Comprehensive Exam B
An 18-month-old child is brought to the emergency department after ingesting an unknown substance. The child is lethargic and pale. Place the nursing interventions in order of priority:
1. Assess the child. 2. Empty the child's mouth of any remaining substance. 3. Identify the ingested substance. 4. Follow ordered measures to prevent additional absorption of the substance. 5. Document the event, the assessment, the actions taken, and the child's response. Rationale: When a child presents with a suspected poisoning, the practical nurse (PN) treats the child first, not the poison. The PN should assess and treat the ABCs and vital signs first. Next, the PN should terminate any remaining exposure to the poison by checking the child's mouth if it was an ingested substance or by removing any toxic substance from the skin or other body area. If possible, the poison should then be identified to determine the appropriate treatment. The PN should then take measures to prevent absorption of the poison, as prescribed, such as administering the antidote or giving activated charcoal. Finally, the PN should document the event, the actions taken, and the child's response.
The practical nurse (PN) reviews the client's intake and output (I&O) for the 8-hour shift. The PN notes that the client has had 50 mL/hour of IV fluids, 500 mL of IV medications, 35 mL of water, and 75 mL of broth. Calculate the client's intake for the 8-hour shift.
1010 Rationale: First determine the total amount of IV fluids in the shift (50 mL × 8 hours = 400 mL). Then add all the fluids together (400 mL IV fluids + 500 mL IV medications + 35 mL water + 75 mL broth = 1010 mL).
While the nurse is assisting with data collection, a 50-year-old client with a Body Mass Index (BMI) of 42 states, "I feel so unloveable". Which is the best response by the nurse?
b. Ask the client to talk about specific concerns. Rationale: Asking the client to discuss specific concerns is the most therapeutic response and provides the nurse with more data. Options C and D assume the client is concerned about obesity, and focus on other people's concerns and with the concerns of a sexual partner. It would be more appropriate to discuss frequency of intercourse later in a discussion of sexual concerns.
A 4 year old is recovering from surgery for a hernia repair. What is the best initial action that the practical nurse (PN) should take in managing the child's pain?
b. Assessing behaviors in response to pain Rationale: Behavioral assessments, such as the FLACC postoperative pain scale, are the most reliable for assessing pain in children aged 3 months to 7 years.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client?
b. Broiled fish, green beans, and an apple Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.
The health care provider (HCP) asks to be notified if the client's systolic blood pressure is greater than 140 mm Hg or less than 90 mm Hg. When the client has a blood pressure of 110/68 mm Hg, what action should the practical nurse (PN) take?
b. Check the blood pressure again at the next scheduled time. Rationale: The client has a systolic blood pressure of 110 mm Hg; therefore, the provider does not need to be called at this time.
When assessing a client, the practical nurse (PN) pinches a large fold of the client's skin. The client's skin does not quickly return to its original place when released. The PN should further assess the client for which condition?
b. Dehydration Rationale: Poor skin turgor may indicate severe dehydration.
A client presents to the clinic for the 6-week postpartum checkup. The practical nurse (PN) suspects that the client may be suffering from postpartum depression. Which intervention should the PN implement? (Select all that apply.)
b. Determine availability of the client's support system. c. Discuss the client's symptoms with the client's health care provider. d. Encourage the client to discuss her feelings and to ask questions. e. Monitor the newborn for appropriate growth and development. Rationale: The PN's role in assisting a client with postpartum depression includes determining the availability of family support and other resources as needed, encouraging the client to verbalize feelings and ask questions, and monitoring the newborn for appropriate growth and development. In order for the client to receive medications and other treatments, the PN should discuss the client's symptoms with the health care provider.
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?
b. Explain the relationship to the charge nurse and ask for reassignment. Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take?
b. Gently lower the client to the floor. Rationale: Option B is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option D is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.
An older client is admitted to the hospital for community-acquired pneumonia. When talking with the client, the practical nurse (PN) learns that the client recently returned from a trip to Japan, quit smoking a month ago, is a vegetarian, and has diabetes. Which risk factor increases the client's potential for contracting pneumonia?
b. History of smoking Rationale: Smoking is a risk factor for pneumonia, along with age, malnutrition, and immunosuppression.
The practical nurse (PN) observes an adolescent client with anorexia nervosa exercising vigorously. Which is the priority nursing intervention?
b. Interrupt the client and offer to go for a walk with the client. Rationale: Interrupting the client and offering to go for a walk will allow the practical nurse (PN) to set the pace and offer the client an opportunity to express feelings in a more constructive way.
A client diagnosed with type 1 diabetes complains of nausea, has respirations that are deep and fast, and has breath with a fruity smell to it. These symptoms are congruent with which condition that requires immediate intervention by the practical nurse (PN)?
b. Ketoacidosis Rationale: Diabetic ketoacidosis (DKA) is characterized by Kussmaul's respirations, fruity smelling breath, nausea, and lethargy. The onset requires immediate attention.
The practical nurse (PN) assesses pain in a client diagnosed with acute pancreatitis. Which symptom would be expected during the assessment?
b. Located in the epigastric region, with radiation to the back; severe and constant Rationale: Pain associated with acute pancreatitis is usually severe and constant and located in the mid-epigastric region, radiating to the back.
A client in the behavioral care unit has been pacing for the last 30 minutes. Which approach by the practical nurse (PN) is the most therapeutic for this client?
b. Observing, asking about and acknowledging the client's feelings. Rationale: Making an observation and asking about and acknowledging the feelings of the client are appropriate therapeutic techniques.
The practical nurse (PN) is caring for a client who has had a stroke on the right side of the brain with residual paralysis. What position is the safest for a client to be placed while resting in bed?
b. On the left side Rationale: The client with a right-sided stroke (cerebrovascular accident [CVA]) will have paralysis on the left side of the body. The practical nurse (PN) should position the client on the left side to leave the functional side up.
The practical nurse (PN) is caring for a client who is 2 days postpartum. The client reports that she has a bright red vaginal discharge. What action should the PN take first?
b. Reassure the client that the bleeding is normal. Rationale: Rubra lochia, which is red, blood-tinged vaginal flow, lasts 2 to 4 days after the birth of the baby.
A client is at high risk for the development of pressure ulcers. Which nursing intervention helps to prevent skin breakdown?
b. Reposition the client at least every 2 hours. Rationale: Repositioning the client at least every 2 hours prevents excess prolonged pressure on the skin and is an intervention that can be implemented without a health care provider prescription.
A 4-year-old child is returned to the child's hospital room following a tonsillectomy. The child remains sleepy from the anesthesia but is easily awakened. The practical nurse (PN) should place the child in which position?
b. Side-lying Rationale: Side-lying is the most effective position to facilitate the drainage of secretions from the mouth and pharynx and thus reduce the possibility of airway obstruction.
The practical nurse (PN) cares for a client who is legally blind. Which intervention should the PN avoid?
b. Speak loudly so the client knows where the voice is coming from. Rationale: The practical nurse (PN) should use a normal tone of voice when speaking to the client with limited eyesight.
The practical nurse (PN) is preparing the parents of a newborn diagnosed with a cleft lip for discharge. Which instruction is most important for the PN to reinforce to the parents?
b. Suction equipment and bulb syringe should be kept at the bedside. Rationale: Suction equipment and a bulb syringe should be kept at the bedside in case the infant aspirates.
The practical nurse (PN) prepares a client for removal of a nasogastric (NG) tube. Which request made by the PN to the client will make the procedure more comfortable for the client?
b. Take a deep breath and hold it until the tube is removed. Rationale: The client should be instructed to take a deep breath and hold it because this will close the epiglottis and allow for easy removal of the tube through the esophagus and nose.
Which approach by the practical nurse (PN) is most helpful in communicating with a 2-year-old child?
b. Talk quietly and assume an eye level position. Rationale: A 2-year-old child is usually afraid of strangers, but when the practical nurse (PN) assumes an eye level position, it is soothing and nonthreatening to the toddler.
The nurse is observing the interaction between a client who delivered her child yesterday and the newborn. Which behaviors indicate inadequate mother-infant bonding? (Select all that apply.)
b. The mother states, "My baby does not seem to like me." d. The mother comments to the nurse "This baby cries all the time to make me mad." Rationale: Maternal comments such as "My baby does not seem to like me" and "The baby cries all the time to make me mad" indicate inadequate mother-infant bonding. Adequate bonding behaviors include singing to the baby, use of claiming expressions (the baby's hands are small like yours) and counting fingers and toes, and stroking the baby's hands.
The practical nurse (PN) observes a group session of five clients who are admitted for severe depression. Which action by the facilitator encourages therapeutic communication? (Select all that apply.)
b. Verbalize the facilitator's perceptions or observations. c. Acknowledge statements made by the clients. d. Allow the clients to select the topic of discussion. Rationale: Making observations, giving recognition, and allowing the clients to select the topics of discussion, encourage therapeutic communication. Giving false reassurance and asking clients to explain their feelings are both nontherapeutic.
The nurse is caring for several clients who have been diagnosed with schizophrenia. Based on information received during change of shift report, which client will the nurse assess first?
c. A client who tells staff he is hearing voices who are telling him to burn his clothing. Rationale: The nurse should visit the client who is hearing voices telling him to burn his clothing. Command hallucinations can lead to violence toward self or others. The other clients are exhibiting behaviors common to schizophrenia but do not clearly indicate a potential for self-harm or harm toward others.
The practical nurse (PN) notes that the client's radial pulse is 50 beats/min and is irregular. What is the priority nursing action?
c. Auscultate the apical pulse rate and rhythm. Rationale: Irregular pulses should always be checked apically. An irregular pulse should be counted for 1 minute at the apical site.
An older female client expresses frustration and embarrassment about her stress incontinence issues. Which information regarding bladder retraining should the practical nurse (PN) provide to the client?
c. Avoid jumping or running. Rationale: Jumping or running may cause more urine to leak from the urethra.
A client who is 36 weeks pregnant is diagnosed with mild preeclampsia. Which assessment finding by the practical nurse (PN) indicates a need to contact the health care provider (HCP)?
c. Blood pressure of 162/98 mm Hg Rationale: A blood pressure of 162/98 mm Hg is elevated for a patient with mild preeclampsia, which indicates an immediate need to contact the health care provider.
After the nurse tells an older client that an indwelling catheter needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond?
c. Calmly reassure the client that the discomfort will be temporary. Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure.
When providing the client diagnosed with osteoporosis, a list of foods that should be part of the client's diet, which items should the practical nurse (PN) include? (Select all that apply.)
c. Cheese d. Chicken e. Tomatoes Rationale: The client diagnosed with osteoporosis should eat a diet that is rich in protein, calcium, vitamins C and D, and iron to prevent further bone loss. Cheese is rich in calcium, chicken is rich in protein, and tomatoes are rich in vitamin C.
A nurse is caring for a client who has undergone an abdominal hysterectomy 8 hours ago. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing action?
c. Determine if pain is causing the client's tachypnea. Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. A high-carbohydrate snack would not likely help the increased respiratory rate. There is no data in the question to suggest that the client's pulmonary secretions are thick.
The nurse is reinforcing instructions for a client who will be undergoing a nephrectomy tomorrow due to renal carcinoma. Which instruction is most important for the nurse to include to prevent postoperative venous thrombosis?
c. Dorsiflex and plantarflex the feet 10 times each hour. Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.
The practical nurse (PN) is caring for a dying client when family members gather at the bedside. Which intervention should the PN implement?
c. Encourage the family to discuss their feelings, fears, and concerns. Rationale: The practical nurse (PN) should support the grieving family by encouraging them to discuss their feelings, fears, and concerns.
The practical nurse (PN) is caring for a client with Graves' disease. The PN should expect which findings with this client?
c. Heat intolerance, exophthalmos, smooth soft skin and hair Rationale: Characteristics of Graves' disease include exophthalmos, heat intolerance, and soft smooth skin and hair in addition to weight loss, nervousness, and fine tremors of the hands.
The practical nurse (PN) reinforces the teaching that a client has received about colostomy care. Which statement made by the client demonstrates adequate understanding?
c. If my stoma is not visible, I should report it to my health care provider. Rationale: Sinking of the stoma may indicate retraction and should be reported to the health care provider.
The practical nurse cares for a client diagnosed with severe osteoarthritis. Which assessment finding would be unusual for the PN to encounter?
c. Low-grade fever and fatigue Rationale: Low-grade fever and fatigue are not characteristics of severe osteoarthritis.
Rh immune globulin will be prescribed for a female in the postpartum period if which situation is present?
c. Mother is Rh-negative; baby is Rh-positive. Rationale: Rh incompatibility occurs when the Rh-negative mother has an Rh-positive baby. To prevent the sensitization in the mother, Rh immune globulin is administered within 72 hours of the birth.
The practical nurse (PN) is repositioning a client who has a chest tube. The tubing becomes stuck on the bed rail, and the chest tube is dislodged from the client's chest. Which interventions have the highest priority? (Select all that apply.)
c. Notify the health care provider immediately. e. Apply an occlusive dressing over the disconnection site. Rationale: The priority nursing actions to take when a chest tube is dislodged is to place an occlusive dressing over the disconnection site and to notify the health care provider immediately.
The practical nurse (PN) reviews the chart of a client in labor. The PN notes that the health care provider (HCP) documented the fetus at +1 station. Where is the fetal presenting part located?
c. One centimeter below the ischial spine Rationale: Fetal presentation is described in stations as they relate to an imaginary line between the ischial spines. Stations above the line are identified as a negative number and stations below the line are described as a positive number. Each number is equal to 1 cm. A fetus at +1 station is 1 cm below the ischial spine.
A client diagnosed with generalized anxiety disorder has a panic attack. These interventions are listed on the plan of care. Which nursing intervention should the nurse recommend removing?
c. Reassure the client that everything is going to be OK. Rationale: Reassuring the client downplays their feelings and discourages discussion of feelings.
A client who has a terminal illness tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide?
c. Talk with the client about thoughts and feelings about death. Rationale: The nurse should first assess the client's feelings about death and determine the extent to which this statement expresses the client's true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options B and D are both premature interventions and should not be implemented until further assessment is obtained.
The nurse is assisting with data collection for a 4-year-old child who is having a well-child exam. Which findings are priorities to be brought to the attention of the health care provider? (Select all that apply.)
c. The child is able to speak using sentences with two or three words. d. The child points to a green bird and a blue flower and says they are red. e. The child has gained 3 pounds and has grown 1½ inch since last year's exam. Rationale: A 4-year-old child should be able to speak using sentences of five to eight words, should recognize colors and should gain 5 pounds and grow 2½ to 3 inches a year. It is normal for children to ride a tricycle by age 3 and to note differences between the sexes.
During a routine physical examination, the client discloses to the practical nurse (PN) that his alcohol consumption has significantly increased. The PN emphasizes to the client how to use more effective coping strategies. Which coping strategies demonstrated by the client indicates that the PN's teaching is effective?
c. The client focuses on strengths and abilities to deal with stressors. Rationale: The client should focus on strengths and abilities to deal with stressors.
The nurse is assisting with data collection for a client who is 3 weeks postpartum. The nurse documents which finding as most closely associated with this stage of the postpartum period?
c. The lochia is thicker, and whitish yellow without foul odor. Rationale: At 3 weeks postpartum, lochia alba is most common. The lochia is thicker, and is colored whitish yellow and does not have a foul odor. The fundus not is palpable above the symphysis pubis or displaced from the midline after the first week postpartum. The lochia should not become redder with activity; this requires health care provider notification.
The home health practical nurse (PN) visits a client recently diagnosed with glaucoma. The PN is correct to question which activity of a client with glaucoma?
c. Use of over-the-counter medication for eye pain relief. Rationale: Eye pain, seeing halos, and vision changes are not normal for the client with glaucoma and should be reported to the health care provider (HCP). Over-the-counter medications should not be taken without health care provider approval.
The practical nurse (PN) is working with a newly graduated nurse and are caring for a client with a hip fracture who is in Buck's traction. The PN realizes the newly graduated nurse understands the purpose of Buck's traction if the orientee makes which statement?
d. "Buck's traction is intended to immobilize the leg and prevent muscle spasms." Rationale: Buck's traction is a type of skin traction that may be applied to immobilize the leg and prevent muscle spasms before surgery.
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, the client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond?
d. "Planning a party and thinking about all your friends sounds like fun." Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The client should support the client's goals rather than tell the client how to spend her time.
The practical nurse (PN) assists an older adult client who has left-sided weakness with ambulation to the bathroom. The client walks with a cane. What is the most effective way for the PN to ensure safe ambulation for the client?
d. Adjust the cane so that the handle is at the level of the client's greater trochanter. Rationale: For maximum stability, the handle of the cane should be level with the client's greater trochanter. The cane should be held on the unaffected side, so the cane and the weaker leg can work together with each step. The practical nurse (PN) should stand on the client's affected side, so the PN can be ready to support the weaker side if needed. The client should hold the cane 4 to 6 inches from the foot for maximum stability.
A practical nurse (PN) prepares to give an older adult client a bath. What action should the PN implement to encourage the most autonomy of the client?
d. Allow the client to wash as much of her body as she can without assistance. Rationale: Client autonomy is achieved by allowing the client to exercise as much control over his or her care as possible. Allowing the client to wash himself or herself without assistance allows the client to have some control over the bathing process.
The practical nurse (PN) is monitoring for increased intracranial pressure in a client with a head injury. What initial finding is most important for the PN to report to the health care provider?
d. Altered level of consciousness Rationale: Altered level of consciousness is the first sign of increasing intracranial pressure.
The practical nurse (PN) reinforces proper foot care with a client who has diabetes. Which instruction is most important for the PN to include in the client's education?
d. Clients with diabetes should cut toenails straight across and smooth them with an emery board. Rationale: Clients with diabetes should cut toenails straight across and smooth them with an emery board.
The practical nurse (PN) is preparing to administer morphine to a client diagnosed with myocardial infarction (MI). Which is the most important action of the morphine for this client?
d. Decrease oxygen demand on the client's heart. Rationale: Morphine is administered to the client with MI because it decreases oxygen demand on the client's heart by dilating coronary blood vessels.
The nurse is working with a client who has been receiving outpatient treatment with methadone for heroin addiction. However, the client has been unable to travel to the methadone clinic for several days due to lack of transportation and inclement weather. The nurse should observe the client for which signs of withdrawal from methadone? (Select all that apply.)
d. Dilated pupils e. Abdominal cramping Rationale: A client who is undergoing withdrawal from opiates such as heroin will exhibit signs of dilated pupils, abdominal cramping, anxiety, insomnia, fever, and diaphoresis.
The nurse has reinforced instructions to parents regarding cord care for a newborn. The nurse realizes instructions were understood if the parents indicate which important principle?
d. Keeping the cord dry will decrease bacterial growth. Rationale: Bacterial growth increases in a moist environment, so keeping the cord dry impedes bacterial growth.
A 10-year-old child has a diagnosis of cystic fibrosis. Which treatment goal is the most important for the practical nurse (PN) to implement?
d. Prevent and treat pulmonary infection. Rationale: The goal of treatment for cystic fibrosis is to prevent and treat pulmonary infections by improving aeration, removing secretions, and administering antibiotics.
The practical nurse (PN) reinforces discharge instructions to a client who has undergone cataract surgery. What instruction should the PN emphasize in the discharge teaching plan of a client who had cataract surgery?
d. Refrain from rubbing and placing pressure on the eyes. Rationale: Clients should be instructed to avoid rubbing or putting pressure on the eyes.
A client is scheduled for a CT scan with contrast media. The PN questions the client about allergies to which foods?
d. Shrimp Rationale: Shrimp is an iodine-rich food that can represent an allergy to contrast media. The PN should question the client further.
Six hours after vaginal delivery, the nurse notes that the client's fundus is soft and boggy. Which action should the nurse take first?
d. Stabilize the bottom of the uterus and massage the fundus until it is firm. Rationale: If the uterus is boggy, the first action should be stabilizing the bottom of the uterus and massage the fundus until it is firm. When the fundus was massaged previously is inconsequential. The lochia will not change to lochia serosa until about a week postpartum.
At the pediatric clinic, the nurse goes to the waiting room to call a 2 year old to be examined. What activity in the 2 year old would cause most concern?
d. The child is not able to hold a cup with a lid to the lips without assistance. Rationale: By age 2, the child should be able to feed self with a spoon and a cup. Temper tantrums are common at this age. It is expected that the child appears bowlegged and potbellied. Children at this age often play side by side next to another child but may not interact much with each other.
The practical nurse (PN) admits a client to the nursing home. Which observation by the PN may indicate the client suffers from presbycusis?
d. The client frequently asks the PN to repeat statements. Rationale: Presbycusis is a sensorial hearing loss associated with aging. Clients with presbycusis have difficulty understanding normal voice tones.
The practical nurse (PN) performs hand hygiene before administering medication to a client. What is the reason for turning off the faucet while holding a paper towel?
d. To prevent transmission of infectious organisms from the faucet to the hands Rationale: The practical nurse (PN) uses the paper towel to turn off the faucet to prevent transmission of infectious organisms from the faucet to the PN's hands.
The practical nurse (PN) reviews the urine culture results for a client who is taking ciprofloxacin for a urinary tract infection. The PN notes that the infection is sensitive only to sulfonamides. What action is most important for the PN to take?
a. Notify the provider of the culture results. Rationale: The nurse should notify the health care provider because the client should be placed on a sulfonamide antibiotic.
The nurse is preparing an older client with a venous ulcer to be discharged home. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?
a. Observe the client change the dressing unassisted. Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been attained. Asking the client to describe the procedure in writing will not determine the ability to change the dressing. Asking how the client feels about changing the dressing is therapeutic, but it also does not determine the client's ability to change the dressing. Asking the family to evaluate the client's skill is not appropriate; this nursing responsibility cannot be delegated.
Before administration of an antiinfective agent to a client with a urinary tract infection, which nursing intervention is most important?
a. Obtain a clean-catch urine specimen. Rationale: A clean-catch urine specimen is used to determine the causative organism and to evaluate the effectiveness of pharmacological therapy in treating the source of the infection. The initial specimen should be obtained before beginning treatment with the antiinfective agent.
The practical nurse (PN) discharges a client who is taking warfarin. What instruction should the PN include in the discharge teaching plan of a client prescribed warfarin? (Select all that apply.)
a. PT/INR should be monitored regularly. c. Medication should be taken at the same time every day. d. Report any unexpected bleeding to the health care provider. Rationale: Warfarin is an anticoagulant. The client's prothrombin time/international normalized ratio (PT/INR) should be monitored regularly. Warfarin should be taken at the same time every day. Unexpected bleeding may indicate that the dose is too high and should be evaluated by the provider.
The nurse is caring for a client who has chronic kidney disease and is undergoing hemodialysis 3 days a week. The client has an arterio-venous (AV) fistula in the right forearm. The nurse expects which aspects to be included in the plan of care? (Select all that apply.)
a. Palpate the client's fistula site for presence of a thrill. b. Assess the client's blood pressure in the left arm. e. Reinforce instructions for a low-protein diet. f. Provide oral care if client experiences dry mouth. Rationale: The AV fistula provides access for hemodialysis and a thrill can be palpated and a bruit auscultated if the fistula is patent. In order to maintain patency, it is crucial that no blood pressure measurements or venipunctures occur on that extremity. It is acceptable to assess the radial pulse in the affected extremity. A client's dietary intake of protein is restricted to reduce the workload of the kidney. Fluid restrictions also reduce the kidney's workload, often causing dry mouth. Oral care reduces client discomfort with dry mouth.
The nurse employed in a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility for a client following a debilitating cardiovascular accident (CVA/stroke). Which action should be included in this instruction?
a. Perform range-of-motion exercises to prevent contractures. Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications.
The practical nurse (PN) prepares to insert a nasogastric tube in a client who is awake and alert. Which interventions are correct? (Select all that apply.)
a. Place the client in a high Fowler position. d. Instruct the client to swallow after the tube has passed the pharynx. Rationale: Placing the client in a high Fowler's position and instructing client to swallow after the tube passes the pharynx are the correct steps to follow during nasogastric intubation.
Which aspect does the nurse expect to see included in the plan of care for a 2-year-old child who will be hospitalized for about a week following an automobile accident?
a. Schedule physical therapy at times other than the child's usual nap. Rationale: A 2-year-old child who is hospitalized should be allowed to continue normal routines, such as naptimes, as much as possible. Most children will regress during hospitalization and introducing new things such as toilet training and riding a tricycle is not realistic or appropriate. The child should be encouraged to keep a favorite stuffed toy.
The mother of an 18 month old complains that her child has already reached "the terrible twos." The mother complains that her child has frequent temper tantrums and refuses to listen. Using Erickson's theory of psychosocial development, what action should the practical nurse (PN) tell the mother to take?
a. Set consistent limits on the child's behavior. Rationale: According to Erickson's psychosocial development theory, children between the ages of 1 and 3 years are learning how to gain some control over themselves and their environment. Having temper tantrums and refusing to listen are expected behaviors at this age. The parent should set consistent limits on the child's behavior.
The nurse is working with a client who is crying, after the client learns she has uterine cancer. Which nonverbal action by the nurse best exhibits active listening?
a. Sit facing the client. Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.
A client is admitted to the unit with angina that occurs during activity and is relieved with rest or nitroglycerin. What classification is this type of angina?
a. Stable angina Rationale: Angina that occurs during periods of activity and is relieved with rest or nitroglycerin is classified as stable angina.
The practical nurse (PN) is monitoring an infant with a patent ductus arteriosus (PDA) for signs and symptoms of congestive heart failure (CHF). Which sign of early CHF should the PN monitor?
a. Tachycardia Rationale: Early signs of congestive heart failure are tachycardia, tachypnea, profuse scalp diaphoresis, fatigue and irritability, sudden weight gain, and respiratory distress.
The practical nurse (PN) provides care for a new mother who is learning to breastfeed. What are the most therapeutic interventions for the client? (Select all that apply.)
a. Teach the client about engorgement. b. Assess the infant's ability to latch on to the breast and suck. d. Teach the client how to use a breast pump and how to store breast milk properly. Rationale: Therapeutic interventions for the client learning to breastfeed include teaching the client about engorgement, assessing the infant's ability to attach to the breast and suck, and teaching the client how to use a breast pump and about the proper storage of breast milk.
An older adult client is admitted to the hospital from home because of failure to thrive. Which observations made by the practical nurse (PN) may indicate that the client is a victim of neglect? (Select all that apply.)
a. The client appears disheveled. c. The client is dehydrated and underweight. e. The client is wearing a sleeveless dress during winter. Rationale: Signs of neglect include a disheveled appearance, dehydration and/or malnutrition, inadequate or inappropriate dress, and the lack of needed physical items such as dentures, eyeglasses, and hearing aids.
A client comes to the community-based clinic complaining of a persistent cough. The practical nurse (PN) understands that the client is at high risk for tuberculosis based on which risk factors for the disease? (Select all that apply.)
a. The client has AIDS. b. The client is an older adult. d. The client has been living in a homeless shelter. Rationale: Risk factors for tuberculosis include an immunodeficiency disease, increased age, and living in crowded conditions, such as in a homeless shelter.
The practical nurse (PN) empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider (HCP)?
b. 240 mL of urinary output is produced in 12 hours. Rationale: An expected urinary output finding is between 400 and 750 mL in 12 hours, with at least an average of 30 mL/hour (240 mL/12 hours = 20 mL/hour).
The practical nurse (PN) attends a group therapy session for clients who have depression. Which observation by the PN could indicate that a client is contemplating suicide?
b. A client mentions that he has given away his cherished watch. Rationale: Clients contemplating suicide often give away prized possessions as a way of saying goodbye.
The health care provider prescribes acetaminophen 650 mg orally for a temperature of more than 100.4° F (38° C). The medication comes in capsules of 325 mg each. The client's temperature is 102° F (38.9° C). The practical nurse (PN) should implement which intervention?
b. Administer two acetaminophen tablets. Rationale: First calculate how many tablets of acetaminophen the client should receive. The amount of medication ordered is x number of tablets = number of tablets/dose.Available medication amount:650/325 × 1 tablet = 2 tablets.The practical nurse (PN) should administer two 325-mg tablets to equal the prescribed dose of 650 mg.
The practical nurse (PN) cares for a client with partial-thickness and full-thickness burns over 25% of the body. Which nursing intervention, if performed in the acute burn phase, would put the client at further risk for injury?
b. Apply pressure dressings. Rationale: Pressure garments are worn in the rehabilitation phase (not the acute phase) of a burn to prevent hypertrophic scarring and contractures.
The practical nurse (PN) suspects that the client is addicted to methamphetamine. What is the best approach for the PN to use in collecting more information about the suspected abuse?
b. Ask the client about how much he uses and how it affects him. Rationale: When assessing a client on drugs, it is best to ask direct but nonjudgmental questions about how much is used and how it affects the client.
The practical nurse (PN) cares for a client with a new diagnosis of pancreatic cancer. The client is interested in using alternative or complementary therapies to treat the cancer. Which intervention has the greatest priority when planning this client's care?
a. Educate the client about the alternative or complementary therapies that interest the client. Rationale: The practical nurse's (PN) role is to educate the client about the alternative or complementary therapies that interest the client.
A client had a transurethral resection of the prostate gland (TURP) 2 days ago, and the catheter was removed earlier today. The client is voiding urine that is brighter red than earlier today, and the urine contains several small clots. Which action is the most appropriate action for the nurse to take?
a. Encourage the client to increase fluid intake. Rationale: A client whose catheter was removed following TURP surgery should be encouraged to increase fluids and reduce activity to prevent bleeding and to reduce clotting, which could obstruct the urinary flow. The nurse should encourage fluids prior to contacting the health care provider. The nurse cannot insert an indwelling catheter without a health care provider prescription.
The practical nurse (PN) in the pediatric unit prioritizes the care of clients according to Maslow's Hierarchy of Needs. After a child's physiological needs are met, what is the next nursing priority?
a. Ensure that the child feels safe and secure. Rationale: The next step on Maslow's Hierarchy of Needs is safety. The practical nurse (PN) should ensure that the child feels safe and secure.
The practical nurse (PN) provides education to a client diagnosed with osteoarthritis. What is the most important exercise instruction the PN should reinforce in the discharge teaching plan of a client with osteoarthritis?
a. Exercise should be stopped if pain occurs. Rationale: Exercise should be stopped if pain occurs.
The client is admitted to the behavioral care unit with a diagnosis of severe depression. These interventions are listed on the plan of care. Which nursing intervention should the nurse question as not beneficial for the client?
a. Force the client to make decisions. Rationale: The client with depression should not be pushed into making decisions or complex choices that he/she is not ready to make.
A client admitted to the hospital for appendicitis has a large bruise above the left eye. The client explains that her husband became upset and hit her. She tells the practical nurse (PN) that her husband has apologized and has been very attentive to her needs. Which phase of the cycle of violence is the client currently experiencing?
a. Honeymoon phase Rationale: In the honeymoon phase, the abuser demonstrates loving behavior, apologizes, and makes promises to change. The victim is trusting, is hopeful for change, and wants to believe the partner's promises.
The practical nurse (PN) admits a client diagnosed with congestive heart failure (CHF) who displays symptoms of a dry hacking cough, frequent shortness of breath, and heart palpitations. On auscultation, the PN notes that the client has crackles in his lungs. These symptoms are associated with which disease process?
a. Left-sided heart failure Rationale: Signs of pulmonary congestion, dyspnea, tachypnea, dry cough, and crackles in the lungs characterize left-sided heart failure.
The practical nurse (PN) provides a client diagnosed with chronic obstructive pulmonary disease (COPD) with discharge instructions. What instructions should the PN reinforce in the discharge teaching plan of a client with COPD? (Select all that apply.)
a. Eat small frequent meals every day. c. Consume a high-calorie, high-protein diet. d. Sit in Fowler position leaning forward to improve breathing. Rationale: Clients with COPD should be encouraged to eat small frequent meals to prevent dyspnea and should maintain a high-calorie, high-protein diet. The most effective position for a client with COPD is in a Fowler position, leaning forward. Increasing the oxygen flow rate to 6 L/m could cause respiratory depression.
The practical nurse (PN) has reinforced instructions to reduce the likelihood of hospital readmission for a client with heart failure. Which statement by the client indicates the need that further instruction is needed? (Select all that apply.)
a. "I will not take my digoxin if my heart rate is higher than 100 beats/min." b. "I should weigh myself once a week and report any increases." c. "It is important to increase my fluid intake whenever possible." Rationale: An increase in edema indicates worsening heart failure and should be reported to the health care provider. Diarrhea can cause the client to develop digoxin toxicity. Digoxin should be held when the heart rate is lower than 60 beats/min. The client with heart failure should weigh daily, not weekly. Increasing fluids can worsen heart failure.
A 2-year-old child in the clinic is diagnosed with otitis media, and the practical nurse (PN) provides information about the disease to the mother. Which information is most important for the PN to provide prior to discharge?
a. Antibiotics should be completed to eliminate infective organism. Rationale: Antibiotics should be completed to eliminate infective organisms.
A client is laughing at a television program when the nurse enters the room of a client who had a crushed foot surgically repaired today. The client states, "My foot is hurting. I would like a pain pill." How should the nurse respond?
a. Ask the client to rate the pain using a 1-10 scale. Rationale: The nurse should not assume the client is not in pain because the client is laughing. Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication.
A client is rushed to the emergency department by friends, who tell the nurse "We think our friend overdosed on heroin." The client is not breathing. There are fresh needle marks on the client's arms. Which intervention should the nurse implement first?
a. Assist the health care provider with intubation. Rationale: Ensuring a patent airway is the primary concern. The nurse should assist the health care provider with intubation, or bag/mask ventilation. Naloxone should reverse the respiratory depression effects of heroin, but opening the airway is the most critical first step. There is no data in the question that suggests the client is experiencing ventricular fibrillation, so the defibrillator is not necessary. Epinephrine will not reverse the respiratory depression effects of heroin.
The practical nurse (PN) is caring for a client diagnosed with end-stage renal disease. Which finding indicates that the client's left arm arteriovenous (AV) fistula is patent?
a. Auscultation of a bruit over the fistula Rationale: Auscultation of a bruit and palpation of a thrill over the AV fistula indicate patency.
The practical nurse (PN) reinforces teaching to the client with a fractured ankle about how to ambulate safely on crutches. When preparing for ambulation, the PN should provide the client with which instructions? (Select all that apply.)
a. Crutch tips should be inspected periodically for wear. c. Crutches should be accurately measured specifically for the client to avoid injury. d. If numbness or tingling in the arms or hands develops, the client should stop ambulating. Rationale: Crutch tips should be inspected periodically for wear. Crutches should be accurately measured specifically for the client; otherwise, a brachial plexus injury could occur. If numbness or tingling in the arms or hands develops, the client should stop ambulating.
The nurse is assisting with data collection for a client who is at the urgent care center with complaints of abdominal pain. The nurse asks about the characteristics of the client's stools. Which description should the nurse report to the health care provider as soon as possible?
a. Daily black, sticky stool Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal.
A 7-year-old child presents to the emergency department with an acute asthma attack. Which assessment finding indicates that the child's condition may be worsening?
a. Decreased wheezing Rationale: Decreased wheezing may signal an inability to move air. A "silent chest" is an ominous sign during an acute asthma attack.
A 2-year-old child is hospitalized with persistent diarrhea. Which signs and symptoms are most indicative of common complications? (Select all that apply.)
a. Dehydration c. Metabolic acidosis e. Signs of electrolyte imbalance Rationale: The major concerns for a child with acute diarrhea are dehydration, the development of metabolic acidosis, and electrolyte imbalances.
