Ch. 1, Ch. 4, Ch. 5, Ch. 19, Ch. 21

A client is crying and grimacing but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 4. Seek family assistance in resolving this problem.

1 1.13

In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

1 1.15

A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)

1 1.3

When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the client is pain free. 3. Titrate downward to prevent toxicity. 4. Titrate to a dosage that is adequate to meet the client's subjective needs.

1 1.9

You are the pediatric unit charge nurse working with a new RN. Which action by the new RN requires the most immediate action on your part? 1. Placing a child who has chemotherapy-induced neutropenia into a negative-pressure room 2. Wearing goggles to change the linens of a patient who has diarrhea caused by Clostridium difficile 3. Instructing UAPs to use an N95 respirator mask when caring for a child who has pertussis 4. Admitting a new patient with respiratory syncytial virus (RSV) infection to a room with another child who has RSV

1 19.7

A patient on the acute psychiatric unit develops neuroleptic malignant syndrome. Which task should be delegated to the mental health assistant? 1. Wiping the patient's body with cool moist towels 2. Monitoring VS every 15 minutes 3. Attaching ECG monitor 4. Assigns the RN to transfer the patient to the ICU

1 21.11

A nursing student reports to you that he has observed several types of behavior among the patients. Which patient needs priority assessment? 1. A patient who is having command hallucinations 2. A patient who is demonstrating clang associations 3. A patient who is verbalizing ideas of reference 4. A patient who is using neologisms

1 21.7

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should you expect to correct this problem? 1. Increase in ventilator rate from 6 to 10 breaths/min 2. Decrease in ventilator rate from 10 to 6 breaths/min 3. Increase in oxygen concentration from 30% to 40% 4. Decrease in oxygen concentration from 40% to 30%

1 4.14

A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for pain. When the student nurse assesses the client, which finding would you instruct the student to report immediately? 1. Respiratory rate of 8 to 10 breaths/min 2. Decrease in pain level from 6 to 2 (on a scale of 10) 3. Request by the client that the room door be closed 4. Heart rate of 90 to 100 beats/min

1 4.17

A client is admitted to your unit for chemotherapy. To prevent an acid-base problem, which finding would you instruct the UAP to report? 1. Repeated episodes of nausea and vomiting 2. Reports of pain associated with exertion 3. Failure to eat all the food on the breakfast tray 4. Client hair loss during the morning bath

1 4.19

The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation

1 4.2

A client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising? 1. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. 2. Administer spironolactone (Aldactone) 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq orally.

1 4.6

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to you, a newly-graduated RN. Which action can you delegate to the UAP? 1. Providing oral care every 3 to 4 hours 2. Monitoring for indications of dehydration 3. Administering 0.45% saline by IV line 4. Assessing daily weights for trends

1 4.8

In your role as the hospital infection control nurse, which policy will you implement to most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? 1. Limit the use of indwelling urinary catheters in all hospitalized clients. 2. Ensure that clients with catheters have at least a 1500-mL fluid intake daily. 3. Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria. 4. Require the use of antimicrobial/antiseptic impregnated catheters for catheterization.

1 5.16

You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will you implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/hr. 3. Administer first dose of oseltamivir (Tamiflu). 4. Obtain blood and sputum specimens for testing.

1 5.2

While working in the pediatric clinic, you receive a telephone call from the parent of a 13-year-old who is receiving chemotherapy for leukemia. The patient's sibling has chickenpox (varicella). Which action will you anticipate taking next? 1. Administer varicella-zoster immune globulin to the patient. 2. Teach the parent about the correct use of acyclovir (Zovirax). 3. Educate the parent about contact and airborne precautions. 4. Prepare to admit the patient to a private room in the hospital.

1 19.10

You have obtained this assessment information about a 3-year-old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up? 1. Frequent swallowing 2. Hypotonic bowel sounds 3. Reports of a sore throat 4. Heart rate of 112 beats/min

1 19.13

As the pediatric unit charge nurse, you are working with a newly-graduated RN who has been on orientation in the unit for 2 months. Which patient should you assign to the new RN? 1. 2-year-old with a ventricular septal defect for whom digoxin (Lanoxin) 90 mcg by mouth has been prescribed 2. 4-year-old who had a pulmonary artery banding and has just been transferred in from the intensive care unit 3. 9-year-old with mitral valve endocarditis whose parents need teaching about IV antibiotic administration 4. 16-year-old with a heart transplant who was admitted with a low-grade fever and tachycardia

1 19.18

You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? (Select all that apply.) 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1, 2 5.13

The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply.) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking a dietary consult to increase fluids on meal trays

1, 2, 3, 4 4.3

You are preparing to care for a 6-year-old who has just undergone allogeneic stem cell transplantation and will need protective environmental isolation. Which nursing tasks will you delegate to the UAP? (Select all that apply.) 1. Stocking the patient's room with the needed personal protective equipment items 2. Teaching the patient to perform thorough hand washing after using the bathroom 3. Reminding visitors to wear a respirator mask, gloves, and gown 4. Posting the precautions for protective isolation on the door of the patient's room 5. Talking to the family members about the reasons for the isolation

1, 3, 4 19.8

Which clients must be assigned to an experienced RN? (Select all that apply.) 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

1,3,5,6 1.6

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions. 1. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia 2. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity 3. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions 4. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000

1,4,3,2 21.20

For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function with your continued support and supervision? 1. Therapeutic touch 2. Application of heat and cold 3. Meditation 4. Transcutaneous electrical nerve stimulation (TENS)

2 1.10

A client received "as needed" (PRN) morphine, lorazepam (Ativan), and cyclobenzaprine (Flexeril). The UAP reports that the client has a respiratory rate of 10/min. What is the priority action? 1. Call the physician to obtain an order for naloxone (Narcan). 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20/min. 4. Double-check the drug order to see what the client should have received.

2 1.11

For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Look at the MAR and chart to note the time of the last dose of analgesic and the client's response. 4. Give the maximum PRN dose within the minimum time frame for relief.

2 1.17

You are assisting with the delivery of a 31-week gestational age premature newborn who requires intubation for RDS. Which medication will you anticipate will be needed first for this infant? 1. Theophylline (Theolair, Theochron) 2. Surfactant (Exosurf) 3. Dexamethasone (Decadron) 4. Albuterol (Proventil)

2 19.15

The team has to apply restraints to a combative patient in order to prevent harm to others or to self. Which action requires your intervention? 1. Mental health assistant uses a quick-release knot 2. MD secures the restraint to the side rail 3. RN check the pulses distal to restraint 4. LPN explains to the patient why he being restrained

2 21.14

A well-known celebrity is admitted to your unit. Several RNs from other units drop by and express an interest in seeing the patient. What is the best response? 1. Please be discreet and do not interrupt the work flow 2. How did you find out that the patient was admitted to this unit? 3. Please wait. I need to call the nursing supervisor about this request 4 I'm sorry; the patient has asked that only family be allowed to visit

2 21.15

An LPN complains to you that she is always assigned to the same patient with chronic depression. What should you do? 1. Look at the assignment sheet and see if there is any way to switch assignments with another LPN 2. Tell her to care for the patient today, but that you will remember the request for future assignments 3. Remind her that continuity of care and patient-centered care are the primary goals 4. Explain that patients with chronic conditions are more likely to fall under the LPN scope of practice

2 21.16

You are interviewing a patient with suicidal ideations and a history of major depression. Which comment concerns you the most? 1. I have had problems with depression most of my adult life 2. My father and my brother both committed suicide 3. My wife is having health problems and she relies on me 4. I am afraid to kill myself, and I wished I had more courage

2 21.9

The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

2 4.1

As the charge nurse, you would assign which client to the step-down unit nurse floated to the intensive care unit for the day? 1. 68-year-old on a ventilator with acute respiratory failure and respiratory acidosis 2. 72-year-old with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent 3. Newly-admitted 56-year-old with diabetic ketoacidosis receiving an insulin drip 4. 38-year-old on a ventilator with narcotic overdose and respiratory alkalosis

2 4.13

The UAP reports to you that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should you suspect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2 4.18

The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate has decreased. What is your best response? 1. "It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." 2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." 3. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." 4. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

2 4.20

You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium

2 4.5

An experienced LPN/LVN reports to you that a client's blood pressure and heart rate have decreased, and when his face is assessed, one side twitches. What action should you take at this time? 1. Reassess the client's blood pressure and heart rate. 2. Review the client's morning calcium level. 3. Request a neurologic consult today. 4. Check the client's pupillary reaction to light.

2 4.9

As the infection control nurse in an acute care hospital, which action will you take to most effectively reduce the incidence of health care-associated infections? 1. Require nursing staff to don gowns to change wound dressings for all clients. 2. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. 3. Screen all newly admitted clients for colonization or infection with MRSA. 4. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug-resistant organisms.

2 5.15

Which information about a client who has meningococcal meningitis is the best indicator that you can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100° F (37.8° C).

2 5.18

You are administering vancomycin (Vancocin) 500 mg IV to a client with a MRSA wound infection when you notice that the client's neck and face are becoming flushed. Which action should you take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the client's temperature.

2 5.19

You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? 1. 3-year-old who has paroxysmal coughing and whose sibling has pertussis 2. 5-year-old who has a new pruritic rash and a possible chickenpox infection 3. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

2 5.5

A client who states that he may have been contaminated by anthrax arrives at the ED. Which action included in the ED protocol for possible anthrax exposure will you take first? 1. Notify hospital security personnel about the client. 2. Escort the client to a decontamination room. 3. Give ciprofloxacin (Cipro) 500 mg by mouth (PO). 4. Assess the client for signs of infection.

2 5.9

You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with rubeola (measles). Which factor is of most concern in determining whether to admit the child to your unit? 1. The unit is staffed with fewer RNs than usual. 2. No negative-airflow rooms are available. 3. The infection control nurse liaison is not present today. 4. There are several children receiving chemotherapy.

2 19.11

Which pediatric pain patient should be assigned to a newly-graduated RN? 1. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

2 19.2

You are working with an LPN/LVN who is caring for a 10-year-old who has severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the LPN/LVN requires that you intervene immediately? 1. Suggesting genetic counseling to the patient 2. Positioning cold packs on the patient's knees 3. Placing a "No Visitors" sign on the patient's door 4. Checking the patient's temperature every 2 hours

2 19.20

You are a public school nurse. Which action will you take to have the most impact on the incidence of infectious diseases in the school? 1. Make soap and water readily available in the classrooms. 2. Ensure that students are immunized according to national recommendations. 3. Provide written information about infection control to all parents. 4. Teach students how to cover their mouths when they cough or sneeze.

2 19.9

As the charge nurse, you are reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned? 1. Male LVN assigned to a male patient with chronic depression and excessive rumination 2. Young male mental health assistant assigned to a female adolescent with anorexia nervosa 3. Female RN assigned to a newly admitted female patient who has command hallucination sand delusions of persecution 4. Older female RN with medical-surgical experience assigned to a male patient with Alzheimer disease

2 21.3

Which action should you delegate to a UAP for the client with diabetic ketoacidosis? (Select all that apply.) 1. Checking fingerstick glucose results every hour 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 4. Assessing for indicators of fluid imbalance 5. Notifying the provider of changes in glucose level

2, 3 4.15

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? (Select all that apply.) 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

2, 3, 4 5.4

A patient needs Klonopin 1 mg PO. The pharmacy delivers clonidine 0.1 mg tablets. A nursing student asks you if Klonopin and clonidine are two different names for the same drug. Place the following steps in the correct sequence so that you can teach the nursing student how ti prevent medication errors. 1. Advise the pharmacy of any corrections as appropriate 2. Recognize the "look-alike, sound-alike" drugs increase the chances of error 3. Consult a medication book to verify the purpose of the drugs and generic and brand names 4. Check the original medication order to verify what was prescribed 5. Write an incident report, as appropriate, if you believe that a system error is occurring 6. Call the MD for clarification of the order as appropriate

2,4,3,6,1,5 21.18

A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps

3 1.14

Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. " Where is the pain located, and does it radiate to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. " What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your activity level and your ability to function?" 5. " What information do you need about pain, healing, and addiction?"

3 1.2

Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia

3 1.4

In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. The client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed.

3 1.7

Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp chest pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an elevated blood pressure

3 1.8

In caring for a 3-year-old with pain, which assessment question would be the most useful? 1. "Can you point to the pain with one finger and tell me what that pain feels like inside of you?" 2. "If number 1 were a little pain and number 10 were a big pain, what number would your pain be?" 3. "The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" 4. "One chip is 'a little bit of hurt' and four chips are 'the most hurt.' How many chips would you take for your hurt?"

3 19.1

A patient with a diagnosis of hypochondriasis has made multiple clinic visits and undergone diagnostic tests for "cancer," with no evidence of organic disease. Today he declares, "I have a brain tumor. I can feel it growing. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response? 1. Present reality: "Sir, you have been seen many times in this clinic and had many diagnostic tests. The results have always been negative." 2. Encourage expression of feelings: "Let me spend some time with you. Tell me about what you are feeling and why you think you have a brain tumor." 3. Set boundaries: "Sir, I will take your VS, but then I am going to call your case manager so that you can discuss the scheduled appointment." 4. Respect the patients wishes: "Sir, sit down and I will make sure that you see the physician right away. Don't worry; we will take care of you."

3 21.1

A patient comes into the walk-in clinic and tells you that he wants to be admitted to alcohol rehabilitation program. Which question is the most important to ask? 1. What made you decide to enter a program at this time? 2. How much alcohol do you usually consume in a day? 3. When was the last time your had a drink? 4. Have you been in a rehabilitation program before?

3 21.10

Which task can be assigned to a medical-surgical UAP who has been floated to the acute psychiatric unit? 1. Performing one-to-one observation of a patient who is suicidal 2. Assisting the OT to conduct a craft class 3. Accompanying an elderly patient who wanders on a walk outside 4. Assisting the medication nurse who is having problems with a patient

3 21.13

A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He is being prescribed haloperidol. What is the priority action? 1. Encourage him to look at you and stay with him until the spasms pass 2. Place the patient on aspiration precautions until the spasms subside 3. Obtain an order for IM or IV diphenhydramine 4. Obtain an order for and administer an anti seizure medication

3 21.19

You arrive home and find that the house of your neighbor (Jane) is on fire. A fireman is physically restraining her from running back into the house. What is the best response? 1. Jane, come and sit in my house until this is over with 2. Jane, calm down and let the fireman do his job 3. Jane, look at me and hold my hand 4. Jane, tell me why you are struggling so hard

3 21.4

There is a patient on the medical-surgical unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should you handle the assignment? 1. Rotate the assignment schedule so that no one has to care for him more than once or twice a week 2. Pair a float nurse and a nursing student and assign the patient to that team because they will have a fresh perspective toward the patient 3. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions 4. Assign yourself as primary caregiver sot hat you can role-model how patients should be treated

3 21.5

Mr. J has a panic disorder and it appears that he is having some problems controlling his anxiety. Which symptoms concern you the most? 1. His HR is increased and reports chest tightness 2. He demonstrates tachypnea and carpopedal spasms 3. He is pacing and pounding his fists together 4. He is muttering to himself and is easily startled

3 21.8

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be sure to monitor? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia

3 4.7

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the UAP who is assisting with the client's care? 1. Teaching the client and family members about means to prevent transmission of VRE 2. Communicating with other departments when the client is transported for ordered tests 3. Implementing contact precautions when providing care for the client 4. Monitoring the results of ordered laboratory culture and sensitivity tests

3 5.10

A 23-year-old client comes to the outpatient clinic reporting increasing shortness of breath, diarrhea, abdominal pain, and epistaxis. Which action should you take first? 1. Assist the client to pinch the anterior nares firmly for 5 minutes. 2. Call an ambulance to take the client immediately to the hospital. 3. Ask the client about any recent travel to Asia or the Middle East. 4. Determine whether the client has had recommended immunizations.

3 5.11

You are admitting four clients with infections to the medical unit, but only one private room is available. Which client is it most appropriate to assign to the private room? 1. Client with diarrhea caused by C. difficile 2. Client with a wound infected with VRE 3. Client with a cough who may have TB 4. Client with toxic shock syndrome and fever

3 5.17

You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection? 1. Client with an implanted port in the right subclavian vein 2. Client who has a midline IV catheter in the left antecubital fossa 3. Client who has a nontunneled central line in the left internal jugular vein 4. Client with a peripherally inserted central catheter (PICC) line in the right upper arm

3 5.6

You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which nursing action can you delegate to an LPN/LVN? 1. Planning ways to improve the client's oral protein intake 2. Teaching the client about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown

3 5.7

A 16-year-old with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? 1. Allowing the patient to decide whether she needs aerosolized medications 2. Placing the patient in a private room to decrease the risk of further infection 3. Scheduling postural drainage and chest physiotherapy (CPT) every 4 hours 4. Planning activities to allow for at least 8 hours of uninterrupted sleep

3 19.12

You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal continuous positive airway pressure ventilation. Which assessment finding is most important to report to the health care provider? 1. Apical pulse rate of 156 beats/min 2. Crackles audible in both lungs 3. Tracheal deviation to the right 4. Oxygen saturation of 93%

3 19.14

After receiving the change-of-shift report, which patient should you assess first? 1. 18-month-old with coarctation of the aorta who has decreased pedal pulses 2. 3-year-old with rheumatic fever who reports severe knee pain 3. 5-year-old with endocarditis who has crackles audible throughout both lungs 4. 8-year-old with Kawasaki disease who has a temperature of 102.2° F (39° C)

3 19.17

You are caring for several children with cancer and are reviewing morning laboratory results for all of your patients. Which of these patient conditions combined with the indicated laboratory result causes you the greatest immediate concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/L 2. A nosebleed with a platelet count of 100,000/mm3 3. Fever with an absolute neutrophil count of 450/mm3 4. Fatigue with a hemoglobin level of 8 g/dL

3 19.3

As the pediatric unit charge nurse, you are making patient assignments for the evening shift. Which patient is most appropriate to assign to an experienced LPN/LVN? 1. 1-year-old with severe combined immunodeficiency disease who is scheduled to receive chemotherapy in preparation for a stem cell transplant 2. 2-year-old with Wiskott-Aldrich syndrome who has orders for a platelet transfusion 3. 3-year-old who has chronic graft-versus-host disease and is incontinent of loose stools 4. 6-year-old who received chemotherapy a week ago and is admitted with increasing lethargy and a temperature of 101° F (38.3° C)

3 19.6

The UAP asks you why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response? 1. "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out from not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."

3 4.11

You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. 4. Take off gown. 5. Perform hand hygiene.

3, 2, 4, 1, 5 5.3

A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? 1. Infuse normal saline at 75 mL/hr. 2. Obtain blood, urine, and sputum for cultures. 3. Place the client on airborne and contact precautions. 4. Give methylprednisolone (Solu-Medrol) 1 g IV.

3. 5.1

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse delegate to an LPN/LVN? 1. Performing ongoing assessments to determine the client's hydration status 2. Explaining the purpose of ordered stool cultures to the client and family 3. Administering the ordered metronidazole (Flagyl) 500 mg PO to the client 4. Reviewing the client's medical history for any risk factors for diarrhea

3. 5.14

You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client.

4 1.1

Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Elderly client with chronic pain who has a hip fracture 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Child with an arm fracture and cystic fibrosis

4 1.12

The physician has ordered a placebo for a client with chronic pain. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? 1. Prepare the medication and hand it to the physician. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice.

4 1.16

On the first day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the first action you should take? 1. Deliver the bolus dose per standing order. 2. Contact the physician to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity.

4 1.19

The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? 1. Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format 2. Giving the ordered dose of Narcan and evaluating the response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

4 1.20

An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting an anesthetic mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Helping the patient to eat a bland, moist, soft diet

4 19.5

Which patient should be assigned to a newly-graduated nurse who has just started on the unit? 1. Patient who is frequently admitted for borderline personality disorder and suicidal gesture 2. Patient admitted yesterday for disorganized schizophrenia and psychosis 3. Patient newly admitted to determine differential diagnosis of depression, dementia, or delirium 4. Patient newly diagnosed with major depression and rumination about loss and suicide

4 21.12

The ED is calling to report on a patient who will be admitted to your acute psychiatric unit. HE has a history of bipolar disorder and was in an altercation that resulted in the death of another. He has contusions, abrasions and minor lacerations. What is the priority question that you should ask? 1. When will the patient be transferred? 2. Will a police officer be with him while he is on the unit? 3. Why isn't the patient being admitted to the trauma unit? 4. What is the patient's current mood and behavior?

4 21.17

A patient diagnosed with paranoid schizophrenia tells you that "Dr. Smith has killed several other patients and now he is trying to kill me." What is the best response? 1. I have worked here a long time. No one has died. You are safe here 2. What has Dr. Smith done to make you think he would like to kill you? 3. All of the staff, including Dr. Smith, are here to ensure your safety. 4. Whenever you are concerned or nervous, talk to me or any of the nurses

4 21.6

You are preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL). Which statement by the client indicates to you the need for additional teaching? 1. "I will call my doctor if I experience muscle twitching or seizures." 2. "I will make sure to take my vitamin D with my calcium each day." 3. "I will take my calcium citrate pill every morning before breakfast." 4. "I will avoid dairy products, broccoli, and spinach when I eat."

4 4.10

You are reviewing the client's morning laboratory results. Which of these results is of most concern to you? 1. Serum potassium level of 5.2 mEq/L 2. Serum sodium level of 134 mEq/L 3. Serum calcium level of 10.6 mg/dL 4. Serum magnesium level of 0.8 mEq/L

4 4.12

You are admitting an older adult client to the medical unit. Which assessment factor alerts you that this client has a risk for acid-base imbalances? 1. History of myocardial infarction 1 year ago 2. Antacid use for occasional indigestion 3. Shortness of breath with extreme exertion 4. Chronic renal insufficiency

4 4.16

The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weigh the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/day. 4. Administer furosemide (Lasix) 40 mg IV push.

4 4.4

You are the charge nurse on the medical unit. Which infection control activity should you delegate to an experienced UAP? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4 5.12

A healthy 65-year-old woman who cares for a newborn grandchild has a clinic appointment in May. The client needs several immunizations, but tells you, "I hate shots! I will only take one today." Which immunization is most important to give? 1. Influenza 2. Herpes zoster 3. Pneumococcal 4. Tetanus, diphtheria, pertussis

4 5.20

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first? 1. Notify the physician about the loose stools. 2. Obtain stool specimens for culture. 3. Instruct the client about correct hand washing. 4. Place the client on contact precautions.

4 5.8

As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in charting.

4 1.5

You obtain this information when assessing a 3-year-old with uncorrected tetralogy of Fallot who is crying. Which finding requires immediate action? 1. The apical pulse rate is 118 beats/min. 2. A loud systolic murmur is heard in the pulmonic area. 3. There is marked clubbing of all of the child's nail beds. 4. The lips and oral mucosa are dusky in color.

4 19.16

You are obtaining the history and physical information for a child who is recovering from Kawasaki disease and receives aspirin therapy. Which information about this patient will concern you most? 1. The child attends a day-care center 5 days a week. 2. The child's fingers have areas of peeling skin. 3. The child is very irritable and cries frequently. 4. The child has not received any immunizations.

4 19.19

. A 6-year-old who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is your best response to this behavior? 1. Remind the child that foods tasted good today and will help the body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mother that the behavior could be a normal expression of anger.

4 19.4

You are caring for a patient in whom a conversation disorder was recently diagnosed. She is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult-age son. What is the priority therapeutic approach to use with this patient? 1. Reassure her that her blindness is temporary and will resolve with time 2. Gently point out that she seems to be able to see well enough to function independently 3. Encourage expression of feelings and link emotional trauma to the blindness 4. Teach ways to cope with blindness, such as methodically arranging personal items

4. 21.2

You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today.

5,3,1,2,4 1.18