LaCharity Final

A 70-kg client who has had unprotected sexual intercourse with a partner who has hepatitis B is to receive 0.06 mL/kg of hepatitis B immune globulin. The immune globulin is available in a 5-mL vial. The nurse will plan to administer __________ mL.

0.06 mL × 70 kg = 4.2 mL

A patient who has cancer will need ongoing treatment for pain. Which brochure is the nurse most likely to prepare that addresses questions related to the first-line treatment of cancer pain? 1. "An Illustrated Guide to the Analgesic Ladder" 2. "Common Questions About Radiation Therapy" 3. "How to Make Preparations for Your Cancer Surgery" 4. "How Nerve Blocks Can Help to Manage Cancer Pain"

1. "An Illustrated Guide to the Analgesic Ladder"

The home health nurse is obtaining a history for a patient who has deep vein thrombosis and is taking warfarin 2 mg/day. Which statement by the patient is the best indicator that additional teaching about warfarin may be needed? 1. "I have started to eat more healthy foods like green salads and fruit." 2. "The doctor said that it is important to avoid becoming constipated." 3. "Warfarin makes me feel a little nauseated unless I take it with food." 4. "I will need to have some blood testing done once or twice a week."

1. "I have started to eat more healthy foods like green salads and fruit."

When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to the nurse that the patient needs additional teaching? 1. "I take my ibuprofen every morning as soon as I get up." 2. "My daughter removed all of the throw rugs in my home." 3. "My husband helps me every afternoon with range-of-motion exercises." 4. "I rest in my reclining chair every day for at least an hour."

1. "I take my ibuprofen every morning as soon as I get up."

The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? 1. "I will avoid exercise because the pain gets worse." 2. "I will use heat or ice to help control the pain." 3. "I will not wear high-heeled shoes at home or work." 4. "I will purchase a firm mattress to replace my old one."

1. "I will avoid exercise because the pain gets worse."

The nurse is monitoring a patient who is at risk for spinal cord compression related to tumor growth. Which patient statement is most likely to suggest an early manifestation? 1. "Last night my back really hurt, and I had trouble sleeping." 2. "My leg has been giving out when I try to stand." 3. "My bowels are just not moving like they usually do." 4. "When I try to pass urine, I have difficulty starting the stream."

1. "Last night my back really hurt, and I had trouble sleeping."

A patient with a right above-the-knee amputation asks the nurse why he has phantom limb pain. What is the nurse's best response? 1. "Phantom limb pain is not explained or predicted by any one theory." 2. "Phantom limb pain occurs because your body thinks your leg is still present." 3. "Phantom limb pain will not interfere with your activities of daily living." 4. "Phantom limb pain is not real pain but is remembered pain."

1. "Phantom limb pain is not explained or predicted by any one theory."

The client has an order for hydrochlorothiazide (HCTZ) 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? Select all that apply. 1. "Take this medication in the morning." 2. "This medication should be taken in two divided doses when you get up and when you go to bed." 3. "Eat foods with extra sodium every day." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase." 6. "Your health care provider may also prescribe a potassium supplement."

1. "Take this medication in the morning." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase." 6. "Your health care provider may also prescribe a potassium supplement."

The nurse is interviewing a patient who was treated several months ago for breast cancer. The patient reports taking nonsteroidal anti-inflammatory drugs (NSAIDs) for back pain. Which patient comment is cause for greatest concern? 1. "The NSAIDs are really not relieving the back pain." 2. "The NSAID tablets are too large, and they are hard to swallow." 3. "I gained weight because I eat a lot before taking NSAIDs." 4. "The NSAIDs are upsetting my stomach in the morning."

1. "The NSAIDs are really not relieving the back pain."

The student nurse, under the supervision of an RN, is reviewing a client's arterial blood gas results and notes an acute increase in arterial partial pressure of carbon dioxide (Paco2) to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates accurate understanding of acid-base balance for this client? 1. "When the Paco2 is acutely elevated, the blood pH should be lower than normal." 2. "This client should be taught to breathe and rebreathe in a paper bag." 3. "An elevated Paco2 always means that a client has an acidosis." 4. "When a client's Paco2 is increased, the respiratory rate should decrease to compensate."

1. "When the Paco2 is acutely elevated, the blood pH should be lower than normal."

The nurse is caring for a patient who had a dual-energy x-ray absorptiometry (DEXA) scan and is now prescribed calcium with vitamin D twice a day. The patient asks the nurse the purpose of this drug. What is the nurse's best response? Select all that apply. 1. "When your calcium and vitamin D levels are low, your risk for osteoporosis and osteomalacia increases." 2. "When your vitamin D level is high, your bones release calcium to keep your blood calcium level in the normal range." 3. "When your blood calcium is low, calcium is released from your bones increasing your risk for fractures." 4. "When blood calcium is normal, long bones are formed increasing a person's height." 5. "The extra calcium and vitamin D will help protect your bones from damage such as fractures." 6. "You can also get extra vitamin D by increasing your intake of beef and pork sources."

1. "When your calcium and vitamin D levels are low, your risk for osteoporosis and osteomalacia increases." 3. "When your blood calcium is low, calcium is released from your bones increasing your risk for fractures." 5. "The extra calcium and vitamin D will help protect your bones from damage such as fractures."

The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply. 1. "Which drugs to you take on a daily basis?" 2. "Do you have any problems with breathing?" 3. "When was your last bowel movement?" 4. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" 5. "Over the past month have you had any dizziness or tinnitus?" 6. "Do you have episodes of drowsiness or decreased alertness?"

1. "Which drugs to you take on a daily basis?" 2. "Do you have any problems with breathing?" 4. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" 6. "Do you have episodes of drowsiness or decreased alertness?"

After the nurse receives the change-of-shift report, which patient should be assessed first? 1. A 20-year-old patient with possible acute myelogenous leukemia who has just arrived on the medical unit 2. A 38-year-old patient with aplastic anemia who needs teaching about decreasing infection risk before discharge 3. A 40-year-old patient with lymphedema who requests help in putting on compression stockings before getting out of bed 4. A 60-year-old patient with non-Hodgkin lymphoma who is refusing the prescribed chemotherapy regimen

1. A 20-year-old patient with possible acute myelogenous leukemia who has just arrived on the medical unit

People at risk are the target populations for cancer screening programs. According to the latest screening recommendations from the American Cancer Society, which of these asymptomatic patients need extra encouragement to participate in cancer screening? Select all that apply. 1. A 21-year-old white American woman who is sexually inactive, for a Pap test 2. A 30-year-old Asian-American woman, for an annual mammogram 3. A 45-year-old African-American man, to talk with health care provider about prostate cancer 4. A 50-year-old white American man, for a fecal occult blood test 5. A 50-year-old white American woman, for a colonoscopy 6. A 70-year-old Asian-American woman who had a total hysterectomy 15 years ago (not for cancer reasons), for a Pap test

1. A 21-year-old white American woman who is sexually inactive, for a Pap test 3. A 45-year-old African-American man, to talk with health care provider about prostate cancer 4. A 50-year-old white American man, for a fecal occult blood test 5. A 50-year-old white American woman, for a colonoscopy

The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern? 1. A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia (PCA). 2. A 65-year-old adult will be discharged with a prescription for nonsteroidal anti-inflammatory drugs (NSAIDS). 3. A 25-year-old adult is prescribed as needed intramuscular (IM) analgesic for pain. 4. A 45-year-old adult is taking oral fluids and foods has orders for IV morphine.

1. A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia (PCA).

A group of patients is assigned to an RN-LPN/LVN team. The LPN/LVN should be assigned to provide patient care and administer medications to which patient? 1. A 36-year-old patient with chronic kidney failure who will need a subcutaneous injection of epoetin alfa 2. A 39-year-old patient with hemophilia B who has been admitted to receive a blood transfusion 3. A 50-year-old patient with newly diagnosed polycythemia vera who will require phlebotomy 4. A 55-year-old patient with a history of stem cell transplantation who has a bone marrow aspiration scheduled

1. A 36-year-old patient with chronic kidney failure who will need a subcutaneous injection of epoetin alfa

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. 1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow

1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 6. A 69-year-old patient with emphysema to be discharged tomorrow

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis? 1. A 68-year-old client with chronic emphysema 2. A 58-year-old client who uses antacids every day 3. A 48-year-old client with an anxiety disorder 4. A 28-year-old client with salicylate intoxication

1. A 68-year-old client with chronic emphysema

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? 1. A 68-year-old patient with a history of smoking and emphysema 2. A 57-year-old patient who experienced a cardiac arrest 3. A 49-year-old postoperative patient who had a colectomy 4. A 29-year-old patient who is recovering from flail chest

1. A 68-year-old patient with a history of smoking and emphysema

According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients? Select all that apply. 1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies 5. Long-acting oral opioids, especially in the immediate postoperative period, for continuous around-the-clock relief 6. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, or ketamine is recommended for postoperative pain

1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies

The nurse is providing end-of-life-care for a patient with terminal liver cancer. The patient is weak and restless. Her skin is cool and mottled. Dyspnea develops, and the patient appears anxious and frightened. What should the nurse do first? 1. Administer an as needed (PRN) dose of morphine elixir. 2. Alert the Rapid Response Team and call the health care provider. 3. Deliver breaths at 20 breaths/min with a bag-valve mask and prepare for intubation. 4. Sit quietly with the patient and offer emotional support and comfort.

1. Administer an as needed (PRN) dose of morphine elixir.

A client's potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising? 1. Administer sodium polystyrene sulfonate 15 g orally. 2. Administer spironolactone 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq (10 mmol/L) orally.

1. Administer sodium polystyrene sulfonate 15 g orally

The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is best assigned to the LPN/LVN? 1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family

1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities

A hospitalized patient with acquired immunodeficiency syndrome (AIDS) has wasting syndrome. Which nursing action is appropriate to assign to an LPN/LVN who is providing care to this patient? 1. Administering oxandrolone 5 mg/day 2. Assessing the patient for other nutritional risk factors 3. Developing a plan of care to improve the patient's appetite 4. Providing instructions about a high-calorie, high-protein diet

1. Administering oxandrolone 5 mg/day

Which tasks are appropriate to assign to an LPN/LVN who is functioning under the supervision of an RN? Select all that apply. 1. Administering sulfacetamide sodium 10% to a child with conjunctivitis 2. Reviewing hand-washing and hygiene practices with clients who have eye infections 3. Showing clients how to gently cleanse eyelid margins to remove crusting 4. Assessing nutritional factors for a client with age-related macular degeneration 5. Reviewing the health history of a client to identify risk for ocular manifestations 6. Performing a routine check of a client's visual acuity using the Snellen eye chart

1. Administering sulfacetamide sodium 10% to a child with conjunctivitis 2. Reviewing hand-washing and hygiene practices with clients who have eye infections 3. Showing clients how to gently cleanse eyelid margins to remove crusting 6. Performing a routine check of a client's visual acuity using the Snellen eye chart

When staff assignments are made for the care of patients who are receiving chemotherapy, what is the major consideration regarding chemotherapeutic drugs? 1. Administration of chemotherapy requires precautions to protect self and others. 2. Many chemotherapeutic drugs are vesicants. 3. Chemotherapeutic drugs are frequently given through central venous access devices. 4. Oral and venous routes of administration are the most common.

1. Administration of chemotherapy requires precautions to protect self and others.

Which patient is at greatest risk for pancreatic cancer? 1. An older African-American man who smokes 2. A young white obese woman with gallbladder disease 3. A young African-American man with type 1 diabetes 4. An elderly white woman who has pancreatitis

1. An older African-American man who smokes

The nurse is working in a community health clinic and a client needs instructions for the care of a hordeolum (stye) on the right upper eyelid. What is the first intervention that the client should try? 1. Apply warm compresses four times per day. 2. Gently perform hygienic eyelid scrubs. 3. Obtain a prescription for antibiotic drops. 4. Contact the ophthalmologist.

1. Apply warm compresses four times per day.

A patient with newly diagnosed acquired immunodeficiency syndrome (AIDS) has a 6-mm induration at 48 hours after a skin test for tuberculosis (TB). Which action will the nurse anticipate taking next? 1. Arrange for a chest x-ray to check for active TB. 2. Tell the patient that the TB test results are negative. 3. Teach the patient about multidrug treatment for TB. 4. Schedule TB skin testing again in 12 months.

1. Arrange for a chest x-ray to check for active TB.

A pregnant client in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important? 1. Arrange for testing for Zika virus infection. 2. Discuss need for multiple fetal ultrasounds during pregnancy. 3. Describe potential impact of Zika infection on fetal development. 4. Assess for symptoms such as rash, joint pain, conjunctivitis, and fever.

1. Arrange for testing for Zika virus infection.

During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

1. Arterial line indicates a blood pressure of 190/112 mm Hg.

Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? Select all that apply. 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair

1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair

In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

1. Assisting the client with preparation of a sitz bath

A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

1. Assisting the patient to sit up on the side of the bed

The nurse is caring for a patient with esophageal cancer. Which task could be delegated to unlicensed assistive personnel (UAP)? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weights

1. Assisting the patient with oral hygiene

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? Select all that apply. 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

1. Attaching cardiac monitor leads 4. Obtaining a 12-lead electrocardiogram (ECG) 6. Having the client chew and swallow aspirin 162 mg

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 4. Checking oxygen saturation using pulse oximetry

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply. 1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 3. Wash all bedding in cold water to reduce and destroy dust mites. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate (MSG). 6. Keep a symptom and intervention diary to learn specific triggers for your asthma.

1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate (MSG). 6. Keep a symptom and intervention diary to learn specific triggers for your asthma.

When scheduling a patient for skin testing for allergies, which information is most important for the allergy clinic nurse to include in patient teaching? 1. Avoid taking antihistamines before the skin testing. 2. Skin testing may be done with an intradermal injection. 3. Swelling and itching may occur at the site of the skin testing. 4. Patient will need to wait in the clinic for 20 minutes after the testing.

1. Avoid taking antihistamines before the skin testing.

The nurse is preparing a discussion of musculoskeletal health maintenance for a group of older adults. Which key points would the nurse be sure to include? Select all that apply. 1. Be aware of and consume foods rich in calcium and vitamin D. 2. Wear hats and long sleeves to avoid sun exposure at all times. 3. Consider exercise with low impact to avoid risk for injury. 4. If you smoke, consider a smoking cessation program. 5. Excessive alcohol intake can interfere with vitamins and nutrients for bone growth. 6. Weight-bearing activities decrease the risk for osteoporosis.

1. Be aware of and consume foods rich in calcium and vitamin D. 3. Consider exercise with low impact to avoid risk for injury. 4. If you smoke, consider a smoking cessation program. 5. Excessive alcohol intake can interfere with vitamins and nutrients for bone growth. 6. Weight-bearing activities decrease the risk for osteoporosis.

Phenylephrine, an adrenergic agonist, has been prescribed as a topical application for a client as an aid to intraocular surgery. Although systemic toxicity is unlikely, which adverse physiologic response is the greatest concern? 1. Cardiovascular response, such as hypertension or ventricular dysrhythmias 2. Renal response, such as urinary retention or urinary incontinence 3. Respiratory response, such as bronchospasm or mucus plugs 4. Musculoskeletal response, such as bone pain or joint stiffness

1. Cardiovascular response, such as hypertension or ventricular dysrhythmias

The charge nurse assigns the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would the RN provide for the LPN/LVN? Select all that apply. 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 4. The patient will no longer need pain medication. 5. Check the neurovascular status of the fingers every hour. 6. Instruct the patient to perform range of motion on the affected wrist.

1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 5. Check the neurovascular status of the fingers every hour.

The nurse is in charge of developing a standard plan of care for an Alzheimer disease care facility and is responsible for assigning and supervising resident care given by LPNs/LVNs and delegating and supervising care given by unlicensed assistive personnel (UAP). Which activity is best to assign to the LPN/LVN team leaders? 1. Checking for improvement in resident memory after medication therapy is initiated 2. Using the Mini-Mental State Examination to assess residents every 6 months 3. Assisting residents in using the toilet every 2 hours to decrease risk for urinary incontinence 4. Developing individualized activity plans after consulting with residents and family

1. Checking for improvement in resident memory after medication therapy is initiated

All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa is given 3. Reminding the client to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the client with prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function

1. Checking for orthostatic changes in pulse and blood pressure 3. Reminding the client to allow adequate time for meals 5. Assisting the client with prescribed strengthening exercises

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? Select all that apply. 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client 6. Administering oral medications as ordered

1. Checking the client's skin for pressure from the device 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 6. Administering oral medications as ordered

The nurse is working with unlicensed assistive personnel (UAP) to provide care for six patients. At the beginning of the shift, the nurse carefully tells the UAP what patient interventions and tasks he or she is expected to perform. Which "Four Cs" guide the nurse's communication with the UAP? Select all that apply. 1. Clear 2. Comprehensive 3. Concise 4. Credible 5. Correct 6. Complete

1. Clear 3. Concise 5. Correct 6. Complete

A nursing student is preparing the equipment to irrigate a client's ear canal. In which circumstances would the supervising nurse intervene before the student starts the irrigation? Select all that apply. 1. Client has a probable perforated eardrum. 2. Client has a foreign body, probably a bean, in the ear canal. 3. Client has a foreign body, probably an insect, in the ear canal. 4. Client has hearing loss related to impacted cerumen. 5. Client is currently being treated for acute otitis media. 6. Client has used ear candles in the past to remove ear wax.

1. Client has a probable perforated eardrum. 2. Client has a foreign body, probably a bean, in the ear canal. 3. Client has a foreign body, probably an insect, in the ear canal. 5. Client is currently being treated for acute otitis media.

The nurse recognizes that there are ethical considerations in helping clients to achieve relief from pain. Which nursing action is the best example of the principle of nonmaleficence? 1. Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. 2. Client has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine. 3. Client is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the client to verbalize personal goals for pain management. 4. Client repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication.

1. Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication.

Which clients would be best to assign to the most experienced nurse in an ambulatory care center that specializes in vision problems and eye surgery? Select all that apply. 1. Client who requires postoperative instructions after cataract surgery 2. Client who needs an eye pad and a metal shield applied 3. Client who requests a home health referral for dressing changes and eyedrop instillation 4. Client who needs teaching about self-administration of eyedrops 5. Client who requires an assessment for recent and sudden loss of sight 6. Client who requires preoperative teaching for laser trabeculoplasty

1. Client who requires postoperative instructions after cataract surgery 3. Client who requests a home health referral for dressing changes and eyedrop instillation 5. Client who requires an assessment for recent and sudden loss of sight 6. Client who requires preoperative teaching for laser trabeculoplasty

Which clients must be assigned to an experienced RN? Select all that apply. 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

1. Client who was in an automobile crash and sustained multiple injuries 3. Client who has returned from surgery and has a chest tube in place 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

A client in the emergency department who is being monitored with a portable cardiac monitor/defibrillator develops this rhythm (refer to figure). Which action will the nurse take first? 1. Defibrillate at 200 joules. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine 1 mg IV. 4. Intubate and manually ventilate.

1. Defibrillate at 200 joules.

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? Select all that apply. 1. Do not rush through your morning activities of daily living. 2. Avoid working with the arms raised. 3. Eat three large meals every day focusing on calories and protein. 4. Organize your work area so that what you use most is easy to reach. 5. Get all of your activities accomplished then take a nap. 6. Don't hold your breath while performing any activities.

1. Do not rush through your morning activities of daily living. 2. Avoid working with the arms raised. 4. Organize your work area so that what you use most is easy to reach. 6. Don't hold your breath while performing any activities.

A patient with systemic lupus erythematosus (SLE) is admitted to the hospital with acute joint inflammation. Which information obtained in the laboratory testing will be of highest concern to the nurse? 1. Elevated blood urea nitrogen level 2. Increased C-reactive protein level 3. Positive antinuclear antibody test result 4. Positive lupus erythematosus cell preparation

1. Elevated blood urea nitrogen level

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? 1. Encourage the patient to eat foods that are high in calories and protein. 2. Feed the patient as quickly as possible to prevent early satiety. 3. Offer lots of fluids between bites of food. 4. Try to get the patient to eat everything on the tray.

1. Encourage the patient to eat foods that are high in calories and protein.

The nurse is supervising a new graduate RN caring for a patient with a fracture of the right ankle who is at risk for complications of immobility. For which action should the supervising nurse intervene? 1. Encouraging the patient to go from a lying to a standing position 2. Administering pain medication before the patient begins exercises 3. Explaining to the patient and family the purpose of the exercise program 4. Reminding the patient about the correct use of crutches

1. Encouraging the patient to go from a lying to a standing position

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? 1. Entering the room without putting on a protective mask and gown 2. Instructing the family that visits are restricted to 10 minutes 3. Giving the client a warm blanket when he says he feels cold 4. Checking the client's pupil response to light every 30 minutes

1. Entering the room without putting on a protective mask and gown

A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time? 1. Fatigue 2. Inability to perform activities of daily living (ADLs) 3. Decreased mobility 4. Muscular weakness

1. Fatigue

The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation

1. Flattened neck veins when the client is in the supine position

The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply. 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin and nifedipine should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by the client's health care provider.

1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin and nifedipine should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful.

The nurse is talking to a group of older women about breast cancer. Based on the most recent guidelines from the American Cancer Society and the American Society of Clinical Oncology, what will the nurse tell the group about the current recommendations for breast cancer screening? 1. For older women in good general health and a life expectancy of 10 or more years, biennial or annual mammography screening is recommended. 2. For women older than the age of 55 years with average risk for breast cancer, mammography screening is recommended every 3 to 5 years. 3. For women older than the age of 70 with average risk for breast cancer, annual screening mammography is not recommended. 4. Starting at age 40 years, all women with average risk for breast cancer should have annual clinical breast examination and mammography screening.

1. For older women in good general health and a life expectancy of 10 or more years, biennial or annual mammography screening is recommended.

The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction? 1. Frequently likes to sit in the hot tub to reduce joint stiffness 2. Prefers to place the patch only on the upper anterior chest wall 3. Saves and reuses the old patches when he can't afford new ones 4. Changes the patch every 4 days rather than the prescribed 72 hours

1. Frequently likes to sit in the hot tub to reduce joint stiffness

A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will the nurse advocate for first? 1. Gabapentin 2. Corticosteroids 3. Hydromorphone 4. Lorazepam

1. Gabapentin

The client reports tinnitus. The nurse decides to review the client's medication list to determine if any medications may be causing or contributing to this adverse effect. Which combination of drugs is cause for greatest concern? 1. Gentamycin and ethacrynic acid 2. Furosemide and metoprolol 3. Vancomycin and nitroglycerin patch 4. Aspirin and calcium supplement

1. Gentamycin and ethacrynic acid

A patient who underwent a right above-the-knee amputation 4 days ago also has a diagnosis of depression. Which order would the nurse clarify with the health care provider? 1. Give fluoxetine 40 mg once a day. 2. Administer acetaminophen with codeine 1 or 2 tablets every 4 hours as needed. 3. Assist the patient to the bedside chair every shift. 4. Reinforce the dressing to the right residual limb as needed.

1. Give fluoxetine 40 mg once a day.

The nurse is preparing to change the linens on the bed of a client who has a sacral wound infected by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) items will be used? Select all that apply. 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. Gown 2. Gloves

A client with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells the nurse, "I feel really dizzy." Which action should the nurse take first? 1. Help the client to sit down. 2. Check the client's apical pulse. 3. Take the client's blood pressure. 4. Have the client breathe deeply.

1. Help the client to sit down.

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which questions would the nurse suggest the student ask to determine nicotine dependence? Select all that apply. 1. How soon after you wake up in the morning do you smoke? 2. Do other members of your family smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 5. Do you smoke indoors or outside? 6. Do you have a difficult time not smoking in places where it is not allowed?

1. How soon after you wake up in the morning do you smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 6. Do you have a difficult time not smoking in places where it is not allowed?

Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? Select all that apply. 1. How to monitor and record daily weight 2. Importance of stopping exercise if heart rate increases 3. Symptoms of worsening heart failure 4. Purpose of chronic antibiotic therapy 5. How to read food labels for sodium content 6. Date and time for follow-up appointments

1. How to monitor and record daily weight 3. Symptoms of worsening heart failure 5. How to read food labels for sodium content 6. Date and time for follow-up appointments

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

1. Humidify the patient's oxygen.

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem? 1. Increase in ventilator rate from 6 to 10 breaths/min 2. Decrease in ventilator rate from 10 to 6 breaths/min 3. Increase in oxygen concentration from 30% to 40% 4. Decrease in oxygen concentration from 40% to 30%

1. Increase in ventilator rate from 6 to 10 breaths/min

The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? 1. Instructing the client to sit up straight and the client responds with a puzzled expression 2. Moving the client's food tray to the right side of his over-bed table 3. Assisting the client with passive range-of-motion (ROM) exercises 4. Combing the hair on the left side of the client's head when the client always combs his hair on the right side

1. Instructing the client to sit up straight and the client responds with a puzzled expression

Which tasks are appropriate to assign to an LPN/LVN who is functioning under the supervision of a team leader or RN? Select all that apply. 1. Irrigating the ear canal to loosen impacted cerumen 2. Administering amoxicillin to a child with otitis media 3. Reminding the client not to blow the nose after tympanoplasty 4. Counseling a client with Ménière disease 5. Suggesting communication techniques for the family of a hearing-impaired older adult 6. Assessing a client with labyrinthitis for headache and level of consciousness

1. Irrigating the ear canal to loosen impacted cerumen 2. Administering amoxicillin to a child with otitis media 3. Reminding the client not to blow the nose after tympanoplasty

The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? Select all that apply. 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the client's position. 5. Provide oral care with chlorhexidine solution at least daily.

1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 5. Provide oral care with chlorhexidine solution at least daily.

Which policy implemented by the infection control nurse will most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? 1. Limit the use of indwelling urinary catheters in all hospitalized clients. 2. Ensure that clients with catheters have at least a 1500-mL fluid intake daily. 3. Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria. 4. Require the use of antimicrobial/antiseptic-impregnated catheters for catheterization.

1. Limit the use of indwelling urinary catheters in all hospitalized clients.

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated

The nurse is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best? 1. Multimodal strategies 2. Standing orders by protocol 3. Intravenous patient-controlled analgesia (PCA) 4. Opioid dosage based on valid numerical scale

1. Multimodal strategies

A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN/LVN whom the nurse is supervising? Select all that apply. 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation 5. Assessing for adverse effects caused by new antiseizure medications 6. Turning the client to his or her side to avoid aspiration

1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 6. Turning the client to his or her side to avoid aspiration

A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing

The nurse is interviewing an older adult client who reports that "lately there has been a roaring sound in my ears." What additional assessments should the nurse include? Select all that apply. 1. Obtain a medication history. 2. Ask about exposure to loud noises. 3. Observe the canal for earwax or foreign body. 4. Assess for signs and symptoms of ear infection. 5. Ask about method of ear hygiene. 6. Ask about diet and nutrition.

1. Obtain a medication history. 2. Ask about exposure to loud noises. 3. Observe the canal for earwax or foreign body. 4. Assess for signs and symptoms of ear infection. 5. Ask about method of ear hygiene.

These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Obtaining stool specimens for fecal occult blood test (FOBT) 2. Having the patient sign a colonoscopy consent form 3. Giving the prescribed polyethylene glycol electrolyte solution 4. Checking for allergies to contrast dye or shellfish

1. Obtaining stool specimens for fecal occult blood test (FOBT)

A 88-year-old client who has not yet had the influenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough, and runny nose starting about 24 hours previously. Which of these prescribed medications is most important for the nurse to administer at this time? 1. Oseltamivir 75 mg PO 2. Guaifenesin 600 mg PO 3. Acetaminophen 650 mg PO 4. Influenza vaccine 180 mcg IM

1. Oseltamivir 75 mg PO

What is the priority nursing concern for a client experiencing a migraine headache? 1. Pain 2. Anxiety 3. Hopelessness 4. Risk for brain injury

1. Pain

A patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What would the nurse be sure to teach the patient? 1. Pain and numbness are expected to be experienced for several days to weeks. 2. Immediately after surgery, the patient will no longer need assistance. 3. After surgery, the dressing will be large, and there will be lots of drainage. 4. The patient's pain and paresthesia will no longer be present.

1. Pain and numbness are expected to be experienced for several days to weeks.

The nurse is making a room assignment for a newly arrived patient whose laboratory test results indicate pancytopenia. Which patient will be the best roommate for the new patient? 1. Patient with digoxin toxicity 2. Patient with viral pneumonia 3. Patient with shingles 4. Patient with cellulitis

1. Patient with digoxin toxicity

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation.

A client who has had recent exposure to Ebola while traveling in Africa arrives in the emergency department with fever, headache, vomiting, and multiple ecchymoses. Which action should the nurse take first? 1. Place the client in a private room. 2. Obtain heart rate and blood pressure. 3. Notify the hospital infection control nurse. 4. Ask the client to describe type of Ebola exposure.

1. Place the client in a private room.

A client who has been diagnosed with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take first? 1. Place the client in an airborne isolation room. 2. Initiate infusion of 500 mL of normal saline bolus. 3. Ask the client about any recent travel to Asia. 4. Obtain sputum specimen and nasal cultures.

1. Place the client in an airborne isolation room.

A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? 1. Position the client sitting up in bed before he or she is fed. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly because there are three more clients to feed. 4. Suction the client's secretions between bites of food.

1. Position the client sitting up in bed before he or she is fed.

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Providing oral care every 3 to 4 hours 2. Monitoring for indications of dehydration 3. Administering 0.45% saline by IV line 4. Record urine output when client voids 5. Assessing daily weights for trends 6. Help the client change position every 2 hours

1. Providing oral care every 3 to 4 hours 4. Record urine output when client voids 6. Help the client change position every 2 hours

At 10:00 am, a hospitalized client receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

1. Put the client on "nothing by mouth" (NPO) status.

The nurse is working with a patient who has a new diagnosis of human immunodeficiency virus (HIV) and who reports current use of injectable heroin and methamphetamine. Which actions by the nurse are appropriate? Select all that apply. 1. Refer the patient to a substance abuse treatment program. 2. Plan for the patient to participate in a needle exchange program. 3. Coordinate the patient's schedule for directly observed antiretroviral drug treatment. 4. Instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy. 5. Provide patient education about the risk of transmitting HIV to others when sharing needles.

1. Refer the patient to a substance abuse treatment program. 2. Plan for the patient to participate in a needle exchange program. 3. Coordinate the patient's schedule for directly observed antiretroviral drug treatment. 5. Provide patient education about the risk of transmitting HIV to others when sharing needles.

While reviewing a hospitalized client's medical record, the nurse obtains this information about cardiovascular risk factors. Which interventions will be important to include in the discharge plan for this client? Select all that apply. Health History: Hypertension for 10 years, Takes hydrochlorothiazide 25 mg daily, Blood pressure range 110/60 to 132/72 mm Hg Family History: Client's mother and 2 siblings have had myocardial infarctions Social History: 20 pack-year history of cigarette use, Walks 2 to 3 miles daily --------- 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing emotional stress 5. Discussion of the risks associated with having a sedentary lifestyle

1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Assess skin turgor by pinching the skin over the back of the hand 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake 6. Seeking a dietary consult to increase fluids on meal trays

1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake

A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report? 1. Repeated episodes of nausea and vomiting 2. Reports of pain associated with exertion 3. Failure to eat all the food on the breakfast tray 4. Client hair loss during the morning bath

1. Repeated episodes of nausea and vomiting

A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding would the nurse instruct the student to report immediately? 1. Respiratory rate of 8 to 10 breaths/min 2. Decrease in pain level from 6 to 2 (on a scale of 1 to 10) 3. Request by the client that the room door be closed 4. Heart rate of 90 to 100 beats/min

1. Respiratory rate of 8 to 10 breaths/min

A patient with acute myelogenous leukemia is receiving induction-phase chemotherapy. Which assessment finding requires the most rapid action? 1. Serum potassium level 7.8 mEq/L (7.8 mmol/L) 2. Urine output less than intake by 400 mL 3. Inflammation and redness of the oral mucosa 4. Ecchymoses present on the anterior trunk

1. Serum potassium level 7.8 mEq/L (7.8 mmol/L)

The nurse is providing care for a client newly diagnosed with early Alzheimer disease (AD). On assessment, which finding would the nurse expect to discover? 1. Short-term memory impairment 2. Rapid mood swings 3. Physical aggressiveness 4. Increased confusion at night

1. Short-term memory impairment

The nurse is caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will the nurse implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/hr. 3. Administer the first dose of oral oseltamivir. 4. Obtain blood and sputum specimens for testing.

1. Start oxygen using a nonrebreather mask.

The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is most important to report to the health care provider? 1. Stools have been black in color. 2. Bruising is present at the right groin. 3. Home blood pressure today was 104/52 mm Hg. 4. Home radial pulse rate has been 55 to 60 beats/min.

1. Stools have been black in color.

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply. 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle 6. Reminding the client to void in a urinal every hour while awake

1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education

1. Supplying injection drug users with sterile injection equipment such as needles and syringes

When administering a blood transfusion to a patient, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Take the patient's vital signs before the transfusion is started. 2. Assure that the blood is infused within no more than 4 hours. 3. Ask the patient at frequent intervals about presence of chills or dyspnea. 4. Assist with double-checking the patient's identification and blood bag number.

1. Take the patient's vital signs before the transfusion is started.

In the care of a patient with neutropenia, what tasks should the nurse instruct unlicensed assistive personnel (UAP) to perform? Select all that apply. 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 4. Gathering the supplies to prepare the room for protective isolation 6. Practicing good hand-washing technique

The nurse delegates the measurement of vital signs to an experienced unlicensed assistive personnel (UAP). Osteomyelitis has been diagnosed in a patient. Which vital sign value would the nurse instruct the UAP to report immediately for this patient? 1. Temperature of 101°F (38.3°C) 2. Blood pressure of 136/80 mm Hg 3. Heart rate of 96 beats/min 4. Respiratory rate of 24 breaths/min

1. Temperature of 101°F (38.3°C)

Which finding in a client with aortic stenosis will be most important for the nurse to report to the health care provider? 1. Temperature of 102.1°F (38.9°C) 2. Loud systolic murmur over sternum 3. Blood pressure of 110/88 mm Hg 4. Weak radial and pedal pulses to palpation

1. Temperature of 102.1°F (38.9°C)

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? 1. The client no longer recognizes family members. 2. The blood glucose level is 234 mg/dL (13 mmol/L). 3. The client reports a continuing headache. 4. The daily weight has increased 2.2 lb (1 kg).

1. The client no longer recognizes family members.

The nurse is caring for a patient who takes warfarin daily for a diagnosis of atrial fibrillation. Which information about the patient is most important to report to the health care provider (HCP)? 1. The international normalized ratio (INR) is 5.2. 2. Bruising is noted at sites where blood has been drawn. 3. The patient reports eating a green salad for lunch every day. 4. The patient has questions about whether a different anticoagulant can be used.

1. The international normalized ratio (INR) is 5.2.

A patient in the allergy clinic who has a rash has received diphenhydramine 50 mg PO. Which patient information is most indicative of a need for action by the nurse? 1. The patient is preparing to drive home. 2. The patient reports itching at the site of the rash. 3. The patient has a history of constipation. 4. The patient states, "My mouth feels so very dry!"

1. The patient is preparing to drive home.

The nurse is evaluating a patient with human immunodeficiency virus (HIV) who is receiving trimethoprim-sulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider? 1. The patient reports a blistering rash. 2. The patient's fluid intake is 2 L/day. 3. The patient's potassium is 3.4 mg/dL (3.4 mmol/L). 4. The patient enjoys spending time outside in the sun.

1. The patient reports a blistering rash.

During assessment of a patient with fractures of the medial ulna and radius, the nurse finds all of these data. Which assessment finding should the nurse report to the health care provider immediately? 1. The patient reports pressure and pain. 2. The cast is in place and is dry and intact. 3. The skin is pink and warm to the touch. 4. The patient can move all the fingers and the thumb.

1. The patient reports pressure and pain.

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

1. The patient was recently in a motor vehicle crash.

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? Select all that apply. 1. The student nurse uses a sterile catheter and glove. 2. The student nurse applies suction while inserting the catheter. 3. The student nurse applies suction during catheter removal. 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter. 6. The student nurse applies suction for at least 20 seconds.

1. The student nurse uses a sterile catheter and glove. 3. The student nurse applies suction during catheter removal. 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter.

When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the client is pain free or acceptable level is reached. 3. Titrate downward to prevent toxicity, overdose, and adverse effects. 4. Titrate to a dosage that is adequate to meet the client's subjective needs.

1. Titrate to the smallest dose that provides relief with the fewest side effects.

Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? 1. Turn the client to one side. 2. Give lorazepam 2 mg IV. 3. Administer oxygen via nonrebreather mask. 4. Assess the client's level of consciousness.

1. Turn the client to one side.

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLs)? Select all that apply. 1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.

1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 5. Be sure the patient's footwear has a firm sole when the patient ambulates.

Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing health care provider before administration? 1. Warfarin 1.0 mg PO 2. Morphine 2 to 4 mg IV 3. Cephalexin 250 mg PO 4. Heparin infusion at 900 units/hr

1. Warfarin 1.0 mg PO

The nurse is preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points should the nurse be sure to include? Select all that apply. 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 4. Expect a few bumps and bruises when you go home. 5. Rest when you are tired. 6. Avoid consuming three or more alcoholic drinks per day.

1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 5. Rest when you are tired

The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that apply. 1. When did you first experience the headache symptoms? 2. Who is the Mayor of Cleveland? 3. What is your health care provider's name? 4. What year and month is this? 5. What is your parents' address? 6. What is the name of this health care facility?

1. When did you first experience the headache symptoms? 3. What is your health care provider's name? 4. What year and month is this? 6. What is the name of this health care facility?

For a patient who is receiving chemotherapy, which laboratory result is of particular importance? 1. White blood cell count 2. Prothrombin time 3. Electrolyte levels 4. Blood urea nitrogen level

1. White blood cell count

When the nurse is educating a group of women of childbearing age about the Zika virus, which information will be included? Select all that apply. 1. Women who are pregnant will be asked about possible Zika exposure at each prenatal visit. 2. Testing for recent infection with the Zika virus is available for women who may have been exposed to Zika. 3. There is a high risk for maternal death when women are infected with the Zika virus during pregnancy. 4. Women who are trying to get pregnant should avoid travel to geographic areas with active Zika virus transmission. 5. Barrier methods such as condoms should be used during intercourse if the sex partner has possible Zika exposure.

1. Women who are pregnant will be asked about possible Zika exposure at each prenatal visit. 2. Testing for recent infection with the Zika virus is available for women who may have been exposed to Zika. 4. Women who are trying to get pregnant should avoid travel to geographic areas with active Zika virus transmission. 5. Barrier methods such as condoms should be used during intercourse if the sex partner has possible Zika exposure.

The emergency department nurse receives a call about a patient with a traumatic finger amputation. What instructions does the nurse provide to the patient's wife? Select all that apply. 1. Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. 2. Put the finger in a watertight, sealed plastic bag. 3. Place the bag directly on ice. 4. Elevate the affected extremity above the patient's heart. 5. Examine the amputation site and apply direct pressure with layers of dry gauze. 6. After performing these steps, call 911 and check the patient for breathing.

1. Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. 2. Put the finger in a watertight, sealed plastic bag. 4. Elevate the affected extremity above the patient's heart. 5. Examine the amputation site and apply direct pressure with layers of dry gauze.

The nurse is caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells the nurse that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3°F (37.9°C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. The nurse decides to notify the client's provider. Place the following report information in the correct order according to the SBAR (situation, background, assessment, recommendation) format. 1. "Dr. S, this is Nurse J from Unit X. I'm calling about Mr. D, who is reporting severe abdominal pain." 2. "He is restless and anxious: temperature is 100.3°F (37.9°C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 3. "Would you like to give me an order for any laboratory tests or additional therapies at this time?" 4. "He had abdominal surgery yesterday. He is on morphine via patient-controlled analgesia, but he says the pain is getting progressively worse." 5. "I have tried to make him comfortable, and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation."

1. "Dr. S, this is Nurse J from Unit X. I'm calling about Mr. D, who is reporting severe abdominal pain." 4. "He had abdominal surgery yesterday. He is on morphine via patient-controlled analgesia, but he says the pain is getting progressively worse." 2. "He is restless and anxious: temperature is 100.3°F (37.9°C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 5. "I have tried to make him comfortable, and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." 3. "Would you like to give me an order for any laboratory tests or additional therapies at this time?"

A client is crying and grimacing but denies pain and refuses pain medication because "my brother is a drug addict and has ruined our lives." What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 4. Seek family assistance in resolving this problem

1. Encourage expression of fears and past experiences.

Methylprednisolone 60 mg IV is prescribed for a patient who is experiencing a systemic lupus erythematosus (SLE) exacerbation. Based on the label for the medication (refer to figure), the nurse will administer __________ mL.

125 mg in 2 mL equals 60 mg in 0.96 mL

The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had a myocardial infarction and the client's spouse. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this teaching."

2. "Can you tell me why you don't feel that you need to make any changes?"

When a patient with tuberculosis (TB) is being prepared for discharge, which statement by the patient indicates a need for further teaching? 1. "Everyone in my family needs to go and see the doctor for TB testing." 2. "I will continue to take my isoniazid until I am feeling completely well." 3. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." 4. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

2. "I will continue to take my isoniazid until I am feeling completely well."

Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, "None of these doctors has done anything to help." Which client statement is cause for greatest concern? 1. "I twisted my back last night, and now the pain is a lot worse." 2. "I'm so sick of this pain. I think I'm going to find a way to end it." 3. "Occasionally, I buy pain killers from a guy in my neighborhood." 4. "I'm going to sue you and the doctor; you aren't doing anything for me."

2. "I'm so sick of this pain. I think I'm going to find a way to end it."

The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response? 1. "It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." 2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." 3. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." 4. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism."

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? 1. "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients." 2. "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." 3. "With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes." 4. "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin."

2. "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients."

The nurse hears in hand-off report that the patient with cancer received an as needed (PRN) oral dose of lorazepam. Which question is the oncoming nurse most likely to ask the off-going nurse in relation to the medication? 1. "What did the patient say about the location and level of the pain?" 2. "Were you able to determine what was making the patient so anxious?" 3. "When is the patient allowed to have another dose of lorazepam?" 4. "Did the patient have a normal bowel movement after the medication?

2. "Were you able to determine what was making the patient so anxious?"

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse's best response? 1. "Let's elevate the head of your bed and see if that helps." 2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." 3. "Sometimes patients also experience dry mouth and difficulty with swallowing." 4. "I will call your health care provider and let him know about this."

2. "Your voice should improve in 6 to 8 weeks after completion of the radiation."

While working on the cardiac step-down unit, the nurse is precepting a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? 1. A 19-year-old client with rheumatic fever who needs discharge teaching before going home with a roommate today 2. A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV 3. A 50-year-old client with newly diagnosed stable angina who has many questions about medications and nursing care 4. A 75-year-old client who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

2. A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV

The nurse has just received a change-of-shift report about these clients on the coronary step-down unit. Which one will the nurse assess first? 1. A 26-year-old client with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today 2. A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change 3. A 56-year-old client who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure 4. A 77-year-old client who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6°F (38.1°C)

2. A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change

For which client with severe migraine headaches would the nurse question an order for sumatriptan? 1. A 58-year-old client with gastrointestinal reflux disease 2. A 48-year-old client with hypertension 3. A 65-year-old client with mild emphysema 4. A 72-year-old client with hyperthyroidism

2. A 48-year-old client with hypertension

Four clients arrive simultaneously at the emergency department. Which client requires the most rapid action by the triage nurse to protect other clients from infection? 1. A 3-year-old client who has paroxysmal coughing and whose sibling has pertussis 2. A 5-year-old client who has a new pruritic rash and a possible chickenpox infection 3. A 62-year-old client who has an ongoing methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. A 74-year-old client who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

2. A 5-year-old client who has a new pruritic rash and a possible chickenpox infection

Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? 1. A 28-year-old newly admitted client with a spinal cord injury 2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness 3. An 85-year-old client with dementia who is to be transferred to long-term care today 4. A 54-year-old client with Parkinson disease who needs assistance with bathing

2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness

Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? 1. A 34-year-old client with newly diagnosed multiple sclerosis (MS) 2. A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS) 3. A 56-year-old client with Guillain-Barré syndrome (GBS) in respiratory distress 4. A 25-year-old client admitted with a C4-level spinal cord injury (SCI)

2. A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS)

Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day? 1. A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis 2. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent 3. A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip 4. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

2. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent

When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/LVN under the supervision of a team leader RN? 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy

2. A patient who needs enemas and antibiotics to control GI bacteria

Which cancer patients could be placed together as roommates? Select all that apply. 1. A patient who has a very low neutrophil count 2. A patient who underwent debulking of a tumor to relieve pressure 3. A patient who just underwent a bone marrow transplantation 4. A patient who had a laminectomy for spinal cord compression 5. A patient who is undergoing brachytherapy for prostate cancer 6. A patient with terminal cancer who is receiving end-of-life care

2. A patient who underwent debulking of a tumor to relieve pressure 4. A patient who had a laminectomy for spinal cord compression

The nurse is supervising an RN who floated from the medical-surgical unit to the emergency department. The float nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide to the RN? Select all that apply. 1. Position the patient supine and turned on his side. 2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. 6. Teach the patient to avoid vigorous nose blowing.

2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. 6. Teach the patient to avoid vigorous nose blowing.

Which information about a client who has meningococcal meningitis is the best indicator that the nurse can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100°F (37.8°C).

2. Appropriate antibiotics have been given for 24 hours.

The nurse is working in a clinic that specializes in the care of clients with ear disorders. A client tells the nurse that he has been taking meclizine. Which question is the nurse most likely to ask to evaluate the effectiveness of the medication? 1. Has the medication helped to relieve the pain in the ear canal? 2. Are you still experiencing the whirling and turning sensations? 3. Have you been able to hear better since you started the medication? 4. Are you still having the itching and discomfort in the outer ear?

2. Are you still experiencing the whirling and turning sensations?

The nurse is supervising a new nurse who has just finished assessing a client for redness and discomfort to the right eye. The new nurse documents "visual acuity N/A." What should the supervising nurse do? 1. Do nothing; the documentation is minimal but acceptable. 2. Ask her to explain the rationale for the documentation. 3. Reassess the client's eye and vision to validate findings. 4. Suggest contacting the clinical educator for documentation tips.

2. Ask her to explain the rationale for the documentation

The nurse is caring for a patient with uterine cancer who is being treated with intracavitary radiation therapy. Unlicensed assistive personnel (UAP) reports that the patient insisted on ambulating to the bathroom and now "something feels like it is coming out." What is the priority action? 1. Assess the UAP's knowledge; explain the rationale for strict bed rest. 2. Assess for dislodgment; use forceps to retrieve and a lead container to store as needed. 3. Assess the patient's knowledge of the treatment plan and her willingness to participate. 4. Notify the health care provider about dislodgment of the radiation implant.

2. Assess for dislodgment; use forceps to retrieve and a lead container to store as needed.

A client received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that the client has a respiratory rate of 10 breaths/min. What is the priority action? 1. Call the health care provider to obtain an order for naloxone. 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20 breaths/min. 4. Double-check the prescription to see which drugs were ordered.

2. Assess the client's responsiveness and respiratory status.

In the care of a client who has sustained recent blindness, which tasks would be appropriate to delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1. Counseling the client to express grief or loss 2. Assisting the client with ambulating in the hall 3. Orienting the client to the surroundings 4. Encouraging independence 5. Obtaining supplies for hygienic care 6. Storing personal items to reduce clutter

2. Assisting the client with ambulating in the hall 5. Obtaining supplies for hygienic care

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit

2. B-type natriuretic peptide

When the nurse is assessing a patient with chronic kidney disease who is receiving epoetin alfa (erythropoietin) injections, which finding most indicates a need to talk with the health care provider (HCP) before giving the medication? 1. Hemoglobin level is 8.9 g/dL (89 g/L). 2. Blood pressure is 198/92 mm Hg. 3. The patient does not like subcutaneous injections. 4. The patient has a history of myocardial infarction.

2. Blood pressure is 198/92 mm Hg.

For a patient with osteogenic sarcoma, which laboratory value causes the most concern? 1. Sodium level of 135 mEq/L (135 mmol/L) 2. Calcium level of 13 mg/dL (3.25 mmol/L) 3. Potassium level of 4.9 mEq/L (4.9 mmol/L) 4. Hematocrit of 40%

2. Calcium level of 13 mg/dL (3.25 mmol/L)

A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse tells the nurse that he does not sleep well because he needs to be sure the client does not wander during the night. He insists on checking each of the medications the nurse gives the client to be sure they are "the same pills she takes at home." Based on this information, which nursing problem is most appropriate for this client? 1. Acute client confusion 2. Care provider role stress 3. Increased risk for falls 4. Noncompliance with therapeutic plan

2. Care provider role stress

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first? 1. Administer the ordered acetaminophen. 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the health care provider about the change in status.

2. Check the Foley tubing for kinks or obstruction.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient symptoms of pneumothorax.

2. Check vital signs every 15 minutes for 1 hour. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory.

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? 1. Assessing the client's respiratory status every 4 hours 2. Checking and recording the client's vital signs every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

2. Checking and recording the client's vital signs every 4 hours

The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction? 1. Client reports shortness of breath. 2. Client is more difficult to arouse. 3. Client is more anxious and nervous. 4. Client reports pain is worsening.

2. Client is more difficult to arouse.

Which client is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

2. Client receiving IV furosemide to treat acute left ventricular failure

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump 2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 6. Client with arthritis who needs scheduled pain medications and heat applications

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen most urgently? 1. Client with peripheral arterial disease who complains of leg cramps when walking 2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope 3. Client with a new permanent pacemaker who has severe itchiness at the wound site 4. Client with angina who took nitroglycerin twice in the last week while exercising

2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope

The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN? 1. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Developing UAP training programs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed

2. Collecting data about the patients' responses to medications used for pain and anorexia

An older client tells the home health nurse that several days ago, he had ranibizumab injected into his eye for treatment of wet age-related macular degeneration. He is now experiencing redness, light sensitivity, and pain. What should the nurse tell the client? 1. These are common side effects that should pass after a few more days. 2. Contact the health care provider (HCP) immediately for possible eye infection. 3. Rest eyes as much as possible and wear sunglasses if lights are too bright. 4. Inform the HCP before next the treatment so that the dosage can be adjusted.

2. Contact the health care provider (HCP) immediately for possible eye infection.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water-seal chamber

Which assessment finding strongly suggests that the patient with cancer is having incident pain? 1. Frequently reports pain about 30 to 35 minutes before next scheduled dose 2. Demonstrates protectiveness of right arm whenever moving or standing up 3. Reports a continuous burning and tingling sensation in left lower leg 4. Appears quiet, withdrawn and depressed when family leaves after visiting

2. Demonstrates protectiveness of right arm whenever moving or standing up

The nurse is preparing a patient who had carpal tunnel release surgery for discharge. Which information is important to provide for this patient? 1. The surgical procedure is a cure for carpal tunnel syndrome (CTS). 2. Do not lift any heavy objects. 3. Frequent doses of pain medication will no longer be necessary. 4. The health care provider should be notified immediately if there is any pain or discomfort.

2. Do not lift any heavy objects.

After chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory result requires particular attention? 1. Platelet counts 2. Electrolyte levels 3. Hemoglobin levels 4. Hematocrit levels

2. Electrolyte levels

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy

2. Encouraging, monitoring, and recording nutritional intake

Which action by the infection control nurse in an acute care hospital will be most effective in reducing the incidence of health care-associated infections? 1. Require nursing staff to don gowns to change wound dressings for all clients. 2. Ensure that dispensers for alcohol-based hand rubs are available in all client care areas. 3. Screen all newly admitted clients for colonization or infection with methicillin-resistant Staphylococcus aureus (MRSA). 4. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug-resistant organisms.

2. Ensure that dispensers for alcohol-based hand rubs are available in all client care areas.

The nurse notes white powder on the arms and chest of a client who arrives at the emergency department and reports possible anthrax contamination. Which action included in the hospital protocol for possible anthrax exposure will the nurse take first? 1. Notify hospital security personnel about the client. 2. Escort the client to a decontamination room. 3. Give ciprofloxacin 500 mg PO. 4. Assess the client for signs of infection.

2. Escort the client to a decontamination room.

A primary nursing responsibility is the prevention of lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to assign to an LPN/LVN? 1. Develop a "quit plan" 2. Explain how to apply a nicotine patch 3. Discuss strategies to avoid relapse 4. Suggest ways to deal with urges for tobacco

2. Explain how to apply a nicotine patch

The nurse is caring for a young client with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action? 1. Notify the charge nurse and make arrangements to transfer to intensive care. 2. Explain significance of BG and insulin and then call the health care provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin.

2. Explain significance of BG and insulin and then call the health care provider.

A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the health care provider, the nurse would anticipate which initial treatment for this patient? 1. A fluid bolus 2. Fluid restrictions 3. Urinalysis 4. Sodium-restricted diet

2. Fluid restrictions

An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20 mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question? 1. Discontinue prednisone after today's dose. 2. Give a "catch-up" dose of varicella vaccine. 3. Check the patient's C-reactive protein level. 4. Administer ibuprofen 800 mg PO TID.

2. Give a "catch-up" dose of varicella vaccine.

The emergency department (ED) nurse should question which health care provider order when providing care for an older adult with a fracture of the left ulna? 1. Get x-rays of left forearm. 2. Give meperidine IM for pain. 3. Monitor vital signs every hour. 4. Elevate left arm on pillows.

2. Give meperidine IM for pain.

A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Blood pressure is 104/62 mm Hg, oxygen saturation is 92%, and the patient reports pain at a level 8 (on a scale of 0 to 10). Which action prescribed by the health care provider will the nurse implement first? 1. Administer morphine sulfate 4 to 8 mg IV. 2. Give oxygen at 4 L/min per nasal cannula. 3. Start an infusion of normal saline at 200 mL/hr. 4. Apply warm packs to painful joints.

2. Give oxygen at 4 L/min per nasal cannula.

The nurse is supervising a student nurse who is caring for a patient with human immunodeficiency virus (HIV). The patient has severe esophagitis caused by Candida albicans. Which action by the student requires the most rapid intervention by the nurse? 1. Putting on a mask and gown before entering the patient's room 2. Giving the patient a glass of water after administering the prescribed oral nystatin suspension 3. Suggesting that the patient should order chile con carne or chicken soup for the next meal 4. Placing a "No Visitors" sign on the door of the patient's room

2. Giving the patient a glass of water after administering the prescribed oral nystatin suspension

The nurse assesses the patient and determines that the patient is having frequent breakthrough cancer pain. Which member of the health care team is the nurse most likely to contact first? 1. Physical therapist to reevaluate physical therapy routines 2. Health care provider to review medication, dosage, and frequency 3. Unlicensed assistive personnel to provide more assistance with activities of daily living 4. Psychiatric clinical nurse specialist to evaluate psychogenic pain

2. Health care provider to review medication, dosage, and frequency

The health care provider telephones the nurse with new prescriptions for a client with angina who is already taking aspirin. Which medication is most important to clarify further with the health care provider? 1. Clopidogrel 75 mg/day 2. Ibuprofen 200 mg every 4 hours as needed 3. Metoprolol succinate 50 mg/day 4. Nitroglycerin patch 0.4 mg/hr

2. Ibuprofen 200 mg every 4 hours as needed

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? 1. Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times.

2. Inform the nurse immediately if the client's respiratory rate and depth increases.

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone 2000 mg IV to treat the infection. 3. Give acetaminophen 650 mg orally to reduce the fever. 4. Give furosemide 40 mg IV to decrease intracranial pressure.

2. Infuse ceftriaxone 2000 mg IV to treat the infection.

The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is most indicative of a need for a change in therapy? 1. Blood pressure is 106/54 mm Hg. 2. International normalized ratio (INR) is 1.2. 3. Bruises are noted at sites where blood has been drawn. 4. Client reports eating a green salad for lunch every day.

2. International normalized ratio (INR) is 1.2.

The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to assign to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter

2. Listening to lung sounds and checking for edema each week

The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

A patient who has sickle cell disease is admitted with vaso-occlusive crisis and reports severe abdominal and flank pain. Which of the analgesic medications on the pain treatment protocol will be best for the nurse to administer initially? 1. Ibuprofen 800 mg PO 2. Morphine sulfate 4 mg IV 3. Hydromorphone liquid 5 mg PO 4. Fentanyl 25 mcg/hr transdermal patch

2. Morphine sulfate 4 mg IV

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the client? Select all that apply. 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

2. N95 respirator 3. Gown 4. Gloves

A patient who has been receiving cyclosporine following an organ transplantation is experiencing these symptoms. Which one is of most concern? 1. Bleeding of the gums while brushing the teeth 2. Nontender lump in the right groin 3. Occasional nausea after taking the medication 4. Numbness and tingling of the feet

2. Nontender lump in the right groin

The RN notes that a client with myasthenia gravis has an elevated temperature (102.2°F [39°C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's best action at this time? 1. Administer an acetaminophen suppository. 2. Notify the health care provider immediately. 3. Recheck vital signs in 1 hour. 4. Reschedule the client's physical therapy.

2. Notify the health care provider immediately.

Which nurse is demonstrating the first step in managing cancer pain by using the ABCDE (ask, believe, choose, deliver, and empower) clinical approach to pain management as recommended by the Agency for Healthcare Research and Quality? 1. Nurse J asks if the time of the prescribed dose of medication can be changed. 2. Nurse K asks the patient to describe pain and uses a numerical pain scale. 3. Nurse L asks the patient to participate and to contribute in pain management. 4. Nurse M asks about pain management options that are appropriate for the patient.

2. Nurse K asks the patient to describe pain and uses a numerical pain scale.

For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Note the time of and client's response to the last dose of analgesic. 4. Give the maximum as needed (PRN) dose within the minimum time frame for relief.

2. Obtain baseline behavioral indicators from family members.

A patient in a long-term care facility who has anemia reports chronic fatigue and dizziness with minimal activity. Which nursing activity will the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Evaluating the patient's response to normal activities of daily living 2. Obtaining the patient's blood pressure and pulse with position changes 3. Determining which self-care activities the patient can do independently 4. Assisting the patient in choosing a diet that will improve strength

2. Obtaining the patient's blood pressure and pulse with position changes

When the occupational health nurse is teaching unlicensed assistive personnel (UAP) about bloodborne pathogen exposure and human immunodeficiency virus (HIV) risk, which information is most important to emphasize? 1. Occupational transmission of HIV from patients to health care workers is relatively rare. 2. Occupational exposure to HIV-containing fluids should be reported immediately to the supervisor. 3. Treatment for occupational exposure to HIV may include use of antiretroviral medications. 4. Postexposure treatment will include HIV testing at baseline and at several intervals after the exposure.

2. Occupational exposure to HIV-containing fluids should be reported immediately to the supervisor.

The nurse notices that the health care provider omits hand hygiene after leaving a client's hospital room. Which action by the nurse is best at this time? 1. Report the health care provider to the infection control department. 2. Offer the health care provider an alcohol based hand sanitizing fluid. 3. Provide the health care provider with a list of upcoming inservices on hand hygiene. 4. Remind the health care provider about the importance of minimizing infection spread.

2. Offer the health care provider an alcohol based hand sanitizing fluid.

Which of these patients who have just arrived at the emergency department should the nurse assess first? 1. Patient who reports several dark, tarry stools and a history of peptic ulcer disease 2. Patient with hemophilia A who is experiencing thigh swelling after a fall 3. Patient who has pernicious anemia and reports paresthesia of the hands and feet 4. Patient with thalassemia major who needs a scheduled blood transfusion

2. Patient with hemophilia A who is experiencing thigh swelling after a fall

The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium

2. Potassium

Which blood test result would the nurse be sure to monitor for the client taking hydrochlorothiazide (HCTZ)? 1. Sodium level 2. Potassium level 3. Chloride level 4. Calcium level

2. Potassium level

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

2. Providing straws and offering fluids between meals

Which actions should the nurse delegate to an unlicensed assistive personnel (UAP) for the client with diabetic ketoacidosis? Select all that apply. 1. Checking fingerstick glucose results every hour 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 4. Assessing for indicators of fluid imbalance 5. Notifying the provider of changes in glucose level 6. Assisting the client to reposition every 2 hours

2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 6. Assisting the client to reposition every 2 hours

The unlicensed assistive personnel (UAP) reports to the nurse that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Respiratory alkalosis

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest

2. Respiratory rate of 8 breaths/min

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? 1. Reassess the client's blood pressure and heart rate. 2. Review the client's morning calcium level. 3. Request a neurologic consult today. 4. Check the client's pupillary reaction to light.

2. Review the client's morning calcium level.

A cheerful older widow comes to the community clinic for her annual checkup. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, "I don't get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing." What is the priority nursing concept to consider in planning care for this client? 1. Cognition 2. Sensory perception 3. Mood and affect 4. Anxiety

2. Sensory perception

The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

2. Setting up oxygen and suction equipment

While administering vancomycin 500 mg IV to a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the client's neck and face are becoming flushed. Which action should the nurse take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the client's temperature.

2. Slow the rate of the vancomycin infusion.

A nursing student is assisting an older client who is alert, conversant, and cognitively intact. The client has decreased vision related to macular degeneration. When would the supervising nurse intervene? 1. Student puts call bell and personal items within reach and locates each item by guiding the client's hand. 2. Student closes the curtains and turns off all of the lights at the end of the shift to encourage rest and sleep. 3. Student talks to the client about family and asks, "So, when was the last time that you saw your uncle?" 4. Student assists during mealtime by opening packages and describing location of foods by using clock coordinates.

2. Student closes the curtains and turns off all of the lights at the end of the shift to encourage rest and sleep.

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

2. Taking vital signs and pulse oximetry readings every 4 hours

The client is diagnosed by the emergency department health care provider (HCP) with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed? 1. The HCP is considering dexamethasone to prevent reoccurrence, and the client has type 2 diabetes. 2. The HCP is considering subcutaneous sumatriptan, and the client took ergotamine 3 hours ago. 3. The HCP is considering metoclopramide, and this is a first-time migraine for the client. 4. The HCP is considering prochlorperazine, and the client drove himself to the hospital.

2. The HCP is considering subcutaneous sumatriptan, and the client took ergotamine 3 hours ago.

The nurse's assessment reveals all of these data when a patient with Paget disease is admitted to the acute care unit. Which finding should the nurse notify the health care provider about first? 1. There is a bowing of both legs, and the knees are asymmetrical. 2. The base of the skull is invaginated (platybasia). 3. The patient is only 5 feet tall and weighs 120 lb. 4. The skull is soft, thick, and larger than normal.

2. The base of the skull is invaginated (platybasia).

The nurse is caring for a client who has heart failure and has a new prescription for sacubitril-valsartan. Which client information is most important to discuss with the health care provider before administration of the medication? 1. The client's oxygen saturation is 92%. 2. The client receives lisinopril 10 mg/day. 3. The client's blood pressure is 150/90 mm Hg. 4. The client's potassium is 3.3 mEq/L (3.3 mmol/L).

2. The client receives lisinopril 10 mg/day.

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? 1. The client's condition is improving. 2. The client's condition is deteriorating. 3. The client will need intubation and mechanical ventilation. 4. The client's medication regime will need adjustments.

2. The client's condition is deteriorating.

The hospital employee health nurse is completing a health history for a newly hired staff member. Which information given by the new employee most indicates the need for further nursing action before the new employee begins orientation to patient care? 1. The employee takes enalapril for hypertension. 2. The employee has allergies to bananas, avocados, and papayas. 3. The employee received a tetanus vaccination 3 years ago. 4. The employee's tuberculin skin test has a 5-mm induration at 48 hours.

2. The employee has allergies to bananas, avocados, and papayas.

The nurse in the outpatient clinic is assessing a 22-year-old patient who needs a physical exam before starting a new job. The patient reports a history of a splenectomy several years previously after an accident but has otherwise been healthy. Which information obtained during the assessment will be of most immediate concern to the nurse? 1. The patient engages in unprotected sex. 2. The oral temperature is 100°F (37.8°C). 3. The blood pressure is 148/76 mm Hg. 4. The patient admits to daily marijuana use.

2. The oral temperature is 100°F (37.8°C).

A patient has a fractured femur. Which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient reports pain. 2. The patient appears confused. 3. The patient's blood pressure is 136/88 mm Hg. 4. The patient voided using the bedpan.

2. The patient appears confused.

Initiation of subcutaneous etanercept for a patient with rheumatoid arthritis is being considered. Which patient information is most important for the nurse to communicate with the health care provider? 1. The patient is currently taking methotrexate. 2. The patient has a positive tuberculin skin test result. 3. The patient has had type 2 diabetes for 5 years. 4. The patient is anxious about having to self-inject.

2. The patient has a positive tuberculin skin test result.

The nurse assesses a 24-year-old patient with rheumatoid arthritis who is considering using methotrexate for treatment. Which patient information is most important to communicate to the health care provider? 1. The patient has many concerns about the safety of the drug. 2. The patient has been trying to get pregnant. 3. The patient takes a daily multivitamin tablet. 4. The patient says that she has taken methotrexate in the past.

2. The patient has been trying to get pregnant.

A patient who has human immunodeficiency virus (HIV) and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider? 1. The patient exclaims, "I'm afraid I'm going to die right here!" 2. The prescribed patient medications include midazolam 2 mg IV immediately. 3. The patient is diaphoretic and tremulous and reports dizziness. 4. The symptoms occurred suddenly while the patient was driving to work.

2. The prescribed patient medications include midazolam 2 mg IV immediately.

A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3 (2.3 x 109/L). 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

2. The white blood cell count is 2300/mm3 (2.3 x 109/L).

The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under an RN's supervision. What will the RN tell the LPN/LVN is the major focus for the patient's care today? 1. To attain pain control over phantom pain 2. To monitor for signs of sufficient tissue perfusion 3. To assist the patient to ambulate as soon as possible 4. To elevate the residual limb when the patient is supine

2. To monitor for signs of sufficient tissue perfusion

After a car accident, a patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency department. Which action prescribed by the health care provider will the nurse implement first? 1. Transport to the radiology department for cervical spine radiography. 2. Transfuse factor VII concentrate. 3. Type and cross-match for 4 units of packed red blood cells (PRBCs). 4. Infuse normal saline at 250 mL/hr.

2. Transfuse factor VII concentrate.

A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement first? 1. Place the client on the hospital alcohol withdrawal protocol. 2. Transport the client to the radiology department for a computed tomography (CT) scan. 3. Make a referral to the social services department. 4. Give the client phenytoin 100 mg PO.

2. Transport the client to the radiology department for a computed tomography (CT) scan.

A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

2. Troponin I level

The nurse is interviewing an older woman and discovers that she has been taking her glaucoma eyedrops by mouth for the past week. What should the nurse do first? 1. Obtain a prescription for tonometry so that her intraocular pressure can be checked. 2. Try to determine how frequently and how much she has been ingesting. 3. Ask her how she decided to take the drops orally instead of instilling them as eyedrops. 4. Call the Poison Control Center and be prepared to describe untoward side effects.

2. Try to determine how frequently and how much she has been ingesting.

The nurse is caring for a postoperative patient with a hip replacement. Which patient care actions can be delegated to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Inspect heels and other bony prominences every 8 hours. 2. Turn and reposition the patient every 2 hours. 3. Assure that the patient's heels are elevated off the bed. 4. Assess the patient's calf regions for redness and swelling. 5. Check vital signs and oxygen saturation via pulse oximetry. 6. Assess for pain and administer pain medication.

2. Turn and reposition the patient every 2 hours. 3. Assure that the patient's heels are elevated off the bed. 5. Check vital signs and oxygen saturation via pulse oximetry.

Which of these patients cared for by the nurse in the clinic presents the highest risk for infection with human immunodeficiency virus (HIV) during sexual intercourse? 1. Uninfected man who reports performing oral intercourse with an HIV-infected woman 2. Uninfected man who is the receiver during anal intercourse with an HIV-infected man 3. Uninfected woman who has had vaginal intercourse with an HIV-infected man 4. Uninfected woman who has performed oral intercourse with an HIV-infected woman

2. Uninfected man who is the receiver during anal intercourse with an HIV-infected man

Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? Select all that apply. 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs.

2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs.

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication

2. Client on the second postoperative day who needs pain medication before dressing changes 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication

Which postoperative client is manifesting the most serious negative effect of inadequate pain management? 1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort 2. Develops venous thromboembolism related to immobility caused by pain and discomfort 3. Refuses to participate in physical therapy because of fear of pain caused by exercises 4. Feels depressed about loss of function and hopeless about getting relief from pain

2. Develops venous thromboembolism related to immobility caused by pain and discomfort

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? 1. "Your wife was not admitted within the time frame that alteplase is usually given." 2. "This drug is used primarily for clients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase."

3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain."

The night shift nurse tells the oncoming dayshift nurse that the cancer patient is on around-the-clock dosing of morphine but that the patient might be having end-of-dose pain. Which question is the most important to ask the night shift nurse? 1. "How many times did you have to give a bolus dose of morphine?" 2. "Did the patient tell you that the pain was greater than a 5/10?" 3. "Did you notify the health care provider (HCP), and were changes prescribed?" 4. "Did you try any nonpharmaceutical therapies or adjuvant medications?

3. "Did you notify the health care provider (HCP), and were changes prescribed?"

The nurse performed postoperative stapedectomy teaching several days ago for a client. Which comment by the client is cause for greatest concern? 1. "I'm going to take swimming lessons in a couple of months." 2. "I have to take a long overseas flight in several weeks." 3. "I can't wait to get back to my regular weightlifting class." 4. "I have been coughing a lot with my mouth open."

3. "I can't wait to get back to my regular weightlifting class."

A 67-year-old patient who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which statement made by the patient when the nurse is obtaining the admission history is of most concern? 1. "I've noticed that I bruise more easily since the chemotherapy started." 2. "My bowel movements are soft and dark brown." 3. "I take ibuprofen every day because of my history of osteoarthritis." 4. "My appetite has decreased since the chemotherapy started."

3. "I take ibuprofen every day because of my history of osteoarthritis."

Which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional teaching? 1. "I will drink 2 to 3 L of fluids every day." 2. "I will drink a glass of water whenever I feel thirsty." 3. "I will drink coffee and cola drinks throughout the day." 4. "I will avoid drinks containing alcohol."

3. "I will drink coffee and cola drinks throughout the day."

The nurse is working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should the nurse direct the caller to do first? 1. "Please call your health care provider" (e.g., decline to advise). 2. "Apply a cool compress to your eyes." 3. "If you are wearing contact lenses, remove them." 4. "Take an over-the-counter antihistamine."

3. "If you are wearing contact lenses, remove them."

The health care provider (HCP) tells the patient with cancer that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. Which patient statement is cause for greatest concern? 1. "My symptoms will eventually be cured; I'm so happy that I don't have to worry any longer." 2. "My doctor is trying to help me control the symptoms; I am grateful for the extension of time with my family." 3. "My pain will be relieved, but I am going to die soon; I would like to have control over my own life and death." 4. "Initially, I may have to take some time off work for my treatments; I can probably work full time in the future."

3. "My pain will be relieved, but I am going to die soon; I would like to have control over my own life and death."

A client's family member comes to the nurse's station and says, "He needs more pain medicine. He is still having a lot of pain." What is the nurse's best response? 1. "The health care provider (HCP) ordered the medicine to be given every 4 hours." 2. "If medication is given too frequently, there are ill effects." 3. "Please tell him that I will be right there to check on him." 4. "Let's wait about 40 minutes. If there he still hurts, I'll call the HCP."

3. "Please tell him that I will be right there to check on him."

The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The client begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." What is the best response? 1. "Let me stop the pump, and we can try oral pain medication to see if it relieves the pain." 2. "I realize that you are scared of the pain, but we must try to wean you off the pump." 3. "Show me where your pain is and describe how it feels compared with yesterday." 4. "Let's take your vital signs; then I will discuss your concerns with the health care provider."

3. "Show me where your pain is and describe how it feels compared with yesterday."

A 22-year-old patient with stage I Hodgkin disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the patient tells the nurse, "Sometimes I'm afraid of dying." Which response is most appropriate at this time? 1. "Many individuals with this diagnosis have some fears." 2. "Perhaps you should ask the doctor about medication." 3. "Tell me a little bit more about your fear of dying." 4. "Most people with stage I Hodgkin disease survive."

3. "Tell me a little bit more about your fear of dying.

The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's best response? 1. "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out from not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."

3. "The client's skeletal muscles are weak because of the low phosphorus."

Family members are encouraging the client to "tough out the pain" rather than risk drug addiction to opioids. The client is stoically abiding. The nurse recognizes that the sociocultural dimension of pain is the current priority for the client. Which question will the nurse ask? 1. "Where is the pain located, and does it radiate to other parts of your body?" 2. "How would you describe the pain, and how is it affecting you?" 3. "What do you believe about pain medication and drug addiction?" 4. "How is the pain affecting your activity level and your ability to function?"

3. "What do you believe about pain medication and drug addiction?"

The nurse is preparing to insert a peripherally inserted central catheter (PICC) in a client's left forearm. Which solution will be best for cleaning the skin prior to the PICC insertion? 1. 70% isopropyl alcohol 2. Povidone-iodine solution 3. 0.5% chlorhexidine in alcohol 4. Betadine followed by 70% isopropyl alcohol

3. 0.5% chlorhexidine in alcohol

After the nurse receives change-of-shift report, which patient should be assessed first? 1. A 42-year-old patient with carpal tunnel syndrome who reports pain 2. A 64-year-old patient with osteoporosis awaiting discharge 3. A 28-year-old patient with a fracture who reports that the cast is tight 4. A 56-year-old patient with a left leg amputation who reports phantom pain

3. A 28-year-old patient with a fracture who reports that the cast is tight

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? 1. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose 2. A 42-year-old client admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm 3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due 4. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy

3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due

The charge nurse is making the daily assignments on the medical-surgical unit. Which patient is best assigned to a float RN who has come from the postanesthesia care unit (PACU)? 1. A 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine 2. A 43-year-old patient with multiple myeloma who requires discharge teaching 3. A 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy 4. A 65-year-old patient with pernicious anemia who has just been admitted to the unit

3. A 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy

For which of these clients is IV morphine the first-line choice for pain management? 1. A 33-year-old intrapartum client needs pain relief for labor contractions. 2. A 24-year-old client reports severe headache related to being hit in the head. 3. A 56-year-old client reports breakthrough bone pain related to multiple myeloma. 4. A 73-year-old client reports chronic pain associated with hip replacement surgery.

3. A 56-year-old client reports breakthrough bone pain related to multiple myeloma.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? 1. A 58-year-old patient on airborne precautions for tuberculosis (TB) 2. A 65-year-old patient who just returned from bronchoscopy and biopsy 3. A 72-year-old patient who needs teaching about the use of incentive spirometry 4. A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

3. A 72-year-old patient who needs teaching about the use of incentive spirometry

Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia

3. A client with progressive pancreatic cancer

The emergency department nurse is caring for a client who was just admitted with left anterior chest pain, possible acute myocardial infarction (MI). Which action will the nurse take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.

3. Administer sublingual nitroglycerin.

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN/LVN? 1. Performing ongoing assessments to determine the client's hydration status 2. Explaining the purpose of ordered stool cultures to the client and family 3. Administering the prescribed metronidazole 500 mg PO to the client 4. Reviewing the client's medical history for any risk factors for diarrhea

3. Administering the prescribed metronidazole 500 mg PO to the client

A patient with wheezing and coughing caused by an allergic reaction is admitted to the emergency department. Which medication will the nurse anticipate administering first? 1. Methylprednisolone 100 mg IV 2. Cromolyn 20 mg via nebulizer 3. Albuterol 3 mL via nebulizer 4. Aminophylline 500 mg IV

3. Albuterol 3 mL via nebulizer

When the community health nurse is counseling a client who has an acute Zika virus infection, which information is most important to include? 1. Drink fluids to prevent dehydration. 2. Use acetaminophen to reduce pain and fever. 3. Apply insect repellant frequently to prevent mosquito bites. 4. Symptoms of Zika infection include fever, red eyes, rash, and joint pain.

3. Apply insect repellant frequently to prevent mosquito bites.

The charge nurse observes an LPN/LVN assigned to provide all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? 1. Administering 600 mg of ibuprofen to the patient 2. Encouraging the patient to perform exercises recommended by a physical therapist 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese

3. Applying ice and gentle massage to the patient's lower extremities

The charge nurse discovers that two nurses have switched patients because Nurse A does "not like to take care of patients with prostate cancer." Which action should the charge nurse take first? 1. Insist that they switch back to the original patient assignments and talk to each of them at the end of the shift. 2. Allow them this flexibility; as long as the patients are well cared for, it doesn't matter if the assignments are changed. 3. Ask Nurse A to explain her position regarding prostate cancer patients and seek alternatives to prevent future issues. 4. Explain to Nurse A and B that all patients deserve kindness and care regardless of their condition or the nurses' personal feelings.

3. Ask Nurse A to explain her position regarding prostate cancer patients and seek alternatives to prevent future issues.

A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take next? 1. Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems. 2. Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day. 3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. 4. Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects.

3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week.

The health care provider prescribes 7 mg morphine IV as needed (PRN). The nursing student prepares the medication and shows the syringe (refer to figure) to the nursing instructor. What should the nursing instructor do first? . Tell the student to review the provider's prescription before administering medication. 2. Waste the medication and tell the student that remediation is required for serious error. 3. Ask the student to demonstrate the calculations and steps required to prepare the dose. 4. Accompany the student to the client's room and observe as the medication is administered.

3. Ask the student to demonstrate the calculations and steps required to prepare the dose.

The nurse is caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should be delegated to the unlicensed assistive personnel (UAP)? 1. Initiating placement of a splint for immobilization during the day 2. Assessing the patient's wrist and hand for discoloration and brittle nails 3. Assisting the patient with daily self-care measures such as bathing and eating 4. Testing the patient for painful tingling in the four digits of the hand

3. Assisting the patient with daily self-care measures such as bathing and eating

The nurse is reviewing medications that have been prescribed for several clients who have disorders of the eye. Which medication prescription is the most important to discuss with the health care provider? 1. Timolol for open-angle glaucoma 2. Cromolyn sodium for allergic conjunctivitis 3. Atropine for acute angle-closure glaucoma 4. Ranibizumab for wet age-related macular degeneration

3. Atropine for acute angle-closure glaucoma

Which physical assessment findings should be reported to the health care provider? 1. Pearly gray or pink tympanic membrane 2. Dense whitish ring at the circumference of the tympanum 3. Bulging red or blue tympanic membrane 4. Cone of light at the innermost part of the tympanum

3. Bulging red or blue tympanic membrane

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection

3. Checking the client's vital signs

The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is most important to report to the health care provider? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client complains about a frequent dry cough. 4. Client says, "I get dizzy sometimes if I stand up fast."

3. Client complains about a frequent dry cough.

A client with stable angina has a prescription for ranolazine 500 mg twice a day. Which client finding is most important for the nurse to discuss with the health care provider? 1. Heart rate is 52 beats/min. 2. Client is also taking carvedilol for angina. 3. Client reports having chronic constipation. 4. Blood pressure is 106/56 mm Hg.

3. Client reports having chronic constipation.

The nurse is caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection? 1. Client with an implanted port in the right subclavian vein 2. Client who has a midline IV catheter in the left antecubital fossa 3. Client who has a nontunneled central line in the left internal jugular vein 4. Client with a peripherally inserted central catheter (PICC) line in the right upper arm

3. Client who has a nontunneled central line in the left internal jugular vein

The nurse is monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min

3. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions

The nurse at the infectious disease clinic has four clients waiting to be seen. Which client should the nurse see first? 1. Client who has a 16-mm induration after a tuberculosis (TB) skin test 2. Client who has human immunodeficiency virus and a low CD4 count 3. Client who has swine influenza (H1N1) and reports increased dyspnea 4. Client who has been exposed to Zika virus and has a rash and joint pain

3. Client who has swine influenza (H1N1) and reports increased dyspnea

The nurse admits four clients with infections to the medical unit, but only one private room is available. Which client is most appropriate to assign to the private room? 1. Client with diarrhea caused by C. difficile 2. Client with vancomycin-resistant enterococcus (VRE) infection 3. Client with a cough who may have active tuberculosis (TB) 4. Client with toxic shock syndrome and fever

3. Client with a cough who may have active tuberculosis (TB)

In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. Client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed.

3. Client's perception of pain must be accepted.

The nurse is providing care for a patient with a rotator cuff tear. What treatment does the nurse expect the health care provider will prescribe first for this patient? 1. Arthroscopic repair of the rotator cuff tear 2. Elimination of movements in the affected shoulder 3. Conservative therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy 4. Pendulum exercises that start slow and progress over 2 weeks

3. Conservative therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action? 1. Perform a complete neurologic assessment. 2. Assess the cranial nerve functions. 3. Contact the Rapid Response Team. 4. Reassess the client in 30 minutes.

3. Contact the Rapid Response Team.

The nurse is asked to float to a different nursing unit. During report, the nurse is told that the patient is receiving IV administration of vincristine that should be completed within the next 15 minutes. The IV site is intact, and the patient is not having any problems with the infusion. The nurse is not certified in chemotherapy administration. What is the priority action? 1. Ask the off-going nurse to stay until the vincristine infusion is finished. 2. Ask the off-going nurse about problems to expect with vincristine infusions. 3. Contact the charge nurse and discuss the lack of chemotherapy certification. 4. Look up drug side effects and monitor because the infusion is almost complete.

3. Contact the charge nurse and discuss the lack of chemotherapy certification.

An athletic young man was recently diagnosed with Ewing sarcoma. He has pain, low-grade fever, and anemia. The surgeon recommends amputation of the right lower leg for an operable tumor. The patient tells the nurse that he is leaving the hospital to go on a long hiking trip. What is the priority nursing concept to consider at this time? 1. Pain 2. Cellular regulation 3. Coping 4. Adherence

3. Coping

An experienced nurse is precepting a newly hired nurse who has 2 years of medical-surgical experience but limited experience with patients who have cancer. The new hire seems to be consistently under medicating the patients' pain. What should the preceptor do first? 1. Reassess all of the patients and administer additional pain medication as needed. 2. Write an incident report and inform the nurse manager about the nurse's performance. 3. Determine the new nurse's understanding and beliefs about cancer pain and treatments. 4. Ask the new nurse about past experience in administering pain medications.

3. Determine the new nurse's understanding and beliefs about cancer pain and treatments.

The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes

A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps

3. Diaphoresis

The nurse is preparing a nursing care plan for a client with a spinal cord injury (SCI) for whom problems of decreased mobility and inability to perform activities of daily living (ADLs) have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes priority? 1. Risk for injury 2. Decreased nutrition 3. Difficulty with coping 4. Impairment of body image

3. Difficulty with coping

The nurse is teaching an older patient about risks for fractures and osteoporosis. Which diagnostic test should the nurse teach about when the goal is to establish the patient's bone strength and determine if osteoporosis is present? 1. Computed tomography (CT) scan 2. Magnetic resonance imaging (MRI) scan 3. Dual-energy x-ray absorptiometry (DXA or DEXA) scan 4. Joint x-rays

3. Dual-energy x-ray absorptiometry (DXA or DEXA) scan

An 80-year-old client on the coronary step-down unit tells the nurse "I do not need to take that docusate. I never get constipated!" Which action by the nurse is most appropriate? 1. Document the medication on the client's chart as "refused." 2. Mix the medication with food and administer it to the client. 3. Explain that his decreased activity level may cause constipation. 4. Reinforce that the docusate has been prescribed for a good reason.

3. Explain that his decreased activity level may cause constipation.

A few minutes after the nurse has given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should the nurse take first? 1. Start oxygen at 6 L/min using a face mask. 2. Obtain IV access with a large-bore IV catheter. 3. Give epinephrine 0.5 mg intramuscularly. 4. Administer albuterol per nebulizer mask.

3. Give epinephrine 0.5 mg intramuscularly.

For a postoperative client, the health care provider (HCP) prescribed multimodal therapy, which includes acetaminophen, nonsteroidal anti-inflammatory drugs, as needed (PRN) opioids, and nonpharmaceutical interventions. The client continuously asks for the PRN opioid, and the nurse suspects that the client may have a drug abuse problem. Which action by the nurse is best? 1. Administer acetaminophen and spend extra time with the client. 2. Explain that opioid medication is reserved for moderate to severe pain. 3. Give the opioid because client deserves relief and drug abuse is unconfirmed. 4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription.

3. Give the opioid because client deserves relief and drug abuse is unconfirmed.

For care of a patient who has oral cancer, which task would be appropriate to assign to an LPN/LVN? 1. Assisting the patient to perform oral hygiene 2. Explaining when brushing and flossing are contraindicated 3. Giving antacids and sucralfate suspension as ordered 4. Recommending saliva substitutes

3. Giving antacids and sucralfate suspension as ordered

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia

3. Hyponatremia

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client's care? 1. Teaching the client and family members about means to prevent transmission of VRE 2. Communicating with other departments when the client is transported for ordered tests 3. Implementing contact precautions when providing care for the client 4. Monitoring the results of ordered laboratory culture and sensitivity tests

3. Implementing contact precautions when providing care for the client

A patient with sickle cell disease is admitted with splenic sequestration. The blood pressure is 86/40 mm Hg, and heart rate is 124 beats/min. Which of these actions will the nurse take first? 1. Complete a head-to-toe assessment. 2. Draw blood for type and cross-match. 3. Infuse normal saline at 250 mL/hr. 4. Ask the patient about vaccination history.

3. Infuse normal saline at 250 mL/hr.

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first? 1. Give acetaminophen 650 mg PO. 2. Administer ondansetron 4 mg IV. 3. Infuse normal saline at 500 mL/hr. 4. Increase oxygen flow rate to 6 L/min.

3. Infuse normal saline at 500 mL/hr.

A patient with graft-versus-host disease after bone marrow transplantation is being cared for on the medical unit. Which nursing activity is best assigned to a travel RN? 1. Administering oral cyclosporine 2. Assessing the patient for signs of infection 3. Infusing 5% dextrose in 0.45% saline at 125 mL/hr 4. Educating the patient about ways to prevent infection

3. Infusing 5% dextrose in 0.45% saline at 125 mL/hr

A client reports a sudden excruciating pain in the left eye with the visual change of colored halos around lights and blurred vision. Which interventions should the nurse expect and perform for this emergency condition? Select all that apply. 1. Prepare the client for photodynamic therapy. 2. Instill a mydriatic agent, such as phenylephrine. 3. Instill a miotic agent, such as pilocarpine. 4. Administer an oral hyperosmotic agent, such as isosorbide. 5. Apply a cool compress to the forehead. 6. Provide a darkened, quiet, and private space for the client.

3. Instill a miotic agent, such as pilocarpine. 4. Administer an oral hyperosmotic agent, such as isosorbide. 5. Apply a cool compress to the forehead. 6. Provide a darkened, quiet, and private space for the client.

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern? 1. Ask the client about his or her bowel movements. 2. Have the client complete a diet diary for the past 2 days. 3. Instruct the client to increase oral intake to 2 to 3 L/day. 4. Ask the client to describe his urine output.

3. Instruct the client to increase oral intake to 2 to 3 L/day.

A patient with an absolute neutrophil count of 300/μL (0.3 × 109/L) is admitted to the oncology unit. Which staff member should the charge nurse assign to provide care for this patient, under the supervision of an experienced oncology RN? 1. LPN/LVN who has floated from the same-day surgery unit 2. RN from a staffing agency who is being oriented to the oncology unit 3. LPN/LVN with 2 years of experience on the oncology unit 4. RN who recently transferred to the oncology unit from the emergency department

3. LPN/LVN with 2 years of experience on the oncology unit

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled. 2. Hyperoxygenate the patient before suctioning. 3. Maintain the head of bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.

3. Maintain the head of bed at a 30- to 45-degree angle.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

3. Marks the tube 1 cm from where it touches the incisor tooth or nares

For a client who has multiple risk factors for primary open-angle glaucoma (POAG), which sign or symptom should be investigated as an early sign of POAG? 1. Loss of central visual field 2. Seeing halos around lights 3. Mild eye aching 4. Loss of peripheral vision

3. Mild eye aching

A patient with a history of liver transplantation is receiving cyclosporine, prednisone, and mycophenolate. Which finding is of most concern? 1. Gums that appear very pink and swollen 2. Blood glucose level of 162 mg/dL (9 mmol/L) 3. Nontender lump above the clavicle 4. Grade 1 + pitting edema in the feet and ankles

3. Nontender lump above the clavicle

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. The nurse notes that no pulse is palpable in the left foot and that it is cold and pale. Which action should the nurse take next? 1. Lower the client's left foot below heart level. 2. Administer oxygen at 4 L/min to the client. 3. Notify the health care provider about the change in status. 4. Reassure the client that embolization is common in endocarditis.

3. Notify the health care provider about the change in status.

The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain? 1. Nurse A uses a behavioral assessment tool when the client is engaged in activities. 2. Nurse B asks a client who doesn't speak English to point to the location of pain. 3. Nurse C uses the same numerical rating scale every day for the same client. 4. Nurse D asks the daughter of a confused client to describe the client's pain.

3. Nurse C uses the same numerical rating scale every day for the same client.

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN? 1. Planning ways to improve the client's oral protein intake 2. Teaching the client about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown

3. Obtaining wound cultures during dressing changes

For a patient receiving the chemotherapeutic drug vincristine, which side effect should be reported to the health care provider (HCP)? 1. Fatigue 2. Nausea 3. Paresthesia 4. Anorexia

3. Paresthesia

A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene? 1. Helping the client ambulate to the bathroom and back to bed 2. Reminding the client not to look at his feet when he is walking 3. Performing the client's complete bathing and oral care 4. Setting up the client's tray and encouraging the client to feed himself

3. Performing the client's complete bathing and oral care

The nurse is caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood glucose level 3. Potassium level 4. Alkaline phosphatase level

3. Potassium level

A community health center is preparing a presentation on the prevention and detection of cancer. Which task would be best to assign to the LPN/LVN? 1. Explain screening examinations and diagnostic testing for common cancers. 2. Discuss how to plan a balanced diet and reduce fats and preservatives. 3. Prepare a poster on the seven warning signs of cancer. 4. Describe strategies for reducing risk factors such as smoking and obesity.

3. Prepare a poster on the seven warning signs of cancer.

The nurse is providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that the nurse intervene immediately? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter 3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution 4. Telling the patient that the PRBCs may cause a serious transfusion reaction

3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution

At a community health clinic, the nurse is teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress? 1. Workplace policies for handling chemicals should be followed. 2. Children and parents should be cautious about aggressive play. 3. Protective eyewear should be worn during sports or hazardous work. 4. Emergency eyewash stations should be established in the workplace.

3. Protective eyewear should be worn during sports or hazardous work.

A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine and methylprednisolone. Which staff member is best to assign to care for this patient? 1. RN who floated to the medical unit from the coronary care unit for the day 2. RN with 3 years of experience in the operating room who is orienting to the medical unit 3. RN who has worked on the medical unit for 5 years and is working a double shift today 4. Newly graduated RN who needs experience with IV medication administration

3. RN who has worked on the medical unit for 5 years and is working a double shift today

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Discussing weight-loss strategies such as diet and exercise with the patient 2. Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping 3. Reminding the patient to sleep on his side instead of his back 4. Administering modafinil to promote daytime wakefulness

3. Reminding the patient to sleep on his side instead of his back

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient about the importance of adequate fluid intake and hydration 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site

3. Removing the inner cannula and cleaning using standard precautions

The nurse observes the unlicensed assistive personnel (UAP) performing all of these interventions for a patient with carpal tunnel syndrome (CTS). Which action requires that the nurse intervene immediately? 1. Arranging the patient's lunch tray and cutting his meat 2. Providing warm water and assisting the patient with his bath 3. Replacing the patient's splint in hyperextension position 4. Reminding the patient not to lift very heavy objects

3. Replacing the patient's splint in hyperextension position

For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment

3. Reporting the amount and type of food consumed from the tray

Two weeks ago, a client with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the client in the cardiology clinic is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles

3. Sinus bradycardia at a rate of 48 beats/min

The home health nurse discovers that an older adult client has been sharing his pain medication with his daughter. Despite the nurse's warnings about the dangers of sharing, he states, "My daughter can't afford to see a doctor or to buy medicine, so I must give her a few of my pain pills." Which member of the health care team is the nurse most likely to consult first? 1. Health care provider to renew the prescription so that client has enough medicine 2. Pharmacist to monitor the frequency of the prescription refills 3. Social worker to help the family locate resources for health care 4. Home health aide to watch for inappropriate medication usage by family

3. Social worker to help the family locate resources for health care

The nurse is on a camping trip. A man is chopping wood and gets struck in the eye with a piece of debris. On examination, a wood splinter is protruding from his eyeball. What should the nurse do first? 1. Have the man lie in the back seat of the car and drive him to the emergency department. 2. Gently remove the piece of wood and place a sterile dressing over the eye. 3. Stabilize the area by carefully resting a plastic cup on the orbital rim and taping it in place. 4. Flush the eye with copious amounts of clean tepid water; then check visual acuity.

3. Stabilize the area by carefully resting a plastic cup on the orbital rim and taping it in place.

The nurse is participating as a team member in the resuscitation of a client who has had a cardiac arrest. The health care provider who is directing the resuscitation asks the nurse to administer epinephrine 1 mg IV. After giving the medication, which action should the nurse take next? 1. Prepare to defibrillate the client. 2. Offer to take over chest compressions. 3. State: "Epinephrine 1 mg IV has been given." 4. Continue to monitor the client's responsiveness.

3. State: "Epinephrine 1 mg IV has been given."

A transfusion of packed red blood cells (PRBCs) has been infusing for 5 minutes when the patient becomes flushed and tachypneic and says, "I'm having chills. Please get me a blanket." Which action should the nurse take first? 1. Obtain a warm blanket for the patient. 2. Check the patient's oral temperature. 3. Stop the transfusion. 4. Administer oxygen.

3. Stop the transfusion.

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)? 1. The patient starts crying and says she can't go on with treatment much longer. 2. The patient reports sharp, stabbing chest pain with every deep breath. 3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. 4. The dressing at the thoracentesis site has 1 cm of bloody drainage.

3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min.

The nurse has received a needlestick injury after giving a client an intramuscular injection, but has no information about whether the client has human immunodeficiency virus (HIV) infection. What is the most appropriate method of obtaining this information about the client? 1. The nurse should personally ask the client to authorize HIV testing. 2. The charge nurse should tell the client about the need for HIV testing. 3. The occupational health nurse should discuss HIV status with the client. 4. HIV testing should be performed the next time blood is drawn for other tests.

3. The occupational health nurse should discuss HIV status with the client.

The nurse is making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider? 1. The patient says that her right leg aches all night. 2. The right calf is warm to the touch and is larger than the left calf. 3. The patient is unable to remember her husband's first name. 4. There are multiple ecchymotic areas on the patient's abdomen.

3. The patient is unable to remember her husband's first name.

A patient is admitted to the intensive care unit with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the most immediate implications for the patient's care? 1. There is no palpable radial or pedal pulse. 2. The patient reports chest pain. 3. The patient's oxygen saturation is 87%. 4. There is mottling of the hands and feet

3. The patient's oxygen saturation is 87%.

A patient with chemotherapy-related neutropenia is receiving filgrastim injections. Which finding by the nurse is most important to report to the health care provider? 1. The patient says, "My bones are aching." 2. The patient's platelet count is 110,000 mm3 (110 × 109/L). 3. The patient's white blood cell count is 39,000 mm3 (39.0 × 109/L). 4. The patient reports that the medication stings when it is injected.

3. The patient's white blood cell count is 39,000 mm3 (39.0 × 109/L).

A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient wants to change position in bed. 2. There is a small amount of clear fluid at the pin sites. 3. The traction weights are resting on the floor. 4. The patient reports pain and muscle spasm.

3. The traction weights are resting on the floor.

Which description by a client reporting vertigo is cause for greatest concern? 1. Dizziness with hearing loss 2. Episodic vertigo 3. Vertigo without hearing loss 4. "Merry-go-round" vertigo

3. Vertigo without hearing loss

During a home visit to an 88-year-old client who is taking digoxin 0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most important to communicate to the health care provider? 1. Apical pulse 68 beats/min and irregular 2. Digoxin taken with meals 3. Vision that is becoming "fuzzy" 4. Lung crackles that clear after coughing

3. Vision that is becoming "fuzzy"

Study Mode: Part 2 Question 338 of 827 ID: 338 HomeHelp Bookmark < Go > A client with Guillain-Barré syndrome (GBS) is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Observe the access site for ecchymosis or bleeding. 2. Instruct the client that there will be three or four treatments. 3. Weigh the client before and after the procedure. 4. Assess the access site for bruit and thrill every 2 to 4 hours.

3. Weigh the client before and after the procedure.

The home health nurse is reviewing the cancer patient's medication list and sees that a bisphosphonate medication has been prescribed. Which question is the nurse most likely to ask to evaluate the efficacy of the medication? 1. "Has the medication helped relieve the discomfort in your mouth?" 2. "Have you noticed any increase or changes in your energy level?" 3. "Has the medication helped to stop the nausea and vomiting?" 4. "Has the medication relieved the bone pain that you were having?"

4. "Has the medication relieved the bone pain that you were having?"

The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL [2.25 to 2.63 mmol/L]). Which statement by the client indicates the need for additional teaching? 1. "I will call my doctor if I experience muscle twitching or seizures." 2. "I will make sure to take my vitamin D with my calcium each day." 3. "I will take my calcium citrate pill every morning before breakfast." 4. "I will avoid dairy products, broccoli, and spinach when I eat."

4. "I will avoid dairy products, broccoli, and spinach when I eat."

During morning care, a patient with a below-the-knee amputation asks the unlicensed assistive personnel (UAP) about prostheses. How will the nurse instruct the UAP to respond? 1. "You should get a prosthesis so that you can walk again." 2. "Wait and ask your doctor that question the next time he comes in." 3. "It's too soon to be worrying about getting a prosthesis." 4. "I'll ask the nurse to come in and discuss this with you."

4. "I'll ask the nurse to come in and discuss this with you."

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? 1. "You should avoid consumption of all forms of alcohol." 2. "Wear your medical alert bracelet at all times." 3. "Protect your loved one's airway during a seizure." 4. "It's OK to take over-the-counter medications."

4. "It's OK to take over-the-counter medications."

The nurse is preparing to administer a beta-adrenergic blocking glaucoma agent. Which statement made by the client warrants additional assessment and notification of the health care provider? 1. "My blood pressure runs a little high if I gain too much weight." 2. "Occasionally, I have palpitations, but they pass very quickly." 3. "My joints feel stiff today, but that's just my arthritis." 4. "My pulse rate is a little low today because I take digoxin."

4. "My pulse rate is a little low today because I take digoxin."

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. The student states that the patient's oral body temperature is elevated at 100.8°F (38.2°C). Which statement by the student indicates correct understanding of this patient's curve shift? 1. "When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve." 2. "When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower." 3. "When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen." 4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

After change of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. A 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. A 57-year-old patient with chronic obstructive pulmonary disease (COPD) and a pulse oximetry reading from the previous shift of 90% saturation 3. A 72-year-old patient with pneumonia who needs to be started on IV antibiotics 4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

After the nurse receives the change-of-shift report at 7:00 am, which client must the nurse assess first? 1. A 23-year-old client with a migraine headache who reports severe nausea associated with retching 2. A 45-year-old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. A 59-year-old client with Parkinson disease who will need a swallowing assessment before breakfast 4. A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain

4. A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain

After the nurse receives a change-of-shift report, which patient should be seen first? 1. A 26-year-old patient with thalassemia who has a hemoglobin level of 8 g/dL (80 g/L) and orders for a blood transfusion 2. A 44-year-old patient admitted 3 days previously for sickle cell crisis who is scheduled for a computed tomographic (CT) scan 3. A 50-year-old patient with stage IV non-Hodgkin lymphoma who is crying and saying, "I'm not ready to die" 4. A 69-year-old patient with chemotherapy-induced neutropenia who has an oral temperature of 100.1°F (37.8°C)

4. A 69-year-old patient with chemotherapy-induced neutropenia who has an oral temperature of 100.1°F (37.8°C)

The charge nurse is making assignments for the day shift. Which patient should be assigned to the nurse who was floated from the postanesthesia care unit (PACU) for the day? 1. A 35-year-old patient with osteomyelitis who needs teaching before hyperbaric oxygen therapy 2. A 62-year-old patient with osteomalacia who is being discharged to a long-term care facility 3. A 68-year-old patient with osteoporosis given a new orthotic device whose knowledge of its use must be assessed 4. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement

4. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement

Which finding should be immediately reported to the health care provider? 1. A change in color vision 2. Crusty yellow drainage on the eyelashes 3. Increased lacrimation 4. A curtainlike shadow across the visual field

4. A curtainlike shadow across the visual field

After change-of-shift report, which newly admitted patient should the nurse assess first? 1. A patient with human immunodeficiency virus (HIV) whose CD4 count is 45 mm3 (45 cells/mcL) 2. A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due 3. A patient with graft-versus-host disease who has frequent liquid stools 4. A patient with hypertension who has angioedema after receiving lisinopril

4. A patient with hypertension who has angioedema after receiving lisinopril

The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weigh the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/day. 4. Administer furosemide 40 mg IV push.

4. Administer furosemide 40 mg IV push.

A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While the nurse is trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority nursing concept to consider in responding to this patient? 1. Elimination 2. Patient education 3. Cellular regulation 4. Anxiety

4. Anxiety

The nurse assesses a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 154/78 mm Hg. 2. Pedal pulses are palpable at + 1. 3. Left groin has a 3-cm bruised area. 4. Apical pulse is 122 beats/min and regular.

4. Apical pulse is 122 beats/min and regular.

The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? Study Mode: Part 2 Question 26 of 827 ID: 26 HomeHelp Bookmark < Go > The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

4. Applying oxygen per nasal cannula as ordered

What is the best way to schedule medication for a client with constant pain? 1. As needed (PRN) at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around-the-clock

4. Around-the-clock

An inexperienced graduate nurse is reviewing the medication administration record (MAR) for a client who has a patient-controlled analgesia (PCA) pump for pain management. The new nurse compares the MAR and the health care provider's (HCP's) prescription, and both indicate that larger doses are prescribed at night compared with doses throughout the day. Which member of the health care team should the new nurse consult first? 1. Ask the client if he typically needs extra medication in the evening. 2. Ask the HCP to verify that the larger amount is the correct dose. 3. Ask the pharmacist to confirm the dosage on the original prescription. 4. Ask the charge nurse if this is a typical dosage for nighttime PCA.

4. Ask the charge nurse if this is a typical dosage for nighttime PCA.

On the first day after surgery, a client receiving an analgesic via patient-controlled analgesia pump reports that the pain control is inadequate. What is the first action that the nurse should take? 1. Deliver the bolus dose per standing order. 2. Contact the health care provider (HCP) to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity.

4. Assess the pain for location, quality, and intensity.

A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the client in cleaning around the Unna boot

4. Assisting the client in cleaning around the Unna boot

The nurse is caring for a patient with osteoporosis who is at increased risk for falls. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist to provide the patient with a walker 4. Assisting the patient with ambulation to the bathroom and in the halls

4. Assisting the patient with ambulation to the bathroom and in the halls

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? 1. Evaluating the patient's reports of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

4. Auscultating the lungs for crackles

Which finding will be most important for the nurse to report to the health care provider about a patient who is taking prednisone chronically after an organ transplant? 1. Multiple arm bruises 2. Sodium level of 146 mEq/dL (146 mmol/L) 3. Blood glucose of 110 mg/dL (6.1 mmol/L) 4. Black-colored stools

4. Black-colored stools

The nurse is preparing a patient for magnetic resonance imaging (MRI). Which action can the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Teach the patient what to expect during the test. 2. Instruct the patient to remove metal objects including zippers. 3. Witness that the patient has signed the consent form. 4. Check and record preprocedure vital signs.

4. Check and record preprocedure vital signs.

When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 0 to 10)

4. Chest pain level of 3 (on a scale of 0 to 10)

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances? 1. History of myocardial infarction (MI) 1 year ago 2. Antacid use for occasional indigestion 3. Shortness of breath with extreme exertion 4. Chronic renal insufficiency

4. Chronic renal insufficiency

A patient with Hodgkin lymphoma who is receiving radiation therapy to the groin area has skin redness and tenderness in the area being irradiated. Which nursing activity should the nurse delegate to the unlicensed assistive personnel (UAP) caring for the patient? 1. Checking the skin for signs of redness or peeling 2. Assisting the patient in choosing appropriate clothing 3. Explaining good skin care to the patient and family 4. Cleaning the skin over the area daily with a mild soap

4. Cleaning the skin over the area daily with a mild soap

A client who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which client information is most important for the nurse to communicate to the health care provider (HCP) before the procedure? 1. Blood glucose level is 144 mg/dL (8 mmol/L). 2. Cardiac monitor shows sinus bradycardia, rate 56 beats/min. 3. Client reports chest pain that occurred yesterday. 4. Client took metformin 500 mg this morning.

4. Client took metformin 500 mg this morning.

The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time? 1. Place an 18-gauge IV in the nondominant arm. 2. Elevate the client's head of bed at least 45 degrees. 3. Instruct the UAP to provide the client with a pitcher of ice water. 4. Contact and notify the health care provider immediately.

4. Contact and notify the health care provider immediately.

The health care provider (HCP) has ordered a placebo for a client with chronic pain. The newly hired nurse feels very uncomfortable administering the medication. What is the first action that the new nurse should take? 1. Prepare the medication and hand it to the HCP. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice and suggestions.

4. Contact the charge nurse for advice and suggestions.

After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

4. Crowing noise during inspiration

The nurse is caring for a patient with rheumatoid arthritis who is taking naproxen twice a day to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider? 1. Joint pain worse in the morning 2. Dry eyes bilaterally 3. Round and moveable nodules under the skin 4. Dark-colored stools

4. Dark-colored stools

A patient seen in the sexually transmitted disease clinic has just tested positive for human immunodeficiency virus (HIV) with a rapid HIV test. Which action will the nurse take next? 1. Ask about patient risk factors for HIV infection. 2. Send a blood specimen for Western blot testing. 3. Provide information about antiretroviral therapy. 4. Discuss the positive test results with the patient.

4. Discuss the positive test results with the patient.

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4. Disinfecting blood pressure cuffs after clients are discharged

The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for documenting dose and time and discuss documentation deficits.

4. Give praise for documenting dose and time and discuss documentation deficits.

Which order prescribed for a client with hypercalcemia would the nurse be sure to question? 1. 0.9% saline at 50 mL/hr IV 2. Furosemide 20 mg orally each morning 3. Apply cardiac telemetry monitoring 4. Hydrochlorothiazide (HCTZ) 25 mg orally each morning

4. Hydrochlorothiazide (HCTZ) 25 mg orally each morning

The nurse is checking medication prescriptions that were received by telephone for a client with hypertensive crisis and tachycardia. Which medication is most important to clarify with the health care provider? 1. Carvedilol 12.5 mg PO BID daily 2. Hydrochlorothiazide 25 mg PO daily 3. Labetalol 20 mg IV over a 2-min time period now 4. Hydroxyzine 50 mg PO as needed (PRN) systolic blood pressure greater than 160 mm Hg

4. Hydroxyzine 50 mg PO as needed (PRN) systolic blood pressure greater than 160 mm Hg

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? 1. Blood pressure every 15 minutes 2. Place two 18-gauge IV lines 3. Oxygen at 3 L via nasal cannula 4. IV 5% dextrose in water (D5W) to run at 250 mL/hr

4. IV 5% dextrose in water (D5W) to run at 250 mL/hr

The nurse is reviewing the laboratory results for a client with an elevated cholesterol level who is taking atorvastatin. Which result is most important to discuss with the health care provider? 1. Serum potassium is 3.4 mEq/L (3.4 mmol/L). 2. Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L). 3. Aspartate aminotransferase (AST) is 30 units/L (0.5 μkat/L). 4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L).

4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L).

Based on this information in a client's medical record, which topic is the highest priority for the nurse to include in the initial teaching plan for a 26-year-old client who has blood pressures ranging from 150/84 to 162/90 mm Hg? Health History: Denies any chronic health problems, Takes no medications currently Physical Exam: Height: 5 feet, 6 inches, Weight: 115 lb (52.2 kg), Body mass index (BMI): 18.6 Social and Diet History: Works as an accountant, 1 glass of wine once or twice weekly, Eats "fast food" frequently -------- 1. Symptoms of acute stroke and myocardial infarction 2. Adverse effects of alcohol on blood pressure 3. Methods for decreasing dietary caloric intake 4. Low-sodium food choices when eating out

4. Low-sodium food choices when eating out

A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced unlicensed assistive personnel (UAP) states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a specimen

4. Measuring the urine output after the catheter is inserted and obtaining a specimen

The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis

4. Metabolic acidosis

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

4. Monitor respiratory effort and oxygen saturation level.

The patient describes a burning sensation in the leg. The health care provider tells the nurse that a medication will be prescribed for neuropathic pain secondary to chemotherapy. The nurse is most likely to question the prescription of which drug? 1. Imipramine 2. Carbamazepine 3. Gabapentin 4. Morphine

4. Morphine

Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Older adult client with chronic pain related to joint immobility 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Opioid-naïve adolescent with an arm fracture and cystic fibrosis

4. Opioid-naïve adolescent with an arm fracture and cystic fibrosis

A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? 1. Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2°F (38.4°C)

4. Oral temperature of 101.2°F (38.4°C)

After cataract surgery, the client experiences all of the symptoms listed below. Which symptom needs to be immediately reported to the health care provider? 1. A scratchy sensation in the operative eye 2. Loss of depth perception with the patch in place 3. Poor vision 6 to 8 hours after patch removal 4. Pain not relieved by prescribed medication

4. Pain not relieved by prescribed medication

The nurse has given morphine sulfate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells the nurse about having frequent watery stools. Which action will the nurse take first? 1. Notify the health care provider about the stools. 2. Obtain stool specimens for culture. 3. Instruct the client about correct hand washing. 4. Place the client on contact precautions.

4. Place the client on contact precautions.

The nurse is caring for several clients who are having problems with their ears. Which client condition is cause for greatest concern? 1. Has discomfort of the ear preceded by a viral infection; the tympanic membrane is erythematous 2. Has been treated with antibiotics for recurrent acute otitis media four times within the past 6 months 3. Reports rapid onset ear pain with pruritus and a sensation of fullness that started after cleaning the ear canal with a finger 4. Reports progressive severe otic pain with purulent discharge and is positive for human immunodeficiency virus

4. Reports progressive severe otic pain with purulent discharge and is positive for human immunodeficiency virus

The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? 1. Serum potassium level of 5.2 mEq/L (5.2 mmol/L) 2. Serum sodium level of 134 mEq/L (134 mmol/L) 3. Serum calcium level of 10.6 mg/dL (2.65 mmol/L) 4. Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)

4. Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)

An LPN/LVN, under the RN's supervision, is assigned to provide nursing care for a client with Guillain-Barré syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? 1. Reports of numbness and tingling 2. Facial weakness and difficulty speaking 3. Rapid heart rate of 102 beats/min 4. Shallow respirations and decreased breath sounds

4. Shallow respirations and decreased breath sounds

The RN is mentoring a student nurse who is caring for a patient with carpal tunnel syndrome of the right hand with neurovascular check ordered every 2 hours. For which action by the student nurse must the RN intervene? 1. Student nurse checks the patient's radial pulse every 2 hours. 2. Student nurse checks for sensation in the patient's right hand. 3. Student nurse assesses color, temperature, and pain in right wrist and hand. 4. Student nurse instructs the patient to avoid movement because of the pain.

4. Student nurse instructs the patient to avoid movement because of the pain.

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status.

4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status.

A healthy 65-year-old client who cares for a newborn grandchild has a clinic appointment in May. The client needs several immunizations but tells the nurse, "I hate shots! I will only take one today." Which immunization is most important to give? 1. Influenza 2. Herpes zoster 3. Pneumococcal 4. Tetanus, diphtheria, pertussis

4. Tetanus, diphtheria, pertussis

At 9:00 pm, the nurse admits a 63-year-old client with a diagnosis of acute myocardial infarction. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine for gastroesophageal reflux disease. 3. The client has ST-segment elevations on the electrocardiogram (ECG). 4. The client reports having continuous chest pain since 8:00 am.

4. The client reports having continuous chest pain since 8:00 am.

The nurse obtains the following data about a patient admitted with multiple myeloma. Which information requires the most rapid action by the nurse? 1. The patient reports chronic bone pain. 2. The blood uric acid level is very elevated. 3. The 24-hour urine test shows Bence Jones proteins. 4. The patient reports new-onset leg numbness.

4. The patient reports new-onset leg numbness.

A patient with iron deficiency anemia who is taking oral iron supplements is evaluated by the nurse in the outpatient clinic. Which finding by the nurse is of most concern? 1. The patient reports that stools are black. 2. The patient complains of occasional constipation. 3. The patient takes a multivitamin tablet every day. 4. The patient takes an antacid with the iron to avoid nausea.

4. The patient takes an antacid with the iron to avoid nausea.

The nurse is transferring a patient with newly-diagnosed chronic myeloid leukemia to a long-term care facility. Which information is most important to communicate to the nurse at the long-term care facility before transferring the patient? 1. Philadelphia chromosome is present in the patient's blood smear. 2. Glucose level is elevated as a result of prednisone therapy. 3. There has been a 20-lb (9.1-kg) weight loss over the last year. 4. The patient's chemotherapy has resulted in neutropenia.

4. The patient's chemotherapy has resulted in neutropenia.

The nurse obtains this information when assessing a patient with human immunodeficiency virus (HIV) who is taking antiretroviral therapy. Which finding is most important to report to the health care provider? 1. The blood glucose level is 144 mg/dL (8 mmol/L). 2. The hemoglobin level is 10.9 g/dL (109 g/L). 3. The patient reports frequent nausea. 4. The patient's viral load has increased.

4. The patient's viral load has increased.

An older patient needs treatment and relief for severe localized pain related to postherpetic neuralgia that developed during chemotherapy. The nurse is most likely to question the prescription of which type of medication? 1. Lidocaine patch 2. Gabapentinoid 3. Capsaicin patch 4. Tricyclic antidepressant

4. Tricyclic antidepressant

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4°F (38.6°C)

4. Tympanic temperature of 101.4°F (38.6°C)

The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports "feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed." Which member of the health care team would be the most appropriate to aid in the client's report of pain? 1. Health care provider to review the dosage and frequency of pain medication 2. Physical therapist for evaluation of function and possible exercise therapy 3. Social worker to locate community resources for complementary therapy 4. Unlicensed assistive personnel to help client with a warm shower in the morning

4. Unlicensed assistive personnel to help client with a warm shower in the morning

A patient with human immunodeficiency virus (HIV) who has been started on antiretroviral therapy is seen in the clinic for follow-up. Which test will be best to monitor when determining the response to therapy? 1. CD4 level 2. Complete blood count 3. Total lymphocyte percent 4. Viral load

4. Viral load

The nurse is preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse? 1. Famotidine 20 mg IV 2. Furosemide 40 mg IV 3. Digoxin 0.25 mg PO 4. Warfarin 2.5 mg PO

4. Warfarin 2.5 mg PO

The nurse is reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the health care provider before surgery? 1. Hematocrit of 33% (0.33) 2. Hemoglobin level of 10.9 g/dL (109 g/L) 3. Platelet count of 426,000/mm3 (426 × 109/L) 4. White blood cell count of 16,000/mm3 (16 × 109/L)

4. White blood cell count of 16,000/mm3 (16 × 109/L)

A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the staff nurses to assess their care of this client.

4. Have a conference with the staff nurses to assess their care of this client.

The oncoming day shift nurse has received the shift report from the night nurse. The day shift nurse has done a quick check on all of the clients and has determined that all are stable and not in acute distress. Prioritize the order in which the oncoming nurse will care for the following clients, 1 being the first and 5 being the last. 1. adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Older man who underwent total knee replacement surgery 2 days ago. He is using the PCA pump frequently with good relief but occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Older woman with advanced Alzheimer disease who requires total care for all ADLs. She struggles during any type of nursing care, and it is difficult to assess her subjecting symptoms. She is awaiting transfer to a long-term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued.

5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued. 3. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 1. adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Older man who underwent total knee replacement surgery 2 days ago. He is using the PCA pump frequently with good relief but occasionally asks for bolus doses. 4. Older woman with advanced Alzheimer disease who requires total care for all ADLs. She struggles during any type of nursing care, and it is difficult to assess her subjecting symptoms. She is awaiting transfer to a long-term care facility.

The day shift nurse is assessing the patient who has breast cancer and notices edema of the face, periorbital edema, and tightness around the neck of the gown. The nurse immediately notifies the health care provider for early signs and symptoms of superior vena cava syndrome. From the figure identify the superior vena cava.

A

The nurse is aware that many eyedrops that are prescribed for glaucoma could cause potentially serious systemic effects. From the figure identify the area where the nurse will teach the client to apply punctal occlusion to prevent systemic absorption.View Figure 1. A 2. B 3. C 4.

A

The nurse is working with a health care provider who prescribes opioid doses based on a specific pain intensity rating (dosing to the numbers). Which client circumstance is cause for greatest concern? 1. A 73-year-old frail female client with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10. 2. A 25-year-old postoperative male client with a history of opioid addiction is prescribed one tablet of oxycodone and acetaminophen for pain of 4 to 5 on a scale of 0 to 10. 3. A 33-year-old opioid-naïve female client who has a severe migraine headache is prescribed 5 mg IV morphine for pain of 7 to 8 on a scale of 0 to 10. 4. A 60-year-old male with a history of rheumatoid arthritis is prescribed one tablet of hydromorphone for pain of 5 to 6 on scale of 0 to 10.

A 73-year-old frail female client with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10.

The oncoming day shift nurse has just received hand over report from the night shift nurse. List the order of priority for assessing and caring for the following patients, with 1 being first and 4 being last. A patient who developed tumor lysis syndrome around 5:00 am A patient scheduled for exploratory laparotomy this morning A patient scheduled for exploratory laparotomy this morning A patient who is currently pain free but had breakthrough pain during the night A patient with anticipatory nausea and vomiting for the past 24 hours A patient with anticipatory nausea and vomiting for the past 24 hours A patient who is currently pain free but had breakthrough pain during the night

A patient who developed tumor lysis syndrome around 5:00 am A patient scheduled for exploratory laparotomy this morning A patient who is currently pain free but had breakthrough pain during the night A patient with anticipatory nausea and vomiting for the past 24 hours

The nurse is supervising an LPN/LVN who says, "I gave the client with myasthenia gravis 90 mg of neostigmine instead of the ordered 45 mg!" In which order should the nurse perform the following actions? Notify the health care provider of the incorrect medication dose. Assess the client's heart rate. Complete a medication error report. Ask the LPN/LVN to explain how the error occurred.

Assess the client's heart rate. Notify the health care provider of the incorrect medication dose. Ask the LPN/LVN to explain how the error occurred. Complete a medication error report.

The nurse is caring for an older woman with hepatic cancer. Unlicensed assistive personnel informs the nurse that the patient's level of consciousness is diminished compared with earlier in the shift. Prioritize the steps of assessment and intervention related to this patient's change of mental status. Check pulse oximeter readings and administer oxygen as needed. Take vital signs, including pulse, respirations, blood pressure, and temperature. Check responsiveness and level of consciousness. Obtain a blood glucose reading; give glucose per protocol. Check ammonia level. Check electrolyte values.

Check responsiveness and level of consciousness. Check pulse oximeter readings and administer oxygen as needed. Take vital signs, including pulse, respirations, blood pressure, and temperature. Obtain a blood glucose reading; give glucose per protocol. Check electrolyte values. Check ammonia level.

Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp chest pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an elevated blood pressure

Client who is having an acute myocardial infarction with severe chest pain

A client with acute coronary syndrome is receiving a continuous heparin infusion. The client is to receive 700 units/hour.Based on the heparin concentration on the label (refer to figure), the nurse will set the infusion pump to deliver __________ mL/hr.

Each mL of the solution contains heparin 40 units; 700 units/hour equals 17.5 mL/hr.

After examining the client's ear canal with an otoscope, the health care provider instructs the nurse to irrigate the ear canal. Place the following steps for ear irrigation in the correct order. Place the tip of the syringe at an angle in the external canal. Watch for fluid return and signs of cerumen. If cerumen does not appear, wait 10 minutes and repeat the irrigation. Fill a syringe with warm irrigating solution. After completion of the irrigation, have the client turn the head to the side to facilitate drainage. Apply gentle but continuous pressure to the syringe plunger.

Fill a syringe with warm irrigating solution. Place the tip of the syringe at an angle in the external canal. Apply gentle but continuous pressure to the syringe plunger. Watch for fluid return and signs of cerumen. If cerumen does not appear, wait 10 minutes and repeat the irrigation. After completion of the irrigation, have the client turn the head to the side to facilitate drainage.

Place the following steps for eyedrop administration in the correct order. Gently press on the lacrimal duct for 1 minute. Gently pull tissue underneath eye downward to expose lower conjunctival sac. Have the client gently close the eye and move it around. Have the client look up and instill the number of prescribed drops. Hold the dropper and stabilize hand on the client's forehead. Have the client sit down and tilt his or her head slightly backward.

Have the client sit down and tilt his or her head slightly backward. Gently pull tissue underneath eye downward to expose lower conjunctival sac. Hold the dropper and stabilize hand on the client's forehead. Have the client look up and instill the number of prescribed drops. Have the client gently close the eye and move it around. Gently press on the lacrimal duct for 1 minute.

The nurse is ambulating a cardiac surgery client whose heart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions? Call the client's health care provider. Have the client sit down. Check the client's blood pressure. Administer as needed (PRN) oxygen by nasal cannula

Have the client sit down. Administer as needed (PRN) oxygen by nasal cannula. Check the client's blood pressure. Call the client's health care provider.

In which order will the nurse take these actions before doing wound irrigation and a dressing change for a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA)? Perform hand hygiene. Put on gown. Place goggles over eyes. Put on mask to cover nose and mouth. Don gloves.

Perform hand hygiene. Put on gown. Put on mask to cover nose and mouth. Place goggles over eyes. Don gloves.

The nurse is preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will the nurse perform the following actions? Remove N95 respirator. Remove gloves. Take off gown. Take off goggles. Perform hand hygiene.

Remove gloves. Take off goggles. Take off gown. Remove N95 respirator. Perform hand hygiene.

The nurse is the team leader RN working with a student nurse. The student nurse is to teach a patient how to use a metered-dose inhaler (MDI) without a spacer. Put in correct order the steps that the student nurse should teach the patient. Remove the inhaler cap and shake the inhaler. Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away. Breathe out completely. Hold your breath for at least 10 seconds. Press down firmly on the canister and breathe deeply through your mouth. Wait at least 1 minute between puffs.

Remove the inhaler cap and shake the inhaler. Breathe out completely. Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away. Press down firmly on the canister and breathe deeply through your mouth. Hold your breath for at least 10 seconds. Wait at least 1 minute between puffs. Wait at least 1 minute between puffs.

A patient with severe iron deficiency anemia is to receive iron dextran complex 25 mg IV. The medication is diluted in 250 mL of normal saline and is to be infused over 6 hours. The nurse will infuse __________ mL/hr. (Round to 2 decimal points.)

To infuse 250 mL of solution during 6 hours, the nurse will need to infuse 41.67 mL/hr.

The nurse is caring for a confused and agitated client who has wrist restraints in place on both arms. Which action included in the client plan of care can be assigned to an LPN/LVN? 1. Determining whether the client's mental status justifies the continued use of restraints 2. Undoing and retying the restraints to improve client comfort 3. Reporting the client's status and continued need for restraints to the health care provider 4. Explaining the purpose of the restraints to the client's family members

Undoing and retying the restraints to improve client comfort