Hesi Exit RN Review

- A registered nurse (RN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the LPN?

ANS - 1. A client with a decubitus ulcer that requires a wound irrigation and dressing change.

- (Y) The clinic nurse is reviewing the laboratory results of an adult client seen in the health care clinic. The nurse determines that the white blood cell count (WBC) is normal if which of the following is noted on the laboratory results?

8400mcg/L

21. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? • Use an electronic sphygmomanometer to take the BP every 30 minutes. • Retake the blood pressure in the same arm, deflating the cuff slowly. • Ask another nurse to recheck the blood pressure to compare results. • Obtain another blood pressure cuff and retake the blood pressure.

ANS = Retake the blood pressure in the same arm, deflating the cuff slowly. Rationale = The nurse should first retake the blood pressure in the right arm, deflating the cuff more slowly (B), because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. There is no indication that the BP needs to be taken frequently (A). If the blood pressure remains low, further assessment is needed, which may include (C). If deflating the cuff slowly does not resolve the discrepancy, the nurse may then need to implement (D). Category: Fundamentals

After an earthquake, four groups of clients are given different tags in accordance with the disaster triage tag system. What is the correct order of treatment priority for each group? a. Red Tags b. Yellow Tags c. Green Tags d. Black Tags

ANS - RED, YELLOW, GREEN and BLACK tags in order for treatment.

A nurse is providing instructions to a client with a diagnosis of artial fibrillation about the need to begin long-term anticoaglant therapy. Which explanation would the nurse provide the client to describe the reasoning for this therapy?

Because the artia are qivering blood flows sluggishly through them, and clots can form long the heart wall, which could then lossen and travel to the lungs or brain.

(Y) Epididymitis has developed as a complication of a urinary tract infection (UTI). The nurse is giving the client instructions to prevent a reoccurrence. The nurse determines that the client needs further instruction if the client states to:

Continue to take the prescribed antibiotics until all the symptoms are gone.

A client with a diagnosis of hyperphosphatemia. The nurse teaches the clieint to eliminate which of the following from the diet?

Fish

- (Y)A client receiving lisinopril (Prinivil) has a white blood cell (WBC) count of 3,800/mm3. The nurse plans to do which of the following in the care of this client?

Follow strict aspectic technique

A nurse is reviewing the record of a client with a diagnosis of cervical cancer. Which risk factor associated with this type of cancer would the nurse expect to note in the client's record?

History of Human Papilloma Virus

- (Y) A nurse is caring for a client with leukemia receiving chemotherapy. The nurse reviews the laboratory results and notes that the neutrophil count is less than 500/mm3. Based on this laboratory result, the nurse includes which of the following as a necessary component of the plan of care?

Monitoring oral temperature every 4 hours.

A client with chronic artial fibrillation is being started on quinidine sulfate (quindex extentabs) as maintenance therapy for dysrhythmia suppression. The nurse determines that the client needs instruction about this medication if the client stated he or she should:

Stop taking the prescribed digoxin (lanoxin) after starting this new medication.

What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction Equipment

(Y) A nurse administers medications to the wrong client. During the investigation of the incident, it is determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is:

defined as the failure to meet established standards of care

A client is to receive cimetidine (Tagamet) 300mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr. should the infusion pump be set to deliver the secondary infusion?

ANS - 150ml/hr. This is calculated as ratio proportion problem: i.e. 50ml/20min : xml/60 min. Multiply extremes and means 50 x 60/20x 1=3000/20 = 150

A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is distended, blood pressure is elevated, and 6,500 ml were infused while 5,500 ml were drained. In response to this finding, what action should the nurse take? a. irrigate the drainage tube with normal saline. b. Instruct the client to cough. c. Turn the client from side to side. d. Lower the head of the bed.

ANS - A Irrigate the drainage tube with normal saline.

Which statement should the nurse include when providing anticipatory guidance to the parents of a 3 year old client? a. It is important to set limits with your child. b. Your child may being to have more nightmares. c. It is important to enroll your child in swimming lessons. d. Your child may being to exhibit more aggressive behavior.

ANS - A It is important to set limits with your child. Anticipatory guidance for the 3 year old client is educating the parents on the importance of setting limit with the child.

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)? a. A client with pancreatic cancer is experiencing intractable pain. b. An older client who fell yesterday and is now complaining of diplopia. c. An older client post-stroke who is aphasic with right-sided hemiplegia. d. An adult newly diagnosed with Type 1 diabetes and high cholestrol.

ANS - C An older client post-stroke who is asphasic with right-sided hemiplegia.

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? a. Ingestion of shellfish or fish oil capsules daily. b. Length and frequency of the client's tobacco use. c. Genetically inherited disorders of family members. d. Frequency of laxative use for chronic constipation.

ANS - D Frequency of laxative use for chronic constipation.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

ANS A - The client voluntarily signed the form. The nurse signs the consent form to witness that the client voluntarily signs the consent. {A) that the client's signature is authentic, and that the client is otherwise competent to give consent.

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications". What initial action is most important for the nurse to take? a. Ask about any past history of drug abuse or addiction. b. Measure the pulse volume and capillary refill distal to the infiltration. c. Compress the infiltrated tissue to measure the degree of edema. d. Evaluate the extent of ecchymosis over the forearm area.

ANS B - Measure the pulse volume and capillary refill distal to the infiltration. Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity.

The nurse leader suffers from headaches, hypertension, and gastrointestinal problems. Which affirmative statement by the leader reflects an appropriate way to manage the stress? a. I will avoid protein b. I will plan a vacation c. I will get enough sleep d. I will participate in support groups.

ANS C - I will get enough sleep Headache, hypertension and gastrointestinal problems indicate physical stress in the leader. Stress can be managed by getting enough sleep. The leader should consume protein in moderate amounts. Planning a vacation would help in managing mental stress. Participating in support groups would help to manage this type of stress.

An adolescent diagnosed with scoliosis. The nurse explains to the adolescent and the parents that treatment will correct the:

Abnormal lateral curvature of the spine.

(Y)A nurse assesses a burn injury and determines that the client sustained a full-thickness fourth-degree burn if which of the following is noted at the site of injury?

Charring at the wound site.

In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate?

High in Calcium and low in phosphorus

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. To ensure a safe environment, the nurse plans to have which of the following items readily available at the client's bedside?

Intubation tray

A nurse is monitoring a client with acute hypoparathyroidism for signs of hypocalcemia. Which of the following would the nurse note if hypocalcemia was present?

Positive Trousseau's sign HYPOCALCEMIA- CHVOSTEK'S SIGN Elicitation: Tapping on the face at a point just anterior to the ear and just below the zygomatic bone Postitive response: Twitching of the ipsilateral facial muscles, suggestive of neuromuscular excitability caused by hypocalcemia.

A clieint is brought to the emergency room following a burn injury. On assessment the nurse notes that the client's eyebrow and nasal hairs are singed. The nurse would identify this type of burn as:

Thermal

18. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? • Take measures to promote as much comfort as possible. • Report any signs of drug addiction to the nurse immediately. • Wait until the client's pain is gone before assisting with personal care. This client's pain will be difficult to manage, since the cause is unknown

ANS - ake measures to promote as much comfort as possible. Correct Rationale - Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause.

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8mg per ml. How many ml should the nurse administer? a. 0.5ml b. 1ml c. 1.5ml d. 2ml

ANS A - 0.5ml divide 4mg/8mg per ml gives you 0.5

ANS - "At 10:00 a.m., a client complained of nausea and vomited. The nurse calls the physician and an antiemetic and a clear liquid diet are prescribed. The nurse administers the antiemetic and the client sleeps for three hours. When the client awakens, the client tells the nurse that he is hungry and would like something to eat. Which food item would be most appropriate for the nurse to give the client?"

Apple Juice

Which assessment is most important for the nurse to make before advancing a client from liquid to solid food?

Chewing ability.

The health care provider prescribes 1000mL of total parenteral nutrition to be administered in 12 hours. Based on this prescription, how many milliliters of solution should be administered per hour? a. 83mL/hr b. 100mL/hr c. 108mL/hr d. 125mL/hr.

ANS - A 83mL/hr.

A 4 month old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? a. Decreased tremors b. Increased hours of sleep c. Weight loss during next 2 days d. More rapid heart rate within 2 days.

ANS - C Weight loss during next 2 days. Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failure.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? a. Kidney dysfunction. b. Cardiovascular disease c. Eye problems, such as glaucoma d. Accidents, including their prevention

ANS - D Accidents, including their prevention Accidents are common during young adulthood because of immature judgement and impulsivity associated with this stage of development.

16. When making the bed of a client who needs a bed cradle, which action should the nurse include? • Teach the client to call for help before getting out of bed. • Keep both the upper and lower side rails in a raised position. • Keep the bed in the lowest position while changing the sheets. • Drape the top sheet and covers loosely over the bed cradle.

ANS - Drape the top sheet and covers loosely over the bed cradle. Rationale - A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics.

A nurse on the day shift is assigned to care for four clients. Following report from the night shfit, which client will the nurse plan to assess first?

Client with pulmonary edema who was treated with furosemide (Lasix) at 5am

A nurse leader of a materinity unit is concerned because staff members openly verbalize racial comments about clients on the unit. The nurse leader would most appropriately manage this concern by:

Discouraging the racial comments.

2. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? • Temperature increases from 98.8° to 99.0° F. • Pulse rate decreases from 78 to 52 beats/min. Correct • Respiratory rate increases from 16 to 24 breaths/min. • Blood pressure increases from 110/84 to 118/88 mm/Hg.

• Pulse rate decreases from 78 to 52 beats/min. Rationale - Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure.

- A client has Buck's extension traction applied to the right leg. The nurse delegating care to the licensed practical nurse (LPN) instructs the LPN to do which of the following to prevent complications of the device?

Inspect the skin on the right leg at least once every 8 hours

Which intervention would best maintain a safe environment for a client with severe hypoparathyroidism?

Institute seizure precautions.

The nurse administers which medicaiton to a client with hepatic encephalopathy that will reduce the client's serum ammonia level?

Lactulose syrup (chronulac) laxative.

Y)"In a client with polycystic kidney disease, a urinary tract infection (UTI) has developed, and the nurse has been discussing discharge instructions with the client. Which statement by the client indicates a need for further teaching?"

Once the symptoms of my infection go away, I can stop taking my antibiotics.

24. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? • Apply flannel pajamas to provide warmth. • Administer a PRN dose of ibuprofen. • Perform range of motion exercises in a warm tub. • Drape the sheets over the footboard of the bed.

S - Drape the sheets over the footboard of the bed. Rationale - The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint.

A nurse provides instructions to the client who received cryosurgery for a local stage 0 cervical tumor. The nurse tells the client.

To avoid tub baths.

A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?

A client attached to a ventilator

A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse (LPN) and a nursing assistant on the team and is planning the client assignments for the day. The RN most appropriately assigns which of the following clients to the LPN?

A client who needs to be suctioned prn

- A registered nurse (RN) is planning the assignments for the day and has a licensed practical nurse (LPN) and a nursing assistant (NA) working on the team. The nurse assigns which client to the LPN?

A one- day postoperative mastectomy client

Nurse assesses a client's burn injury and determines that the client sustained a partial-thickness superficial burn. Based on this determination, which finding did the nurse note?

A wet, shiny, weeping wound surface.

A neonate is born with exstrophy of the bladder, and the parents are visibly upset. They are told that corrective surgery will be performed as soon as possible. How can the nurse best assist the parents at this time? a. Teaching the parents about preoperative and postoperative care b. Caring for the newborn in the same manner as any other newborn. c. Keeping the newborn as clean as possible to decrease the odor of urine. d. Reassuring the parents that after surgery their newborn will grow and develop without any after effects.

ANS - B Caring for the newborn in the same manner as any other newborn.

The nurse is reinforcing home care instructions with a client who is being discharged following transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the clients discharge instructions? A- Avoid strenuous activity for 6 weeks B- Report fresh blood in the urine C- Take acetaminophen for fever 101 D- Consume 6 to 8 glasses of water daily

ANS - B Report fresh blood in the urine.

A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continous positive airway pressure (CPAP). His vital signs are temp 98.8F, heart rate 118 beat/minute, respirations 46 breaths/minute, blood presure 176/92. While completing the pulmonary assessment, his oxygen reading is 78% and he is difficult to arouse. Which action should the nurse implement? a. Administer PRN nebulizer treatment b. Increase oxygen delivery by 10% c. complete neurological assessment d. Prepare for rapid sequence intubation

ANS - D Prepare for rapid sequence intubation.

The nurse is feeding a client who was admitted this morning wiht syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement? a. Elevate head of bed for 30 minutes after meals. b. Perform oral care before meals. c. Allow small amount of liquids with meals. d. Provide nectar thickened liquids

ANS - D Provide nectar thickened liquids

The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate intervention by the nurse? a. Paresthesia of fingers due to carpal tunnel syndrome. b. Stinging pain related to Plantar fascitis c. Burning pain due to a Morton's neuroma. d. Sharp pain related to a crushed femur.

ANS - D Sharp pain related to a crushed femur.

Which condition should be reported immediately to the primary healthcare provider? a. Pelvic pain immediately after colposcopy b. Light vaginal bleeding for 1 to 2 days following a hysterosalpingogram. c. Rectal bleeding for 2 days after prostate biopsy d. Body Temp 102 F with vaginal discharge 48 hours after cervical biopsy.

ANS - D The client with cervical biopsy should immediately report to the primary healthcare provider if experiencing a body temperature of 102F with vaginal discharge. This is because fever and vaginal discharge that develops 48 hours after cervical biopsy may be signs of infection related to the procedure.

The nurse would expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit what initial symptoms? a. Dull, left lower cramping pain and low grade fever. b. Change in bowel habits, blood in stool and unexplained anemia. c. Rigid board-like abdomen and elevated while blood cell count. d. Diarrhea, abdominal pain, and weight loss.

ANS - Diarrhea, abdominal pain, and weight loss.

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

ANS B - Localized red rash comprised of flat areas, pinpoint to 0.5cm in diameter.

A client is taking lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. The nurse evaluates that the client best understands the disorder and medication regime if the client states that he or she should take which of the following products for pain?

Acetaminophen (Tylenol) Zollinger-Ellison syndrome - is a complex condition in which one or more tumors form in your pancreas or the upper part of your small intestine (duodenum). These tumors, called gastrinomas, secrete large amounts of the hormone gastrin, which causes your stomach to produce too much acid. The excess acid, in turn, leads to peptic ulcers.

The client is being admitted to the hospital after receiving a radium implant for cervial cancer. The nurse takes which priority action in care of this client?

Admit the client to a private room

(Y) A nurse is caring for a client with hypoparathyroidism. In planning for discharge from the hospital, the nurse identifies which of the following as a potential psychosocial nursing diagnosis?

Anxiety related to the need for lifelong dietary interventions to control the disease.

A charge nurse observes a nursing assistant talking in an unusually loud voice to a client with delirium. The charge nurse takes which action?

Ascertains the client's safety, calmly asks the nursing assistant to join the nurse outside the room, and inform the nursing assistant that her voice was unusually loud

A nurse is caring for a woman in the postpartum unit. When the nurse checks the postition of the fundus, the nurse notes that the fundus is dislaced to one side. Which of the following nursing actions is appropriate?

Assist the client to empty the bladder

A nurse is caring for a postoperative client who underwent pelvic exenteration. The physician has changed the client's diet from nothing by mouth to clear liquids. The nurse checks which of the following before administering the diet

Bowel Sounds

The nurse counseling a client who has developed renal failure and is exploring the client's feelings about dialysis. After determining that the client is active, and is most upset about the disruption in the daily routine, the nurse advises the client to explore which treatment option with the physician?

Continous ambulatory peritoneal dialysis (CAPD)

MED/SURG/PEDI/GERI - A Nurse stops at the scene of an automobile accident to assist the victims. The nurse notes that a victim has sustained a traumatic open pneumothorax. The nurse implements which immediate action to assist this victim?

Covers the chest wound.

A client who is newly diagnosed with chronic renal failure is scheduled to begin hemodialysis. The nurse interprets which of the following neurological or psychological findings exhibited by the client to be atypical?

Euphoria

ANS - An adult client with renal insufficiency has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietician and then plans to allow the client to have how many mL of fluid from 7:00 a.m. to 3:00 p.m.?

600ml

A nurse caring for a client with hypoparathyroidism evaluates achievement of the expected outcomes of the plan of care. Which of the following would be an appropriate expected outcome for this client?

The client verbalizes that therapy for hypocalcemia is lifelong.

A nurse providing preoperative information to a client scheduled for a laser trabecloplasty for the treatment of primary open-angle glaucoma. Which information would the nurse provide to the client?

You may return to work 1 to 2 days following procedure.

A nurse reviewing the record of a client with Meniere's disease prepares dietary instructions for the client. Which of the following dietary prescriptions would the nurse expect to be prescribed for the client?

low Sodium - Meniere's disease is a disorder of the inner ear that causes spontaneous episodes of -vertigo — a sensation of a spinning motion — along with fluctuating hearing loss, ringing in the ear (tinnitus), and sometimes a feeling of fullness or pressure in your ear. In many cases, Meniere's disease affects only one ear.

A nurse is planning care for a hallucinating and delusional client who has been rescued from a suicide attempt. The nurse plans to:

Initiate one to one suicide precautions

A home care nurse has instructed a client in safety measures for using oxygen in the home. The nurse determines that the client needs additional instructions if the client states he should:

Keep the oxygen concentrator as close to the room wall as possible.

The nurse is preparing to administer medications to a client with hepatic encephalopathy. The nurse expects to note which medication is prescribed?

Lactulose syrup ( chronulac

An emergency room nurse is performing an assessment of a client who sustained circumferential burns of both legs. The nurse should assess which of the following first?

Peripheral pulses

The nurse is caring for the client being discharged to home with a tracheostomy. Which approach should the nurse take to help the client adjust best to caring for the tracheostomy at home?

Provide sufficient practice time for skill development before discharge.

A nurse is caring for a child with osteosarcoma after amputation of the left lower limb. The child is continously complaining of aching and cramping in the missing limb. The initial nursing action is which of the following?

Reassure the child that this is a temporary condition

- (Y)"A female client with a history of chronic urinary tract infection complains of burning and urinary frequency. To determine whether the current problem is of renal (kidney) origin, the nurse would assess whether the client has pain or discomfort in the:"

Right or left costovertebral angle

- A nurse hangs a 1000 mL bag of intravenous (IV) fluid for an assigned client. Forty-five minutes later, the nurse notes that the client is complaining of a pounding headache, is dyspneic, apprehensive, and has an increased pulse rate. The IV bag has 500 mL remaining. The nurse should take which of the following actions first?"

Shut off the IV infusion

The nurse is one of several people who witness a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tried to get up, and the victim's leg appears fractured. The nurse would plan to:

Stay with the victim and encourage the victim the remain still.

A client with acute respiratory distress syndrome (ARDS) being mechanically ventilated has received a dose of vecuronium bromide (Norcuron). The nurse determines that the medication has had the intended effect if the client:

Stops fighthing (bucking) the ventilator.

- (Y) A client has a diagnosis of hypoparathyroidism. The nurse assesses that the client has a positive Trousseau's sign if the client has which of the following responses when tested?

• Carpopedal spasm when a blood pressure cuff is inflated on the arm for 3 min HYPOCALCEMIA- TROUSSEAU'S SIGN Elicitation: Inflating a sphygmomanometer cuff above systolic blood pressure for several minutes Postitive response: Muscular contraction including flexion of the wrist and metacarpophalangeal joints, hyperextension of the fingers, and flexion of the thumb on the palm, suggestive of neuromuscular excitability caused by hypocalcemia

- (Y) A client being discharged from the mental health unit has a history of anxiety and command hallucinations to harm self or others. The nurse teaches the client about interventions for hallucinations and anxiety. The nurse determines that the client understands these measures when the client says:

• I call my clinical specialist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone

3. The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? • Raise the bed to a comfortable working level. • Bend the client's knee. • Move the knee toward the chest as far as it will go. • Cradle the client's heel. Correct

•Ans - Cradle the client's heel. Correct Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times.

A nurse caring for a victim of a burn injury during the emerent/resuscitative phase. On assessment of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should immediately

Notify the physician

- Oral lactulose (Chronulac) is prescribed for a client with a hepatic disorder, and the home care nurse provides instructions to the client regarding the medication. The nurse determines that the client needs additional instructions if the client states to:

Notify the physician if nausea occurs.

A nurse is caring for a client with chronic renal failure whose daily fluid allotment is determined by calculating the previous day's output plus insensible losses through the lungs(Insensible loss from the respiratory tract is about 400 mls/day- minimal insensible loss in an adult is 800 msl/day). If the client's urine output for the previous day was 300 mL, the nurse anticipates how many milliliters of fluid will be allotted for today?"

700ml

A nurse is assigned to care for four clients. in planning client rounds, which client would the nurse assess first?

A client receiving oxygen via nasal cannula who had difficult breathing during the previous shift.

A elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgement? a. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. b. The nurse assigned to care for the client who was at lunch at the time of the fall. c. The nurse who transferred the client to the chair when the fall occurred. d. The charge nurse who completed round 30 minutes before the fall occurred.

ANS - C. The nurse who transferred the client to the chair when the fall occurred. The four elements of malpractice are: 1. breach of duty owed. 2. Failure to adhere to the recognized standard of care. 3. Direct causation of injury, and 4. evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring" C implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B and D).

The head nurse of the emergency department (ED) is assigning duties to volunteer nurses to care for a group of clients injured in a mass casualty situation. Which assignments are appropriate in this situation. Select all that apply. a. The general staff nurse should organize nursing services. b. The trauma nurse manager should organize ancillary services. c. The medical-surgical nurse should recommend clients for discharge. d. The ED nurse leader should direct the ancillary departments to deliver supplies. e. The hospital nurse leader should identify clients who can be transferred out of the unit.

ANS - 2, 3, 4 - The trauma nurse manager should organize ancillary services. The medical-surgical nurse should recommend clients for discharge. The ED nurse leader should direct the ancillary departments to deliver supplies.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

ANS - A - Assist the ambulating patient back to bed. An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize demands.

The school nurse is implementing standards to manage students and provide a safe and healthy school setting. Which action is most important for the nurse to implement? A- Maintain student immunization records B- Develop an emergency plan for the school C- Ensure that medical supplies are available D- Conduct annual student health assessments

ANS - A Maintain student immunization records

The nurse is preparing to administer 1,000ml of dextrose 25% TPN to a client with ulcerative colitis. Which intervention is most important for the nurse to implement? a. Review the client's intake and output. b. Assess vital signs prior to administration c. Administer TP through Central Line. d. Evaluate the client's nutritional history.

ANS - Administer TPN through central line.

12. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? • Fiber. • Folate. • Ascorbic acid. • Vitamin B12

ANS - Vitamin B12 Rationale - Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegetables and fruits.

17. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? • Document the client's request in the medical record. • Ask the client if this decision has been discussed with his healthcare provider. • Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. • Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

ANS - Ask the client if this decision has been discussed with his healthcare provider. Rationale - Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action.

22. A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? • Help the client to accept the final stage of life. • Assist and support the client in establishing short-term goals. • Encourage the client to make future plans, even if they are unrealistic. • Instruct the client's family to focus on positive aspects of the client's life.

ANS - Assist and support the client in establishing short-term goals. Rationale - Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B).

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

ANS - B - Reassess the client's blood pressure using a larger cuff. The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B).

An adolescent female suffering from severe cystic acne is placed on isotretinoin. What important facts should the nurse tell the client about isotretinoin. Select all that apply. a. Inform the client to use vinyl helmet straps. b. Inform the client about the risk of teratogenicity. c. Inform the client that skin improvement may take time. d. Inform the client to scrub vigorously to remove blackheads. e. Inform the client to use abrasive cleaners to remove blackheads.

ANS - B, C - Inform the client about the risk of teratogenicity. Inform the client that skin improvement may take time. Even is a adolescent is not sexually inactive, the nurse should discuss viable birth control options with the client due to the risk of teratogenicity with isotretinoin.

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances? a. Restrict family visits b. Withhold analgesic medications c. Plan for maximum periods of rest d. Keep the room light on most of the time.

ANS - C Plan for maximum periods of rest. Sleep deprivation alone can cause these disturbances because of the interruption in rapid eye movement REM sleep. Lack of contract with significant others increases anxiety and feelings of isolation, which can lead to disturbances in rest. Pain limits or interrupts periods of sleep and rest.

A pt with possible pneumonia come to the hospital and the nurse need to do an assessment but the family don't want to leave the room, what the nurse need to do first? A -Call the security B- Put the family out of the room C- Put a pneumonia droplet sign in the door D - Continue with the assessment and put mask to the family

ANS - C Put a pneumonia droplet sign in the door.

A young woman is diagnosed as having genetically related amenorrhea. What is the primary nursing intervention at this time? a. Supporting her physical abilities b. Discussing her altered body image c. Trying to meet her emotional needs d. Exploring other reproductive options with her.

ANS - C Trying to meet her emotional needs.

A public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Case management and screening for clients with HIV. B. Regional relocation center for earthquake victims. C. Vitamin supplements for high-risk pregnant women. D. Lead screening for children in low-income housing.

ANS - C Vitamin supplements for high-risk pregnant women

A nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement from the client indicates teaching by the nurse is effective? a. After meals I will take a 10 minute walk b. After meals I will drink 8oz (240ml) of water c. After meals I will rest in a sitting position for one hour. d. After meals I will lie down in bed for at least 20 minutes.

ANS - C after meals I will rest in a sitting position for one hour. Gravity (Sitting up after meals) facilitates digestion and prevents reflux of stomach contents into the esophagus.

While assessing a client, the nurse finds redness and swelling of the scrotum. The client reports fever and pus in the urine. Which treatment strategies would be beneficial? Select all that apply. a. Radiotherapy b. Chemotherapy c. Analgesic therapy d. Antibiotic therapy e. Hormone therapy

ANS - C, D - Pus in the urine of the client indicates pyuria. Redness and swelling of the scrotum associated with fever and pyuria indicate epididymitis. The treatment of epididymis includes analgesic therapy and antibiotic therapy.

A confused older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? a. Apply adult diapers after each attempt to void. b. Check residual urine volume using an indwelling urinary catheter. c. Assist the client to the bedside commode every two hours. d. Instruct the client to use the call button when a bedpan is needed.

ANS - C. Assist the client to bedside commode every two hours.

8. What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? • Check capillary refill of toes on lower extremity with Unna's paste boot. • Apply dressing to wound area before applying the Unna's paste boot. • Wrap the leg from the knee down towards the foot. • Remove the Unna's paste boot q8h to assess wound healing.

ANS - Check capillary refill of toes on lower extremity with Unna's paste boot. Rationale - The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D).

13. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? • Page the unit manager to address the situation. • Close the demographic screen on the computer. • Instruct the UAP to end the phone call immediately. • Send a UAP into the client's room to relieve the nurse.

ANS - Close the demographic screen on the computer. Rationale - The greatest priority is for the charge nurse to close the computer screen (B), because health information stored in computerized systems is considered to be Protected Health Information (PHI) under HIPAA (Health Insurance Portability and Accountability Act). (A, C, and D) may be indicated, but are of less priority than (B). Category: Fundamentals

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

ANS - D - gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A postoperative client preparing for discharge with a new medication. b. A client requiring daily dressing changes of a recent surgical incision. c. A client scheduled for a chest x-ray after insertion of a nasogastric tube. d. A client with asthma who requested a breathing treatment during the previous shift.

ANS - D A client with asthma who requested a breathing treatment during the previous shift.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? a. A client complaining of muscle aches, a headache, and history of seizures. b. A client who twisted her ankle when rollerblading and is requesting medication for pain. c. A client with a minor laceration on the index finger sustain while cutting an eggplant. d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

ANS - D A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

A client is undergoing treatment for schizophrenia with antipsychotic drugs. During a client assessment, the primary healthcare provider noticed an increase in body temperature and unstable blood pressure. Which adverse effect of the antipsychotic drug caused this condition in the client? a. Akathisia b. Tardive dyskinesia c. Extrapyramidal symptoms d. Neuroleptic malignant syndrome

ANS - D Neuroleptic malignant syndrome Neuroleptic malignant syndrome is the adverse effect caused by antipsychotic drugs. The symptoms are fever and unstable blood pressure. Akathisia is thee one of the symptoms of pseudoparkinsonism. Tardive dyskinesia is one the adverse effects of antipsychotic drugs. The symptoms of this adverse effect are characterized by involuntary contractions of oral and facial muscles. Extrapyramidal symptoms is one the adverse effects of antipsychotic drugs. The symptoms of this adverse effect are involuntary motor symptoms.

11. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? • Use disposable plates and utensils. • Stay in a room with the door closed. • Dispose of soiled dressings in plastic bags that are securely closed. Correct • Others who are in the same room with the client should wear a mask.

ANS - Dispose of soiled dressings in plastic bags that are securely closed. Rationale - Contact precautions require the use of a barrier that prevents contact with wound secretions on soiled dressings, which are best disposed of in tightly closed plastic bags (C). (A) is not necessary with contact precautions. (B and D) should be implemented for airborne, droplet precautions, or protective environments. Category: Fundamentals

5. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? • Empty the client's urinary drainage bag. • Draw up the irrigating solution into the syringe. • Secure the client's catheter to the drainage tubing. • Use aseptic technique to instill the irrigating solution.

ANS - Draw up the irrigating solution into the syringe. To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time.

6. Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? • Removing the empty food tray from a client with a urinary catheter. • Washing and combing the hair of a client with a fractured leg in traction. • Administering oral medications to a cooperative client with a wound infection. • Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Correct

ANS - Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Rationale - possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves.

14. A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? • Most herbs are toxic or carcinogenic and should be used only when proven effective. • There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. • Herbs should be obtained from manufacturers with a history of quality control of their supplements. • Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

ANS - Herbs should be obtained from manufacturers with a history of quality control of their supplements. Rationale - The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading

25. A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? • May I ask your daughter to help you with your personal hygiene? • I will ask one of the female nurses to bathe you. Correct • A staff member on the next shift will help you. • I will keep you draped and hand you the supplies as you need them.

ANS - I will ask one of the female nurses to bathe you. Rationale - Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task (B). (A and D) are less respectful of the client's cultural and spiritual preferences. (C) delays the client's care.

19. An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? • Use a mechanical lift to transfer from the bed to a chair. • Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. • Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. • Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. Correct

ANS - Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. Rationale - A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams

9. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? • Check for a blood return. • Reposition the client's arm. Correct • Remove the IV site dressing. • Flush the lock with saline.

ANS - Reposition the client's arm. Rationale - If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion.

10. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? • Sensory pattern, area, intensity, and nature of the pain. Correct • Trigger points identified by palpation and manual pressure of painful areas. • Schedule and total dosages of drugs currently used for breakthrough pain. • Sympathetic responses consistent with onset of acute pain.

ANS - Sensory pattern, area, intensity, and nature of the pain. Rationale - The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A).

23. What is the most effective way to implement a teaching plan? • Teach the information that the client wants to learn first. • Streamline the teaching plan to include only essential information. • Present to the client all the information necessary to meet the objectives. • Provide the client with written material to review before teaching sessions.

ANS - Teach the information that the client wants to learn first. Rationale = Teaching is most effective when it responds to the learner's needs, and learning begins when a person identifies a need for knowing or acquiring an ability to do something (A). (B and C) provide widely varied amounts of content, each of which should consider an individual's learning styles, level of education, reading ability, culture, age, and readiness to learn. Providing written information (D) may or may not be the best way to teach when various learning styles and other client factors are considered. Category: Fundamentals

20. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? • Use distraction techniques during times of spiritual stress and crisis. • Reassure the client that his faith will be regained with time and support. • Consult with the staff chaplain and ask that the chaplain visit with the client. • Use reflective listening techniques when the client expresses spiritual doubts.

ANS - Use reflective listening techniques when the client expresses spiritual doubts. Rationale - The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C).

15. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? • Encourage the student to associate with non-smokers only while attempting to stop smoking. • Tell the student that he is still young and should continue to try various smoking cessation methods. • Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. • Provide the student with the latest research data describing the long-term effects of tobacco use.

ANS - • Encourage the student to associate with non-smokers only while attempting to stop smoking. Rationale - It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers, so (A) is the most important intervention for the nurse to implement. (B) is not likely to be helpful and offers no concrete suggestions for smoking cessation. (C) is condescending. Risks associated with smoking must already be known to this adolescent who is already attempting to stop the habit (D). Category: Fundamentals

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.

ANS A - Observe the appearance of the skin under the ice pack. The first action taken by the nurse should be to assess the skin for any possible thermal injury (A)

The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

ANS B - Continue asking the mother questions about the child. Eye contact is a culturally-influenced form of non-verbal communication. In some non-western cultures, such as Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child.

A nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? a. Clamp the tube for 20 minutes b. Flush the tube with water. c. Administer the medications. d. Crush the tablets and dissolve in sterile water.

ANS B - Flush the tube with water. The NGT tube should be flushed before, after and in between each medication administered. (B). Once all medications are administered, the NGT should be clamped for 20 minutes.

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

ANS B - Initiate an alternate site for the IV infusion of the medication. cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated. (b) before issuing the next dose.

During resuscitation of a critically injured client in a bomb blast, the nurse finds the client is breathing spontaneously. Which nursing intervention would the nurse perform in this situation? a. Inserting an endotracheal tube b. Providing non-rebreather mask c. Providing mechanical ventilation d. Providing bag-valve-mask (BVM) ventilation

ANS B - Providing non-rebreather mask. A non-rebreather mask is used in spontaneously breathing clients. Providing an endotracheal tube and mechanical ventilation is beneficial in clients with significantly impaired consciousness.

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

ANS C - Examining a chest x-ray obtained after the tubing was inserted.

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

ANS D - 500mL/5mg x 1mg/1000mcg x 30mcp/1min x 60 min/hr. = 180mL/hr.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

ANS D - Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distension.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

ANS D - Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D)

The nurse performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? a. Encourage the client to cough to help loosen secretions. b. Advise the client to increase the intake of oral fluids. c. Rotate the suction catheter to obtain any remaining secretions. d. Re-oxygenate the client before attempting to suction again.

ANS D - Re-oxygenate the client before attempting to suction again. Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. (D) may be performed after the client is re-oxygenated and additional suctioning is performed.

While triaging clients after an earthquake that has caused mass casualties, the nurse notes that a client with a massive head injury does not respond to stimulation and cannot breathe independently. Which color tag would be given to the client? a. Red b. Black c. Green d. Yellow

Ans - B Black tag An incident that has caused mass casualties, a military form of triage is performed to provide the best care for the most people. In such instances, clients who may otherwise have been resuscitated are often classified as expectant. Therefore a client with a massive head injury who is unable to respond to any kind of stimulus and is unable to breathe independently would be classified with a black tag.

7. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? • Maintain in a lateral position using protective wrist and vest devices. • Position prone with a small pillow below the diaphragm. • Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation

Ans - Position prone with a small pillow below the diaphragm. Rationale - The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point.

4. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? • Continue gabapentin. Correct • Discontinue ibuprofen. • Add aspirin to the protocol. Add oral methadone to the protocol

Ans 1 - Continue gabapentin Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an anti-seizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Non-opioid analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests.

1. The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? • The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. • The client tells the nurse that she does not have much of an appetite today. • The nurse notes that there are numerous scatter rugs throughout the house. • The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Ans 3 - The nurse notes that there are numerous scatter rugs throughout the house. Rationale - Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.).

A home care nurse is making home visits to an older client with urinary incontinence who is very disturbed by the incontinent episodes. The nurse assesses the client's home situation to determine environmental barriers to normal voiding. The nurse determines that which item may be contributing to the client's problem.

Bathroom located on the second floor bedroom on the first floor

(Y )A nurse administers the morning dose of digoxin (Lanoxin) to the client. When the nurse charts the medication, the nurse discovers that a dose of 0.25 mg was administered rather than the prescribed dose of 0.125 mg. The nurse should take which appropriate action?

Complete an incident report

A nurse manager has implemented a change in the method of documenting nursing care. A license practical nurse (LPN) is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following would be the best approach in dealing with the LPN?

Confront the LPN and encourage verbalization of feelings regarding the change.

A nurse manager is implementing a change in the documentation system in the nursing unit. The documentation regarding client care will be made on a computer system rather than in a narrative form. A nurse who is resistant to the change is not taking an active part in facilitating the process of change. Which of the following would be the best initial approach in dealing with the resistance from the nurse?

Confront the nurse about his or her behavior regarding the change.

(Y) A nurse is preparing to administer medications to an assigned client and notes that the order for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the physician to clarify the order and asks the physician to prescribe a dosage within the recommended range. The physician refuses to change the order and instructs the nurse to administer the dose as prescribed. Which of the following actions would the nurse take?

Contact the nurse supervisor

The nurse is planning for the initial visit between the parents and a newborn infant diagnosed with respiratory distress syndrome. Which of the following should the nurse plan to best facilitiate bonding during the initial visit?

Encourage the parents to touch their infant.

Immediately after an abdominal surgical procedure, a nurse is caring for a client who lost a significant amount of blood during surgery. Which of the following assessment findings would indicate a sign of a potential complication?

Increasing Restlessness

A nursing staff member approaches a nurse manager and tells the manager that another nurse is tying knots in the air vent salem sump nasogastric tubes that are connected to suction. The nurse manager most appropriately handles this situation by:

Reviewing the skills checklist of the nurse who is trying the knots to assess if this skill has ever been performed and validated.