NCLEX Practice Questions HURST REVIEW (Fundamentals)

Right upper quadrant pain

A client at 31 weeks gestation is being seen by the primary healthcare provider for reports of generalized illness. When assessing the client, the nurse would immediately report what symptom to the primary health care provider? 1. Right upper quadrant pain 2. Nausea with vomiting 3. Severe headache 4. Blurred vision

1. Gown 2. Gloves

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room? Select all that apply 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. Assess the client for lightheadedness.

The nurse is transferring the client from the bed to the wheelchair. Which nursing intervention would the nurse implement after assisting the client to a sitting position on the side of the bed. 1. Assess the client for lightheadedness. 2. Move the wheelchair closer to the bed. 3. Lower the bed to the lowest position. 4. Position the foot of the stronger leg closer to the bed.

1. Weigh QD 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W.

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? Select all that apply 1. Weigh QD 2. IV of Normal Saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day

2. Irrigates the pressure ulcer with half-strength hydrogen peroxide.

The charge nurse is observing a nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50 mL normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.

1. You are wanting your sons to assist you in deciding about treatment options.

A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons.

1. The consent form is signed. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? Select all that apply 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

4. Remind the primary healthcare provider of the importance of standard precautions.

The nurse notices the primary healthcare provider removes gloves after performing an invasive procedure on a client. The healthcare provider then enters another client's room without washing hands. What is the initial action by the nurse? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 5. Humalog 8 units subcutaneously.

The nurse should wear gloves when administering which medication? Select all that apply 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.

3. Caffeine and some medications may interfere with sleep.

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.

3. Check the client's identification band.

A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first? 1. Obtain all supplies for the procedures. 2. Explain the procedure to the client. 3. Check the client's identification band. 4. Verify client has signed consent forms.

4. Empty and compress bulb when 2/3 full.

A client returns from post anesthesia care unit (PACU) following a mastectomy with a Jackson-Pratt drain in place. What action by the nurse is important? 1. Empty drain every eight hours. 2. Irrigate drain with NS every shift. 3. Drape tubing above breast incision. 4. Empty and compress bulb when 2/3 full.

2. Water only

A new nurse enters the linen room for supplies and finds a pile of sheets on fire. What type of fire extinguisher is most appropriate for the nurse to use in this situation? 1. Foam type 2. Water only 3. Dry powder 4. Carbon dioxide

3. Instruct the client in guided imagery techniques.

A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.

1. Close the OR doors at all times during a surgical case. 2. Minimize traffic in the OR. 4. Monitor the sterile field at all times. 5. Immediately discard any object that becomes contaminated.

A nurse works in the operating room (OR) as a circulator. Which actions should the nurse perform to help prevent surgical-site infections? Select all that apply 1. Keep the OR doors closed during a surgical case. 2. Minimize traffic in the OR. 3. Ensure the room has negative air flow. 4. Monitor the sterile field at all times. 5. Immediately discard any object that becomes contaminated.

2. Decreases potential skin breakdown from immobility.

An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.

1. Providing information to the client. 3. Providing emotional support. 5. Fostering a sense of security.

An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? Select all that apply 1. Providing information to the client. 2. Promoting client compliance. 3. Providing emotional support. 4. Ensuring the client's wishes for treatment are followed. 5. Fostering a sense of security.

B. Implementation

On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The nurse does not want to "bother the physician this early." During the change-of-shift report, the patient develops ventricular tachycardia and has to be resuscitated. What part of the nursing process did the nurse fail to perform? A. Evaluation B. Implementation C. Assessment D. Planning

1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime.

The home health nurse is caring for a client who is identified as high risk for falls. What evaluation would indicate a therapeutic response to home fall prevention education? Select all that apply 1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime. 3. Only uses assistive devices when leaving home. 4. Goes barefoot while in the home. 5. Uses throw rugs in walking areas to prevent slipping.

2. Trousseau's sign noted when taking blood pressure.

Staff notifies the nurse that a client receiving tube feedings has increased liquid stool with new rectal excoriation. Following an assessment, the nurse is most concerned about what additional symptom? 1. Reports feeling increasingly tired. 2. Trousseau's sign noted when taking blood pressure. 3. Increased resistance to care activities. 4. Reports abdominal cramping.

1. Request the surgeon visit the client again before surgery.

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Request the surgeon visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the surgeon explained those options yesterday.

3. Slander

The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence

4. Covers the client with a bath blanket.

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? 1. Closes the door for privacy. 2. Introduces self and explains the procedure. 3. Bathes the client without the help of others. 4. Covers the client with a bath blanket.

2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time.

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

1. Eliminate chocolate in the evening. 3. Perform progressive relaxation techniques at bedtime. 5. Leisurely walk 3 hours prior to bedtime.

Which discharge instruction should the nurse implement for a client diagnosed with insomnia? Select all that apply 1. Eliminate chocolate in the evening. 2. Drink a glass of red wine 1 hour prior to bedtime. 3. Perform progressive relaxation techniques at bedtime. 4. Take acetaminophen/diphenhydramine 2 tablets at bedtime. 5. Leisurely walk 3 hours prior to bedtime. 6. Increase the air flow on the continuous positive airway pressure (CPAP) machine.

A. Moral distress

A nurse has been having difficulty sleeping since the death of a patient who had a stressful family situation involving a DNR (do not resuscitate) order. She is arguing with her husband and coworker and is complaining about working conditions. The nurse's symptoms could be signs of what problem? A. Moral distress B. Moral confusion C. Immoral distress D. Change fatigue

1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 6. Position client in semi fowler's position after feeding.

After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse develops interventions to safely provide oral feedings to the client. What interventions should the nurse include in this plan of care? Select all that apply 1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 3. Have dietary puree foods. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 6. Position client in semi fowler's position after feeding.

3. Metabolic acidosis

The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

C. Nonmaleficence

The nurse observes a coworker diverting narcotics by administering normal saline to a patient in pain. By not reporting this observation, the nurse is in violation of what ethical principle concerning the patients under the care of the impaired nurse? A. Autonomy B. Justice C. Nonmaleficence D. Veracity

1. Nonmaleficence

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? 1. Nonmaleficence 2. Beneficence 3. Justice 4. Fidelity

A. Beneficence B. Nonmaleficence C. Autonomy

A patient with metastatic cancer tells the nurse, "I am tired and do not want to be put on a breathing machine." The patient's out-of-town son wants "everything done for my mother" when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply.) A. Beneficence B. Nonmaleficence C. Autonomy D. Justice E. Paternalism

1. Loud crying with pain.

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

4. The mid-clavicular to mid-axillary lines comparing side to side

Over which locations does the nurse auscultate breath sounds? 1. Trachea and lateral areas of thoracic cage 2. Anterior and posterior aspects of all lung fields 3. The mid-section as well as the lateral section of the lungs 4. The mid-clavicular to mid-axillary lines comparing side to side

A. Withdrawing treatment

The family of a patient who is receiving mechanical ventilation for respiratory distress associated with an inoperable brain tumor asks that the patient be extubated to "allow natural death" to occur. This is an example of what situation? A. Withdrawing treatment B. Rationing care C. A criminal act D. Withholding treatment

3. Have client read a newspaper at 14 inches (36 cm).

What action should the nurse take when testing a client's near vision? 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.

3. Position the client on their side.

What intervention should the nurse take when providing oral care for the unconscious client? 1. Brush teeth with a stiff toothbrush. 2. Use thumb and index finger to hold the client's mouth open while brushing teeth. 3. Position the client on their side. 4. Rinse by injecting water into the center of client's mouth.

4. Mask

What personal protective equipment should the nurse wear into the room of a client who has been placed on droplet precaution? 1. Gloves 2. Gown 3. Goggles 4. Mask

2. Left-lateral

A charge nurse is teaching a new nurse on the labor and delivery floor the proper positioning of a client following an epidural. The charge nurse knows the teaching was successful when the new nurse places the client in which position? 1. Lithotomy 2. Left-lateral 3. Semi-Fowler's 4. Right-lateral

2. Include a daytime exercise plan.

A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene intervention would the nurse share with the client to promote falling asleep? 1. Take a cool bath. 2. Include a daytime exercise plan. 3. Take an antihistamine at bedtime. 4. Scan the news feeds on the computer.

2. Administer the prescribed PRN analgesic. 3. Assist the client to stand at the bedside to void. 6. Assist the client to the bathroom and turn on running water.

Eight hours after a cholecystectomy a male client has tried unsuccessfully to urinate using a urinal in bed. Which nursing interventions would the nurse implement? Select all that apply 1. Insert a straight catheter. 2. Administer the prescribed PRN analgesic. 3. Assist the client to stand at the bedside to void. 4. Emphasize that the client must void within 2 hours. 5. Encourage the client to increase fluid intake to 500 mL/hr. 6. Assist the client to the bathroom and turn on running water.

1. Not permissible because the housekeeper is not medical personnel.

The housekeeper and a nurse, having lunch together in the staff lounge, begin discussing the housekeeper's neighbor who has been admitted to the floor. The housekeeper occasionally helps the neighbor with shopping and cleaning. The conversation is overheard by the unit secretary, though no names were mentioned. The conversation is reported to the nurse manager, who determines the situation reflects what HIPAA criteria? 1. Not permissible because the housekeeper is not medical personnel. 2. Is permissible since the housekeeper does help care for the neighbor. 3. Not permissible despite family stating housekeeper is "like family". 4. Is permissible given that no other family members are available now.

3. "I bathe in the tub at least 6 times per week."

The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? 1. "I shower 3 - 4 times per week." 2. "I apply moisturizers at least daily." 3. "I bathe in the tub at least 6 times per week." 4. "I drink 64 ounces (1.89 L) of liquid per day."

A. The hospital ethics committee C. The nursing supervisor D. The nursing ethics committee

The nurse is concerned that the physician is ignoring the wishes of the patient and family in the care of a patient. The nurse should take these concerns to: (Select all that apply.) A. The hospital ethics committee B. The ANA (American Nurses Association) C. The nursing supervisor D. The nursing ethics committee E. he policy and procedure committee

4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective? 1. "My child drinks 1000 mL of fluids daily." 2. "My child is eating more fruit every day." 3. "I administered the prescribed oil-retention enema 6 days ago to my child." 4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

2. Properly reposition every 2 hour

When caring for a client on extended bedrest, which intervention should the nurse implement to decrease the risk of contractures? 1. Use a large pillow to support the head and shoulders. 2. Properly reposition every 2 hours. 3. Use a knee gatch to place knees at a 30 degree angle. 4. Place a trochanter roll along the inner aspect of each thigh.

2. Places hands under client's axilla.

Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.

1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 5. Performing hand hygiene after removing gloves

A charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? Select all that apply 1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 3. Wearing a N95 respirator while caring for a child who has respiratory syncytial virus (RSV) 4. Putting on a gown to take care of a client who has toxoplasmosis 5. Performing hand hygiene after removing gloves

1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station.

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? Select all that apply 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.

3. "I have to be sure not to touch the dropper to any part of my eye."

A client diagnosed with glaucoma is being instructed on self-instillation of eye drops. What statement by the client would indicate to the nurse that teaching was successful? 1. "I should look into the mirror to be sure I am getting the drops in." 2. "I will put all drops in my eyes and then close eyes for 5 minutes." 3. "I have to be sure not to touch the dropper to any part of my eye." 4. "I have to pull down the upper lid when putting the eye drops in."

2. Throw rugs on kitchen tile floor.

A home care nurse is making an initial visit to an elderly client recently discharged following hip surgery. When evaluating the home environment, what environmental hazard is most concerning to the nurse? 1. Lamp plugged into extension cord. 2. Throw rugs on kitchen tile floor. 3. Gas fireplace in the living room. 4. Non-working wall socket in hall.

B. Assess and analyze the level of care needed by the patient.

A patient in the critical care unit has an order to be transported off the unit for a diagnostic procedure. The nurse fails to ensure that the patient is properly monitored during transport, and the patient experiences a cardiac arrest. Which of the following actions did the nurse fail to adequately perform? A. Make the proper nursing diagnosis. B. Assess and analyze the level of care needed by the patient. C. Act as a patient advocate to postpone the examination. D. Communicate findings in a timely manner.

1. Remove indwelling catheter 3. Remove hospital ID band 5. Wash body head to toe

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? Select all that apply 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 5. Places tube end into a glass of water to assess for bubbling.

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki

The nurse is teaching a community education course regarding complementary and/or alternative therapies. Which therapies would the nurse include in the course as complementary and/or alternative therapies? Select all that apply 1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki 5. Zumba

1. Chest drainage unit 5. Soiled dressing

When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? Select all that apply 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information

3. Bending from the waist to pick up the object.

A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.

2. A 62 year old client who speaks only Spanish. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted.

Which client is legally able to sign a consent for surgery? Select all that apply 1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating.

1. Weakness requiring assistance to move in bed.

Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed. 2. Daily intake of at least 85 percent of food offered. 3. Occasional forgetfulness. 4. Continent of bowel and bladder.

4. A client scheduled for knee replacement surgery has an above the knee amputation performed

Which is an example of a sentinel event? 1. The terminally ill client is referred to hospice and dies 3 months later. 2. A client has a mammogram which reveals small cyst. 3. A client with a laceration to the knee falls when getting up unassisted after being instructed to remain in bed. 4. A client scheduled for knee replacement surgery has an above the knee amputation performed

2. Increase the flow rate of the irrigation solution until the urine is a light pink.

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. "I catheterize myself twice a day."

A home health nurse is visiting an adolescent with a myelomeningocele. The nurse realizes more instruction is needed when the client makes what statement? 1. "I might need to get glasses." 2. "I catheterize myself twice a day." 3. "I drink bottled water all day long." 4. "I do upper arm exercises every day."

C. Assessment

A nurse is caring for a patient with chronic heart failure who is very ill. The patient has a "no code" order. The patient goes into ventricular fibrillation and the nurse defibrillates the patient. The nurse states she was unaware of the "no code" order. What part of the nursing process did the nurse fail to perform? A. Planning B. Evaluation C. Assessment B. Implementation

2. Place allergy alert bracelet on client. 5. Send list of allergies to dietary department.

A client has been admitted with multiple severe allergies, including food and medications. The nurse knows what actions are most important to protect the client? Select all that apply 1. Assign client to a private, sterile room. 2. Place allergy alert bracelet on client. 3. Have client wear mask when in hallway. 4. Attach sign listing allergies above the bed. 5. Send list of allergies to dietary department.

1. Stop the feeding and assess gastric residual volume in 1 hour

A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.

4. Use the mechanical lift and with another UAP, transfer the client to the chair.

A client who has right sided weakness and weighs 280 pounds (140 kg) needs to be transferred from the bed to the chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1. Stand at the client's right side. 2. You are physically fit and at lesser risk for injury. 3. Using proper body mechanics will prevent you from injuring yourself. 4. Use the mechanical lift and with another UAP, transfer the client to the chair.

1. Partially compensated metabolic acidosis

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? 1. Partially compensated metabolic acidosis 2. Partially compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Partially compensated respiratory acidosis

2. Discuss the plan of care with the client, family, and curandero.

A home health nurse is caring for a Mexican-American client who has been discharged from the hospital post myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Discuss the plan of care with the client, family, and curandero. 3. Ask the curandero to leave so that the client can be assessed. 4. Explain to the family that the curandero is not a reliable healthcare option.

3. There is a palpable femoral pulse with a compression.

The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? 1. Chest wall visibly rises with rescue breathing. 2. Skin color and temperature becomes pink and warm. 3. There is a palpable femoral pulse with a compression. 4. A sinus beat appears on monitor during compression.

1. Flickering overhead light 4. Bent electrical bed cord 5. Cracked electrical socket

When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? Select all that apply 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket

2. Have client return to bed and utilize slide board to transfer to litter.

When the surgical transport team arrives to take a client to the operating room, the client is sitting in a chair in the room. What is the best way for the nurse to get the client onto the transport litter? 1. Using a foot stool, assist client to step up and crawl onto litter. 2. Have client return to bed and utilize slide board to transfer to litter. 3. With feet placed apart, grasp client around waist and lift onto litter. 4. Put Hoyer pad under client, using Lift to move client from chair to litter.

2. Clarify the prescription with the primary healthcare provider.

The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action? 1. Check the prescription prior to sending it to the pharmacy. 2. Clarify the prescription with the primary healthcare provider. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection.

2. "Spicy food and caffeine might cause me pain."

The nurse is instructing a client newly diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed omeprazole. What comment by the client indicates to the nurse that the teaching was successful? 1. "I should lay down after eating a big meal." 2. "Spicy food and caffeine might cause me pain." 3. "If the pain gets worse, I should take two pills." 4. "I will take the omeprazole whenever I have pain."

2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

A client reports difficulty sleeping since starting a new job. The nurse's assessment identifies that the client is also working after hours from home. Which teachings are appropriate to promote sleep in this client? Select all that apply 1. Vary bed times to determine time best to promote sleep. 2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

1. Applies sterile gloves prior to opening catheter kit.

The nurse is observing a new LPN insert an indwelling foley catheter for a client. The nurse knows it is necessary to intervene when the new LPN initiates what action? 1. Applies sterile gloves prior to opening catheter kit. 2. Pours iodine solution over the sterile cotton balls. 3. Lubricates catheter by dipping into water-soluble gel. 4. Identifies client and elevates bed to waist height.

1. Tighten stomach muscles. 3. Keep weight to be lifted close to body. 5. Avoid twisting the body.

The nurse is caring for a client that requires lifting. What techniques should the nurse utilize to prevent injury to self and potentially the client? Select all that apply 1. Tighten stomach muscles. 2. Keep the knees straight. 3. Keep weight to be lifted close to body. 4. Bend at the waist. 5. Avoid twisting the body.

1. Limit intake of carbonated beverages. 4. Limit consumption of beans, onions, and broccoli. 5. Release the pouch clamp to release the gas in the colostomy pouch.

The nurse is caring for a client with a colostomy who is experiencing excess flatulence. Which instructions should the nurse provide the client? Select all that apply 1. Limit intake of carbonated beverages. 2. Encourage fluid intake of 1000 mL/24 hours. 3. Create a small hole in the colostomy stoma pouch. 4. Limit consumption of beans, onions, and broccoli. 5. Release the pouch clamp to release the gas in the colostomy pouch.

4. A form of a living will. It specifies your wishes regarding healthcare and treatment options should you become incapacitated

The nurse asks if the client has an advance directive. The client responds by saying, "I have heard of advance directives, but I do not have one. What is an advance directive?" Which response by the nurse is appropriate? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. A form of a living will. It specifies your wishes regarding healthcare and treatment options should you become incapacitated.

C. No. There were no damages associated with failure to document

The nurse fails to record a set of vital signs on a blood transfusion report, which is against hospital policy. The patient does not sustain any damage as a result. Can the nurse be charged with malpractice in this case? A. No. Documentation is not part of the duty of nurse. B. Yes. Even though there were no damages, the nurse failed to follow hospital protocol. C. No. There were no damages associated with failure to document D. Yes. Failure to document always results in negligence.

1. "Coughing and deep breathing should be performed hourly to prevent pneumonia."

The nurse instructs a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that teaching has been effective? 1. "Coughing and deep breathing should be performed hourly to prevent pneumonia." 2. "Coughing and deep breathing are needed to prevent blood clots." 3. "Coughing and deep breathing will aide with healing by increasing available oxygen." 4. "Coughing and deep breathing will help resolve any blood clots that have formed. "

2. "I will apply the anti-embolism stockings before getting out of bed." 4. "Prior to applying the stockings, I will look for reddened areas on my skin."

The nurse is assisting the client on the correct procedure for applying anti-embolism stockings. Which statement by the client indicates that the client understands the procedure? Select all that apply 1. "The stockings should be applied when my legs are swollen." 2. "I will apply the anti-embolism stockings before getting out of bed." 3. "I will apply cortisone-10 ointment to skin on both legs every day." 4. "Prior to applying the stockings, I will look for reddened areas on my skin." 5. "When pulling up the stockings, I will allow for an extra roll of the stocking at my calves.

1. The two-handed method is used to recap a needle

Which action by a nurse requires intervention by the charge nurse? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.

1. Taking wrestling classes at the gym once a week.

Which activity should the nurse recognize as increasing the risk for a client developing a community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection? 1. Taking wrestling classes at the gym once a week. 2. Traveling on an airplane next to someone coughing. 3. Eating raw fruits without washing them. 4. Working in close proximity to several co-workers.

1. Donning personal protection equipment. 3. Disposing of soiled gloves in the appropriate receptacle. 4. Wearing gloves when coming into contact with client's secretions. 6. Performing hand hygiene after removal of soiled gloves

Which nursing action represents measures taken to protect the client from a mode of infection transmission in the chain of infection? Select all that apply 1. Donning personal protection equipment. 2. Administering the Haemophilus influenzae type B (HIB) immunization to a child. 3. Disposing of soiled gloves in the appropriate receptacle. 4. Wearing gloves when coming into contact with client's secretions. 5. Teaching importance of long pants and sleeves and insect repellent to reduce the risk of West Nile Virus. 6. Performing hand hygiene after removal of soiled gloves.

1. Remove the client from the room immediately.

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.

2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump.

While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take? 1. Continue to use the infusion pump and request a replacement pump. 2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. 3. Clamp and disconnect the infusion tubing prior to obtaining a replacement pump. 4. Slow the infusion to a keep-open rate and obtain a replacement pump.

4. You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns.

A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don't know what to do." What is the best response for the nurse as client advocate? 1. Your children are correct. The open heart surgery is the best thing for your health. 2. You feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery. 3. I can contact your primary healthcare provider so that you can discuss your concerns regarding open heart surgery. 4. You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns.

1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure.

A client who only speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what to the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.

1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes.

A client who was diagnosed with amyotropic lateral sclerosis (ALS) has been immobile for 2 weeks. Which of the nursing interventions would the nurse implement? Select all that apply 1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. 5. Encourage a fluid intake of 1500 mL/24 hours.

4. "The stockings are too difficult to put on every morning."

A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."

1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 5. Long fingernails and artificial fingernails increase microbial load on the hands.

A nurse enters the operating room (OR) with artificial fingernails in place. What should the charge nurse explain to the nurse? Select all that apply 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial fingernails are allowed to be worn in the OR. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 4. A more vigorous scrub is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands.

4. Client on heparin drip reporting bleeding gums when brushing teeth.

A nurse has received morning report on multiple clients. What client should the nurse assess first? 1. Client on 2/L min, of oxygen by nasal cannula with pneumonia. 2. Client with Crohn's disease reporting two semi-loose stools. 3. Client one day post-appendectomy reporting abdominal cramps. 4. Client on heparin drip reporting bleeding gums when brushing teeth.

1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus.

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield.

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

2. All users of the AED must be trained in its operation. 3. CPR should be taught to users. 4. Primary healthcare provider oversight is needed to ensure proper maintenance. 5. The local EMS should be notified of the type and location of AEDs.

A nurse is planning to teach a group who works at a local mall about proper use of automated external defibrillators (AED). Which points should the nurse emphasize? Select all that apply 1. The standard AED can be used on children over the age of 5. 2. All users of the AED must be trained in its operation. 3. CPR should be taught to users. 4. Primary healthcare provider oversight is needed to ensure proper maintenance. 5. The local EMS should be notified of the type and location of AEDs.

3. "Can you please repeat that prescription again slowly?

A recently hired primary healthcare provider from India has started working at the local hospital. When receiving new phone prescriptions, the nurse is unable to understand the primary healthcare provider's thick accent. Which comment by the nurse is most likely to successfully resolve the issue? 1. "I'll have to get someone who can understand you." 2. "I can't understand you. You need to say it again." 3. "Can you please repeat that prescription again slowly? " 4. "I don't know what you are trying to say."

2. Grilled cheese with tomatoes 5. Chicken sandwich on wheat toast

A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? Select all that apply 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast

0.5tabs

A client receiving treatment for hypertension is scheduled to receive hydrochlorothiazide 25 mg orally. Based on the label on the bottle, how many tablets should the nurse administer?

2. Immediately inform the primary healthcare provider that the client requests additional information about the bronchoscopy procedure.

A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which nursing intervention should the nurse implement? 1. Explain the bronchoscopy procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Immediately inform the primary healthcare provider that the client requests additional information about the bronchoscopy procedure. 3. Give the client an information pamphlet on the bronchoscopy procedure, and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed.

3. Inform the primary healthcare provider that the client has concerns about the surgery.

Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery and what the alternative treatments are." What should the nurse do first? 1. Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider. 2. Reinforce that it is not unusual for clients to have questions about surgery. 3. Inform the primary healthcare provider that the client has concerns about the surgery. 4. Use open ended questions to explore client's concerns.

2. "Which part of this procedure has you most concerned?"

The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so independently. What statement by the nurse is appropriate? 1. "Many spouses have been able to learn this procedure." 2. "Which part of this procedure has you most concerned?" 3. "Don't you have any family to help you with this procedure?" 4. "Are you worried about caring for your spouse?"

3. Rate the client's pain using the pain scale used in the ED.

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.

1. Inform the charge nurse.

The nurse tries to notify the primary healthcare provider (PHP) that the dosage of newly prescribed medication is higher than recommended. The PHP cannot be located and the medication is scheduled to be administered in 30 minutes. Which intervention should the nurse implement next? 1. Inform the charge nurse. 2. Administer the medication as prescribed. 3. Document the prescribed medication dosage in the nursing notes. 4. Administer the recommended dosage until the PHP is contacted.

3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave.

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? Select all that apply 1. Administering a 0900 medication at 1030. 2. Administering a medication to an incorrect client. 3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave. 5. Raising the side rails without a prescription when a client is at risk to fall.

B. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. C. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area

Where should a nurse place the stethoscope when auscultating heart sounds? Select all that apply A. First intercostal space left of the sternum to hear sounds from the pulmonic valve area. B. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. C. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. D. Fifth intercostal space left side of sternum to hear sounds from the mitral area. E. Apex of the heart to hear the loudest 2nd heart sound (S2).

1. Clean gloves while performing a heel stick on an infant.

Which action by a nurse would indicate that this nurse is following standard precautions? 1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter.