client has a history of gastroesophageal reflux disease (GERD). From this history, what does the nurse recognize as an increased risk for this client? 1. Diminished colonic motility 2. Esophageal hemorrhage 3. Aspiration pneumonia 4. Stress ulcers

3. Aspiration pneumonia

The RN, LPN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? You answered this question Incorrectly 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling the primary healthcare provider about lab results. 5. Teaching the diabetic client foot care.

3. Assessment of newly admitted clients. 5. Teaching the diabetic client foot care.

3. Discussing client with staff not providing direct care.

he nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.

3. Document the findings.

3. Performing bathing and oral care for the client

A homecare client with terminal cancer is taking morphine sulfate and reports the current dose is no longer relieving the pain. What would the nurse tell the client about the increased discomfort? 1. The pain medication will need to be taken consistently around the clock. 2. A different pain medication will need to be prescribed since addiction has occurred. 3. As the cancer spreads, the pain medication will no longer help. 4. A tolerance to the current dose has occurred, so the dose will need to be increased.

4. A tolerance to the current dose has occurred, so the dose will need to be increased.

The emergency room nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? 1. Position client on the left side. 2. Apply warm blankets to legs. 3. Administer I.M. pain medication. 4. Alert the operating room staff. 5. Notify the primary healthcare provider. 6. Palpate mass to determine size.

4. Alert the operating room staff 5. Notify the primary healthcare provider

During client care rounds, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client. The primary healthcare provider writes the prescription. Which statement best describes this process? 1. Collaboration with the ancillary care providers. 2. Collaboration between the primary healthcare provider and the dietician. 3. Collaboration with the risk management team. 4. Collaboration among members of the multi-disciplinary team.

4. Collaboration among members of the multi-disciplinary team.

A client has been started on intravenous gentamicin for osteomyelitis. The nurse informs the client frequent blood work will be done to monitor the amount of medication in the body. The nurse knows what labs are a priority to check every three days for the client? 1. BUN and creatinine. 2. Liver function studies. 3. Hemoglobin and hematocrit. 4. Peak and trough levels.

4. Peak and trough levels.

Which client should the nurse see first? 1. 53 year old client with chest pain scheduled for a stress test today 2. 62 year old client with mild shortness of breath and chronic obstructive pulmonary disease 3. 66 year old client with angina scheduled for a cardiac catheterization this AM 4. 78 year old client who had a left hemispheric stroke 4 days ago

1. 53 year old client with chest pain scheduled for a stress test today

After receiving report from the previous shift nurse, Which client should the nurse assess first? 1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness. 2. Client diagnosed with dementia who needs assistance with ambulating. 3. Client with a halo device requesting to be transferred to the bedside chair. 4. Client diagnosed with a traumatic brain injury who cannot recall portions of the accident.

1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness.

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

The nurse, caring for a client who has terminal cancer, finds that the client is extremely restless. In response to this data, what would be the appropriate nursing action? 1. Play soothing music. 2. Use chamomile aromatherapy. 3. Place soft restraints on arms. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.

1. Play soothing music 2. Use chamomile aromatherapy 4. Dim room lights 5. Keep conversations quiet 6. Massage forehead

The nurse is planning care for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). What should the nurse recognize as the child's likely view of this illness in order to properly plan care? 1. Punishment 2. Disturbance to body image 3. Rejection from parents 4. Change in routine with friends

1. Punishment

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.

3. Assist the client into a supine position in bed.

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? 1. Anger 2. Acceptance 3. Bargaining 4. Depression

3. Bargaining

An adult client's parent, who is a physician, comes to the nurse's station and requests the client's chart. The physician is not the client's primary healthcare provider but is employed by the hospital. What action should the nurse take? 1. Provide the physician with the chart. 2. Ask the primary healthcare provider to consult the physician in the client's care. 3. Explain to the physician why access to the chart cannot be provided. 4. Obtain verbal permission from the client for the physician to view the chart.

3. Explain to the physician why access to the chart cannot be provided.

The nurse initiated teaching for a client newly diagnosed with hypertension. What comments by the client indicate to the nurse that teaching has been successful? 1. "I have to take my medications on time every morning." 2. "One glass of wine with dinner would be acceptable." 3. "I will eliminate sodium from my daily food intake." 4. "Stress-reduction techniques can lower my pressure." 5. "Walking once a week is good exercise for me." 6. "I should add more fresh fruits and vegetables to my diet."

1. "I have to take my medications on time every morning." 2. "One glass of wine with dinner would be acceptable." 4. "Stress-reduction techniques can lower my pressure." 6. "I should add more fresh fruits and vegetables to my diet."

Following a large hurricane, multiple clients arrive at the emergency room for treatment. The charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned to an LPN? 1. Child with superficial burns on both upper arms. 2. Adolescent with bruising to left upper quadrant. 3. Crying toddler missing both upper front teeth. 4. Adult reporting headache and blurred vision. 5. Elderly adult reporting nausea and heartburn.

1. Child with superficial burns on both upper arms. 3. Crying toddler missing both upper front teeth.

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room? 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. Gown 2. Gloves

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which instruction is most important for this client? You answered this question Correctly 1. Do postural drainage just before meals. 2. Consume fluids only at meal times. 3. Prepare meals high in carbohydrates. 4. Plan rest periods before and after meals.

4. Plan rest periods before and after meals.

Which clients can the nurse assign to the same room? Select all that apply 1. A 48 year old female one day postoperative appendectomy and a 30 year old female with nephrolithiasis 2. A 41 year old male with nausea, vomiting, and diarrhea and a 62 year old male with neutropenia 3. A 41 year old male with Methicillin-resistant Staphylococcus aureus (MRSA) infection and a 42 year old male with Clostridium difficile 4. A 14 year old two days postoperative splenectomy and an 80 year old female with Parkinson's disease 5. A 57 year old female with chronic obstructive pulmonary disease (COPD) and an 68 year old female with asthma

1. A 48 year old female one day postoperative appendectomy and a 30 year old female with nephrolithiasis 5. A 57 year old female with chronic obstructive pulmonary disease (COPD) and an 68 year old female with asthma

The nurse leader is planning to change the method of client documentation on the unit. Some employees accept the change without difficulty; however, some of the employees are resistant to change and try to sabotage the plans for change. Which action should the nurse leader take to reduce resistance to change on the unit? You answered this question Correctly 1. Allow staff on the unit a voice in the plan for change. 2. Discourage discussion between supporters and resisters. 3. Set an implementation date and begin the new method. 4. Announce that the plan for change is set by administration.

1. Allow staff on the unit a voice in the plan for change.

1. Child with superficial burns on both upper arms. 3. Crying toddler missing both upper front teeth.

Which client would be appropriate for the RN to assign to the LPN? 1. Client scheduled for an MRI of the kidneys. 2. Client requiring administration of antineoplastic medications. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 4. Client post ileal conduit surgery this AM without drainage in the drainage bag. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.

1. Client scheduled for an MRI of the kidneys. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.

The home health nurse is assessing the home environment for threats to the safety of the toddler who lives in the home. Which observations should be included in this assessment? Select all that apply 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit?

1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach?

An emergency room nurse is assessing a child with a suspicious spiral fracture to the right arm. The nurse is aware the best evidence to support possible child abuse is what? 1. Inconsistency between injury and explanation of the cause. 2. Child withdraws when the parent tries to hug or comfort. 3. Parents leave the room when questioned about the injury. 4. Lack of parental concern with injury or pending treatment.

1. Inconsistency between injury and explanation of the cause.

An experienced RN and LPN are working with a new nurse who has just recently passed NCLEX®. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor is most important for consideration when delegating? 1. Lack of experience of the new nurse. 2. The preferences of the LPN who has experience. 3. RN's desire to avoid confrontation. 4. Assignment of equal number of clients to the RN, LPN and new nurse.

1. Lack of experience of the new nurse.

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1. Prepare a client's room for return from surgery. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube.

A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? Select all that apply 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm

1. Right sided mastectomy 3. Negative Allen's test 5. Presence of A-V shunt to right forearm

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1. Some clients may have dental issues, making chewing difficult 2. There may be a decreased appetite in clients 3. Caloric and nutritional needs may vary somewhat depending on activity levels

A nurse is planning an educational session on safety for parents of young children. What safety points should the nurse include? Select all that apply 1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present. 5. Vitamins should be referred to as candy so that children will take them. 6. A child at age 7 may sit in the front seat of a car.

1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present.

A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision? 1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. 2. The charge nurses do that to everyone. It can be annoying sometimes, wwhen they ask about your client care. 3. Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention. 4. You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.

1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments.

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Using alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2. Instituting contact precautions for all who enter the client's room 4. Dedicating equipment for use only in the client's room

The nurse, assessing the lung sounds of a client diagnosed with pneumonia, notes diminished lung sounds and dull percussion in the lower lungs bilaterally. What intervention is correct by the nurse? 1. Place the client in a left lateral recumbent position. 2. Instruct the client to perform incentive spirometry every hour. 3. Encourage the client to increase fluid intake of at least 50 mL/ hour. 4. Have the client use the bedpan to avoid overexertion and exacerbation of symptoms.

2. Instruct the client to perform incentive spirometry every hour.

What teaching points should the nurse include when educating a client how to prevent a venous stasis ulcer? You answered this question Correctly 1. Elevate legs above heart for 5 minutes, twice a day. 2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Treat itching with prescribed topical corticosteroids. 5. Minimize stationary standing.

2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Treat itching with prescribed topical corticosteroids. 5. Minimize stationary standing.

A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what measures will the nurse include in the client's initial plan of care? 1. Approach the client from his left side. 2. Place the client's meal on the right side of the over bed table. 3. Request a consult for an ophthalmologist. 4. Stand directly in front of the client when addressing. 5. Have client look at the left side of the body.

2. Place the client's meal on the right side of the over bed table 5. have client look at the left side of the body

The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? 1. Design a booklet for school districts on handling aggression. 2. Survey students to determine attitudes towards weapons. 3. Provide information on anger management to grade schools. 4. Investigate existing safety procedures in the schools.

2. Survey students to determine attitudes towards weapons.

What should the nurse emphasize when teaching clients how to decrease the risk of chronic obstructive pulmonary disease? 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals. 5. Get a yearly influenza and pneumococcal vaccination.

3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals.

What should the nurse emphasize when teaching clients how to decrease the risk of chronic obstructive pulmonary disease? Select all that apply 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals. 5. Get a yearly influenza and pneumococcal vaccination.

3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals.

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome? 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

3. Foamy urine 4. Periorbital edema

The nurse is caring for a female client who is at risk for renal failure. The nurse has completed the initial assessment of the most recent lab results so that any concerns can be reported to the primary healthcare provider. Which assessment finding warrants further action? 1. Hemoglobin of 12 g/dl (120 g/L) 2. Hematocrit of 38% (0.38) 3. Potassium levels of 5.2mEq/L (5.2 mmol/L) 4. BUN of 15 mg/dl. (5.35 mmol/L)

3. Potassium levels of 5.2mEq/L (5.2 mmol/L)

The nurse is caring for a client undergoing electroconvulsive therapy (ECT) for major depression. What is the nurse's most important intervention during the treatment? 1. Monitor vital signs and cardiac functioning. 2. Provide support to the client's arms and legs. 3. Provide suctioning as needed. 4. Place electrodes on temples.

3. Provide suctioning as needed.

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? Select all that apply 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client.

3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family.

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

3. Restrict any visitors with visible illnesses.

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. Ambulate in the room 2. Perform crede' exercises 3. Reassess the fundus in 30 minutes. 4. Massage the fundus.

4. Massage the fundus

After a heart catheterization a client reports severe foot pain on the side of the femoral insertion site. The nurse notes pulselessness, pallor, and a cold extremity. What should be the nurse's first action? You answered this question Correctly 1. Administer an anticoagulant. 2. Warm the room. 3. Increase intravenous fluids. 4. Notify the primary healthcare provider.

4. Notify the primary healthcare provider.

A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? You answered this question Correctly 1. Inspect the catheter tubing for obstruction. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.

4. Stop the irrigation flow.

In what order should the nurse assess assigned clients following shift report? Place in priority order.

client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). client who is one day post splenectomy. client diagnosed with cancer who is crying and states, "I am not ready to die" client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? 1. Blank affect. 2. Decreased ability to swing arms. 3. Waddling gait. 4. Walking on toes. 5. Pill-rolling tremor. 6. Stiff muscles.

1. Blank affect. 2. Decreased ability to swing arms. 5. Pill-rolling tremor. 6. Stiff muscles.

When teaching a client about lactose intolerance, what should the nurse include? 1. Common symptoms of lactose intolerance include abdominal bloating, diarrhea, and gas. 2. Symptoms of lactose intolerance generally occur three hours after consuming foods high in lactose. 3. Calcium rich foods should be consumed. 4. The client can drink lactose-free milk. 5. Vitamin D foods should be increased in the diet.

1. Common symptoms of lactose intolerance include abdominal bloating, diarrhea, and gas 3. Calcium rich foods should be consumed 4. The client can drink lactose-free milk 5. Vitamin D foods should be increased in the diet

Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Demonstrate post operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.

3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the unlicensed assistive personnel (UAP)? 1. Obtain a urine sample from an infant. 2. Empty a nasogastric (NG) canister for client with ileus. 3. Feed a child with bilateral burns of hands. 4. Change an ostomy appliance on child with stoma. 5. Ambulate an adolescent two days post appendectomy.

3. Feed a child with bilateral burns of hands. 5. Ambulate an adolescent two days post appendectomy.

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

3. Gather and apply dressings to open wounds.

3. Have an LPN/VN perform collect data on the client and report results to RN.

Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in intracranial pressure (ICP). What is the nurse's priority action? 1. Position client on the right side. 2. Call the primary healthcare provider. 3. Lower the head of the bed immediately. 4. Hyperventilate client with a bag valve mask.

4. Hyperventilate client with a bag valve mask

A client with a history of syncope and transient arrhythmias has been ordered a Holter monitor for 48 hours. The nurse knows that teaching has been effective when the client makes what statement? 1. No follow up care will be needed after the monitor is removed. 2. It is okay to shower or bath while wearing this equipment. 3. I have to take it easy and not exercise for the next two days. 4. It's important to write down all my activities during this time.

4. It's important to write down all my activities during this time.

A client diagnosed with renal failure has been admitted to the medical unit. An arterial blood gas (ABG) analysis has been prescribed by the primary healthcare provider. Which ABG interpretation by the nurse is appropriate? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogastric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1. Prepare a client's room for return from surgery. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube.

What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)? 1. Private room. 2. Room with a client who has biliary colic. 3. Room with a client who is 3 days post operative hip replacement. 4. Room with a client who is in skeletal traction due to broken femur.

1. Private room.

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? You answered this question Correctly 1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position 5. Place ice packs under axilla for fever greater than 101°F (38.3°C)

1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

2. Promote decisions based on the nurses value system

3. Gather and apply dressings to open wounds.

A client on routine dialysis asks the nurse about the process of a family member donating a kidney. In what order should the nurse explain the steps for kidney organ donation? You answered this question Incorrectly The Correct Order The donor and recipient will undergo tissue typing and antibody screening. The donor will undergo a psychosocial examination and counseling. The recipient and donor will be assessed and treated for any dental caries. The recipient will undergo hemodialysis. The recipient will receive immunosuppressive agents.

correct order

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? You answered this question Correctly 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1. Monitor for contractures. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 6. Refer to physical therapist.

A client has been admitted with a diagnosis of portosystemic encephalopathy (PSE) secondary to Laennec's cirrhosis. The client is lethargic with slurred speech and is oriented only to self. Assessment findings include grossly distended abdomen, bruised and jaundiced skin, fine bibasilar crackles and +4 pitting edema to lower extremities. The nurse is aware that what lab result is most likely responsible for the client's neurological deterioration? Exhibit You answered this question Correctly 1. Albumin 2.0 gm/dl 2. Sodium 129 meq/L 3. Bilirubin 2.0 gm/dl 4. Ammonia 80 mcg/dl

4. Ammonia 80 mcg/dl

A medical secretary is transcribing hand written medical orders for several clients. When the charge nurse reviews the orders, several seem to have transcription errors. What orders should the nurse verify immediately with the primary healthcare provider? You answered this question Incorrectly 1. "Adm. Diagnosis: Anterior MI cardiac enzymes x 3 & 12-lead ECT." 2. "S/P cataract removal to OD Continue eye gtts twice daily to OU" 3. "H & P: Client indicates hx of cirrhosis with HDV, HTN and IDDM." 4. "Dx: renal insufficiency. Fluid restriction 1000mL/24 hr with I & D q shift." 5. "Reports hx of COPD x 20 years, with occasional wet cough and SBO."

1. "Adm. Diagnosis: Anterior MI cardiac enzymes x 3 & 12-lead ECT." 4. "Dx: renal insufficiency. Fluid restriction 1000mL/24 hr with I & D q shift." 5. "Reports hx of COPD x 20 years, with occasional wet cough and SBO."

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

1. Loud crying with pain.

The nurse providing palliative care to a client would include which outcomes in the teaching plan? 1. Maintaining the client's quality of life 2. Minimizing family caregiver stress 3. Managing the client's pain 4. Managing the client's and family's emotional needs 5. Attending to the client's spiritual needs 6. Ensuring the client understands that disease focused treatments will cease

1. Maintaining the client's quality of life 2. Minimizing family caregiver stress 3. Managing the client's pain 4. Managing the client's and family's emotional needs 5. Attending to the client's spiritual needs

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's Disease (AD). What signs should the nurse include? 1. Mild disorientation 2. Difficulty with words and numbers 3. Poor personal hygiene 4. Agitation 5. Visual agnosia 6. Dysgraphia

1. Mild disorientation 2. Difficulty with words and numbers

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? You answered this question Correctly 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

A newly appointed nurse manager on the unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemented a plan to assign breaks and lunch. The UAPs are angry and refuse to change to the new system. What should be the nurse manager's first action in this situation? 1. Plan a unit staff meeting to discuss the problem and receive input for resolution. 2. Inform the staff that the plan will be implemented and those not following the plan will be disciplined. 3. Ask the charge nurse to address the problem daily as it occurs. 4. Plan a meeting with all UAPs to discuss the problem and reason for the new assignments.

1. Plan a unit staff meeting to discuss the problem and receive input for resolution.

A 70 year old client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's blood pressure is 198/94 mm Hg. What would be the best action for the charge nurse to delegate at this time? You answered this question Correctly 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3. Have the LPN/LVN administer the 0900 furosemide and enalapril now.

Which client with a heat-related illness should the emergency room nurse provide attention to first? 1. Elderly person with reports of dizziness and syncope following working in the yard in the sun for several hours. 2. Football player who was at summer practice and developed severe leg cramps, nausea, tachycardia, and diaphoresis. 3. Low income individual who reports that the power has been turned off and has not had air conditioning for several days and who is experiencing increased respiratory rate, fatigue, extreme diaphoresis, and hypotension. 4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

An elderly client with a recent diagnosis of atrial fibrillation (AF) caused by valvular heart disease, tells the nurse, "My daughter has AF and she only has to take one dabigatran pill a day. I have to take warfarin daily and have my blood checked every month. Why do I have to do all of this?" What education would the nurse provide to the client? 1. Your daughter's atrial fibrillation must not be caused by a heart valve problem so she can take a medication that does not require routine clotting studies. 2. Each primary healthcare provider may treat this dysrhythmia differently based on what the provider is used to prescribing. 3. When your daughter gets older, her primary healthcare provider will switch her to warfarin for the treatment of atrial fibrillation. 4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.

4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.

The nurse is caring for a client who has aphasia. What interventions should the nurse include in the plan of care to improve communication with this client? You answered this question Correctly 1. Increase speaking volume and tone. 2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Assist client to brush and floss teeth. 2. Administer sodium polystyrene sulfonate enema. 3. Evaluate pain relief after narcotic administration. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. 6. Monitor client for pain while assisting with ambulation.

1. Assist client to brush and floss teeth. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation.

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist

A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Which of the following RNs should not be assigned to this baby? You answered this question Correctly 1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy.

2. A nurse who is 10 weeks pregnant.

The nurse is preparing to give a client's prescribed ampicillin dose. How many mL will the nurse give to the client? Answer to the first decimal place. Answer with numbers and decimal only. Ampicillin 200 mg IM every 8 hours 1g/4mL (250mg/1mL)

0.8

After reviewing the client assignments, the LPN/VN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? 1. Ask the LPN/VN how the client assignment should be adjusted. 2. Assign one of the LPN/VN's clients to another nurse. 3. Encourage the LPN/VN to use teamwork skills in caring for the clients. 4. Develop a strategic plan to assist with client assignments.

1. Ask the LPN/VN how the client assignment should be adjusted.

The nurse is assigned a group of clients on the inpatient psychiatric unit. Which client presents the greatest risk for violence toward others? 1. 24 year old man with paranoid delusions 2. 62 year old woman with bipolar disorder 3. 72 year old man with major depression 4. 28 year old woman with borderline personality disorder

1. 24 year old man with paranoid delusions

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake? Select all that apply 1. Calf liver 2. Feta cheese 3. Fresh spinach 4. Shrimp 5. Tuna 6. Tofu

1. Calf liver 2. Feta cheese 4. Shrimp 5. Tuna

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

Which victim would the nurse decontaminate first in a biological terrorist event? 1. Client who was exposed but is exhibiting no symptoms 2. Client who has an open leg fracture and head injury 3. Client who is not breathing and has no palpable pulse 4. Client with minor cuts and abrasions

1. Client who was exposed but is exhibiting no symptoms

In what order will the nurse provide instructions to a client on using a cane?

With cane on stronger side of body, support body weight with both legs. Move cane forward 6-10 inches (15 - 25 cm). Advance weaker leg forward toward the cane. Advance stronger leg forward toward cane.

What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning? 1. Eat a light breakfast two hours before the test. 2. Dress in loose, comfortable clothing. 3. Take nitroglycerin dose 15 minutes prior to test. 4. Limit drinks with caffeine to 8 ounces (240 mL) within 12 hours.

2. Dress in loose, comfortable clothing

A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse? 1. "I feel like food gets stuck in my throat when I eat." 2. "I have a hard time brushing my teeth properly." 3. "My fingers burn when I go outside in the winter." 4. "I get short of breath whenever I exercise."

1. I feel like food gets stuck in my throat when I eat

A client diagnosed with pancreatic cancer is being discharged home to live with an adult child. What action should the nurse take to promote continuity of care? You answered this question Correctly 1. Identify community services available for the client and family. 2. Refer client for hospice care. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides.

1. Identify community services available for the client and family.

The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the morning of the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.

2. I'll have to drink contrast while x-rays are taken.

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion? You answered this question Incorrectly 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

1. Diabetes mellitus. 2. Cigarette smoking. 4. Long-term use of corticosteroids.

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? Select all that apply 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? Select all that apply 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have client grab the wheelchair with the right arm. 6. Have client grab the wheelchair with the left arm.

2. Place the wheelchair on the right side of the bed. 4. Face the wheelchair toward the head of the bed. 6. Have client grab the wheelchair with the left arm.

The nurse is making an initial homecare visit to a client following a stroke. The client has right arm weakness and a limp in the right leg. While evaluating the client's ability to prepare food, the nurse is most concerned about what actions? 1. Uses skid-proof shoes when walking in kitchen. 2. Pours boiling water from pan into cup of tea. 3. Heats food in microwave instead of the oven. 4. Uses electric chopper to dice up vegetables. 5. Prepares and cooks large casserole in oven.

2. Pours boiling water from pan into cup of tea 5. Prepares and cooks large casserole in oven

The nurse is making an initial homecare visit to a client following a stroke. The client has right arm weakness and a limp in the right leg. While evaluating the client's ability to prepare food, the nurse is most concerned about what actions? Select all that apply 1. Uses skid-proof shoes when walking in kitchen. 2. Pours boiling water from pan into cup of tea. 3. Heats food in microwave instead of the oven. 4. Uses electric chopper to dice up vegetables. 5. Prepares and cooks large casserole in oven.

2. Pours boiling water from pan into cup of tea 5. Prepares and cooks large casserole in oven

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.

2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 5. Alert all off-duty personnel to stand by in case of call- in.

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

2. Protein must be limited because of elevated ammonia levels

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Provide positive feedback to the UAP.

2. Refuse the delegated intervention.

A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information, what should the nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assist the float nurse with the clients case. 3. Notify the charge nurse of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.

3. Notify the charge nurse of the observations.

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? You answered this question Correctly 1. Obtaining a sterile urine specimen from a Foley catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing a Foley catheter on a client postpartum.

3. Taking vital signs on a client 12 hours postpartum.

The charge nurse on the postpartum unit is making assignments. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which nurse should be assigned to care for this client? 1. The RN with 8 years' experience in the Intensive Care Unit. 2. The RN with 10 years' experience pulled from the ER. 3. The RN with 5 years' experience in the Labor and Delivery unit. 4. The RN with 2 weeks' experience on the post-partum unit.

3. The RN with 5 years' experience in the Labor and Delivery unit.

Which assigned client should the nurse see first? You answered this question Correctly 1. Diagnosed with urinary tract infection 2 days ago who is to be discharged. 2. Admitted last night with a diagnosis of severe pneumonia. 3. 45 year old who had a hernia repair 24 hours ago. 4. Scheduled for an endoscopy in two hours.

2. Admitted last night with a diagnosis of severe pneumonia.

A client with diabetes has a history of ignoring the primary healthcare provider's prescription for daily medication management of the illness. The client has been working toward a health promotion goal of increased adherence to prescribed medication regimen. Which outcome suggests that the client has met the health promotion goal? 1. Client has lost five pounds. 2. Client takes medication as prescribed. 3. Client has been hospitalized twice for complications of diabetes. 4. Client walks one mile per day.

2. Client takes medication as prescribed

A right-handed client's intravenous (IV) infusion has infiltrated at the client's left dorsal metacarpal vein. The nurse would initially assess which vein to start another intravenous infusion? 1. Basilic vein 2. Cephalic vein 3. Median antecubital vein 4. Dorsal metacarpal vein

2. Cephalic vein

What signs/symptoms would the nurse expect to find in a client diagnosed with osteoarthritis (OA) in the knee? 1. Sjogren's syndrome 2. Clicking sound when knee bends 3. Fever 4. Pain that is worse after activity 5. Severe fatigue

2. Clicking sound when knee bends 4. Pain that is worse after activity

Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

3. Tracheal deviation and dyspnea

The medical surgical nurse is admitting a client diagnosed with deep vein thrombosis (DVT) of the right leg. The client suddenly begins to report shortness of breath. Which additional early signs/symptoms indicative of a complication would the nurse need to report to the primary healthcare provider immediately? 1. Tachycardia with tachypnea. 2. Restlessness and dizziness. 3. Pain in the lower right leg. 4. A positive Homan's sign.

2. Restlessness and dizziness.

The nurse is caring for a primipara client at 27 weeks gestation. Which client learning need should the nurse identify as priority at this stage of pregnancy? 1. Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care

2. Signs of preterm labor

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective? 1. "My child drinks 1000 mL of fluids daily." 2. "My child is eating more fruit every day." 3. "I administered the prescribed oil-retention enema 6 days ago to my child." 4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

During a disaster, four clients arrive at the emergency department (ED). Which client should the nurse assess first? 1. Confused client wondering around ED. 2. Client with a compound fracture. 3. Client having agonal respirations. 4. Client with sucking chest wound.

4. Client with sucking chest wound.

A newly hired unlicensed assistive personnel (UAP) at a long-term care facility is being instructed on the proper method of feeding a stroke client with dysphagia. The nurse knows teaching was successful when the UAP makes what statement? 1. "Feeding the client in semi-fowlers position is easier." 2. "I should not allow the client to do any self-feeding." 3. "Thickened liquids are safer for the client to swallow." 4. "I am offering the client a drink after each bite to help digestion."

3. "Thickened liquids are safer for the client to swallow."

3. Airway

Which task would be appropriate for the charge nurse to assign to a LPN/VN? You answered this question Correctly 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a PICC line that a client accidentally pulled out.

3. Bolus feeding a client who has a gastrostomy tube.

A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the nurse that discharge teaching has been effective? 1. I will need to eat a low fat diet since I no longer have a gallbladder. 2. I can expect drainage from the incisions for a few days. 3. I may have some mild pain from the procedure. 4. I should plan to limit my activities and not return to work for several weeks.

3. I may have some mild pain from the procedure

A gunshot victim is brought by ambulance to the emergency room with an open pneumothorax. A bio-occlusive dressing to the chest. The nurse then notes increased dyspnea and sub-q emphysema in the client. What is the nurse's priority action? 1. Prepare client for insertion of chest tube. 2. Apply a non-rebreather with 100% oxygen. 3. Loosen one side of the bio-occlusive dressing. 4. Obtain a tracheostomy kit and call the surgeon.

3. Loosen one side of the bio-occlusive dressing

Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that further instruction is necessary when the client makes what statement? 1. "I must include a lot of fluid in my daily routine." 2. "I need to take my antibiotics at the same time daily." 3. "Rest and mild exercise are important for my recovery." 4. "Decreasing fiber in my diet can help prevent recurrences."

4. "Decreasing fiber in my diet can help prevent recurrences."

A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would require an immediate intervention? 1. The nasogastric (NG) tube contents are pale green. 2. An abdominal dressing with the tape on 3 sides of the dressing. 3. Abdominal pain of 5 on 10 point pain scale when client coughs. 4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.

4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.

What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 1. Inform the client of the need to avoid irritants such as carbonated beverages. 2. Ask client if they are eating small, frequent meals. 3. Monitor for GI upset 30 minutes after meals. 4. Remind the client to avoid tight fitting clothes.

4. Remind the client to avoid tight fitting clothes.

What information should the nurse include in teaching an oncology client the purpose of taking epoetin? 1. Emergency treatment of anemia. 2. Improves quality of life. 3. Used for the prevention of pure red cell aplasia (PRCA). 4. Decreases the need for transfusion.

4. Decreases the need for transfusion.

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

4. Give magnesium citrate 296 mL at 3 PM today.

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Obtaining a sterile urine specimen from a Foley catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing a Foley catheter on a client postpartum.

3. Taking vital signs on a client 12 hours postpartum.

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration? 1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 5. Ability to follow commands

1. Ability to swallow 2. Gag reflex 3. LOC 4. Cough reflex

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.

1. Apply defibrillator pads to bare skin 3. Continue CPR until advised to deliver shocks 4. Stop CPR while machine analyzes the rhythm 5. Shout "clear" prior to activating shock button

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action.

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understanding of client rights? 1. Clients can receive and send mail, but staff must check for hazards. 2. Clients are not allowed to receive mail while hospitalized. 3. Receiving mail from family is not encouraged. 4. Clients are allowed to send or receive mail after the first 72 hours after admission.

1. Clients can receive and send mail, but staff must check for hazards.

Which of the following should the nurse teach regarding nutrition for a client with celiac disease? Select all that apply 1. Gluten is a protein found in wheat and oats. 2. A gluten intolerant person can eat foods that are made with barley or rye. 3. Fruits can be eaten on a gluten free diet. 4. Gluten causes inflammation of the large intestines of people with celiac disease. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

1. Gluten is a protein found in wheat and oats. 3. Fruits can be eaten on a gluten free diet. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

The housekeeper and a nurse, having lunch together in the staff lounge, begin discussing the housekeeper's neighbor who has been admitted to the floor. The housekeeper occasionally helps the neighbor with shopping and cleaning. The conversation is overheard by the unit secretary, though no names were mentioned. The conversation is reported to the nurse manager, who determines the situation reflects what HIPAA criteria? You answered this question Incorrectly 1. Not permissible because the housekeeper is not medical personnel. 2. Is permissible since the housekeeper does help care for the neighbor. 3. Not permissible despite family stating housekeeper is "like family". 4. Is permissible given that no other family members are available now.

1. Not permissible because the housekeeper is not medical personnel.

What should the nurse include about transmission of the chickenpox virus while teaching a group of parents about the importance of vaccination? 1. Direct contact 2. Indirect contact 3. Airborne 4. Droplet 5. Common vehicle

1. Direct contact 2. Indirect contact 3. Airborne

A nurse enters the operating room (OR) with artificial fingernails in place. What should the charge nurse explain to the nurse? Select all that apply 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial fingernails are allowed to be worn in the OR. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 4. A more vigorous scrub is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands.

1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 5. Long fingernails and artificial fingernails increase microbial load on the hands.

A client prescribed oral iron medication is reporting nausea after administration. What should the nurse teach the client to decrease this symptom? 1. Take the iron with a class of milk. 2. Eat bran cereal immediately after ingesting iron. 3. Drink orange juice with the iron medication. 4. Take docusate sodium at bedtime.

3. Drink orange juice with the iron medication.

What is the most effective method of stroke prevention that the nurse should teach to the public? 1. Administering platelet inhibitors to prevent clot formation. 2. Undergoing transluminal angioplasty to open a stenosed artery and improve blood flow. 3. Maintaining normal weight, exercising, and controlling comorbid conditions. 4. Administering tissue plasminogen activator (tPA).

3. Maintaining normal weight, exercising, and controlling comorbid conditions.

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. Increase the flow rate of the irrigation solution until the urine is a light pink.

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.

3. Obtain a normal body weight and exercise regularly.

A nurse manager has recognized that nurses on one shift do not seem to be working well together and, on occasions, refuse to help each other when needed. What strategy could the nurse manager use that would help with team building? 1. Avoid discussing conflicts to build a positive work environment. 2. Model behaviors that create a caring environment and promote trust. 3. Create a shared vision of the unit and agency mission and purpose. 4. Recognize nurses who demonstrate commitment to team efforts. 5. Make nurses aware of the messages that their behaviors send to the team. 6. Have nurses agree upon roles, responsibilities, and proper lines of communication.

2. Model behaviors that create a caring environment and promote trust. 3. Create a shared vision of the unit and agency mission and purpose. 4. Recognize nurses who demonstrate commitment to team efforts. 5. Make nurses aware of the messages that their behaviors send to the team. 6. Have nurses agree upon roles, responsibilities, and proper lines of communication.

While preparing to administer intravenous of chemotherapy the nurse accidently pulls the tubing apart, spilling the solution onto the floor. After clamping the tubing, what is the nurse's immediate action? 1. Use disposable towels to clean up the liquid. 2. Obtain spill kit specific to this type of solution. 3. Complete an incident report for supervisor. 4. Call housekeeping to help clean up the floor.

2. Obtain spill kit specific to this type of solution.

3. Assist the client into a supine position in bed.

A client is being cared for on the orthopedic unit following a football game injury which resulted in a fracture of the left tibia and fibula. An open reduction of the fracture has been performed and a leg cast was applied. The client is receiving Morphine via a Patient Controlled Analgesia (PCA) pump at 2 mg/hr. The client begins reporting an increase in the pain level (9/10) that is not being relieved by the current Morphine dosing, and is experiencing a sensation that "pins are sticking" in the left foot. What action by the nurse is needed? You answered this question Correctly 1. Increase the PCA dosing of Morphine. 2. Elevate the foot of the bed. 3. Perform neurovascular checks. 4. Apply ice around sides of cast. 5. Prepare for possible bivalving of the cast. 6. Notify primary healthcare provider.

3. Perform neurovascular checks. 5. Prepare for possible bivalving of the cast. 6. Notify primary healthcare provider.

3. Prepare a sitz bath for a postpartum client.

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What actions should the nurse take? 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home. 5. Follow procedure to return medication to the resident's supply.

3. Report what was seen to the supervisor. 5. Follow procedure to return medication to the resident's supply.

Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chick peas and asparagus, apple, tea

2. Vegetable soup, whole wheat toast, skim milk

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understanding of client rights? You answered this question Correctly 1. Clients can receive and send mail, but staff must check for hazards. 2. Clients are not allowed to receive mail while hospitalized. 3. Receiving mail from family is not encouraged. 4. Clients are allowed to send or receive mail after the first 72 hours after admission.

1. Clients can receive and send mail, but staff must check for hazards.

The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? You answered this question Incorrectly 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq

2. Weight gain of 4 pounds in one week 5. Serum potassium of 3.2 mEq

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? Select all that apply 1. Put a pillow under the costal margin. 2. Place in the right side lying position. 3. Perform passive range of motion exercises to right shoulder. 4. Take vital signs every 10 - 15 minutes for first hour. 5. Instruct the client to avoid strenuous exercise for 1 month.

1. Put a pillow under the costal margin. 2. Place in the right side lying position. 4. Take vital signs every 10 - 15 minutes for first hour.

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? You answered this question Correctly 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

1. Share the assessment findings with the interdisciplinary team.

What interventions would be appropriate for the nurse to make for a child who is in Bryant's traction? Select all that apply 1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed. 3. Reposition child infrequently so that traction is maintained. 4. Place child prone for one hour daily to prevent contractures. 5. Remove adhesive traction straps daily to prevent skin breakdown. 6. Use wrist restraints to keep child from turning over.

1. Perform neurovascular checks every 2 hours 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1. Use of 2% milk instead of whole milk 2. Eat air-popped popcorn instead of potato chips 4. Incorporate plant sources of protein

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education has been successful when a nurse selects which set of ABGs as metabolic acidosis? 1. pH - 7.32, PaCO2 - 48, HCO3 - 23 2. pH - 7.29, PaCO2 - 42, HCO3 - 19 3. pH - 7.5, PaCO2 - 30, HCO3 - 22 4. pH - 7.35, PaCO2 - 35, HCO3 - 26

2. pH - 7.29, PaCO2 - 42, HCO3 - 19

The day shift nurse in a long-term care facility has been noticing that the adult brief on a total-care client has not been changed since the previous day's shift and perineal care has not been provided, despite the brief being full with urine and feces. The client's perineal area is becoming excoriated from the contact with excrements. The nurse has spoken with the night shift nurse on 2 occasions about the concerns and was told by the night shift nurse that she takes care of the clients and to stay out of her business. What action should the day shift nurse take next? 1. Avoid reporting the night shift nurse to prevent job loss or disciplinary actions. 2. Report the client findings and previous discussions to the charge nurse. 3. Notify the agency attorney of the breach in care being provided. 4. Tell the client's family that they should report the night shift nurse.

2. Report the client findings and previous discussions to the charge nurse.

The telemetry unit nurse is assessing a newly admitted client following a fall at home. The client has been diagnosed with a left sided cerebrovascular accident (CVA), including aphasia, and a sprained wrist. What is the most effective method the nurse could use to assess the client's pain? You answered this question Incorrectly 1. Monitor vital signs for elevations. 2. Observe client's non verbal behaviors. 3. Assess sleeping position client chooses. 4. Ask client to point to the pain rating scale.

2. Observe client's non verbal behaviors.

A nurse has been educating a client newly diagnosed with diabetes, about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? Select all that apply 1. "I should cut my toenails with nail clippers." 2. "Drying both feet thoroughly is important." 3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes."

3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes."

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

3. Recent increased care demands

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40; arterial line BP 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138. What action should the nurse take first? You answered this question Correctly 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.

4. Auscultate lung sounds.

The nurse is demonstrating ostomy care to a client with a new stoma in the sigmoid area of the colon. The nurse knows teaching is successful when the client completes care in what order?

Remove ostomy bag and old flange. Wash stoma with warm soapy water. Apply skin protectant and allow drying. Cut center of new flange to fit stoma. Place stoma adhesive onto new flange. Press flange into place and attach bag.

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? You answered this question Correctly 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

1. 3+ pedal edema 4. Purse-lip breathing 5. Pale nail beds

A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? Select all that apply 1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron

1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 4. Single use boot covers 5. Single use apron

1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist

1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness.

When teaching a client about lactose intolerance, what should the nurse include?

1. Common symptoms of lactose intolerance include abdominal bloating, diarrhea, and gas. 3. Calcium rich foods should be consumed. 4. The client can drink lactose-free milk. 5. Vitamin D foods should be increased in the diet.

A community health nurse, participating in a health fair, is educating a community group about risk factors for developing varicose veins. What risk factors should the nurse include? 1. Sitting for prolonged periods 2. Obesity 3. Female 4. Leg exercises 5. Wearing high-heeled shoes

1. Sitting for prolonged periods 2. Obesity 3. Female 5. Wearing high heeled shoes

The nurse is teaching a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include? You answered this question Correctly 1. Promote a diet rich in fruits and vegetables. 2. Provide instruction on benefits of carotid endarterectomy. 3. Limit sodium intake to 2 grams/day. 4. Engage in low intensity exercise once a week. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day.

1. Promote a diet rich in fruits and vegetables. 3. Limit sodium intake to 2 grams/day. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day.

A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? You answered this question Correctly 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.

1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze.

What assessment data would a nurse expect to find in a client diagnosed with a severe episode of acute inflammatory bowel disease? Select all that apply 1. Dark yellow urine 2. Fever 3. Frequent, hard stools 4. Lower abdominal cramping 5. Tachycardia

1. Dark yellow urine 2. Fever 4. Lower abdominal cramping 5. Tachycardia

The nurse is preparing to educate a client diagnosed with essential hypertension on how to decrease the risk of developing complications. What topics should the nurse include? Select all that apply 1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week. 5. Reduce sodium intake to less than 2700 mg/day.

1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week.

1. Plan a unit staff meeting to discuss the problem and receive input for resolution.

A client who needs to have a stool specimen for an occult blood test is instructed by the nurse to avoid which substances two hours prior to testing? Select all that apply 1. Liver 2. Tomato 3. Ibuprofen 4. Sardines 5. Ascorbic acid

1. Liver 3. Ibuprofen 4. Sardines 5. Ascorbic acid

A client diagnosed with renal failure has been admitted to the medical unit. An arterial blood gas (ABG) analysis has been prescribed by the primary healthcare provider. Which ABG interpretation by the nurse is appropriate? pH - 7.33 PaCO2 - 36 HCO3 - 20 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils? 1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian

1. Occupational therapist

A nurse is educating a group of community citizens about risk factors for developing peripheral neuropathy. Which risk factors should the nurse include? Select all that apply 1. Uncontrolled diabetes 2. Alcohol abuse 3. Vitamin A deficiency 4. Rheumatoid arthritis 5. Varicella-zoster virus

1. Uncontrolled diabetes 2. Alcohol Abuse 4. Rheumatoid arthritis 5. Varicella-zoster virus

A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant? You answered this question Correctly 1. Ventricular fibrillation 2. Ventricular tachycardia 3. 2nd degree AV block 4. Atrial fibrillation

1. Ventricular fibrillation

What discharge education should a nurse provide to a client post hip replacement with a metal joint? 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.

1. Weight bearing limits 2. Use of high seated chair 3. Sexual intercourse in dependent position for up to 6 months 5. Use of long handled tongs to assist with dressing

A client diagnosed Alzheimer's disease has been prescribed memantine. What should the nurse teach the caregiver about this medication? 1. When beginning this medication provide ambulatory assistance. 2. This medication is prescribed to help improve mild dementia. 3. This medication must be taken without food. 4. If a dose is missed, double the next dose. 5. If the client cannot swallow the capsule you sprinkle on applesauce.

1. When beginning this medication provide ambulatory assistance. 5. If the client cannot swallow the capsule you sprinkle on applesauce.

The nurse is monitoring a client in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? 1. pH 7.32 2. PaCO2 47 3. HCO3 25 4. PaO2 78

1. pH 7.32

2. Move the client to a private room with contact precautions.

A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include? You answered this question Correctly 1. Approach client from the right side. 2. Place personal items within easy reach. 3. Maintain eye patch over right eye. 4. Administer antiemetic for reports of nausea. 5. Assist client to turn, cough, and deep breathe every 2 hours. 6. Place client prone for 1 hour.

2. Place personal items within easy reach. 3. Maintain eye patch over right eye. 4. Administer antiemetic for reports of nausea.

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the primary healthcare provider about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. I will notify the primary healthcare provider about your headaches, after the group session

A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."

3. "Have you had any thoughts of harming yourself or the baby?"

3. The client with myasthenia gravis on pyridostigmine.

A full-term client is admitted in labor, 5 centimeters dilated and having contractions 3 minutes apart which last 60 seconds. The current blood pressure is 85/50. What is the nurse's priority action? 1. Turn IV fluids to wide open. 2. Apply oxygen at 2L by nasal cannula. 3. Position the client onto the left side. 4. Recheck blood pressure in opposite arm.

3. Position the client onto the left side.

The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area

3. Start two large bore IVs

A client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm. 3. Have the staff RN recheck the BP. 4. Ask the LPN to recheck the client's BP.

3. Have the staff RN recheck the BP.

What turning method should the nurse use to turn a client who has a spinal injury? 1. Lateral transfer 2. Slide sheet procedure 3. Logrolling 4. Mechanical lift transfer

3. Logrolling

A client is being discharged with halo traction. What should the nurse teach about home care of this traction? You answered this question Incorrectly 1. Showering is permitted. 2. Apply baby powder under the halo vest to prevent irritation. 3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique. 5. Driving is allowed after discharge.

3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique.

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take? 1. Administer a second dose of pyridostigmine. 2. Place client in side lying position. 3. Notify the primary healthcare provider. 4. Prepare for intubation and mechanical ventilation.

3. Notify the primary healthcare provider.

3. Pneumothorax

The nurse is preparing to give a client's prescribed ceftazidime dose. How many mL will the nurse give to the client? Answer to the first decimal place. Answer with numbers and decimal only.

3.6

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? You answered this question Correctly 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

4. Biologically-based therapies.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? Exhibit You answered this question Correctly 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4. Respiratory alkalosis

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Symptoms of West Nile Virus include headache, fever, and fatigue

An unlicensed assistive personal (UAP) has been floated to the emergency department (ED) because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the charge nurse could assign? You answered this question Correctly 1. Clean and restock exam rooms after client discharge. 2. Follow another UAP who has worked there previously. 3. Sit at the reception desk and answer incoming calls. 4. Escort clients from the ED to other areas for tests.

4. Escort clients from the ED to other areas for tests.

The nurse discovers that a client was given the wrong medication. After verifying the client is stable, an incident report is completed. What is the proper disposition of the report? 1. Send a copy of the report to the primary healthcare provider. 2. Notify the State Board of Nursing about the incident report. 3. Document that a report was completed on the client's chart. 4. Give the report to the hospital's risk management team.

4. Give the report to the hospital's risk management team.

During morning report, the nurse learns that a client's call bell is not working and maintenance cannot do repairs until tomorrow. The nurse is aware that the safest temporary method for the client to signal staff is what? 1. Provide a hand-held bell for client to ring. 2. Ask family to stay with client to alert staff. 3. Tell client to call out loudly to the staff. 4. Have staff visit client's room every 15 minutes.

4. Have staff visit the client's room every 15 minutes

What is the priority nursing action for a pregnant client in labor who is having an epidural catheter inserted for pain management? 1. Perform a thorough skin prep of the insertion site. 2. Obtain the client's consent for the procedure. 3. Assure the client that residual effects of the procedure won't be felt. 4. Monitor maternal blood pressure.

4. Monitor maternal blood pressure.

In what order should the home health nurse see assigned clients? Place in priority order. You answered this question Correctly The Correct Order Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. Client diagnosed with rheumatoid arthritis who requires an occupational consult.

correct route

A nurse has been assigned to care for five clients. In what order should the nurse assess these clients after shift report? Place in priority order from highest to lowest priority. You answered this question Correctly The Correct Order Client hospitalized to rule out abdominal aortic aneurysm who is reporting deep, aching pain in the flank area. Client whose BP is reported by the UAP to be 200/102 at present. Client diagnosed with an arterial ulcer to the right leg who reports pain of 8/10. Client with Buerger's disease reporting numbness, tingling and cold in toes. Client diagnosed with peripheral vascular disease requesting information on smoking cessation.

correct order

What clients could safely be delegated to the LPN/VN? 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

A nurse is planning to provide information to a group of adults considering smoking cessation. What information should the nurse include? You answered this question Incorrectly 1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 4. All smokers need to have a prescription for bupropion SR in order to quit. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.

1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.

Which assignment would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? You answered this question Correctly 1. Totaling I & O records on five clients at the end of the shift. 2. Assessing VS on a client who was admitted 30 minutes ago. 3. Administering nasogastric (NG) tube feeding. 4. Changing an abdominal surgical dressing on a client that is 3 days post op.

1. Totaling I & O records on five clients at the end of the shift.

2. Move the client to a private room with contact precautions

The crisis line nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What is the nurse's most appropriate response? 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Have another person call 911 for an ambulance."

1. "I want to help you to resolve the problem." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Have another person call 911 for an ambulance."

While reviewing the prescriptions written by a primary healthcare provider, the nurse notes that ibuprofen 30 mg by mouth every 6 hours is prescribed for a child weighing 6 kg. The drug information book states that the appropriate dosage range is 20-30 mg/kg/24 hours. What action should the nurse take? You answered this question Correctly 1. Administer the ibuprofen at 30 mg by mouth every 6 hours. 2. Contact the nursing supervisor regarding the prescription. 3. Ask the pharmacist to calculate the appropriate dose. 4. Notify the primary healthcare provider.

1. Administer the ibuprofen at 30 mg by mouth every 6 hours.

What signs/symptoms would the nurse expect to assess in an elderly client diagnosed with acute decompensated heart failure (ADHF)? You answered this question Incorrectly 1. Thick, white sputum 2. Crackles that clear with coughing 3. Wheezing 4. Orthopnea 5. Apical pulse 88/min 6. S3 gallop

3. Wheezing 4. Orthopnea 6. S3 gallop

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