Test 1

A client is to receive an antibiotic in 50 mL of D5 W over 30 minutes using an infusion pump. The nurse will set the infusion pump to deliver how many mL per hour? Round off to the nearest whole number.

100ml/hr

A client is scheduled for an electroencephalogram (EEG). Which intervention should the nurse implement?

Hold sedatives, but allow client to have breakfast and other medicines.

What information should the nurse give a pregnant client who comes to the clinic reporting hemorrhoids and constipation?

Increased rectal pressure from the gravid uterus may result in hemorrhoids, hormones decrease maternal GI motility, resulting in constipation more fluid and fiber is needed in the diet, increase daily fluid intake

A nurse is providing care to a post-operative parathyroidectomy client. Which complication takes priority?

Laryngospasm

The nurse reinforces instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication?

"I will have to limit my intake of spinach, something that I really love."

A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse?

"There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. "

An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the nurse. Which statement by the UAP indicates that further teaching is needed?

"When caring for a client who has a suppressed immune response, a N95 mask should be worn."

Which client assignments are most appropriate for the LPN to accept when working on the pediatric unit?

10 year old paraplegic in for bowel training, 7 year old in Buck's traction for a femur fracture

The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.

90mg/day

Which client should the nurse see first?

A client with a blood pressure drop from 150/80 to 120/60.

What side effects would the nurse expect to find in a client who has received too much levothyroxine?

Angina, heat intolerance, tremors

Which interventions are appropriate for the nurse to initiate for a client post liver biopsy?

Apply direct pressure to site immediately after needle is removed, monitor puncture site every 15 minutes for 1 hour, advise client that pain may occur as the anesthetic wears off.

The nurse monitors the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache?

Assisting the client into a side lying position, providing a back massage, providing heat therapy, using distraction techniques.

Which findings does the nurse expect to find when monitoring a client admitted with left sided congestive heart failure?

Bibasilar crackles, orthopnea

What activities should the nurse reinforce to a group of adolescents who have been diagnosed with rheumatoid arthritis?

Bicycle riding, swimming

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan?

Case manager

Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client?

Case manager

Which task would be appropriate for the LPN to accept from the charge nurse?

Changing a colostomy bag.

The nurse is reinforcing teaching to a client, who has reduced peripheral circulation, on how to care for the feet. What points should the nurse include?

Check shoes for rough spots in the lining, file toenails straight across, break in new shoes gradually

The nurse should monitor the results of which laboratory test for a client taking atorvastatin?

Cholesterol level

A client diagnosed with schizophrenia comes up to the nurse and says, Tick, tock, duck clock. Clock, clock, tick, tock. How would the nurse document this impaired communication?

Clang association

Which task would be appropriate for the LPN/VN to accept from the charge nurse?

Collect data on a new client admit, bolus feeding a client who has a gastrostomy tube, reinserting a nasogastric tube (NG) that a client accidentally pulled out, monitor patient control analgesic (PCA) pump pain medication being delivered to a client.

Parents bring their child to the clinic with left knee pain after suffering a fall on the playground. Which action should the nurse initiate first?

Compare the appearance of the left knee to the right knee

The nurse is caring for an immobile client. Which complication is the nurse's priority?

Deep vein thrombosis

The nurse is caring for a client with right-sided paresis due to a stroke. The client is preparing for discharge in a few days. The nurse discovers that the spouse has been feeding the client. What should the nurse do?

Determine the reason why the spouse is not encouraging self-care by the client.

A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take?

Discuss client rights with the primary healthcare provider.

A LPN/VN plans to reinforce education that was provided to a group of new parents about how to prevent burn injuries in children. What points should be included?

Eliminate use of placemats, establish "no" zones for space heaters, cover unused electrical outlets.

Which tasks should the nurse assign to the unlicensed assistive personnel (UAP)?

Empty the indwelling catheter bag, assist a client with position change every 2 hours, apply anti-embolism stockings.

A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation?

Ferrous sulfate

What should the nurse include when reinforcing teaching to a client in renal failure about peritoneal dialysis?

Following the prescribed dwell time, lower the bag to allow the fluid to drain out, the fluid that is returned should be clear in appearance, a sweet taste may be experienced when peritoneal dialysis is used.

Which documentation entries by the LPN would be appropriate to place in a client's electronic record?

Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services, permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon, transferred to surgical suite per stretcher with side rails up, in stable condition.

Three hours after delivery of a client's newborn, the nurse monitors for bladder distention. What signs would the nurse note if the client's bladder is distended?

Fundus 3 cm above umbilicus, excessive lochia, tenderness above symphysis pubis

A client sustained a skull fracture in a motor vehicle crash. The nurse knows this client is at risk for increased intracranial pressure and, therefore, would place the client in which position?

Head of bed at 30 to 45 degrees, head midline, neck in neutral position

In what position should the nurse place a client post intracranial surgery?

Head of bed elevated 30 degrees

What factor would most likely predispose a client with a compound femoral fracture to develop shock?

Loss of blood into soft tissues surrounding the fracture

A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement?

Maintain a low level of stimuli, remove all dangerous objects from environment, convey a calm attitude toward the client.

A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia, with an IV, NG tube to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do?

Maintain the patency of the NG tube.

A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen?

Many people of faith believe that one way God works to heal is through medication.

The nurse is caring for a client who is drowsy and has an elevated PCO2 level. What are some common medications that can cause this elevated level?

Narcotics, antiemetics, hypnotics

The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. What actions should the nurse take to ensure client safety?

Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies, stop the medication on the client's medication administration record, check the client's allergy band against the list of client allergies documented in the medical record.

The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial data collection, the client reports experiencing "numb feet." What is the nurse's first action?

Observe the client's feet for signs of injury.

The nurse is providing care for a client admitted with a diagnosis of myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration?

Offer small bites of food, allow client to rest between each bite of food

A client in the long-term care facility has been prescribed hydrochlorothiazide. What side effect should the nurse expect to observe?

Orthostatic hypotension

After applying oxygen using bi-nasal prongs to a client who is hypoxic, the nurse should implement which action?

Post signs on the client's door and in the client's room indicating that oxygen is in use

Which tasks would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)?

Prepare a client's room for return from surgery, assist a client with perineal care after having diarrhea, clean nares around a client's nasogastric (NG) tube.

Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first?

Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke."

A client 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?

Providing information to the client, providing emotional support, fostering a sense of security.

An expected outcome for a client with pneumonia is: "The airway will be free of secretions." Which action by the nurse is most important in meeting this goal?

Question an order for a cough suppressant medication.

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse collect data on first?

Receiving treatment for dehydration, and is now picking at bedding and IV tubing

What action should the nurse take when a client receiving 40 mL/hr of enteral feedings has a gastric residual volume of 250 mL?

Recheck gastric residual volume in 1 hour.

After injecting enoxaparin subcutaneously into the abdomen, which action should the nurse take?

Remove the needle and engage the needle safety device

The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair?

Removing the hair with clippers, applying hair removal cream.

A client asks the nurse, "What causes hypermagnesemia?" The nurse should reinforce to the client that hypermagnesemia can occur secondary to what health problem?

Renal insufficiency

Which nursing statement about a client reflects correct documentation in the hospital medical record?

Skin warm and dry to touch.

After a thoracotomy, which intervention by the nurse would enable the client to cough most effectively?

Splint the incision during deep breathing and coughing exercises.

The nurse cares for a client who is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which precaution is important for the nurse to implement?

Stock the client's room with dedicated equipment.

A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother?

Takes offense to the abrupt nature of the treatment.

The nurse is gathering data on a health history with a client who is 10 weeks pregnant. During the interview, the client states, "I'm not so sure I'm really happy about this pregnancy". Which response by the nurse is most appropriate?

Tell me more about how you are feeling.

A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate?

Tell me what the voices are saying to you.

Which nursing actions would indicate proper sterile technique?

The nurse does not allow any sterile item to get within one inch of the drape border, the nurse's arms stay above the waist, when adding sterile saline to a sterile bowl-the nurse places the inside of the bottle cap up, the nurse discards a package that becomes wet.

Which components of the communication cycle should the nurse include as necessary for effective verbal communication?

There is a sender for every message, a clear message is formulated, there is a receiver for every message.

The nurse is reinforcing teaching to the family of a diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client?

Treat a mild episode with 10-15 grams of carbohydrate.

The nurse is planning care for a client who has a fractured hip. Which nursing interventions are appropriate for this client?

Turn every two hours, place a pillow between legs when turning, encourage fluid intake, encourage ankle and foot exercises

For a client with a major burn, which evaluation criteria best indicates that fluid resuscitation is effective during the first 24 hour of care?

Urine output of 30-50 mL per hour

The nurse has identified that a client receiving oxygen has nasal irritation. Which client action would require the nurse to intervene?

Use of petroleum jelly on the nares and cheeks.

A client reports difficulty sleeping since starting a new job. The nurse's data collection identifies that the client is also working after hours from home. Which guidelines are appropriate to promote sleep in this client?

Use the bedroom for only sleep, schedule meal times earlier in the evening, avoid caffeine in the evening, use a white noise machine to help lull to sleep.

Which meal option should the client diagnosed with gout select?

Vegetable soup, whole wheat toast, skim milk

The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client?

Warm the finger prior to the stick.

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate?

Wears sterile gloves to clean the ulcer, cleans ulcer with normal saline, cleans ulcer in a full circle, beginning in the center and working toward the outside.

The client has suicidal ideations with a vague plan for suicide. The nurse, who is reinforcing teaching to the family about caring for the client at home, should emphasize which points?

When the client stops talking about suicide, the risk has increased Warning signs, even if indirect, are generally present prior to a suicide attempt One suicide attempt increases the chance of future suicide attempts Report sudden behavioral changes

What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia?

White blood cell count of 3,800 (3.8 x 109/L), platelet count of 90,000/µL (90 x 109/L), red blood cell count of 3.0 million/mcL (3.0 x 1012/L)

Which client diagnosis would require the nurse to initiate droplet precaution?

Whooping cough