NCLEX Practice Test (UnionWorld)
A nurse is caring for a 19-year-old female admitted for psychosis. The patient tells the nurse that she sees numerous people in the room speaking to her. The nurse and the patient are the only two people in the room. Which of the following statements by the nurse would be most appropriate? "Really? Tell me more about who they are and what they are saying." "There is no one here but you and me. You are hallucinating." "Stop paying attention to them and focus on me right now." "I understand that you hear and see other people with us, but I do not. We are alone in the room together."
"I understand that you hear and see other people with us, but I do not. We are alone in the room together."
A hospice nurse is caring for a patient who has made the decision to pass away at home. The patient is refusing to eat or drink. During a visit, one of the patient's adult children asks the following question, "Why is my mom not eating or drinking? Can't we give her something to help her get her strength back?" Which of these is the most appropriate response to this question? "I'm not sure. Sometimes, these patients can go back and forth with their appetite." "That is normal. It probably means she is very close to passing." "I understand this is difficult. We are going to make sure your mom is comfortable and will provide anything that she asks for." "I agree. Let's see if we can get her to take in a little something."
"I understand this is difficult. We are going to make sure your mom is comfortable and will provide anything that she asks for."
A nurse is educating a female patient on her recent diagnosis of chronic obstructive pulmonary disease (COPD). Which of these patient statements shows that she needs further education about her disease? "I understand that smoking is what caused this and I need to quit now." "My lungs are susceptible to infection, so I will not skip my yearly flu and pneumonia vaccines." "My lungs will heal if I use all my inhalers as directed." "I will need to modify my activities and take frequent rest breaks."
"My lungs will heal if I use all my inhalers as directed."
A nurse is educating the parents of a newborn that has been diagnosed with phenylketonuria (PKU). Which of these statements indicates that the nurse needs to do further education on the nature and management of this disorder? "Our child will be able to eat more protein once he reaches adolescence." "We understand that our child can develop mental retardation and movement disorders if we do not care from him properly." "We have the option to breastfeed our child or feed him with special formula while he is an infant." "We will need to provide daily supplementation of tyrosine."
"Our child will be able to eat more protein once he reaches adolescence."
The nurse is preparing immunizations for a 12-month-old child. The child is previously up to date on his vaccinations. The nurse anticipates preparing which of these immunizations? Select all that apply A. MMR B. Tdap C. Rotavirus D. Varicella E. Meningococcal
A & D
Which of these procedures and/or conditions is improperly paired with the preferred patient positioning? A patient post lumbar puncture/spinal tap should be in left or right lateral decubitus. A patient with hypovolemic shock should be in trendelenburg. A patient receiving an enema should be in Sims. A patient undergoing a tube feeding should be in semi-Fowlers.
A patient post lumbar puncture/spinal tap should be in left or right lateral decubitus.
A mother calls the healthcare provider's office regarding a prescription ordered for her child. The prescription states, "give 30 milliliters (mL) every 12 hours." The mother tells the nurse that the only measuring device she has at home is a tablespoon. How many tablespoons of medication will the nurse instruct the mother to give? 3 tablespoons 2 tablespoons 6 tablespoons 1 tablespoon
2 tablespoons
A nurse is assigned five patients on a medical surgery floor. There are two LPNs and one nursing assistant also working the shift. Which of the following interventions are appropriate to delegate to the supportive nursing staff? Select all that apply. A. auscultating breath sounds on a 70-year-old client with emphysema B. changing bed linens on a 44-year-old client while he is in radiology for an MRI C. assisting a 83-year-old client with history of unstable gait to the restroom D. administering IV Toradol (Ketorolac tromenthamine) to a 56-year-old recovering from a stroke E. taking vital signs on a 65-year-old client whose blood pressure was last 80/46
B & C
A nurse is caring for a 37-year-old male diabetic patient admitted post operatively below-knee amputation as a result of poor wound healing after a motor vehicle accident. Which of the following comments by the patient indicates ineffective coping with his post-operative recovery? Select all that apply. A. "When can I start physical therapy so I learn how to move around again?" B. "I am going to work with a prosthetics specialist to fit a new lower limb." C. "Just order me a wheelchair, it's not like I'm going to walk with one leg." D. "I will ensure that my blood sugars are appropriately managed." E. "I don't want to see my leg. This is just a bad dream."
C & E
A nurse is preparing a bag of chemotherapy agent for one of the patients. The nurse accidentally pierces a hole through the bag while attempting to spike it. A moderate amount of chemotherapy spills onto the ground. Which of the following actions should the nurse perform first? Clean up the spill with wet paper towels. Call the pharmacy to have the chemotherapy redosed. Cordon off the area and notify housekeeping/facilities of the spill. Continue to prime chemotherapy tubing.
Cordon off the area and notify housekeeping/facilities of the spill.
A nurse is planning care for an immobile, bedridden patient. Which of the following is not a complication of immobility? decubitus ulcer(s) diarrhea contractures hypercalcemia
Diarrhea
A nurse is working in a nursing home when there is a fire in the kitchen and cafeteria area. Which of the following is the first priority for the nurse in this situation? Ensure that all patients are moved out of harm's way. Remove all flammable materials from the area and evacuate to allow firefighters to extinguish the fire. Evacuate all patients from the building immediately. Report to the area of the fire and take measures to extinguish and/or contain it, if possible.
Ensure that all patients are moved out of harm's way.
A 57-year-old woman presents for evaluation of worsening hot flashes. She states that her menstrual cycles have become more irregular over the past year. She wants to know if she is a candidate for hormone replacement therapy (HRT), but she is concerned about any potential risks associated with taking it. The nurse should communicate this information to the patient: HRT is only helpful for the symptoms of vaginal dryness and atrophy; it has no benefit on hot flashes, sweating, or mood swings. HRT decreases the risk of breast and ovarian cancer, but can increase the risk of uterine and colon cancer. HRT decreases the risk of coronary artery disease (CAD) and myocardial infarction (MI), but can increase the risk of osteoporosis, headaches, and insomnia. HRT decreases the risk of osteoporosis, but can increase the risk of coronary artery disease (CAD), breast cancer, deep vein thrombosis (DVT), and stroke.
HRT decreases the risk of osteoporosis, but can increase the risk of coronary artery disease (CAD), breast cancer, deep vein thrombosis (DVT), and stroke.
A first-time mom brings in her 1-year-old for his well child visit. The nurse asks about his age-appropriate developmental milestones. Which of her answers would be a red flag that there is a developmental delay? He is able to "coo," but he isn't saying any other words yet. He can hold a sippy cup between his hands, but he can't pick up bits of food or transfer food or his cup from hand to hand yet. He recognizes his name and will look and smile when I call to him. He can crawl, pull up, and stand on his own, but he cannot take steps without falling.
He can hold a sippy cup between his hands, but he can't pick up bits of food or transfer food or his cup from hand to hand yet.
A nurse working an overnight hospital shift is administering medications to her patients. Which of these is the most important thing to do prior to giving medications to her patients? Identify the patient by name and date of birth on the patient's wristband and match it to the medication order. Match the room and bed number to the room and bed number on the medication order. Ask the patient his or her name and match it to the one on the medication order. Identify the patient by name and room number and match the information on the medication order.
Identify the patient by name and date of birth on the patient's wristband and match it to the medication order.
A nurse is taking care of a patient who is exhibiting signs of severe stress. Which of these nursing interventions is least helpful for the nurse to use to minimize the patient's stress in this situation? Identify all of the patient's stressors. Identify new coping strategies. Identify the patient's weaknesses. Identify the patient's regular coping mechanisms.
Identify the patient's weaknesses.
Prior to surgery, a surgeon requests that the nurse review the surgical procedure, risks, benefits, and alternative therapies with a client. Which response by the nurse is most appropriate? Discuss with the client and family the implications for surgery, risks, benefits, and alternative therapies. Indicate in the chart that informed consent has been obtained. Postpone the procedure until the provider can meet with the client. Instruct the surgeon that only the provider performing the procedure can obtain informed consent.
Instruct the surgeon that only the provider performing the procedure can obtain informed consent.
A nurse is counseling an obese patient on the importance of weight loss. The patient is a 52-year-old African-American male whose body mass index (BMI) is 38. He has hypertension, hypercholesterolemia, and type II diabetes. Which of these is the correct advice for the nurse to give this patient? Intense exercise of at least 60 minutes daily will work to help him lose weight without changing his diet. A liquid diet must be started so that he can jumpstart his weight loss and feel better immediately. Slow, incremental weight loss is best as a 10-pound change can improve his overall health. Drastic changes are necessary and a weightloss of more than 50 pounds quickly is best.
Slow, incremental weight loss is best as a 10-pound change can improve his overall health.
A nurse is monitoring a patient during a blood transfusion. The patient acutely develops flank and chest pain accompanied by hypotension, respiratory distress, and tachycardia. The nurse notes scant brownish discolored urine in the patient's foley bag. Which of these answer choices correctly describes both the nurse's first action as well as the name of this patient's transfusion reaction? Administer normal saline immediately due to hemolysis. Stop the transfusion immediately due to hemolysis. Stop the transfusion immediately due to allergic reaction. Administer epinephrine immediately due to allergic reaction.
Stop the transfusion immediately due to hemolysis.
A nurse is working on the telemetry unit when one of her patients suddenly exhibits Torsades de Pointes. The nurse knows that which of these is true about this arrhythmia? It is treated with the administration of sodium bicarbonate (HCO3) and the implantation of a pacemaker. Patients with this arrhythmia generally exhibit no physical signs or symptoms. It can be short-lived and self-limited without any treatment, but it can lead to ventricular fibrillation if not corrected and treated. It is a precursor to a Wenckebach or Mobitz type I heart block.
It can be short-lived and self-limited without any treatment, but it can lead to ventricular fibrillation if not corrected and treated.
Which of these statements regarding RhoGAM injections is correct? It is given at 12 weeks and 28 weeks to a mother who is Rh positive if the father is Rh negative. It is given at 28 weeks and at the baby's birth to a mother who is Rh negative if the father is Rh positive. It is given at 12 weeks and 28 weeks to a mother who is Rh negative if the father is Rh positive. It is given at 28 weeks and at the baby's birth to a mother who is Rh positive if the father is Rh negative.
It is given at 28 weeks and at the baby's birth to a mother who is Rh negative if the father is Rh positive.
A 55-year-old female is 22 hours post-op from a total thyroidectomy. The nurse is reviewing the patient's most recent laboratory studies and preparing her for discharge. The nurse notes no abnormalities other than a slightly low calcium level. Which of these is the correct course of action for the nurse to take? Notify the surgeon immediately of the abnormal result. Notify the patient of the result and make sure to tell her to ask the surgeon about it at her follow-up appointment. No notification is necessary as this is a completely normal finding after a total thyroidectomy. Notify the surgeon of the result whenever the nurse sees the surgeon rounding on the floor again.
Notify the surgeon immediately of the abnormal result.
Which of these is a correct statement regarding the diagnosis of phlebitis? Phlebitis is treated with a 10-day course of oral antibiotics, preferably a third or fourth generation cephalosporin. Phlebitis may present as fever; redness, swelling, and pain at the IV site; slowing of intravenous flow; and a visible red streak extending from the catheter insertion site. Phlebitis should be treated with the cessation of intravenous therapy, the application of cool compresses and keeping the affected limb at or below the patient's heart level. Phlebitis may present with pain, swelling in the area around the catheter insertion site, coolness and paleness of the area around the catheter insertion site, and a slowing of intravenous flow.
Phlebitis may present as fever; redness, swelling, and pain at the IV site; slowing of intravenous flow; and a visible red streak extending from the catheter insertion site.
A nurse has just completed a blood draw for a patient with unknown HIV status. Which of the following is the correct way to dispose of the needle? Carefully recap the needle and place it in the nearest puncture-resistant container. Place the needle in the nearest puncture-resistant container. Place the needle into any biohazard disposal container if there is not a puncture-resistant one nearby. Break the needle then place it in a puncture-resistant container far away from patient care areas.
Place the needle in the nearest puncture-resistant container.
A nurse is taking care of an intoxicated male patient who has been involved in a motor vehicle accident. Although not critically injured, the patient refuses to remain on his gurney, continuously gets up to leave the ED, and is unsteady on his feet. The nurse is given a written order by the physician to use wrists restraints on the patient. When the nurse tells the patient this, he refuses. Which of these is the correct action for the nurse to take? Report to the physician that the patient is refusing the restraints. Discuss the patient's concerns with him and try to reach an agreement about remaining on the gurney until further evaluation and treatment. Respect the patient's right to refuse treatment and allow him to sign out of the ED against medical advice (AMA). Place the patient in restraints in accordance with the policies of the facility.
Place the patient in restraints in accordance with the policies of the facility.
A nurse taking care of a patient needs to have a lengthy discussion about a sensitive aspect of the patient's care. To have therapeutic communication with this patient, the nurse should do which of these? Say everything that needs to be discussed first and listen to what the patient has to say only after that, giving no regard to nonverbal communication. Allow the patient to do most of the talking and see where the conversation leads while using nonverbal cues that indicate disagreement when necessary. Create a conversation plan that may or may not be followed, depending on how the patient reacts and be mindful of nonverbal communication. Plan a conversation that is patient- and goal-directed, being mindful of nonverbal communication.
Plan a conversation that is patient- and goal-directed, being mindful of nonverbal communication.
A patient admitted to the hospital with an idiopathic spontaneous pneumothorax was successfully treated with a tube thoracostomy. The nurse is preparing him for discharge. He asks what the likelihood is that he will have this problem again. What is the most accurate response that the nurse should give this patient? Yes, recurrence can occur, but generally heals much more quickly than the initial episode. No, there is no evidence that this problem typically reoccurs. Recurrence occurs in up to 30% of patients and can be treated by obliterating the pleural space. No, but you may be at an increased risk for developing a tension pneumothorax.
Recurrence occurs in up to 30% of patients and can be treated by obliterating the pleural space.
Which of these patients would a nurse determine is not at a significant risk for aspiration? a 15-year-old with vomiting from a gastrointestinal illness a 45-year old male who has had significant facial trauma a 25-year-old intoxicated male with an altered level of consciousness a 35-year-old female who is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG) tube
a 15-year-old with vomiting from a gastrointestinal illness
Which of these examples correctly identifies a nurse demonstrating the ethical principle of justice? keeping a patient's records private and only communicating sensitive information to appropriate staff and caregivers arranging for a translator to be present prior to a conversation with the practitioner regarding the diagnosis and treatment plan for a non-English speaking patient honoring a DNR order on a young patient with a terminal illness taking responsibility for a medication administration error that caused harm to a patient
arranging for a translator to be present prior to a conversation with the practitioner regarding the diagnosis and treatment plan for a non-English speaking patient
A nurse is checking on her patients and notes that one of them has slid down in the bed. The patient states that he is uncomfortable, but that he is unable to reposition himself on his own. The nurse knows that in order to help him and avoid injury to herself, she needs to ____. stand behind him and lift him primarily using her legs bend from her waist and move him up as quickly as possible ask the patient to wait a moment while she finds another nurse to assist her in repositioning him have him bend his knees and push himself up while she pulls him into the correct position
ask the patient to wait a moment while she finds another nurse to assist her in repositioning him
Which of these complications of immobility is correctly paired with the proper nursing intervention? constipation: frequent repositioning every 2 hours bone demineralization: passive range of motion exercises twice daily depression: maintaining a dark and quiet environment atelectasis: deep breathing exercises and incentive spirometry
atelectasis: deep breathing exercises and incentive spirometry
The nurse is working in an oncology clinic caring for a patient currently undergoing treatment for colorectal cancer. Which of these tumor markers would most likely be used to monitor the patient's disease? alpha fetoprotein beta human chorionic gonadotropin (HCG) prostate specific antigen (PSA) carcinoembryonic antigen (CEA)
carcinoembryonic antigen (CEA)
A nurse has a 75-year-old patient with COPD and diabetes that requires care from a pulmonologist, endocrinologist, respiratory therapist, physical therapist, occupational therapist, as well as services from a social worker and registered dietician. The nurse knows that this interdisciplinary action across the various areas of medicine is known as ____. cooperation collaboration facilitation integration
collaboration
A nurse in the emergency room is taking care of a 4-year-old patient who has a suspected case of impetigo. The nurse knows that which of the following precautions is most important to prevent the spread of this infection? airborne precautions contact precautions standard precautions droplet precautions
contact precautions
A nurse is caring for a patient who just had an arterial line surgically placed in the femoral artery. Preoperative vitals showed a normal heart rate and blood pressure. The nurse knows that if the patient were to suffer the unexpected complication of an inadvertent puncture of the artery, she would most likely see which of these changes in this patient's vital signs? increased heart rate and decreased blood pressure decreased heart rate and increased blood pressure increased heart rate and increased blood pressure decreased heart rate and decreased blood pressure
increased heart rate and decreased blood pressure
The nurse at a family practice is responsible for reviewing home safety issues with all patients. She knows that there is an increased risk of falls in which of these two groups of patients? the elderly and school-age children toddlers and the elderly infants and toddlers infants and the elderly
infants and the elderly
A patient with a suspected renal tumor is being admitted for an intravenous pyelogram (IVP). The nurse discusses the procedure with the patient in addition to taking a full medical history. Which of these pieces of information reported in the patient's history should the nurse report to the physician performing the IVP? iodine allergy penicillin allergy past history of kidney stones past history of appendectomy
iodine allergy
A nurse is working at a high school health fair. She speaks to an 18-year-old male who is about to go to college and live in the dormitory. He states that he gets his annual flu shot, but other than that, he hasn't had any vaccinations in several years. Which of these vaccinations should the nurse discuss with this patient? herpes zoster vaccination pneumococcal vaccination meningococcal vaccination hepatitis B vaccination
meningococcal vaccination
A nurse is caring for a patient who recently had surgery to set a fracture and now has his extremity casted. Which of these nursing examinations is not typically utilized to assess for compartment syndrome? passive stretch/movement exam circulatory exam motor strength exam neurological exam
motor strength exam
A nurse caring for an insulin-dependent diabetic patient forgets to give him his dose of insulin. This action precipitates an episode of diabetic ketoacidosis which requires care in the ICU. In a court of law, the nurse may be found guilty of ____. misconduct malpractice dereliction of duty negligence
negligence
When considering the principles of ethics of the nursing profession, acting in a manner that avoids harm refers to the principle of ____. beneficence fidelity justice nonmaleficence
nonmaleficence
You are caring for a patient who has suffered a severe traumatic injury. He is currently catheterized. During your shift, you note that the patient has only produced 150 cc of urine. You check his total output in the past 24 hours and it is 350 cc. By definition, this patient has which of these diagnoses? polyuria anuria oliguria dysuria
oliguria (less than 400 in 24 hours)
Which of these examples is most illustrative of a nurse acting as an advocate for the patient? explaining a patient's test results in greater detail after they've been given by the treating practitioner telling the patient which treatment would be best based on your clinical opinion and past experience sharing a patient's status over the phone with a concerned neighbor who calls to ask how the patient is doing giving a postoperative patient pain medication even though he or she has refused it
explaining a patient's test results in greater detail after they've been given by the treating practitioner
An 82-year-old patient with advanced Alzheimer disease is brought in by his daughter for a concern about a new medication. She states that since he started taking Haldol for increasing psychotic behavior, he has began having bizarre movements. The nurse knows that this drug can cause which of these behaviors? brief but erratic and irregular movements that interrupt normal motion brief, intermittent, repetitive localized muscle twitches of the face opening and closing of the mouth and repetitive, rhythmic tongue protrusion occasional, brief but sudden jerks of the extremities especially when falling asleep
opening and closing of the mouth and repetitive, rhythmic tongue protrusion
A hospice nurse has been caring for a patient with terminal cancer for the past 2 weeks. The nurse has implemented numerous interventions during this time with the patient, primary caregiver, and family. As the nurse assesses the effectiveness of the care plan, which of these should be the highest priority when measuring the actual outcomes with the expected patient-stated goals? depression and anxiety relief dehydration and electrolyte imbalance correction spiritual and religious needs pain and symptom control
pain and symptom control
A nurse is examining an elderly patient who presents to the emergency department complaining of shortness of breath. The nurse notes a displaced point of maximal impulse (PMI) and a cardiac thrill. Which examination technique is the nurse using? percussion auscultation palpation inspection
palpation
A nurse is preparing to administer packed red blood cells to a patient. Which of these steps is the most important when administering blood and blood products to any patient? proper venous access patient identification patient consent ensure compatibility
patient identification
The nurse is admitting a 70-year-old patient for a procedure. The patient has type I diabetes mellitus with significant peripheral neuropathy, atrial fibrillation controlled with antiarrhythmic medications, and osteoarthritis bilaterally in his knees. He is also on anticoagulants with an INR of 3.0. Given that the nurse knows about the individual risk factors that raise the risk of a fall, accident, or injury while hospitalized, which of the following should be identified as the most significant risk factor for this patient? atrial fibrillation peripheral neuropathy anticoagulant therapy bilateral knee osteoarthritis
peripheral neuropathy
A nurse is caring for a patient with severe renal impairment. The patient has an intravenous catheter and is receiving fluids per the physician's order. On a routine check, the nurse notes the patient is dyspneic, and the patient states that he feels short of breath. The nurse suspects fluid overload. Which of these other physical findings would help to confirm the nurse's suspicion? hypotension bradycardia basilar crackles and rales a flat, rigid abdomen
basilar crackles and rales
A nurse enters the exam room of a new pediatric client. The nurse notices there are four adults in the room and one other child. The nurse asks for everyone to identify themselves and notes that the new pediatric client is with the child's mother, step-father, father, step-mother, and half-brother from her father and step-mother. What type of family dynamic is described? blended family non-traditional family adoptive family traditional nuclear family
blended family
A patient with severe renal artery stenosis is under nursing care. Which of the patient's vital signs would the nurse most likely find to be abnormal as a result of this condition? oxygen saturation pulse respirations blood pressure
blood pressure
A nurse is caring for a patient with a prn order for narcotic, opioid pain medication. The nurse utilizes a pain assessment scale and determines the patient would benefit from the administration of the drug. After administration, which of these should the nurse assess for as an unintended side effect of this class of medication? indigestion diarrhea dry mouth pruritus
pruritis
A critical patient with multiple traumas has a Swan-Ganz catheter in place for invasive hemodynamic monitoring. Which of these values requires the brief inflation of a balloon at the distal port of the catheter? central venous pressure pulmonary capillary wedge pressure cardiac output pulmonary artery pressure
pulmonary capillary wedge pressure
A nurse begins working in a rehabilitation facility and notes that many patients suffer falls. She identifies the appropriate cases and brings them to the attention of her nurse manager. Together, they begin to identify the factors contributing to the increased number of falls and work on ways to improve this. The nurse knows that she is participating in which of these processes? collaboration quality improvement interdisciplinary care continuity of care
quality improvement
A nurse sees a 12-year-old female for a well-child visit. The child's mother is concerned that since a recent car accident, the child wants to co-sleep with the mother and is afraid of the dark. The nurse explains that this is representative of which defense mechanism? dissociation regression acting out reaction formation
regression
A nurse is caring for a patient with newly diagnosed type II diabetes mellitus who has been ordered to begin metformin. The nurse knows that the presence of which of the following in the patient's medical history would represent a contraindication to this therapy? seizure disorder renal failure uncontrolled hypertension polycystic ovary syndrome (PCOS)
renal failure
A patient has an arterial blood gas (ABG) drawn. The results are as follows: pH7.3, PCO246, and HCO329. Based on these findings, what condition does this patient have? respiratory alkalosis respiratory acidosis metabolic acidosis metabolic alkalosis
respiratory acidosis
A nurse is working at a pregnancy crisis clinic. She is caring for a 15-year-old girl who is there for a pregnancy test. When the nurse gives her the positive result, the girl becomes distraught and seems overwhelmed. The nurse begins to discuss the patient's situation with her and shares that she too was once an unwed mother at the age of 16. In terms of therapeutic communication, this example most specifically demonstrates which of its essential conditions? self-disclosure genuineness respect empathy
self-disclosure
Which of these is not considered to be an important risk factor for delayed and/or impaired wound healing? obesity sun exposure alcoholism cigarette smoking
sun exposure
A nurse is assessing a 6-year-old Asian child with injuries sustained after "falling from a bicycle." The child's injuries are inconsistent with the provided history. He is brought in by his mother, a physician, who also has resolving facial injuries. When questioned, the mother cannot recall how she received her injuries. Which of the following factors supports the nurse's suspicion of child abuse? suspicion of spousal abuse high level of parental education This situation is not likely child abuse. the ethnic heritage of the child and family
suspicion of spousal abuse
A nurse is administering an intravenous drug to a patient for the first time. Which of these signs and/or symptoms would indicate that the patient is having an anaphylactic reaction to the medication? paresthesias fatigue hypertension tachycardia
tachycardia
A nurse is counseling a patient with a chief complaint of excessive daytime fatigue. The treating practitioner has ordered that the patient keep a daily sleep log for a period of 2 weeks. The nurse is educating the patient on what elements are important to include in the log. Which of these is typically not necessary to record? sleep partner reported irregularities such as restless legs, apneic periods, etc. any medications (prescription and over-the-counter) and herbal supplements and the time they are taken the timing and amount of food consumed throughout the day the amount of daily exercise and timing of workouts
the timing and amount of food consumed throughout the day
The nurse is caring for an acutely ill patient in the ER with a suspected myocardial infarction (MI). His symptoms began about 3 hours ago. The nurse is the first to review his cardiac lab values. Based on his suspected diagnosis, which of these cardiac enzymes would the nurse expect to see elevated? troponin creatine kinase MB (CK-MB) no elevations as it is too early to see laboratory changes lactate dehydrogenase (LDH)
tropinin
There has been a mass casualty shooting at a nearby school. A nurse is working in the emergency department and is asked to triage clients as they arrive at the hospital. One of the clients arriving at the emergency department is in a wheelchair speaking to a nurse frantically while clutching his leg around a bloodied bandage and his foot is oddly angled. Based on this information, which of the following tag colors would the triage nurse assign this client? green red yellow black
yellow
A 67-year-old postmenopausal female presents for a general health screening. She has not had a physical in the past 5 years. She states she is in good health and takes no medications. She is concerned about having osteoporosis. She asks if she can have a test to see if she has it. Which of these is the correct response from the nurse to this patient? "You might be a candidate for a dual-energy x-ray absorptiometry or DEXA scan, but since you have no history of recent fractures or hormone replacement therapy, you don't need one yet." "You should have a spinal x-ray as this is the safest and easiest way to detect osteoporosis. We can discuss this today during your visit." "You are in good health and have no risk factors for osteoporosis. You do not need a screening examination yet." "A dual-energy x-ray absorptiometry or DEXA scan is the best test to check for osteoporosis. Given your health history and age, you should discuss having this test with our practitioner."
"A dual-energy x-ray absorptiometry or DEXA scan is the best test to check for osteoporosis. Given your health history and age, you should discuss having this test with our practitioner."
A 20-year-old female presents to the urgent care with complaints of fever, headache, vomiting, and a rash that has progressed over the past 24 hours. During her physical exam, she has positive Kernig and Brudzinski tests. A lumbar puncture is ordered. Which of these statements is the correct rationale for ordering this test that the nurse should explain to the patient? "Based on your symptoms and exam findings, we need to relieve some of the pressure caused by an excess of cerebrospinal fluid (CSF) with this procedure to help you feel better." "Based on your symptoms and exam findings, we need to deliver some medication to your cerebrospinal fluid (CSF) to treat your condition." "Based on your symptoms and exam findings, a lumbar puncture will help us to determine if you have a mass in your brain or an infection in your cerebrospinal fluid (CSF)." "Based on your symptoms and exam findings, we need to determine if you have an infection in your cerebrospinal fluid (CSF) called meningitis."
"Based on your symptoms and exam findings, we need to determine if you have an infection in your cerebrospinal fluid (CSF) called meningitis."
A nurse is evaluating a young adult patient who has presented to the emergency department with the chief complaint of abdominal pain. If the nurse is using the PQRST method of pain assessment, which of the following questions should be asked for the "S" portion of the assessment? "How severe is your pain on a scale of 1 to 10, where 1 is minimal pain and 10 is the most intense pain?" and "Are you experiencing any other symptoms in addition to your pain?" "Have you ever had these same symptoms previously?" and "Do you have a history of a previous abdominal surgery?" "How did your pain start?" and "Is there anything that you can do that stops your pain?" "Tell me more about your pain: is it sharp, stabbing, superficial, or does it start and stop?"
"How severe is your pain on a scale of 1 to 10, where 1 is minimal pain and 10 is the most intense pain?" and "Are you experiencing any other symptoms in addition to your pain?"
A nurse has just received report and taken over care of a new patient admitted to the floor for pneumonia. The patient is febrile and has been started on IV antibiotics. Based on this information, which of these statements from this patient should concern the nurse the most? "I have a cough and a lot of phlegm." "I feel tired and get chilled off and on." "My chest hurts when I breathe and cough." "I'm itching and my mouth feels swollen."
"I'm itching and my mouth feels swollen."
A 44-year-old HIV-positive client presents to the emergency room for concerns of cellulitis in his arm. The client admits to frequently injecting illicit drugs in that arm. Which preventive-care statement made by the nurse is the most appropriate for the client? "People with HIV are more likely to get infections like cellulitis." "There are local needle and syringe exchange programs that can provide clean supplies to help reduce the spread of infection." "Stopping illicit drug use will improve your life." "Your HIV was caused by illicit drug use. You should stop using illicit drugs before you get more infections."
"There are local needle and syringe exchange programs that can provide clean supplies to help reduce the spread of infection."
A nurse asks a 17-year-old female about her sexual status. The client states that she is not sexually active, but she and her girlfriend have been talking about it and are planning to be in the near future. Which statement by the nurse is most appropriate? "Girls should not have sex with girls." "While you cannot get pregnant from having sex with a same-sex partner, you should still use protection such as a female condom to prevent sexually transmitted infections." "Abstinence until marriage is the best practice. This way you will know you are emotionally ready for sex." "Since you are both girls, you do not need to use protection as neither of you will get pregnant."
"While you cannot get pregnant from having sex with a same-sex partner, you should still use protection such as a female condom to prevent sexually transmitted infections."
A 250-pound patient is prescribed a medication that comes in 750 mg tablets. His order is for 30mg/kg/d to be given three times daily (TID). How many tablets should the nurse should give this patient for a single dose? 3 tablets 4.5 tablets 7 tablets 1.5 tablets
1.5 tablets
The nurse is working in a pediatrics office and is seeing a 3-yr-old female for a well child visit. During the history, the nurse asks how much the child sleeps at night and during daytime naps. Which of these would be an acceptable answer, given the child's age and developmental stage? 10 to 13 hours a day 9 to 11 hours a day 8 to 10 hours a day 14 to 17 hours a day
10-13 hours a day
A newborn infant is having her first neonatal assessment. Her cry is strong, her pulse is 130 bpm, her respiration effort is normal, she has good muscle tone, and her trunk and proximal extremities are pink, but her hands and feet are blue. What would this infant's APGAR score be? 3 12 9 6
9 (max score of 10)
A nurse is caring for patient on IV fluids. The patient's order states that she is to receive 500 mLs of 5% D 0.45 normal saline over a 2-hour period. The patient's IV tubing has a drip factor of 10 gtts/ml. Approximately how many drops per minute should be administered? 30 gtts 42 gtts 83 gtts 57 gtts
42
A nurse is working in a clinic. She must give an adult patient a single intramuscular injection (IM) of penicillin G benzathine. The vial of medication states there are 600,000 units/mL. The patient's order is for 2.4 million units given as a single dose. How many mLs of medication should the nurse draw up to give the correct dose this patient. 4 mL 6 mL 5 mL 3 mL
4mL
A nurse is caring for a patient who is receiving intravenous fluids via an infusion pump at the rate of 150 cc/hour. The infusion pump has recently been repaired and the nurse wants to double-check to ensure that it is functioning properly; however, she is called away by another patient. If the nurse notes that there is currently 600 cc in the IV bag, what is the remaining volume she should expect to find in the IV bag upon her return in 20 minutes? 550 cc 500 cc 525 cc 575 cc
550 cc
The nurse is assessing the vital signs of a 6-month-old infant. Which of these respiratory rates is cause for concern? 40 63 59 32
63
A nurse is taking care of an elderly patient with a significant essential tremor that includes an intentional tremor. Which of these assistive devices would be most beneficial to this patient for his activities of daily living? a button hook a voice amplifier a dressing stick a leg lifter
A button hook
A middle-aged female with Meniere's Disease is hospitalized for another condition. During her stay, she has a severe attack of Meniere's. Which of these assistive devices would be least helpful to implement into your care plan? a shower chair a utensil cuff a walker a personal sound amplifier
A utensil cuff
A 2-year-old presents to the urgent care clinic for cerumen impaction. The nurse is instructed to perform an ear irrigation. Which interventions should the nurse take? A. Position the child with affected ear facing upward. B. Cleanse the external ear and external canal to clear any visible debris. C. Use a cotton-tip applicator to clean the internal canal as much as possible prior to the irrigation. D. Pull the tragus downward and backward, insert syringe, and direct the solution toward the top of the ear. E. Pull the pinna downward and backward, and insert the syringe to direct the flow of solution toward the top of the ear.
A, B & E
A nurse is preparing discharge arrangements for an elderly client with a right ankle fracture. The client is scheduled to go to a skilled nursing and rehabilitation facility. Which of the following interventions are appropriate for providing continuity of care during the facility transition? Select all that apply. A. secures a client bed at the new facility B. transfers the complete medical record C. discards the current medication schedule as it will change at the new facility D. discusses the transport and transfer information with the client and family E. schedules follow-up appointment with the surgeon in six weeks
A, B, D, E
A nurse is giving a presentation about the benefits of exercise on overall health. Which of these statements about exercise should the nurse include in her presentation? "Exercise ____." Select all that apply. A. decreases the risk for osteoporosis B. improves cardiovascular and respiratory function C. increases metabolic rate and assists in weight management D. decreases the need for sleep E. decreases mobility
A, B, and C
Select the appropriate personal protective equipment (PPE) that will be applied prior to entering the room of a patient with influenza. A. gloves B. mask C. gown D. goggles E. respirator
A, B, and C
Which of these interventions are congruent with cultural competence? Select all that apply. A. Listen with respect. B. Integrate caregivers into the patient's care. C. Use family members as interpreters for medically sensitive information. D. Evaluate the effectiveness of the care plan. E. Project personal views upon patients.
A, B, and D
Which of the following are intrinsic risk factors for skin breakdown? Select all that apply. A. poor nutritional status B. shearing/mechanical forces C. urinary and/or fecal incontinence D. bony prominences E. wedge or positioning device use
A, C, and D
The nurse is caring for a patient with a central venous access device. Which of the following are appropriate nursing actions? Select all that apply. A. Take blood pressure readings on the contralateral side of the central venous access device. B. Use chlorhexidine for cleansing the insertion site and use impregnated dressing. C. Practice sterile technique when assessing and caring for the central venous access device, including a mask for both the nurse and patient. D. Draw invasive laboratory procedures on the same side as the central venous access device. E. Allow the central venous line to be soaked in soap and water to cleanse the external lumens between use.
A,B & C
Which of the following statements are correct concerning the medical emergency of retinal detachment? Select all that apply. A. Without emergent ophthalmic evaluation, surgical intervention, and correction, permanent and total blindness may result. B. Immediate interventions include placing the patient in a supine position with the head turned toward the side of the affected eye. C. Patient history includes a sudden, painful, and complete loss of vision. D. Retinal detachments may occur either spontaneously or following trauma. E. The elderly, greater than 85 years of age, are at the highest risk for retinal detachment.
A,B & D
A client is discussing starting acupuncture to help with smoking cessation. The nurse educates the client that acupuncture is contraindicated with which conditions: A. pacemaker placement B. seizure disorder C. arrhythmias D. hypertension E. coumadin (Warfarin) therapy A, B, and E A and E A, B, and C C and D
A,B & E
Which of these are stages of grief as described by Elizabeth Kubler-Ross? Select all that apply. A. depression B. elation C. acceptance D. anger E. denial
A,C,D,E
A nurse is giving discharge instructions to a 45-year-old male who has been hospitalized for chronic pancreatitis. Which of these statements should be a critical part of the dietary counseling for this patient? eat foods high in fat and cholesterol avoid alcohol entirely do not take multivitamins or calcium supplements drink plenty of fruit juices
Avoid alcohol entirely
A nurse is on-call after hours for a pediatric clinic. A parent calls and states that her 1-year-old child has a fever of 104ºF. She asks the nurse what can she do until she can bring the child in for evaluation in the morning. Which of these recommendations is incorrect for this patient? Place child in a tepid bath. Give the child plenty of fluids. Administer aspirin based on the manufacturer's weight-based recommendations. Avoid heavy, bulky, or warm clothing and blankets.
Administer aspirin based on the manufacturer's weight-based recommendations.
A nurse is caring for a patient with a suspected urinary tract infection (UTI). The patient's urinalysis confirms infection and she is started on appropriate antibiotic therapy. To help with her symptoms of pain and discomfort, the physician also recommends she use over-the-counter phenazopyridine (pyridium). Which of these is an important piece of counseling the nurse should give on phenazopyridine ? Advise the patient that she will likely not have to finish her antibiotic if she also takes this drug. Advise the patient that she will likely have less urine output on this drug. Advise the patient that she will likely have orange-colored urine while taking this drug. Advise the patient that she should take this drug daily in order to prevent another urinary tract infection.
Advise the patient that she will likely have orange-colored urine while taking this drug.
The nurse is assessing the electrocardiogram (EKG) reading of an elderly woman who has presented to the urgent care clinic with complaints of chest tightness, dyspnea, fatigue, and "fluttering" in her chest. The nurse should identify this rhythm (shown in the attached visual) as which of these? atrial fibrillation supraventricular tachycardia atrial flutter normal sinus rhythm
Afib
A travel nurse enters a contract to work at community health centers around the United States. Using her knowledge of the risk factors for hypertension, which of the following patient populations is at the highest risk? African Americans between ages 30 to 60 living in the Northeast African Americans over the age of 60 living in the Southeast African Americans under the age of 60 with an inactive lifestyle African Americans under the age of 30 with hyperlipidemia
African Americans over the age of 60 living in the Southeast
A newly graduated nursing student accepts a position with a company that provides hospice care. Which of these is the most important thing that this nurse needs to do before he begins this position? Analyze his own feelings about death and dying. Completely understand all of the legal responsibilities and issues that are involved in death. Review and memorize all of the conceptual frameworks related to grief and loss. Review and understand how to effectively teach coping strategies for patient and families.
Analyze his own feelings about death and dying.
A nurse is caring for a patient who has orders for assessment of cranial nerves I-VII. Which of these techniques will the nurse use for her assessment? Ask the patient to follow an object through the six cardinal fields of gaze. Ask the patient to open his mouth and say "Ahh" watching for symmetrical rise of the uvula in the posterior pharynx. Ask the patient if he can hear a noise (finger snap, etc.) from each ear. Ask the patient to shrug his shoulders upward against resistance.
Ask the patient to follow an object through the six cardinal fields of gaze.
A nurse is caring for a patient who has just undergone a major life-changing event. The patient exhibits signs of near complete detachment from her surroundings and appears disoriented. She expresses thoughts and feelings of being completely overwhelmed by her current situation. When caring for a patient in a crisis such as this, which of the following is the first priority of the nurse? Identify all of the information contributing to the current crisis situation and help the patient identify and discuss all of the emotions that are present. Provide the appropriate physical and emotional support this patient needs to return to pre-crisis levels of functioning. Assess the patient for the potential for harm (to self and others) and take appropriate safety precautions. Assess the patient's current access to, and functioning of, her support systems and teach appropriate coping mechanisms.
Assess the patient for the potential for harm (to self and others) and take appropriate safety precautions.
A nurse is caring for a 77-year-old, hearing-impaired, client immediately post-operative total hip arthroplasty. The nurse starts discussing post-operative care with the client. The client becomes increasingly agitated with the nurse. Which intervention should the nurse perform? Notify the provider. Give the client more pain medication. Reassure the client that decreased hearing is a common side effect of anesthesia. Assist the client in obtaining and wearing her hearing aids.
Assist the client in obtaining and wearing her hearing aids.
A 26-year-old primigravida mother presents for her prenatal care visit at 24 weeks. She states that she has been feeling well. The nurse notes that the mother has gained 30 pounds since her first prenatal visit at 8 weeks, at which she had a normal weight. The nurse counsels the mother on which of these possible complications related to excess weight gain during pregnancy? Select all that apply. A. Increased risk for stress fractures B. Increased risk for developing hypertension C. Increased risk for preeclampsia D. Increased risk for developing Type II Diabetes E. Increased risk for premature birth
B,C & D
The nurse working in the ICU takes a phone call from an unknown person inquiring about the status of one of the patients under her care. Which of the following is the best course of action for the nurse? Take all of the caller's information and list it in the patient's chart prior to sharing the requested information. Check the patient's chart to see if the person is listed to receive confidential information about the patient's medical condition and care. Tell the person that the information cannot be given over the phone. Tell the person the patient's condition and reassure them the best care is being given.
Check the patient's chart to see if the person is listed to receive confidential information about the patient's medical condition and care.
A 31-year-old woman presents to the clinic for pregnancy counseling. The nurse takes her medical history and learns that she is currently under orthopedic care for a torn labrum in her right hip. She has a history of gastric ulcers. Her medications include a multivitamin, vitamin C, ibuprofen, and Cytotec prescribed by her orthopedist. Which of these topics would be the nurse's highest priority in communication with this patient? Ibuprofen in not safe for use in pregnancy; Tylenol is a safer choice to manage pain. Cytotec is contraindicated in pregnancy and could result in miscarriage. She should see a gastroenterologist as pregnancy may trigger a flare of her gastric ulcers. A torn hip labrum should be completely healed or surgically corrected prior to becoming pregnant.
Cytotec is contraindicated in pregnancy and could result in miscarriage
A nurse is caring for a patient receiving intravenous drug therapy via an infusion pump. The pump continues to sound an alarm and the nurse is unsure if it is administering the drug correctly. Which of these is the correct course of action for the nurse to follow? Discontinue the infusion, replace the pump with a functioning one, and leave the malfunctioning pump outside of the patient's room for someone else to try. Continue to try to get the pump to work as to keep on schedule with the patient's drug therapy. Discontinue the infusion, replace the pump with a functioning one and restart the infusion, and then label the broken pump and place it in a designated area for broken equipment. Silence the alarm, continue the infusion, and watch the patient for signs of further problems.
Discontinue the infusion, replace the pump with a functioning one and restart the infusion, and then label the broken pump and place it in a designated area for broken equipment.
While caring for a chronically ill, hospitalized male, the nurse notes that he and his wife are often hostile and angry with each other when she visits him. The nurse notes that the patient's physical, emotional, and mental health is suffering as a result. Which of these is the correct course of action for the nurse to take at this time? Discuss the observations and concerns with the patient and suggest that he begin individual counseling to better cope with his wife's anger. Arrange for a psychological consult for the patient to see if he should begin a trial of antidepressant medication. Discuss the observations and concerns with the patient and his wife. Discuss and explore family therapy to help them develop better patterns and methods of communication. Discuss your observations with the patient's wife and explain that her involvement in his care is not helpful.
Discuss the observations and concerns with the patient and his wife. Discuss and explore family therapy to help them develop better patterns and methods of communication.
A nurse is taking care of a 20-year-old male who is post-op for a surgical repair of a right tibia and fibula fracture following a motor vehicle accident. The patient has an external fixation device. Which of these is true concerning the nursing care of this patient? Frequent repositioning will be necessary to ensure his comfort and prevent skin breakdown. The skin examination should demonstrate warmth, redness, purulent drainage, and edema at the sights of the pin insertions. The neurological examination is normal if he has some loss of sensation and paresthesias in the right plantar surface and toes. The patient will experience a high degree of pain and muscle spasms that will require large amounts of pain medications and muscle relaxants.
Frequent repositioning will be necessary to ensure his comfort and prevent skin breakdown.
The nurse has been ordered to perform gastric lavage on a patient. The nurse knows that which of these statements is correct regarding gastric lavage? Gastric lavage should not be performed on an unconscious patient or a patient with an impaired gag reflex unless an endotracheal tube is placed first. It is not essential to confirm the correct placement of the nasogastric tube prior to administering the ordered solution if careful measurements were done prior to the placement of the tube. Patient positioning is not important when performing a gastric lavage. The proper length of the nasogastric tube is found by measuring the distance from the nose to the earlobe and then to the mid sternal area.
Gastric lavage should not be performed on an unconscious patient or a patient with an impaired gag reflex unless an endotracheal tube is placed first.
Which of these typically does not factor into a patient's perception of and response to pain? support system past experience with pain fatigue gender
Gender
A 44-year-old female patient has recently had her annual physical exam. She calls to inquire about the results of her lipid testing. Her results are as follows: total cholesterol 235 mg/dL, triglycerides 300 mg/dL, LDL 155 mg/dL, and HDL 42 mg/dL. Which of these is the correct way for the nurse to present the results to this patient? Give the patient the values and let her know they fall within normal limits. Give the patient the values and tell her that she is at high risk of coronary artery disease (CAD) and that she will just need to go on some medication. Give the patient the values and explain that her lipids are mildly elevated. Discuss some lifestyle modifications that she can use to help improve these values going forward. Give the patient the values and schedule her for a further cardiac testing as a precaution.
Give the patient the values and explain that her lipids are mildly elevated. Discuss some lifestyle modifications that she can use to help improve these values going forward.
An emergency room nurse is giving discharge instructions to a 15-year-old male who has suffered an orthopedic injury during a soccer game. He has been instructed to use crutches and limit weight bearing until further evaluation by a specialist. When instructing this patient, which of these is the correct way to describe the proper use of crutches? Straighten the arms and place your body weight on either the hand grips or armpit pads as you swing your uninjured leg as far as you can in front of you. Keeping the arms slightly bent, place the crutches about one foot in front of you, shifting your body weight to the hand grips as you swing your uninjured leg to, or just in front of, the crutches. Straighten the arms and allow your body weight to rest on the armpit pads as you swing your uninjured leg in front of you, then pull the crutches to your standing leg. ` Keeping the arms slightly bent, place the crutches as far as you can in front of you, and allow your body weight to rest on the armpit pads while you swing your uninjured leg to meet the crutches.
Keeping the arms slightly bent, place the crutches about one foot in front of you, shifting your body weight to the hand grips as you swing your uninjured leg to, or just in front of, the crutches.
A home health nurse visits a pleasant, independent 89-year-old female. At her appointment, the patient appears confused and agitated and has difficulty answering questions. The patient's vital signs are normal. Which of the following is the most appropriate nursing action? Call 911 and have the patient evaluated by EMS. Make arrangements for the patient to be evaluated by her primary healthcare provider, and stay with her until she is seen to ensure her safety. Ask the patient to give a detailed history of her day to identify the underlying cause for her altered mental status. Since the patient's vital signs are normal, schedule another home-health appointment within 12 hours to see the patient again.
Make arrangements for the patient to be evaluated by her primary healthcare provider, and stay with her until she is seen to ensure her safety.
When preparing for a clean catch urine specimen, what will the nurse need to do differently for female versus male patients? Allow a male specimen to sit for 20 to 30 minutes prior to transport to the lab. Use disinfectant on the outside of the female specimen containers only. Make sure the female patients have two antiseptic wipes. Instruct the males to begin voiding directly into the specimen container.
Make sure the female patients have two antiseptic wipes.
Calculate the pregnant mother's expected delivery date based on this information: First day of last menstrual period (LMP): August 12, 2018 Last day of the LMP: August 19, 2018 Menstrual periods: regular Gravida 1, Para 1, Abortions 0, Living children 2 May 26, 2019 May 12, 2019 May 19, 2019 There is not enough information to calculate the expected delivery date.
May 19, 2019
A 35-year-old male is brought to the emergency room by his wife. She states that he's had the "stomach flu" for the past 2 days with severe diarrhea and vomiting. During the interview, the patient tells the nurse that he's weak and fatigued. He also complains of lightheadedness, muscle spasms, as well as numbness and tingling in his extremities. The nurse is the first to review the laboratories ordered by the practitioner. Based on the patient's history and symptoms, which of these results should the nurse report immediately to the ordering practitioner? Sodium (Na⁺) of 136 mEq/L Potassium (K⁺) of 2.6 mEq/L Calcium (Ca⁺) of 8.7 mg/dL Magnesium (Mg⁺) of 2.2 mg/dL
Potassium (K⁺) of 2.6 mEq/L
A 75-year-old female recovering from a broken hip is being discharged from a healthcare facility. After completing her care plan after discharge, the nurse learns that her patient has a 78-year-old husband with dementia that she cares for at home. He has been staying with other family members during her convalescence. Which of these is the correct course of action for the nurse? Leave the discharge care plan as it is; assume that the family will continue taking care of her husband. Confront the patient and ask her why she didn't disclose the information about caring for her husband prior to completing her discharge care plan. Re-evaluate and revise her discharge care plan to ensure that the patient and her husband are both well taken care of at home. Trust that the patient's rehabilitation has been sufficient and she can immediately resume all previous activities related to caring for her husband at home.
Re-evaluate and revise her discharge care plan to ensure that the patient and her husband are both well taken care of at home.
The nurse is caring for a patient admitted for a severe flare-up of inflammatory bowel disease. The physician has ordered an enema containing betamethasone. The nurse knows that the commonly used type of enema to give a medication is which of these? cleansing enema carminative enema return-flow enema retention enema
Retention enema
Which of these age groups is incorrectly matched with its developmental needs? Adolescents need preparation for the changes of puberty. Infants need to form bonds with their parents and caregivers. School-aged children need consistency and to feel secure in their environments. The elderly need help finding meaning and purpose in their lives.
School-aged children need consistency and to feel secure in their environments.
A nurse is caring for a hospitalized Hindu patient who is served a salsbury steak dinner. Which of these is the most appropriate action for the nurse to take? She should be aware that Hindus do not eat beef, but serve him the meal anyway and hope that he will not complain. She should be aware that Hindus do not eat beef and make an effort to find an acceptable alternative meal. She should be aware that Hindus do not eat beef, but tell him that he needs to eat the steak to keep his strength up. She should be aware that Hindus do not eat beef and ask the patient if he is okay without eating a protein for dinner.
She should be aware that Hindus do not eat beef and make an effort to find an acceptable alternative meal.
A nurse is conducting a home visit for a program that monitors at-risk children. Her patient is a 2-year-old female who appears to be in good health. The mother asks when her daughter will need dental care. Which of these is the correct answer to this question? She does not need regular dental check-ups and cleanings until she has all her adult teeth in. She should continue brushing at home twice daily and contact a dentist if her daughter complains of any pain. She should begin seeing a dentist at the age of 5 for regular check-ups and cleanings. She should begin seeing a dentist now for regular check-ups and cleanings.
She should begin seeing a dentist now for regular check-ups and cleanings.
A 25-year-old female with a normal menstrual cycle presents for her annual pap smear and breast exam. She has no positive family history of breast cancer. The nurse is counseling the patient on when to do her own breast self-examination (BSE). Which of these should she tell the patient? She has no family history of breast cancer, so BSE is not necessary, but she should return for her annual evaluation. She should perform her BSE every month on day 12 to 14 of her menstrual cycle. She should perform her BSE every month whenever she remembers to do so. She should perform her BSE every month on day 5 to 7 of her menstrual cycle.
She should perform her BSE every month on day 5 to 7 of her menstrual cycle.
A nurse is caring for a patient who needs an enema. Which of these is the best position in which to place the patient followed by the correct description of the position? Fowler's position: patient lying on his or her back with the head of the bed lowered so that the feet are elevated with the knees bent and legs apart. Lateral position: patient on his or her side (right or left) with knees slightly bent and a pillow placed between the legs for comfort. Right prone position: patient lying on his or her stomach with the right leg and knee flexed. Sim's position: patient in a prone/lateral position on his or her side with the upper leg flexed and drawn in toward the chest and the upper arm flexed at the elbow.
Sim's position: patient in a prone/lateral position on his or her side with the upper leg flexed and drawn in toward the chest and the upper arm flexed at the elbow.
A terminally ill male patient who is mentally competent declines palliative radiation for his inoperable brain tumor. The nurse knows that this patient is refuSing treatment based on which of these legal standards? The Patient Self Determination Act The Patients' Bill of Rights The Health Insurance Portability and Accountability Act The Uniform Anatomical Gift Act
The Patient Self Determination Act
A nurse is caring for a patient who has limited social contacts and family during her convalescence. The nurse knows that she needs to incorporate support systems into this patient's care plan. Which of these is a reason for the helpfulness of support systems in a patient's recovery? Support systems keep patients busy so they can take their mind off of their condition during the treatment process. Support systems have scientifically been shown to speed recovery and healing in patients with multiple different conditions and disorders. Support systems can help take the burden of care off of the nurse so that he or she can care for other patients as well. Support systems keep patients accountable for maintaining any changes in lifestyle that are a result of their condition and/or treatment.
Support systems keep patients accountable for maintaining any changes in lifestyle that are a result of their condition and/or treatment.
A nurse is caring for a patient who must give a sputum culture. The patient has consented for the procedure and the nurse is giving him the proper instructions. Which of these are the proper instructions the nurse should give to the patient for this test? Take a deep breath, cough and expel the sputum into the container while avoiding allowing saliva to enter as well. Taking a sharp breath in through your nose, mix the mucous that's cleared from that with sputum cleared from your throat and expel both into the container. After holding your breath for 5 seconds, clear your throat and expel the sputum into the container avoiding saliva to enter as well. Cough deeply and expel all of the oral contents into the container.
Take a deep breath, cough and expel the sputum into the container while avoiding allowing saliva to enter as well.
A nurse is working in a pregnancy crisis center. A 15-year-old girl comes into the center and requests a pregnancy test. Her test results are positive. To tell her when her baby is due, the nurse will need to know which of these things? the first day of her last menstrual period (LMP) the last date that she had intercourse the length (in days) of her menstrual cycles the last day of her last menstrual period (LMP)
The first day of her last menstrual period
In which of these situations is a nurse in violation of HIPAA guidelines? The nurse has a conversation with a patient about the results of his labs and other diagnostic tests with the patient's wife present in the room. The nurse jots a patient's name and vitals on a scrap piece of paper rather than directly into the medical record, but shreds it after the information has been recorded. The nurse forgets to close out a patient's electronic medical record and leaves the information on the monitor where it can be read by other patients and visitors. The nurse has a conversation about a patient's change in status with the nurse that's about to take over care in earshot of a nurse's aid who is not assigned to that patient.
The nurse forgets to close out a patient's electronic medical record and leaves the information on the monitor where it can be read by other patients and visitors.
A nurse inadvertently administers the wrong dose of antibiotic to a patient recovering from surgery. Which of these is the correct course of action for the nurse when documenting this in the patient's medical record? The nurse should just document the dosage given in the patient's chart. An incident report is not necessary because it was simply the wrong dosage of a drug that was ordered. The nurse should create an incident report and include a copy of the report in the patient's medical record. The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence. The nurse should tell the patient of the incident and ask his or her preference on if an incident report should be created and if one is, it should be included in the patient's medical record.
The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence.
A widowed woman is being admitted for emergency cardiac surgery by the nurse. She is asking the nurse questions about who will make decisions for her if something goes wrong during her surgery. Which of these is the correct course of action for the nurse? The nurse should inform and educate this client about advance directives, help coordinate their creation, and ensure they are in the medical record. The nurse should inform and educate this client that the nurse will act as a healthcare proxy for the patient, should the client be rendered incapable of making medical decisions for herself. The nurse is not involved with advance directives. She should alert a social worker that the patient needs help establishing advance directives. The nurse should inform the physician and advocate for the delay of surgery until the patient seeks legal counsel.
The nurse should inform and educate this client about advance directives, help coordinate their creation, and ensure they are in the medical record.
A nurse is working in an indigent health clinic and has been asked to counsel and educate a patient undergoing treatment for latent tuberculosis infection with isoniazid for 9 months. Which of these is correct information for the nurse to give this patient regarding his disease and treatment? The most common side effect of isoniazid is optic neuritis, so he will need to report any vision changes or eye pain to the clinic immediately. The patient should avoid close contact with others in his household until he has been on therapy for at least 2 months. The patient will notice a reduction of his frequent coughing spells and fever once he begins taking the medication. The patient should take vitamin B6 (pyridoxine) in order to reduce the risk of peripheral neuropathy while taking isoniazid.
The patient should take vitamin B6 (pyridoxine) in order to reduce the risk of peripheral neuropathy while taking isoniazid.
A nurse is setting up and assisting in a sterile surgical procedure. According to the principles of surgical asepsis, the nurse understands that which of these statements is correct? The tray is considered to be unsterile if a blood-soaked gauze from the patient is placed back onto the tray. The surgeon holds a surgical instrument out of view of the surgical field and below waist level, but does not touch anyone or anything. This instrument is still considered sterile and may be used. The skin must be sterile prior to the start of the procedure. The edges of a sterile field are also considered to be sterile.
The tray is considered to be unsterile if a blood-soaked gauze from the patient is placed back onto the tray.
The nurse is performing a nutritional assessment for a patient who is 134 kg and 1.93 meters in height. Which of these would be a correct statement about this patient's nutritional status? This patient has normal body weight. This patient is underweight and in need of weight gain. This patient is obese and in need of weight reduction. There is not enough information given to assess the patient's nutritional status.
This patient is obese and in need of weight reduction
What is the intended purpose of a medication reconciliation? To ensure that a patient is properly taking each medication and understands the indications for the use of each. To create a potential list of all possible side effects of a patient's medications so that they can be screened for the occurence of unwanted side effects. To create a complete and current list of all medications and alternative therapies for review and evaluation for possible interactions. To create a current list of all medications, over-the-counter drugs, alternative therapies, and herbal drugs and vitamins that can be used upon transfer or discharge.
To create a complete and current list of all medications and alternative therapies for review and evaluation for possible interactions.
A nurse is beginning a new position working in a pain management clinic. On her first day, her precepting nurse asks her what the four phases of pain are, in sequential order. Place the four phases in the correct order. A. modulation B. perception C. transmission D. transduction
Transduction Transmission Modulation Perception
A trauma patient presents to the ER with severe hemorrhage. His blood type is O positive. Based on this information, the nurse knows that he may receive blood only from a person with which of these blood types? type AB (positive or negative) type AB positive Type O blood (positive or negative) type A positive
Type O blood (+ and -)
A nurse working in an obstetrics practice returns from her lunch break and finds four new phone messages for which she must return calls. Out of these four, which one is the highest acuity? a 35-year-old in her 20th week of pregnancy who has gained 10 pounds thus far, but has not gained any weight in the past week a 26-year-old in her 15th week of pregnancy who is concerned that she has not yet felt the baby move a 29-year-old in her 38th week of pregnancy who is concerned as she has noted an increase in fetal movement a 32-year-old in her 36th week of pregnancy who has had a continuous, worsening headache for the past 48 hours
a 32-year-old in her 36th week of pregnancy who has had a continuous, worsening headache for the past 48 hours Warning sign of preeclampsia
A nurse has just received report on all four of his patients for his upcoming shift on a medical/surgical floor. Which of the patients should the nurse attend to first? a 72-year-old with COPD complaining of worsening dyspnea and a pulse oximetry reading of 90% a 63-year-old with atrial fibrillation treated with digoxin and metoprolol who is in a normal rate and rhythm a 70-year-old who is 12 hours post operative for a total left knee replacement who has some serosanguinous oozing from the incision a 55-year-old who is 24 hours post operative for a bilateral mastectomy complaining of pain that is 6 out of 10
a 72-year-old with COPD complaining of worsening dyspnea and a pulse oximetry reading of 90%
A nurse is reviewing laboratory results for a 45-year-old male patient's annual exam. She needs to alert the provider with any abnormal results. Using her knowledge of the recommended levels for a fasting lipid profile, which of these results should she report? a total cholesterol of 195 mg/dL a high-density lipoprotein (HDL) of 35 mg/dL a low-density lipoprotein (LDL) of 95 mg/dL a triglyceride of 100 mg/dL
a high-density lipoprotein (HDL) of 35 mg/dL
The nurse is delivering dinner trays to patients under the care of a colleague due to being short-staffed on her medical-surgical floor. She comes across a tray that is not assigned to a patient, but is ordered as a mechanical soft diet. There are four patients who still do not have dinner trays. Which of these patients would likely need this type of diet? a patient who is to undergo a diagnostic colonoscopy in the morning a patient who is postoperative for a total thyroidectomy a patient has renal failure and undergoes dialysis a patient who has gastritis
a patient who is postoperative for a total thyroidectomy
A nurse is working with a patient who has a contagious condition. In recalling the chain of infection, the nurse knows that an environment favorable for the growth and reproduction of an infectious agent is referred to as ____. a susceptible host a reservoir a vector a portal of entry
a reservoir
A nurse is caring for a patient with dilated cardiomyopathy who is hospitalized for an acute flare of congestive heart failure (CHF). The patient has symptoms of fatigue, weakness, and dyspnea. The nurse notes peripheral edema as well as coolness and pallor in the distal extremities. Given this patient's physiologic status, which of the following nursing interventions would be indicated? Select all that apply. A. Teach and encourage the patient to perform appropriate light exercise interspersed with frequent rest periods. B. Teach and encourage the patient to perform coughing, deep breathing, and incentive spirometry exercises. C. Provide appropriate analgesia for occurrences of chest pain and give supplemental oxygen as indicated per the practitioner's orders. D. Take proper precautions to protect the patient from falls and injuries during transfers and ambulation. E. Elevate the lower extremities to reduce peripheral edema and improve circulation with the use of sequential devices of TED hose.
a,c,d,e
A 23-year-old male presents to the emergency department with complaints of progressively worsening abdominal pain and nausea over the past 12 hours. The nurse takes his vital signs and notes that he has a fever. The abdomen examination reveals a somewhat rigid abdomen with guarding and extreme tenderness in the right lower quadrant midway between the umbilicus and the superior iliac spine. Normal bowel sounds are present. Based on this history and presentation, which of these medical emergencies should the nurse suspect? acute gastrointestinal bleed intussusception peritonitis acute appendicitis
acute appendicitis
A nurse is admitting a patient with congestive heart failure (CHF) treated with atenolol for an acute exacerbation of chronic obstructive pulmonary disease (COPD). The nurse notes a potential drug-to-drug interaction with one of the patient's newly prescribed medications. Which of the following drugs should not be used to treat this patient's COPD exacerbation? ipratropium corticosteroids theophylline albuterol
albuterol
Which of these patients is correctly matched with the proper therapeutic environment? an angry, intoxicated patient in a private room with restraints on a manic patient in a room with the television and radio on a depressed patient in a private room that is dimly lit a patient with suicidal ideation that is the farthest down the hall from the nurses' station
an angry, intoxicated patient in a private room with restraints on
A nurse is caring for four patients on a med/surg floor of a hospital. Based on what the nurse knows about risk factors for sensory and/or perceptual alterations, which of these patients would least likely be at risk of potentially developing this problem? an elderly patient who is recovering from a hysterectomy whose pain is well controlled an adult with a number of traumatic burn injuries that have been surgically debrided and whose pain is poorly controlled an adult admitted for overnight observation following a mild head trauma related to a motor vehicle accident a blind adult recovering from a laparoscopic cholecystectomy whose pain is well controlled
an elderly patient who is recovering from a hysterectomy whose pain is well controlled
A 52-year-old male with type II diabetes has blood pressure readings between 125/84 and 134/92 mm Hg. His urinalysis shows no abnormalities. He is prescribed an ACE inhibitor. Based on what the nurse knows about this class of medications, which of these would be an abnormality found on his serum chemistry as a result of being on this medication? hyperkalemia hypernatremia hypomagnesemia hyperglycemia
hyperkalemia
When considering the source of a postoperative fever, the nurse knows that which of these is usually not a likely source? a urinary tract infection pneumonia a wound infection dehydration
dehydration
Which of these scenarios correctly describes proper delegation by a nurse? delegating a nursing assistant to educate a patient on a new medication delegating vitals on a patient who is experiencing chest pain to a nursing assistant delegating wound assessment on a postoperative patient complaining of increased pain to a nursing assistant delegating a bath of a quadriplegic patient to a nursing assistant
delegating a bath of a quadriplegic patient to a nursing assistant
A nurse is discussing the diagnosis of a terminal disease with a patient. When the nurse asks the patient about how he is feeling about all of the information she's giving him, he states,"I don't think there's anything wrong with me...I'm not worried at all." This statement is an example of what kind of defense mechanism? denial displacement projection suppression
denial
Among these disorders, identify the one that is improperly matched with the electrolyte imbalance. hyperparathyroidism and hypercalcemia syndrome of inappropriate antidiuretic hormone (SIADH) and hyponatremia diabetes insipidus (DI) and hyponatremia Addison's disease and hyperkalemia
diabetes insipidus (DI) and hyponatremia
A patient with a 3-day history of worsening fever, productive cough, and fatigue comes to the office for evaluation. The nurse would most likely expect to hear which of the following on her chest examination? dullness with percussion and abnormal breath sounds with auscultation hyperresonance with percussion and normal breath sounds with auscultation hyperresonance with percussion and abnormal breath sounds with auscultation dullness with percussion and normal breath sounds with auscultation
dullness with percussion and abnormal breath sounds with auscultation (pneumonia)
A 16-year-old sexually active female patient with a history of pelvic inflammatory disease (PID) presents to the emergency room with complaints of sudden right-sided lower abdominal pain and gastrointestinal distress. She cannot recall the date of her last menstrual period, but states she knows that she's "late." Her exam demonstrates a unilateral, right adnexal mass. The nurse knows that this patient likely has which of these prenatal complications? ectopic pregnancy spontaneous abortion gestational trophoblastic disease (GTD) premature rupture of membranes (PROM)
ectopic pregnancy
A nurse on the medical/surgical floor is caring for an elderly, postoperative patient with dementia who is in restraints because she refuses to stay in bed or keep her IVs in. The nurse knows that she will have to provide range of motion exercises and ask if the patient needs to use the restroom how often? every 4 hours every 2 hours every 8 hours every 6 hours
every 2 hours
A nurse is counseling an 87-year-old female patient and her daughter. The patient is obese, has multiple medical problems, including dementia, and takes numerous medications. The patient is preparing to move in with her daughter for full-time care. Which of the following is least important for the nurse to discuss with the patient and her daughter. fall prevention and safety fire safety and prevention side effects of her medications proper ergonomics for lifting/assisting the patient in her activities of daily living
fire safety and prevention
A patient admitted to the ICU with an order for complete bowel rest is started on total parenteral nutrition (TPN). On the second day, the nurse notes that the patient has developed hypertension. The physical assessment demonstrates mild peripheral edema, neck vein distension and the presence of mild crackles and rales on auscultation of the lungs bilaterally. Which of these complications of TPN is this patient likely experiencing? fluid overload pneumothorax hypoglycemia infection
fluid overload
According to Eric Erikson's theory of psychosocial development, which of these is the major conflict that needs to be resolved for adults age 35 to 64? intimacy versus isolation industry versus inferiority generativity versus stagnation ego integrity versus despair
generativity versus stagnation
A nurse begins working in a pediatric clinic. She will be administering IM injections to patients who range in age from infancy to adolescence. The nurse knows that all of these muscles may be used for injection sites for all of these age groups except ____. vastus lateralis ventrogluteal gluteus maximus rectus femoris
gluteus maximus (not until 1 years old)
Which of these is the correct order of events a nurse should follow when applying personal protective equipment (PPE)? handwashing, gloves, gown, eye protection, and mask handwashing, gown, mask, eye protection, and gloves mask, eye protection, handwashing, gloves, and gown gown, mask, eye protection, handwashing, and gloves
handwashing, gown, mask, eye protection, and gloves
A 65-year-old Hispanic male has just been diagnosed with type II diabetes mellitus. He and his daughter are speaking with the nurse in an exam room about his new diagnosis, his medication regimen, and some dietary modifications that he needs to implement. The patient uses a walker to move around, but his daughter says he prefers a cane at home. He speaks in Spanish to his daughter, but she speaks English and Spanish. He seems to follow along well and at the end of the visit, he states that he would like to get better. Given this scenario, which of the following is most likely to be a barrier for this patient's adherence to the nurse's instructions? his language barrier his physical condition his attitude and motivation his absence of support systems
his physical condition
A 72-year-old female is admitted to the hospital for community-acquired pneumonia. At the time of admission, she is dehydrated, hypotensive, complains of weakness, and has a productive cough with thick, green sputum. She has a history of diverticulosis, but is otherwise healthy. She is started on a course of IV levofloxacin and on day 4 of treatment, begins to have diarrhea. The nurse knows that which of these places this patient at the greatest risk of Clostridium difficile (C. diff) infection? community-acquired pneumonia advanced age hospital admission diverticulosis
hospital admission
A nurse who works in an outpatient surgical center develops a new respiratory illness. She has atypical symptoms and is not responding to conventional therapies. Her work history includes spending considerable amounts of time in her facility's central supply and equipment sterilization areas. Her treating physician suspects her illness is linked to a workplace exposure. Where is the best place for the nurse to obtain information regarding her potential workplace exposures? the equipment manufacturer's service center and help desk the Material Safety Data Sheets (MSDS) at her facility the Occupational Safety and Health Administration (OSHA) website the Centers for Disease Control and Prevention's (CDC) reportable illness hotline
the Material Safety Data Sheets (MSDS) at her facility
The nurse is planning to delegate tasks for her patients at the nursing home. The nurse knows that she does not need which of these to ensure successful supervision of the delegated tasks? the ability to provide clear direction and communication the ability to provide criticism and negative feedback the ability to problem-solve the ability to provide timely follow-up
the ability to provide criticism and negative feedback
Which of these is not considered one of the six stages of viral growth? the log stage the release and lysis stage the attachment stage the penetration stage
the log stage
Which of these is typically not an essential part of the nurse's information review prior to administering a medication to a patient? the patient's current diagnoses the patient's listed medication allergies the patient's family history the "rights" of administration
the patient's family history
A nurse is volunteering in an indigent clinic. She is seeing a patient whom she suspects has active tuberculosis. In this disease process, which of the following body systems serves as both the reservoir and portal of entry for this infection? the respiratory system the gastrointestinal system the integumentary system the hematologic system
the respiratory system
A nurse is taking care of a previously healthy adult patient with a newly diagnosed serious medical condition. The patient is apprehensive and confused by all of the information, tests, test results, and the number of medical practitioners involved in the care plan. The nurse knows that it is her job to inform and educate this patient on the rights and responsibilities of those receiving healthcare as specified in the Patients' Bill of Rights. According to this document, which of the following is not included in this discussion? the responsibility to inform the healthcare staff of any previous conditions and medications the right to choose any provider or plan for healthcare the right to be informed about and participate in the decisions regarding medical treatment the right to refuse any treatment
the right to refuse any treatment
A nurse is present when a physician speaks with a patient about an upcoming invasive diagnostic procedure. The physician describes the procedure in detail and discusses all possible alternative procedures and treatments and what the potential ramifications are if the patient decides not to have the procedure. The nurse knows that the patient cannot give informed consent based on this discussion because the physician forgot to include which of these? the recommendation to see another physician for a second opinion on the necessity of the procedure the opportunity for the patient to ask his or her questions about the procedure the risks and benefits of the procedure (including death) the cost of the procedure and whether or not insurance will pay for it
the risks and benefits of the procedure (including death)