Hurst Review Questions (3)
A home care nurse is making an initial visit to an elderly client recently discharged following hip surgery. When evaluating the home environment, what environmental hazard is most concerning to the nurse? 1. Lamp plugged into extension cord. 2. Throw rugs on kitchen tile floor. 3. Gas fireplace in the living room. 4. Non-working wall socket in hall.
2. Throw rugs on kitchen tile floor.
A nurse enters a client's room to find the client on the floor having a seizure. Which nursing action is appropriate for this client? 1. Hold the client's arms and legs. 2. Insert a padded tongue blade in the client's mouth. 3. Assist the client back into the bed. 4. Place a rolled towel under the client's head.
4. Place a rolled towel under the client's head.
The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems? Select all that apply 1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). 2. Gestational age 38 weeks. 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.
1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.
The nurse is discussing television, video games, and internet usage with a group of parents who have 8 to 10 year old children. What should the nurse include? Select all that apply 1. Keep TVs, iPads, and other screens out of kids' bedrooms. 2. Turn off all screens during meals. 3. Allow screen time only after chores and homework are complete. 4. Have a screen free day once a week. 5. Limit screen time to 2 hours daily. 6. Use screen time as a reward for good behavior.
1. Keep TVs, iPads, and other screens out of kids' bedrooms. 2. Turn off all screens during meals. 3. Allow screen time only after chores and homework are complete. 4. Have a screen free day once a week. 5. Limit screen time to 2 hours daily.
The nurse walks into a client's room and discovers the radioactive uterine implant lying on the bed. In what order should the nurse properly dispose of the implant? a. Put on gloves b. Place implant in lead lined container c. Call radiation department to take the implant out of the room d. Pick up implant with tongs
a. Put on gloves. d. Pick up implant with tongs. b. Place implant in lead lined container. c. Call radiation department to take the implant out of the room.
A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological
3. Airway
Which activity by the unlicensed assisted personnel (UAP) assisting a client with Parkinson's disease would require intervention by the nurse? 1. Assisting the client with ambulating to the bathroom and back to bed 2. Reminding the client not to look down while walking 3. Performing bathing and oral care for the client 4. Encouraging the client to feed self
3. Performing bathing and oral care for the client
A newly married wife tells the nurse, "I told my husband that I may not know how to cook, but I can sure do the dishes!" Which defense mechanism is the client displaying? 1. Projection 2. Displacement 3. Sublimation 4. Compensation
4. Compensation
What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)? 1. Private room. 2. Room with a client who has biliary colic. 3. Room with a client who is 3 days post operative hip replacement. 4. Room with a client who is in skeletal traction due to broken femur.
1. Private room
A nurse is in the mall when a shopper who suddenly becomes non-responsive. Obtaining an available AED, the nurse would initiate what emergency interventions? Select all that apply 1. Clear everyone before shock. 2. Turn on the machine. 3. Initiate shock immediately. 4. Place pads on client's chest. 5. Await arrival of paramedics. 6. Shave client's chest.
1. Clear everyone before shock. 2. Turn on the machine. 4. Place pads on client's chest.
A young adult diagnosed with schizophrenia is admitted to the crisis center with exacerbation of psychotic behaviors. The client responds well to a medication regime of chlorpromazine three times daily. The nurse is reviewing discharge instructions and knows teaching was successful when the client makes what statements? Select all that apply 1. "This medication will help me control my behavior." 2. "I should take this medication only if I feel anxious." 3. "I need to have blood levels checked periodically." 4. "My medication will eventually cure my disorder." 5. "I must apply sunscreen and wear a hat if outside."
1. "This medication will help me control my behavior." 5. "I must apply sunscreen and wear a hat if outside."
The nurse is transferring the client from the bed to the wheelchair. Which nursing intervention would the nurse implement after assisting the client to a sitting position on the side of the bed. 1. Assess the client for lightheadedness. 2. Move the wheelchair closer to the bed. 3. Lower the bed to the lowest position. 4. Position the foot of the stronger leg closer to the bed.
1. Assess the client for lightheadedness.
A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? Select all that apply 1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby 5. Allows baby to cry vigorously for 15 minutes
1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby
The nurse is assisting with a client who will receive electroconvulsive therapy (ECT). The anesthesiologist administers succinylcholine chloride intravenously. What adverse effects should the nurse monitor for post procedure? Select all that apply 1. Malignant hyperthermia 2. Hypokalemia 3. Apnea 4. Tetany 5. Arrhythmias
1. Malignant hyperthermia 3. Apnea 4. Tetany 5. Arrhythmias
Which finding in fetal heart rate during a non-stress test would indicate to the nurse that a potential problem for the fetus may exist? 1. Increases 30 beats per minute for 20 seconds with fetal movement. 2. Increases 8 beats per minute for 10 seconds with fetal movement. 3. Remains unchanged with maternal movement. 4. Increases 5 beats per minute for 30 seconds with maternal movement.
2. Increases 8 beats per minute for 10 seconds with fetal movement.
A client with a diagnosis of endocarditis and a new peripherally inserted cential catheter (PICC) line has been discharged home to receive daily intravenous antibiotics for six more weeks. The home health nurse is making an assessment visit today. What instruction by the nurse is most important initially? 1. Take antibiotics before dental procedures. 2. Brush and floss teeth at least twice daily. 3. Report any flu like symptoms immediately. 4. Include rest periods throughout the day.
2. Brush and floss teeth at least twice daily.
What does a non-stress test tell the nurse about a pregnant client? 1. That the baby is going to be a boy or girl 2. The baby is doing well and the placenta is providing enough oxygen at this time 3. That the baby's heart is healthy and there are no birth defects 4. That the mother is strong enough to undergo vaginal delivery
2. The baby is doing well and the placenta is providing enough oxygen at this time
A client on the med-surg unit is being treated for dehydration and pneumonia. The UAP has entered the room to complete AM care, but the client refuses, reporting feeling too tired from a "poor night's sleep". The UAP reports the refusal to the nurse. What statement by the nurse provides the best explanation to the UAP? 1. "Explain to the client that we are short staffed, so AM care needs done at this time." 2. "Don't worry about it; just tell the next shift they will need to do this client care." 3. "Let's look over your shift assignments to see if we can rearrange some other tasks." 4. "It is crucial for this client to be able to rest, so clean sheets can wait till tomorrow."
3. "Let's look over your shift assignments to see if we can rearrange some other tasks."
Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distension in the client who had a indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.
3. Prepare a sitz bath for a postpartum client.
The nurse is assessing a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time? 1. Blood glucose level 2. Ankles for edema 3. Twenty-four hour diet recall 4. Confirmation of last menstrual period
3. Twenty-four hour diet recall
While preparing an IV in the med room, you observe a new nurse drawing up a dose of insulin in a tuberculin syringe. What is your priority action? 1. Report the incident immediately to the charge nurse. 2. Tell new nurse you will prepare and give the insulin dose. 3. Discuss procedure to prepare insulin with the new nurse. 4. Draw up insulin but let new nurse administer the injection.
3. Discuss procedure to prepare insulin with the new nurse.
Which nursing action takes priority once a term infant has delivered vaginally? 1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints
3. Dry the baby
A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would require an immediate intervention? 1. The nasogastric (NG) tube contents are pale green. 2. An abdominal dressing with the tape on 3 sides of the dressing. 3. Abdominal pain of 5 on 10 point pain scale when client coughs. 4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.
4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.
The nurse enters a client's room and finds the client masturbating. Which action by the nurse would be most appropriate for the nurse to take? 1. Ask the client to stop 2. Remain in the room until client has finished. 3. Document the activity in the client's chart. 4. Quietly leave the room
4. Quietly leave the room
A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now? 1. Cancel physical therapy and allow client to leave. 2. Ask client to stand with crutches to check the size. 3. Tell client insurance will not permit use of old crutches. 4. Send client with crutches to physical therapy for evaluation.
4. Send the client with crutches to physical therapy for evaluation.
The nurse is caring for a client prescribed ondansetron due to postoperative nausea. Which side effect is the nurse most worried about the client experiencing with administration of this medication? 1. Respiratory depression 2. Hyperglycemia 3. Malignant hypertension 4. Torsades de pointes
4. Torsades de pointes
Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in intracranial pressure (ICP). What is the nurse's priority action? 1. Position client on the right side. 2. Call the primary healthcare provider. 3. Lower the head of the bed immediately. 4. Hyperventilate client with a bag valve mask.
4. Hyperventilate client with a bag valve mask.
What personal protective equipment should the nurse wear into the room of a client who has been placed on droplet precaution? 1. Gloves 2. Gown 3. Goggles 4. Mask
4. Mask
The nurse is caring for a client that is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse's best response? 1. Bring the swaddled baby to the mother. 2. Explain that the cause of death must be determined before she can see the baby. 3. Ask her if she is sure she wants to see the baby. 4. Tell her it would be better to wait until she is in her room before she sees the baby.
1. Bring the swaddled baby to the mother.
A nurse is planning an educational session on safety for parents of young children. What safety points should the nurse include? Select all that apply 1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present. 5. Vitamins should be referred to as candy so that children will take them. 6. A child at age 7 may sit in the front seat of a car.
1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present.
A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look great today, so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."
2. "I see you are wearing a bright blue sweater today."
Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should be placed in the waste basket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.
1. Contaminated gloves should be removed in the client's room.
A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? BP 90/40; HR 125; RR 30 and labored; + jugular venous distention (JVD) with subcutaneous emphysema noted to right shoulder area. Select all that apply 1. Apply occlusive dressing to chest. 2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen. 5. Position client on right side.
2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen.
The nurse is presenting a seminar to expectant teen parents regarding infant car seat safety. What statement from a teen parent indicates to the nurse that teaching was successful? 1. "It's okay to place the car seat up front as long as it faces backwards." 2. "The baby has to stay rear facing until at least 40 pounds or 40 inches." 3. "Regular seat belts can be used if the child does not like the booster seat." 4. "An infant must stay in the backseat, facing backward, till at least a year old."
4. "An infant must stay in the backseat, facing backward, till at least a year old."
How would a case manager best describe a clinical pathway to nursing students? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by a professional medical organization such as the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider prescriptions for client care, which expedite the prescription process and can be customized to individual clients. 4. A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.
4. A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.
The nurse is caring for a client taking enoxaparin. Which group of symptoms should be reported to the primary healthcare provider? 1. AST of 12 U/L and ALT 20 U/L 2. Hematocrit of 46% decreased to 35% and blood pressure decreases from 122/78 to 108/54 3. Ecchymosis around the abdominal subcutaneous injection site and platelet count of 200,000. 4. Hemoglobin of 14.5 g/dL (2.3 mmol/L) increased to 16 g/dL (2.5 mmol/L) and increased erythemia of oral mucus membranes.
2. Hematocrit of 46% decreased to 35% and blood pressure decreases from 122/78 to 108/54
A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational points should the nurse include? Select all that apply 1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%. 4. Have estimated glomerular filtration rate measured every five years. 5. Increase protein intake to 30% of total calories eaten per day.
1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%.
The nurse is assessing the injection site of a healthy client who received a Mantoux skin test 48 hours ago. Which finding at the injection site indicates a need for further evaluation? 1. 16 mm induration 2. 4 mm erythrokeratodemia 3. 0.1 mL bluish colored hard wheal 4. Multiple fluid-filled vesicles
1. 16 mm induration
The nurse assessing clients in a pediatric clinic would refer which child for further assessment? 1. A 20 month old who only says "no." 2. A 1 year old who says three words 3. A 9 month old who says "dada" and "mama" 4. A 4 month old who laughs out loud
1. A 20 month old who only says "no."
The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? Select all that apply 1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed.
1. Apply ice to perineum for first 12 hours. 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed.
The nurse is providing discharge dietary instructions to a client diagnosed with full thickness burns to the right hand. To promote tissue healing, which food examples should the nurse provide to the client? Select all that apply 1. Pasta 2. Oranges 3. Brown rice 4. Chicken breast 5. Electrolyte drink
2. Oranges 4. Chicken breast
The nurse is presenting discharge instructions, including dietary restrictions, to a client newly diagnosed with Cushing's disease. The nurse knows the teaching has been successful when the client chooses what selections? Select all that apply 1. Baked salmon, sauteed kale and cauliflower rice 2. Barbeque pork loin, cole slaw, and corn on the cob 3. Corn beef, sauerkraut, swiss cheese sandwich with potato wedges 4. Spaghetti squash lasagna with ground turkey 5. Sushi with soy sauce, fried rice, and fortune cookie
1. Baked salmon, sauteed kale and cauliflower rice 4. Spaghetti squash lasagna with ground turkey
A client has been instructed not to take non-steroidal anti-inflammatory drugs (NSAIDs) post lumbar laminectomy with spinal fusion. The nurse knows that education was successul when the client identifies which medications should be avoided? Select all that apply 1. Celecoxib 2. Ibuprofen 3. Naproxen 4. Acetaminophen 5. Indomethacin
1. Celecoxib 2. Ibuprofen 3. Naproxen 5. Indomethacin
A nurse from the maternity unit is pulled to the medical-surgical unit for the first four hours of the shift. Which clients would be appropriate for the charge nurse to assign to the nurse from the maternity unit? Select all that apply 1. Client with rheumatic fever 2. Client scheduled for an appendectomy 3. Client one day post cardiac catheterization 4. Client diagnosed with Methicillin-Resistant Staphylococcus Aureus 5. Client newly admitted with Guillian-Barre Syndrome
1. Client with rheumatic fever 2. Client scheduled for an appendectomy 3. Client one day post cardiac catheterization
Two hours post chest tube insertion, the nurse notes 100 mL of dark bloody drainage in the collection chamber of the closed drainage unit (CDU). What action should the nurse take? 1. Document the findings. 2. Notify the primary healthcare provider. 3. Decrease the amount of suction. 4. Use a padded hemostat to clamp the chest tube.
1. Document the findings.
A client comes into the emergency department (ED) with intense abdominal pain. The nurse completes a physical assessment and evaluates the vital signs and lab work. Based on the information gathered, the nurse expects which diagnostic test will be priority? Exhibit 1. Transvaginal ultrasound 2. Esophagogastroduodenoscopy (EGD) 3. CAT Scan of the abdomen 4. KUB (Kidney, Ureter, and Bladder)
1. Transvaginal ultrasound
A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident for assistive devices that will be needed upon discharge. Which resources should the case manager include for this client? Select all that apply 1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils 6. Large button closures on clothes
1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils
What should the nurse include in the teaching plan for a client receiving external beam radiation? Select all that apply 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment.
1. Small marks will be placed on the skin to mark the treatment area. 3. The radiation therapist can see, hear, and talk with you at all times during treatment.
A client has returned to telemetry unit following a partial thyroidectomy. What symptoms would alert the nurse to a serious complication of that surgery? Select all that apply 1. Tachycardia 2. Stiff muscles 3. Hypotension 4. Confusion 5. Fever
1. Tachycardia 4. Confusion 5. Fever
The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? Select all that apply 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.
1. The consent form is signed. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.
The nurse assesses bruises on a child's face, the hands, and the feet. When questioned, the parents state their child is so clumsy. What action by the nurse demonstrates client advocacy? 1. The nurse reports the incident to the Child Protective Services. 2. The nurse notifies the parent's clergy. 3. The nurse reports the assessment to the primary healthcare provider. 4. The nurse speaks to the parents privately about any concerns.
1. The nurse reports the incident to the Child Protective Services.
Which action by a nurse requires intervention by the charge nurse? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.
1. The two-handed method is used to recap a needle.
A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons.
1. You are wanting your sons to assist you in deciding about treatment options.
The nurse is monitoring a client in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? 1. pH 7.32 2. PaCO2 47 3. HCO3 25 4. PaO2 78
1. pH 7.32
A client has received discharge education post extracapsular cataract surgery. Which statement made by the client indicates to the nurse that further teaching is needed? 1. "A protective eye patch will be needed for 24 hours." 2. "I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal." 3. "I will clean the surgical eye with a clean tissue, wiping once from the inner aspect of the closed eye to the outer eye." 4. "When sleeping, I will avoid lying on the same side of my affected eye."
2. "I will notify my primary healthcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal."
The nurse is teaching a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that teaching has been successful? Select all that apply 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption."
2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 5. "There is no restriction on egg white consumption."
A client who has been prescribed zolpidem for insomnia has received medication education. Which statement by the client indicates to the nurse that education was successful? 1. "There is a high potential for tolerance with this medication." 2. "I may do things in my sleep that I will not remember the next day." 3. "Daytime drowsiness is rare when taking this medication." 4. "The most common side effects of this medication are confusion and a bitter aftertaste."
2. "I may do things in my sleep that I will not remember the next day."
A resident who shares a semi-private room with a terminally ill resident in a long- term facility becomes aware of the death of a prior roommate. The resident states "We were just talking this morning." Which communication response would the nurse initiate? 1. "I think you will feel better later." 2. "You were talking this morning?" 3. "Now you know I cannot respond to you." 4. "Why did you say that you talked this morning?"
2. "You were talking this morning?"
A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure? 1. Prophylactic antibiotics 2. A unit of cryoprecipitate 3. Packed red blood cells 4. Fresh frozen plasma
2. A unit of cryoprecipitate
The staff nurse is caring for a 3-month old client receiving potassium IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management? Select all that apply 1. Uses a 15 gtt factor drip chamber when changing the IV tubing. 2. Applies elbow restraints to prevent dislodgement of the IV catheter. 3. Checks the IV site for blood return hourly. 4. Instructs unlicensed assistive personnel (UAP) to count drip rate hourly. 5. Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy.
2. Applies elbow restraints to prevent dislodgement of the IV catheter. 3. Checks the IV site for blood return hourly. 5. Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy.
A nurse is teaching a group of women about human papillomavirus (HPV). What should the nurse tell the women that human papillomavirus puts women at risk for? 1. Human immunodeficiency virus 2. Cervical cancer 3. Hepatitis B 4. Cirrhosis
2. Cervical cancer
A client rescued from a house fireis being treated for burns to both arms and suspected inhalation injury. What data collected by the nurse has the highest priority? 1. Estimation of total surface burn area 2. Characteristics of cough and sputum 3. Calculation of client weight and age 4. Extent of edema to arms
2. Characteristics of cough and sputum.
Several clients have reported to the charge nurse that they are not receiving pain relief when a certain RN administers their pain medication. The charge nurse has noticed that the RN has been looking unkempt in appearance and seems to be in a daze much of the time. What is the most appropriate action for the charge nurse to take? 1. Lessen the nurse's client assignment to see if things improve. 2. Discuss the concerns directly with the nurse. 3. Give the nurse a 6 month period to be observed. 4. Avoid confronting the nurse so that the client's care will not be jeopardized.
2. Discuss the concerns directly with the nurse.
A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? Select all that apply 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia
2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 6. Hyperphosphatemia
A client is curious about visible appearance changes related to menopause. What menopausal changes, in general, would the nurse explain to the client? 1. Bone loss and fractures. 2. Loss of muscle mass. 3. Improved skin turgor and elasticity. 4. A reduction in waist size.
2. Loss of muscle mass.
The nurse should wear gloves when administering which medication? Select all that apply 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.
2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 5. Humalog 8 units subcutaneously.
A client who has Parkinson's disease has a new prescription for benztropine. What should the nurse include when teaching the client and spouse about this medication? Select all that apply 1. This medication blocks dopamine in the brain to decrease tremors and muscle stiffness. 2. Notify your primary healthcare provider if you develop urinary retention. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 4. No lab tests are needed while taking this medication. 5. Sit up or stand up slowly to prevent lightheadedness.
2. Notify your primary healthcare provider if you develop urinary retention. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 5. Sit up or stand up slowly to prevent lightheadedness.
The nurse is planning care for a client admitted with a diagnosis of new onset myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration? Select all that apply 1. Provide thin liquids such as water with meals. 2. Offer small bites of food. 3. Allow client to rest between each bite of food. 4. Offer small meals in the morning and larger meals in the evening. 5. Position client upright with head tilted slightly back when eating. 6. Provide meals 30 minutes before administration of cholinesterase inhibitor medication.
2. Offer small bites of food. 3. Allow client to rest between each bite of food.
A client has been transferred from the emergency room to the cardiac unit with a diagnosis of anterior wall MI with elevation of ST segment (STEMI). Which initial action by the nurse takes priority? 1. Obtain the client's vital signs. 2. Place client on cardiac monitor. 3. Auscultate bilateral lung sounds. 4. Perform cardiac output assessment.
2. Place client on cardiac monitor.
Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.
2. Places hands under client's axilla.
A client in the third trimester of pregnancy arrives at the emergency room reporting general illness. The client is noted to have a blood glucose level of 390 mg/dL and is diagnosed with gestational diabetes. The primary healthcare provider prescribes 30 units of NPH insulin subcutaneously stat. What is the nurse's priority action? 1. Administer the dose of insulin immediately. 2. Question the type of insulin prescribed. 3. Insert an IV for an insulin infusion. 4. Question the dose of the insulin.
2. Question the type of insulin prescribed.
A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.
2. Wrap each digit individually to prevent webbing.
A client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm. 3. Have the staff RN recheck the BP. 4. Ask the LPN to recheck the client's BP.
3. Have the staff RN recheck the BP.
A home care nurse is assessing a client with a forearm cast recently applied for a displaced radial fracture. What client comment should the nurse consider the priority concern? 1. "The cast feels tight on my arm." 2. "There is an odd smell inside my cast." 3. "I can't open up my fingers this morning." 4. "The pain medicine is not relieving my pain."
3. "I can't open up my fingers this morning."
A client admitted in the manic phase of bipolar disorder approaches the nursing station in the middle of the night, demanding the therapist be called immediately. What response by the nurse is appropriate? 1. "Calm down first, and then I will call your therapist." 2. "It's against the rules to call in the middle of the night." 3. "You must be distressed to want to talk at this late hour." 4. "That's a valid request, but it must wait until morning."
3. "You must be distressed to want to talk at this late hour."
A nurse is receiving morning report on the cardiovascular unit. What client should be the nurse's priority assessment? 1. A client with ejection fraction of 20% and dyspnea at rest. 2. A client with a chest tube to suction and sub-q emphysema. 3. A client two days past abdominal aorta aneurysm repair with decreased pedal pulses. 4. A client s/p coronary artery bypass graft three days ago with WBC's of 17,000 mm3.
3. A client two days past abdominal aorta aneurysm repair with decreased pedal pulses.
What nursing intervention takes priority for the client one day postoperative bowel resection reporting pain of a 6 on a 0 to 10 pain scale? 1. Assist the client in changing positions. 2. Use a distraction technique. 3. Administer the prescribed analgesic. 4. Encourage the client to walk.
3. Administer the prescribed analgesic.
During a health fair, a client asks the nurse about the methods used to detect prostate cancer. What should the nurse tell the client about the detection process? 1. Abdominal x-rays to detect the presence of lesions and masses. 2. A serum calcium test to detect elevated levels, which may indicate bone metastasis. 3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate. 4. A magnetic resonance image (MRI) study to detect tumors and other abnormal growths.
3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate.
Which action should the nurse take for a client who is of the Roman Catholic faith? 1. Notifying dietary that all food is required to be kosher. 2. Administering last rites to the client if death is imminent. 3. Ensuring there is no meat served with meals on Fridays during Lent. 4. Positioning the dying client's bed facing Mecca (east).
3. Ensuring there is no meat served with meals on Fridays during Lent.
What action should the nurse take when testing a client's near vision? 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.
3. Have client read a newspaper at 14 inches (36 cm).
The nurse is caring for a client post hysterectomy. Based on data obtained from the nurse's notes, what should be the nurse's initial response? Exhibit 1. Retake the vital signs. 2. Administer the ordered dopamine to maintain a blood pressure of 110 systolic. 3. Increase the IV rate of the lactated ringer's solution. 4. Raise the head of the bed to 30 degrees.
3. Increase the IV rate of the lactated ringer's solution.
A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information, what should the nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assist the float nurse with the clients case. 3. Notify the charge nurse of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.
3. Notify the charge nurse of the observations.
After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority? 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask
3. Place the client in the knee-chest position
The nurse is caring for a female client who is at risk for renal failure. The nurse has completed the initial assessment of the most recent lab results so that any concerns can be reported to the primary healthcare provider. Which assessment finding warrants further action? 1. Hemoglobin of 12 g/dl (120 g/L) 2. Hematocrit of 38% (0.38) 3. Potassium levels of 5.2mEq/L (5.2 mmol/L) 4. BUN of 15 mg/dl. (5.35 mmol/L)
3. Potassium levels of 5.2mEq/L (5.2 mmol/L)
The nurse is caring for a client undergoing electroconvulsive therapy (ECT) for major depression. What is the nurse's most important intervention during the treatment? 1. Monitor vital signs and cardiac functioning. 2. Provide support to the client's arms and legs. 3. Provide suctioning as needed. 4. Place electrodes on temples.
3. Provide suctioning as needed.
After drawing up insulin for subcutaneous administration, the nurse receives a return phone call from a primary healthcare provider who wants to give prescription orders on a new admit. The nurse asks a new nurse to administer the insulin dose. What action should the new nurse take? 1. Administer the insulin dose to the client. 2. Consult with the charge nurse about administering the insulin dose to the client. 3. Tell the nurse that whoever draws up the medication has to administer that medication. 4. Offer to take the call from the primary healthcare provider so the nurse can administer the insulin.
3. Tell the nurse that whoever draws up the medication has to administer that medication.
A nurse is caring for a client who had a total hip replacement 2 days ago. What assessment finding would be a priority concern for the nurse? 1. Small amount of red drainage on the surgical dressing. 2. Continues to report pain in hip when being repositioned. 3. Temperature of 101.8°F (38.7°C). 4. Slight swelling in the leg on the affected side.
3. Temperature of 101.8°F (38.7°C).
The nurse is teaching a pregnant teenage client about resources available through the health department. The client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say? 1. What does the baby's father think about an abortion? 2. I know this is a difficult decision. 3. What are your thoughts about abortion? 4. There are many options other than abortion.
3. What are your thoughts about abortion?
A client 34 weeks pregnant is scheduled for a visit at the prenatal clinic one week after receiving an injection of prenatal betamethasone due to the potential for premature labor. The client had been resting at home all week, as ordered. What assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Blood pressure of 92/50 2. Fasting blood sugar of 75 3. Tympanic temperature of 100º F 4. Muscle weakness with cramping
4. Muscle weakness with cramping
After a heart catheterization a client reports severe foot pain on the side of the femoral insertion site. The nurse notes pulselessness, pallor, and a cold extremity. What should be the nurse's first action? 1. Administer an anticoagulant. 2. Warm the room. 3. Increase intravenous fluids. 4. Notify the primary healthcare provider.
4. Notify the primary healthcare provider.
Which client in the emergency department should the nurse identify as being the highest priority? 1. Client with emphysema reporting shortness of breath. 2. Client with a cut on the left calf with moderate bleeding. 3. Client with onset of confusion 1 hour prior to arrival. 4. Client with facial swelling and rash after taking azithromycin.
4. Client with facial swelling and rash after taking azithromycin.
The nurse is caring for a client on the oncology unit. The client asks, "Why do I need this LifePort to receive my chemotherapy?" What evidence should the nurse consider when answering? 1. IV infusions can be more rapidly administered via an implantable IV port 2. Implantable IV ports are kept sterile and therefore do not become infected 3. Chemotherapeutic agents are more readily absorbed from implantable IV ports 4. Implantable ports are beneficial when long-term and/or multiple IV therapy is indicated.
4. Implantable ports are beneficial when long-term and/or multiple IV therapy is indicated.
A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.
4. Opportunity to verbalize memories.
A client who is in the manic phase of bipolar disorder was admitted to the psychiatric unit two days ago. Since admission, the client has been overly active, dressing bizarrely and sleeping very little. What type of activity should be planned for this client for the period following the evening meal? 1. Encourage the client to watch TV with the other clients on the unit. 2. Engage the client in a game of ping pong. 3. Suggest that the client play monopoly with other clients. 4. Provide soft lighting in the client's room for reading.
4. Provide soft lighting in the client's room for reading.
A tour bus is involved in an accident, sending several clients to the emergency room (ER) for treatment. An unconscious client with multiple internal injuries requires immediate surgery. When itemizing the client's belongings, the nurse finds a wallet containing four thousand dollars. What is the appropriate method for the nurse to secure the money? 1. Place wallet inside client's pants and then in belongings bag. 2. Secure the money in an envelope in the ER narcotics drawer. 3. Sign money over to the hospital CEO until client is discharged. 4. Tally cash with 2nd nurse, document and lock in hospital safe.
4. Tally cash with 2nd nurse, document and lock in hospital safe.
A client is admitted with irritable bowel syndrome (IBS) and shingles. The nurse is discussing the client assignments with the charge nurse. Which staff member should not be assigned to this client? 1. The nurse with a history of roseola. 2. The unlincesed assitive personnel (UAP) with no history of roseola. 3. The UAP with a history of chicken pox. 4. The LPN/VN with no history of chicken pox.
4. The LPN/VN with no history of chicken pox.
A mass casualty disaster has occurred and clients are being received at the emergency department. In what order should the nurse assess these clients? Sort from highest priority to lowest priority. a. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. b. Client with an open chest wound that is beginning to show signs of tracheal deviation. c. Client with blunt trauma to the spine that is unable to move extremities. d. Client with traumatic amputations with agonal respirations.
b. Client with an open chest wound that is beginning to show signs of tracheal deviation. c. Client with blunt trauma to the spine that is unable to move extremities. a. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. d. Client with traumatic amputations with agonal respirations.
The nurse is caring for a client in the emergency department following an argument with the spouse. The client describes a verbal argument that began to get physical with shoving of the client. There is a history of domestic violence. Which phase of the cycle of violence is the client describing? 1. Honeymoon phase 2. Tension-building phase 3. Acute battering phase 4. Remorse phase
b. Tension-building phase
In what order should the nurse assess assigned clients following shift report? Place in priority order. a. Client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. b. Client two days post thyroidectomy who has a negative Trousseau's sign. c. Client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. d. Client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation.
c. Client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. d. Client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. a. Client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. b. Client two days post thyroidectomy who has a negative Trousseau's sign.
A nurse has been assigned to care for five clients. In what order should the nurse assess these clients after shift report? Place in priority order from highest to lowest priority. a. Client diagnosed with peripheral vascular disease requesting information on smoking cessation. b. Client with Buerger's disease reporting numbness, tingling and cold in toes. c. Client diagnosed with an arterial ulcer to the right leg who reports pain of 8/10. d. Client whose BP is reported by the UAP to be 200/102 at present. e. Client hospitalized to rule out abdominal aortic aneurysm who is reporting deep, aching pain in the flank area.
e. Client hospitalized to rule out abdominal aortic aneurysm who is reporting deep, aching pain in the flank area. d. Client whose BP is reported by the UAP to be 200/102 at present. c. Client diagnosed with an arterial ulcer to the right leg who reports pain of 8/10. b. Client with Buerger's disease reporting numbness, tingling and cold in toes. a. Client diagnosed with peripheral vascular disease requesting information on smoking cessation.