funds

Two weeks ago, a patient had a foley catheter inserted, and now there are orders to remove it. The patient asks, "Would it be easier to leave the catheter in and not take it out for a while?" How should the nurse reply?

"A catheter with a drainage bag can cause an infection."

The nurse is performing an admission assessment on a client at high risk for suicide. The nurse should prepare to ask the client which assessment question to elicit data related to this risk?

"Do you have a plan to commit suicide?"

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statement?

"I drink hot chocolate before bedtime."

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?

"I need to collect the urine in the cup after I start to urinate."

The nurse is reinforcing instructions about home safety measures to a parent. Which statement by the parent indicates a need for further teaching?

"I need to refer to medication as 'candy' only when really necessary."

The nurse is teaching a patient about using sublingual nitroglycerin at home. Which statement by the patient indicates understanding of the teaching?

"I will place the tablet under my tongue and let it absorb."

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate?

"Let's step away from the crowd to discuss it."

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?

"What can I do for you?"

The home health nurse visits an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which is the appropriate response?

"You must be feeling all alone at this point."

The IV with Nitroglycerin is infusing at 6 ml/hr. The concentration of the IV is 50 mg in 250 mL of D5W. How many mg/hr is the patient receiving? Record your answer using one decimal place.

1.2

Heparin sodium, 1000 units/hour IV, is ordered for a patient with a blood clot in the leg. It is supplied as 50,000 units in 500 mL of dextrose and water. How many milliliters per hour should be set on the controller? (Round your answer to the nearest whole number).

10

A patient's eye opens only the verbal stimuli, the patient is oriented to time, place, and person, and the patient moves to localized pain. Which score would this patient receive on the Glasgow Coma Scale? Record your answer using a whole number.

13

You are caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." Upon examination you note wound evisceration. Place in order the steps for handling this complication. 1. Cover the intestine with sterile moistened gauze. 2. Stay calm and stay with the client. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the physician. 5. Put the client into a semi-Fowler position with knees slightly flexed. 6. Prepare the client for surgery as ordered.

2, 5, 3, 4, 1, 6

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

3, 2, 4, 1, 5

A 7-year old pediatric patient is admitted to hospital. You are tasked with determining what dose of the medicine he should be prescribed. If the adult dose is 100mg and the child weighs 40kg, what dose - using Young's rule - should the child be administered?

37

The nurse is assigned to care for 4 clients this shift. Based on information provided in the change of shift report at 0700, in which order should the nurse see the clients? Arrange and select the correct order below. 1. A client who has discharge orders, but is awaiting a ride home. 2. A client whose blood sugar was 68 and was given oral glucose at 0600. 3. A client who will be going for throat surgery at noon today. 4. A client who was admitted at 0500 who has pneumonia and requires frequent suctioning.

4, 2, 3, 1

You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3° F (38° C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR format. 1. "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 2. "He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse." 3. "I have tried to make him comfortable and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." 4. "Would you like to give me an order for any laboratory tests or additional therapies at this time?"5. "Dr. S, this is Nurse J. I'm calling about Mr. D, who is reporting severe abdominal pain."

5, 2, 1, 3, 4

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?

: 53-year-old admitted with a perforated ulcer

The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.

Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement , Advises the client transport technician, "This client has fragile bones due to cancer, so move the client very carefully." , Interprets the results of a client's diagnostic testing to the unit clerk

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action?

Acknowledge the client's anger and continue to encourage participation in care.

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply.

Acting as a witness that the client signed the consent form voluntarily , Documenting in the medical record the date and time the signature was obtained , Verifying that the client is competent to provide informed consent

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse delegate to an LPN/LVN?

Administering the ordered metronidazole (Flagyl) 500 mg PO to the client

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal?

Allowing the client to unwrap the utensils and prepare his own meal for eating

For a patient with a wound that is bleeding profusely, which nursing intervention could result in an increase damage to the patient?

Applying a heat pack

The nurse asks an unlicensed assistive personnel (UAP) to give a client a sitz bath to treat the client's painful hemorrhoids. The UAP states "I've never done that before, what is that?" What is the most appropriate action for the nurse to take?

Ask another UAP who has done the procedure previously to administer the treatment.

The nurse has just begun a sterile wound dressing change for a resident at a long-term care facility when the nurse's pager goes off, indicating a health care provider is calling the nurse with prescriptions for a different resident. What should be the nurse's action?

Ask the unit secretary to obtain a call back number for the health care provider.

A nurse assigns a task to unlicensed assistive personnel. They state, "We can't do that." Which is the best initial response for the nurse to make?

Ask the unlicensed assistive personnel (UAP) the reason for the response

The nurse informs the patient, "I need to attend to another patient urgently. If you don't mind waiting, I will change your clothes at a later time, or I can ask someone else to assist you." Which type of communication does the statement made by the nurse demonstrate?

Assertive

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse?

Assess the client's and the spouse's perception of the event.

What should the culturally sensitive nurse do for a Muslim woman being treated in the hospital? (Select all that apply.)

Assign only female staff to care for her. , Keep her head and extremities covered as much as possible. , Allow privacy

The nurse, performing an abdominal examination, inspects the client's abdomen. Which assessment technique does the nurse perform next?

Auscultation

The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's 'sweet 16' birthday party, I'll be ready to die." Which phase of coping is this client experiencing?

Bargaining

A client receives a prescription for a 5-mg dose of a drug. The oral preparation of this drug is only available as 3 mg/capsule. Which intervention should the practical nurse (PN) implement?

Call the health care provider about the prescribed dose.

An older adult client who attends an adult day care program and is wheelchair-mobile has redness in the sacral area. Which information is most important for the practical nurse (PN) to provide?

Change positions in the chair at least every hour.

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

Change the password for entering computer files at least monthly. , Shred the printout of the nurse's flowchart at the end of the nurse's shift. , Use own user name and password when logging into the computer system.

You are admitting four clients with infections to the medical unit, but only one private room is available. Which client is it most appropriate to assign to the private room?

Client with a cough who may have TB

The HIV unit nursing team, composed of the registered nurse (RN) case manager, staff RNs, and staff practical nurses (PNs), is meeting to discuss a client who has developed anorexia related to HIV medications. The client has lost 15 pounds in the previous 2 months. Which action should the team implement to continue the nursing process?

Collaborate with the client to set goals.

A nurse on the evening shift reviews a chart and finds that the patient did not receive a morning dose of insulin as prescribed. After notifying the charge nurse, which nursing action is a priority?

Complete an incident report according to hospital policy

The practical nurse (PN) is administering medications to a client via a nasogastric tube. The 0900 medications include a sustained-release spansule. Which action should the PN take when administering the sustained-release drug via the nasogastric tube (NGT)?

Consult the health care provider for a different drug form that can be crushed.

The nurse should institute which type of precaution for a client diagnosed with Clostridium difficile?

Contact

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.

Crush each medication separately before administration , Determine if the medications are available in liquid form , Flush the tube before and after medication administration

A client is experiencing less sleep than usual due to nocturia. Which client information is important for the practical nurse (PN) to provide?

Decrease your intake of fluids after the evening meal.

When performing sterile wound care in the acute care setting, the practical nurse (PN) obtains a bottle of normal saline from the bedside table that is labeled opened and is dated 48 hours before the current date. What is the best action for the PN to take?

Discard the saline solution and obtain a new and unopened bottle.

The practical nurse (PN) is using the Glasgow Coma Scale to perform a neurological assessment. A comatose client winces and pulls away from a painful stimulus. What action should the PN take next?

Document that the client responded to a painful stimulus.

The practical nurse (PN) obtains lying and standing blood pressure measurements for a client who complains of dizziness upon standing up from the computer at work. The PN determines that systolic pressure decreases 24 mm Hg when standing. What intervention is most important for the PN to implement?

Encourage the client to flex both feet before rising slowly.

A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which of the following actions does the nurse take to help ensure the success of the interview? Select all that apply.

Ensuring that the room is private , Seeing that distracting objects are removed from the room

A client who states that he may have been contaminated by anthrax arrives at the ED. Which action included in the ED protocol for possible anthrax exposure will you take first?

Escort the client to a decontamination room.

A nurse is caring for a patient who wanders out of the facility. The nurse applies a safety reminder device (SRD) without a primary health care provider's prescription. The nurse can be charged for which legal violation?

False imprisonment

The practical nurse (PN) is caring for a dyspneic client whose oxygen saturation rate is currently 95%. What position is best for this client?

Fowler's with both legs supported.

The practical nurse (PN) is observing a new unlicensed assistive personnel (UAP) perform indwelling catheter care for a female client who is incontinent of feces. What action by the UAP causes the nurse to intervene and correct the action?

Frequently rinses the washcloth used to clean the perineum.

The nurse is planning to reinforce nutrition instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African American heritage?

Fried foods

During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound?*

Full-thickness skin loss to dermis and subcutaneous tissues.

As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated LPN. The LPN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first?

Give praise for correctly charting the dose and time and discuss the deficits in charting.

You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? (Select all that apply.)

Gown , Gloves

Which clinical manifestation in a patient using nonsteroidal antiinflammatory drugs (NSAIDs) would the nurse classify as a common adverse effect?

Hematemesis

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is:

Impaired bowel movement related to inadequate fluid intake

Which action should the practical nurse (PN) implement to ensure that eye ointment is distributed evenly across the eye and lid margin?

Instill the ointment along the lower inner edge of the eyelid from the inner to the outer canthus.

The primary healthcare provider instructs the licensed practical nurse to medicate a patient if the patient's body temperature rises above 120(F). In which section would LPN record the information, using the SOAPIER documentation format?

Intervention

The practical nurse (PN) is assessing the orientation of an older adult client. The client is unable to remember the year and reports being lost and unfamiliar with the surroundings. What documentation is the most accurate for the PN to make?

Is disoriented to time and place.

The licensed practical nurse is reinforcing teaching about the self-administration of insulin to an Asian patient, who is not making eye contact during the interaction. Based on the nurse's knowledge about cultural communication patterns, which belief about maintaining eye contact does the nurse conclude the patient has?

It usually is a sign of being impolite

Which action is most important for the practical nurse (PN) to implement when donning sterile gloves?

Keep gloved hands above the elbows.

A client has been admitted to the hospital with vomiting, diarrhea and extreme weakness. Her husband has stayed at her bedside since admission. She is on bed-rest and is receiving IV therapy. A nursing intervention that will promote rest and comfort for the client would be:

Keeping the emesis basin and bedpan empty and clean for her use

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply

Measure from tip of nose to earlobe to xiphoid process , Place a small piece of tape at the point of measurement

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? (Select all that apply.)

N95 respirator , Gown , Gloves

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behavior by the client indicates ineffective coping?

Neglecting personal grooming

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?

Nonmaleficence

A client is admitted with back pain. During the assessment the nurse notes his vital signs to be; Temperature 103.2 F, pulse 90, respiration 30, and blood pressure 128/88. The initial nursing action should be;

Notify the charge nurse of the vital signs so that she can notify the physician

A patient who is alert and oriented is threatening to leave the hospital against medical advice (AMA). What action should the nurse take?

Notify the physician that the patient is threatening to leave AMA.

The nurse and an unlicensed assistive personnel (UAP) are assigned 7 patients on an oncology unit. Which tasks should be appropriate for the nurse to assign to the UAP? (Select all that apply.)

Obtaining a client's height and weight , Feeding a client had an eye enucleation 2 days ago , Calculating the intake and output for a client who is receiving radiation therapy

A patient states, "I'm really strung out about this pregnancy." The nurse responds by asking, "What about this pregnancy worries you?" What communication technique is this?

Open-ended question

A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first?

Place the client on airborne and contact precautions.

The nurse is assisting in the care of a client receiving an opioid for pain. The nurse should make note of which finding to detect an adverse effect of this medication?

Rate and rhythm of respiration

In some health care facilities, the LPN/LVN is allowed to take telephone orders from a physician. What is one precaution the nurse must take when receiving a verbal order?

Repeat the order to the physician

When reinforcing instructions to an oriented client and the client's family regarding how to use the patient controlled analgesia (PCA) pump with both a basal and demand dose, the nurse should include which instructions? Select all that apply.

Report an inability to void. , Notify the nurse if nausea and vomiting occur. , Let the nurse know the pain level the client is experiencing. , Instruct the client to push the button when the pain level begins to increase.

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I don't know why this is being reported. I told the health care provider (HCP) that it was an accident." What is the best response by the nurse?

Reporting your child's injuries is required by law. It is for your child's safety and protection."

A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse?

Request that the spouse tell the client to call back

The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?

Sanguineous drainage

A Jewish patient dies unexpectedly. The family is requesting that postmortem care be carried out by an orthodox jew, such as a family member or a member of the Jewish Burial Society. To respect the traditions of the patient's religion, which nursing action would be best?

Secure the needed supplies and allow a family member to perform the care

A patient diagnosed with malignancy is unsure whether to choose chemotherapy, radiation, or both. Which technique is most appropriate for helping the patient sort out his or her thoughts?

Silence

The nurse observes skin changes in a patient who has been immobile for a long period. The skin over the shoulder blade area is red and does not blanch on pressure. There is also warmth, edema, and induration at the site. Which stage of pressure ulcer do these assessment findings indicate?

Stage I ulcer

estion 85 A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor

The practical nurse (PN) determines that a client's radial pulse is irregular. What action should the PN take next?

Take an apical pulse for 1 minute to verify irregularity.

A 72 yr. old client was admitted to the hospital for pneumonia. He is receiving oxygen at 6L by mask. The nurse would avoid which action, when obtaining vital signs?

Taking an oral temperature

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

A resident at a long-term care facility has chronic migraines which are usually treated with medication, an ice pack and some caffeinated tea. The nurse is in the process of receiving change of shift report when an unlicensed assistive personnel (UAP) reports this client is having a migraine. The nurse instructs the UAP to obtain an ice pack, wrap it in a towel, and apply it to the resident. Instead, the UAP gives the resident over the counter acetaminophen. The UAP also provides the resident with a heating pad which has burned the resident's forehead by the time the nurse enters the resident's room with medication 20 minutes later. The incident is referred to the quality assurance committee who will likely make which determination?

The UAP is at fault for acting outside of their scope of practice.

The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted?

The client looks at the surgical site.

The nurse is working with a client admitted with delirium and reduced level of consciousness due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated soon. The client is not able to make decisions. Who will make decisions for the client?

The health care proxy

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality?

The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home

After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply.

The restraints are being released every 2 hours. , A safety knot has been used to secure the restraints. , The call light has been placed within reach of the client.

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child?

Touching the child during the examination

Question 72 An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately without obtaining an informed consent.

The nurse is caring for a non-English speaking client. Best practices for client safety and quality of care incorporates which actions by the nurse? Select all that apply.

Use interpreters who are familiar with health care. , Avoid the use of relatives as interpreters to prevent misinterpretation. , Use dialect-specific interpreters who are the same gender if possible. , Become familiar with common health care words used in the client's language

A nurse is attempting to interview a patient who speaks a different language, but an interpreter is not available. The family member is the only person in the clinic who can translate. In an effort to collect the needed data, which strategy would the nurse use?

Use the family member as the translator while conducting the interview

Which characteristic of a well-written goal statement is not met in the goal statement: "Patient will understand how to use a sliding scale to administer insulin coverage to manage blood sugar levels by discharge to home"?

Uses a measurable verb

A client who is chronically confused is hospitalized for a urinary tract infection. The client is pulling at intravenous tubing and indwelling urinary catheter. Rather than placing wrist restraints, what can the nurse do to prevent the client from removing these essential items? (Select all that apply.)

Using mittens over the client's hands , Asking family members to stay with the client , Placing the client nearer the nurse's station , Keeping the tubing out of the client's visual field

A student nurse is using a gait belt to ambulate a patient with right-sided weakness. Which action by the student nurse indicates that additional teaching is required?

Walks on the patient's left side

A registered nurse (RN) and a licensed practical nurse (LPN) assess the patients on the unit. Which duties are the RN's responsibilities? Select all that apply.

Write the admission assessment and care plan , Check the accuracy of actual transcription of orders , Organize and implement the plan for patient discharge

During a follow-up visit with a patient recently started on Coumadin, the home health nurse is concerned after seeing an herbal remedy that enhances the effect of anticoagulants by the patient's bedside. That herbal remedy is:

ginseng.