Comprehensive Exam 2
106. To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication? a. Review the client's fasting blood glucose levels for a hyperglycemic trend. b. Determine if the client has ever had a hypersensitivity reaction to penicillins. c. Restrict the use of dairy products in the client's diet for the next 3 weeks. d. Take the client's vital signs prior to the first dose and once daily for 14 days.
B
12. A healthcare provider (HCP) asks the nurse to give a medication to a client, and the nurse tells the HCP that the client is allergic to the medication. The HCP says, "Give the medication or I will report this to your supervisor." What response should the nurse provide? a. Walk away and ignore the threatening statement. b. Give the prescribed medication and document the situation. c. Tell the HCP that both of you should talk to the supervisor now. d. Respond that this client is not assigned to the nurse.
C
14. Which type of delivery of nursing care is organized around tasks? a. Team nursing. b. Primary nursing. c. Case management. d. Functional nursing.
D
115. A child with nephrotic syndrome is receiving prednisone (Deltasone). Which priority nursing diagnosis should the nurse include in the plan of care? a. Nausea. b. Risk for Infection. c. Risk for Bleeding. d. Disturbed Body Image.
B
94. A young adult female comes to the health clinic to confirm a positive home pregnancy test. After determining the client's last menstrual period (LMP) as February 14, what expected date of birth (EDB) should the nurse calculate? a. January 7. b. October 17. c. November 21. d. December 11.
C
57. Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first? a. Assess the client's current oxygen saturation level. b. Auscultate the client's breath sounds bilaterally. c. Prepare to administer a dose of naloxone (Narcan) IV. d. Attempt to arouse the client to stimulate respirations.
D
53. A nurse is caring for a male client with paranoid schizophrenia who believes that his antipsychotic medications are poison. Which intervention is best for the nurse to implement? a. Describe the need for consistently taking medications. b. Offer the medication in a concentrated form. c. Discard the medication and document the client's refusal. d. Approach the client with the medication 30 minutes later.
D
52. A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client? a. A negative pressure room. b. A semi-private room on a surgical unit. c. A postpartum room in the birthing center. d. A private room on a medical unit.
D
102. Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)? a. An older client with intestinal obstruction and septic shock. b. A near-drowning victim with a history of respiratory arrest. c. An adolescent with an autoimmune disease. d. An adult male with a myocardial infarction and pericarditis.
A
120. The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider? a. Sinus bradycardia at 50 beats per minute. b. Flaccid paralysis below the level of the injury. c. Systolic blood pressure 80 mm Hg after 2 fluid boluses. d. SpO2 is 88% with shallow, slow respirations.
D
15. During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond? a. "Tell me about the drugs you use now." b. "Explain what you mean by many drugs." c. "Do you mean legal drugs or illegal ones?" d. "What kind of drugs are you talking about?"
A
92. A client has a precipitous delivery attended only by the nurse. What nursing intervention has the highest priority? a. Ensure an adequate airway in the newborn. b. Massage the uterine fundus until it is firm. c. Clamp and cut the umbilical cord. d. Assess for signs of placental detachment.
A
98. A client who delivered a 9 pound 2 ounce infant 3 hours ago is experiencing uterine atony. Which action should the nurse implement first? a. Massage the fundus. b. Catheterize the bladder. c. Establish venous access. d. Prep for surgical intervention.
A
105. Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? a. African-American women who are 30 to 35 years of age. b. Survivors of violence that occurred at least 5 years ago. c. Active armed forces reserve unit returning from Europe. d. Full-time students who are attending public colleges.
B
118. A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? a. History of alcohol intake. b. Time of last meal. c. Frequency of vomiting. d. Intensity of pain.
D
4. Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide? a. Give the toddler nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so the child is hungry at mealtimes. d. Explain to the child in a firm manner what is expected.
A
107. The nurse is informed that a client is returning to the unit from the post-anesthesia care unit following abdominal surgery. Which task is best to delegate to the unlicensed assistive personnel (UAP)? a. Assess breathing pattern after transport is completed. b. Notify the family that the client is returning from surgery. c. Report to the charge nurse the appearance of the dressing. d. Assist the transport team with transferring the client to the bed.
D
47. An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids? a. Begin wearing the aids in quiet environments to experiment with adjustments. b. Wear the hearing aids for an hour a day at first, gradually increasing the time. c. Keep the volume on low until the conditions with noises are audible. d. Use one hearing aid until comfortable, then add the second aid.
A
108. A client at 13-weeks gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information? a. Level of fetal lung maturity. b. Presence of genetic disorders. c. Quantification of alpha-fetoprotein levels. d. Determination of gestational age.
B
59. Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse implement? a. Avoid any intramuscular medications to prevent localized bleeding. b. Have vitamin K available in the event the client begins to bleed. c. Notify the healthcare provider if the partial thromboplastin time is greater than 50 seconds. d. Start instruction for self-administered SC heparin injections for long-term home therapy.
A
29. Which biological practices are federally regulated for healthcare workers? (Select all that apply.) a. Standard precautions. b. N-95 tuberculosis standard. c. Blood-borne pathogen standard. d. Biological product exposure limit (BPEL). e. Resource Conservation and Recovery Act (RCRA). f. As Low as Reasonably Allowable standard (ALARA).
A, B, C
35. A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload? a. Increase in size. b. Decrease in length. c. Increase in number. d. Decrease in excitability.
A
39. A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement? a. Refer for further diagnostic evaluation. b. Determine exposure of others to the tuberculosis. c. Begin anti-tubercular drug therapy. d. Quarantine or isolate to control communicability.
A
45. When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? a. Record these findings in the client's record. b. Observe closely for possible dehiscence. c. Notify the healthcare provider that the client's wound is producing a sanguineous drainage. d. Increase the IV fluid rate and encourage the client to eat more ice chips.
A
16. A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become addicted to paint fumes?" What is the best response for the nurse to provide? a. "Only hard drugs like cocaine and heroin can cause problems with addiction." b. "Tell me what you think may have caused him to start inhaling paint fumes." c. "Abuse of any of the inhalants can eventually lead to addiction." d. "Any time you use an illegal substance, you are abusing drugs."
C
86. The nurse is assessing an older adult client's living arrangements and care. Which situation should the nurse identify as contributing the most to the client's vulnerability for elder abuse? a. The caregiver's stress level is overwhelming. b. Programs for older adults are not being utilized. c. Several generations in the family are providing care. d. The client does not appreciate the care provided by the family.
A
50. A mother calls the emergency department because her 9-year-old son has just fallen on his face and one of his front teeth has fallen out. Which instructions should the nurse provide to preserve the tooth's viability? a. Clean the tooth with toothpaste. b. Place the tooth in milk or water. c. Put the tooth back in the child's mouth. d. Gently place the tooth in a plastic bag.
B
78. A client at 26-weeks gestation comes to the labor and delivery unit and complains, "Something is not right". Which finding should the nurse assess further? a. Estriol is absent from the maternal saliva. b. The cervix is effacing and dilated to 2 cm. c. Fetal fibronectin is absent in vaginal secretions. d. Irregular mild uterine contractions occurring daily.
B
100. A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? a. Write the correct prescription as a verbal order received from the healthcare provider. b. Correct the misspelled medication in the written prescription and initial the change. c. Consult with the pharmacist to determine the best medication for the client. d. Contact the healthcare provider to clarify the prescription intended for the client.
D
63. While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take? a. Notify respiratory therapy immediately for a PRN bronchodilator treatment. b. Obtain a prescription to increase the tidal volume setting on the ventilator. c. Stop mechanical ventilation and re-assess the client's lung sounds bilaterally. d. Suction the client's endotracheal tube and auscultate following suctioning.
D
83. The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow? a. Check the pilot balloon to ensure that it is firm. b. Verify the healthcare provider's prescription for the required cuff pressure. c. Use a manometer to maintain cuff pressure between 25 and 30 mmHg. d. Inject air until no air is auscultated over the larynx during a deep breath.
D
46. When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement? a. Lower the extremity below the level of the client's heart. b. Gather the supplies needed to discontinue the IV fluid. c. Obtain an intravenous infusion pump to regulate the rate of infusion. d. Convert the IV to a saline lock until the healthcare provider is notified.
B
67. When assessing a client's interior eye structures with an ophthalmoscope, which action should the nurse use? a. Use a red-free filter. b. Adjust the diopters. c. Direct a wide-beam light. d. Dilate the client's pupils.
B
76. Which client requires the most immediate intervention by the nurse? a. A client with low back pain who is experiencing tolerance to the effects of an analgesic. b. An adolescent with a history of drug addiction who is requesting a sedative. c. A client with a chronic renal disease who is demonstrating a therapeutic response to a diuretic. d. A young adult who is reporting an anaphylactic response to an antibiotic.
D
37. A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid replacement at 20 ml/kg. How many ml should the nurse administer? (Enter numeric value only.)
400
41. A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? (Enter numeric value only.)
90
116. Which responsibility best describes the role of a nurse as manager? a. Development of long range career goals. b. Maintenance of harmony within the agency. c. Assignment of nursing personnel and resources. d. Delivery of client care while meeting agency goals.
D
104. A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first? a. Flush the catheter to maintain patency of the CVC access. b. Describe the placement and rationale for care of the catheter. c. Reassure the client that the TPN administration is temporary. d. Provide passive range of motion to the right arm and neck.
B
31. An elderly client is admitted with suspected bacterial pneumonia and lethargy. Ten minutes after the nurse initiates low-flow oxygen per nasal cannula and a peripheral IV with a secondary infusion of ticarcillin (Ticar), the client becomes disoriented, restless, and tachypneic. Which nursing action has the highest priority? a. Call for the emergency resuscitation team and retrieve the unit's crash cart. b. Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute. c. Observe the client's trunk and back for any hives and ask about the onset of urticaria. d. Notify the healthcare provider and prepare to administer IV diphenhydramine (Benadryl).
B
73. The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the mother's lap, chewing on a toy. Which action should the nurse implement first? a. Elicit reflexes. b. Auscultate heart and lungs. c. Examine eyes, ears, and mouth. d. Take an axillary temperature.
B
80. What is the underlying pathophysiologic process between free radicals and destruction of a cell memb rane? a. Inadequate mitochondrial ATP. b. Enzyme release from lysosomes. c. Defective chromosomes for protein. d. Defective integral membrane proteins.
B
89. A young adult female is brought to the emergency room by family members who report that she ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented? a. IV administration of Narcan. b. Syrup of ipecac per nasogastric tube. c. Acetylcysteine (Mucomyst) 140 mg/kg. d. Gastric lavage with normal saline.
C
111. What is the most effective way to implement a teaching plan? a. Teach the information that the client wants to learn first. b. Streamline the teaching plan to include only essential information. c. Present to the client all the information necessary to meet the objectives. d. Provide the client with written material to review before teaching sessions.
A
110. A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.) a. Airway and breathing. b. Pain management. c. Sleep and rest. d. Definitive therapy.
A, B, C, D
97. Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.) a. Economics. b. Workforce. c. Technology. d. Interventions. e. Socio-economic status. f. Legislation/regulation.
A, C, F
114. The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first? a. Document the change in pulse rate on the graphics sheet. b. Review the client's medical history for cardiac problems. c. Reassess the rate and characteristics of the client's pulse. d. Ask the UAP to recheck the client's pulse in thirty minutes.
C
121. A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding? a. Deep tendon reflexes 1+. b. Blood pressure of 140/90. c. Respirations of 10. d. Urinary output of 130 ml in 4 hours.
C
122. A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? a. Ask the parents to participate in encouraging the child's fluid intake. b. Tell the child he can go outside after he drinks a full glass of water. c. Offer the child a popsicle and allow him to pick the flavor he prefers. d. Make a game of seeing who can finish a glass of water first--the nurse or the child.
C
64. The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? a. An older man who is always happy and chooses to view only the good in every situation. b. A single mother who seeks the support of her two teenage daughters during difficult times. c. A successful businessman who is accustomed to handling highly-stressful situations. d. A teacher who seeks information about her disease and wants to continue teaching.
D
91. A client with chronic kidney disease (CKD) and severe anemia refuses blood transfusions. The healthcare provider prescribes epoetin alfa. Which action should the nurse explain to the client about the medication's therapeutic response? a. Accelerates neutrophil production, maturation, and activation. b. Activates the immune system with development of T and B cells and natural killer cells. c. Stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes. d. Increases production and maturation of granulocytes and macrophages.
C
25. Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis? a. Jaundice. b. Vomiting. c. Peripheral edema. d. Left upper quadrant pain.
C
87. What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply.) a. White patches. b. Cherry angiomas. c. Border irregularity. d. Lesion with asymmetry. e. Lesion with color variations. f. Lesion of 3 to 5 mm diameter.
C,D,E
70. The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction in the ventricles? a. T wave of 0.16 second. b. PR interval of 0.18 second. c. QT interval of 0.34 second. d. QRS interval of 0.14 second.
D
9. The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? a. Hand washing prior to preparation of the injection. b. Method used to aspirate medication from a vial. c. Selection and rotation of injection sites. d. Proper disposal of injection equipment.
B
90. The nurse asks an older female client with cognitive impairment who has been hospitalized for three days how her previous evening was. The client replies, "I had the best time. My husband took me out to dinner and then to a concert. The music was wonderful." Which term should the nurse document to best describe the client's response? a. Delusions. b. Confabulation. c. Concretization. d. Circumstantiality.
B
96. Which assessment is most important for the nurse to implement when performing a comprehensive assessment for an older adult? a. Chronic illnesses. b. Functional abilities. c. Immunologic function. d. Physical signs of aging.
B
7. An adult male with a history of heart failure tells the nurse that his lower extremities and feet swell when he sits at his computer all day. Which response is best for the nurse to provide? a. Limit the amount of table salt that you add to your meals. b. Take a daily vitamin with minerals to correct imbalances. c. Get up and walk around frequently during the day. d. Elevate your feet every night to reduce swelling.
C
72. The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot who has a prescription for partial weight-bearing. Which intervention should the nurse to implement before the client is discharged? a. Review the client's most recent serum calcium level. b. Verify that the crutches fit snugly under the axilla. c. Observe the client while demonstrating crutch walking. d. Determine if the client lives alone or with others.
C
103. While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? a. Continue the interview process and record the findings. b. Refer the client to a psychiatric outpatient clinic. c. Determine if there is a family history of emotional disorders. d. Encourage the woman to attend citizenship classes.
A
34. A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client? a. A terminally ill and depressed client with cancer. b. A client who is planning to have an elective abortion. c. A suicidal client who has made a highly-lethal attempt. d. A client who refuses a blood transfusion due to religious beliefs.
A
60. A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? a. Obstruction at the urinary bladder neck. b. Ureteral calculi obstruction. c. Ureteropelvic junction stricture. d. Partial post-renal obstruction due to ureteral stricture.
A
17. What instrument should the nurse use to determine the presence of deep tendon reflexes? a. Goniometer. b. Wood's lamp. c. Reflex hammer. d. Transilluminator.
C
22. A 6-year-old boy says he does not like the food at the hospital. A review of the child's intake reveals that he has eaten very little for the past 2 days. The nurse formulates a nursing problem of, "Imbalanced nutrition, less than body requirements." What action should the nurse implement? a. Select nutritious foods on the menu for the child. b. Provide the child with any snack foods between meals. c. Encourage family members to bring foods from home. d. Arrange the child's meal tray with generous portions of food.
C
32. About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat? a. A chocolate bar. b. A soft drink. c. Peanut butter crackers. d. A piece of buble gum.
C
101. The nurse is preparing to perform oral care for an unconscious client. In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.) a. Place an emesis basin under the client's chin. b. Position the client in a flat side-lying position. c. Raise bed to a comfortable working height. d. Lower the side rail between the nurse and the client.
C, D, B, A
56. A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care? a. Determination of the compatibility of the intravenous fluids and prescribed antibiotics. b. Provision of nursing staff education about safe administration of IV antibiotics. c. Maintenance of data related to the number of IV infiltration occurrences in the hospital. d. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes.
D
58. A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part of preoperative teaching, what information should the nurse provide? a. The transverse loop ostomy is permanent. b. Easily removable appliances allow independence in self-care. c. Daily irrigation is started after the J pouch heals. d. Stool is eventually expelled through the rectum.
D
109. Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse? a. An adult who had a colon resection yesterday and has an IV. b. An older adult who has a fever of unknown origin. c. A woman who had an acute brain attack (stroke, CVA) 6 hours ago. d. A teenager with a femoral fracture who is in traction.
A
123. Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure 135/90, temperature 97.6 F, pulse rate of 98 beats/minute, and respiratory rate 22 breaths/minute. The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching. What action should the nurse take? a. Notify the healthcare provider of the client's status. b. Assess vital signs q15 minutes until stable. c. Place the client in a vest-type restraining jacket. d. Encourage the client to take a warm bath to help relax.
A
10. The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented? (Place the first action on top and last action on the bottom.) a. Review medications client is taking. b. Measure the client's vital signs. c. Complete an incident report. d. Notify the healthcare provider.
B, A, D, C
93. The charge nurse, along with another RN and a practical nurse (PN) are caring for clients on a medical/surgical unit. Which nursing action should be assigned to the PN? a. Assist a client to look at the colostomy stoma for the first time. b. Access a central venous catheter via an implanted port. c. Develop a teaching plan for a client with rheumatoid arthritis. d. Administer a bolus tube feeding through a gastrostomy tube.
D
81. A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question? a. Morphine sulfate 5 mg IV on call to operating room. b. Atropine sulfate 0.4 mg IM on call to operating room. c. Betaxolol (Betoptic) one drop in each eye the morning of surgery. d. Benzodiazepine (Valium) 5 mg by mouth the morning of surgery.
B
84. A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first? a. Notify the healthcare provider. b. Stop the irrigation flow. c. Document the finding and continue to observe. d. Irrigate the catheter with a large piston syringe.
B
117. The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase a. blood pressure to 140/80. b. urine output to 55 ml/hr. c. pulse to 132 beats/min. d. respirations to 24 breaths/min.
B
119. A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated, if the need arises. How should the nurse respond? a. Nurses use their best judgment based on the client's condition. b. The healthcare team must honor the written wishes of the client. c. Notify the healthcare provider of the family's wishes, so a decision can be made. d. Every effort must be made to honor the family's wishes about their loved one.
B
124. The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first? a. Counsel the UAP about the inaccurate blood pressure readings. b. Observe the UAP performing blood pressure measurements. c. Make staff members aware of the possible errors in blood pressure readings. d. Ask the education department to provide additional training for the UAP.
B
18. Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)? a. Type 1 DM and a serum hemoglobin-A1c of 3.5%. b. Type 1 DM and retinopathy and mild vision loss. c. Type 2 DM and hypertension controlled by metoprolol. d. Type 2 DM and a history of morbid obesity for 5 years.
B
13. Which action should the nurse take first when performing tracheostomy care? a. Cleanse around the stoma. b. Suction the tracheostomy. c. Oxygenate with 100% oxygen. d. Secure the new neck strap.
C
40. During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention should the nurse implement? a. Prepare a written schedule to remind the client when to take each dose of aspirin. b. Observe the client place each dose in the correct boxes of her pill container. c. Contact the client's healthcare provider to report the assessment findings. d. Ask a family member to ensure that the client takes the medication as prescribed.
C
49. A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response? a. "You need to stop thinking negative thoughts. They get in the way of your recovery." b. "You are no bother to me or to the staff. We want you to get well and not feel sad anymore." c. "I have known many clients with depression who have felt better after several weeks of treatment." d. "You are feeling very pessimistic, but that is part of your illness. It should go away as you recover."
C
65. A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of labor. The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction. What action should the nurse implement at this time? a. Discontinue the oxytocin (Pitocin) infusion. b. Notify the healthcare provider. c. Administer 10 L of oxygen via face mask. d. Place the client on her left side.
D
113. The new parents express concern that they did not have the opportunity to hold and bond with their infant immediately after birth because the mother received anesthesia during an emergency cesarean delivery. What information should the nurse provide? a. The baby is healthy and they should not worry about the delay between birth and their first visit. b. Early contact is essential for optimum parent-infant relationships. c. The time immediately after birth is the critical period for human attachment. d. Bonding is a process that occurs over time and begins with the first parent-newborn contact.
D
20. The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN? a. A client receiving Lactated Ringer's solution requests pain medication. b. A client with a history of falls needs assistance to the bathroom. c. A client's indwelling urinary catheter requires manual irrigation. d. A client with an epidural infusion reports lower extremity parasthesia.
D
28. Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder? a. Describes success in dismissing persistent thoughts that used be bothersome. b. Reports that the obsessions and compulsions experienced are silly. c. Avoids obsessive verbalizations while interacting with family and staff. d. Participates in one social or recreational activity each morning and afternoon.
D
75. A client who has been taking a diuretic and ACE inhibitor for hypertension has a blood pressure of 160/90. Today a new drug, carvedilol (Coreg), is prescribed, and the client expresses concern about receiving so many different medications. What action should the nurse implement? a. Explain the rationale for the administration of all three medications to the client. b. Withhold the newly prescribed medication until contacting the healthcare provider. c. Administer the newly prescribed medication and withhold the other two medications. d. Document the client's BP and refusal to take the newly prescribed medication.
A
88. A newborn is brought to the admissions nursery by the nurse and the father of the baby. The baby weighs 9 pounds 3 ounces and measures 21 inches head to toe. Which description is a correct assessment of this infant? a. Above average in weight but average in length. b. Above average in weight and length. c. Above average in weight but below average in length. d. Macrosomia with an average length.
A
99. A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? a. Place the client in mechanical restraints until calm. b. Administer a PRN dose of haloperidol (Haldol) IM. c. Use a calm, soothing voice to diffuse the situation. d. Encourage the client to focus on his feelings of anger.
A
125. After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O 2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next? a. Collect blood for hemoglobin and hematocrit. b. Start the first transfusion of blood. c. Insert an indwelling urinary catheter. d. Encourage alternate rest periods with activity.
B
26. While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first? a. Unexplained weight gain. b. Current hair care practices. c. Family history of alopecia. d. Absence of axillary hair.
B
27. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? a. Use an electronic sphygmomanometer to take the BP every 30 minutes. b. Retake the blood pressure in the same arm, deflating the cuff slowly. c. Ask another nurse to recheck the blood pressure to compare results. d. Obtain another blood pressure cuff and retake the blood pressure.
B
36. The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit? a. An older client with end-stage cirrhosis who had a liver biopsy 4 hours ago. b. A client scheduled for a femoro-popliteal bypass surgery tomorrow. c. A middle-aged client with acute pancreatitis and lower left quadrant pain. d. A female client with angina and ectopy noted on the telemetry monitor.
B
43. The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement? a. Prepare for intubation. b. Defibrillate at 200 joules. c. Insert intravenous catheter. d. Obtain arterial blood gases.
B
61. Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional? a. "I really wish that my birthday wasn't so soon." b. "I don't talk about things like that anymore." c. "The doctor won't talk with me about this." d. "I think I should talk about this in group."
B
66. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? a. Page the unit manager to address the situation. b. Close the demographic screen on the computer. c. Instruct the UAP to end the phone call immediately. d. Send a UAP into the client's room to relieve the nurse.
B
74. Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting? a. Promote hygiene by ensuring that children's faces and hair are kept clean. b. Ensure that all enrolled children have been immunized for Hepatitis A. c. Put a strip bandage on bleeding injuries to prevent contamination of others. d. Teach children the correct handwashing technique to use after toileting.
B
79. A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's first action? a. Hyperextend the client's neck. b. Call for emergency assistance. c. Document the finding as a normal expectation. d. Reassure the client that the voice change is temporary.
B
8. A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU). What is the priority nursing action? a. Determine the client's pain. b. Take the client's vital signs. c. Calculate the IV infusion rate. d. Check the postop prescriptions.
B
5. Which action should the nurse implement when implementing a physical assessment of an older client? a. Avoid unnecessary touching while interacting with the client. b. Apply additional pressure to palpate the hepatic edge. c. Arrange the exam sequence to minimizes position changes. d. Speak loudly and slowly when telling the client how to assist.
C
82. During the initial home visit, the nurse performs a family assessment. Which component is most important for the nurse to consider? a. The legal definition of family in the United States. b. Members of the group that are direct descendents or bonded by marriage. c. An exploration of the group relationships, structure, functions, and roles. d. Cultural differences among members of the extended family.
C
95. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? a. Use disposable plates and utensils. b. Stay in a room with the door closed. c. Dispose of soiled dressings in plastic bags that are securely closed. d. Others who are in the same room with the client should wear a mask.
C
3. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? a. Dismiss the staff nurse's report about the float nurse because it may be just gossip. b. Call the nursing supervisor and request a different employee be sent to the unit. c. Assign the float nurse to function as an unlicensed assistive personnel (UAP) for the day. d. Arrange for someone to be available to assess and assist the float nurse.
D
42. Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion of packed red blood cells? a. Skin turgor. b. Weight. c. Oxygen saturation. d. Vital signs.
D
38. The nurse calculates the mean arterial pressure (MAP) for a client whose blood pressure is 152/90. What is the MAP in mm Hg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
111
77. The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement? a. Limit visitors to immediate family to decrease exposure to infection. b. Maintain "clean" technique in the change of wound dressing and IV site. c. Assess and document skin condition around the incision and IV site at each shift. d. Require the use of a face mask by staff when providing care requiring close contact.
C
112. A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased lochia flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of 102.2 F , chills, pelvic pain, and uterine tenderness. What action should the nurse take? a. Review the complete blood count. b. Tell client to discard pumped milk. c. Initiate a 24-hour urine collection. d. Arrange for the baby to room-in.
A
11. A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first? a. Prednisone (Deltasone) 10 mg PO. b. Albuterol (Proventil) 0.5% solution per nebulizer. c. Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. d. Oxygen 2 to 6 liters per minute using a nasal cannula.
C
55. A graduate nurse (GN) tells the RN preceptor, "I need to insert a nasogastric tube, and though I was checked off on this procedure in my nursing school's simulation lab, I have never inserted one on a real person." How should the preceptor respond? a. "I must see documentation of successful check-off by your school's instructor." b. "Performing the procedure on a simulator is different from performing it on a real person." c. "Let's review the procedure, then I will supervise you while you perform the procedure." d. "I will help you, but we need to inform the client that you are new at doing this."
C
6. When culturing a wound, the nurse should obtain the sample from which part of the wound? a. The outer edges of the wound. b. All necrotic sections of the wound. c. Areas containing purulent or pooled exudates. d. Any particularly painful area of the wound.
C
30. The nurse is planning to withdraw 10 ml of urine from the port on the tubing of a client's indwelling catheter to obtain a urine specimen. In which order should the nurse implement these actions? (Arrange from first on top to last on the bottom.) a. Clamp the drainage tubing. b. Place in a biohazard bag. c. Document the procedure. d. Label the urine specimen.
A, D, B, C
44. When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? a. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. b. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption. c. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping. d. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention.
D
1. Which type of management style is a case management model for nursing care delivery? a. Patient focused and primary nursing. b. Clinically oriented and business oriented. c. Centralized and decentralized systems models. d. Clinical pathways and patient classifications
A
19. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? a. Encourage the student to associate with non-smokers only while attempting to stop smoking. b. Tell the student that he is still young and should continue to try various smoking cessation methods. c. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. d. Provide the student with the latest research data describing the long-term effects of tobacco use.
A
51. A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he eats and drinks a snack before going to bed, and that he checks his blood glucose before eating in the morning. This client requires further teaching on which subject? a. Storing nitroglycerin. b. Fluid intake. c. Blood glucose monitoring. d. Diabetic diet.
A
62. A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct? a. "An antibiotic ointment is placed in each newborn's eyes to prevent infection." b. "Conjunctivitis neonatorum is common in newborns." c. "This type of question should be discussed with your pediatrician." d. "Most infants have drainage from their eyes which usually resolves within 2 to 3 days of life."
A
2. The nurse is assessing a client with multiple trauma from a motorcycle crash who is being ventilated due to multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse monitor as an indicator of MODS progression? a. Cardiac function. b. Renal function. c. Hepatic function. d. Coagulation system.
B
21. An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first? a. Counsel the girl regarding hygiene. b. Ask if she is going to the bathroom frequently. c. Teach the girl the importance of practicing safe sex. d. Encourage the girl to see the school counselor.
B
23. After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take? a. Replace the empty tank without reporting the situation to any members of the agency. b. Complete an adverse occurrence report and submit it to the nurse-manager. c. Send an anonymous letter explaining the situation to the family of the client. d. Advise the flight crew of the situation, then suggest that no further discussion be held.
B
24. Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa? a. Improve the client's body perception. b. Consume at least 50% of all meals. c. Exercise no more than one hour daily. d. 5% decrease in serum potassium levels.
B
33. The nurse is assigned a client with numerous treatments and decides it is not possible to complete all the needed treatments in the time scheduled for this shift. Which process should the nurse use? a. Delegate tasks to competent team members. b. Prioritize tasks with the most crucial needs first. c. Report the incomplete treatments to next shift nurse. d. Start with the easiest treatment first.
B
48. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? a. Place a sterile drape under the client's buttocks. b. Instruct the client to inhale and then exhale slowly. c. Discard the gloves and apply new sterile gloves. d. Apply a sterile lubricant to the end of the catheter.
D
69. A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another singleton at 35-weeks gestation. How should the nurse record her gravity and parity using the GTPAL system? a. 3-0-3-0-3. b. 3-1-1-1-3. c. 4-1-2-0-4. d. 4-2-1-0-3.
C
54. A male client who is two days postoperative for a bowel resection moves as little as possible and does not use the incentive spirometer unless specifically reminded. The client reports his pain level at an 8 on a 10-point scale, but refuses a PRN dose of an opioid analgesic and tells the nurse that he can "tough it out." What response is best for the nurse to provide? a. Side effects are not a concern because they usually decrease over time. b. Very few clients become addicted to opioids when using them for pain control. c. There are multiple options of medications that can be offered if one drug does not relieve the pain. d. Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from surgery.
D
68. The nurse is preparing a teaching plan for the parents of a 3-year-old who is newly diagnosed with Duchenne muscular dystrophy (DMD). Which implementation should the nurse include in the initial teaching plan? a. Refer to a nutritionist for dietary management. b. Encourage the parents to join a grief support group. c. Teach the parents to suction the child's oropharynx. d. Develop an active range of motion (ROM) exercise schedule.
D
71. Which action should the nurse implement when using the confrontation technique during a vision exam? a. Use an ophthalmoscope to watch the client's pupil constrict when a strong light is shown on it. b. Stand behind the client and direct the client to tell the nurse when an object enters the peripheral field of vision. c. Show the client a series of four cards with printing of varying sizes and ask which card the client sees most clearly. d. Sit facing the client and while look directly at the client's face, move an object inward from the periphery.
D
85. The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding perianal care is effective? a. Soaks in a sitz bath for 40 minutes after each diarrhea stool. b. Takes prescribed antidiarrheal medication after each diarrhea stool. c. Applies witch hazel compresses to provide relief from anal irritation. d. Cleans perianal area with mild soap and water after each diarrhea stool.
D
