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The practical nurse (PN) selects the ventrolateral site to administer an intramuscular (IM) injection to an adult. Identify the Injection site.
"Upper outer quadrant"
A client who had a knee replacement surgery and received a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL pre-filled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)
0.6
The healthcare provider prescribed octreotide 150 mcg/day subcutaneously for a client with dumping syndrome. The medication is available in 0.2 mg/mL vials. How many mL should the practical nurse (PN) administer? (Enter numerical value only. If rounding is required, round to the nearest hundredth).
0.75mL
The practical nurse (PN) is preparing cefazolin 400 mg IM for a client with a gram-positive infection. The available vial is labeled, "Cefazolin 1 gram," and the instructions for reconstitution state, for IM use, add 2 mL sterile water for injection. The total volume after reconstitution is 2.5 mL. After reconstitution, how many mL should be administered to the client? (Enter numeric value only. If rounding is required, round to the whole number, nearest tenths/hundredth).
1mL
A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
21 gtt/min
A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).
30
The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client's needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on the bottom.) A. A 10-year-old child with bleeding lacerations on both knees after falling on the playground. B. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode. C. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness. D. A 12-year-old child with a history of asthma who is wheezing and complaining of shortness of breath.
A 12-year-old child with a history of asthma is wheezing and complaining of shortness of breath. Wheezing and shortness of breath indicate respiratory distress, which can be a medical emergency for a child with asthma. Prompt intervention and assessment of the child's respiratory status are crucial. A 7-year-old child who has type 1 diabetes mellitus is experiencing extreme hunger and shakiness. These symptoms may indicate hypoglycemia, which requires immediate attention to prevent further complications. The PN should assess the child's blood glucose levels and provide appropriate treatment. A 10-year-old child with bleeding lacerations on both knees after falling on the playground. While bleeding lacerations require attention, they are not immediately life-threatening or likely to cause severe complications. However, the PN should still address this child's injuries promptly and provide appropriate wound care. A 5-year-old child is crying uncontrollably because of an incontinent bowel episode. While the child's distress is significant, it does not indicate an immediate life-threatening condition or urgent medical need. The PN should provide comfort, and reassurance, and assist with appropriate hygiene measures for the child.
A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next? A. "Are you planning to obey the voices?" B. "Have you taken any hallucinogens?" C. "When did these voices begin?" D. "Do you believe the voices are real?"
A. "Are you planning to obey the voices?"
A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next? A. "Are you planning to obey the voices?" B. "Have you taken any hallucinogens?" C. "When did these voices begin?" D. "Do you believe the voices are real?"
A. "Are you planning to obey the voices?"
The client is a young male who appears to be 25-30 years old. He was found unconscious on a sidewalk by a jogger who was passing. The jogger called an ambulance, and the EMT's transported the ent to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT CT of the head in the emergency room showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests. The PN reinforces education about seizures to the client and asks him to explain what he understands about his condition. Which statements indicate understanding? Select all that apply A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." B. "There are really no lifestyle changes that I can do that will affect my risk of having another seizure." C. "I may never know why I started having seizures."
A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." C. "I may never know why I started having seizures." D. "Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not."
Which statement by an older female client who lost her spouse two years ago should indicate to the practical nurse (PN) that the client may need bereavement counseling? A. "I realize that life must go on, but sometimes I wonder why." B. "Sometimes I have trouble remembering simple things." C. "I depend on children who fortunately live close-by." D. "I hate that my health does not allow me to do what I used to do." E. "I hate that my health does not allow me to do what I used to do."
A. "I realize that life must go on, but sometimes I wonder why."
A client who has atrial fibrillation is prescribed warfarin therapy. Which of the following statements by the client indicates an understanding of the medication? A. "I should avoid foods that are high in vitamin K.". B. "I should take this medication with food.". C. "I should report any unusual bleeding or bruising to my provider.". D. "I should avoid taking aspirin while taking this medication.".
A. "I should avoid foods that are high in vitamin K.".
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best? A. "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" C. "Part of recovery is accepting your new body image, and you will need to look at your incision." D. "You will feel better when you see that the incision is not as bad as you may think."
A. "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready."
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best? A. "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" X C. "Part of recovery is accepting your new body image, and you will need to look at your incision." X D. "You will feel better when you see that the incision is not as bad as you may think."
A. "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready."
A nurse is caring for a client with a specific phobia. Which statement by the nurse is accurate regarding phobias? A. "Phobias are characterized by persistent and irrational fear.". B. "Phobias can be caused by biological factors only.". C. "Phobias can be diagnosed based on physical symptoms.". D. "Phobias can be managed with medication alone.".
A. "Phobias are characterized by persistent and irrational fear.".
A nurse is assessing a client with panic disorder. Which statement by the nurse would be appropriate during the assessment? A. "Tell me about your coping strategies and support system.". B. "How often do you experience panic attacks and what triggers them?". C. "What medications are you currently taking for your panic disorder?". D. "Have you ever had any laboratory tests done for your panic disorder?".
A. "Tell me about your coping strategies and support system.".
A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days. The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth. A. 0.7 mL. B. 1.0 mL. C. 1.3 mL. D. 1.7 mL.
A. 0.7 mL.
The practical nurse (PN) observes unlicensed assistive personnel (UAP) preparing to obtain the rectal temperature of a 2-year-old child with leukemia. Which action should the PN take? A. Advise the UAP to take a tympanic rather than rectal temperature. B. Remind the UAP to lubricate the thermometer before insertion. C. Instruct the UAP to report the results to the PN immediately. D. Observe the UAP to ensure the thermometer is inserted correctly.
A. Advise the UAP to take a tympanic rather than rectal temperature.
Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)? A. Collect fingerstick glucose levels. B. Implement bleeding precautions. C. Obtain daily weights. D. Check urine for albumin. E. Check urine for albumin.
A. Collect fingerstick glucose levels.
A nurse is planning care for a client with a phobia. Which nursing intervention is appropriate for this client? A. Encouraging the client to face their fear gradually. B. Administering benzodiazepines as needed for acute anxiety. C. Providing psychoeducation about the causes and effects of phobias. D. Teaching the client relaxation techniques to manage anxiety. E. Teaching the client relaxation techniques to manage anxiety.
A. Encouraging the client to face their fear gradually.
A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and the rituals I use are stupid, but I cannot control them. People laugh at me, but they do not understand how awful it is. I am a burden to my family because I cannot hold a job. I do not know how much longer I can live this way." Which information is most important for the practical nurse (PN) to ask in response to the client's statements? A. Inquire if the distress could lead to considering suicide as an option. B. Question about which rituals are most often used to reduce anxiety. C. Determine what makes the client think people are laughing. D. Ask if the obsessions and compulsions interfere with sleep.
A. Inquire if the distress could lead to considering suicide as an option.
A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and the rituals l use are stupid, but I cannot control them. People laugh at me, but they do not understand how awful it is. I am a burden to my family because I cannot hold a job. I do not know how much longer I can live this way." Which information is most important for the practical nurse (PN) to ask in response to the client's statements? A. Inquire if the distress could lead to considering suicide as an option. B. Question about which rituals are most often used to reduce anxiety. X C. Determine what makes the client think people are laughing. X D. Ask if the obsessions and compulsions interfere with sleep.
A. Inquire if the distress could lead to considering suicide as an option.
A new unlicensed assistive personnel (UAP) is completing an orientation assignment and is caring for an immobilized client who needs a complete bed bath. Which is the best way for the practical nurse (PN) to evaluate this UAP's performance? A. Inspect the client's skin near the end of the bathing procedure. v B. Verify with the client that the bath was complete and thorough. X C. Request the UAP to report and chart when the bath is complete. X D. Ask another UAP to help the orientee ensure satisfactory care.
A. Inspect the client's skin near the end of the bathing procedure.
Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.) A. Palpate the rate and volume of the pulse. B. Measure body weight at the same time daily. C. Check fingernails for the presence of clubbing D. Observe the color and amount of urine. E. Compare muscle strength of both arms.
A. Palpate the rate and volume of the pulse. B. Measure body weight at the same time daily. D. Observe the color and amount of urine.
The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.) A. Paper tape. B. Small gauze pad. C. Sterile gloves. D. Exam gloves. E. Three mL syringe.
A. Paper tape. B. Small gauze pad. D. Exam gloves.
A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide? A. Refer to the dermatologist for prescribed long-term therapy. B. Wash the hair and skin daily with mild soap and warm water. C. Express blackheads and follow with an exfoliating scrub. D. Omit chocolate, carbonated drinks, and fried foods from the diet.
A. Refer to the dermatologist for prescribed long-term therapy.
A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide? A. Refer to the dermatologist for prescribed long-term therapy. B. Wash the hair and skin daily with mild soap and warm water. C. Express blackheads and follow with an exfoliating scrub. D. Omit chocolate, carbonated drinks, and fried foods from the diet.
A. Refer to the dermatologist for prescribed long-term therapy.
The practical nurse (PN) heard adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour. Which action should the PN take next? A. Report the findings to the charge nurse. B. Review the last balance of intake and output. C. Slow the DSW infusion rate to 50 ml/hour. D. Document the findings and monitor the client.
A. Report the findings to the charge nurse.
The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.) A. S4. B. S2. C. S1. D. S3.
A. S4. D. S3.
In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure? A. Suction the trachea. B. Insert a urinary catheter. C. Apply soft restraints. D. Insert a nasogastric tube.
A. Suction the trachea.
The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Transport a urine culture sample to the laboratory. B. Obtain a post-voided residual (PVR) volume. C. Teach the client with fluid restrictions how to measure urine output. D. Irrigate an indwelling urinary catheter for a client with bladder suspension. E. Empty bedside drainage unit for a client with an indwelling urinary catheter.
A. Transport a urine culture sample to the laboratory. E. Empty bedside drainage unit for a client with an indwelling urinary catheter.
When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.). A. Urticaria. B. Hypertension. C. Diaphoresis. D. Nausea. E. Anxiety. F. Edema.
A. Urticaria. C. Diaphoresis. F. Edema.
After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment? A. Use a peak flow meter to assess the respiratory status. B. Administer a stat dose of corticosteroids. C. Document the normal finding in the client's health record. D. Repeat a dose of the client's rescue drug.
A. Use a peak flow meter to assess the respiratory status.
The nurse is caring for a client who receives a prescription for valproic acid in which the maximum safe dosage is 60 mg/kg/day. How many mg/day is the maximum safe dosage for a client who weighs 176 pounds? (Enter numerical value only.). A. 4012 mg/day. B. 4800 mg/day. C. 3520 mg/day. D. 6171 mg/day
B. 4800 mg/day.
The practical nurse (PN) is caring for a client with psychosis who demonstrates an inability to communicate effectively. Which method should the PN use to interact with the client? A. Discourage group activities. B. Engage in regular contact. C. Touch the client when speaking. D. Establish a no-harm contract.
B. Engage in regular contact.
A male client tells the practical nurse (PN) that he is afraid of getting cancer so he plans to quit smoking cigarettes by switching to a smokeless tobacco product. How should the PN respond? A. Remind the client that he is likely to gain weight when attempting to stop smoking. X B. Provide information to the client about risks associated with smokeless tobacco. C. Explain to the client that obesity is a more significant health risk than smoking. X D. Encourage the client to continue with this plan to reduce his risk for cancer.
B. Provide information to the client about risks associated with smokeless tobacco.
A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective? A. Granulating tissue in foot ulcer. B. Reduced level of pain. C. Improved visual acuity. D. Full volume of pedal pulses. E. Full volume of pedal pulses.
B. Reduced level of pain.
An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance? A. Metabolic alkalosis. B. Respiratory alkalosis. C. Metabolic acidosis. D. Respiratory acidosis.
B. Respiratory alkalosis.
The patient is being assisted to the bathroom for the first time. The recent experience caused a sudden guard and ended up at the hospital. The options for the practical course (PN) are: A. Maximize funding and avoid undue pressure on the cesarean incision. B. Return the patient to bed and maintain bed rest until the local flow stabilizes. C. Adjust fluid consistency and continue to monitor the local flow amount. D. Withhold bladder emptying until the Foley catheter is removed and contract the fundus.
B. Return the patient to bed and maintain bed rest until the local flow stabilizes.
The patient is being assisted to the bathroom for the first time. The recent experience caused a sudden guard and ended up at the hospital. The options for the practical course (PN) are: A. Maximize funding and avoid undue pressure on the cesarean incision. B. Return the patient to bed and maintain bed rest until the local flow stabilizes. C. Adjust fluid consistency and continue to monitor the local flow amount. D. Withhold bladder emptying until the Foley catheter is removed and contract the fundus.
B. Return the patient to bed and maintain bed rest until the local flow stabilizes.
Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client? A. Wrap the bag in place for comfort. B. Secure a protective cover over the bag. C. Give directions to leave the pack in place. D. Fill the ice pack with crushed ice
B. Secure a protective cover over the bag.
A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, "The client reports feeling thirsty and hungry all the time." How should the nurse label this type of data? A. Objective data B. Subjective data C. Primary data D. Secondary data.
B. Subjective data
The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement? A. Inspect for sacral edema. B. Measure urinary output. C. Auscultate all lung fields. D. Check mental acuity.
C. Auscultate all lung fields.
A client reports experiencing numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) prioritize reporting to the healthcare provider? A. Hematocrit B. Albumin and protein levels C. Electrolytes D. White blood cell count (WBC)
C. Electrolytes
When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night? A. Reassure the client that someone will check on him hourly. B. Place fresh water and a glass within reach on the bedside table. C. Ensure that the call bell is easily accessible to the client. D. Offer the client an evening snack before providing oral care.
C. Ensure that the call bell is easily accessible to the client.
A child who weighs 55 pounds receives a prescription for cefotaxime 150 mg/kg/day intravenously in divided doses every 6 hours. How many mg should the nurse administer each day? A. 3000 mg. B. 3300 mg. C. 3600 mg. D. 3750 mg.
D. 3750 mg.
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review? A. Serum calcium B. Haemoglobin and hematocrit C. White blood cell count (WBC) D. Blood urea nitrogen (BUN) and creatinine
D. Blood urea nitrogen (BUN) and creatinine
A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take? A. Check the client's temperature B. Assess the client's level of consciousness. C. Ask the client about any history of allergies. D. Obtain a blood sample for culture and sensitivity.
D. Obtain a blood sample for culture and sensitivity.
The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding? A. Missing pulse. B. Light pressure applied to pulse. C. Pulse skips beats. D. Thready pulse volume.
D. Thready pulse volume.
The practical nurse (PN) selects the ventrolateral site to administer an intramuscular (IM) injection to an adult. Identify the Injection site.
Upper outer quadrant
A client reports that she ingested 1/2 of a liter of a prep solution for a colonoscopy. How many mL of fluid intake should the practical nurse (PN) document? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
1 liter is equal to 1000 milliliters. Therefore, to calculate the fluid intake in mL, we can multiply 1/2 liter by 1000 mL/liter: 1/2 liter * 1000 mL/liter = 500 mL So, the practical nurse should document 500 mL as the client's fluid intake.
A client reports that she ingested 1/2 of a liter of a prep solution for a colonoscopy. How many mL of fluid intake should the practical nurse (PN) document? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
500mL
4 ounce apple Juice 8 ounces milk 4 ounces broth 4 ounces tea A client remains on strict intake and output (1&0) on the first postoperative day and documents the last 8 hours of intake on the 1&0 bedside record above. How many mL should the practical nurse (PN) document in the client's electronic medical record (EMR)? (Enter numeric value only.)
591.4 ml
A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next? A. "Are you planning to obey the voices?" B. "Have you taken any hallucinogens?" C. "When did these voices begin?" D. "Do you believe the voices are real?"
A. "Are you planning to obey the voices?"
The client is a young male who appears to be 25-30 years old. He was found unconscious on a sidewalk by a jogger who was passing. The jogger called an ambulance, and the EMT's transported the ent to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT CT of the head in the emergency room showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests. The PN reinforces education about seizures to the client and asks him to explain what he understands about his condition. Which statements indicate understanding? Select all that apply A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." B. "There are really no lifestyle changes that I can do that will affect my risk of having another seizure." C. "I may never know why I started having seizure
A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." C. "I may never know why I started having seizures." D. "Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not."
Which statement by an older female client who lost her spouse two years ago should indicate to the practical nurse (PN) that the client may need bereavement counseling? A. "I realize that life must go on, but sometimes I wonder why." B. "Sometimes I have trouble remembering simple things." C. "I depend on children who fortunately live close-by." D. "I hate that my health does not allow me to do what I used to do." E. "I hate that my health does not allow me to do what I used to do."
A. "I realize that life must go on, but sometimes I wonder why."
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best? A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" C. "Part of recovery is accepting your new body image, and you will need to look at your incision." D. "You will feel beter when you see that the incision is not as bad as you may think."
A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready."
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best? A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" C. "Part of recovery is accepting your new body image, and you will need to look at your incision." D. "You will feel better when you see that the incision is not as bad as you may think."
A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready."
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best? A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" X C. "Part of recovery is accepting your new body image, and you will need to look at your incision." X D. "You will feel better when you see that the incision is not as bad as you may think."
A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready."
A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say? A. "The combination of trimethoprim and sulfamethoxazole has a synergistic effect that inhibits bacterial growth more effectively than either drug alone.". B. "The combination of trimethoprim and sulfamethoxazole has an additive effect that reduces the dosage and frequency of administration of each drug.". C. "The combination of trimethoprim and sulfamethoxazole has an antagonistic effect that prevents the development of resistance to either drug.". D. "The combination of trimethoprim and sulfamethoxazole has a selective effect that targets only the bacteria causing the UTI and spares the normal flora.".
A. "The combination of trimethoprim and sulfamethoxazole has a synergistic effect that inhibits bacterial growth more effectively than either drug alone.".
A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.). A. "You may notice that your reaction time is slower than before.". B. "You may experience some difficulty with learning new things.". C. "You may have more neurotransmitters in your brain as you age.". D. "You may lose some of your sense of smell and taste over time.". E. "You may have more oxygen delivery to your brain cells as you age.".
A. "You may notice that your reaction time is slower than before.". B. "You may experience some difficulty with learning new things.". D. "You may lose some of your sense of smell and taste over time.".
A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. The triage nurse does a rapid assessment of the client. 1915: Client arrives via personal car to the emergency department with facial drooping and garbled speech. Click to highlight the data that indicates the client is in need of immediate health interventions. A. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. B. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. C. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. D. After having a few drinks at a local seafood resta
A. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. B. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. C. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. E. 1915: Client arrives via personal car to the emergency department with facial drooping and garbled speech.
The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP? A. A client with continuous urinary bladder irrigation via a 3-way catheter. B. A client with urinary urgency and incontinence who is asking for a bedpan. C. A client with a full urinary bedside drainage unit after receiving a diuretic. D. A client with paraplegia who needs an urinary condom-catheter change.
A. A client with continuous urinary bladder irrigation via a 3-way catheter.
The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP? A. A client with continuous urinary bladder irrigation via a 3-way catheter. B. A client with urinary urgency and incontinence who is asking for a bedpan. X C. A client with a full urinary bedside drainage unit after receiving a diuretic. X D. A client with paraplegia who needs a urinary condom-catheter change.
A. A client with continuous urinary bladder irrigation via a 3-way catheter.
The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP? A. A client with continuous urinary bladder irrigation via a 3-way catheter. B. A client with urinary urgency and incontinence who is asking for a bedpan. X C. A client with a full urinary bedside drainage unit after receiving a diuretic. X D. A client with paraplegia who needs an urinary condom-catheter change.
A. A client with continuous urinary bladder irrigation via a 3-way catheter.
After completing post-anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer? A. A primigravida whose perineal pain has worsened one hour after being medicated. B. A primigravida who passed a small clot when she sat up on the edge of the bed. X C. A multigravida whose peri-pad is 1/2 saturated with lochia rubra after one hour. X D. A multigravida complaining of strong afterbirth pains when breastfeeding.
A. A primigravida whose perineal pain has worsened one hour after being medicated.
After completing post-anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer? A. A primigravida whose perineal pain has worsened one hour after being medicated. B. A primigravida who passed a small clot when she sat up on the edge of the bed. C. A multigravida whose peri-pad is 1⁄2 saturated with lochia rubra after one hour. D. A multigravida complaining of strong afterbirth pains when breastfeeding.
A. A primigravida whose perineal pain has worsened one hour after being medicated.
The healthcare provider gives a pregnant woman a prescription for one prenatal vitamin with iron daily and tells her to increase iron-rich foods in her diet because her hemoglobin is 8.2 g/dL or (5.09 mmol/L). When a list of iron-rich foods is given to the client, she tells the practical nurse (PN) that she is vegetarian and does not eat anything that "bleeds." Which instruction should the PN provide? (Select all that apply.) A. Add lentils and black beans to soups. B. Eat red meat just until the anemia is resolved. C. Take two prenatal vitamins with iron daily. D. Oatmeal is a good choice for breakfast. E. Increase green leafy vegetables in the diet.
A. Add lentils and black beans to soups.
The healthcare provider gives a pregnant woman a prescription for one prenatal vitamin with iron daily and tells her to increase iron-rich foods in her diet because her hemoglobin is 8.2 g/dL or (5.09 mmol/L). When a list of iron-rich foods is given to the client, she tells the practical nurse (PN) that she is vegetarian and does not eat anything that "bleeds." Which instruction should the PN provide? (Select all that apply.) A. Add lentils and black beans to soups. B. Eat red meat just until the anemia is resolved. C. Take two prenatal vitamins with iron daily. D. Oatmeal is a good choice for breakfast. E. Increase green leafy vegetables in the diet.
A. Add lentils and black beans to soups. D. Oatmeal is a good choice for breakfast. E. Increase green leafy vegetables in the diet.
The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take? A. Administer a prescribed PRN dose of analgesic. B. Notify the nursing supervisor of the uncontrolled pain. C. Give the next prescribed dose of antiviral medication. D. Obtain an oxygen tank for home administration.
A. Administer a prescribed PRN dose of analgesic.
The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take? A. Administer a prescribed PRN dose of analgesic. B. Notify the nursing supervisor of the uncontrolled pain. C. Give the next prescribed dose of antiviral medication. D. Obtain an oxygen tank for home administration.
A. Administer a prescribed PRN dose of analgesic.
A client receives new prescriptions at 1000 that include discontinuing IV fluids and IV antibiotics. Which prescription should the practical nurse (PN) administer at 1300? A. Ampicillin 500 mg PO q8h. B. Lisinopril 5 mg PO every day. C. Metformin 1000 mg PO BID. D. Pantoprazole 40 mg PO every day
A. Ampicillin 500 mg PO q8h.
A client receives new prescriptions at 1000 that include discontinuing IV fluids and IV antibiotics. Which prescription should the practical nurse (PN) administer at 1300? A. Ampicillin 500 mg PO q8h. B. Lisinopril 5 mg PO every day. C. Metformin 1000 mg PO BID. D. Pantoprazole 40 mg PO every day.
A. Ampicillin 500 mg PO q8h.
Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients? A. An adult who is one day postoperative for a laparoscopic cholecystectomy. B. An older client who is one day postoperative with a colostomy for colon cancer. C. An older adult who is scheduled for foot amputation due to diabetes complications. D. An adult with alcoholism, cirrhosis, and hepatic encephalopathy.
A. An adult who is one day postoperative for a laparoscopic cholecystectomy.
A client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take? A. Ask the client if he is currently hearing voices. B. Have the unlicensed assistive personnel (UAP) escort the client down to his room. C. Record the event but do not disturb the client. D. Administer an as-needed (PRN) dose of haloperidol.
A. Ask the client if he is currently hearing voices.
A client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take? A. Ask the client if he is currently hearing voices. v B. Have the unlicensed assistive personnel (UAP) escort the client down to his room. C. Record the event but do not disturb the client. D. Administer an as-needed (PRN) dose of haloperidol.
A. Ask the client if he is currently hearing voices.
The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Which action should the PN implement first? A. Ask the client to describe what happened B. Inform the charge nurse of the situation C. Complete a client adverse incident report D. Call the agency-based client advocate
A. Ask the client to describe what happened
The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication he had to request three times. Which action should the PN implement first? A. Ask the client to describe what happened. B. Inform the charge nurse of the situation C. Complete a client adverse incident report. D. Call the agency-based client advocate.
A. Ask the client to describe what happened.
The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication he had to request three times. Which action should the PN implement first? A. Ask the client to describe what happened. B. Inform the charge nurse of the situation C. Complete a client adverse incident report. D. Call the agency-based client advocate.
A. Ask the client to describe what happened.
An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and tries unsuccessfully to give him a drink of water. Which action should the nurse take? A. Ask the wife to stop and assess the client's swallowing reflex. B. Give the wife a straw to help facilitate the client's drinking. C. Assist the wife and carefully give the client small sips of water. D. Obtain thickening powder before providing any more fluids.
A. Ask the wife to stop and assess the client's swallowing reflex.
The client is a 76-year-old male who was brought into the emergency room by his daughter. She states that he has not been feeling well, and she became worried when she had a phone conversation with him. She stated that he sounded "confused and not himself." Exhibits here Review H and P and nurse's notes. What other assessment techniques can the nurse use to identify the potential source of the client's new-onset confusion and decreased appetite? Select all that apply. A. Ask to see the client's list of home medications B. Determine if the client has recently lost a loved one C. Measure the client's vital signs D. Collect a sputum and urine culture and sensitivities E. Perform a 12-lead electrocardiogram F. Have the client ambulate across the room. G. Ask about the client's last bowel movement H. Measure the client's abdominal circumference
A. Ask to see the client's list of home medications B. Determine if the client has recently lost a loved one C. Measure the client's vital signs E. Perform a 12-lead electrocardiogram H. Measure the client's abdominal circumference
Exhibits here Review H and P and nurse's notes. What other assessment techniques can the nurse use to identify the potential source of the client's new-onset confusion and decreased appetite? Select all that apply. History and Physical Nurses' Notes The client is a 76-year-old male who was brought into the emergency room by his daughter. She states that he has not been feeling well, and she became worried when she had a phone conversation with him. She stated that he sounded "confused and not himself." A. Ask to see the client's list of home medications B. Determine if the client has recently lost a loved one C. Measure the client's vital signs D. Collect a sputum and urine culture and sensitivities E. Perform a 12-lead electrocardiogram F. Have the client ambulate across the room. G. Ask about the client's last bowel movement H. Measure the client's abdominal circumference
A. Ask to see the client's list of home medications B. Determine if the client has recently lost a loved one C. Measure the client's vital signs E. Perform a 12-lead electrocardiogram H. Measure the client's abdominal circumference
Chest x-ray: Consolidation in the right lower lobe consistent with pneumonia Review H and P, nurse's notes, flow sheet, doctor's order, and Imaging studies. What statements indicate the client's confusion is resolving? Select all that apply. A. Asks how long he has been in the hospital B. Drinking broth C. States he is hungry D. Clawing at the air E. Keeps trying to get out of bed to find the swimming pool F. Recognizes his daughter G. Oriented to time, place, and self H. Oxygen saturation on 0.5L of 100%
A. Asks how long he has been in the hospital B. Drinking broth C. States he is hungry F. Recognizes his daughter
Chest x-ray: Consolidation in the right lower lobe consistent with pneumonia Review H and P, nurse's notes, flow sheet, doctor's order, and Imaging studies. What statements indicate the client's confusion is resolving? Select all that apply. A. Asks how long he has been in the hospital B. Drinking broth C. States he is hungry D. Clawing at the air E. Keeps trying to get out of bed to find the swimming pool F. Recognizes his daughter G. Oriented to time, place, and self H. Oxygen saturation on 0.5L of 100%
A. Asks how long he has been in the hospital B. Drinking broth C. States he is hungry F. Recognizes his daughter G. Oriented to time, place, and self
The client was admitted to the medical floor. Upon arrival, the client was assessed: He is difficult to arouse but follows commands. He has a peripheral IV which is infusing normal saline at 145 mL/hr. No redness or edema at the site. Breath sounds are clear and equal bilaterally. He appears pink and well-perfused. The client had a tonic-clonic seizure that lasted for 3 minutes and 5 seconds. The client became apneic during the seizure and the oxygen saturation dropped to 48%. The client was manually ventilated at 100% oxygen and padding was placed around the vent for safety. After the seizure, the client was turned to his left for recovery. The physician comes to the bedside following the seizure and prescribes phenytoin. The PN administers the phenytoin as prescribed. What are the possible toxic effects of phenytoin that the PN should closely monitor the client for after administration? Select all that apply A. Ata
A. Ataxia B. Drowsiness C. Altered blood coagulation F. Vertigo G. Visual disturbances
The client was admitted to the medical floor. Upon arrival, the client was assessed: He is difficult to arouse but follows commands. He has a peripheral IV which is infusing normal saline at 145 mL/hr. No redness or edema at the site. Breath sounds are clear and equal bilaterally. He appears pink and well-perfused. The client had a tonic-clonic seizure that lasted for 3 minutes and 5 seconds. The client became apneic during the seizure and the oxygen saturation dropped to 48%. The client was manually ventilated at 100% oxygen and padding was placed around the vent for safety. After the seizure, the client was turned to his left for recovery. The physician comes to the bedside following the seizure and prescribes phenytoin. The PN administers the phenytoin as prescribed. What are the possible toxic effects of phenytoin that the PN should closely monitor the client for after administration? Select all that apply A
A. Ataxia B. Drowsiness C. Altered blood coagulation F. Vertigo G. Visual disturbances
During a routine prenatal visit at the antepartal clinic, a multipara at 35 weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the practical nurse (PN) report to the registered nurse? A. Blood pressure. B. Due date. C. Fundal height. D. Gravida and parity.
A. Blood pressure.
During a routine prenatal visit at the antepartal clinic, a multipara at 35 weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the practical nurse (PN) report to the registered nurse? A. Blood pressure. B. Due date. C. Fundal height. D. Gravida and parity.
A. Blood pressure.
The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the charge nurse? Reference ranges: Blood urea nitrogen (BUN): [Adult: 10 to 20 mg/dL or 3.6 to 7.1 mmol/L] Platelets: [150,000 to 400,000/mm3 or 150 to 400 x 109/L] A. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L B. Platelet count 135,000/mm3 or 135 x 109/L C. Decreased deep tendon reflexes. D. Periodic nausea and vomiting.
A. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L
The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the charge nurse? Reference ranges: Blood urea nitrogen (BUN): [Adult: 10 to 20 mg/dL or 3.6 to 7.1 mmol/L] Platelets: [150,000 to 400,000/mm3 or 150 to 400 x 109/L] A. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L v B. Platelet count 135,000/mm3 or 135 x 109/L X C. Decreased deep tendon reflexes. X D. Periodic nausea and vomiting.
A. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L v
A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action. A. Blowing forcefully into the mouthpiece. B. Exhaling slowly after two seconds. C. Using a tight seal around the mouthpiece. D. Sitting upright during the treatment.
A. Blowing forcefully into the mouthpiece.
A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action. A. Blowing forcefully into the mouthpiece. B. Exhaling slowly after two seconds. C. Using a tight seal around the mouthpiece. D. Sitting upright during the treatment.
A. Blowing forcefully into the mouthpiece.
The nurse interviews a client admitted for an outpatient procedure and enters a long list of home medications into the medical record. The nurse observes several medications that are prescribed for the same indications. Which instruction is best for the nurse to communicate to the client regarding the multiple prescriptions? A. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment. B. Use a medication reminder system to prevent omitting to take the right medications at the right time. C. Make certain a family member knows the name and use of all medications currently being taken. D. Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider E. Remove resuscitation equipment from the room.
A. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment.
A client is recovering in the critical care unit following a cardiac catheterization. Intravenous (IV) nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. Which action should the nurse implement? A. Check femoral site for hematoma formation. B. Stimulate the client to take deep breaths. C. Evaluate the integrity of the IV insertion site. D. Assess distal lower extremity capillary refill.
A. Check femoral site for hematoma formation.
Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)? A. Check the medical record for the correct signed consent form prior to the examination. B. Explains the examination and ask the client to sign the consent form. C. Explain to a family member and obtain their signature on the consent form. D. Asks if the client understands the exam and why the consent form must be signed.
A. Check the medical record for the correct signed consent form prior to the examination.
Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)? A. Check the medical record for the correct signed consent form prior to the examination. B. Explains the examination and ask the client to sign the consent form. C. Explain to a family member and obtain their signature on the consent form. D. Asks if the client understands the exam and why the consent form must be signed.
A. Check the medical record for the correct signed consent form prior to the examination.
Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)? A. Collect fingerstick glucose levels. B. Implement bleeding precautions. C. Obtain daily weights. D. Check urine for albumin. E. Check urine for albumin.
A. Collect fingerstick glucose levels.
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.). A. Contains a list with definitions of unfamiliar terms. B. Written at a twelfth-grade reading level. C. Uses common words with few syllables. D. Uses pictures to help illustrate complex ideas. E. Printed using a 12-point type font.
A. Contains a list with definitions of unfamiliar terms. D. Uses pictures to help illustrate complex ideas.
The client is a 29-year-old with a history of type 1 diabetes from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town, and her insulin pump was damaged. She had forgotten her backup long-acting insulin at home, so she took the 6-hour drive home. By the time she arrived at home, she was having nausea and vomiting. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency room. A. Correct electrolytes that are out of normal range. B. Promote oxygenation to tissues. C. Prevent hyperventilation. D. Reverse dehydration. E. Replace insulin. F. Provide respiratory support.
A. Correct electrolytes that are out of normal range. D. Reverse dehydration. E. Replace insulin.
A nurse is caring for a client who has variant angina and is prescribed verapamil. Which of the following are expected outcomes of this medication? (Select all that apply.) A. Decreased heart rate B. Increased contractility C. Dilated coronary arteries D. Reduced blood pressure E. Relieved chest pain.
A. Decreased heart rate C. Dilated coronary arteries D. Reduced blood pressure E. Relieved chest pain.
A nurse is reviewing laboratory results for a client who has been taking amoxicillin-clavulanate (Augmentin) for a bacterial respiratory tract infection. Which of the following findings should alert the nurse to a possible adverse effect of this medication? (Select all that apply.). A. Elevated serum creatinine level. B. Elevated serum alanine aminotransferase level. C. Elevated serum potassium level. D. Elevated white blood cell count.
A. Elevated serum creatinine level. B. Elevated serum alanine aminotransferase level. D. Elevated white blood cell count.
When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.). A. Fresh or frozen vegetables without sauce. B. Fruits without sauce. C. Pickled olives. D. Canned soup. E. Cottage cheese.
A. Fresh or frozen vegetables without sauce. B. Fruits without sauce
Ancient is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure? A. Gather the procedure tray and equipment. B. Cleanse the site and cover with a sterile towel. C. Keep the patient NPO (nothing by mouth) and encourage them to void. X D. Place the patient in an orthopneic position.
A. Gather the procedure tray and equipment.
Ancient is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure? A. Gather the procedure tray and equipment. B. Cleanse the site and cover with a sterile towel. C. Keep the patient NPO (nothing by mouth) and encourage them to void. D. Place the patient in an orthopneic position.
A. Gather the procedure tray and equipment.
The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility: A. Health care proxy documentation. B. Name of funeral home to contact. C. Client's wishes regarding organ donation. D. Contact information for the client's next of kin. E. Contact information for the client's next of kin.
A. Health care proxy documentation.
The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility: A. Health care proxy documentation. B. Name of funeral home to contact. C. Client's wishes regarding organ donation. D. Contact information for the client's next of kin. E. Contact information for the client's next of kin.
A. Health care proxy documentation.
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility? A. Health care proxy documentation. B. Name of funeral home to contact. C. Client's wishes regarding organ donation. D. Contact information for the client's next of kin.
A. Health care proxy documentation.
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility? A. Health care proxy documentation. B. Name of funeral home to contact C. Client's wishes regarding organ donation D. Contact information for the client's next of kin
A. Health care proxy documentation.
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility? A. Health care proxy documentation. B. Name of funeral home to contact. C. Client's wishes regarding organ donation. D. Contact information for the client's next of kin.
A. Health care proxy documentation.
The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report? A. History of vomiting at home for 3 days prior to surgery. B. Soft abdomen, absent bowel sounds, no bleeding on dressing. C. Declining to take ice chips for complaints of dry mouth. D. Peripheral pulses present with full ran
A. History of vomiting at home for 3 days prior to surgery.
The client is a 29-year-old female with a history of type 1 diabetes from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town for a business trip, and her insulin pump was damaged when she accidentally dropped it on the floor. She had forgotten her backup long-acting insulin at home, so she decided to take the 6-hour drive home without any insulin. By the time she arrived home, she was having nausea and vomiting, abdominal pain, and rapid breathing. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency room. A. Hyperglycemia. B. Ketonuria. C. Metabolic acidosis. D. Hypokalemia. E. Dehydration. F. Kussmaul respirations.
A. Hyperglycemia. B. Ketonuria. C. Metabolic acidosis. E. Dehydration. F. Kussmaul respirations.
A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg by mouth (PO) for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication? A. Hypertension. B. Apical heart rate 72 beats/minute. C. Muscle weakness. D. Blood pressure 90/76 mm Hg
A. Hypertension.
Which order would the nurse question? Select all that apply The client is a 51-year-old male who was admitted to the hospital with pneumonia. He has been experiencing fever, cough, shortness of breath, and chest pain for the past three days. A. Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). B. Enalapril 10 mg every morning. C. Supplemental oxygen 10 L/min via nasal cannula. D. Continuous pulse oximetry. E. Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin. F. Admit to the medical floor. G. Vital signs every 4 hours. H. Chest x-ray now. I. Sputum culture and sensitivity. J. Levofloxacin 500 mg intravenously every 24 hours.
A. Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). B. Enalapril 10 mg every morning. C. Supplemental oxygen 10 L/min via nasal cannula.
In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority? A. Impaired physical mobility relative to muscle rigidity. B. Risk for aspiration relative to muscle weakness. C. Risk for constipation relative to immobility. D. Self-care deficit relative to motor disturbance.
A. Impaired physical mobility relative to muscle rigidity.
The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which intervention(s) should the nurse implement? (Select all that apply.). A. Include the family in the discharge teaching. B. Encourage the client to attend reading classes. C. Face the client when speaking. D. Speak loudly when teaching. E. Provide the daughter with written instructions.
A. Include the family in the discharge teaching. C. Face the client when speaking. E. Provide the daughter with written instructions.
A new unlicensed assistive personnel (UAP) is completing an orientation assignment and is caring for an immobilized client who needs a complete bed bath. Which is the best way for the practical nurse (PN) to evaluate this UAP's performance? A. Inspect the client's skin near the end of the bathing procedure. B. Verify with the client that the bath was complete and thorough. C. Request the UAP to report and chart when the bath is complete. D. Ask another UAP to help the orientee ensure satisfactory care.
A. Inspect the client's skin near the end of the bathing procedure.
During a fecal impaction removal, an older client complains of feeling dizzy and cold. Which intervention should the nurse implement? A. Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back. B. Insert a gloved finger into the rectum and gently massage the rectal sphincter. C. Stop the procedure and observe for a reduction in symptoms before continuing. D. Encourage the client to take slow, deep breaths while continuing the procedure.
A. Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back.
A client who has four gold seed implants on a chest wall tumor is on radiation precautions. What basic precautions should the practical nurse (PN) observe when administering direct care to this client? A. Minimal time, maximum distance, and protective shielding. B. Rotate the assignment with other staff during the shift. C. Virtual observation and wearing a film badge for exposure. D. Standard precautions with negative pressure isolation.
A. Minimal time, maximum distance, and protective shielding.
A client who has four gold seed implants on a chest wall tumor is on radiation precautions. What basic precautions should the practical nurse (PN) observe when administering direct care to this client? A. Minimal time, maximum distance, and protective shielding. B. Rotate the assignment with other staff during the shift. C. Virtual observation and wearing a film badge for exposure. D. Standard precautions with negative pressure isolation.
A. Minimal time, maximum distance, and protective shielding.
Discussed the DASH diet with the client and gave examples of appropriate portion sizes. Review H and P, nurse's note, and laboratory results. What other nutritional recommendations would be helpful for this client in reducing the risk for type 2 diabetes? Select all that apply. A. Minimize the number of refined grains in the diet B. Eliminate sugary beverages and juices from the diet C. Increase the amount of dietary fiber D. Double the usual amount of protein in the diet E. Only select feed items with no fat F. Take a cinnamon supplement
A. Minimize the number of refined grains in the diet B. Eliminate sugary beverages and juices from the diet C. Increase the amount of dietary fiber
Discussed the DASH diet with the client and gave examples of appropriate portion sizes. Review H and P, nurse's note, and laboratory results. What other nutritional recommendations would be helpful for this client in reducing the risk for type 2 diabetes? Select all that apply. A. Minimize the number of refined grains in the diet B. Eliminate sugary beverages and juices from the diet C. Increase the amount of dietary fiber D. Double the usual amount of protein in the diet E. Only select feed items with no fat F. Take a cinnamon supplement
A. Minimize the number of refined grains in the diet B. Eliminate sugary beverages and juices from the diet C. Increase the amount of dietary fiber
A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.). A. Monitor ETT markings between 22 and 26 cm at teeth line. B. Check for capillary refill of 3 seconds or less. C. Obtain a portable chest x-ray to verify ETT location. D. Assess for symmetrical chest movement. E. Auscultate for presence of bilateral breath sounds.
A. Monitor ETT markings between 22 and 26 cm at teeth line. C. Obtain a portable chest x-ray to verify ETT location. D. Assess for symmetrical chest movement. E. Auscultate for presence of bilateral breath sounds.
While caring for a client one day following a thyroidectomy, the practical nurse (PN) notes that the client's voice is hoarse. What action should the PN take? A. Notify the unit charge nurse of the finding. B. Administer humidified oxygen per nasal cannula. C. Obtain a cup of ice chips for the client. D. Ensure that the drainage device is compressed.
A. Notify the unit charge nurse of the finding.
While caring for a client one day following a thyroidectomy, the practical nurse (PN) notes that the client's voice is hoarse. What action should the PN take? A. Notify the unit charge nurse of the finding. B. Administer humidified oxygen per nasal cannula. C. Obtain a cup of ice chips for the client. D. Ensure that the drainage device is compressed.
A. Notify the unit charge nurse of the finding.
After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care? A. Observe for signs of depression. B. Monitor for urinary incontinence. C. Provide a wide variety of meal choices. D. Apply sequential compression stockings.
A. Observe for signs of depression.
The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin the seizure, what should the PN implement immediately? (Select all that apply.) A. Observe the progression of the seizure. B. Hold the extremities close to the body. C. Insert a tongue blade between the teeth. D. Pad the side rails with pillows. E. Loosen clothing around the neck.
A. Observe the progression of the seizure.
The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin the seizure, what should the PN implement immediately? (Select all that apply.) A. Observe the progression of the seizure. B. Hold the extremities close to the body. C. Insert a tongue blade between the teeth. D. Pad the side rails with pillows. E. Loosen clothing around the neck.
A. Observe the progression of the seizure. D. Pad the side rails with pillows. E. Loosen clothing around the neck.
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply). A. Orange juice. B. Apple juice. C. Hot chocolate. D. Chicken broth. E. Black coffee.
A. Orange juice. B. Apple juice. D. Chicken broth.
Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.) A. Palpate the rate and volume of the pulse. B. Measure body weight at the same time daily. C. Check fingernails for the presence of clubbing D. Observe the color and amount of urine. E. Compare muscle strength of both arms.
A. Palpate the rate and volume of the pulse. B. Measure body weight at the same time daily. D. Observe the color and amount of urine
The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.) A. Paper tape. B. Small gauze pad. C. Sterile gloves. D. Exam gloves. E. Three mL syringe.
A. Paper tape. B. Small gauze pad. D. Exam gloves.
Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement? A. Place pillows to maintain alignment. B. Raise the head of the bed at 30 degrees. C. Flex legs and place blanket between legs. D. Measure blood pressure and pulse rate.
A. Place pillows to maintain alignment.
Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement? A. Place pillows to maintain alignment. B. Raise the head of the bed at 30 degrees. C. Flex legs and place blanket between legs. D. Measure blood pressure and pulse rate.
A. Place pillows to maintain alignment.
A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply). A. Provide a safe and calm environment for the client during a panic attack. B. Use therapeutic communication skills to establish rapport and trust with the client. C. Educate the client about panic disorder and its treatment options. D. Encourage the client to participate in cognitive-behavioral therapy (CBT). E. Refer the client to self-help groups for peer support and education.
A. Provide a safe and calm environment for the client during a panic attack. B. Use therapeutic communication skills to establish rapport and trust with the client. C. Educate the client about panic disorder and its treatment options. D. Encourage the client to participate in cognitive-behavioral therapy (CBT). E. Refer the client to self-help groups for peer support and education.
A client is admitted following a motor vehicle collision. When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands. The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward. Which action should the nurse implement? A. Report the finding to the healthcare provider. B. Document the purposeful response to pain. C. Initiate seizure precautions immediately. D. Administer a prescribed PRN analgesic.
A. Report the finding to the healthcare provider
The practical nurse (PN) heard adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour. Which action should the PN take next? A. Report the findings to the charge nurse. B. Review the last balance of intake and output. C. Slow the DSW infusion rate to 50 ml/hour. D. Document the findings and monitor the client.
A. Report the findings to the charge nurse.
A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement? A. Reposition the client and provide a back rub. B. Provide a cup of hot chocolate at bedtime. C. Offer the client a prescribed sleep medication. D. Administer an as-needed (PRN) prescription for pain.
A. Reposition the client and provide a back rub.
A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement? A. Reposition the client and provide a back rub. B. Provide a cup of hot chocolate at bedtime. C. Offer the client a prescribed sleep medication. D. Administer an as-needed (PRN) prescription for pain.
A. Reposition the client and provide a back rub.
The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.) A. S4. B. S2. C. S1. D. S3.
A. S4 is another abnormal heart sound, which occurs during late diastole and is associated with conditions such as ventricular hypertrophy and reduced ventricular compliance. D. S3 is an extra heart sound that occurs during diastole (the filling phase of the cardiac cycle). It is commonly associated with conditions such as heart failure and volume overload. S3 is often described as a low-frequency, dull, and distant sound heard after S2 (the second heart sound).
A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do? A. Sleep with an extra pillow under their head B. Sleep on their left side C. Sleep on their right side D. Sleep on their back. E. Relieved chest pain.
A. Sleep with an extra pillow under their head
A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. The triage nurse does a rapid assessment of the client. Exhibits Select the interdisciplinary team members who should assist the client in recovery. Select all that apply. A. Speech Therapist. B. Case Manager. C. Physical Therapist. D. Pharmacy Technician. E. Chief Nursing Officer. F. Respiratory Therapist. G. Medical Assistant. H. An Occupational Therapist
A. Speech Therapist. B. Case Manager. C. Physical Therapist. H. An Occupational Therapist
The client is a 29-year-old with a history of type 1 diabetes from the age of 6. She controls her blood glucose with an insulin pump and uses a continuous glucose monitor. The client was out of town, and her insulin pump was damaged. She had forgotten her backup long-acting insulin at home, so she took the 6-hour drive home. By the time she arrived at home, she was having nausea and vomiting. Her blood glucose meter read over 500 mg/dL (27.8 mmol/L). She took a dose of insulin glargine and took herself to the emergency room. A. Start an insulin drip at 0.1 u/kg/hr. B. Give a long-acting insulin dose. C. Provide an oral medication that will enhance insulin production. D. Change the intravenous fluid to 5% dextrose and 0.45% sodium chloride with 20 mEq potassium. E. Have the client drink as much as they can tolerate. F. Give 1 L of 0.9% sodium chloride IV. G. Promote removal of electrolytes with a diuretic. H. Giv
A. Start an insulin drip at 0.1 u/kg/hr. D. Change the intravenous fluid to 5% dextrose and 0.45% sodium chloride with 20 mEq potassium. F. Give 1 L of 0.9% sodium chloride IV. I. Replacing potassium as needed
A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client's activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply. *. A. Stop the heparin infusion immediately. B. Administer protamine sulfate as ordered. C. Notify the health care provider of the result. D. Draw a prothrombin time (PT) and international normalized ratio (INR) level. E. Monitor the client for signs and symptoms of bleeding.
A. Stop the heparin infusion immediately. B. Administer protamine sulfate as ordered. C. Notify the health care provider of the result. E. Monitor the client for signs and symptoms of bleeding.
In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure? A. Suction the trachea. B. Insert a urinary catheter. C. Apply soft restraints. D. Insert a nasogastric tube.
A. Suction the trachea.
A dentist informs the practical nurse (PN) that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce the risk of gingivitis. How should the PN respond? A. Suggest an increase in fruits and vegetables is more beneficial. B. Encourage the client to get plenty of exercise as well as the dietary change. C. Remind the client to make sure the dairy products are fortified with Vitamin D. D. Provide written information about the warning signs of cancer. E. Provide written information about the warning signs of cancer.
A. Suggest an increase in fruits and vegetables is more beneficial.
A dentist informs the practical nurse (PN) that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce the risk of gingivitis. How should the PN respond? A. Suggest an increase in fruits and vegetables is more beneficial. v B. Encourage the client to get plenty of exercise as well as the dietary change. X C. Remind the client to make sure the dairy products are fortified with Vitamin D. X D. Provide written information about the warning signs of cancer. X E. Provide written information about the warning signs of cancer.
A. Suggest an increase in fruits and vegetables is more beneficial.
A client at 39 weeks gestation is admitted in early labor. During the focused assessment, the practical nurse (PN) reviews the obstetrical history of the client who states that she has been pregnant five times but has only two living children, both of whom were full-term. The other three pregnancies were miscarriages during the first trimester. Which parity should the PN document for the term, premature, abortion, and living children (TPAL) for this client? A. Term 2, Premature 0, Abortion 3, Living 2. B. Term 6, Premature 3, Abortion 3, Living 2. C. Term 2, Premature 1, Abortion 0, Living 3. D. Term 3, Premature 0, Abortion 3, Living 2.
A. Term 2, Premature 0, Abortion 3, Living 2.
A client at 39 weeks gestation is admitted in early labor. During the focused assessment, the practical nurse (PN) reviews the obstetrical history of the client who states that she has been pregnant five times but has only two living children, both of whom were full-term. The other three pregnancies were miscarriages during the first trimester. Which parity should the PN document for the term, premature, abortion, and living children (TPAL) for this client? A. Term 2, Premature 0, Abortion 3, Living 2. B. Term 6, Premature 3, Abortion 3, Living 2. C. Term 2, Premature 1, Abortion 0, Living 3. D. Term 3, Premature 0, Abortion 3, Living 2.
A. Term 2, Premature 0, Abortion 3, Living 2.
A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client? (Select all that apply.) A. The client will have no signs of infection in the wound by day 7. B. The client will report pain level of 4/10 or less during dressing changes. C. The client will consume at least 75% of meals and snacks daily. D. The client will reposition self in bed every 2 hours with assistance. E. The client will demonstrate proper wound care technique before discharge.
A. The client will have no signs of infection in the wound by day 7. B. The client will report pain level of 4/10 or less during dressing changes. E. The client will demonstrate proper wound care technique before discharge.
A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.). A. The client's oxygen saturation level is 85%. B. The client is eating less than half of meals C. The client's heart rate is 110 beats per minute. D. The client is reading a book. E. The client's blood pressure is 160/90 mmHg.
A. The client's oxygen saturation level is 85%. C. The client's heart rate is 110 beats per minute. E. The client's blood pressure is 160/90 mmHg.
The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. The mother says the boy is in pain and needs medical help. The nurse should assess the injury and decide the appropriate action to take. Help the nurse reason out the best assessment. A. The injury may require medical attention, as the mother mentioned that the boy is in pain B. The abrasions on the boy's leg and hand have healed C. The mother describes what she did after her child got injured D. The boy lacks coordination when answering the nurse's questions
A. The injury may require medical attention, as the mother mentioned that the boy is in pain
The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. The mother says the boy is in pain and needs medical help. The nurse should assess the injury and decide the appropriate action to take. A. The injury may require medical attention, as the mother mentioned that the boy is in pain. B. The abrasions on the boy's leg and hand have healed. C. The mother describes what she did after her child got injured. D. The boy lacks coordination when answering the nurse's questions.
A. The injury may require medical attention, as the mother mentioned that the boy is in pain.
The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. The mother says the boy is in pain and needs medical help. The nurse should assess the injury and decide the appropriate action to take. A. The injury may require medical attention, as the mother mentioned that the boy is in pain. v B. The abrasions on the boy's leg and hand have healed. X C. The mother describes what she did after her child got injured. X D. The boy lacks coordination when answering the nurse's questions.
A. The injury may require medical attention, as the mother mentioned that the boy is in pain.
A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.). A. The patient's physical abilities and limitations. B. The patient's cognitive abilities and limitations. C. The patient's interests and preferences. D. The patient's age and gender. E. The patient's cultural and religious background.
A. The patient's physical abilities and limitations. B. The patient's cognitive abilities and limitations. C. The patient's interests and preferences. E. The patient's cultural and religious background.
What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer. The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20. A. To prevent hypoxia and tissue damage due to pneumonia. B. To lower the blood pressure and reduce the workload of the heart. C. To increase the oxygen saturation and improve the respiratory function. D. To dilate the bronchioles and decrease the inflammation of the lungs. E. None F. None
A. To prevent hypoxia and tissue damage due to pneumonia.
The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound] A. Wheeze B. Rhonchi C. Stridor. D. Fine crackles.
A. Wheeze
The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound] A. Wheeze. B. Rhonchi. C. Stridor. D. Fine crackles.
A. Wheeze.
A nurse is teaching a client with hypertension about antihypertensive drugs. Which of the following statements by the client indicates an understanding of the teaching? A. "Antihypertensive drugs work by increasing the blood flow to my heart and kidneys." B. "Antihypertensive drugs can lower my blood pressure by affecting different parts of my cardiovascular system." C. "Antihypertensive drugs are safe to use with any other medications or supplements I might take." D. "Antihypertensive drugs will cure my hypertension if I take them as prescribed.". E. "Antihypertensive drugs will cure my hypertension if I take them as prescribed.".
B. "Antihypertensive drugs can lower my blood pressure by affecting different parts of my cardiovascular system."
A nurse is teaching a client who has a fungal infection about fluconazole. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication with food to prevent stomach upset.". B. "I should avoid drinking alcohol while taking this medication.". C. "I should use a barrier method of contraception while taking this medication.". D. "I should stop taking this medication if I develop a rash.".
B. "I should avoid drinking alcohol while taking this medication.".
A nurse is providing education to a client prescribed an antidepressant for their phobia. Which statement by the client indicates a need for further teaching? A. "This medication will help regulate my mood and anxiety.". B. "I should expect to see immediate results after taking this medication.". C. "I may experience side effects such as nausea and drowsiness.". D. "It's important to take this medication consistently as prescribed.". E. "It's important to take this medication consistently as prescribed.".
B. "I should expect to see immediate results after taking this medication.".
A client is diagnosed with influenza A and is prescribed oseltamivir. Which of the following statements by the client indicates a need for further education? A. "This medication will shorten the duration of my symptoms.". B. "This medication will prevent me from spreading the virus to others.". C. "This medication will work best if I start taking it within 48 hours of symptom onset.". D. "This medication may cause nausea and vomiting as side effects.".
B. "This medication will prevent me from spreading the virus to others.".
A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? A. "There is no one who will hurt you.". B. "You seem quite frightened right now.". C. "You are in a safe place.No one can get to you here.". D. "What would you like to see me do to protect you?".
B. "You seem quite frightened right now."
The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment? A. Urinary output. B. Ability to swallow. C. Frequency of bowel movements. D. Blood pressure while standing.
B. Ability to swallow.
The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment? A. Urinary output. B. Ability to swallow. C. Frequency of bowel movements. D. Blood pressure while standing.
B. Ability to swallow.
The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment? A. Urinary output. B. Ability to swallow. C. Frequency of bowel movements. D. Blood pressure while standing.
B. Ability to swallow.
A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first? A. Obtain a urine specimen for analysis. B. Administer a prescribed opioid analgesic. C. Strain the urine for the presence of stones. D. Prepare the client for a prescribed computed tomography (CT) scan. E. Prepare the client for a prescribed computed tomography (CT) scan.
B. Administer a prescribed opioid analgesic.
A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states that it still takes at least two hours to fall asleep at night. Which action should the nurse implement? A. Encourage the client to exercise every day to eliminate bedtime wakefulness. B. Advise the client that lifestyle changes often take several weeks to be effective. C. Ask the client for a description of the exercise schedule that is being followed. D. Determine the amount of weight the client has lost since increasing activity.
B. Advise the client that lifestyle changes often take several weeks to be effective.
The practical nurse (PN) is feeding a 2-month-old male infant with heart failure due to a ventricular septal defect (VSD). Which intervention should the PN implement? A. Weigh before and after feeding. B. Allow the infant to rest before feeding. C. Feed the infant when he cries. D. Insert a nasogastric feeding tube.
B. Allow the infant to rest before feeding.
The practical nurse (PN) is feeding a 2-month-old male infant with heart failure due to a ventricular septal defect (VSD). Which intervention should the PN implement? A. Weigh before and after feeding. B. Allow the infant to rest before feeding. C. Feed the infant when he cries. D. Insert a nasogastric feeding tube.
B. Allow the infant to rest before feeding.
Which is the best approach for the nurse to use when interviewing a client about intimate partner violence? A. Ask questions in a vague, non-specific format. B. Begin with questions that are less sensitive in nature. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.
B. Begin with questions that are less sensitive in nature.
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? A. CP is one of the most common permanent physical disabilities in children. B. Brain damage with CP is not progressive but does have a variable course. C. Severe motor dysfunction determines the extent of successful habilitation. D. Continued development of the brain lesion determines the child's outcome.
B. Brain damage with CP is not progressive but does have a variable course.
A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication? A. Decreasing gastrointestinal (GI) cramping and nausea. B. Chest pain and dysrhythmia. C. Vasodilation of the extremities. D. Hypotension and tachycardia
B. Chest pain and dysrhythmia.
An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units each morning. Which finding should the practical nurse (PN) document as evidence that the amount of insulin is inadequate? A. States her feet are constantly cold along with feeling numb. B. Consecutive evening serum glucose greater than 260 mg/dL. C. A wound on the ankle that starts to drain and becomes painful. D. Reports nausea in the morning but still able to eat breakfast.
B. Consecutive evening serum glucose greater than 260 mg/dL.
An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units each morning. Which finding should the practical nurse (PN) document as evidence that the amount of insulin is inadequate? A. States her feet are constantly cold along with feeling numb. B. Consecutive evening serum glucose greater than 260 mg/dL. C. A wound on the ankle that starts to drain and becomes painful. D. Reports nausea in the morning but still able to eat breakfast.
B. Consecutive evening serum glucose greater than 260 mg/dL.
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first? A. Ask the client if she has previously been catheterized. B. Consult with the charge nurse about the catheter. C. Obtain a 30 mL syringe and a vial of sterile water. D. Position the client and observe the urinary meatus.
B. Consult with the charge nurse about the catheter.
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first? A. Ask the client if she has previously been catheterized. B. Consult with the charge nurse about the catheter. C. Obtain a 30 mL syringe and a vial of sterile water. D. Position the client and observe the urinary meatus.
B. Consult with the charge nurse about the catheter.
The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate? A. Elevated blood pressure. B. Curling's ulcer. C. Compartment syndrome. D. Excruciating pain.
B. Curling's ulcer.
The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate? A. Elevated blood pressure. B. Curling's ulcer. C. Compartment syndrome. D. Excruciating pain.
B. Curling's ulcer.
The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate? A. Elevated blood pressure. B. Curling's ulcer. C. Compartment syndrome. D. Excruciating pain.
B. Curling's ulcer.
Reference Range: 1329545. A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement? A. Decrease expiratory flow time. B. Decrease expiratory pressure. C. Increase rate of ventilation. D. Increase ventilator tidal volume.
B. Decrease expiratory pressure.
A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate? A. Assist in discharging stable clients to home. B. Determine the acuity and number of casualties arriving at the facility. C. Delegate tasks to emergency health care specialists. D. Provide informational updates to members of the media.
B. Determine the acuity and number of casualties arriving at the facility.
When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first? A. Administer a prescribed PRN stool softener B. Determine the client's usual bowel patern C. Encourage the client to ambulate more frequently D. Recommend increasing high-fiber foods daily
B. Determine the client's usual bowel patern
A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching? A. Substitute natural fruit juices for carbonated drinks. B. Encourage active range of motion to limit stiffness. C. Use electric heating pad when pain is at its worst. D. Avoid the consumption of wine, beer, and coffee.
B. Encourage active range of motion to limit stiffness.
The nurse observes a client using an incentive spirometer. Which action should the nurse take? A. Notify the healthcare provider that the client is having difficulty using the spirometer. B. Encourage the client to continue to inhale slowly into the spirometer until the goal is met. C. Offer to demonstrate the correct use of the incentive spirometer to the client. D. Remind the client to cough after each use of the spirometer to help clear the lungs.
B. Encourage the client to continue to inhale slowly into the spirometer until the goal is met.
The practical nurse (PN) is caring for a client with psychosis who demonstrates an inability to communicate effectively. Which method should the PN use to interact with the client? A. Discourage group activities. B. Engage in regular contact. C. Touch the client when speaking. D. Establish a no-harm contract.
B. Engage in regular contact.
A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement? A. Assess the client for nerve pain or paralysis. B. Ensure the client has minimal clutter in the room. C. Evaluate the client's neurological status after exercising. D. Monitor the client's blood cell laboratory values.
B. Ensure the client has minimal clutter in the room.
A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement? A. Assess the client for nerve pain or paralysis. B. Ensure the client has minimal clutter in the room. C. Evaluate the client's neurological status after exercising. D. Monitor the client's blood cell laboratory values.
B. Ensure the client has minimal clutter in the room.
A female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement? A. Assess the client for nerve pain or paralysis. B. Ensure the client has minimal clutter in the room. C. Evaluate the client's neurological status after exercising. D. Monitor the client's blood cell laboratory values.
B. Ensure the client has minimal clutter in the room.
A female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement? A. Assess the client for nerve pain or paralysis. B. Ensure the client has minimal clutter in the room. C. Evaluate the client's neurological status after exercising. D. Monitor the client's blood cell laboratory values.
B. Ensure the client has minimal clutter in the room.
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide? A. Emphasize that using safe sex practices removes the risk of STIs. B. Explain that reinfections occur from sex with untreated partners. C. Clarify that all STIs are transmitted through sexual intercourse. D. Provide counseling that most contraceptives protect against infection.
B. Explain that reinfections occur from sex with untreated partners.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arrive. B. Explain that the client will start to lose consciousness and the body systems will slow down. C. Offer to discuss the client's health status with each of the adult children. D. Reassure the spouse that the healthcare provider will notify when to call the children.
B. Explain that the client will start to lose consciousness and the body systems will slow down.
Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)? A. Check the medical record for the correct signed consent form prior to the examination. B. Explains the examination and ask the client to sign the consent form. C. Explain to a family member and obtain their signature on the consent form. D. Asks if the client understands the exam and why the consent form must be signed.
B. Explains the examination and ask the client to sign the consent form.
Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)? A. Check the medical record for the correct signed consent form prior to the examination. B. Explains the examination and ask the client to sign the consent form. C. Explain to a family member and obtain their signature on the consent form. D. Asks if the client understands the exam and why the consent form must be signed.
B. Explains the examination and ask the client to sign the consent form.
After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching? A. Assessment of tobacco use geared toward adolescents. B. Exploration of stress self-management techniques. C. Video with statistics showing trends in suicide rates. D. Handouts for local substance abuse treatment centers
B. Exploration of stress self-management techniques.
After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching? A. Assessment of tobacco use geared toward adolescents. B. Exploration of stress self-management techniques. C. Video with statistics showing trends in suicide rates. D. Handouts for local substance abuse treatment centers.
B. Exploration of stress self-management techniques.
After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.). A. Take out dentures and place in a labeled cup. B. Gently close the eyes. C. Place a small pillow under the head. D. Apply a body shroud. E. Remove resuscitation equipment from the room.
B. Gently close the eyes. C. Place a small pillow under the head. E. Remove resuscitation equipment from the room.
When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Drink electrolyte fluid replacements. B. Give a dose of regular insulin as prescribed. C. Resume normal physical activity. D. Measure urine output over the next 24 hours.
B. Give a dose of regular insulin as prescribed.
Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis? A. I think I had this disease for a long time, but the doctor did not find it. B. I have found the support I need from my faith and family. C. I understand this is a disease that occurs mostly in older men. D. I do not have any use for those who say this disease is going to win.
B. I have found the support I need from my faith and family.
Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis? A. I think I had this disease for a long time, but the doctor did not find it. B. I have found the support I need from my faith and family. C. I understand this is a disease that occurs mostly in older men. D. I do not have any use for those who say this disease is going to win.
B. I have found the support I need from my faith and family.
The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions? A. Exenatide acts in the same way as insulin in lowering blood glucose. B. Inject exenatide within 30 minutes before or after a meal. C. There are no precautions about taking exenatide with other medications. D. Notify your healthcare provider if you start having abdominal pain.
B. Inject exenatide within 30 minutes before or after a meal.
The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take? A. Determine if the UAP would like assistance. B. Instruct the UAP to lower the bed for safety. C. Assume care of the client immediately. D. Remain in the room to supervise the UAP.
B. Instruct the UAP to lower the bed for safety.
The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take? A. Determine if the UAP would like assistance. B. Instruct the UAP to lower the bed for safety. C. Remain in the room to supervise the UAP. D. Assume care of the client immediately.
B. Instruct the UAP to lower the bed for safety.
The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take? A. Determine if the UAP would like assistance. B. Instruct the UAP to lower the bed for safety. C. Assume care of the client immediately. D. Remain in the room to supervise the UAP.
B. Instruct the UAP to lower the bed for safety.
The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take? A. Determine if the UAP would like assistance. B. Instruct the UAP to lower the bed for safety. C. Remain in the room to supervise the UAP. D. Assume care of the client immediately.
B. Instruct the UAP to lower the bed for safety.
The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes. He has a history of depression, which is treated with paroxetine 10 mg orally every day. The client also states that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works In a chemical factory where he is occasionally exposed to fumes. The client's BMI is 28. Which of the following indicates an understanding? (Select all that apply) A. If my fasting blood sugar is less than 100 next time, I can go back to my usual eating habits. B. Making these changes will also help me avoid other chronic health conditions. C. I can never eat sugar again. D. If I make the changes we talked about, I will not get type 2 diabetes. E. If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked.
B. Making these changes will also help me avoid other chronic health conditions. E. If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked.
The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes. He has a history of depression, which is treated with paroxetine 10 mg orally every day. The client also states that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works In a chemical factory where he is occasionally exposed to fumes. The client's BMI is 28. Which of the following indicates an understanding? (Select all that apply) A. If my fasting blood sugar is less than 100 next time, I can go back to my usual eating habits. B. Making these changes will also help me avoid other chronic health conditions. C. I can never eat sugar again. D. If I make the changes we talked about, I will not get type 2 diabetes. E. If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked.
B. Making these changes will also help me avoid other chronic health conditions. E. If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked.
A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first? A. Ask the mother if any visitors were expected to arrive. B. Match ID bands of all infants and mothers on the unit. C. Determine if the newborn is in the nursery. D. Activate the lockdown procedure.
B. Match ID bands of all infants and mothers on the unit.
A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first? A. Ask the mother if any visitors were expected to arrive. B. Match ID bands of all infants and mothers on the unit. C. Determine if the newborn is in the nursery. D. Activate the lockdown procedure.
B. Match ID bands of all infants and mothers on the unit.
The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ottoxicity, which action should the PN take? A. Check for changes in vision. X B. Monitor the client's hearing. C. Observe the skin for a rash. X D. Measure the urinary output.
B. Monitor the client's hearing.
The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take? A. Check for changes in vision. B. Monitor the client's hearing. C. Observe the skin for a rash. D. Measure the urinary output.
B. Monitor the client's hearing.
The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take? A. Check for changes in vision. B. Monitor the client's hearing. C. Observe the skin for a rash. D. Measure the urinary output.
B. Monitor the client's hearing.
Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse? A. Diarrhea and flatulence. B. Muscle pain. C. Altered taste. D. Abdominal cramps.
B. Muscle pain.
The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client? A. Tenderness. B. Musical and drumlike. C. Absent sounds. D. Pain.
B. Musical and drumlike.
While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Serum blood glucose (BG) level. B. Neutrophil count. C. Serum albumin. D. Hematocrit.
B. Neutrophil count.
The nurse notes that the client's oxygen saturation is 88% on room air. What is the priority action by the nurse? The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20. A. Increase the supplemental oxygen to 15 L/min via nasal cannula. B. Notify the health care provider of the client's condition. C. Administer ibuprofen as ordered for fever. D. Obtain a sputum culture from the client. E. None F. None
B. Notify the health care provider of the client's condition
The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.) A. Keep the battery door closed during storage. B. Observe and report any ear drainage after removing the device. C. Store the device on window sill to prevent loss. D. Verify that the device is labeled with client's identification. E. Remove ear wax from the device's surface
B. Observe and report any ear drainage after removing the device. E. Remove ear wax from the device's surface
The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.) A. Keep the battery door closed during storage. B. Observe and report any ear drainage after removing the device. C. Store the device on window sill to prevent loss. D. Verify that the device is labeled with client's identification. E. Remove ear wax from the device's surface.
B. Observe and report any ear drainage after removing the device. E. Remove ear wax from the device's surface.
A male client who is admitted with bipolar disorder, manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol. 5 mg intramuscularly STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion? A. Release the client as soon as composure is regained. B. Observe for extrapyramidal symptoms, such as dystonia. C. Secure the room with padded walls and minimal furnishings. D. Provide one-on-one observation at all times.
B. Observe for extrapyramidal symptoms, such as dystonia.
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first? A. Demonstrate how to use the equipment. B. Observe how UAP obtains temperatures. C. Show UAP how to chart temperatures. D. Return the thermometer for recalibration.
B. Observe how UAP obtains temperatures.
The nurse is assessing a 3-month-old infant who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? (Select all that apply.). A. Increased temperature. B. Peripheral pallor of the skin. C. Increased respiratory rate. D. Increased pulse rate. E. Restlessness. F. Clenched fists.
B. Peripheral pallor of the skin. D. Increased pulse rate. E. Restlessness. F. Clenched fists.
In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement? A. Leave the saline lock in place and notify the charge nurse. B. Plan to apply pressure over the site for several minutes. C. Encourage the client to drink additional oral fluids. D. Prepare a warm pack to apply after removing the lock.
B. Plan to apply pressure over the site for several minutes.
In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement? A. Leave the saline lock in place and notify the charge nurse. B. Plan to apply pressure over the site for several minutes. C. Encourage the client to drink additional oral fluids. D. Prepare a warm pack to apply after removing the lock
B. Plan to apply pressure over the site for several minutes.
A male client tells the practical nurse (PN) that he is afraid of getting cancer so he plans to quit smoking cigarettes by switching to a smokeless tobacco product. How should the PN respond? A. Remind the client that he is likely to gain weight when attempting to stop smoking. B. Provide information to the client about risks associated with smokeless tobacco. C. Explain to the client that obesity is a more significant health risk than smoking. D. Encourage the client to continue with this plan to reduce his risk for cancer.
B. Provide information to the client about risks associated with smokeless tobacco.
An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take? A. Document the client's loss of memory in the record. B. Remind the client what day of the week it is. C. Encourage the client to rest during the day. D. Notify the family of the change in the client's condition.
B. Remind the client what day of the week it is.
An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take? A. Document the client's loss of memory in the record. B. Remind the client what day of the week it is. C. Encourage the client to rest during the day. D. Notify the family of the change in the client's condition.
B. Remind the client what day of the week it is.
The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.) A. Keep the battery door closed during storage. B. Remove ear wax from the device's surface. C. Verify that the device is labeled with the client's identification. D. Store the device on the window sill to prevent loss. E. Observe and report any ear drainage after removing the device.
B. Remove ear wax from the device's surface. C. Verify that the device is labeled with the client's identification. E. Observe and report any ear drainage after removing the device.
The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.) A. Keep the battery door closed during storage. B. Remove ear wax from the device's surface. C. Verify that the device is labeled with the client's identification. D. Store the device on the window sill to prevent loss. E. Observe and report any ear drainage after removing the device.
B. Remove ear wax from the device's surface. C. Verify that the device is labeled with the client's identification. E. Observe and report any ear drainage after removing the device.
A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement? A. Leaving the client alone to give them space. B. Removing any potential means of self-harm from the client's environment. C. Encouraging the client to confront their feelings of hopelessness. D. Telling the client that they should be grateful for what they have.
B. Removing any potential means of self-harm from the client's environment.
Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client? A. Wrap the bag in place for comfort. B. Secure a protective cover over the bag. C. Give directions to leave the pack in place. D. Fill the ice pack with crushed ice
B. Secure a protective cover over the bag.
A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour. Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L). A. 24-hour intake at the current infusion rate. B. Serum potassium level of 3.1 mEq/L (3.1 mmol/L). C. Gastric output of 900 mL in the last 24 hours. D. Increased blood urea nitrogen (BUN).
B. Serum potassium level of 3.1 mEq/L (3.1 mmol/L).
The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT Computerized tomography scan of the head. Which action should the nurse take first? A. Begin continuous observation for transient episodes of neurologic dysfunction. B. Start two large bore intravenous (IV) catheters and review inclusion criteria for IV fibrinolytic therapy. C. Administer aspirin to prevent further clot formation and platelet clumping. D. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
B. Start two large bore intravenous (IV) catheters and review inclusion criteria for IV fibrinolytic therapy.
A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement? A. Turn the infant onto the right side. B. Suction the oral and nasal passages. C. Give oxygen by positive pressure. D. Stimulate the infant to cry
B. Suction the oral and nasal passages.
A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement? A. Turn the infant onto the right side. B. Suction the oral and nasal passages. C. Give oxygen by positive pressure. D. Stimulate the infant to cry.
B. Suction the oral and nasal passages.
The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPS needs additional information about the turning procedure? A. An abduction pillow is placed between the client's legs when positioned. X B. The client is told to keep both legs straight and together while turning. C. The UAPS keep their backs straight and knees bent when moving the client. X D. A turning sheet is used under the client for turning and repositioning.
B. The client is told to keep both legs straight and together while turning.
The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPS needs additional information about the turning procedure? A. An abduction pillow is placed between the client's legs when positioned. B. The client is told to keep both legs straight and together while turning. C. The UAPS keep their backs straight and knees bent when moving the client. D. A turning sheet is used under the client for turning and repositioning.
B. The client is told to keep both legs straight and together while turning.
An older postoperative client has the nursing problem, "Impaired mobility related to fear of falling." Which desired outcome best directs the practical nurse's (PN) actions for this client? A. The client will use self-affirmation statements to decrease fear. B. The client will ambulate with assistance for 94 hours. C. The physical therapist will instruct the client in the use of a walker. D. The PN will place a gait belt on the client prior to ambulation.
B. The client will ambulate with assistance for 94 hours.
An older postoperative client has the nursing problem, "Impaired mobility related to fear of falling." Which desired outcome best directs the practical nurse's (PN) actions for this client? A. The client will use self-affirmation statements to decrease fear. B. The client will ambulate with assistance for q4 hours. C. The physical therapist will instruct the client in the use of a walker. D. The PN will place a gait belt on the client prior to ambulation.
B. The client will ambulate with assistance for q4 hours.
The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobulin isoenzyme (CK-MB) levels. What should the PN consider the most significant risk for this client on the second day of admission? A. The lab results indicate risk factors for transient ischemic attack (TIA), and neurological vital signs should be monitored. B. The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias. v C. The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented. X D. The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI).
B. The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias.
The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobulin isoenzyme (CK-MB) levels. What should the PN consider the most significant risk for this client on the second day of admission? A. The lab results indicate risk factors for transient ischemic attack (TIA), and neurological vital signs should be monitored. B. The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias. C. The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented. D. The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI).
B. The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias.
A client whose first child was delivered by cesarean section is 20 weeks pregnant with her second child and wishes to have a vaginal birth after cesarean (VBAC). What information is most important for the practical nurse (PN) to obtain? A. Client's intent regarding breastfeeding of the newborn. B. The type of uterine incision used for previous birth. C. History of contracting Herpes simplex virus. D. Religious preference of the client's family.
B. The type of uterine incision used for previous birth.
A client whose first child was delivered by cesarean section is 20 weeks pregnant with her second child and wishes to have a vaginal birth after cesarean (VBAC). What information is most important for the practical nurse (PN) to obtain? A. Client's intent regarding breastfeeding of the newborn. B. The type of uterine incision used for previous birth. C. History of contracting Herpes simplex virus. D. Religious preference of the client's family.
B. The type of uterine incision used for previous birth.
The practical nurse (PN) is caring for a client newly diagnosed with diabetes mellitus (DM). Which finding is an early sign of hypoglycemia? A. Polyuria. B. Tremors. C. Bradycardia. D. Difficulty swallowing.
B. Tremors
The practical nurse (PN) is caring for a client newly diagnosed with diabetes mellitus (DM). Which finding is an early sign of hypoglycemia? A. Polyuria. B. Tremors. C. Bradycardia. D. Difficulty swallowing.
B. Tremors.
An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client? A. Reduce the client's interaction with others during the day. B. Use distraction and therapeutic communication skills. C. Awaken the client earlier for daily morning care. D. Clarify reality with the client about delusional thoughts.
B. Use distraction and therapeutic communication skills.
The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement? A. Fluid volume intake and output. B. Vital sign measurement. C. Volume of peripheral pulses. D. Incisional pain scale rating.
B. Vital sign measurement
The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement? A. Fluid volume intake and output. B. Vital sign measurement. C. Volume of peripheral pulses. D. Incisional pain scale rating.
B. Vital sign measurement.
A client is being treated for chronic kidney disease (CKD). On examination, the client has elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement? A. Use a cushion when sitting. B. Weigh every morning. C. Perform a range of motion exercises. D. Document abdominal girth. E. None F. None
B. Weigh every morning.
A client is being treated for chronic kidney disease (CKD). On examination, the client has elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement? A. Use a cushion when sitting. B. Weigh every morning. C. Perform a range of motion exercises. D. Document abdominal girth. E. None
B. Weigh every morning.
The practical nurse (PN) is caring for a client who has a tracheostomy tube. After donning sterile gloves, in which sequence should the PN should implement these interventions? (Arrange from the first action on top to last on the bottom.) A: Insert sterile suction catheter in tracheostomy tube. B: Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. C: Activate suction by covering the catheter opening. D: Withdraw and rotate the catheter while suction is applied.
B: Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. A: Insert sterile suction catheter in tracheostomy tube. C: Activate suction by covering the catheter opening. D: Withdraw and rotate the catheter while suction is applied.
A nurse is teaching a group of nursing students about the components of critical thinking. Which of the following statements by a student indicates a need for further teaching? A. "Reflection is thinking about what I did and how I can improve." B. "Analysis is breaking down a complex situation into smaller parts." C. "Inference is making assumptions based on my experience." D. "Evaluation is checking the reliability and validity of information.".
C. "Inference is making assumptions based on my experience."
After the change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the Immediate attention of the PN? A. An older client whose blood pressure (BP) is 100/70 after receiving meperidine for pain related to a hip fracture. X B. A client who has pink urine draining from the indwelling urinary catheter following transurethral prostatectomy. X C. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. D. A client who has brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis.
C. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal.
After the change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the Immediate attention of the PN? A. An older client whose blood pressure (BP) is 100/70 after receiving meperidine for pain related to a hip fracture. B. A client who has pink urine draining from the indwelling urinary catheter following transurethral prostatectomy. C. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. D. A client who has brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis.
C. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal.
The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client? A. Administer prescribed PRN sleep medications. B. Encourage use of prescribed analgesic perineal sprays. C. Administer prescribed stool softener. D. Encourage breastfeeding to promote uterine involution.
C. Administer prescribed stool softener.
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take? A. Administer the medication and alert the charge nurse. B. Hold the medication and document cardiac assessment. C. Administer the medication and document the heart rate. D. Hold the medication and recheck the heart rate in 1 hour.
C. Administer the medication and document the heart rate.
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take? A. Administer the medication and alert the charge nurse. B. Hold the medication and document cardiac assessment. C. Administer the medication and document the heart rate. D. Hold the medication and recheck the heart rate in 1 hour.
C. Administer the medication and document the heart rate.
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this, what action should the PN take? A. Administer the medication and alert the charge nurse. B. Hold the medication and document cardiac assessment. C. Administer the medication and document the heart rate. D. Hold the medication and recheck the heart rate in 1 hour.
C. Administer the medication and document the heart rate.
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this, what action should the PN take? A. Administer the medication and alert the charge nurse. B. Hold the medication and document cardiac assessment. C. Administer the medication and document the heart rate. D. Hold the medication and recheck the heart rate in 1 hour.
C. Administer the medication and document the heart rate.
The practical nurse (PN) is assisting the recreational director of a long-term care facility in planning outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity should the PN suggest that meets the physical and social needs of these residents? A. A picnic in the park. B. An outdoor concert. C. An outdoor game of balloon volleyball. D. A tea party in the courtyard.
C. An outdoor game of balloon volleyball.
The practical nurse (PN) is assisting the recreational director of a long-term care facility in planning outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity should the PN suggest that meets the physical and social needs of these residents? A. A picnic in the park. B. An outdoor concert. C. An outdoor game of balloon volleyball. D. A tea party in the courtyard.
C. An outdoor game of balloon volleyball.
A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine. Which instruction should the nurse provide? A. Any level of fever is serious and should be reported right away. B. Keep the child home from daycare for the next two days. C. Apply a cool pack to the injection site to reduce discomfort. D. Chewable children's aspirin will help prevent inflammation.
C. Apply a cool pack to the injection site to reduce discomfort.
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take? A. Review the client's serum calcium level. B. Administer an as-needed (PRN) antianxiety medication. C. Ask the UAP to take the blood pressure in the other arm. D. Tell the UAP to use a different sphygmomanometer.
C. Ask the UAP to take the blood pressure in the other arm.
Which action should the practical nurse (PNA) prioritize for postoperative patient with a PCA (Patient- Controlled Analgesia) machine? A. Coffee ground secretions drainage via nasogastric tube. B. Nasogastric tube suctioning. C. Assessing pain management response. D. Ineffective pain management report:
C. Assessing pain management response.
Which action should the practical nurse (PNA) prioritize for postoperative patient with a PCA (Patient- Controlled Analgesia) machine? A. Coffee ground secretions drainage via nasogastric tube. B. Nasogastric tube suctioning. C. Assessing pain management response. D. Ineffective pain management report:
C. Assessing pain management response.
The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge take? A. Deny the medication aide's request to leave before all medications are given. B. Ask each unlicensed assistive personnel (UAP) to give medications to their assigned residents. C. Assign the remainder of medication administration to another PN who is performing treatments. D. Document why all the medications were not given to each of the residents.
C. Assign the remainder of medication administration to another PN who is performing treatments.
The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation? A. Deny the medication aide's request to leave before all medications are given. B. Ask each unlicensed assistive personnel (UAP) to give medications to their assigned residents. C. Assign the remainder of medication administration to another PN who is performing treatments. D. Document why all the medications were not given to each of the residents.
C. Assign the remainder of medication administration to another PN who is performing treatments.
The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation? A. Deny the medication aide's request to leave before all medications are given. B. Ask each unlicensed assistive personnel (UAP) to give medications to their assigned residents. C. Assign the remainder of medication administration to another PN who is performing treatments. D. Document why all the medications were not given to each of the residents.
C. Assign the remainder of medication administration to another PN who is performing treatments.
The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement? A. Inspect for sacral edema. B. Measure urinary output. C. Auscultate all lung fields. D. Check mental acuity. E. Check mental acuity.
C. Auscultate all lung fields.
The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement? A. Inspect for sacral edema. B. Measure urinary output. C. Auscultate all lung fields. D. Check mental acuity. E. Check mental acuity.
C. Auscultate all lung fields.
The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds (4,581 grams). The infant is jittery and has a heel stick glucose level of 40 mg/dL (2.2 mmol/L) 30 minutes after birth. Based on this information, which intervention should the practical nurse (PN) implement first? Reference range: Blood glucose neonate: [30 to 60 mg/dL or 1.7 to 3.3 mmol/L] A. Repeat the heel stick for glucose in one hour. B. Offer nipple feedings of 10% dextrose. C. Begin frequent feedings of breast milk or formula. D. Assess for signs of hypocalcemia.
C. Begin frequent feedings of breast milk or formula.
The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds (4,581 grams). The infant is jittery and has a heel stick glucose level of 40 mg/dL (2.2 mmol/_) 30 minutes after birth. Based on this information, which intervention should the practical nurse (PN) implement first? Reference range: Blood glucose neonate: [30 to 60 mg/dL or 1.7 to 3.3 mmol/L] A. Repeat the heel stick for glucose in one hour. X B. Offer nipple feedings of 10% dextrose. X C. Begin frequent feedings of breast milk or formula. D. Assess for signs of hypocalcemia.
C. Begin frequent feedings of breast milk or formula.
The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first? A. Heart sounds. B. Chest pain. C. Bilateral lung sounds. D. Mood and affect. E. Mood and affect.
C. Bilateral lung sounds.
The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first? A. Heart sounds. B. Chest pain. C. Bilateral lung sounds. D. Mood and affect. E. Mood and affect.
C. Bilateral lung sounds.
A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects? A. Tachycardia B. Hyperglycemia C. Bronchospasm D. Hyperkalemia.
C. Bronchospasm
The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take? A. Tell the pharmacy to send an accurate child's dosage. B. Ask another nurse if adult dosages are ever given to children. C. Call the healthcare provider and clarify the prescription. D. Request verification of the prescription by the charge nurse. E. Request verification of the prescription by the charge nurse.
C. Call the healthcare provider and clarify the prescription.
The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take? A. Tell the pharmacy to send an accurate child's dosage. B. Ask another nurse if adult dosages are ever given to children. C. Call the healthcare provider and clarify the prescription. D. Request verification of the prescription by the charge nurse. E. Request verification of the prescription by the charge nurse.
C. Call the healthcare provider and clarify the prescription.
A male client with a chronic medical condition tells the practical nurse (PN) that he wants no heroics to prolong his life if anything should happen to him. Which action should the PN take? A. Place a "Do Not Resuscitate" sign outside the client's door and at the bedside. X B. Reassure the client that life-saving measures will not be taken without consent. C. Complete an advance directive form and place it in the medical record. D. Notify the client's healthcare provider of the client's wishes as soon as possible.
C. Complete an advance directive form and place it in the medical record.
A male client with a chronic medical condition tells the practical nurse (PN) that he wants no heroics to prolong his life if anything should happen to him. Which action should the PN take? A. Place a "Do Not Resuscitate" sign outside the client's door and at the bedside. B. Reassure the client that life-saving measures will not be taken without consent. C. Complete an advance directive form and place it in the medical record. D. Notify the client's healthcare provider of the client's wishes as soon as possible.
C. Complete an advance directive form and place it in the medical record.
An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A. Addiction. B. Phobia. C. Compulsion. D. Obsession.
C. Compulsion.
The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take? A. Instruct the UAP to report any abnormal findings. B. Remind the UAP to check the client's pulse volume C. Demonstrate the correct pulse site to the UAP D. Confirm the accuracy of the pulse rate obtained by the UAP
C. Demonstrate the correct pulse site to the UAP
A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery. Which action is most important for the nurse to implement? A. Discuss the character of labor from endogenous vs. exogenous oxytocin. B. Ask the healthcare provider to discuss the issue with the client. C. Discuss alternative ways to support the client's birth plan. D. Explain the indications for induction related to post-term pregnancy.
C. Discuss alternative ways to support the client's birth plan.
A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure? A. Nosocomial transmission in the medical area. B. Food contamination from flood waters. C. Drinking water contaminated by sewage. D. Close living quarters at evacuation centers.
C. Drinking water contaminated by sewage.
A client reports experiencing numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) prioritize reporting to the healthcare provider? A. Hematocrit B. Albumin and protein levels C. Electrolytes D. White blood cell count (WBC)
C. Electrolytes
An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take? A. Request that the man get up and leave. B. Report the incident to the family. C. Exit the room and quietly close the door. D. Ask when the nurse should return.
C. Exit the room and quietly close the door.
An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take? A. Request that the man get up and leave. B. Report the incident to the family. C. Exit the room and quietly close the door. D. Ask when the nurse should return.
C. Exit the room and quietly close the door.
An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take? A. Request that the man get up and leave. B. Report the incident to the family. C. Exit the room and quietly close the door. D. Ask when the nurse should return.
C. Exit the room and quietly close the door.
Two weeks after cast application, a client with a fractured right arm returns to the clinic for evaluation. The client seems upset and tells the practical nurse (PN) that the healthcare provider said a callus has formed on the bone. Which action should the PN take? A. Prepare to assist in applying a new cast to reduce pressure points. B. Report the client's concern to the healthcare provider. C. Explain this is an expected part of the bone healing process. D. Teach the client strategies to prevent further calluses.
C. Explain this is an expected part of the bone healing process.
Two weeks after cast application, a client with a fractured right arm returns to the clinic for evaluation. The client seems upset and tells the practical nurse (PN) that the healthcare provider said a callus has formed on the bone. Which action should the PN take? A. Prepare to assist in applying a new cast to reduce pressure points. X B. Report the client's concern to the healthcare provider. X C. Explain this is an expected part of the bone healing process. v D. Teach the client strategies to prevent further calluses.
C. Explain this is an expected part of the bone healing process. v
A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A. Explain to the family that they must accept their mother's decision. B. Discuss success of clinical trials and ask the client to consider participating for one month. C. Explore the client's decision to refuse treatment and offer support. D. Ask the client with her children present if she fully understands the decision she has made.
C. Explore the client's decision to refuse treatment and offer support.
A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the practical nurse (PN) implement? A. Elevate the leg above the heart. B. Massage the calf and foot. C. Extend the leg and flex the foot. D. Check the pedal pulse in the affected leg.
C. Extend the leg and flex the foot.
A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the practical nurse (PN) implement? A. Elevate the leg above the heart. B. Massage the calf and foot. C. Extend the leg and flex the foot. D. Check the pedal pulse in the affected leg.
C. Extend the leg and flex the foot.
For the past six hours, a postoperative male client has refused pain medication because he believed that he could "tough it out." When an opioid analgesic is administered, the client has difficulty obtaining a satisfactory level of comfort. Which action is best for the practical nurse (PN) to use in assisting this client to deal with his pain? A. Dim the lights in the room and close the door. B. Turn the television on to the client's favorite show. C. Guide the client through slow, rhythmic breathing.D. Obtain a prescription for a higher dose of pain medication.
C. Guide the client through slow, rhythmic breathing.
For the past six hours, a postoperative male client has refused pain medication because he believed that he could "tough it out." When an opioid analgesic is administered, the client has difficulty obtaining a satisfactory level of comfort. Which action is best for the practical nurse (PN) to use in assisting this client to deal with his pain? A. Dim the lights in the room and close the door. B. Turn the television on to the client's favorite show. C. Guide the client through slow, rhythmic breathing. D. Obtain a prescription for a higher dose of pain medication.
C. Guide the client through slow, rhythmic breathing.
The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermittent suction. The client reports dizziness and tingling in the digits. Which assessment finding by the PN should be reported to the healthcare provider? A. Regular heart rate of 100 beats per minute on telemetry. X B. Hypoactive bowel sounds on assessment. C. Heart rate of 90 beats per minute with premature ventricular contractions (PVCS) noted on telemetry. D. Hyperactive bowel sounds on assessment.
C. Heart rate of 90 beats per minute with premature ventricular contractions (PVCS) noted on telemetry.
The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermittent suction. The client reports dizziness and tingling in the digits. Which assessment finding by the PN should be reported to the healthcare provider? A. Regular heart rate of 100 beats per minute on telemetry. B. Hypoactive bowel sounds on assessment. C. Heart rate of 90 beats per minute with premature ventricular contractions (PVCS) noted on telemetry. D. Hyperactive bowel sounds on assessment.
C. Heart rate of 90 beats per minute with premature ventricular contractions (PVCS) noted on telemetry.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A. Ketonuria. B. Peripheral edema. C. Hypokalemia. D. Elevated blood pressure.
C. Hypokalemia.
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event? A. Domestic violence assistance. B. Blood pressure screening. C. Immunizations that are available. D. Outreach for support group information.
C. Immunizations that are available.
The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has continuous feeding via a gastrostomy tube (GT). Which instruction is most important for the PN to emphasize? A. Report any drainage observed around the GT insertion site. B. Use plenty of pillows to position the client on the side after bathing. C. Keep the head of the bed raised while the tube feeding is infusing. D. Raise the entire bed while bathing the client to reduce back strain.
C. Keep the head of the bed raised while the tube feeding is infusing.
The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has continuous feeding via a gastrostomy tube (GT). Which instruction is most important for the PN to emphasize? A. Report any drainage observed around the GT insertion site. B. Use plenty of pillows to position the client on the side after bathing. C. Keep the head of the bed raised while the tube feeding is infusing. D. Raise the entire bed while bathing the client to reduce back strain.
C. Keep the head of the bed raised while the tube feeding is infusing.
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take? A. Refer client to the social worker for support therapy. B. Encourage client to implement relaxation techniques. C. Leave the client's room and return later in the day. D. Explain that insulin is a life-saving drug for the client. E. Explain that insulin is a life-saving drug for the client.
C. Leave the client's room and return later in the day.
After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)? A. Procure platelet products from the blood bank. B. Titrate oxygen to the prescribed parameters. C. Monitor an intravenous infusion rate on an established schedule. D. Insert a urinary catheter for an uncomplicated client.
C. Monitor an intravenous infusion rate on an established schedule.
In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting- Which intervention is best for the PN to implement? A. Encourage the child to drink adequate amounts of cool, clear liquids. X B. Instruct the mother to play with the child for stimulation and distraction. X C. Monitor the child's oxygen saturation level via pulse oximeter. v D. Administer a dose of acetaminophen as needed (PRN) per prescription.
C. Monitor the child's oxygen saturation level via pulse oximeter.
In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting- Which intervention is best for the PN to implement? A. Encourage the child to drink adequate amounts of cool, clear liquids. B. Instruct the mother to play with the child for stimulation and distraction. C. Monitor the child's oxygen saturation level via pulse oximeter. D. Administer a dose of acetaminophen as needed (PRN) per prescription.
C. Monitor the child's oxygen saturation level via pulse oximeter.
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Serum sodium level. B. Hematocrit. C. Neutrophil count. D. Platelet count.
C. Neutrophil count.
A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take? A. Encourage the client to continue with the scheduled surgery. B. Document that the client has expressed concerns about the surgery. C. Notify the charge nurse of the client's concerns about surgery. D. Remind the client that the consent has already been obtained.
C. Notify the charge nurse of the client's concerns about surgery.
A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take? • A. Encourage the client to continue with the scheduled surgery. B. Document that the client has expressed concerns about the surgery. C. Notify the charge nurse of the client's concerns about surgery. D. Remind the client that the consent has already been obtained.
C. Notify the charge nurse of the client's concerns about surgery.
A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care? A. Neurology unit supervisor. B. Adult nurse practitioner. C. Nurse case manager. D. Risk management nurse.
C. Nurse case manager.
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first? A. Show the UAP how to chart temperatures. B. Return the thermometer for recalibration. C. Observe how the UAP obtains temperatures. D. Demonstrate how to use the equipment.
C. Observe how the UAP obtains temperatures.
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first? A. Show the UAP how to chart temperatures. B. Return the thermometer for recalibration. C. Observe how the UAP obtains temperatures. D. Demonstrate how to use the equipment
C. Observe how the UAP obtains temperatures.
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long-term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first? A. Show the UAP how to chart temperatures. B. Return the thermometer for recalibration. C. Observe how the UAP obtains temperatures. D. Demonstrate how to use the equipment.
C. Observe how the UAP obtains temperatures.
A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem? A. Nausea. B. Fatigue. C. Pain when eating. D. Altered taste sensation.
C. Pain when eating.
The PN Identifies that the client is having a tonic-clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/min. The PN calls for help and 2 other PNs enter the room. Which three actions will the PN anticipate taking next? A. Begin chest compressions. B. Watch the seizure activity and document the time and client movement. C. Place pillows around the bed rails to provide padding. D. Stop the IV fluids. E. Increase the supplemental oxygen to 10 L/min via nasal cannula. F. Manually ventilate the client with a bag-valve mask.
C. Place pillows around the bed rails to provide padding. E. Increase the supplemental oxygen to 10 L/min via nasal cannula. F. Manually ventilate the client with a bag-valve mask.
The PN Identifies that the client is having a tonic-clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/min. The PN calls for help and 2 other PNs enter the room. Which three actions will the PN anticipate taking next? A. Begin chest compressions. B. Watch the seizure activity and document the time and client movement. C. Place pillows around the bed rails to provide padding. D. Stop the IV fluids. E. Increase the supplemental oxygen to 10 L/min via nasal cannula. F. Manually ventilate the client with a bag-valve mask.
C. Place pillows around the bed rails to provide padding. E. Increase the supplemental oxygen to 10 L/min via nasal cannula. F. Manually ventilate the client with a bag-valve mask.
The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit. The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier. Which response should the nurse provide? A. A bottle is generally much better than using a pacifier. B. The bottle will assist in preventing thumb sucking. C. Prolonged bottle use can increase the risk for cavities. D. Using milk rather than juice helps to avoid tooth decay.
C. Prolonged bottle use can increase the risk for cavities.
A nurse is administering protamine sulfate to a client who has received an overdose of heparin. What are some important nursing considerations for this medication? *. A. Protamine sulfate should be given slowly intravenously within 30 minutes of heparin administration. B. Protamine sulfate should be given rapidly intramuscularly within 60 minutes of heparin administration. C. Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration. D. Protamine sulfate should be given rapidly intramuscularly within 30 minutes of heparin administration.
C. Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration.
The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding? A. Consensual pupillary constriction present. B. Nystagmus present with pupillary focus. C. Pupils reactive to accommodation. D. Peripheral vision intact.
C. Pupils reactive to accommodation.
The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding? A. Consensual pupillary constriction present. B. Nystagmus present with pupillary focus. C. Pupils reactive to accommodation. D. Peripheral vision intact.
C. Pupils reactive to accommodation.
The practical nurse (PN) identifies which client behaviors that can increase the client's risk for hypertension? (Select all that apply.) A. Drinks a protein supplement for breakfast every day. B. Eats eight ounces of nonfat yogurt for lunch daily. C. Regularly selects salty snacks to eat in the evening. D. Walks briskly for two miles every day after work. E. Chews tobacco while playing baseball every weekend.
C. Regularly selects salty snacks to eat in the evening. E. Chews tobacco while playing baseball every weekend.
The practical nurse (PN) identifies which client behaviors that can increase the client's risk for hypertension? (Select all that apply.) A. Drinks a protein supplement for breakfast every day. B. Eats eight ounces of nonfat yogurt for lunch daily. C. Regularly selects salty snacks to eat in the evening. D. Walks briskly for two miles every day after work. E. Chews tobacco while playing baseball every weekend.
C. Regularly selects salty snacks to eat in the evening. E. Chews tobacco while playing baseball every weekend.
A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority? A. Administer a PRN dose of acetaminophen. B. Encourage the client to drink fluids. C. Report the findings to the charge nurse. D. Monitor the client's serum lipid levels.
C. Report the findings to the charge nurse.
A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority? A. Administer a PRN dose of acetaminophen. B. Encourage the client to drink fluids. C. Report the findings to the charge nurse. D. Monitor the client's serum lipid levels.
C. Report the findings to the charge nurse.
A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority? A. Administer a PRN dose of acetaminophen. B. Encourage the client to drink fluids. C. Report the findings to the charge nurse. D. Monitor the client's serum lipid levels.
C. Report the findings to the charge nurse.
The practical nurse (PN) is assisting with the preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement? A. Determine if this is the first indwelling catheter the client has had. X B. Ask the client if he finished the bowel sterilization prescription. X C. Review the client's expectations of elimination after surgery. D. Verify that the client had nothing by mouth (NPO) for the past 24 hours.
C. Review the client's expectations of elimination after surgery.
The practical nurse (PN) is assisting with the preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement? A. Determine if this is the first indwelling catheter the client has had. B. Ask the client if he finished the bowel sterilization prescription. C. Review the client's expectations of elimination after surgery. D. Verify that the client had nothing by mouth (NPO) for the past 24 hours.
C. Review the client's expectations of elimination after surgery.
A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now. How should the PN respond? A. Explain that the healthcare provider probably prescribed a different medication while he is hospitalized. B. Tell the client that he is probably confused since being hospitalized tends to disorient clients. C. Tell the client that the PN will verify that the dispensed medication is the valid prescription. D. Explain that the pharmacy often substitutes generic equivalents for more expensive brands.
C. Tell the client that the PN will verify that the dispensed medication is the valid prescription.
A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now. How should the PN respond? A. Explain that the healthcare provider probably prescribed a different medication while he is hospitalized. B. Tell the client that he is probably confused since being hospitalized tends to disorient clients. C. Tell the client that the PN will verify that the dispensed medication is the valid prescription. D. Explain that the pharmacy often substitutes generic equivalents for more expensive brands.
C. Tell the client that the PN will verify that the dispensed medication is the valid prescription.
A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now. How should the PN respond? A. Explain that the healthcare provider probably prescribed a different medication while he is hospitalized. B. Tell the client that he is probably confused since being hospitalized tends to disorient clients. C. Tell the client that the PN will verify that the dispensed medication is the valid prescription. D. Explain that the pharmacy often substitutes generic equivalents for more expensive brands.
C. Tell the client that the PN will verify that the dispensed medication is the valid prescription.
The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action? A. The client is lying in a supine position in the bed. B. The cannula is pressed snugly against the client's cheeks. C. The flowmeter shows 1 liter of oxygen being delivered. D. There is no humidifier attached to the delivery system.
C. The flowmeter shows 1 liter of oxygen being delivered.
The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action? A. The client is lying in a supine position in the bed. B. The cannula is pressed snugly against the client's cheeks. C. The flowmeter shows 1 liter of oxygen being delivered. D. There is no humidifier attached to the delivery system.
C. The flowmeter shows 1 liter of oxygen being delivered.
The client is a 26-year-old female with acute appendicitis. She has a 12-year history of type 1 diabetes and no other significant medical history. The appendectomy was completed without Issue, and the client will be admitted to the surgical floor to recover. The PN prepares to give 2 units of Insulin lispro. What should the PN double-check with a second nurse? Select all that apply. A. The sliding scale insulin lispro order B. The type of insulin to be administered C. The insulin vial for color and clarity D. The dose of insulin drawn up in the syringe E. The expiration date on the insulin vial F. The history and physical with the diabetes diagnosis listed G. The insulin concentration H. The site for the insulin administration
C. The insulin vial for color and clarity D. The dose of insulin drawn up in the syringe E. The expiration date on the insulin vial G. The insulin concentration
The client is a 26-year-old female with acute appendicitis. She has a 12-year history of type 1 diabetes and no other significant medical history. The appendectomy was completed without Issue, and the client will be admitted to the surgical floor to recover. The PN prepares to give 2 units of Insulin lispro. What should the PN double-check with a second nurse? Select all that apply. A. The sliding scale insulin lispro order B. The type of insulin to be administered C. The insulin vial for color and clarity D. The dose of insulin drawn up in the syringe E. The expiration date on the insulin vial F. The history and physical with the diabetes diagnosis listed G. The insulin concentration H. The site for the insulin administration
C. The insulin vial for color and clarity D. The dose of insulin drawn up in the syringe E. The expiration date on the insulin vial G. The insulin concentration
The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first? A. The six-hour-old with a large sacral "stork bite". B. The two-day-old with negative Ortolani's sign. C. The ten-hour-old with circumoral cyanosis. D. The one-day-old with a positive Babinski's reflex.
C. The ten-hour-old with circumoral cyanosis.
The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first? A. The six-hour-old with a large sacral "stork bite". B. The two-day-old with negative Ortolani's sign. C. The ten-hour-old with circumoral cyanosis. D. The one-day-old with a positive Babinski's reflex.
C. The ten-hour-old with circumoral cyanosis.
Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.) A. Height and weight of client prior to admission. B. History of pain medication use during the past year. C. Time of last administration of pain medication. D. Client's pain rating on a scale of 1 to 10. E. Effectiveness of last pain medication administered.
C. Time of last administration of pain medication. D. Client's pain rating on a scale of 1 to 10. E. Effectiveness of last pain medication administered.
Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.) A. Height and weight of client prior to admission. B. History of pain medication use during the past year. C. Time of last administration of pain medication. D. Client's pain rating on a scale of 1 to 10. E. Effectiveness of last pain medication administered.
C. Time of last administration of pain medication. D. Client's pain rating on a scale of 1 to 10. E. Effectiveness of last pain medication administered.
The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat? A. Avocados and cheese. B. Fresh fruits. C. Yogurt or buttermilk. D. Green leafy vegetables.
C. Yogurt or buttermilk.
A client with diabetic ketoacidosis (DKA) is receiving regular insulin. Which action should the practical nurse (PN) implement to evaluate the effectiveness of the insulin dosage? A. Smell the client's breath for resolution of a fruity odor. B. Determine the client's orientation to time and space. C. Measure the client's urinary output for an increased volume. D. Check fingerstick blood glucose for a decrease in the level.
Check fingerstick blood glucose for a decrease in the level.
The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound] A. Wheeze. B. Rhonchi. C. Stridor. D. Fine crackles.
Choice A: Explanation: Based on the provided audio clip, the sound heard is a high-pitched, continuous, musical sound. This sound is characteristic of wheezing, which is caused by the narrowing of the airways due to inflammation, bronchoconstriction, or the presence of mucus. Wheezing is commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. Choice B: Rhonchi: Rhonchi are low-pitched, coarse, ratling sounds that typically indicate the presence of mucus or fluid in the larger airways. Rhonchi are often heard in conditions such as pneumonia or bronchitis, but they are different from the high-pitched wheezing sound heard in the audio clip. Choice C: Stridor: Stridor is a high-pitched, harsh, and crowing sound that is heard during inspiration. It is often associated with upper airway obstruction, such as in cases of croup, epiglottitis, or a foreign body obstruction. The sound in the audio clip does not match the characteristics of stridor. Choice D: Fine crackles: Fine crackles are discontinuous, high-pitched, and brief sounds that are typically heard during inspiration. They are often described as "velcro-like" or "rice crispies" and are associated with conditions such as pulmonary fibrosis or congestive heart failure. The sound in the audio clip does not resemble fine crackles.
A client asks a nurse about the differences between major depressive disorder (MDD) and dysthymia. Which of the following responses by the nurse is accurate? A. "MDD is less severe than dysthymia but lasts for at least 2 years.". B. "Dysthymia is characterized by alternating episodes of mania and depression.". C. "Unlike MDD, dysthymia does not impair social or occupational functioning.". D. "Dysthymia is chronic and lasts for at least 2 years, but is less severe than MDD.". E. Anxiety.
D. "Dysthymia is chronic and lasts for at least 2 years, but is less severe than MDD.".
A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching? A. "I will wash the patient's left side first, then move to the right side.". B. "I will wash the patient's right side first, then move to the left side.". C. "I will wash both sides of the patient at the same time, starting from the head and moving down.". D. "I will ask the patient which side they prefer to wash first, then follow their preference.".
D. "I will ask the patient which side they prefer to wash first, then follow their preference.".
A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and is unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client? A. "Come into the recreation area. We have your favorite card game and I will play it with you." B. "Why do you want to stay in your room today?" C. "I know you are sad about not seeing your family as often, but they are visiting as much as they can." D. "May I sit with you for a while?"
D. "May I sit with you for a while?"
A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and is unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client? A. "Come into the recreation area. We have your favorite card game and I will play it with you." X B. "Why do you want to stay in your room today?" X C. "I know you are sad about not seeing your family as often, but they are visiting as much as they can." X D. "May I sit with you for a while?"
D. "May I sit with you for a while?"
A nurse is administering tetracycline to a client who has acne vulgaris. The client tells the nurse that he usually takes calcium supplements with his meals. How should the nurse respond? A. "You can continue to take calcium supplements as long as you take them with food.". B. "You should avoid taking calcium supplements while you are on tetracycline therapy.". C. "You can take calcium supplements with tetracycline as long as you drink plenty of water.". D. "You should take calcium supplements at least 2 hours before or after tetracycline.".
D. "You should take calcium supplements at least 2 hours before or after tetracycline.".
The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior? A. Sinus tachycardia. B. Menstrual cramps. C. Hypertension. D. Amenorrhea. E. Amenorrhea.
D. Amenorrhea
Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly? A. Leg exercises not performed because of placement of antiembolism hose. B. Antiembolism stockings removed hourly during leg exercises. C. Client demonstrates ability to move all extremities well. D. Antiembolism stockings on, leg exercises performed hourly.
D. Antiembolism stockings on, leg exercises performed hourly.
A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. Which response should the practical nurse (PN) make? A. Explain that all of the staff are doing the best they can. B. Tell the daughter to talk with the unit's nurse manager. C. Reassure the daughter that the mother will get better care. D. Ask for a description of what happened during the night.
D. Ask for a description of what happened
The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use? A. Observe body language and movement. B. Identify effective pain relief measures. C. Provide a numeric pain scale. D. Ask the client to describe the pain.
D. Ask the client to describe the pain.
The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents? A. Whatever the parents decide, the staff will be available to support the decision. B. The child's prognosis will not develop complications if surgery is delayed. C. Some children do outgrow this type of problem and waiting may be beneficial. D. Ask the parents to explain what they understand about the child's diagnosis.
D. Ask the parents to explain what they understand about the child's diagnosis.
The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents? A. Whatever the parents decide, the staff will be available to support the decision. B. The child's prognosis will not develop complications if surgery is delayed C. Some children do outgrow this type of problem and waiting may be beneficial. D. Ask the parents to explain what they understand about the child's diagnosis.
D. Ask the parents to explain what they understand about the child's diagnosis.
In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed. Which action should the PN implement? A. Apply gloves and empty the drainage bag B. Remove the looped tubing from the bed C. Measure the urinary output in the bag D. Attach the drainage bag to the bed frame
D. Attach the drainage bag to the bed frame
In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed. Which action should the PN implement? A. Apply gloves and empty the drainage bag. B. Remove the looped tubing from the bed. C. Measure the urinary output in the bag. D. Attach the drainage bag to the bed frame.
D. Attach the drainage bag to the bed frame.
In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed. Which action should the PN implement? A. Apply gloves and empty the drainage bag. B. Remove the looped tubing from the bed. C. Measure the urinary output in the bag. D. Attach the drainage bag to the bed frame.
D. Attach the drainage bag to the bed frame.
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review? A. Serum calcium B. Hemoglobin and hematocrit C. White blood cell count (WBC) D. Blood urea nitrogen (BUN) and creatinine
D. Blood urea nitrogen (BUN) and creatinine
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review? A. Serum calcium X B. Hemoglobin and hematocrit X C. White blood cell count (WBC) X D. Blood urea nitrogen (BUN) and creatinine
D. Blood urea nitrogen (BUN) and creatinine
The practical nurse (PN) is monitoring the neurological vital signs of a client with a recently closed head injury. Which vital sign trends indicate increased intracranial pressure (ICP) and should be reported to the charge nurse? A. Heart rate above 110 beats/minute, elevated respiratory rate, and hypotension. B. Bounding pulse rate, groaning respiratory effort, and elevated blood pressure. C. Thready rapid pulse, trembling, perspiration, weakness, and irritability. D. Bradycardia, irregular respiratory patterns, widening pulse pressure.
D. Bradycardia, irregular respiratory patterns, widening pulse pressure.
The practical nurse (PN) is monitoring the neurological vital signs of a client with a recently closed head injury. Which vital sign trends indicate increased intracranial pressure (ICP) and should be reported to the charge nurse? A. Heart rate above 110 beats/minute, elevated respiratory rate, and hypotension. B. Bounding pulse rate, groaning respiratory effort, and elevated blood pressure. X C. Thready rapid pulse, trembling, perspiration, weakness, and irritability. X D. Bradycardia, irregular respiratory patterns, widening pulse pressure.
D. Bradycardia, irregular respiratory patterns, widening pulse pressure.
A client with diabetic ketoacidosis (DKA) is receiving regular insulin. Which action should the practical nurse (PN) implement to evaluate the effectiveness of the insulin dosage? A. Smell the client's breath for resolution of a fruity odor. B. Determine the client's orientation to time and space. C. Measure the client's urinary output for an increased volume. D. Check fingerstick blood glucose for a decrease in the level.
D. Check fingerstick blood glucose for a decrease in the level.
A client with diabetic ketoacidosis (DKA) is receiving regular insulin. Which action should the practical nurse (PN) implement to evaluate the effectiveness of the insulin dosage? A. Smell the client's breath for resolution of a fruity odor. B. Determine the client's orientation to time and space. C. Measure the client's urinary output for an increased volume. D. Check fingerstick blood glucose for a decrease in the level.
D. Check fingerstick blood glucose for a decrease in the level.
The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen? A. Overconcern about appearance can be harmful. B. Playpens provide a sense of security for the child. C. Playpens provide a safe environment for a toddler. D. Children need time to actively explore their environment.
D. Children need time to actively explore their environment.
The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen? A. Overconcern about appearance can be harmful. B. Playpens provide a sense of security for the child. C. Playpens provide a safe environment for a toddler. D. Children need time to actively explore their environment.
D. Children need time to actively explore their environment.
An unlicensed assistive personnel (UAP) removes isolation attire before leaving the room of a client who requires droplet precautions. Which action should the PN take? A. Instruct the UAP in correct removal of contaminated gloves. B. Remind the UAP to remove the gown before removing gloves. C. Advise the UAP to remove the mask after exiting the room. D. Confirm that the UAP has correctly handled the isolation attire.
D. Confirm that the UAP has correctly handled the isolation attire.
An unlicensed assistive personnel (UAP) removes isolation attire before leaving the room of a client who requires droplet precautions. Which action should the PN take? A. Instruct the UAP in correct removal of contaminated gloves. B. Remind the UAP to remove the gown before removing gloves. C. Advise the UAP to remove the mask after exiting the room. D. Confirm that the UAP has correctly handled the isolation attire.
D. Confirm that the UAP has correctly handled the isolation attire.
An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first? A. Carry on with surgical preparation of the client without a signed informed consent. B. Ask the man's friend to sign the informed consent since the client is unresponsive. C. Notify the unit manager that an emergency court order is needed to allow surgery. D. Continue to provide life support until a thorough search for a guardian is completed.
D. Continue to provide life support until a thorough search for a guardian is completed.
The mother of a young child with eczema asks about the type of clothing that is best for her child's comfort. Which choice should the practical nurse (PN) recommend? A. Polyester. B. Silk. C. Rayon. D. Cotton.
D. Cotton.
The mother of a young child with eczema asks about the type of clothing that is best for her child's comfort. Which choice should the practical nurse (PN) recommend? A. Polyester. B. Silk. C. Rayon. D. Cotton.
D. Cotton.
While changing the dressing of a client who is immobile, the practical nurse (PN) observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the PN should evaluate which of the client's laboratory values? A. C-reactive protein level. B. Serum blood glucose (BG) level. C. Serum albumin. D. Culture for sensitive organisms.
D. Culture for sensitive organisms.
While changing the dressing of a client who is immobile, the practical nurse (PN) observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the PN should evaluate which of the client's laboratory values? A. C-reactive protein level. B. Serum blood glucose (BG) level. C. Serum albumin. D. Culture for sensitive organisms.
D. Culture for sensitive organisms.
When the practical nurse (PN) atempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make? A. A. "You must ambulate to avoid complications which could cause more discomfort than ambulating." B. B. "I know you feel angry about the pain of ambulation, but this is a necessary part of getting well." C. C. "Your healthcare provider has left specific instructions to ambulate on the first postoperative day." D. D. "I will be back in 30 minutes to help you get out of bed and walk around the room today."
D. D. "I will be back in 30 minutes to help you get out of bed and walk around the room today."
A male client with acute kidney injury (AKI) is scheduled for his first hemodialysis treatment and asks the practical nurse (PN) how the treatments will be evaluated for effectiveness. The PN explains that blood samples will be collected for analysis. Which laboratory value should the PN explain as the best indicator of each hemodialysis? A. Elevated potassium. B. Decreased calcium. C. Lowered hemoglobin. D. Decreased creatinine.
D. Decreased creatinine.
A male client with acute kidney injury (AKI) is scheduled for his first hemodialysis treatment and asks the practical nurse (PN) how the treatments will be evaluated for effectiveness. The PN explains that blood samples will be collected for analysis. Which laboratory value should the PN explain as the best indicator of each hemodialysis? A. Elevated potassium. B. Decreased calcium. C. Lowered hemoglobin. D. Decreased creatinine.
D. Decreased creatinine.
A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first? A. Explain the daily schedule of unit activities. B. Review client rights of hospitalization. C. Offer the client an as-needed (PRN) medication. D. Describe the functions of the practical nurse (PN).
D. Describe the functions of the practical nurse (PN).
A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first? A. Explain the daily schedule of unit activities. B. Review client rights of hospitalization. C. Offer the client an as-needed (PRN) medication. D. Describe the functions of the practical nurse (PN).
D. Describe the functions of the practical nurse (PN).
A nurse is establishing a therapeutic relationship with a client with anxiety disorder. What is the primary goal of this intervention? A. Prescribe medication for immediate relief. B. Educate the client about various relaxation techniques. C. Assist the client in challenging irrational thoughts. D. Develop measurable and realistic outcomes. E. Develop measurable and realistic outcomes.
D. Develop measurable and realistic outcomes.
The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take? A. Report abnormal findings to the charge nurse. B. Observe for blanching of the nailbed. C. Repeat the process with a different nailbed. D. Document the capillary refill time.
D. Document the capillary refill time.
The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take? A. Report abnormal findings to the charge nurse. B. Observe for blanching of the nailbed. C. Repeat the process with a different nailbed. D. Document the capillary refill time.
D. Document the capillary refill time.
The practical nurse (PN) hears an older resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take? A. Report the incident and the UAP for further action by the nurse manager. B. Tell both of them to lower their voices in consideration of other residents. C. Tell the resident and the UAP that shouting is not permitted. D. Enter the room and tell the UAP to leave the room immediately.
D. Enter the room and tell the UAP to leave the room immediately.
The practical nurse (PN) hears an older resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take? A. Report the incident and the UAP for further action by the nurse manager. X B. Tell both of them to lower their voices in consideration of other residents. X C. Tell the resident and the UAP that shouting is not permitted. X D. Enter the room and tell the UAP to leave the room immediately.
D. Enter the room and tell the UAP to leave the room immediately.
A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients. Which action should the practical nurse (PN) implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay with the client. B. Administer an as needed (PRN) medication for agitation. C. Notify the client's healthcare provider. D. Escort the client to a calm and quiet place
D. Escort the client to a calm and quiet place
A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients. Which action should the practical nurse (PN) implement first? A. Instruct an unlicensed assistive personnel (VAP) to stay with the client. B. Administer an as needed (PRN) medication for agitation. C. Notify the client's healthcare provider. D. Escort the client to a calm and quiet place.
D. Escort the client to a calm and quiet place.
A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? A. Assign the newly hired UAP to clients who require the least complex level of care. B. Ask the most experienced UAP on the team to partner with the newly hired UAP. C. Review the UAP's skills checklist and experience with the person who hired the UAP. D. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.
D. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.
The practical nurse (PN) is reviewing instructions for the use of pilocarpine ophthalmic drops with a client who has glaucoma. The client replies that the drops should be used to anesthetize the eye if eye pain is experienced. What action should the PN implement? A. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common. X B. Reteach the client about the action of the eye drops to decrease pressure in the eyes. X C. Document in the chart that the client understands the action and use of the eye drops. X D. Explain to the client that the eye drops do provide pain relief, but do not anesthetize the eyes.
D. Explain to the client that the eye drops do provide pain relief, but do not anesthetize the eyes.
The practical nurse (PN) is reviewing instructions for the use of pilocarpine ophthalmic drops with a client who has glaucoma. The client replies that the drops should be used to anesthetize the eye if eye pain is experienced. What action should the PN implement? A. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common. B. Reteach the client about the action of the eye drops to decrease pressure in the eyes. C. Document in the chart that the client understands the action and use of the eye drops. D. Explain to the client that the eye drops do provide pain relief, but do not anesthetize the eyes.
D. Explain to the client that the eye drops do provide pain relief, but do not anesthetize the eyes.
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect? A. Altered level of consciousness. B. Rapid mood swings. C. Excessive motor activity. D. Failure to recognize familiar objects.
D. Failure to recognize familiar objects.
The practical nurse (PN) is caring for a client with a new prescription for fluticasone furoate nasal spray, a glucocorticoid prescribed for the client's nasal allergy symptoms. In reinforcing instructions about self-administration of the nasal spray, the PN should emphasize the need for the client to take which action before self-administration? A. Deep breathe and cough. B. Check glucose levels before and after administration. C. Exhale through the mouth. D. Gently blow the nose.
D. Gently blow the nose.
The practical nurse (PN) is caring for a client with a new prescription for fluticasone furoate nasal spray, a glucocorticoid prescribed for the client's nasal allergy symptoms. In reinforcing instructions about self-administration of the nasal spray, the PN should emphasize the need for the client to take which action before self-administration? A. Deep breathe and cough. B. Check glucose levels before and after administration. C. Exhale through the mouth. D. Gently blow the nose.
D. Gently blow the nose.
Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the practical nurse (PN) to ask the child? A. Did the child perform a fingerstick? B. How much did the child exercise today? C. When did the child last urinate? D. Has the child eaten recently?
D. Has the child eaten recently?
Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the practical nurse (PN) to ask the child? A. Did the child perform a fingerstick? B. How much did the child exercise today? C. When did the child last urinate? D. Has the child eaten recently?
D. Has the child eaten recently?
A male client attends a community support program for mentally impaired and chemical-abusing clients. The client tells the practical nurse (PN) that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client? A. Diabetes. B. Glaucoma. C. Hypertension. D. Hepatitis.
D. Hepatitis.
A male client attends a community support program for mentally impaired and chemical-abusing clients. The client tells the practical nurse (PN) that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client? A. Diabetes. B. Glaucoma. C. Hypertension. D. Hepatitis.
D. Hepatitis.
The practical nurse (PN) is providing care for a client who is receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the PN? A. Dry mouth with thirst. B. Warm skin with elastic turgor. C. Low-grade fever with diaphoresis. D. Hives with pruritus.
D. Hives with pruritus.
The practical nurse (PN) is providing care for a client who is receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the PN? A. Dry mouth with thirst. B. Warm skin with elastic turgor. C. Low-grade fever with diaphoresis. D. Hives with pruritus.
D. Hives with pruritus.
The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care? A. Encourage the client to resume normal activities after medication administration. X B. Observe the client for involuntary movements of the lips and tongue every day. C. Perform a daily whisper test of the client's hearing to detect symptoms of ototoxicity. X D. Implement ongoing assessments for signs of shallow or slow breathing.
D. Implement ongoing assessments for signs of shallow or slow breathing.
The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care? A. Encourage the client to resume normal activities after medication administration. B. Observe the client for involuntary movements of the lips and tongue every day. C. Perform a daily whisper test of the client's hearing to detect symptoms of ototoxicity. D. Implement ongoing assessments for signs of shallow or slow breathing.
D. Implement ongoing assessments for signs of shallow or slow breathing.
A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A. Client's healthcare power of attorney. B. Fall at home as reason for admission. C. Currently prescribed medications. D. Increasing confusion of the client. E. Increasing confusion of the client.
D. Increasing confusion of the client.
While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse? A. Full facial flushing. B. Profuse diaphoresis. C. Lower leg weakness. D. Irregular heart rate.
D. Irregular heart rate.
While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse? A. Full facial flushing. B. Profuse diaphoresis. C. Lower leg weakness. D. Irregular heart rate.
D. Irregular heart rate.
A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic of pregnancy at this initial visit. A. Concerns about parenting. B. Cultural practices related to childbearing. C. Complications associated with childbirth. D. Knowledge about labor and delivery.
D. Knowledge about labor and delivery.
A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit? A. Concerns about parenting. B. Cultural practices related to childbearing. C. Complications associated with childbirth. D. Knowledge about labor and delivery.
D. Knowledge about labor and delivery.
A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement? A. Consult with the charge nurse about implementing suicide precautions. X B. Sit quietly in the client's room until the client is ready to verbalize his feelings. X C. Notify a member of the client's family of the need to come stay with the client. X D. Leave the room after offering to return to the client's room at a later time. E. Leave the room after offering to return to the client's room at a later time.
D. Leave the room after offering to return to the client's room at a later time.
A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement? A. Consult with the charge nurse about implementing suicide precautions. B. Sit quietly in the client's room until the client is ready to verbalize his feelings. C. Notify a member of the client's family of the need to come stay with the client. D. Leave the room after offering to return to the client's room at a later time. E. Leave the room after offering to return to the client's room at a later time.
D. Leave the room after offering to return to the client's room at a later time.
A client with a long history of migraine headaches asks the nurse if there are non-pharmaceutical ways to help obtain pain relief. Which intervention should the nurse offer? A. Monitor your blood pressure. B. Take a few days off work. C. Learn muscle relaxation techniques. D. Lie down in a dark, quiet room.
D. Lie down in a dark, quiet room.
On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take? A. Insert an indwelling catheter to empty the bladder and contract the fundus. B. Check fundal consistency and continue to monitor the lochial flow amount. C. Return the client to bed and maintain bedrest until the lochial flow slows. D. Massage the fundus and avoid direct pressure on the cesarean incision.
D. Massage the fundus and avoid direct pressure on the cesarean incision.
On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take? A. Insert an indwelling catheter to empty the bladder and contract the fundus. X B. Check fundal consistency and continue to monitor the lochial flow amount. X C. Return the client to bed and maintain bedrest until the lochial flow slows. X D. Massage the fundus and avoid direct pressure on the cesarean incision.
D. Massage the fundus and avoid direct pressure on the cesarean incision.
A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology? A. Systemic autoimmune vasculopathy. B. Autonomic neuropathy. C. Impaired neuron function. D. Muscle fiber degeneration.
D. Muscle fiber degeneration.
A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Which instruction should the practical nurse (PN) provide to the client prior to discharge? A. Apply a cold pack to any "hot spots" on the cast. B. Keep the left leg in a dependent position. C. Expect some increase in pain. D. Never scratch under the cast. E. Never scratch under the cast.
D. Never scratch under the cast.
A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Which instruction should the practical nurse (PN) provide to the client prior to discharge? A. Apply a cold pack to any "hot spots" on the cast. B. Keep the left leg in a dependent position. C. Expect some increase in pain. D. Never scratch under the cast. E. Never scratch under the cast.
D. Never scratch under the cast.
A client arrives at the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold? A. Aspirin. B. Heparin. C. Morphine. D. Nitroglycerin.
D. Nitroglycerin.
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next? A. Continue with the blood pressure assessment. B. Reposition the stethoscope over the brachial artery. C. Reinflate the cuff to a higher number. D. Note the presence of an auscultatory gap.
D. Note the presence of an auscultatory gap.
A male preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take? A. Document that the client has expressed concerns about the surgery. B. Encourage the client to continue with the scheduled surgery. C. Remind the client that the consent has already been obtained. D. Notify the charge nurse of the client's concerns about surgery.
D. Notify the charge nurse of the client's concerns about surgery.
A male preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take? A. Document that the client has expressed concerns about the surgery. X B. Encourage the client to continue with the scheduled surgery. X C. Remind the client that the consent has already been obtained. X D. Notify the charge nurse of the client's concerns about surgery.
D. Notify the charge nurse of the client's concerns about surgery.
A client with irritable bowel syndrome (IBS) is receiving dicyclomine, an anticholinergic drug. Prior to administering the next dose, the practical nurse (PN) determines that the client's mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take A. Check vital signs. B. Notify the charge nurse. C. Monitor hemoglobin. D. Provide oral care. E. Observe and report any ear drainage after removing the device.
D. Provide oral care.
A client with irritable bowel syndrome (IBS) is receiving dicyclomine, an anticholinergic drug. Prior to administering the next dose, the practical nurse (PN) determines that the client's mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take A. Check vital signs. B. Notify the charge nurse. C. Monitor hemoglobin. D. Provide oral care. E. Observe and report any ear drainage after removing the device.
D. Provide oral care.
A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide? A. Wash the hair and skin daily with mild soap and warm water. B. Omit chocolate, carbonated drinks, and fried foods from the diet. C. Express blackheads and follow with an exfoliating scrub. D. Refer to the dermatologist for prescribed long-term therapy.
D. Refer to the dermatologist for prescribed long-term therapy.
A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide? A. Wash the hair and skin daily with mild soap and warm water. B. Omit chocolate, carbonated drinks, and fried foods from the diet. C. Express blackheads and follow with an exfoliating scrub. D. Refer to the dermatologist for prescribed long-term therapy.
D. Refer to the dermatologist for prescribed long-term therapy.
The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long-term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first? A. Demonstrate how to use the equipment. B. Observe how UAP obtains temperatures. C. Show UAP how to chart temperatures. D. Return the thermometer for recalibration.
D. Return the thermometer for recalibration.
A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation? A. Suicidal ideation is a diagnosis in itself. B. Suicidal ideation is more common in older adults. C. Suicidal ideation always involves a detailed plan for self-harm. D. Suicidal ideation can be a symptom of various underlying mental health conditions. E. Suicidal ideation can be a symptom of various underlying mental health conditions.
D. Suicidal ideation can be a symptom of various underlying mental health conditions.
The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include? A. Crush to increase absorption. B. Store at room temperature. C. Administer with a meal. D. Take before bedtime. E. Take before bedtime.
D. Take before bedtime.
The practical nurse (PN) is preparing a client for discharge who receives a prescription for oral prednisone to treat a severe allergic reaction. Which teaching about medication administration should the PN reinforce? A. Take on an empty stomach. B. Take before bedtime. C. Take only as needed. D. Take with food.
D. Take with food.
The practical nurse (PN) is preparing a client for discharge who receives a prescription for oral prednisone to treat a severe allergic reaction. Which teaching about medication administration should the PN reinforce? A. Take on an empty stomach. B. Take before bedtime. C. Take only as needed. D. Take with food.
D. Take with food.
A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "WOW! You have big breasts." Which response is best for the PN to provide? A. Do you really think so? B. If you talk like that again, I will tell your parents. C. The size of my breasts is of no concern to you. D. That language is not allowed.
D. That language is not allowed.
A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "WOW! You have big breasts." Which response is best for the PN to provide? A. Do you really think so? B. If you talk like that again, I will tell your parents. C. The size of my breasts is of no concern to you. D. That language is not allowed.
D. That language is not allowed.
A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching? A. The client is the oldest of their siblings. B. The client's father lives in the client's home. C. The client's mother has asthma. D. The client has several siblings.
D. The client has several siblings.
The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the practical nurse (PN) note as the most significant indicator of possible child abuse? A. The child looks at the floor when answering the nurse's questions. X B. The mother describes in detail what she did for her injured child. C. The abrasions on the child's arms, legs, and chest have healed. X D. The injury description by the mother varies from the child's version.
D. The injury description by the mother varies from the child's version.
The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the practical nurse (PN) note as the most significant indicator of possible child abuse? A. The child looks at the floor when answering the nurse's questions. B. The mother describes in detail what she did for her injured child. C. The abrasions on the child's arms, legs, and chest have healed. D. The injury description by the mother varies from the child's version.
D. The injury description by the mother varies from the child's version.
The mother of an 8-year-old boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment finding should the PN note as the most significant indicator of possible child abuse? A. The mother refuses to answer questions about family history. B. The child has several abrasions on the chest and legs. C. The child looks at the floor when answering the nurse's questions. D. The mother's version of the injury is different from the child's version.
D. The mother's version of the injury is different from the child's version.
The mother of an 8-year-old boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment finding should the PN note as the most significant indicator of possible child abuse? A. The mother refuses to answer questions about family history. B. The child has several abrasions on the chest and legs. C. The child looks at the floor when answering the nurse's questions. D. The mother's version of the injury is different from the child's version.
D. The mother's version of the injury is different from the child's version.
The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding? A. Missing pulse. B. Light pressure applied to pulse. C. Pulse skips beats. D. Thready pulse volume.
D. Thready pulse volume.
The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first? A. Clean up and organize the nurses' workstations. B. Write a narrative shift summary for each client. C. Calculate and record intake and output totals. D. Verify completion of all new prescriptions.
D. Verify completion of all new prescriptions.
The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first? A. Clean up and organize the nurses' workstations. B. Write a narrative shift summary for each client. C. Calculate and record intake and output totals. D. Verify completion of all new prescriptions.
D. Verify completion of all new prescriptions.
The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L); Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L); and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm (14 x 10^9/L). Which intervention should the nurse implement? Reference Range:. Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]. Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]. White Blood Cell [5000 to 10,000/mm² (5 to 10 x 10^9/L)]. A. Move Client D into an isolation room 24 hours before surgery. B. Ask the dietitian to add a banana to Client C's breakfast tray. C. Increase Client A's oxygen to 4 liters a minute per cannula. D. Verify that Client B has two units of packed cells available.
D. Verify that Client B has two units of packed cells available.
The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include? A. Instill 3 mL of normal saline before suctioning. B. Instruct the client to cough as the suction tip is removed. C. Apply a water-soluble lubricant to the catheter. D. Wear protective goggles while performing the procedure. E. Wear protective goggles while performing the procedure.
D. Wear protective goggles while performing the procedure.
The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes. He has a history of depression, which is treated with paroxetine 10 mg orally every day. The client also states that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's BMI is 28. His random blood sugar is 8.7 Review H and P and laboratory results. What should be included in the treatment regimen for this client? Select all that apply. A. Short-acting insulin B. Oral anti-diabetic C. Long-acting insulin D. Weight-reduction treatment E. Extra carbohydrates F. Exercise planning G. Nutrition education
D. Weight-reduction treatment F. Exercise planning G. Nutrition education
The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes. He has a history of depression, which is treated with paroxetine 10 mg orally every day. The client also states that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's BMI is 28. His random blood sugar is 8.7 Review H and P and laboratory results. What should be included in the treatment regimen for this client? Select all that apply. A. Short-acting insulin B. Oral anti-diabetic C. Long-acting insulin D. Weight-reduction treatment E. Extra carbohydrates F. Exercise planning G. Nutrition education
D. Weight-reduction treatment F. Exercise planning G. Nutrition education
What is the most common type of shock in children? A. septic B. anaphylactic C. distributive D. hypovolemic
D. hypovolemic
Option 1: Pre-diabetes Option 2: Impaired glucose tolerance The client's fasting blood glucose level of 122 mg/dL (6.8 mmol/L) falls within the range of 100 to 125 mg/dL (5.56 to 6.9 mmol/L), indicating impaired glucose tolerance. This suggests that the client's blood sugar levels are higher than normal but not high enough to be classified as diabetes mellitus. Impaired glucose tolerance is considered a precursor to diabetes and indicates an increased risk of developing diabetes in the future. It is important for the practical nurse to educate the client about lifestyle modifications to manage blood sugar levels and prevent the progression to diabetes.
Drag from word choices to complete the sentence. Based on the laboratory data, the client has
The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Transport a urine culture sample to the laboratory. B. Obtain a post-voided residual (PVR) volume. C. Teach the client with fluid restrictions how to measure urine output. D. Irrigate an indwelling urinary catheter for a client with bladder suspension. E. Empty bedside drainage unit for a client with an indwelling urinary catheter.
E. Empty bedside drainage unit for a client with an indwelling urinary catheter.
The practical nurse (PN) is preparing cefazolin 400 mg IM for a client with a gram-positive infection. The available vial is labeled, "Cefazolin 1 gram," and the instructions for reconstitution state, for IM use, add 2 mL sterile water for injection. The total volume after reconstitution is 2.5 mL. After reconstitution, how many mL should be administered to the client? (Enter numeric value only. If rounding is required, round to the whole number, nearest tenths/hundredth).
The concentration of cefazolin after reconstitution can be calculated as follows: Concentration = Total amount of drug / Total volume after reconstitution Since the available vial contains 1 gram (1000 mg) of cefazolin and the total volume after reconstitution is 2.5 mL, we can calculate the concentration: Concentration = 1000 mg / 2.5 mL = 400 mg/mL Therefore, after reconstitution, the concentration of cefazolin is 400 mg/mL. To administer a dose of 400 mg, we divide the desired dose by the concentration: Volume to administer = Desired dose / Concentration Volume to administer = 400 mg / 400 mg/mL = 1 mL
56. The practical nurse (PN) is caring for a client who has a tracheostomy tube. After donning sterile gloves, in which sequence should the PN should implement these interventions? (Arrange from the first action on top to last on the bottom.) A. Insert sterile suction catheter in tracheostomy tube. B. Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. C. Activate suction by covering the catheter opening. D. Withdraw and rotate the catheter while suction is applied.
The correct sequence for the interventions when caring for a client with a tracheostomy tube, after donning sterile gloves, is as follows: Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. Insert sterile suction catheter in tracheostomy tube. Activate suction by covering the catheter opening. Withdraw and rotate the catheter while suction is applied. The first step is to hyperoxygenate the client using a bag valve mask (BVM) with the nondominant hand. This helps to ensure that the client receives adequate oxygenation during the suctioning procedure. Next, the sterile suction catheter is inserted into the tracheostomy tube. The catheter is carefully advanced until resistance is met, ensuring it does not force its way in. After the catheter is inserted, the suction is activated by covering the catheter opening. This creates negative pressure and allows for the removal of secretions. Finally, the catheter is withdrawn and rotated while suction is applied. This helps to thoroughly suction the secretions from the tracheostomy tube.
A client who had a knee replacement surgery and received a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL pre-filled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)
To calculate how many milliliters (mL) the practical nurse (PN) should administer each day, we can first determine the total daily dosage of enoxaparin. The prescribed dosage is 30 mg every 12 hours, so the total daily dosage is: 30 mg + 30 mg = 60 mg Next, we can calculate the number of milliliters (mL) needed to deliver the total daily dosage. Since the medication is available in a concentration of 30 mg per 0.3 mL, we can set up a proportion to find the equivalent mL for 60 mg: 30 mg / 0.3 mL = 60 mg / x mL Cross-multiplying, we get: 30 mg * x mL = 60 mg * 0.3 mL 30x = 18 Dividing both sides by 30, we find: x = 0.6 mL
4 ounce apple Juice 8 ounces milk 4 ounces broth 4 ounces tea A client remains on strict intake and output (1&O) on the first postoperative day and documents the last 8 hours of intake on the I&O bedside record above. How many mL should the practical nurse (PN) document in the client's electronic medical record (EMR)? (Enter numeric value only.)
To calculate the total intake in milliliters (mL), we need to convert the given measurements from ounces to milliliters and then sum them up. 1 ounce (oz) is approximately equal to 29.57 milliliters (mL). Given intake: 4 ounces apple juice = 4 oz * 29.57 mL/oz = 118.28 mL 8 ounces milk = 8 oz * 29.57 mL/oz = 236.56 mL 4 ounces broth = 4 oz * 29.57 mL/oz = 118.28 mL 4 ounces tea = 4 oz * 29.57 mL/oz = 118.28 mL Total intake = 118.28 mL + 236.56 mL + 118.28 mL + 118.28 mL = 591.4 mL
The healthcare provider prescribed octreotide 150 mcg/day subcutaneously for a client with dumping syndrome. The medication is available in 0.2 mg/mL vials. How many mL should the practical nurse (PN) administer? (Enter numerical value only. If rounding is required, round to the nearest hundredth).
To calculate the volume of medication to administer, we can use the following conversion: 1 mg = 1000 mcg Given that the prescribed dose is 150 mcg/day, we need to convert it to milligrams: 150 mcg = 150/1000 mg = 0.15 mg Since the medication is available in 0.2 mg/mL vials, we can calculate the volume to administer using the following equation: Volume (mL) = Dose (mg) / Concentration (mg/mL) Volume (mL) = 0.15 mg / 0.2 mg/mL Volume (mL) = 0.75 mL Therefore, the practical nurse (PN) should administer 0.75 mL of the medication.
Exhibits Drag from word choices to complete the sentence. Based on the laboratory data, the client has ( Pre-diabetes ) related to (Occupational exposure) (HAS LAB RESULTS) Lab Test Laboratory Results Normal Range Total cholesterol (5.41 209 mg/dL mmol/L) <200 mg/d| (<5.17 mmol/_) High-density lipoprotein mmol/L) 43 mg/dL (1.11 > 45 mg/dL (> 0.75 mmol/L) Low-density lipoprotein 166 mg/dL (4.29 <130 mg/dL (<3.36
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