36

55). A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action?

Explore the family's thoughts and concerns about the client's refusal of food

9). The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?

Grilled chicken, green beans, and mashed potatoes

69). The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

Take the blood pressure sitting and standing Missed: 4 Wrong: 2

72). The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?

Tell the UAP to tell the charge nurse about the needs of the client in the next room

28). The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hours ago. Which finding requires an immediate report to the registered nurse?

Temperature spike to 101.2 F (38.4 C)

15). The health care provider orders 2 mEq/kg (2 mmol/kg) of 8.4% sodium bicarbonate IV to be administered over the next 4 hours. The client weighs 150 lb and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL D5W with 150 mEq (150 mmol) sodium bicarbonate. At what rate should the nurse set the infusion pump?

The correct syringe has liquid filled to the 1.3 mL mark.

16). The nurse has received a prescription from the health care provider to administer 80 mg methylprednisolone IVP. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.

The correct syringe has liquid filled to the 1.3 mL mark.

5). A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention?

Wrap the newborn's upper body in a blanket restraint for the circumcision

SIADH can occur due to lung cancer

and is characterized by water retention, increased total body water, and dilutional hyponatremia. Hyponatremia may cause neurologic complications (eg, confusion, seizures). SIADH treatment includes fluid restriction, oral salt tablets, and administration of 3% saline IV and/or vasopressin receptor antagonists.

SIADH

is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions.

13). The nurse is reinforcing teaching on self-administering ophthalmic lubricating ointment medication to a client with newly diagnosed Sjögren's syndrome. Which client statement indicates the need for further teaching?

"After applying the ointment, I'll close my eyes tightly and rub the lid for 2-3 minutes."

48). The practical nurse (PN) is reinforcing instructions for the caregiver of an 8-month-old who weighs 16.5 lb. The health care provider has prescribed oral amoxicillin 25 mg/kg/day in 2 divided doses for 5 days as treatment for acute otitis media. Amoxicillin for oral suspension comes packaged as 125 mg/5 mL. Which instruction by the PN requires intervention by the registered nurse?

"Give your baby 7.5 mL of the medicine at 8 AM and 8 PM."

6). The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further?

"I am having problems extending my fingers since this morning."

61). The nurse reinforces discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching?

"I have to use a walker because I can't bear any weight on this knee yet."

50). An experienced practical nurse is assisting the registered nurse in caring for a hospitalized client with a prescription for a transfusion of packed red blood cells to be hung over 3 hours. Which statement by the practical nurse indicates the correct rationale for asking the client to void prior to starting the transfusion?

"If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed red blood cells." Missed: 3 Wrong: 1

58). The nurse is preparing a client for a magnetic resonance cholangiopancreatography (MRCP). Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.

- "I had my last period 6 weeks ago." - "I have a hearing aid implanted in my ear." Missed: 3,4 Wrong: 2,5

51). The practical nurse reviews the admission history of a 70-year-old client with newly diagnosed chronic obstructive pulmonary disease (COPD). Which statements by the client does the nurse recognize as the most significant contributing factors to the development of COPD? Select all that apply.

- "I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year." - "I was a car mechanic for about 40 years and had my own garage." Wrong: 2, 4

26). The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse reinforce with the client regarding this test? Select all that apply.

- "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." - "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." -"You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

59). A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which instructions should the nurse reinforce to correctly answer the client's question? Select all that apply.

- "No food or drink is allowed 8 hours prior to the test." - "The day prior to the procedure your diet will be clear liquids." - "You will drink polyethylene glycol as directed the day before." Wrong: 2

43). The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma attack? Select all that apply.

- Accessory muscle use - Chest tightness - Diminished breath sounds bilaterally - High-pitched wheezing on expiration - Tachypnea Missed: 1,3, Wrong: 5

11). The practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply.

- Achieve and maintain a healthy weight - Drink plenty of fluids - Restrict alcohol consumption Wrong:3

2). A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which interventions should the nurse anticipate to prevent wound dehiscence? Select all that apply.

- Administer docusate orally every day - Administer ondansetron IV prn for nausea - Apply an abdominal binder - Monitor blood sugar to maintain tight glucose control

4). The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply.

- Administer warmed, humidified oxygen via facemask - Provide mouth care with oral sponges - Start the client on incentive spirometer

23). A client is suspected of having Graves' disease (hyperthyroidism). Which signs and/or symptoms are expected to be present in this client? Select all that apply.

- Anxiety - Heart palpitations - Protrusion of the eyeballs Wrong: 6

67).A client diagnosed with cirrhosis is experiencing pruritus. Which actions will the nurse take to promote comfort and minimize pruritus? Select all that apply.

- Apply cool, wet cloths to skin - Gently apply calamine lotion - Promote the use of cotton gloves - Request that the client cut nails short

17). A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.

- Apply patch to the upper arm or chest - Fold used patches in half with sticky sides together before discarding - Rotate sites each time a new patch is applied Missed: 1

49). The nurse is preparing to administer medications to an 84-year-old client with dementia, agitation, and heart failure. Knowing that this client does not like to take pills and often allows only a few to be administered, the nurse prioritizes the oral medications by importance to the client's well-being. Which medications would be most important for the client to receive? Select all that apply.

- Aripiprazole - Furosemide - Lisinopril

74). The licensed practical nurse (LPN) is monitoring a client receiving a transfusion of packed red blood cells (PRBCs). Ten minutes after the transfusion is initiated, the client has shortness of breath and slight chest tightness. What initial actions are appropriate in managing this transfusion reaction? Select all that apply.

- Assess the client's breath sounds - Notify the supervising registered nurse (RN) - . Stop the infusion of PRBCs

45). A client is being discharged today following a partial gastrectomy. Which instructions for recuperating at home should be included? Select all that apply.

- Avoid intake of fluids with meals - Consume low-carbohydrate meals - Eat small, frequent meals Missed: 3 Wrong: 1,4

34). The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply.

- Cardiac and renal changes may put the client at risk for hypervolemia - Older adults may have more fragile veins, increasing the risk of infiltration - Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin Missed: 3 Wrong: 1

21). The nurse is caring for a child newly diagnosed with cystic fibrosis. What interventions does the nurse expect to be included in the client's multidisciplinary plan of care? Select all that apply.

- Chest physiotherapy - Genetic counseling - Spiritual support Wrong: 4

20). The nurse is caring for a client with community-acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.

- Crackles - Pleuritic chest pain - Productive cough Missed: 1 Wrong: 2

62). The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.

- Do not leave a tourniquet on more than 1 minute while looking for a vein - If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes Wrong: 4

47). Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply.

- Ensure the client is given an analgesic 30-60 minutes before tube removal - Instruct the client to breathe in, hold it, and bear down while the tube is being removed - Prepare a sterile airtight petroleum jelly gauze dressing - Provide the health care provider with sterile suture removal equipment

1). The nurse cares for a client admitted to the hospital due to confusion. The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s) should the nurse expect to implement? Select all that apply.

- Fluid restriction - Seizure precautions - Strict record of fluid intake and output Missed: 4 It is important for the nurse to anticipate these problems and institute seizure precautions. Wrong: 3 Oral salt tablets to increase serum sodium

36). A client receives intermittent bolus enteral feedings through a nasogastric tube. Which are appropriate nursing actions prior to starting the feeding? Select all that apply.

- Flush the tube before and after the feeding - Place the client in the semi-Fowler position - Start the feeding after obtaining a gastric residual volume <100 mL

66). The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply.

- Guide suppository along the rectal wall - Hold buttocks together firmly after insertion - Position client supine with knees and feet raised - Use gloved fifth finger for insertion Missed: 2,3,4,5 Wrong: 1

41). Which positions are correct when caring for clients undergoing therapeutic procedures? Select all that apply.

- High-Fowler's for a paracentesis in cirrhosis - Sims for soap-suds enema administration - Supine position after lumbar puncture Missed: 4,5 Wrong: 3

52). The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.

- Keep head of the bed at ≥30 degrees - Maintain endotracheal cuff pressure - Monitor for abdominal distension every 4 hours - Use caution when administering sedatives

76). The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.

- Lying pulse 80/min, standing pulse 110/min - Osteoarthritis of knees - Takes carbidopa/levodopa - Uses a cane to ambulate

68). The nurse reinforces teaching to a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include? Select all that apply.

- Notify the health care provider if you feel a fluttering or rapid heartbeat - You will need to take this medication for the rest of your life

56). The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions should the nurse expect to implement when caring for this client? Select all that apply.

- Notify the registered nurse immediately of pin site drainage or increased pain - Perform neurovascular checks every 2-4 hours for 24 hours - Perform sterile pin care per institutional policy Wrong: 2

8). Which teaching instructions should the nurse reinforce to a client with advanced chronic obstructive pulmonary disease? Select all that apply.

- Obtain a pneumococcal vaccine - Report increased sputum Wrong: 5

40). A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.

- Offer the client an elbow to hold, and walk a half-step ahead for guidance - Say "goodbye" when leaving the room to help orient the client - Use a clock-face pattern to explain food arrangement on the client's meal tray

30). The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? Select all that apply.

- Post a hearing impairment sign on the client's door - Speak directly facing the client

63). A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.

- Report any redness, swelling, warmth, or drainage from your incisions - Wash incisions daily with soap and water in the shower and gently pat them dry - Wear an elastic compression hose on your legs and elevate them while sitting Missed: 2 Wrong: 1

64). Which steps should the nurse take to decompress the stomach for a client with abdominal distension and vomiting after insertion of a large-bore nasogastric (NG) tube? Select all that apply.

- Wear an elastic compression hose on your legs and elevate them while sitting - Leave the blue pigtail air vent open to air - Use an adaptor to connect main NG lumen to suction tubing Missed: 2,3 Wrong: 1, 4

12). An elderly client with staphylococcal pneumonia treated with IV antibiotic therapy for 3 days becomes extremely short of breath and restless and is difficult to arouse. Which additional findings indicate to the nurse that the client may be developing sepsis? Select all that apply.

-Absent bowel sounds -Capillary refill time of 5 seconds - Serum glucose level of 180 mg/dL (10 mmol/L) Missed: 1 Wrong: 3

75). The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What initial actions are appropriate for the nurse to take? Select all that apply.

-Ask the date of last bowel movement and administer prescribed stool softeners -Examine the catheter for kinks and obstructions Wrong: 5

70). A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?

0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours Missed:1 Wrong: 4

19). The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen. Place the following steps for ear irrigation in the correct order. All options must be used.

1). Assess the client for fever, ear infection, or tympanic membrane injury 2). Place the client in a sitting position with the head tilted toward the affected ear 3). Place a towel and an emesis basin under the ear 4). Straighten the ear canal by pulling the pinna up and back 5). Gently irrigate the ear canal with a slow, steady flow of solution

24). The nurse enters the hospital room and finds the client lying still and quiet on the floor. Arrange the following actions in the correct order. All options must be used.

1). Check the client for responsiveness 2). Activate the emergency response system 3). Check the client for breathing and a pulse 4). Begin cardiopulmonary resuscitation 5). Notify the health care provider

71). The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used.

1). Measure, mark, and lubricate tube 2). Instruct client to extend neck back slightly 3). Gently insert tube just past nasopharynx 4). Ask client to flex head forward and swallow 5). Advance tube to the marked point 6). Verify tube placement and anchor

14). A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse reinforces the use of the "huff" coughing technique to facilitate secretion removal. Place the steps in the correct order.

1). Position the body upright 2). Take 3 deep breaths, inhaling through the nose using abdominal breathing and exhaling slowly through pursed lips 3). Lean forward and inhale deeply through the nose 4). Hold breath for 2-3 seconds while keeping the throat open 5). Force the breath out gently using the abdominal muscles while making 3 short "ha" sounds (huff cough)

18). A nurse administers an intramuscular (IM) injection using the Z-track technique. Place the steps in chronological order. All options must be used.

1). Pull the skin 1-1 ½" (2.5-3.5 cm) laterally and away from the injection site 2). Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle 3). Inject medication slowly with dominant hand while maintaining traction 4). Wait 10 seconds after injecting the medication and withdraw the needle 5). Release the hold on the skin, allowing the layers to slide back to their original position 6). Apply gentle pressure at the injection site but do not massage

60). The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order. All options must be used.

1). Place client in semi-Fowler's position 2). Preoxygenate (hyper-oxygenate) with 100% oxygen 3). Insert catheter the length of the airway without applying suction 4). If resistance is felt, withdraw the catheter 0.4-0.8 in (1-2 cm) 5). Apply intermittent suction while rotating the suction catheter while withdrawing

SIADH treatment includes:

1.Fluid restriction to <1000 mL/day 2.Oral salt tablets to increase serum sodium (Option 3) 3.Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations 4. Vasopressin receptor antagonists (eg, conivaptan) The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration.

35). The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best?

18-gauge

39). The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the nurse reinforce when teaching the client?

4-point gait Missed: 3 Wrong: 2

22). The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first?

A client post cholecystectomy reporting increased nausea

3). The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis?

A client receiving intravenous broad-spectrum antibiotics daily

25). The practical nurse is collecting data on a client with acute diverticulitis. Which finding will the nurse report immediately to the registered nurse?

Abdominal pain has progressed to the left upper quadrant

57). The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip?

Atrial paced rhythm

37). The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required?

Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place Missed: 1 Wrong: 4

44). A nurse receives information in a change of shift report. Which client is the priority?

Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites

73). Which client finding is most important for the nurse to follow up?

Client with rash that has purplish blotches that do not blanch

7). The nurse observes a client who is postoperative total right hip replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs?

Descends with the cane on the step first, followed by the right leg and then the left leg

10). A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?

Discard urine and container, and restart the 24-hour urine collection tomorrow morning

65). An elderly client is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using the accessory muscles to breathe. Which prescription should the nurse question?

IV morphine 2 mg now, may repeat every 2 hours Missed: 3 Wrong

29). The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse finds increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate?

Incentive spirometer

32). A client with community-acquired pneumonia is receiving 0.9% normal saline at 50 mL/hr. Pulse oximetry shows 95% on nasal oxygen at 3 L/min. The registered nurse adds a nursing diagnosis of ineffective airway clearance to the care plan. Which prescription would the practical nurse expect to best facilitate secretion removal?

Increase 0.9% normal saline to 125 mL/hr

53). The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?

Noisy breathing

38). The nurse caring for a client with an ileal conduit observes that the stoma appears bluish gray. What is the nurse's best action?

Report the findings to the health care provider immediately

54). A client has a subclavian vein central venous access device (CVAD). The nurse attempts to flush the catheter with 0.9% normal saline solution using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What is the nurse's next most appropriate action?

Reposition the client Missed: 4 Wrong; 2

42). The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management?

Steak, tomato basil soup, and cornbread Missed: 4 Wrong: 1

31). An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?

The client has a tuberculosis infection

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