Final test
Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection?
1. Cleans perineum from front to back after newborn soils diaper.2. Makes certain the umbilical cord remains dry with each diaper change.
Which task would be appropriate for the charge nurse to assign to a LPN/VN?
1. Collect data on a new client admit. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection?
1. Color Changes 2. Drainage 3. Odor 4. Fever 6. Increased Pain
The nurse is planning to teach a group of assisted living residents about tuberculosis (TB) infection. What should the nurse include?
1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 5. Proper disposal of tissues.
The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective?
1. Decreased anxiety 2. Relief of chest pain 4. Lowered blood pressure
A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement?
1. Depersonalization
Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality?
1. Develop a trusting relationship. 2. Be honest when communicating with the client. 5. Give clear explanations of procedures before hand.
The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider?
1. Difficulty waking up 3. Blurry vision 5. Vomiting
What should the nurse include when educating a client about the use of nitroglycerin sublingual.
1. Do not swallow nitroglycerin. 3. The medication may burn when taken. 4. Sit or lie down when taking this medication.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment?
1. Dramatic decrease in pain after beginning medications.
The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement?
1. I will wear long sleeves and a hat when I go for my afternoon walks.
A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take?
1. Administer the digoxin.
A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response?
3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider."
A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate. What is the best reply for the nurse to make?
3. "This medication will stop the growth of the embryo to save your fallopian tube."
The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client?
3. Bacterial resistance is decreased.
A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client?
3. Broiled white fish, baked potato, mixed salad and tea
The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share?
3. Client who has a fractured hip.
Which client requires immediate intervention by the nurse?
3. Client with a fractured femur reporting sharp chest pain of 4/10.
Which client should the nurse, working the Emergency Department (ED), see first?
3. Client with adrenal insufficiency who feels weak.
The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery?
3. Client's last menstrual period was 8 weeks ago.
What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center?
3. Client's plan for transportation and care at home.
A hospice nurse is assessing a client reporting chronic pain (5/10 on the pain scale). In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client?
3. Massage therapist
A client who has been on a psychiatric unit because of several attempted suicides states, "I am happy to be going home today." What is the nurse's best analysis of this statement?
3. May have decided on another suicide plan.
The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?
3. Metabolic acidosis
A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect?
3. Pseudoparkinsonism
The primary healthcare provider (PHP)has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's best first action?
3. Question prescription with primary healthcare provider.
Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement?
3. Rapid weight gain 4. Decreased blood glucose level
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action?
3. Read about formalin on the Material Safety Data Sheet (MSDS).
A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers?
3. Recent sore throat
A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample.
A nurse has received the following arterial blood gas results on a client with a post bowel resection: pH 7.48; PCO2 30; HCO3 24. Which acid/base imbalance is the client experiencing?
3. Respiratory alkalosis
The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes?
3. Secure the dressing with Montgomery straps.
A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions?
3. The B12 injections will be continued for the client's life.
Which pediatric client should the nurse see first?
3. Three year old with wheezes in right lower lobe.
A client at 36 weeks gestation is receiving magnesium sulfate for treatment of pre-eclampsia. Which finding by the nurse requires immediate action?
3. Urinary output (UOP) of 100cc/4hours
Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding?
3. Urinary tract infection
The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take?
2. Administer another Mantoux tuberculin skin test at a different site.
A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority?
2. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn.
The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache?
2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.
The nurse is caring for a client prescribed vancomycin for Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. What nursing intervention is appropriate?
2. Verify that the client's BUN and creatinine are within normal range
The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client?
2. Warm the finger prior to the stick.
The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary?
3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion."
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect?
3. Flail chest
What should the nurse include when teaching a client in renal failure about peritoneal dialysis?
3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 6. A sweet taste may be experienced when peritoneal dialysis is used.
An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has?
3. Hypokalemia 4. Metabolic alkalosis
What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain?
3. Impaired speech. 4. Decreased
During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action?
3. Initiate the missing client protocol.
The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include?
3. Intravenous administration of isotonic saline.
Which factor would most likely predispose a client to developing shock following a fracture of the femur?
3. Loss of blood into soft tissues surrounding the fracture
When assessing a client's testes, which finding would indicate to the nurse the need for further investigation?
3. Lump the size of a piece of rice.
The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test?
3. Wear a particulate respirator 5. Initiate airborne precautions.
The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct?
3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.
A nurse is teaching a client about the prescription aripiprazole discmelt. The nurse documents that teaching has been effective when the client makes which statement?
4. "I will allow the tablet to dissolve in my mouth."
An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed?
4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn."
A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first?
4. Administer furosemide 20 mg intravenous push (IVP).
A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan?
4. An absence of corneal irritation
The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse best meet the religious dietary needs for this client?
4. Ask the client about dietary preferences needed to meet religious guidelines.
A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention?
4. Assess bilateral radial pulses
What task by the RN should be performed first?
4. Assessing a newly admitted client.
A nurse is caring for a client who has developed ventricular fibrillation. Where should the nurse place the conductive electrodes for maximum defibrillation effectiveness?
4. Below the right clavicle to the right of the sternum and just below the left nipple.
What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis?
4. Bicycle riding 5. Swimming
Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client?
4. Case manager
A home health nurse visits a recently discharged client with right-sided paresis due to a stroke. The nurse discovers that the spouse has been feeding the client. What action should the nurse take?
4. Determine why the spouse is not encouraging self-care by the client.
After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action?
4. Gently massage the tragus of the ear.
The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP?
4. Hang a familiar object on the door to enhance room recognition.
The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client?
4. Increase fiber.
What instruction is most important to include when teaching a child how to self administer a combined dose of isophane suspension and regular insulin subcutaneously?
4. Insulin syringes should be stored at room temperature.
The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway?
4. Jaw thrust maneuver
The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which sign or symptom would cause the greatest concern?
4. Muscle spasms
The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have?
4. No chest drainage will be necessary.
Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit?
1. 10 year old paraplegic in for bowel training. 4. 7 year old in Buck's traction for a femur fracture.
What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage?
4. Suction equipment
The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene?
4. TPN appears oily in consistency
Which home routines help reduce the risk of skin damage in a client with impaired sensation?
4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Check condition of all equipment used in the home.
These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first?
4. The client with a sucking chest wound and tension pneumothorax.
A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment?
2. 4 mm Hg
The nurse is working at the triage station. Which client should the nurse triage first?
2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. "
A client with chronic alcoholism has been admitted to the intensive care unit after overdosing on alcohol. Which medication should the nurse prepare to administer?
2. Thiamine 100 mg IV twice a day
A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform?
2. Time-out
The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client?
2. Treat a mild episode with 10-15 grams of carbohydrate.
The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene?
2. Use petroleum jelly on the nares and cheeks.
The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported?
1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics.
Which tasks would be appropriate for the nurse to assign to an LPN/VN?
1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 5. Check for urinary retention. 6. Remove wound sutures.
The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment?
3. Auscultate breath sounds.
What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw?
1. Chew the acetylsalicylic acid prior to swallowing.
Which client should the charge nurse assign to a new RN?
1. Child needing pre-operative medication prior to reduction of a fracture.
The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications?
1. Kidney stones 3. Osteoporosis
In what position should the nurse place a client post liver biopsy?
4. Right Lateral Decubitus
The nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent?
1. A bruit is heard with a stethoscope. 2. A thrill is felt on palpation.
A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure?Place actions in the correct order.
-Elevate head of bed to fowler's position. -Measure distal NG tube from nose tip to earlobe to xiphoid process. -Lubricate 2-3 inches of distal NG tube. -Insert NG tube into unobstructed naris. -Advance NG tube upward and backward until resistance is met. -Rotate catheter and advance into nasopharynx. -Have client swallow ice as NG tube advances into stomach. -Secure NG tube.
A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take.
-Initiate oxygen.Insert another IV line. -Obtain blood sugar level. -Insert NG tube. -Repeat vital sign checks
The nurse manager is teaching the principle of least restrictive intervention on a psychiatric unit with a new nurse. In order to demonstrate understanding of this principle, in what order would the new nurse correctly place interventions from least restrictive to most restrictive? Place in correct order from least restrictive to most restrictive.
-Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. -Walk the client out to the courtyard. -Take the client to the quiet room for a time out. -Place client in the isolation room with staff observation. -Restrain client's arms with wrist restraints. -Use four point soft cloth restraints.
What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bedrest?
1. "Clients on bedrest should be placed on therapeutic mattresses." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."
The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful?
1. "Exhale completely before using my inhaler." 3. "Inhale slowly and push down firmly on the inhaler." 4. "Rinse my mouth with water after using my inhaler."
What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective?
1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects."
The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion?
1. "Please tell me how I can best help you control your pain."
A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response?
1. "The pain you feel is real."
A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse?
1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. "
The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease?
1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt."
A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition?
1. A known allergy to gelatin.
The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected?
1. Abrupt onset of dyspnea, fever.
A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate?
1. Administer oxygen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm
A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? exhibit: Hgb - 15 g/dl (2.3 mmol/l) Hct - 42% Platelets - 110,000/ mm3 aPTT - 110 seconds INR - 1.2
1. Administer protamine sulfate 50 mg over 10 minutes.
A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client?
1. Alternating pressure mattress 2. Hospital bed 4. Suction equipment 5. Oxygen
The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client?
1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends.
What side effects would the nurse expect to find in a client who has received too much levothyroxine?
1. Angina 4. Heat intolerance 5. Tremors
Which intervention should the nurse initiate for a client post liver biopsy?
1. Apply direct pressure to site immediately after needle is removed. 2. Assess puncture site every 15 minutes for 1 hour. 5. Advise client that pain may occur in right shoulder as the anesthetic wears off.
A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic?
1. Are you feeling afraid now?
A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client?
1. Ask the primary healthcare provider to prescribe a diabetes educator consult.
A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class?
1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history.
Post thyroidectomy, the nurse assesses the client for complications by performing which assessment?
2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual?
1. Attend an activity with the client who is reluctant to go alone. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.
Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)?
1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Help position a client for a portable chest x-ray. 5. Collect a stool specimen.
A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child?
1. Blood cultures times two
While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding?
1. Breech presentation
A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation?
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.
The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include?
1. Check shoes for rough spots in the lining. 2. File toenails straight across. 4. Break in new shoes gradually.
A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include?
1. Checking your vital signs frequently. 2. Examining the dressing for bleeding. 3. Listening to and percussing your lungs. 5. Palpating around the incision site for air under the skin.
The nurse is teaching parents of a school aged child about interventions to keep the child safe. Which interventions would be appropriate to include in the health promotion plan?
1. Encourage bicycle helmet use when riding bikes. 2. Teach children to swim at an early age. 4. Keep firearms in the home locked and unloaded. 5. Teach "stop, drop, and roll" in case clothing catches on fire.
A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected?
1. Ensure a do-not-resuscitate prescription has been provided.
The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure?
1. Face shield 3. Gown 4. Mask 5. Regular exam gloves
A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include?
1. Fever greater than 100.4° F (38° C) for 2 or more days. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn.
A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client?
1. Firm, nodular liver 2. Ascites 4. Increased ALT and AST levels 6. Bleeding from the GI tract
A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse?
1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate?
1. Frequently initiate contact with client.
Three hours after delivery of a client's newborn, the nurse assesses for bladder distention. What signs would the nurse note if the client's bladder is distended?
1. Fundus 3 cm above umbilicus 2. Excessive lochia 5. Tenderness above symphysis pubis
The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects?
1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning. 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication.
What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation?
1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 5. The client needs to increase fluid intake.
The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do?
1. Inform the primary healthcare provider immediately. 3. Inform the client to watch for signs of bleeding.
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit?
2. Client diagnosed with seizure disorder.
The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take?
1. Inform the primary healthcare provider of the observations made regarding quad cane use, and imbalance assessment.
The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?"
1. It will increase the level of serotonin in the brain.
A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation?
1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.
The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body?
1. Lowers the blood glucose 2. Provides more energy
A client has just delivered a newborn. Based on the primary healthcare provider's notation, what prescriptions does the nurse anticipate administering to the mother? exhibit: Healthy male (21 inches long, 7 pounds) delivered to 22 y/o female Para 1 Gravida 1. Client is Rh negative and the newborn is Rh positive. Rubella titer less than 1:8. Hepatitis B status negative. Tetanus toxoid 2 years ago
1. Measles, mumps and rubella (MMR) vaccine 4. RH0(D) immune globulin
Which action, if done by a nurse, needs to be interrupted by the charge nurse?
1. Mixes diazepam and hydromorphone in one syringe.
What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland?
1. Monitor intake and output. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.
A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement?
1. Monitor stools for occult blood. 2. Place on fall prevention. 4. Restrict venipunctures.
When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism?
1. Nervousness 3. Exophthalmos 6. Hot and sweating
A nurse is planning to teach a group of men about their sildenafil prescription. What information should the nurse include?
1. Notify primary healthcare provider if prescribed an alpha-adrenergic blocker. 3. Sildenafil should be taken only once per day if needed. 5. The most common side effects are flushing, headache, and dyspepsia.
The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase?
1. On-going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 4. Relapse prevention plan. 5. Continued peer support.
Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider?
1. Parent states infant tastes salty. 2. Frequent coughing with thick, blood-streaked sputum. 3. Foul-smelling, greasy stools. 5. No weight gain since last check-up.
A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document?
1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first?
1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke."
Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)?
1. Primipara needing assistance with breastfeeding. 3. Primipara who is two days post op cesarean section.
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea?
1. Progesterone
In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients?
1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 6. Obtain assistance from other nurses or nurse assistants as needed.
A client is admitted with a diagnosis of myasthenia gravis. What interventions should the nurse include to manage this client's swallowing and chewing impairment?
1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids.
Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)?
1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation.
A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance?
1. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses' reasons for not using pain level scale.
Which nurse is providing cost effective care to a client?
1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations.
An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip?
1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult?
1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery.
The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena?
1. Speaking up for the underrepresented, such as the poor and uneducated persons. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located.
What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition?
1. Suggest client eat several small meals a day, with the largest at breakfast.
The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury?
1. Suggest that the family lock up medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.
The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day?
1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them.
The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility?
1. Turn every two hours 2. Place a pillow between legs when turning 4. Encourage fluid intake 5. Encourage ankle and foot exercises
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse?
1. Undergoing surgery for placement of a central venous catheter.
A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client?
1. Use simple words.
What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia?
1. White blood cell count of 3,800 (3.8 x 109/L) 3. Platelet count of 90,000/µL (90 x 109/L) 5. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L)
The nurse in the outpatient clinic performs an assessment on a client who takes propranolol for management of palpitations associated with mitral valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider?
2. "I feel a little short of breath when walking."
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider?
2. "I had rheumatic fever when I was 10 years old."
A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag?
2. 2nd and 3rd degree burns over 75 % of the body.
The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements?
2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements."
The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed?
2. "I will instill normal saline bullets to liquefy secretions."
A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful?
2. "I will not elevate the head of the bed."
A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)?
2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"
A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take?
2. Begin treatment by inserting two large bore IVs of Normal Saline.
Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure?
2. Bibasilar crackles 3. Orthopnea
A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse?
2. Blood pressure reading.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain?
2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve.
The critical care nurse is caring for four clients who develop rhythm changes within moments of each other. Which client (with a rhythm change from a normal sinus rhythm) should the nurse assess first?
2. Correct: This client has a very slow ventricular rate at 40 beats per minute (bmp), due to complete heart block. Cardiac output can be decreased which decreases perfusion to the vital organs and can cause shock. This client should be assessed first.
The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment?
2. Denial
A client arrives at the emergency department with a pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, what intervention should the nurse initiate?
2. Document the finding.
A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood?
2. Elevated reticulocyte count
A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms?
2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia
What symptoms does the nurse expect to see in a client with bulimia nervosa?
2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain
A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation?
2. Ferrous sulfate
A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding?
2. Fistula formation with an abscess
The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications?
2. I may expect increased sweating while taking this drug.
The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials?
2. In a chemotherapy sharps container
A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective?
2. Increase in uninary output
Which suggestion should the nurse provide to a client reporting frequent episodes of constipation?
2. Increase intake of fruit in the diet.
An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this?
2. Listen to the family's concerns and report those to the primary healthcare provider.
An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action?
2. Lung assessments every 2-4 hours.
A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement?
2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client.
A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually?
2. Mammography 3. Influenza vaccine
A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen?
2. Many people of faith believe that one way God works to heal is through medication.
The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety?
2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record.
A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first?
2. Notify the primary healthcare provider immediately.
The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment?
4. Setting the alarm clock for medication times.
Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)?
2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence.
A client received a leg cast that was applied following fracturing the left femur. What assessment finding would be a priority for the nurse to report to the primary healthcare provider?
2. Pain not relieved by elevation, cold packs, and pain medication.
A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do?
2. Place the client in a negative pressure room.
Which finding should a nurse expect when assessing a healthy 65 year old client?
2. Presbyopia
The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth?
2. Presence of a carotid pulse with each compression
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair?
2. Removing the hair with clippers. 4. Using a depilatory cream.
A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance?
2. Respiratory alkalosis
The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching?
2. Salami
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action?
2. Scared and lonely and grabs the nurse's hand for comfort.
A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother?
2. Takes offense to the abrupt nature of the treatment.
A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence?
2. Tenderness over the kidney
A client with a history of increasing dyspnea over the past week comes to the emergency department. After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to document?
2. The client was on 2 L of oxygen by nasal canula.
The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points?
2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes.
As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number.Enter the answer for the question below.
29.95 or 30
The nurse is caring for a client on the medical unit. The client has an IV of 1000 mL D5W with 50,000 units heparin. The infusion is to run at 60 mL per hour. How many units/hour is the client receiving? Round answer to the nearest whole number.Enter the answer for the question below.
3,000 units/hr
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response?
3. "Come to the clinic now so that we can help you."
A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal?
3. "I may use any hard plastic container with a screw-on cap."
An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication?
3. "I will have to watch my intake of salads, something that I really love."
A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "My child has not been able to sleep since being put on methyphenidate." What is the best response for the nurse to make?
3. "To prevent insomnia, give your child the last daily dose at least 6 hours before bedtime."
A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs further instruction?
3. "When I rise from a chair, I should position my crutches on my unaffected side."
The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation?
3. 500
A nurse assesses the 5 minute Apgar on a term, newborn infant. Based on the Apgar score, what should be the nurse's priority intervention?
3. Administer "blow-by" oxygen while suctioning.
A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider?
3. Anxiety
Which intervention can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
3. Apply a condom catheter to an incontinent client.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do?
3. Consult with the pharmacy for a different medication concentration.
A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority?
3. Contact the regional organ procurement team.
A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action?
3. Decrease stimuli in the room.
A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority?
3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night.
When caring for young adult clients, which developmental tasks would the nurse expect to see?
3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return.
A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take?
3. Discuss client rights with the primary healthcare provider.
A nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate?
3. Escort the client to an easel and canvas in order for the client to paint.
The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority?
3. Examine the client's feet for signs of injury.
The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection?
3. Expectorating moderate amounts of thin, white sputum 5. Crackles clearing with cough
A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning?
3. Notify social services to arrange a home visit.
A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first?
3. Place on droplet precautions.
The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide?
3. Positioning the client in side-lying position.
The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client?
3. Spending time in brief one on one interactions with the nurse.
One week ago a client was involved in a motor vehicle crash and was brought to the Emergency Department. The client received two sutures to the forehead and was sent home. Today, the client's spouse notes the client "acts drunk" and cannot control the right foot and arm. Based on this data, what should the nurse suspect?
3. Subdural hematoma
The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside?
3. Surgical scissors
What should a nurse teach a client who has been diagnosed with hepatitis A?
3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice.
A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate?
3. Tell me what the voices are saying to you.
A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client?
4. Notify the primary healthcare provider.
During shift change the night charge nurse reports to the day charge nurse that a client, admitted with an ingestion of unknown drugs, received a prescription for physical restraint at 3:00 am because the client was incoherent, combative, and attempting to leave the facility. On last assessment at 7:00 am, the client was still combative. What is the best action by the day shift charge nurse?
4. Obtain a prescription from the primary healthcare provider.
Which client must the nurse assign to a private room?
4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)
A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with?
4. Pre-term labor client with twins at 28 weeks gestation.
After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first?
4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.
Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick?
4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.
A client has an order for two units of packed red blood cells (PRBCs) to be administered. The current IV prescribed is D5LR with 20 mEq KCL at 125 mL/hr infusing through a 22 gauge needle to the left hand. What action should the nurse take?
4. Start another IV with an 18 gauge needle to the right arm.
The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which action by the nurse indicates that further instruction on transmission of this disease is needed?
4. States that the newborn may contract herpes from the birth canal.
The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first?
4. Stop the infusion.
A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent?
4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy.
What is most important for the nurse to do prior to initiating peritoneal dialysis?
4. Warm the dialysate fluid.
Which client diagnosis would require the nurse to initiate droplet precaution?
4. Whooping cough
Based on the Parkland formula, the primary healthcare provider has determined that a burn victim needs 9,250 mL of LR intravenously over the first 24 hours. How many milliliters of LR should the nurse administer over the first eight hours? Round answer to the nearest whole number.
4625
The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.
5mg x 18 kg = 90 mg/day
A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last.
First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire.
The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL ofD5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number.
x = 2400 min. divide by 60 = 40 hours
