Introduction to Clinical Nursing Final Exam

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's best course of action? [31] 1. Ask the prescriber to change the order 2. Crush the pill with a mortar and pestle 3. Hide the capsule in a piece of solid food 4. Open the capsule and sprinkle it over pudding

1

Which of the following is the most effective way to break the chain of infection? [28] 1. Hand hygiene 2. Wearing gloves 3. Placing patients in isolation 4. Providing private rooms for patients

1

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. What is the best nursing action to take first? [23] 1. Call the nursing supervisor to discuss the situation 2. Discuss the problem with a colleague 3. Leave the nursing unit and go home 4. Say nothing and begin your work

1

Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? [28] 1. Wash them with soap and water 2. Use an alcohol-based hand cleaner 3. Rinse them and use the alcohol-based cleaner 4. Wipe them with a paper towel

1

Unmet and partially met goals require the nurse to do which of the following? (Select all that apply) [20] 1. Redefine priorities 2. Continue intervention 3. Discontinue care plan 4. Gather assessment data on a different nursing diagnosis 5. Compare the patient's response with that of another patient

1, 2

A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hosprial with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply) [16] 1. A problem-focused approach 2. A structured comprehensive approach 3. Using multiple visits to gather a complete database 4. Focusing on the functional health pattern of the role-relationship

1, 3

Review the following nursing diagnoses and identify the diagnoses that are correctly stated. (Select all that apply) [17] 1. Anxiety related to fear of dying 2. Fatigue related to chronic emphysema 3. need for mouth care related to inflamed mucosa 4. Risk for infection

1, 4

A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml 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?

150

A patient is taking albuterol through a pressurized metered-dose inhaler that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the inhaler last? [31] _______ days.

16

A nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse's best action before giving the medication is to: [19] 1. Have the nurse colleague check the dose with her before giving the medication 2. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, an the potential side effects 3. Ask the nurse colleague to administer the medication to her patient 4. Administer the medication as prescribed and on time

2

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with the possible risks, complications, and benefits? [23] 1. Family member 2. Surgeon 3. Nurse 4. Nurse Manager

2

A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? [31] 1. Only the patient's physician can give this information 2. The student provides the name of the medication and a description of its desired effect 3. Information about medications is confidential and cannot be shared 4. He has to speak with his assigned nurse about this

2

A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs or redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the would and applying dressings correctly to the nurse. These behaviors are an example of: [20] 1. Evaluative measure 2. Expected outcome 3. Reassessment 4. Standard of care

2

A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of "risk for infection." Which of the following is an appropriate goal statement for the diagnosis? [20] 1. Patient will remain afebrile to discharge 2. Patient's wound will remain free of infection by discharge 3. Patient will receive ordered antibiotic on time over next 3 days 4. Patient's abdominal incision will be covered with a sterile dressing for 2 days

2

After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: [31] 1. Follow ISMP guidelines for safe medication abbreviations 2. Explain to the physician that the order needs to be given to a registered nurse 3. Write the order on the patient's order sheet and read it back to the physician 4. Ensure that the six rights of medication administration are followed when giving the medication

2

If a patient who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: [31] 1. Sepsis 2. Phlebitis 3. Infiltration 4. Fluid overload

2

If an infectious disease can be transmitted directly from one person to another, it is a: [28] 1. Susceptible host 2. Communicable disease 3. Port of entry to a host 4. Port of exit from the reservior

2

The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? [31] 1. Call the pharmacist to interpret the order 2. Call the physician to have the order clarified 3. Consult the unit manager to help interpret the order 4. Ask the unit secretary to interpret the physician's handwriting

2

The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline the nurse will follow? [23] 1. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. 2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. 3. The patient can not make changes in the advance directive once admitted to the hospital. 4. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

2

The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines that the appropriate route for administering the diuretic according to: [31] 1. Hospital policy 2. The prescriber's orders 3. The type of medication ordered 4. The patient's size and muscle mass

2

The nurse reviews a patient's medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietician and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? [19] 1. Preventative 2. Controlling for adverse reaction 3. Consulting 4. Counseling

2

What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? [28] 1. Use an autoclave 2. Use boiling water 3. Use ethylene oxide gas 4. Use chemicals for disinfection

2

When a nurse is performing surgical hand asepsis, the nurse must keep hands: [28] 1. Below elbows 2. Above elbows 3. At a 45-degree angle 4. In a comfortable position

2

A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of "imbalanced nutrition: less than body requirements related to reduced intake of food." For the goal of "Patient will return to baseline weight in 3 months," which of the following outcomes would be appropriate? (Select all that apply) [20] 1. Patient will discuss source of depression by next clinic visit. 2. Patient will acheive a calorie intake of 2400 daily in 2 weeks. 3. Patient will report improvement in appetite in 1 week. 4. Patient will identify food protein sources

2, 3

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of "risk for impaired skin integrity." Which of the following goals are appropriate for the patient? (Select all that apply) [18] 1. Patient will be turned every 2 hours within 24 hours 2. Patient will have normal bowel function within 72 hours 3. Patient's skin will remain intact through discharge 4. Patient's skin condition will improve by discharge

2, 3

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, IV infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0-10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply) [18] 1. The family comes to visit the patient 2. The patient expresses concern about pain control 3. The patient's vital signs change, showing a drop in blood pressure. 4. The charge nurse approaches the nurse and requests a report at end of shift.

2, 3

In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an IV catheter? (Select all that apply) [19] 1. Following the procedural guideline for IV insertion 2. Seeking necessary knowledge about the steps of the procedure from a more experienced nurse 3. Showing confidence in performing the correct IV insertion technique 4. Being sure that the IV dressing covers the IV site completely

2, 3

Which of the following are examples of collaborative problems? (Select all that apply) [17] 1. Nausea 2. Hemorrhage 3. Wound infection 4. Fear

2, 3

A nurse on a cancer unit is reviewing and revising the written plan of care for a patient who has the nursing diagnosis of nausea. Place the steps in their proper order: [19] 1. The nurse revises approaches in the plan for controlling environmental factors that worsen nausea 2. The nurse enters data in the assessment column showing new information about the patient's nausea 3. The nurse adds the current date to show that the diagnosis of nausea is still relevant 4. The nurse decides to use the patient's self-report of appetite and fluid intake as evaluation measures

2, 3, 1, 4

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? (Select all that apply) [19] 1. The application of the skin barrier is a dependent measure 2. The call to the ostomy and wound care specialist is an indirect care measure 3. The cleansing of the skin is a direct care measure 4. The application of the skin barrier is a direct care measure

2, 3, 4

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. [17] 1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical criteria 3. Clusters clinical criteria that form a pattern 4. Chooses diagnostic label

2, 3, 4, 1

A nurse is caring for a patient who recently had coronary bypass surgery. Which are legal sources of standards of care the nurse uses to deliver safe healthcare? (Select all that apply). [23] 1. Information provided by the head nurse 2. Policies and procedures of the employing hospital 3. State Nurse Practice Act 4. Regulations identified in the Joint Commission's manual. 5. The American Nurses Association standards of practice.

2, 3, 4, 5

The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply) [17] 1. Daughter's concern of mother's risk for injury 2. Pacing 3. Patient getting lost easily 4. Daughter working part time 5. Getting up frequently

2, 3, 5

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply) [20] 1. Patient drinks contents of water glass 2. Patient's lungs are clear to auscultation in bases 3. Patient reports abdominal pain on a scale of 0 to 10 4. Patient's rate and depth of breathing are normal with head of bed elevated

2, 4

A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of "imbalanced nutrition: more than body requirements," the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply) [20] 1. The patient eats 2000 calories a day 2. The patient is weighed during each clinic visit 3. The patient discusses factors that increase the risk of an asthma attack 4. The patient's food diary that tracks intake of daily meals is reviewed

2, 4

Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply) [18] 1. Patient will eat at least three fourths of each meal by 1 week 2. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week 3. Patient will eat foods with high-calorie content by 1 week 4. Give patient liquid supplements 3 time a day

2, 4

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. [16] 1. "You say you've lost weight. Tell me how much weight you have lost in the past month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. That you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor - correct?"

2, 4, 1, 5, 3

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2-3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37 C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply) [17] 1. Vital sign results 2. Abdominal distension 3. Age of patient 4. Change in bowel elimination pattern 5. Abdominal pain 6. No past history of hospitalization

2, 4, 5

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply) [27] 1. Insert a urinary catheter 2. Leave a night light on in the bathroom 3. Ask the physician to order a restraint 4. Keep the bed in low position with upper and lower side rails up 5. Assign a staff member to stay with the patient 6. Provide scheduled toileting during the night shift 7. Keep the pathway from the bed to the bathroom clear

2, 6, 7

A home health nurse notices significant bruising on the 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? [23] 1. Document her findings and treat the patient 2. Instruct the mother on safe handling of a 2-year-old child 3. Contact a child abuse hotline 4. Discuss this story with a colleague

3

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse? [20] 1. Suctioning the airway 2. Sitting the patient up in bed 3. Auscultating lungs sounds 4. Patient describing type of discomfort

3

A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? [31] 1. Give the medication 2. Identify the patient using two identifiers 3. Withhold the medications and verify the medication orders 4. Provide medication education to the mother to help her better understand her child's medications

3

A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer? [19] 1. Standing orders are used to meet our physician's preferences. 2. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias 3. Standing orders allow us to respond quickly and safely to a rapidly changing situation 4. Standing orders minimize the documentation we have to provide

3

A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? [18] 1. This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening 2. The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care 3. During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient 4. The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding

3

A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse check the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventative intervention? [19] 1. Tertiary 2. Direct care 3. Primary 4. Secondary

3

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nursing manager because this action is a violoation of which act? [23] 1. Mental Health Parity Act 2. Patient Self-Determination Act (PSDA) 3. Health Insurance Portability and Accountability Act (HIPPA) 4. Emergency Medical Treatment and Active Labor Act

3

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is example of the nurse avoiding an error in: [17] 1. data collection 2. data clustering 3. data interpretation 4. making a diagnostic statment

3

A nurse stops to help in an emergency at at the scene of an accident. The injured party files a suit and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? [23] 1. The nurse's auto insurance 2. The nurse's homeowner's insurance 3. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence. 4. The Patient Care Partnership, which may grant immunity from suit if the injured party contends.

3

A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of "acute pain." A nursing-sensitive outcome suitable for this diagnosis would be: [20] 1. Patient will achieve pain relief by discharge 2. Patient will be free of a surgical wound infection by discharge 3. Patient will report reduced pain severity in 2 days 4. Patient will describe purpose of pain medicine by discharge

3

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? [27] 1. Give the child milk 2. Give the child syrup of ipecac 3. Call the poison control center 4. Take the child to the emergency department

3

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? [28] 1. It keeps an incontinent patient's skin dry 2. It can get caught in the linens or equipment 3. It obstructs the normal flushing action of urine flow 4. It allows the patient to remain hydrated without having to urinate

3

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as "deficient knowledge regarding insulin administration related to inexperience with disease management." Which of the following patient care goals are long term? [18] 1. Patient will explain relationship of insulin to blood glucose control 2. Patient will self-administer insulin 3. Patient will achieve glucose control 4. Patient will describe steps for preparing insulin in a syringe

3

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? [28] 1. Provide a dark, quiet room to calm the patient 2. Reduce the level of precautions to keep the patient from angry 3. Explain the reasons for isolation procedures and provide meaningful stimulation 4. Limit family and other caregiver visits to reduce the risk of spreading infection

3

A patient is receiving an IV push medication. If the drug infiltrates into the outer tissues, the nurse: [31] 1. Continues to let the IV run 2. Applies a warm compress to the infiltrated site 3. Stops the administration of the medicine and follows agency policy 4. Should not worry about this because vesicant filtration is not a problem

3

A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? [31] 1. Set up the follow-up appointments with the physician for the patient 2. Ensure that someone will provide housekeeping for the patient at home 3. Ensure that the home care agency is aware of medication and health teaching needs. 4. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.

3

Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. [28] 1. Illness stage 2. Convalescence 3. Prodromal stage 4. Incubation period

3

The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? [16] 1. The nurse is making an accurate clinical inference 2. The nurse has gathered cues to identify a potential problem area 3. The nurse has allowed stereotyping to influence her assessment 4. The nurse wants to validate her information with the other nurse

3

The nurse's first action after discovering an electrical fire in a patient's room is to: [27] 1. Activate the fire alarm 2. Confine the fire by closing all doors and windows 3. Remove all patients in immediate danger 4. Extinguish the fire by using the nearest fire extinguisher

3

The nursing diagnosis readiness for enhanced communication is an example of a(n): [17] 1. Risk nursing diagnosis 2. Actual nursing diagnosis 3. Health promotion nursing diagnosis 4. Wellness nursing diagnosis

3

When does implementation begin as the fourth step of the nursing process? [19] 1. During the assessment phase 2. Immediately in some critical situations 3. After the care plan has been developed 4. After there is mutual goal setting between a nurse and patient

3

While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has been violated? [28] 1. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action 2. Fluid flows in the direction of gravity 3. A sterile field becomes contaminated by prolonged exposure to air 4. None of the principles were violated

3

You are the night shift nurse and are caring for a newly admitted patient who appears confused. The family asks to see the patient's medical record. What is the first nursing action to take? [23] 1. Give the family the record 2. Give the patient the record 3. Discuss the issues that concern the family with them 4. Call the nursing supervisor

3

During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in correct order: [19] 1. Review the care plan 2. Decide if the nursing interventions remain appropriate 3. Reassess the patient 4. Compare assessment findings to validate existing nursing diagnoses

3, 1, 4, 2

A nurse is sued for failure to monitor a patient appropriately after a procedure,. Which of the following statements are correct about this lawsuit? (Select all that apply) [23] 1. The nurse represents the plaintiff. 2. The defendant must prove injury, damage, or loss. 3. The person filing the lawsuit has the burden of proof. 4. The plaintiff must prove that a breach in the prevailing standard of care caused an injury.

3, 4

During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply) [16] 1. Family report 2. Chest x-ray film 3. Physical examination with auscultation of the lungs 4. Medical record summary of x-ray film findings

3, 4

In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply) [17] 1. The nurse who listens to lung sounds after a patient reports "difficulty breathing" 2. The nurse who considers conflicting cues in deciding which diagnostic label to choose 3. The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema 4. The nurse who identifies a diagnosis on the basis of a single defining characteristic

3, 4

What type of interview techiniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply) [16] 1. Active listening 2. Open-ended questioning 3. Closed-ended questioning 4. Problem-oriented listening

3, 4

A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order. [27] 1. Explain what you plan to do 2. Wrap a limb restraint around a wrist or ankle with soft part toward skin and secure 3. Determine that restraint alternatives fail to ensure the patient's safety 4. Identify the patient using proper identifier 5. Pad the patient's wrist

3, 4, 1, 5, 2

Put the following steps for removal of protective barriers after leaving an isolation room in order: [28] 1. Untie top, then bottom mask strings and remove from face 2. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side 3. Remove gloves 4. Remove eyewear or goggles 5. Perform hand hygiene

3, 4, 2, 1, 5

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an IV line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply) [27] 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes antihypertensives and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

3, 4, 5, 6, 7

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? [27] 1. Begin cardiopulmonary resuscitation 2. Restrain the child to prevent injury 3. Place a tongue blade over the tongue to prevent aspiration 4. Clear the area around the child to protect the child from injury

4

A family member is providing care to a loved care who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? [28] 1. Wear gloves before eating or handling food 2. Place any soiled materials into a bag and double bag it 3. Have the family member check with the doctor about need for immunization 4. Perform hand hygiene after care and/or handling contaminated equipment or material

4

A goal specifies the expected behavior or response that indicates: [20] 1. The specific nursing action was completed 2. The validation of the nurse's physical assessment 3. The nurse has made the correct nursing diagnoses 4. Resolution of a nursing diagnosis or maintenance of a healthy state

4

A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. the nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? [20] 1. Uses walker during ambulation 2. Presence of altered balance 3. Limited mobility in lower extremities 4. Observation of distance patient is able to walk

4

A patient has the nursing diagnosis of "nausea." The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? [18] 1. Provide frequent mouth care 2. Maintain IV infusion at 100 mL/hr 3. administer prochlorperazine (Compazine) via rectal suppository 4. Consult with dietician on initial foods to offer patient 5. Control aversive odors or unpleasant visual stimulation that triggers nausea

4

A patient is to receive cephalexin (Keflex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? [31] 1. 1/2 tablet 2. 1 tablet 3. 1 1/2 tablets 4. 2 tablets

4

A woman who is a Jehovah's Witness has severe, life-threatening injuries and is hemorrhaging following a car accident. The healthcare provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood. What is the nurse's responsibility? [23] 1. Obtain a court order to give the blood 2. Coerce the husband into giving the blood 3. Call security and have the husband removed from the hospital 4. Abide by the husband's wishes and inform the healthcare provider

4

Setting a time frame for outcomes of care serves which of the following purposes? [18] 1. Indicates which outcome has priority 2. Indicates the time it takes to complete an intervention 3. Indicates how long a nurse is schedules to care for a patient 4. Indicates when the patient is expected to respond in the desired manner

4

The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? [20] 1. Evaluating the patient's response to selected nursing interventions 2. Selecting an observable or measurable state or behavior that reflects goal achievement 3. Reviewing the patient's nursing diagnoses and establishing goals and outcome statements 4. Matching the results of evaluative measures with expected outcomes to determine patient's status

4

The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case, the finding of nausea is which of the following? [16] 1. An objective finding 2. A clinical inference 3. A validation 4. A concomitant symptom

4

The nurse wears a gown when: [28] 1. The patient's hygiene is poor 2. The nurse is assisting with medication administration 3. The patient has AIDS or hepatitis 4. Blood or body fluids may get onto the nurse's clothing from a task that he or she plans to perform

4

Which is the most likely means of transmitting infection between patients? [28] 1. Exposure to another patient's cough 2. Sharing equipment between patients 3. Disposing of soiled linen in a shared linen bag 4. Contact with a health care worker's hands

4

The nurse follows a series of steps to objectively evaluate the degree of success in achieving outcomes of care. Place the steps in the correct order. [20] 1. The nurse judges the extent to which the condition of the skin matches the outcome criteria 2. The nurse tries to determine why the outcome criteria and actual condition of the skin do not agree 3. The nurse inspects the condition of the skin 4. The nurse reviews the outcome criteria to identify the desired skin condition 5. The nurse compares the degree of agreement between desired and actual condition of the skin

4, 3, 5, 1, 2

10.A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom.

A

16.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? A. Continue gabapentin. B. Discontinue ibuprofen. C. Add aspirin to the protocol. D. Add oral methadone to the protocol.

A

34.The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? A. Healthcare provider. B. Client's family. C. Case manager. D. Chief of staff.

A

4.What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs.

A

40.When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? A. Locate the perineum. B. Transfer to a commode. C. Attach the catheter to a drainage bag. D. Manipulate a syringe to inflate the balloon.

A

53.A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 0800, 1200, 1600, 2000. B. 800. C. Every other day at 0800. D. 0800, 1200, 1600, 2000, 0000, 0400.

A

56.A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicoden) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A. Accused of diversion. B. Reported for stealing. C. Reported for a HIPAA violation. D. Accused of unprofessional conduct.

A

65.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? A. Check capillary refill of toes on lower extremity with Unna's paste boot. B. Apply dressing to wound area before applying the Unna's paste boot. C. Wrap the leg from the knee down towards the foot. D. Remove the Unna's paste boot q8h to assess wound healing.

A

71.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.

A

74.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? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown.

A

83.While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs? A. Speak initially with the oldest family member to show respect. B. Realize that Southeast Asians may not take Western medications. C. Ask the husband to step out during the mother's pelvic examination. D. Tell the family that planning health care is provided in private with the client.

A

89.What action is most important for the nurse to implement when placing a client in the Sim's position? A. Raise the bed to a waist-high working level. B. Elevate the head of the bed 45 degrees. C. Place a pillow behind the client's back. D. Bring the client to one edge of the bed.

A

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

A

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.

A

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.

A

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

A

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

A

The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source

A

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.

A

The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift

A

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

A

When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones

A

Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals

A

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

A

20.The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Pre-medicate the client with an analgesic. B. Inform the client of the plan for moving to the chair. C. Obtain and place a portable commode by the bed. D. Ask the client to push the IV pole to the chair. E. Clamp the indwelling catheter. F. Assess the client's blood pressure.

A,B,D,F

21.A client is demonstrating a positive Chvostek's sign. What action should the nurse take? A. Observe the client's pupil size and response to light. B. Ask the client about numbness or tingling in the hands. C. Assess the client's serum potassium level. D. Restrict dietary intake of calcium-rich foods.

B

49.When caring for an immobile client, what nursing diagnosis has the highest priority? A. Risk for fluid volume deficit. B. Impaired gas exchange. C. Risk for impaired skin integrity. D. Altered tissue perfusion.

B

60.A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A. Bradycardia. B. Increase in pulse rate. C. Peripheral vasodilation. D. Increase in cardiac output.

B

63.The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? A. Portable syringe pump. B. Cassette infusion pump. C. Volumetric controller. D. Nonvolumetric controller.

B

69.On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate.

B

7.A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client.

B

91.The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A. Passive ROM exercises to all joints on all extremities four times a day. B. Active ROM exercises to both arms and legs two or three times a day. C. Active ROM exercises with weights twice a day with 20 repetitions each. D. Passive ROM exercises to the point of resistance and slightly beyond.

B

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

B

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.

B

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

B

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.

B

The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B

When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication

B

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? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

C

30.As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? A. Take the child back to his room. B. Recruit others to restrain the child. C. Ask the mother to be present to soothe the child. D. Show the child how to manipulate the equipment.

C

6.Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model.

C

77.A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa.

C

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

C

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.

C

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? 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 rounds 30 minutes before the fall occurred.

C

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

C

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

C

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

C

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.

C

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

C

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.

C

19.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? A. Fiber. B. Folate. C. Ascorbic acid. D. Vitamin B12.

D

41.A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? A. Ensure cultural customs are observed. B. Increase oxygen flow to 4L/minute. C. Auscultate bilateral lung fields. D. Inform the family that death is imminent.

D

90.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? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel.

D

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

D

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

D

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.

D

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.

D

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

D

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

D

In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal

D

The nurse is 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.

D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

D

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.

D

Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation

D

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.

D

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.

D

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

D

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: [27] 1. A safe environment promotes patient activity 2. Assessment focuses on environmental factors only 3. Teaching home safety is a difficult to do in the hospital setting 4. Most accidents in the older adult are caused by lifestyle factors

1

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the IV line, and the patient asking to be turned. Which of the following does the nurse perform first? [18] 1. Reconnect the drainage tube 2. Inspect the condition of the IV dressing 3. Improve the patient's comfort and turn her onto her side 4. Obtain the next IV fluid bag from the medication room

1

A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses his inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? [16] 1. Health perception- health management pattern 2. Value-belief pattern 3. Cognitive-perceptual pattern 4. Coping-stress tolerance pattern

1

At 3am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? [27] 1. Prepare for an influx of patients 2. Contact the American Red Cross 3. Determine how to restore essential services 4. Evacuate patients per the disaster plan

1

Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exist, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? [19] 1. Cognitive 2. Interpersonal 3. Psychomotor 4. Consultative

1

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? [17] 1. Risk for aspiration 2. Acute confusion 3. Readiness for enhanced coping 4. Sedentary lifestyle

1

The nurse takes a medication to a patient, and the patient tells him or her to take it way because she is not going to take it. What is the nurse's next action? [31] 1. Ask the patient's reason for refusal 2. Explain that she must take the medication 3. Take the medication away and chart the patient's refusal 4. Tell the patient that her physician knows what's best for her

1

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: [27] 1. Place a bed alarm device on the bed 2. Place the patient in a belt restraint 3. Provide one-on-one observation of the patient 4. Apply wrist restraints

1

A new graduate nurse is being mentored by a more experienced nurse. They are discussing the ways nurses need to remain active professionally. Which of the statements below indicates the new graduate understands ways to remain involved professionally? (Select all that apply) [23] 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have several years of experience and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, D.C. because of the shortage of nurses."

1, 2

How does the nurse support a culture of safety? (Select all that apply) [27] 1. Completing incident reports when appropriate 2. Completing incident reports for a near miss 3. Communicating product concerns to an immediate supervisor 4. Identifying the person responsible for an incident

1, 2, 3

A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of "impaired skin integrity related to pressure and moisture on skin." The patient is 72-years-old and had a stroke. The weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply) [19] 1. Review the set of all possible nursing interventions for the patient's problem 2. Review all possible consequences associated with each possible nursing action 3. Consider own level of competency 4. Determine the probability of all possible consequences

1, 2, 4

Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply) [17] 1. Acute pain related to lumbar disk repair 2. Sleep deprivation related to difficulty falling asleep 3. Constipation related to inadequate intake of fluids 4. Potential nausea related to nasogastric tube insertion

1, 2, 4

What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply) [16] 1. Active listening 2. Back channeling 3. Validating 4. Use of open-ended questions 5. Use of closed-ended questions

1, 2, 4

A nurse identifies several interventions to resolve a patient's nursing diagnosis of "impaired skin integrity." Which of the following are written in error? (Select all that apply) [18] 1. Turn the patient regularly from side to back to side. 2. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence 3. Apply a pressure-relief device to bed 4. Apply transparent dressing to sacral pressure ulcer

1, 3

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as "deficient knowledge regarding insulin administration related to inexperience with disease management." What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply) [18] 1. Goal within reach of the patient 2. The nurse's own competency in teaching about insulin 3. The patient's cognitive function 4. Availability of family members to assist

1, 3, 4

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply) [27] 1. Smoking is prohibited around oxygen 2. Demonstrate how to adjust the oxygen flow rate based on patient symptoms 3. Do not use electrical equipment around oxygen 4. Special precautions may be required when traveling with oxygen

1, 3, 4

Which of the following statements correctly describe the evaluation process? (Select all that apply) [20] 1. Evaluation is an ongoing process 2. Evaluation usually reveals obvious changes in patients 3. Evaluation involves making clinical decisions 4. Evaluation requires the use of assessment skills

1, 3, 4

Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply) [19] 1. Seeks necessary knowledge 2. Reassesses the patient's condition 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure

1, 3, 5

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) [23] 1. Taking and selling controlled substances 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written physician's order.

1, 4

Which of the following are examples of data validation? (Select all that apply) [16] 1. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record 2. The nurse asks the patient if he is having pain and then asks the patient to rate the severity 3. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content 4. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement 5. The nurse asks the patient to describe a symptom by saying "Go on."

1, 4

A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply) [16] 1. The skin around the wound is tender to touch 2. Fluid intake for 8 hours is 800 mL 3. Patient has a heart rate of 78 and regular 4. Patient has drainage from surgical wound 5. Body temperature is 101F (38.3 C) 6. Patient asks, "I'm worried that I won't return to work when I planned."

1, 4, 5

The patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patient's experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply). [23] 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to follow the six rights of medication administration 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

1, 5

A nurse check a patient's IV line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment? [16] 1. Agenda setting 2. Problem-focused 3. Objective 4. Use of structured database format

2

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital verses one for home care? [18] 1. The goals of care will always be more long term 2. The patient and family need to be able to independently provide most of the health care 3. The patient's goals need to be mutually set with family members who will care for him or her 4. The expected outcomes need to address what can be influenced by interventions

2

A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply) [16] 1. Maintain a neutral facial expression 2. Lean forward when interacting with the patient 3. Acknowledge the patient's answers through head nodding 4. Limit direct eye contact

2, 3

A patient is being discharged today. In preparation the nurse removes the IV line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? [20] 1. Patient expresses acceptance of health status by day of discharge 2. Patient's surgical would will remain free of infection 3. Patient's IV site will remain free of phlebitis 4. Patient understands when to call physician to report possible complications

3

A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? [16] 1. So you've had an upset stomach and began vomiting - correct? 2. Have you taken anything for your stomach? 3. Is anything else bothering you? 4. Have you taken any medication for your vomiting?

3

A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? [28] 1. Notify the health care provider and use surgical technique to change the dressing 2. Reassure the patient and check the wound later 3. Notify the health care provider and support the patient's fluid and nutritional needs 4. Alert the patient and caregivers to the presence of an infection to ensure care after discharge

3

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? [16] 1. Setting the stage 2. Gather information about a patient's chief concerns 3. Collecting the assessment 4. Termination

3

The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? [19] 1. Meeting the patient's expressed wishes 2. Indirect care measure 3. Protecting a patient from injury 4. Staying organized when implementing a procedure

3

The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? [28] 1. Leave the gloves on to administer the medication 2. Remove gloves and administer the medication 3. Remove gloves and perform hand hygiene before administering the medication 4. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room

3

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patient's medical diagnoses on the message board. Later in the day, the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPPA)? [23] 1. Discussing the patient conditions in the nursing report room at the change of shift 2. Allowing nursing students to review patient charts before caring for patients to whom they are assigned 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

3

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: [17] 1. Need for improved bowel function related to change in diet 2. Patient needs improved function related to alteration in elimination 3. Constipation related to inadequate fluid intake 4. Constipation related to hard infrequent stools

3

Which outcome allows you to measure a patient's response to care more precisely? [18] 1. The patient's wound will appear normal within 3 days 2. The patient's wound will have less drainage within 72 hours 3. The patient's wound will reduce in size to less than 4 cm (1 1/2 inches) by day 4. 4. The patient's wound will heal without redness or drainage by day 4.

3

The nurse check the IV solution that is infusing into the patient's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site what changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply) [20] 1. Checked the IV infusion location in left arm 2. Checked the type of IV solution 3. Confirmed from nurses' notes the time of dressing change and checked label 4. Inspected the condition of the IV dressing

3, 4

The family of a patient who is confused and ambulatory insist that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply) [27] 1. Contact the nursing supervisor 2. Restrict the family member's visiting privileges 3. Ask the family to stay with the patient if possible 4. Inform the family of the risks associated with side-rail use 5. Thank the family for being conscientious and put the four rails up 6. Discuss alternatives with the family that are appropriate for this patient

3, 4, 6

A couple is with their adolescent daughter for a school physical and state they are worries about all the saftey risks affecting this age. What is the greatest risk for injury to an adolescent? [27] 1. Home accidents 2. Physiological changes of aging 3. Poisoning and child abduction 4. Automobile accidents, suicide, and substance abuse

4

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? [23] 1. Health Insurance Portability and Accountability Act (HIPPA) 2. Americans with Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA)

4

A nurse accidentally gives a patient a medication at the wrong time. The nurse's first priority is to: [31] 1. Complete an occurence report 2. Notify the healthcare provider 3. Inform the charge nurse of the error 4. Assess the patient for adverse effects

4

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? [16] 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern

4

A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? [31] 1. Outward 2. Back 3. Upward and back 4. Upward and outward

4

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is "diarrhea related to intestinal colitis." This is an incorrectly stated diagnostic statement, best described as: [17] 1. Identifying the clinical sign instead of an etiology 2. Identifying a diagnosis based on prejudicial judgment 3. Identifying the diagnostic study rather than a problem caused by the diagnostic study 4. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

4

The nurse writes an expected-outcome statement in measurable terms. An example is: [18] 1. Patient will be pain free 2. Patient will have less pain 3. Patient will take pain medication every 4 hours 4. Patient will report pain acuity less than 4 on a scale of 0 to 10.

4

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? [27] 1. Activity intolerance 2. Impaired bed mobility 3. Acute pain 4. Risk for falls

4

The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? [31] 1. 2 mL 2. 5 mL 3. 16 mL 4. 30 mL

4

When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient's tolerance, this is an example of what type of implementation skill? [19] 1. Interpersonal 2. Cognitive 3. Collaborative 4. Psychomotor

4

11.Which statement best describes durable power of attorney for health care? A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. B. The healthcare decisions made by another person designated by the client are not legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.

A

15.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? A. Sensory pattern, area, intensity, and nature of the pain. B. Trigger points identified by palpation and manual pressure of painful areas. C. Schedule and total dosages of drugs currently used for breakthrough pain. D. Sympathetic responses consistent with onset of acute pain.

A

22.When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? A. Flush the lumen with the saline solution and administer the medication through the lumen. B. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. D. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

A

23.Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating.

A

26.In evaluating client care, which action should the nurse take first? A. Determine if the expected outcomes of care were achieved. B. Review the rationales used as the basis of nursing actions. C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care.

A

75.A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration.

A

81.The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? A. Complains of inability to empty bladder. B. Temperature of 99.8° F and pulse of 108. C. Post-voided residual volume of 750 ml. D. Specimen collection for culture and sensitivity.

A

82.While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? A. Discontinue the administration of the bolus feeding. B. Auscultate the client's breath sounds bilaterally. C. Elevate the head of the bed to a high Fowler's position. D. Administer a PRN dose of a prescribed antiemetic.

A

A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation

A

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.

A

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.

A

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.

A

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.

A

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.

A

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.

A

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

A

64.A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A. Snack of potato chips, and diet soda. B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C. Breakfast of eggs, bacon, toast, and coffee. D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E. Bedtime snack of crackers and milk.

A, B, C, E

Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.

A, E

The nurse identified that the patient has pain on a scale of 7, he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Write a three-part nursing diagnostic statement using the PES format. [17]

Acute pain r/t incisional trauma evidenced by pain reported at 7, with guarding, and restricted turning and positioning.

12.A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A. Low fat and low sodium foods. B. Combination of plant proteins to provide essential amino acids. C. Limited complex carbohydrates and fiber. D. Increased amount of vitamin C and beta carotene rich foods.

B

18.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? A. Document the client's request in the medical record. B. Ask the client if this decision has been discussed with his healthcare provider. C. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

B

24.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? A. Check for a blood return. B. Reposition the client's arm. C. Remove the IV site dressing. D. Flush the lock with saline.

B

27.Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? A. Assessment. B. Analysis. C. Implementation. D. Evaluation.

B

28.The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? A. Determine when the IV solution was started. B. Slow the IV infusion to keep vein open rate. C. Assess the IV insertion site for swelling. D. Report the finding to the healthcare provider.

B

29.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? A. May I ask your daughter to help you with your personal hygiene? B. I will ask one of the female nurses to bathe you. C. A staff member on the next shift will help you. D. I will keep you draped and hand you the supplies as you need them.

B

33.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? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life.

B

43.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? A. Temperature increases from 98.8° to 99.0° F. B. Pulse rate decreases from 78 to 52 beats/min. C. Respiratory rate increases from 16 to 24 breaths/min. D. Blood pressure increases from 110/84 to 118/88 mm/Hg.

B

47.What client statement indicates to the nurse that the client requires assistance with bathing? A. I wasn't able to pack a bag before I left for the hospital. B. I don't understand why I'm so weak and tired. C. I only bathe every other day. D. I left my eyeglasses at home.

B

5.A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client.

B

61.The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? A. She is almost sure to be less able to adapt than before. B. It's highly likely that she will recover and return to her pre-illness state. C. If you can interest her in something besides religion, it will help her stay well. D. Cultural strains contribute to each woman's tendencies for recurrences of depression.

B

76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area.

B

78.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? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution.

B

79.When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame.

B

85.What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field.

B

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

B

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.

B

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

B

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?

B

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.

B

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.

B

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

B

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.

B

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.

B

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.

B

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.

B

Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.

B

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

B

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml.

B

The 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 as prescribed. D. Crush the tablets and dissolve in sterile water.

B

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.

B

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."

B

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis

B

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.

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.

B

The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly

B

The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain

B

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

B

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

B

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.

B

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

B

1.What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals.

C

35.A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. Your children are old enough to help you make decisions about their futures. B. The social worker can tell you about placement alternatives for your children. C. Tell me what you would like to see happen with your children in the future. D. You have just received bad news, and you need some time to adjust to it.

C

36.In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Request hospice care for the client. B. Report the client's acuity level to the nursing supervisor. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent.

C

37.When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A. There is no reason to be so angry. B. Why do I need to leave your room? C. What is concerning you this morning? D. Let me call the client advocate for you.

C

39.When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A. Confirm the finding by further assessing the client for jugular vein distention. B. Offer the client high protein snacks between regularly scheduled mealtimes. C. Continue the planned nursing interventions to restore the client's fluid volume. D. Change the plan of care to include a nursing diagnosis of impaired skin integrity.

C

42.The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse include in this client's plan of care? A. Ineffective breathing pattern. B. Impaired gas exchange. C. Risk for aspiration. D. Ineffective airway clearance.

C

44.A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A. Hydrogel. B. Exudate absorber. C. Wet to moist dressing. D. Transparent adhesive film.

C

46.A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Transferrin. B. Prealbumin. C. Serum albumin. D. Urine urea nitrogen.

C

48.How should the nurse handle linens that are soiled with incontinent feces? A. Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B. Place an isolation hamper in the client's room and discard the linens in it. C. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

C

51.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? A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

C

52.The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A. Stage 1 pressure sore draining sero-sanguineous drainage. B. Pressure sore at bony prominence with exudate noted. C. One-inch pressure sore draining serous fluid. D. Pressure sore on heel with a small amount of purulent drainage.

C

57.A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A. A quasi-intentional tort because a similar mistake can happen to anyone. B. Failure to respect client autonomy to choose based on intentional tort law. C. Assault and battery with deliberate intent to deviate from the consent form. D. An unintentional tort because the client benefited from having the myelogram.

C

68.Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record.

C

9.Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. The nurse will provide client instruction for daily foot care. B. The client will demonstrate proper trimming toenail technique. C. Upon discharge, the client will list three ways to protect the feet from injury. D. After instruction, the nurse will ensure the client understands foot care rationale.

C

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private.

C

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.

C

In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens

C

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.

C

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.

C

The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness

C

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

C

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

C

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

C

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.

C

Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C

Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers

C

Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse

C, D

13.A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? A. The responses to biofeedback have not been well established and may be a waste of time and money. B. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. C. Although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms. D. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

D

17.To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A. Can you describe where your pain is the most severe? B. What is your pain intensity on a scale of 1 to 10? C. Is your pain best described as aching, throbbing, or sharp? D. Which activities during a routine day are impacted by your pain?

D

2.What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes.

D

25.Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A. Ensure that the client's perineal area is cleansed twice a day. B. Maintain accurate documentation of the fluid intake and output. C. Encourage frequent ambulation if allowed or regular turning if on bedrest. D. Obtain a prescription for removal of the catheter as soon as possible.

D

3.Which statement is an example of a correctly written nursing diagnosis statement? A. Altered tissue perfusion related to congestive heart failure. B. Altered urinary elimination related to urinary tract infection. C. Risk for impaired tissue integrity related to client's refusal to turn. D. Ineffective coping related to response to positive biopsy test results.

D

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

D

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

D

38.The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? A. Withdraw the tube and apply additional lubricant to the tube. B. Encourage the client to bear down and continue to insert the tube. C. Remove the tube and check the client for a fecal impaction. D. Ask the client to relax and run a small amount of fluid into the rectum.

D

45.A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? A. Review the client's medical record for an advance directive. B. Determine if a do-not-resuscitate prescription has been obtained. C. Document that the client is being discharged against medical advice. D. Evaluate the client's mental status for competence to refuse treatment.

D

50.The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? A. Administer a PRN antihypertensive prescription. B. Provide the client with an additional blanket. C. Encourage additional fluid intake. D. Turn the client q2h.

D

54.The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A. A 10-year-old who was burned by a camp fire earlier today. B. A 70-year-old who has a postoperative infection from a surgery one week ago. C. A 23-year-old woman who sprained her knee while bicycling. D. A 55-year-old woman who has had moderate low back pain for three months.

D

55.A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, Will it hurt to have my tonsils and adenoids taken out? Which response is best for the nurse to provide? A. It may hurt a little because of the incision made in your throat. B. It won't hurt because you're such a big boy. C. It won't hurt because we put you to sleep. D. It may hurt but we'll give you medicine to help you feel better.

D

58.A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical. What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students. B. Notify the student's clinical instructor of the situation. C. Ask the student if permission was obtained from the client. D. Explain that the records are hospital property and may not be removed.

D

59.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? A. Apply flannel pajamas to provide warmth. B. Administer a PRN dose of ibuprofen. C. Perform range of motion exercises in a warm tub. D. Drape the sheets over the footboard of the bed.

D

62.A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A. Solicit information on hospitalization from the insurance company. B. Look up previous medical records from archived hospital documents. C. Ask the client to discuss previous hospitalizations in the last 5 years. D. Elicit specific facts about past hospitalizations with direct questions.

D

66.A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions.

D

67.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience.

D

70.The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance.

D

72.A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again.

D

73.The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. Ask another staff member for assistance. B. Request that supplies are delivered in smaller containers. C. Push the box against the wall to provide support while lifting. D. Bend at the knees when lifting heavy objects.

D

8.The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs or symptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health.

D

80.While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down.

D

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

D

86.A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies.

D

87.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? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. 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.

D

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.

D

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.

D

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

D

The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time

D