NCSBN Review Pretest New
A female client is admitted for a breast biopsy. She says, tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." Which of these statements would be the best response by the nurse? "Are you wondering about the effects on your sexuality?" "You sound concerned that your partner will reject you." "I hear you saying that you have a fear for the loss of love." "Are you worried that the surgery will lead to changes?"
"Are you worried that the surgery will lead to changes?" Correct
The 70 year-old male is recently diagnosed with osteoporosis. The nurse is teaching the client about this disease. Which of the following client responses requires further education by the nurse? (Select all that apply.) "It sounds like I'll need to drink more milk and eat more cheese and yogurt." "I should ask for help to clean the gutters instead of climbing a ladder." "Exercising in an aquatics class will make my bones much stronger." "I don't believe the doctor because I heard that only women can get osteoporosis." "I need to stop smoking."
"Exercising in an aquatics class will make my bones much stronger." "I don't believe the doctor because I heard that only women can get osteoporosis."
After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond with which statement? "He may be scared and taking it out on you. Let's talk to figure out what to do next." "I will talk with him and try to figure out what to do or what the problem is." "Ignore him and get the rest of your work done. Someone else can care for him the rest of the day." "He has a lot of problems. You need to have patience with him."
"He may be scared and taking it out on you. Let's talk to figure out what to do next."
The nurse is performing the initial assessment of a client in the emergency department. Which statement by the client most strongly suggests domestic violence? "No one else in the family is as accident prone as I am." "I have only been married for two months." "I am determined to leave my house in a week." "I have tried leaving home, but have always gone back."
"I have tried leaving home, but have always gone back." Correct!
A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? "I need you to go to the waiting area. You can come back when you're more in control." "I'm going to give you a few minutes alone so you can calm down." "I can't think when you are yelling at me. Talk to me in a normal voice." "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security."
"I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Correct!
A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.) "I should sit down and discuss my wishes for end of life care with my loved ones." "My wishes for end of life treatment are stated in writing." "A living will must be renewed by a designated family member each time I am hospitalized." "A living will is a legal document that becomes a permanent part of my health care record." "It lists all my assets and how they should be divided among my family after I die." "I will need to identify someone to be my health care proxy."
"I should sit down and discuss my wishes for end of life care with my loved ones." Correct! "My wishes for end of life treatment are stated in writing." Correct! "I should sit down and discuss my wishes for end of life care with my loved ones." Correct! "My wishes for end of life treatment are stated in writing." Correct! "I will need to identify someone to be my health care proxy." Correct!
The nurse is providing information to a 28 year-old female, who is a type 1 diabetic and planning a pregnancy. The nurse is assessing the client's understanding of insulin therapy during pregnancy. Which statement, made by the client, indicates a need for more teaching? "If I bottle-feed my baby, my insulin needs should return to normal within 7 to 10 days after birth." "I will probably need to give myself more insulin during the second and third trimesters of my pregnancy. "I may be more likely to experience hypoglycemia during the first three months of pregnancy." "I will need to increase my insulin dosage during the first three months of pregnancy."
"I will need to increase my insulin dosage during the first three months of pregnancy."
The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) "I will take the old patch off before I apply the new patch on." "If my pain is too great while I am on the patch, I can take a supplemental pain medication." "I should cut up the patch before I throw it away so no one else can use it." . "It may take up to a half day or longer for the patch to start working, the first time I use it." "I can soak in a hot tub to help decrease my pain."
"I will take the old patch off before I apply the new patch on." "If my pain is too great while I am on the patch, I can take a supplemental pain medication." "It may take up to a half day or longer for the patch to start working, the first time I use it."
The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) "I will take the old patch off before I apply the new patch on." "If my pain is too great while I am on the patch, I can take a supplemental pain medication." "I should cut up the patch before I throw it away so no one else can use it." "It may take up to a half day or longer for the patch to start working, the first time I use it." "I can soak in a hot tub to help decrease my pain."
"I will take the old patch off before I apply the new patch on." Correct! "If my pain is too great while I am on the patch, I can take a supplemental pain medication." Correct Response "It may take up to a half day or longer for the patch to start working, the first time I use it." Correct!
A client is scheduled to receive an oral solution of radioactive iodine (131I). What information is the priority for the nurse to include when teaching the client about this treatment? "Your family can use the same bathroom as you are using, without any special precautions." "Drink plenty of water and empty your bladder often during the initial three days of therapy." "In the first 48 hours, you should avoid contact with children and pregnant women; be sure to flush the commode twice after urination or defecation." "Use disposable utensils for two days; if you feel nauseous within 12 hours of the first dose, please vomit in the toilet and flush it twice."
"In the first 48 hours, you should avoid contact with children and pregnant women; be sure to flush the commode twice after urination or defecation." Correct!
A male client admitted with a diagnosis of a spinal cord injury (SCI) at level C-5 asks the nurse how the injury will affect his sexual function. Which statement is the best response? "Normal sexual function is not possible." "Ejaculation will be normal." "Sexual functioning will not be impaired at all." "Sexual functioning may be possible."
"Sexual functioning may be possible." Correct!
The client, who is four days post-op for a transverse colostomy and is scheduled for discharge tomorrow, asks the nurse to empty the colostomy pouch. What is the best response by the nurse? "Let me demonstrate to you how to empty the pouch." "Show me what you have learned about emptying your pouch." "You should be emptying the pouch yourself." "What have you learned about emptying your pouch?"
"Show me what you have learned about emptying your pouch." Correct
A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? "Are your stools also black?" "How long have you had an upset stomach?" "Come to the clinic so you can be seen by the health care provider." "This is a common and temporary side effect of this medication."
"This is a common and temporary side effect of this medication."
A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? "Are your stools also black?" "How long have you had an upset stomach?" "Come to the clinic so you can be seen by the health care provider." "This is a common and temporary side effect of this medication."
"This is a common and temporary side effect of this medication." Correct Response
A client who has been experiencing influenza-like symptoms for the past 24 hours calls the health clinic and asks about the antiviral medication zanamivir (Relenza). How should the triage nurse respond? "Do you have trouble swallowing big pills?" "Your chart states that you have asthma, so this product would not be recommended." "Come in right away so we can treat you." "Call back tomorrow when you are sure you have the flu."
"Your chart states that you have asthma, so this product would not be recommended."
A client who has been experiencing influenza-like symptoms for the past 24 hours calls the health clinic and asks about the antiviral medication zanamivir (Relenza). How should the triage nurse respond? "Do you have trouble swallowing big pills?" "Your chart states that you have asthma, so this product would not be recommended." "Come in right away so we can treat you." "Call back tomorrow when you are sure you have the flu."
"Your chart states that you have asthma, so this product would not be recommended." Correct Response
An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs), and is unable to drive. List the order of the steps in the case management process by dragging and dropping the options below. Assessment of biophysical and sociocultural considerations Identification of nursing diagnoses Evaluation of progress towards client's goals Referral to personal care attendant and transportation services Reassessment of health status and ADL ability
. Assessment of biophysical and sociocultural considerations Identification of nursing diagnoses Referral to personal care attendant and transportation services Reassessment of health status and ADL ability Evaluation of progress towards client's goals
The interdisciplinary team is reviewing charts for potential candidates for hospice care. Which of the following clients meet the criteria for hospice care? (Select all that apply.) 91 year-old with Alzheimer's disease, who is no longer able to eat or drink oral fluids 72 year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy 53 year-old client with chronic, unrelieved pain, who is addicted to narcotics following a back injury 46 year-old with end stage liver disease, on a wait list for a donor organ 8 year-old client with acute myelogenous leukemia, for whom all treatment options have failed
91 year-old with Alzheimer's disease, who is no longer able to eat or drink oral fluids Correct! 72 year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy Correct! 8 year-old client with acute myelogenous leukemia, for whom all treatment options have failed Correct!
The nurse has just listened to the change of shift report on an orthopedic unit. Which of the following clients should the nurse check first? A 16 year-old who had an open reduction of a fractured wrist 10 hours ago A 72 year-old who returned from a right hip replacement surgery two hours ago A 20 year-old in skeletal traction for two weeks since a motorcycle accident A 75 year-old who is in skin traction of the left leg prior to a scheduled fractured hip repair surgery
A 72 year-old who returned from a right hip replacement surgery two hours ago Correct!
Which of these clients should the nurse assess and monitor for Clostridium difficile (C. difficile) diarrhea? A young adult at home taking a prescribed aminoglycoside An older adult client living in a retirement center taking prednisone A hospitalized middle-aged client receiving IV cephalexin (Keflex) An adolescent taking tetracycline for acne
A hospitalized middle-aged client receiving IV cephalexin (Keflex) Correct!
1.The national statement of client rights and the client self-determination act 2.The clinical pathway protocol of the agency and the emergency department 3.Orders written by the health care provider in the emergency department 4.A notarized original of the advance directive brought in by the partner
A notarized original of the advance directive brought in by the partner
The nurse is caring for a young adult client with an acute attack of inflammatory bowel disease. Which of the following findings indicates a potential complication? (Select all that apply) Visible blood and mucus in the stool Abdominal distention Chills and fever Frequent diarrhea Abdominal pain and tenderness
Abdominal distention Chills and fever
A nurse is providing home care for a client with chronic bilateral heart failure. Which nursing diagnosis should have the priority when planning care for this client? Constipation related to immobility from challenges with breathing Risk for infection related to ineffective mobilization of secretions Impaired skin integrity related to dependent edema Activity intolerance related to an imbalance in oxygen supply and demand
Activity intolerance related to an imbalance in oxygen supply and demand Correct!
Indicate the location of pain that supports the diagnosis of suspected pancreatitis. (Insert picture of abdomen in anatomical position with arrows pointing to abdomen and umbilicus. Choose correct area)
Acute pancreatitis produces sharp pain in the epigastric (just under xyphoid process area because of the anatomical position of the pancreas behind the stomach. It is not unusual for a client to report "my stomach hurts" yet be holding the pelvic or periumbilical region. The client may even report upper back pain. Nurses need to clearly assess correct locations regardless of how the client identifies it verbally.
The client is admitted to the hospital with a diagnosis of exacerbation of right ventricular heart failure. Which of the following findings would the nurse expect with right-sided heart failure? (Select all that apply.) Anorexia and nausea Peripheral edema Cough Orthopnea Abdominal discomfort
Anorexia and nausea Peripheral edema Abdominal discomfort
A parent calls the hospital hot line and is connected to the triage nurse. The caller states: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would provide the best information to help the nurse to determine if the child has swallowed a corrosive substance? "Ask the child if the mouth is burning or throat pain is present." "Has the child had vomiting, diarrhea or stomach cramps?" "Take the child's pulse at the wrist and see if the child has trouble breathing lying flat." "What color are the child's lips and nails and has the child voided today?"
Ask the child if the mouth is burning or throat pain is present." Correct Response
A 65-year-old Hispanic-Latino client diagnosed with prostate cancer rates his pain as a six on a 0 to 10 scale. Other than Ibuprofen (Motrin), the client refuses all pain medication even though this does not relieve his pain. What should be the next action for the nurse to take? Document the situation in the progress notes Ask the client about the refusal of certain pain medications Talk with the client's family about the situation Report the situation to the primary care provider
Ask the client about the refusal of certain pain medications Correct!
A 5 month-old is hospitalized with a diagnosis of bronchiolitis related to respiratory syncytial virus (RSV). The parent reports the baby has been sneezing and wheezing, has had a runny nose for two days, and has not eaten for more than nine hours. Vital signs are: temperature 100.2 F (38 C), pulse 102, respiratory rate 32. Place the nurse's actions in order of priority by dragging and dropping the options below. Institute droplet isolation precautions Assess for respiratory distress Promote adequate tissue oxygenation Administer prescribed medications Promote desired fluid intake Provide family teaching
Assess for respiratory distress Promote adequate tissue oxygenation Institute droplet isolation precautions Administer prescribed medications Promote desired fluid intake Provide family teaching
The nurse is providing care to a client in labor. The client has chosen natural childbirth with assistance from a doula, her mother and boyfriend. Which of the following nursing actions can help the client achieve her goal of an unmedicated labor and birth? Limit the number of interactions with the doula Offer pain medication on a regular basis Assess the effectiveness of the labor support team and offer suggestions as needed Encourage the client to stay in bed in a side-lying position or semi-Fowler's position
Assess the effectiveness of the labor support team and offer suggestions as needed Correct!
The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders? Attach a monitoring band to the client's wrist Explain the risk of walking with no purpose Frequently reorient the client to time, person, place Apply a restraint to keep keep the client in a chair when awake
Attach a monitoring band to the client's wrist Correct Response
The nurse enters the client's room and finds the client, who was previously alert, lethargic and slow to respond. Prioritize the nursing actions by dragging and dropping the options below. Complete a quick neurological assessment: orientation, pupil response, ability to follow commands Attempt to elicit a response by physically shaking the client and loudly stating "open your eyes and talk to me." Call the rapid response team and report the client's situation; request immediate assistance Remain with the client; send another staff member to get the list of medications and the chart
Attempt to elicit a response by physically shaking the client and loudly stating "open your eyes and talk to me." Complete a quick neurological assessment: orientation, pupil response, ability to follow commands Call the rapid response team and report the client's situation; request immediate assistance Remain with the client; send another staff member to get the list of medications and the char
The health care provider has ordered a vanillylmandelic acid test and catecholamine test for a middle-aged client. Which of the following points should the nurse discuss with the client prior to these tests? (Select all that apply.) Continue taking all prescribed medications Avoid excessive physical exercise several days prior to the test A 24-hour urine collection procedure is required Identify and minimize factors contributing to stress and anxiety
Avoid excessive physical exercise several days prior to the test Identify and minimize factors contributing to stress and anxiety A 24-hour urine collection procedure is required Avoid caffeinated beverages, bananas, chocolate, cocoa, licorice and citrus fruit
A 62 year-old client is admitted to the emergency department. The client has a history of anemia and peptic ulcer disease and is now experiencing chest pain, nausea and dizziness. The nurse anticipates which laboratory tests to be ordered right away? (Select all that apply.) Cardiac enzymes Toxicology screen Complete blood count (CBC) Lipid panel Helicobactor pylori (H. pylori)
Cardiac enzymes Complete blood count (CBC)
A client is diagnosed with protein-energy malnutrition secondary to colitis. Which findings would support this diagnosis? (Select all that apply.) Cholesterol 110 mg/dL (2.85 mmol/L) Total lymphocyte count (LTC) 1000/mcL High blood pressure Hemoglobin 10.9 g/dL (6.76 mmol/L) Sodium 146 mEq/L (146 mmol/L) Increased lean body mass
Cholesterol 110 mg/dL (2.85 mmol/L) Correct Response Total lymphocyte count (LTC) 1000/mcL Correct! Hemoglobin 10.9 g/dL (6.76 mmol/L) Correct!
A 30 year-old client at 39-weeks gestation has just delivered and experienced a fetal demise. The client's partner is at the bedside. Which of the following nursing actions are appropriate at this time? (Select all that apply.) Place the infant on the maternal abdomen, skin-to-skin Clean and wrap the baby and offer it to the parents to view or hold when desired Ask the parents if there are any special religious or cultural rituals for neonatal death Offer the option of an autopsy to the parents at this time Stay with the parents and offer supportive care to both of them
Clean and wrap the baby and offer it to the parents to view or hold when desired Correct! Ask the parents if there are any special religious or cultural rituals for neonatal death Correct! Stay with the parents and offer supportive care to both of them Correct!
The nurse is preparing a speech to a local service organization about clinical trials in cancer care. Which of the following statements would be correct to include? (Select all that apply.) Clinical trials have led to improved cancer prevention and treatment There is a clinical trial protocol for all types of people with cancer A clinical trial is one of the first steps in the research process Clinical trials require approval of a human subjects review board
Clinical trials have led to improved cancer prevention and treatment Correct!
The nurse is assessing a client who is two days post-surgery and notes new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take?1.Make a clinic appointment with the primary health provider for follow-up care the next day 2.Teach a family member clean dressing change technique and address safety measures in the home 3.Collaborate with the health care provider about the change of condition 4.Collaborate with the dietitian for increasing protein and calcium in the diet
Collaborate with the health care provider about the change of condition
A community health clinic nurse is assessing a walk-in client who is experiencing lightheadedness. The client has a history of arthritis and takes naproxen (Aleve) and treats high cholesterol with fish oil and garlic. The assessment reveals that the client is pale, blood pressure is 88/40, pulse is 114, respiratory rate is 22, and temperature is 98.2 F (36.7 C). What specifically should the nurse ask this client about? (Select all that apply.) Tingling or numbness in the extremities Color of bowel movements Bruising Frequency and amount of naproxen used Photophobia
Color of bowel movements Correct Response Bruising Correct! Frequency and amount of naproxen used Correct!
The nurse is named in a lawsuit. Which of these factors will offer the best protection for the nurse in a court of law? Sworn statement that health care provider orders were followed Above-average performance reviews prepared by nurse manager Complete and accurate documentation of assessments and interventions Clinical specialty certification by an accredited organization
Complete and accurate documentation of assessments and interventions
A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager?1. Schedule a staff conference, without the nurse present, to collect information 2. Confront the nurse about the suspicions in a private meeting 3. Consult with human resources personnel about the issue and needed actions 4. Counsel the employee to resign to avoid investigation and rumors
Consult with human resources personnel about the issue and needed actions
The client is transported to the emergency department with minor injuries suffered during a home fire. The client experiences intense anxiety after learning his home was completely destroyed. What is the most important initial intervention for this client? Provide a brochure on methods to promote relaxation Explore the feelings of grief associated with the loss Determine available community and personal support resources Suggest that the client rent an apartment with a sprinkler system
Determine available community and personal support resources Correct Response
The client with newly diagnosed irritable bowel syndrome (IBS) states: "All this fiber I have to eat now is making me full of gas! It makes me want to stop taking it." What instruction by the nurse will help the client manage this side effect and increase compliance with the diet? (Select all that apply.) Discuss a work-up for lactose intolerance with the health care provider Cut back on fiber and then add it again slowly to the diet Eat a balanced and nutritious variety of foods Eat three regularly scheduled meals every day Reduce intake of gas-forming foods
Discuss a work-up for lactose intolerance with the health care provider Correct Response Cut back on fiber and then add it again slowly to the diet Correct Response Reduce intake of gas-forming foods Correct
A client frequently admitted to the locked psychiatric unit repeatedly compliments and then invites one of the nurses to go out on a date. The nurse should take which of these approaches?
Discuss the boundaries of a therapeutic relationship with the client
A client is admitted to the hospital following an automobile accident. Upon admission the client's blood alcohol concentration was 0.18%. Twelve hours after admission the client is diaphoretic, tremulous, and irritable; pulse and blood pressure measurements are elevated. The client states: "I have to get out of here." What is the most likely cause for these findings? Dissatisfaction with hospital care Anxiety related to being hospitalized Shock related to the injuries Early stage of alcohol withdrawal
Early stage of alcohol withdrawal Correct!
A new nursing assistant is instructed to weigh clients diagnosed with anorexia nervosa only if the clients wear a gown with underwear but no street clothing. What is the rationale for this intervention? Allows the nursing assistant to better assess the client's skin Promotes feelings of success with gaining weight Eliminates the risk of hiding objects in clothing or shoes Symbolically removes barriers between the client and staff
Eliminates the risk of hiding objects in clothing or shoes Correct!
The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate?1. Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time 2. Encourage the client to discuss this decision with the health care provider and family 3. Tell the family members that the client's preference is to go home to die 4. No action is needed at this time unless the client repeats the statement to another caregiver
Encourage the client to discuss this decision with the health care provider and family
A postoperative client has a prescription for acetaminophen with codeine. What should a nurse recognizes as a primary effect of this combination? Increased onset of action Minimized side effects Prevention of drug tolerance Enhanced pain relief
Enhanced pain relief Correct!
A client arrives in the emergency department after a radiologic accident at a local factory. After placing the client in a decontamination room, the nurse gives priority to which intervention? Ensure physiologic stability of the client Double bag the client's contaminated clothing Wrap the client in blankets to minimize staff contamination Begin decontamination procedures for the client
Ensure physiologic stability of the client Correct Response
The nurse is assessing a client in the labor and delivery unit. Which of the following actions is correct when using palpation to assess the characteristics and pattern of uterine contractions? Place a hand on abdomen below the umbilicus and palpate uterine tone with fingertips Evaluate intensity by pressing fingertips into the uterine fundus Determine frequency by timing the end of one contraction until the end of the next contraction Assess uterine contractions every 30 minutes throughout the first stage of labor
Evaluate intensity by pressing fingertips into the uterine fundus Correct!
The client is diagnosed with post-traumatic stress disorder (PTSD). What are the some of the more common treatment options for PTSD? (Select all that apply.) Eye movement desensitization and reprocessing (EMDR) Selective serotonin reuptake inhibitors (SSRIs) Opioid analgesics Cognitive behavioral therapies
Eye movement desensitization and reprocessing (EMDR) Correct Response Selective serotonin reuptake inhibitors (SSRIs) Correct! Cognitive behavioral therapies Correct!
A primigravida in the third trimester is hospitalized with a diagnosis of preeclampsia. The nurse determines that the client's blood pressure has a trend of increased readings. Which action should the nurse take first? Take the temperature Check the client's deep tendon reflexes Have the client turn to the left side Check the protein level in urine
Have the client turn to the left side
A client diagnosed with diabetes mellitus has a blood glucose of 175 this morning. After the nurse reports this lab result along with the client's findings of being hungry and thirsty, what type of insulin should the nurse expect the health care provider to order? Humulin-R insulin Mixture of insulin aspart (NovoLog) and insulin glargine (Lantus) Insulin glargine (Lantus) NPH insulin (Humulin-N)
Humulin-R insulin Correct!
The nurse is assessing a 28 year-old female for risk factors contributing to osteoporosis. Which statement reported by the client should alert the nurse that additional teaching about this disease is indicated? (Select all that apply.) "I get sun exposure daily and always use sunblock protection." "I'm just started following the Mediterranean diet and already feel more energized." "I'm a professional dancer and train 8 to 10 hours a day." "I take 1000 mg OsCal (calcium carbonate) every morning with breakfast." "I consume only skim milk, never whole milk."
I'm a professional dancer and train 8 to 10 hours a day." Correct"I take 1000 mg OsCal (calcium carbonate) every morning with breakfast."
The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning the care of this client? Heal the infection Protection for the granulation tissue Debride the eschar Keep the tissue intact
If the black tissue (eschar) is dry and intact, no treatment is necessary; the stable eschar serves as the bot.
The client is admitted with anemia, suspected to be caused by slowly bleeding esophageal varices. Which physician order should the nurse question? Obtain complete blood count (CBC) Send three stool samples for occult blood Administer ranitidine (Zantac) 150 mg tab twice a day by mouth Insert nasogastric (NG) tube to gravity
Insert nasogastric (NG) tube to gravity
A registered nurse (RN) works for a visiting nurse agency (VNA) and makes a home visit to admit a client newly diagnosed with type 1 diabetes. The client has a small foot ulcer that was debrided and needs daily wound care. Which of the following options is the most important intervention to ensure a successful outcome? Involve the client in making health care decisions Schedule daily RN visits to the client Refer to a local diabetes support group Arrange for a friend or relative to visit daily
Involve the client in making health care decisions Correct!
The nurse recognizes that obtaining accurate post anesthesia vital signs is extremely important. Which of the following client conditions are not appropriate for electronic blood pressure measurement? (Select all that apply.) Irregular heart rate Blood pressure greater than 140 mm Hg systolic Shivering Peripheral vascular obstruction
Irregular heart rate Shivering Peripheral vascular obstruction
A nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which of these findings should the nurse anticipate the infant might exhibit? Irritability Lethargy Sunken anterior fontanelle Negative Moro reflex
Irritability
The nurse listens to report about a newly admitted client who has a skin ulcer that's tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions must be taken for this hospitalized client? (Select all that apply.) Keep all equipment in the client's room for his/her sole use Place the client in a single room Wear mask when providing routine care to the client Perform hand hygiene after direct contact with the client and before leaving the room Keep the door to the room closed, with a notice for visitor
Keep all equipment in the client's room for his/her sole use Correct! Place the client in a single room Correct! Perform hand hygiene after direct contact with the client and before leaving the room Correct! Keep the door to the room closed, with a notice for visitors Correct!
A 63 year-old client is diagnosed with severe pneumonia. Which intervention by the nurse promotes the client's comfort? Keep conversations short Increase oral fluid intake Encourage visits from family Incorrect Monitor vital signs frequently
Keep conversations short Correct Response
A nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the nurse asks the child, "Are you ready to take your medicine?" the response is an immediate, "No!" What would be an appropriate next action by the nurse? Give the medication to the parent and ask the parent to give it Explain to the child that the medicine must be taken now Leave the room and return five minutes later and give the medicine Mix the medication with ice cream or applesauce
Leave the room and return five minutes later and give the medicine Correct!
The nurse manager is interviewing a prospective employee who just completed the agency application. Which approach should the nurse manager use to assess skills competencies of this potential employee? "Let's talk about your comfort zone for working independently." "Let's review your skills checklist for type and level of skill for tasks." Correct! "What types of complex client-care tasks or assignments do you prefer?" "What degree of supervision for basic care do you think you need?"
Let's review your skills checklist for type and level of skill for tasks." Correct!
The nurse cares for a client who was admitted in status epilepticus and whose last seizure was four hours ago. What is the most important nursing assessment for this client? Level of consciousness Vital signs and oxygen saturation Injuries to the extremities Respiratory status
Level of consciousness
The nurse receives an order for several medications for a client. Which combination of medications would require the nurse to contact the provider to discuss the orders? (Select all that apply.) Insulin Finasteride (Propecia, Proscar) Lithium (Eskalith, Lithobid) Furosemide (Lasix) Amlodipine (Norvasc) Verapamil (Calan, Covera, Isoptin, Verelan)
Lithium (Eskalith, Lithobid) Correct Response Furosemide (Lasix) Correct!
An x-ray initially confirms the placement of a nasogastric (NG) feeding tube in the stomach. The nurse is now preparing to administer a medication through the tube. What action will the nurse take to verify tube placement? Measure the pH of aspirated gastric contents Assess for client coughing during administration of the medication Auscultate for the sound of air produced by forcing air through the NG tube Place the end of the tube in water and observe for bubbling
Measure the pH of aspirated gastric contents
A nurse is anticipating providing guidance to parents of a toddler about readiness for toilet training. Which statement describes what the nurse should know in order to provide such guidance? Neuronal impulses are interrupted at the base of the ganglia Myelination of the spinal cord is completed by this age Correct Response The child learns voluntary sphincter control through repetition The toddler can understand cause and effect
Myelination of the spinal cord is completed by this age Correct Response
The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrates the shared governance model? Nursing departments share responsibility for client outcomes Staff groups are appointed to discuss nursing practice and client education issues An appointed board oversees any administrative decisions Non-nurse managers supervise nursing staff in groups of units
Nursing departments share responsibility for client outcomes
The charge nurse sends a certified nursing assistant (CNA) to help a registered nurse (RN) with the admission of a client with multiple health problems. Which of the following tasks would be appropriate for the the CNA to perform with the nurse during the admission process? (Select all that apply.) Orient the client to the room Collect a urine specimen Obtain routine vital signs (temperature, pulse, respirations, blood pressure) Assist the client to change into a gown Observe and document the client's ability to walk to the bathroom
Orient the client to the room Collect a urine specimen Obtain routine vital signs (temperature, pulse, respirations, blood pressure) Assist the client to change into a gown
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing intervention would provide the most comfort to the client? Swab the mouth with glycerin swabs Allow the client to melt ice chips in the mouth Perform frequent oral care using a tooth sponge Provide mints to freshen the breath
Perform frequent oral care using a tooth sponge Correct!
The 75 year-old female client is newly diagnosed with urge incontinence. She confides that she is often incontinent of large amounts of urine and expresses a fear of falling when rushing to the bathroom. What are the most appropriate nursing interventions to review with the client? (Select all that apply.) Assist with pessary insertion Perform pelvic floor muscle exercises Review preoperative instructions Schedule urination Restrict foods that may irritate the bladder
Perform pelvic floor muscle exercises Correct! Schedule urination Correct! Restrict foods that may irritate the bladder Correct!
The health care team is planning discharge for a 90 year-old client diagnosed with musculoskeletal weakness. Which intervention would be the priority to help prevent falls in the home? Begin therapy for muscle strengthening and balance Place night lights in the bedroom and bathroom Wear eyeglasses and hearing aid Take calcium and vitamin D supplements
Place night lights in the bedroom and bathroom Correct Response
The nurse is reviewing the lab results for a male client on a heparin infusion to treat a deep vein thrombosis (DVT) and cellulitis of the right lower leg. Which of the lab results would the nurse be most concerned about? Lab Results White blood cells Lab Results 15,100 per microliter (15.1 x 109/L) Lab Results Platelet count Lab Results 50,000 per microliter (500 x 109/L) Lab Results Hemoglobin Lab Results 14 g/dL (8.69 mmol/L or 140 g/L) Lab Results Hematocrit Lab Results 45% (0.45) Lab Results Partial Thromboplastin Time Lab Results 55 seconds White blood cells Partial thromboplastin time Hematocrit Hemoglobin Platelet count
Platelet count
The clinic nurse assists the health care provider with physical examinations and the collection of laboratory specimens. Which of these findings does the nurse recognize as being reportable to the public health department? Positive eye discharge confirming conjunctivitis Clinical findings of impetigo Skin scraping confirming the presence of ringworm Positive stool culture for shigella
Positive stool culture for shigella Correct Response
The nurse reviews the most recent lab results for a client on telemetry who is experiencing premature ventricular beats at 12 per minute. Which lab test would require immediate action by the nurse? Magnesium 2.4 mg/dL (1.2 mmol/L) Calcium 9 mg/dL (2.25 mmol/L) Potassium 2.5 mEq/L (2.5 mmol/L) Correct! Partial thromboplastin time (PTT) 70 seconds
Potassium 2.5 mEq/L (2.5 mmol/L) Correct
The triage nurse identifies that a 16 year-old client is legally married and has signed the consent form for treatment. What should be an appropriate action by the nurse? Ask the teenager to wait until a parent or legal guardian can be contacted Refer the teenager to a community pediatric hospital emergency department Proceed with the triage process in the same manner as any adult clien Withhold treatment until telephone consent can be obtained from the partner
Proceed with the triage process in the same manner as any adult client Correct!
The nurse is caring for a newly admitted client with a diagnosis of hyperosmolar hyperglycemic nonketotic state (HHNS). Which interventions would the nurse expect the health care provider to order? (Select all that apply.) Rapid infusion of intravenous fluids NPH insulin as IV bolus and then titrated by weight Check blood glucose levels every four hours BUN and creatinine levels
Rapid infusion of intravenous fluids BUN and creatinine levels
The health care provider orders an osmotic diuretic for a client diagnosed with a traumatic brain injury (TBI). Why is this medication ordered? Reduce pulmonary edema Reduce intracranial pressure Prevent electrolyte imbalance Prevent seizures
Reduce intracranial pressure Correct!
The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program? Reduce readmissions to the hospital Reduce insurance costs Increase client understanding of discharge instructions Increase satisfaction with nursing care
Reduce readmissions to the hospital Correct
The client, who is 12-hours post gastric bypass surgery, is restless and reports increasing back and shoulder pain unrelieved by pain medication. What action should the nurse take first? Report the complaint to the surgeon immediately Check the nasogastric (NG) tube for patency and reposition the tube Roll the client to side-lying position to ensure the epidural analgesia catheter is still in place Place the client in Trendelenburg position
Report the complaint to the surgeon immediately
A client, who is receiving a blood transfusion, reports having a headache and low back pain. What are the nurse's actions? (Select all that apply.) Flush the line with saline Send the tubing and bag to the blood bank Establish a saline lock or patent IV Administer acetaminophen (Tylenol) 1000 mg Stop the blood transfusion Obtain first voided urine (within one hour of reaction)
Send the tubing and bag to the blood bank Establish a saline lock or patent IV Stop the blood transfusion Obtain first voided urine (within one hour of reaction)
A client, who is receiving a blood transfusion, reports having a headache and low back pain. What are the nurse's actions? (Select all that apply.) Flush the line with saline Send the tubing and bag to the blood bank Establish a saline lock or patent IV Administer acetaminophen (Tylenol) 1000 mg Stop the blood transfusion Obtain first voided urine (within one hour of reaction)
Send the tubing and bag to the blood bank Correct! Establish a saline lock or patent IV Correct Response Stop the blood transfusion Correct! Obtain first voided urine (within one hour of reaction) Correct Response
A child is brought to the emergency department with suspected ingestion of a toxic substance. Place the following actions in priority order by dragging and dropping the options. Obtain a history of the ingestion Reverse or eliminate the toxic substance Start an IV infusion Stabilize the child
Stabilize the child Start an IV infusion Obtain a history of the ingestion Reverse or eliminate the toxic substance
A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first?1.Viral pneumonia with atelectasis 2.Tension pneumothorax with slight tracheal deviation to the right 3.Acute asthma with episodes of bronchospasm 4.Spontaneous pneumothorax with a respiratory rate of 38
Tension pneumothorax with slight tracheal deviation to the right
The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.)
The UAP applies a fingertip pulse oximeter on a client's finger with dark blue nail polish The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor
A client who is HIV-positive is diagnosed with a herpes simplex type 1 (HSV-1) infection. The nurse understands that which issue is the most likely reason for the HSV-1 infection in this client? The client has experienced emotional stress The client had contact with saliva The client is immunosuppressed The client has a history unprotected sexual activities
The client is immunosuppressed
A nurse is assigned to care for four clients. After listening to change-of-shift report, how would the nurse prioritize care for the following clients? (Drag the responses into the correct order.) The client with a tracheostomy The client who is in skeletal traction The client scheduled for a colonoscopy The postoperative client who has an order to be discharged to home
The client with a tracheostomy The client scheduled for a colonoscopy The client who is in skeletal traction The postoperative client who has an order to be discharged to home
A client takes 20 mg of furosemide by mouth at 10 am. What information would be essential for the nurse to include at the change of shift report at 3 pm? The client's potassium level is 4 mEq/L prior to medication administration The client is to receive another dose of furosemide at 10 pm The client's urine output was 1500 mL in five hours The client lost two pounds in the last 24 hours
The client's urine output was 1500 mL in five hours Correct!
The client is observed falling out of bed when reaching for something on the overbed table. The client then states: "Don't just stand there. I feel fine - help me up." What is the correct order of actions the nurse should take? Obtain a complete set of vital signs Call the health care provider Assist the client back to bed, with help from other staff Complete an incident report
The first step is always to assess the client for any obvious injuries and to obtain a complete set of vital signs (especially blood pressure) and neurologic assessments. If the client does not appear to be injured, staff members can assist the client back into bed. The nurse should then call the health care provider to report the incident. Finally, the nurse should complete the incident report. Of course, personal items should be placed close to the client so that s/he can reach them.
The nurse is checking on clients in the unit. Which of these findings indicates that an infusion pump set to deliver a morphine drip basal rate of 10 mL per hour, plus PRN dosages for breakthrough pain, is not functioning correctly? The client states: "I just can't get relief from my pain." The level of the drug is 100 mL at 9 am and is 50 mL at 12 noon The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon The client complains of discomfort at the IV insertion site
The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon Correct!
The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? The nurse could be reprimanded for not clearing the information first with hospital administration The nurse could be fired for breach of confidentiality There won't be any consequences because the client's real name was not used There won't be any consequences because the information was posted on a website for nursing professionals
The nurse could be fired for breach of confidentiality
Mass casualty survivors are brought to the emergency department (ED) after a disaster. The nurse is assigned to four clients who were triaged in the field and have just arrived in the ED. Which client will the nurse care for first? The person with multiple wounds and an open fracture The person with hypotension and a sucking chest wound The person with head trauma requiring mechanical ventilation The person with an undisplaced fracture of the radius
The person with hypotension and a sucking chest wound Correct!
The nurse is assessing the uterine fundus of a client who delivered a healthy neonate 10 hours ago. Identify the area where the nurse would expect to feel the fundus. Use your cursor to select an area on the image below. Insert picture of female abdomen in anatomical position
The uterus should be felt at the level of the umbilicus from about 1 to 24 hours after birth. Choose small box over umbilicus
A client is to receive three doses of potassium chloride 10 mEq in 100 mL of 0.9% normal saline to infuse over 30 minutes each. Which action is a priority assessment to perform before the nurse gives this medication? Bowel sounds Grip strength Urine output Correct! Oral fluid intake
Urine output Correct!
The oncology nurse is preparing to administer the initial dose of vincristine to a child diagnosed with acute lymphocytic leukemia (ALL). Which intervention is most appropriate to add to the plan of care? (Select all that apply.) Verify blood return before, during and after intravenous administration Monitor liver enzyme tests Monitor for numbness or tingling in the fingers and toes Apply ice to the injection site if extravasation occurs Select appropriate catheter for intrathecal administration
Verify blood return before, during and after intravenous administration Monitor liver enzyme tests Monitor for numbness or tingling in the fingers and toes
The oncology nurse is preparing to administer the initial dose of vincristine to a child diagnosed with acute lymphocytic leukemia (ALL). Which intervention is most appropriate to add to the plan of care? (Select all that apply.) Verify blood return before, during and after intravenous administration Monitor liver enzyme tests Monitor for numbness or tingling in the fingers and toes Apply ice to the injection site if extravasation occurs Select appropriate catheter for intrathecal administration
Verify blood return before, during and after intravenous administration Correct! Monitor liver enzyme tests Correct Response Monitor for numbness or tingling in the fingers and toes Correct!
A nurse is teaching a client with a diagnosis of metastatic bone disease about actions to prevent hypercalcemia. It would be important for the nurse to include which of these points? Walking as much as possible keeps the calcium in the bone A restriction of fluid intake is to be less than one liter per day At least five servings of dairy products are to be eaten daily Early recognition of findings associated with tetany
Walking as much as possible keeps the calcium in the bone
A client with a central line catheter is being discharged. Which of the following methods is the most accurate way to evaluate the client's partner's ability to provide central line catheter dressing changes at home? Allow repeated practice on a lifelike mannequin Provide pamphlets and pictures about the skill Watch the partner change the dressing Send the partner to a class about how to change dressings
Watch the partner change the dressing
A client with a central line catheter is being discharged. Which of the following methods is the most accurate way to evaluate the client's partner's ability to provide central line catheter dressing changes at home? Allow repeated practice on a lifelike mannequin Provide pamphlets and pictures about the skill Watch the partner change the dressing Send the partner to a class about how to change dressings
Watch the partner change the dressing Correct Response
A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this client's plan of care within the initial 24 hours? Wear masks with shields if there is potential for fluid splash Use disposable utensils and plates for meals Provide soft easily digested food with frequent snacks Wear gown and gloves during client contact
Wear gown and gloves during client contact Correct Response
The order is for 900 mg of nafcillin and the nurse has a powder in a vial labeled "Nafcillin 1 gram, dilute with 3.4 mL of sterile water to produce 1 gram in 4 mL." How many milliliters will the nurse administer? Report the answer to the nearest tenth. _____mL.
x = 3.6 mL
