Critical Care HESI Practice Questions
ANS = D
A 76-year-old widower is terminally ill. He is very quiet & is unwilling to have visitors. During the initial contact with this client, what should the nurse do? a. Assess what the client knows about death & the dying process b. Avoid talking about his condition unless he initiates the discussion c. Encourage him to accept phone calls from those who wish to visit with him d. Explore the extent to which he understands his situation & what the information means to him
ANS = C
A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? a. Bathing will not be permitted b. Dressings will be changed daily c. Personal protective equipment will be worn by staff d. Room temperature will be kept below 72° F (22.2° C)
ANS = D
A burn victim has waxy white areas interspersed with pink & red areas on the anterior trunk & all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? a. 20% b. 25% c. 30% d. 36%
ANS = D
A client arrives in the emergency department in cardiac arrest. Which priority action indicates that the nurse is acting as a leader? a. Trying to find the reason for the disease b. Asking for the history of any other diseases c. Waiting for the primary health care provider d. Resuscitating the client using clinical protocols
ANS = C
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, & legs. Which are the priority nursing assessments? a. Level of consciousness & pupil size b. Characteristics of pain & blood pressure c. Quality of respirations & presence of pulses d. Observation of abdominal contusions & other wounds
ANS = A, B, D
A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? (Select all that apply) a. Fever b. Tachypnea c. Hypertension d. Abdominal rigidity e. Increased bowel sounds
ANS = B
A client diagnosed with tuberculosis is taking Isoniazid. To prevent a food & drug interaction, the nurse should advise the client to avoid which food? a. Hot dogs b. Red wine c. Sour cream d. Apple juice
ANS = B
A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client? a. Sims b. Semi-Fowler c. Trendelenburg d. Dorsal recumbent
ANS = C
A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? a. Increase fluids b. Increase fiber in the diet c. Wash hands with soap & water d. Wash hands with an alcohol-based hand sanitizer
ANS = B
A client has a craniotomy for a meningioma. For which response should the nurse assess the client in the post-anesthesia care unit? a. Dehydration b. Blurred vision c. Wound infection d. Narrowing pulse pressure
100
A client has a prescription for an antibiotic in an IVPB of 50 mL of D5W to run for 30 minutes. The microdrip tubing has a drop factor of 60 gtt/mL. At what rate should the nurse set the IV infusion? Record your answer using a whole number. - ______ gtts/min
ANS = D
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? a. "Is your job demanding or stressful most of the time?" b. "Do you participate in any strenuous sports activities on a regular basis?" c. "Does anyone in your family have a history of central nervous system problems?" d. "Were you aware of anything different or unusual just before your seizure began?"
ANS = C
A client has an open reduction & internal fixation for a fractured hip. Postoperatively the nurse should place the client's affected extremity in which position? a. External rotation b. Slight hip flexion c. Moderate abduction d. Anatomic body alignment
ANS = C
A client has been admitted with a urinary tract infection. The nurse receives a urine culture & sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others? a. Insert a urinary catheter b. Initiate droplet precautions c. Move the client to a private room d. Use a high-efficiency particulate air (HEPA) respirator during care
ANS = C
A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation? a. Begin active exercises b. Make a referral to the physical therapist c. Position the client to prevent contractures d. Avoid moving the affected extremities unless necessary
ANS = D
A client hospitalized for heart failure is receiving Digoxin & will continue taking the drug after discharge. What should be included in the plan of care for the next few days? a. Monitoring vital signs & encouraging a vigorous aerobic exercise program b. Providing written material on the adverse effects of the medication c. Contacting Social Services for a home health nursing consultation d. Teaching the client how to count the pulse
ANS = D
A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the primary healthcare provider? a. Start a 24-hour urine collection b. Prepare for urinary catheterization c. Teach the client how to perform perineal care d. Obtain a urine specimen for culture & sensitivity
ANS = D
A client injured in a motor vehicle accident was brought to the emergency & taken immediately for a scan. The client's family arrives later & asks about the client's health. What should the nurse tell the client's family? a. "Please do not worry, everything will be alright." b. "I am sorry; I do not have any information about the client." c. "You will have to wait for the primary healthcare provider." d. "Please wait; I will update you as soon as I have any information."
ANS = D
A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide therapy via tablets has been prescribed. The nurse anticipates that the dosage will be changed frequently during the first week of therapy. While the dosage is being adjusted, what action does the nurse perform? a. Administer the medication after meals b. Administer the medication on an empty stomach c. Evaluate the client's psychological responses between medication doses d. Evaluate the client's muscle strength every hour after the medication is given
ANS = D
A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? a. Advising the client to join a support group immediately after discharge b. Assuring the family that staff members will take care of the client's needs c. Reminding the client to keep medical follow-up appointments after discharge d. Conducting a multidisciplinary staff conference early during the client's hospitalization
ANS = D
A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, what will the nurse include in the teaching? a. Take the iodine daily to increase the formation of thyroid hormone b. Understand that medication will be temporary until the body adjusts to post-surgical activities c. Take the propylthiouracil that is prescribed to stimulate the secretion of thyroid-stimulating hormone d. Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone
ANS = A
A client is admitted to the hospital for an adrenalectomy. The nurse is providing postoperative care before the client's replacement steroid therapy is regulated fully. The nurse should monitor the client for which complication? a. Hypotension b. Hypokalemia c. Hypernatremia d. Hyperglycemia
ANS = B
A client is admitted to the hospital for cranial surgery. What does the nurse include in the preoperative plan of care? a. Helping the client put on a wig before the client's visitors arrive b. Obtaining the client's consent for shaving the head c. Braiding the client's hair to keep it contained during surgery d. Instructing the client that with all cranial surgeries, the head is shaved after anesthesia has been administered
ANS = B
A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? a. Determine the client's emotional state b. Give prescribed drugs to promote bronchiolar dilation c. Provide education about the impact of a family history d. Encourage the client to use an incentive spirometer routinely
ANS = C
A client is admitted to the hospital with partial- & full-thickness burns of the chest & face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? a. Loss of skin integrity caused by the burns b. Potential infection as a result of the burn injury c. Inadequate gas exchange caused by smoke inhalation d. Decreased fluid volume because of the depth of the burns
ANS = A
A client is admitted to the hospital with severe burns. Which client response should the nurse anticipate during the acute phase of burn recovery? a. Unstable vital signs b. Decreased urinary output c. High serum potassium levels d. Reduced intravascular fluid volume
ANS = C
A client is admitted to the hospital with the diagnosis of acute salmonellosis. Which priority medication will the nurse prepare to administer? a. Opioids b. Antacids c. Electrolytes d. Antidiarrheals
ANS = A
A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? a. Place the head & neck in alignment b. Administer 1 gram mannitol intravenously (IV) as prescribed c. Increase the ventilator's respiratory rate to 20 breaths/minute d. Administer 100 mg of pentobarbital IV as prescribed
ANS = A
A client is admitted with a diagnosis of chronic adrenal insufficiency. Which roommate should be avoided when assigning a room for this client? a. A young adult client with pneumonia b. An adolescent client with a fractured leg c. An older adult client who had a brain attack d. A middle-aged client who has cholecystitis
ANS = B
A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission & identifies the client's potassium level of 6.0 mEq/L. Which drink will the nurse recommend be included in the client's diet? a. Milk b. Tea c. Orange juice d. Tomato juice
ANS = D
A client is brought to the emergency department following ingestion of pesticides. The primary health care provider orders gastric suction. Which task can be delegated to the unlicensed assistive personnel (UAP) in this situation? a. Monitoring the vital signs b. Evaluating the client response c. Gastric suctioning through vented tube d. Emptying & measuring the gastric drainage
ANS = B
A client is diagnosed with heart failure & is admitted for medical management. Which statement made by the client may indicate worsening heart failure? a. "I am unable to run a mile (1.6 kilometers) now." b. "I wake up at night short of breath." c. "My wife says I snore very loudly." d. "My shoes seem larger lately."
ANS = B
A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client? a. Renin causes a gradual decrease in arterial pressure b. Lipid plaque formation occurs within the arterial vessels c. Development of atheromas within the myocardium is characteristic d. Mobilization of free fatty acid from adipose tissue contributes to plaque formation
ANS = D
A client is having a tonic-clonic seizure. Which is a priority nursing action? a. Elevating the head of the bed b. Restraining the client's arms and legs c. Placing a tongue blade in the client's mouth d. Taking measures to prevent injury
ANS = A, C, E
A client is hospitalized with dehydration & dysphagia. Which tasks are appropriate to delegate to a licensed practical nurse? (Select all that apply) a. Administer medications b. Perform initial swallow screen c. Assist UAP with ambulating client d. Complete admission skin assessment e. Record vital signs on electronic health record
ANS = A
A client is receiving patient-controlled analgesia (PCA) after surgery. What does the nurse identify as the primary benefit with this type of therapy? a. Client is able to self-administer pain-relieving drugs as necessary b. Amount of medication received is determined entirely by the client c. Amount of drug used for analgesia matches sleep-wake cycles d. Self-administration relieves the nurse of monitoring the client for pain relief
ANS = A
A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client? a. Before the surgery b. During the convalescent phase c. On discharge from the hospital d. When it is time for a prosthesis
ANS = B
A client is scheduled for skin cancer surgery & has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? a. Ambivalent feelings are present & acknowledged b. A sedative type of medication has been given recently c. A complete history & physical has not been performed & recorded d. A discussion of alternatives with two primary healthcare providers has not occurred
ANS = B
A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? a. "You will receive the anesthesia through a face mask." b. "You will receive medication through an IV catheter." c. "We will give you an oral medication about 1 hour before the procedure." d. "The medicine will be injected into your spine."
ANS = A
A client is to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is most important for the nurse to obtain? a. Infusion pump b. Tall IV pole c. Clamp taped at the bedside d. Infusion set delivering 60 drops/mL
ANS = D
A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is what? a. Electromyography b. Pyridostigmine test c. History of physical deterioration d. Edrophonium chloride test
ANS = C
A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? a. Restore the client's health b. Promote the client's recovery c. Relieve the client's discomfort d. Support the client's significant others
ANS = A
A client presents to the emergency department with weakness & dizziness. The BP is 90/60 mm Hg, pulse is 92 & weak, & body weight reflects a 3-pound loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? a. Deficient fluid volume b. Impaired skin integrity c. Inadequate nutritional intake d. Decreased participation in activities
ANS = D
A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms? a. "Can you describe the pain?" b. "Where exactly do you feel the pain?" c. "Which activities make the pain worse?" d. "What other discomfort do you experience?"
ANS = D
A client reports left-sided chest pain after playing racquetball. The client is hospitalized & diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a. Dull sound on percussion b. Vocal fremitus on palpation c. Rales with rhonchi on auscultation d. Absence of breath sounds on auscultation
ANS = D
A client requiring long-term ventilator management is discharged from the health care facility. Which health care setting should this client be referred to? a. Home care b. Rehabilitation c. Assisted living d. Intermediate care
ANS = C
A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site 9 months ago. The site is healed, & the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present? a. Notify the infection control officer b. Inform the operating room of the MRSA c. Obtain an order to culture the client's blood d. Call the surgeon for an infectious disease consultation
ANS = C
A client states, "I feel like my heart is jumping out of my chest, and it is skipping beats." The client passes a thallium stress test; however, the healthcare provider identifies one premature ventricular complex (PVC) and several premature atrial complexes (PACs) on the 24-hour follow-up Holter monitor. Which question is most important for the nurse to ask the client? a. "Do you eat foods high in vitamins?" b. "Do you have small children at home?" c. "How much caffeine do you consume each day?" d. "How many glasses of water do you drink per day?"
ANS = C
A client sustains a back injury after falling 20 feet. In which position should the nurse place the client? a. Lateral position with a pillow between the knees b. Any position that reduces pain & is comfortable c. Supine position while not allowing the spine to flex d. Sitting position with a pillow placed in the small of the back
ANS = B
A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? a. Provide low-sodium milk b. Provide high-protein drinks c. Provide foods that are low in potassium d. Provide 10% more calories in the form of fats
ANS = C
A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, & reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer
ANS = C
A client who had surgery for a laryngectomy is returned to the surgical unit from the post-anesthesia care unit. In which position is it most appropriate for the nurse to place the client at this time? a. Prone with the head turned to one side b. Supine with the knees flexed at 10 degrees c. Lateral with the head slightly elevated & flexed d. Supine with the head in a hyperextended position
ANS = A
A client who had thoracic surgery is admitted to the post-anesthesia care unit. What should the nurse do after the chest tube is attached to a disposable plastic water-seal drainage system? a. Ensure the security of the connections from the client to the drainage unit b. Empty the drainage container and measure and record the amount once a day c. Verify that there is vigorous bubbling in the wet suction control compartment d. Check that the fluid level in the water-seal compartment increases with expiration
ANS = C
A client who has a Hgb of 6 gm/dL is refusing blood because of religious reasons. What is the most appropriate action by the nurse? a. Call the chaplain to convince the client to receive the blood transfusion b. Discuss the case with coworkers c. Notify the primary healthcare provider of the client's refusal of blood products d. Explain to the client that they will die without the blood transfusion
ANS = C
A client who is admitted to the hospital & requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? a. "My doctor will know what to do." b. "My family can make the decisions for me." c. "If something happens to me, I would rather die." d. "If I have a heart attack, I do not want any medication."
ANS = D
A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu & is concerned about the need for special care at home. What should the nurse instruct the client to do? a. Skip the oral hypoglycemic pill, drink plenty of fluids, & stay in bed b. Avoid food, drink clear liquids, take a daily temperature, & stay in bed c. Eat as much as possible, increase fluid intake, & call the office again the next day d. Take the oral hypoglycemic pill, drink warm fluids, & check your blood sugar before meals & at bedtime
ANS = A
A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? a. Contact an interpreter provided by the hospital b. Contact the client's family member to translate for the client c. Communicate with the client using Spanish phrases the nurse learned in a college course d. Communicate with the client with the use of a hospital-approved Spanish dictionary
ANS = A
A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care? a. Use a consistent approach to care & encourage participation b. Prepare equipment while doing the procedure & explain the treatment to the client c. Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature d. Arrange for a change of staff every 4 to 5 days & have the client select the time for the procedure to be done
ANS = D
A client who was hospitalized with partial- & full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? a. Readiness to discuss the client's deformities b. Indication of a change in family relations c. Need for more time to think about the future d. Beginning realization of implications for the future
ANS = A
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? a. Arteriolar constriction occurs b. The cardiac workload decreases c. Contractility of the heart decreases d. The parasympathetic nervous system is triggered
640
A client who weighs 80 kg is being immunosuppressed by daily maintenance doses of cyclosporine to prevent organ transplant rejection. The dose prescribed is 8 mg/kg each day. How many milligrams should the nurse plan to administer each day? Record your answer using a whole number. - ______ mg
ANS = D
A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect & need to monitor frequently in this client? a. Localized seizures b. Skin desquamation c. Hyperactive reflexes d. Ascending weakness
ANS = A
A client with a leg prosthesis & a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what? a. Falls b. Impaired cognition c. Imbalanced nutrition d. Impaired gas exchange
ANS = B
A client with a mental illness in the emergency unit needs to undergo an emergency surgery. What would be the nurse's first course of action to prevent any legal complications? a. Wait for a court order to intervene on the client's behalf b. Obtain consent from a person legally authorized to give it on the client's behalf, if available c. Obtain a court order to state that the client is incompetent to decide for himself or herself d. Request that the primary healthcare provider start the procedure without the client's consent
ANS = A
A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? a. Enhances the quality of the client's life b. Reduces the likelihood of a respiratory infection c. Prevents the malabsorption syndrome from occurring d. Cures the cachexia that results from bone cancer & chemotherapy
ANS = B
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client & visitor safety during transport, the nurse should implement which precaution? a. No special precautions are required b. Cover the infected site with a dressing c. Drape the client with a covering labeled biohazardous d. Place a surgical mask on the client
ANS = D
A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essential nursing intervention? a. "Maintain elevation of both legs." b. "Massage the legs when they are painful." c. "Apply a hot water bottle to the legs." d. "Check pulses in the legs regularly."
ANS = B
A client with cirrhosis of the liver & ascites has been taking Chlorothiazide, a Thiazide Diuretic. Why did the provider add Spironolactone to the client's medication regimen? a. To stimulate sodium excretion b. To help prevent potassium loss c. To increase urine specific gravity d. To reduce arterial blood pressure
ANS = A
A client with hyperthyroidism is to receive Methimazole. What instructions does the nurse provide? a. Initial improvement will take several weeks b. There are few side effects associated with this drug c. This medication may be taken at any time during the day d. Large doses are used to quickly correct the functions of the thyroid
ANS = B, E
A client with hypoglycemia is admitted to the hospital. Which duties can the registered nurse (RN) safely delegate to the licensed practical nurse (LPN)? (Select all that apply) a. Intravenous fluid intervention b. Administering oral medications c. Monitoring the fluctuating vitals d. Analyzing the case history of the client e. Administering intramuscular medication
ANS = D
A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide, and long-term steroid therapy has been initiated. What is especially important for the nurse to ensure? a. The client increases sodium intake b. Protective isolation is established c. Total daily fluid intake is decreased d. The client is monitored for an exacerbation of symptoms
ANS = D, E
A client with postural hypotension requires nursing care. Which task can be safely delegated by the registered nurse to unlicensed nursing personnel (UNP)? (Select all that apply) a. Mobilizing the client b. Assessing the pulse rate c. Assessing the blood pressure d. Managing foot care of the client e. Maintaining oral hygiene of the client
ANS = 0.2
A client with terminal bone cancer is to receive 2 mg of hydromorphone IV every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. - ______ mL
ANS = A
A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more & regain strength." Which stage of grieving does the nurse concludes the client is experiencing? a. Bargaining b. Frustration c. Depression d. Rationalization
ANS = D
A family has decided to withhold extraordinary care for a newborn with severe abnormalities. How should the nurse interpret this decision? a. The newborn has no rights b. It is the same as euthanasia c. It is illegal professional practice d. The newborn is being allowed to die
ANS = D
A female client terminally ill with cancer says to the nurse, "My husband is avoiding me. He doesn't love me anymore because of this awful tumor!" What is the nurse's most appropriate response? a. "What makes you think he doesn't love you?" b. "Avoidance is a defense. He needs your help to cope." c. "Do you think he's having difficulty dealing with your illness?" d. "You seem very upset. Tell me how your husband is avoiding you."
ANS = A
A frantic parent calls stating their child has swallowed dish soap. What should the nurse advise? a. Call poison control b. Induce vomiting immediately c. Give syrup of ipecac, one tablespoon d. Give activated charcoal, & expect black stools for 24 hours
ANS = A
A green-tagged client arrives at the emergency department (ED) after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this client? a. Implementing decontamination measures b. Performing a head to toe physical examination c. Placing a special bracelet with a disaster number d. Taking a digital photo & placing it on the medical record
ANS = B
A healthcare provider prescribes Epoetin subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first? a. Demonstrate the injection technique b. Assess the client's readiness to learn c. Explain how to perform sterile technique d. Encourage the client to contact a home healthcare agency
ANS = D
A healthcare provider prescribes Famotidine & Magnesium hydroxide/Aluminum hydroxide antacid for a client with a peptic ulcer. The nurse should teach the client to take the antacid at what time? a. Only at bedtime, when Famotidine is not taken b. Only if Famotidine is ineffective c. At the same time as Famotidine, with a full glass of water d. One hour before or 2 hours after Famotidine
18
A healthcare provider prescribes Lidocaine HCl, 1.5 mg per minute, for a client whose ECG tracing reveals multiple premature ventricular complexes (PVCs). The nurse adds 500 mg of Lidocaine HCl to 100 mL of D5W. To administer the correct amount of medication, at what rate should the nurse set the IV infusion pump? Record your answer using a whole number. - _____ mL/hr
ANS = B, E
A healthcare team is caring for a 68-year-old client with diabetes insipidus. Which task is most suitable to be delegated to licensed practical nurse (LPN) to provide effective client care? (Select all that apply) a. Emptying the urinary drainage bag b. Monitoring urine output c. Feeding the client with food d. Administration of intravenous fluids e. Administering oral rehydration medication
ANS = D
A healthcare team is caring for a client with dental pain. Which task is most suitable to be delegated to unlicensed assistive personnel (UAP) to provide effective client care? a. Administering analgesics b. Administering IV antibiotics c. Administering nerve block anesthesia d. Administering mouth wash for oral hygiene
ANS = A, C, D
A healthcare team is caring for a post-surgical client who underwent knee surgery. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? (Select all that apply) a. Changing the dressing b. Ambulating the client c. Administration of oral analgesics d. Reinforcing leg exercise instructions e. Administering IV antibiotics
ANS = C
A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what? a. Promote gluconeogenesis b. Produce an antiinflammatory effect c. Promote cell growth & bone union d. Decrease pain medication requirements
ANS = C
A home health nurse on a first visit checks the client's vital signs & obtains a blood sample for an INR. After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? a. "I would, but my back hurts today." b. "Okay. It will be my good deed for the day." c. "Of course. I want to do whatever I can for you." d. "I would like to, but it is not in my job description."
ANS = C
A hospice nurse is caring for a dying client & the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? a. Cohesiveness b. Educational level c. Cultural background d. Socioeconomic status
ANS = A
A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? a. Coin in the umbilicus b. Tight diaper over the umbilicus c. Binder that encircles the umbilicus d. Adhesive tape across the umbilicus
ANS = A
A mother whose child has been killed in a school bus accident tells the nurse that her child was just getting over the chickenpox & did not want to go to school but she insisted that the child go. The mother cries bitterly & says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may do what? a. Grow in intensity & duration b. Progress to a psychiatric illness c. Be easier to understand & to accept d. Cause the mourner to experience a pathological grief reaction
ANS = D
A neonate born at 32 weeks' gestation & weighing 3 lb (1361 g) is admitted to the NICU. When should the nurse take the neonate's mother to visit the infant? a. When the infant's condition has stabilized b. When the infant is out of immediate danger c. When the primary healthcare provider has provided written permission d. When the mother is well enough to be taken to the intensive care unit
ANS = A
A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do? a. Honor the client's decision & document the behavior and all interventions b. Use an authoritarian approach to induce the client to take the prescribed medication c. Call the primary healthcare provider & request that the client be discharged against medical advice d. Start proceedings to have the client declared incompetent & seek a court order permitting medication
ANS = C
A nurse administers IV therapy to the wrong client. What possible legal complications might the nurse face in such situation? a. Assault b. Battery c. Malpractice d. False imprisonment
ANS = B
A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? a. Tympany b. Borborygmi c Abdominal bruit d. Pleural friction rub
ANS = C
A nurse assisting in a research study calculates the risk-benefit ratio & concludes that there were no harmful effects associated with a survey of diabetic clients. This researcher was applying which principle? a. Human dignity b. Human rights c. Beneficence d. Utilitarianism
ANS = A
A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? a. It is unlikely that the client will regain the ability to walk b. It prepares them for wearing braces c. It assists them in overcoming orthostatic hypotension d. They have the strength in the upper extremities for self-transfer
ANS = B
A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? a. Warmth b. Numbness c. Skin desquamation d. Generalized discomfort
ANS = C
A nurse is caring for a client 8 hours after surgery. The client's portable wound drainage device is half full of drainage. After emptying the drainage collection chamber, how will the nurse create negative pressure in the system? a. Attaching the device to a wall suction unit b. Milking the tubing toward the suction device c. Compressing the device while closing the air plug d. Keeping the device in a position lower than the site of insertion
ANS = B
A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? a. Curing the condition permanently b. Raising mucous secretions from the chest c. Limiting pulmonary secretions by decreasing fluid intake d. Convincing the client that the condition is emotionally based
ANS = D
A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area & fluid loss should the nurse consider when evaluating fluid loss in a client with burns? a. Equal b. Unrelated c. Inversely related d. Directly proportional
ANS = D
A nurse is caring for a client who has just returned from the post-anesthesia care unit after having a thyroidectomy. Which action has priority during the first 24 hours after surgery when the nurse is concerned about thyroid storm? a. Performing range-of-motion exercises b. Humidifying the room air continuously c. Assessing for hoarseness every two hours d. Checking vital signs every two hours after they stabilize
ANS = D
A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? a. Strip the chest tube periodically b. Administer the prescribed cough suppressant at the scheduled times c. Empty and measure the drainage in the collection chamber each shift d. Keep the drainage system lower than the level of the client's chest
ANS = A
A nurse is caring for a client with expressive aphasia. Which action should the nurse include when planning for the long-term care of this client? a. Begin helping the client to write b. Encourage the client to acknowledge that this disability is permanent c. Wait for communication to be initiated by the client even if it takes a long time d. Assist family members to accept the fact that they cannot communicate verbally with the client
ANS = D
A nurse is caring for a client with renal failure. The client wants to go back home but the family members want the client to undergo a kidney transplant. The nurse gives details about the possible threats & benefits of the surgery to the family & informs them that the client wants to stay home. What role does the nurse play here? a. Educator b. Manager c. Caregiver d. Advocate
ANS = C
A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? a. Decreased rate of glomerular filtration b. Excessive blood loss through the burned tissues c. Plasma proteins moving out of the intravascular compartment d. Sodium retention occurring as a result of the aldosterone mechanism
ANS = A
A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span & cannot concentrate. The nurse suspects which effects of sensory deprivation? a. Cognitive response b. Emotional response c. Perceptual response d. Physical response
ANS = A
A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? a. Atrial fibrillation b. Forearm laceration c. Migraine headache d. Respiratory infection
ANS = D
A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? a. Trimming toenails so that they are short & rounded b. Checking bathwater temperature by putting the toes in first c. Using alcohol to rub hands, feet, legs, & arms at least two times a day d. Seeking professional treatment for any minor injuries to the extremities
ANS = C
A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? a. Eating beef & veal is prohibited b. Consumption of fish with scales is forbidden c. Meat & milk at the same meal are forbidden d. Consuming alcohol, coffee, & tea are prohibited
ANS = B, C, E
A nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? (Select all that apply) a. When consent has been obtained from the spouse b. When consent has been given specifically by a court c. When self-consent has been granted by a court order d. When consent has been given by a grandparent e. When consent has been obtained from at least one parent of the minor
ANS = D
A nurse is preparing a client for discharge from the emergency department. Which client statement provides evidence that the client understands the instructions for the prescribed high-dose ampicillin? a. "I should take this medication with meals." b. "I can stop taking this medication when I feel better." c. "I will miss eating my yogurt while taking this medication." d. "I must increase my intake of fluids while taking this medication."
ANS = D
A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority? a. Notifying the receiving unit of the transfer b. Having the client's records ready for the transfer c. Verifying that the family has been notified of the transfer d. Checking that a bag-valve mask is available during the transfer
ANS = B
A nurse is preparing to teach a client to apply a Nitroglycerin patch as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? a. Apply the patch on a distal extremity b. Remove a previous patch before applying the next one c. Massage the area gently after applying the patch to the skin d. Apply a warm compress to the site before attaching the patch
ANS = B
A nurse is providing discharge instructions about Digoxin. Which response should a nurse include as a reason for a client to withhold the Digoxin? a. Chest pain b. Blurred vision c. Persistent hiccups d. Increased urinary output
ANS = B
A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction (MI). Which statement by the client indicates the nurse needs to follow up? a. "I want to stay as pain-free as possible." b. "I am not good at remembering to take medications." c. "I should not have any problems in reducing my salt intake." d. "I wrote down my dietary information for future reference."
ANS = A
A nurse is providing post-procedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention? a. Monitor the vital signs every 15 minutes b. Maintain the client in the supine position c. Keep the client's lower extremities in extension d. Administer the prescribed oxygen at 4 L/min via nasal cannula
ANS = C
A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? a. Fruits b. Grains c. Red meat d. Vegetable oils
ANS = C
A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? a. Discharge in AM b. Blood glucose monitoring AC & bedtime c. Erythromycin 250 mg TIW d. Dalteparin 5000 international units SQ BID
ANS = B
A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returning to the situation. What is the best response by the nurse manager? a. "She must not have the financial resources to leave her husband." b. "Most women try to leave about six times before they are successful." c. "There's nothing the staff can do; people are free to choose their own lives." d. "These women should be told how stupid they are to stay in that kind of situation."
ANS = B
A nurse is working with an unlicensed assistive personnel (UAP) in caring for a group of clients. Which statement by the UAP indicates a correct understanding of the UAP's role? a. "I will turn off clients' IVs that have infiltrated." b. "I will take clients' vital signs after their procedures are over." c. "I will use unit written materials to teach clients before surgery." d. "I will help by giving medications to clients who are slow in taking pills."
ANS = C
A nurse notes that the primary healthcare provider has scheduled a surgery for an unconscious client. An informed consent has not yet been obtained. What course of action does the nurse expect to be taken to deal with the situation? a. The client's spouse will give informed consent for the surgery b. The procedure will be postponed till the client is able to give consent c. The surrogate decision maker designated by the client will give consent d. The primary healthcare provider will perform the procedure without waiting for consent
ANS = A
A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the Lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect? a. Demonstration of a personal bias b. Problem solving based on assessment c. Determination of client acuity to set priorities d. Consideration of the complexity of client care
ANS = D
A nurse performs full range-of-motion exercises on a client's extremities. When putting an ankle through range-of-motion exercises, what must the nurse perform? a. Flexion, extension, & rotation b. Abduction, flexion, adduction, & extension c. Pronation, supination, rotation, & extension d. Dorsiflexion, plantar flexion, eversion, & inversion
ANS = D
A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve? a. Increasing mobility b. Preventing contractures c. Limiting orthostatic hypotension d. Preventing pressure on peripheral blood vessels
ANS = C
A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action? a. Authority b. Autonomy c. Accountability d. Responsibility
ANS = C
A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? a. Inform the client of the results b. Ensure that the results are placed in the client's medical record c. Notify the client's primary healthcare provider of the results d. Obtain results of the other lab tests that were performed
ANS = A, B, C
A nurse signs as a witness to informed consent provided by the client. What does the signature of the nurse imply? (Select all that apply) a. That the client's signature is authentic b. That the client has given consent voluntarily c. That the client appears to be competent to give consent d. That the client cannot refuse treatment after its initiation e. That the client has received a proper explanation of procedures from the nurse
ANS = A
A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? a. Become aware of their personal values b. Gain information related to their needs c. Make correct decisions related to their health d. Alter their value systems to make them more socially acceptable
ANS = B
A nurse who promotes freedom of choice for clients in decision-making best supports which principle? a. Justice b. Autonomy c. Beneficence d. Paternalism
ANS = B
A nurse's coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. How should the nurse respond? a. Answer the questions softly so other people will not hear b. Decline to discuss the friend's medical condition c. Give the coworker the name of the client's primary healthcare provider, so the coworker can contact the provider instead d. To provide reassurance, tell the coworker of the friend's test results that are within normal limits
ANS = C
A nurse, while assessing different survivors of a tornado, assigns a red tag to a client. What could be the casualty condition of the client? a. No treatment, expected to die b. Treatment can be delayed, minor injuries c. Requires emergent treatment, threat to life d. Require immediate treatment, major injuries
ANS = B
A nursing instructor provides teaching about the ethical principle of nonmaleficence to a group of nursing students. What is appropriate for the nurse to include in the education? a. Treat all patients equitably & fairly b. Act in ways to prevent harm to patients c. Tell the patient the truth about their health d. Help the patients to make informed choices
ANS = C
A nursing student is listing the characteristics of an ethical issue. Which point listed by the nursing student requires correction? a. An ethical issue occurs if it is perplexing & if it is not easy to think logically or make a decision b. An ethical issue occurs if it is not possible to resolve solely through a review of scientific data c. An ethical issue occurs if the problem aims at the greatest good for the greatest number of people d. An ethical issue occurs if the answer to the problem has a profound relevance for areas of human concern
ANS = A
A nursing student is listing the different aspects of obtaining informed consent from clients. Which point mentioned by the nursing student needs correction? a. "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." b. "Informed consent should be obtained in all situations except during extraordinary circumstances." c. "Informed consent is provided by clients based on the full disclosure of risks, benefits, alternatives, & consequences of refusal." d. "The primary healthcare provider legally has to disclose facts in terms that the client is able to understand to make an informed choice."
ANS = A
A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent? a. Battery b. Invasion of privacy c. False imprisonment d. Defamation of character
ANS = A, C, E
A nursing supervisor sends an unlicensed healthcare worker to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the health care worker? (Select all that apply) a. Taking routine vital signs b. Applying a sterile dressing c. Answering clients' call lights d. Administering saline infusions e. Changing linens on an occupied bed f. Assessing client responses to ambulation
ANS = D
A patient who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities? a. The student expects the interpreter to act as the patient's advocate b. The student expects the interpreter to have a health care background c. The student maintains steady eye contact with the patient d. The student talks only to the interpreter about the patient
ANS = A, D, E
A patient who had been receiving palliative care for cancer has deteriorated & now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? (Select all that apply). a. Chemotherapy b. Repositioning c. Regular oral care d. Blood transfusion e. Radiation therapy
ANS = B
A patient with a terminal illness is grateful for the care received in the hospital & has slowly started to come to terms with imminent death. The nurse recognizes that the patient's behavior & attitude is most consistent with which cultural group? a. German culture b. Somalian culture c. Ukrainian culture d. More secular culture
ANS = C
A patient with chronic renal failure stops responding to the treatment. On examination, the primary healthcare provider determines that the patient is terminally ill. What is the best nursing intervention in this situation? a. Suggest that the family members get a second opinion b. Suggest that the family members continue to try different treatments c. Encourage the family members to provide palliative care to the patient d. Inform the family members that the disease is no longer curable & the patient will die shortly
ANS = A
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare? a. Cool, moist towels b. Dry, sterile dressings c. Analgesic sunburn spray d. Vitamin A & D ointment
ANS = C
A post-operative client is discharged to home. Which statement made by the nurse would be beneficial for the client's care in the home? a. "I will change the dressing every day." b. "I will recommend a physical therapy referral." c. "I will provide you with a homecare service referral." d. "I will not allow any family member to be present during dressing change."
ANS = C
A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an IV infusion, administer oxygen, & draw blood for laboratory tests. The client's apprehension is increasing, & she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be alright, & that everything is under control. What is the best interpretation of the nurse's statement? a. Adequate, because the preparations are routine & need no explanation b. Effective, because the client's anxieties would increase if she knew the danger involved c. Questionable, because the client has the right to know what treatment is being given & why d. Incorrect, because only the primary healthcare provider should offer assurances about management of care
ANS = B
A primary healthcare provider prescribes Propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse & complains of feeling tired & looking pale. What should the nurse do? a. Advise the client to get more rest. b. Schedule the client for an appointment. c. Instruct the client to skip one dose daily. d. Tell the client to increase the medication.
ANS = C
A primary nurse receives prescriptions for a newly admitted client & has difficulty reading the healthcare provider's writing. Who should the nurse ask for clarification of this prescription? a. Nurse practitioner b. House healthcare provider who is on call c. Healthcare provider who wrote the prescription d. Nurse manager familiar with the healthcare provider's writing
ANS = D
A recent immigrant from mainland China is critically ill & dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? a. "Do you like living in this country?" b. "When did you come to this country?" c. "Is there a family member who can translate for you?" d. "Which family member do you prefer to receive information?"
ANS = A
A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes? a. "A nurse should provide a personal point of view." b. "Negotiations should be held in formal settings only." c. "Negotiation takes place immediately after gathering information." d. "The group agrees to a statement of the problem during the negotiation process."
ANS = C
A registered nurse is teaching a group of student nurses about concepts of triage in a mass casualty incident. Which statement of the student nurse indicates effective learning? a. "I will issue a black tag to class II, urgent clients." b. "I will issue a yellow tag to class I, emergent clients." c. "I will issue a green tag to class III, non-urgent clients." d. "I will issue a red tag to class IV, expected-to-die clients."
ANS = C
A registered nurse is teaching a student nurse about the functions and utilization of trauma centers. Which statement of the student nurse indicates effective learning? a. "Clients requiring advanced life support should be sent to a level II trauma center." b. "Most injured clients requiring urgent treatment should be sent to a level I trauma center." c. "Clients requiring stabilization with major injuries should be sent to a level III trauma center." d. "Clients requiring full continuum of trauma services should be sent to a level IV trauma center."
ANS = A
A spouse spends most of the day with a client who is receiving chemotherapy for inoperable bone cancer. The spouse asks the nurse, "What can I do to help?" How can the nurse best support the client's spouse? a. Assist the couple to maintain open communication b. Offer the couple a description of the disease process c. Instruct the spouse about the action of the medications d. Meet privately with the spouse to explore personal feelings
ANS = C
A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable & needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? a. Add a placebo to the morphine to appease the spouse b. Discuss with the spouse the risk for morphine addiction c. Assess the client's pain before increasing the dose of morphine d. Check the client's heart rate before increasing the morphine to the next level
ANS = C
A terminally ill patient has died in the hospital & it is time to inform the patient's family members. The nurse is unsure how to console the family members. Which member of the interprofessional team is appropriate for the nurse to ask for support in informing & consoling the family? a. Primary health care provider b. Pharmacist c. Social worker d. Occupational therapist
ANS = C
A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of what? a. Libel b. Negligence c. Breach of confidentiality d. Defamation of character
ANS = A
A woman comes to the office of her healthcare provider reporting shortness of breath & epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? a. "Do you have chest pain?" b. "Are you feeling anxious?" c. "Do you have any palpitations?" d. "Are you feeling short of breath?"
ANS = B
According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? a. Anger b. Denial c. Bargaining d. Depression
ANS = B, D, E
After reviewing a patient's reports, the primary healthcare provider suggests palliative care for the patient. Which conditions would qualify the patient for this type of care? (Select all that apply). a. Peptic ulcer b. Chronic renal failure c. Cognitive impairment d. Congestive heart failure e. Chronic obstructive lung disease
ANS = C
After teaching a family member how to administer subcutaneous enoxaparin sodium, how should a nurse evaluate the effectiveness of the training? a. Return demonstration on a manikin b. Verbalization of the side effects of the medication c. Observing the family member administering enoxaparin sodium to the client d. Correctly verbalizing all necessary steps in enoxaparin sodium administration
ANS = C
Among which group of women are breast cancer death rates the lowest? a. Hawaiian b. Puerto Rican c. Asian American d. African American
ANS = B
An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? a. "The prevalence of hypertension is about equal for women of all races." b. "The higher-risk population is composed of African-American men and women." c. "The highest-risk population consists of older Caucasian-American men and women." d. "The prevalence of hypertension is greater for African-American men than for African-American women."
ANS = C
An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client & orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? a. The nurse should wait for the court's order to give blood to the client b. The nurse should proceed with the transfusion in order to save the client's life c. The nurse should inform the primary healthcare provider & not give blood to the client d. The nurse should explain to the family member that the client needs this transfusion
ANS = A
An elderly adult with Parkinson's disease falls while going to the bathroom & gets injured. The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system? a. The nurse should document the incident in the occurrence report tool b. The nurse should provide information in the medical record about the occurrence c. The nurse should document in the client's medical report that an occurrence report has been filed d. The nurse should document in the client's medical report that the primary healthcare provider has been contacted
ANS = D
An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? a. Confirm the client's relationship first b. Ask the client's primary healthcare provider c. Inform the nurse manager and show the records d. Explain that medical health records are confidential
ANS = A
An older adult client who is confused & often does not recognize family members is admitted to a nursing home. The client appears slovenly, often soiling clothing with feces & urine. How can the nurse best manage this problem? a. Toileting the client every 2 hours b. Placing the client in orientation therapy c. Supervising the client's bathroom activities closely d. Explaining to the client how offensive the behavior is to others
ANS = A
An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful & confused & falls all the time. A mini-mental examination indicates that the client is oriented to person, place, & time, & the client does not comment when asked directly how the bruises & abrasions occurred. What is the next appropriate nursing action? a. Interview the client without the presence of family members b. Report the abuse to the appropriate state agency for investigation c. Accept the adult child's explanation until more data can be collected d. Refer the client's clinical record to the hospital ethics committee for review
ANS = D
An older, confused client is being cared for at home by an adult child who works full-time. The client has lost weight & is wearing soiled & inappropriate clothing. The home care nurse suspects elder neglect. What should the nurse do? a. Discuss the situation with the adult child b. Ask the client whether the adult child is neglectful c. Avoid reporting the situation to prevent alienation of the adult child d. Report the suspicion of neglect by the adult child to adult protective services
ANS = A
As an acute episode of rheumatoid arthritis subsides, active & passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints, because this may precipitate what? a. Pain b. Swelling c. Nodule formation d. Tophaceous deposits
ANS = C
Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? a. Administering oxygen b. Using an incentive spirometer c. Having the client breathe into a paper bag d. Administering an IV containing bicarbonate ions
ANS = C
During a follow-up visit three weeks after a laryngectomy, a client exhibits concern that the laryngectomy tube may become dislodged. What should the nurse teach the client to do if the tube becomes dislodged? a. Reinsert another tube immediately. b. Notify the healthcare provider at once. c. Keep calm because this is no immediate emergency. d. Quickly take action to prevent the tracheal stoma from closing.
ANS = D
During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, & feeling as if the collars of shirts are getting tight. Of the additional assessment findings, which one should the nurse report to the practitioner? a. Increased appetite b. Recent weight loss c. Feelings of warmth d. Fluttering in the chest
ANS = B
During a routine checkup a patient reports concerns over weight gain despite trying juice cleanses & other trend diets. The nurse records the patient's weight & BMI at a healthy range, but the patient states, "I wish I were as thin as my co-workers." The patient is at risk for what culturally-bound condition? a. Neurasthenia b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios
ANS = B
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? a. Stimulating crying b. Suctioning the airway c. Using an Ambu bag with oxygen support d. Placing the infant in the reverse Trendelenburg position
ANS = D
During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? a. Suggest that an antiemetic be prescribed b. Change the feeding schedule to omit nights c. Request that the type of solution be changed d. Gather more data from the night nurse about the technique used
ANS = B
During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? a. Hypokalemia & hyponatremia b. Hyperkalemia & hyponatremia c. Hypokalemia & hypernatremia d. Hyperkalemia & hypernatremia
ANS = C
During the immediate posttrauma period after injury to the frontal lobe of the brain, the nurse places a client in what position? a. Supine b. Side-lying c. Semi-Fowler d. Trendelenburg
ANS = A
Given below in the table are the conditions of four different clients. Which client's care should be delegated to unlicensed assistive personnel (UAP) to achieve effective outcomes in the care? a. Client A b. Client B c. Client C d. Client D
ANS = C
How can the lines of communication be improved in a healthcare organization during the process of delegation? a. By considering all aspects of client care b. By selecting experienced nursing assistants as delegatees c. By appreciating & valuing each other's cultural perspectives d. By selecting a delegatee having similar strengths as that of the delegator
ANS = B
Immediately after a bilateral adrenalectomy a client is receiving corticosteroids that are to be continued after discharge from the hospital. Which statement by the client indicates to the nurse that additional education is needed? a. "I need to have periodic tests of my blood for glucose." b. "I am glad that I only have to take the medication once a day." c. "I must take the medicine with meals while I have food in my stomach." d. "I should tell the doctor if I am overly restless or have trouble sleeping."
ANS = C
Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position? a. Provides the greatest comfort b. Restores circulating blood volume c. Helps stop bleeding if any should occur d. Reduces the fluid trapped in the biliary ducts
ANS = D
Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing & is bleeding heavily from a wound on the foot. What should be the nurse's first intervention? a. Treat the victim for shock b. Start rescue breathing immediately c. Apply surface pressure to the foot wound d. Safely remove the victim from the immediate vicinity
ANS = B
In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. Which statement from the client indicates a correct understanding of the nurse's instructions? a. "I will sit in a chair for several hours every day." b. "I will inspect the incision for healing when I change the dressing." c. "I will check to see whether the staples have dissolved within a few days." d. "I will call the health care clinic if I see any clear drainage coming from the incision."
ANS = B, C, D
In what instances can a minor give consent for himself or herself for medical treatment? (Select all that apply) a. The minor can give consent for his or her siblings b. The minor can give consent for any venereal disease c. The minor can give consent if he or she is lawfully married d. The minor can give consent for a drug or substance abuse e. The minor can give consent for an abortion
ANS = C
In which positions should the nurse place a client who has just had a right pneumonectomy? a. Right or left side-lying b. High-Fowler or supine c. Supine or right side-lying d. Left side-lying or semi-Fowler
ANS = C
It is determined that a staff nurse has a drug abuse problem. What approach to the staff nurse's addiction should be taken as an initial intervention? a. Counseled by the staff psychiatrist b. Dismissed from the job immediately c. Referred to the employee assistance program d. Forced to promise to abstain from drugs in the future
ANS = D
Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction? a. Restraints can be used when less restrictive interventions are not successful b. Restraints can be used when all other alternatives have been tried & exhausted c. Restraints can be used only to ensure the physical safety of the resident or other residents d. Restraints can be used anytime without a written order from the healthcare provider
ANS = D
On a home visit to an older adult with chronic heart failure, the nurse notes that a 6-month-old grandchild lies quietly in a crib, rarely smiles or babbles, & barely has basic needs attended. The client is the primary caregiver for the infant. What should the nurse do? a. Advise the purchase of appropriate toys designed for this age level b. Inform the client that the child will be cognitively impaired if he is not stimulated c. Explain the need for the family to hire a mother's helper for the home d. Initiate a referral to an appropriate agency to assess the need for a home health aide & schedule a family conference
ANS = B
On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? a. Prepare for blood transfusions b. Notify the surgeon immediately c. Make the client nothing by mouth (NPO) d. Administer the prescribed preoperative sedative
ANS = C
The charge nurse is preparing for the arrival of clients to the emergency department (ED) after a mass casualty incident (MCI). The hospital has an automatic tracking system that is implemented during MCIs. Which decision should the nurse use the system for during this MCI? a. To determine the number of on-call staff needed b. To determine the specific plan to be implemented c. To determine how many casualties of each acuity level can be safety accepted d. To determine how many clients can be safety discharged to allow for new admissions
ANS = C
The client with methicillin-resistant staphylococcus aureus (MRSA) is admitted to the medical unit. Which of the following tasks should be performed by the registered nurse? a. Feeding b. Administrating oral medication c. Initiating IV antibiotic therapy d. Changing the dressing of a postoperative wound
ANS = C
The grieving wife of a client who has just died says to the nurse, "We should've spent more time together. I always felt that the children's needs came first." The nurse recognizes that the wife is experiencing what? a. Displaced anger b. Shame for past behaviors c. Expected feelings of guilt d. Ambivalent feelings about her husband
ANS = C
The healthcare provider prescribes Isosorbide Dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the Isosorbide Dinitrate is prescribed. How will the nurse respond? a. "It prevents excessive blood clotting." b. "It suppresses irritability in the ventricles." c. "It improves oxygen supply to heart tissue." d. "The inotropic action increases the force of contraction of the heart."
ANS = A
The healthcare provider prescribes Nitroglycerin ointment for a client who was admitted for chest pain & a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? a. "I may experience a headache." b. "Confusion is a common adverse effect." c. "A slow pulse rate in an expected side effect." d. "Increased blood pressure readings may occur initially."
ANS = B
The healthcare team is caring for a client with neutropenia. Which task is delegated to unlicensed assistive personnel? a. Administering antibiotics b. Assisting with personal hygiene c. Monitoring for signs & symptoms of infection d. Teaching the client & caregivers about how to avoid infection
ANS = A
The nurse assesses a client receiving IV fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? a. Crackles in lungs b. Supple skin turgor c. Urine output of 240 mL over 8 hours d. Increase in blood pressure from 110/76 to 124/68 mmHg
ANS = D
The nurse assists the healthcare provider in performing a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the healthcare provider to document? a. Homans b. Romberg c. Chvostek d. Queckenstedt
ANS = A
The nurse finds that an 80-year-old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality? a. Advocating on behalf of the client b. Discussing the client's problem with the other nurse c. Arranging a permanent accommodation in the hospital d. Suggesting the family join the client in a long-term healthcare facility
ANS = D
The nurse informs a client's family that the client is in pain & does not wish to proceed with chemotherapy. What is the role of the nurse in this situation? a. Manager b. Educator c. Caregiver d. Advocate
ANS = C
The nurse interviews a client about a current health problem. The nurse then obtains & documents the client's temperature, BP, & HR. Which step of the nursing process is involved in this situation? a. Planning b. Diagnosis c. Assessment d. Implementation
ANS = B
The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? a. X-ray reports b. Severity of pain c. Results of blood work d. Family caregiver interview
ANS = A
The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview? a. Asking about the client's current concerns b. Ensuring the interview follows a strict agenda c. Asking questions that promote short responses by the client d. Telling the client what he or she should expect from the visit
ANS = D
The nurse is assisting a client out of bed. Which is the priority nursing action? a. Monitoring the client's blood pressure b. Assessing the client's level of consciousness c. Ensuring the call bell is within the client's reach d. Assisting the client from a supine to an upright position
ANS = A, B, E
The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate? (Select all that apply) a. Documenting vital signs b. Documenting urine output c. Assessing the laboratory findings d. Administering diuretic intravenously e. Repositioning the client every one or two hours
ANS = B
The nurse is caring for a client before, during, & immediately after surgery. Which type of care is provided to the client? a. Care that supports physical functioning b. Care that supports homeostatic regulation c. Care that supports psychosocial functioning d. Care that provides immediate short-term help in physiological crises
ANS = B
The nurse is caring for a client in the post-anesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. What action should the nurse take? a. Clamp the tube b. Consider this an expected event c. Instill the tube with iced normal saline d. Notify the surgeon immediately
ANS = D
The nurse is caring for a client who is 1 day postoperative for a left hip fracture repair. During the assessment, which finding should the nurse assess further? a. Pain at the surgical site b. Small amount of serosanguineous drainage c. Decreased range of motion to the left extremity d. Sudden shortness of breath
ANS = C
The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation? a. Educator b. Manager c. Advocate d. Administrator
ANS = A
The nurse is caring for a client with burns & reviews the client's laboratory results: BUN 30 mg/dL; Cr 2.4 mg/dL; serum potassium 6.3 mEq/L; pH, 7.1; PO₂ 90 mm Hg; & Hgb 7.4 g/dL. Which condition does the nurse suspect the client has based upon these findings? a. Azotemia b. Hypokalemia c. Metabolic alkalosis d. Respiratory alkalosis
ANS = A
The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles & says, "No." What should the nurse do? a. Monitor for nonverbal cues of pain b. Check the pressure dressing for bleeding c. Assist the client to ambulate around his room d. Irrigate the client's nasogastric tube with sterile water
ANS = D
The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? a. Oxygen therapy b. Cardiac monitoring c. Nutrition supplements d. Venous thromboembolism (VTE) prevention
ANS = B
The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care? a. Client with red tag b. Client with black tag c. Client with green tag d. Client with yellow tag
ANS = A
The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound? a. Red b. Black c. Green d. Yellow
ANS = C
The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? a. Careful monitoring for crepitus b. Bed rest with range-of-motion exercises c. Coughing & deep breathing every hour d. Covering the chest tube site with a sterile dressing
ANS = C
The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? a. Justice b. Veracity c. Autonomy d. Beneficence
ANS = A
The nurse is helping devise a training plan to familiarize health care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? a. Drills b. Tabletop exercises c. Access to the policy d. Computer simulations
ANS = B
The nurse is making rounds and stops to check a client who has had a total hip arthroplasty. Which action by the unlicensed assistive personnel (UAP) ([continuing care assistant (CCA]) will cause the nurse to intervene? a. The client's heels are kept off the bed b. The UAP (CCA) elevates the client's affected leg on a pillow c. The UAP (CCA) uses a pillow to keep the client's legs abducted d. The client uses a walker when ambulating with the UAP (CCA)
ANS = C
The nurse is managing a client who underwent cardiac bypass surgery. Which healthcare member can be safely delegated the task of monitoring electrocardiography? a. Nurse aide b. Certified technician c. Cross-trained technician d. Licensed vocational nurse (LVN)
ANS = C
The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? a. Ensuring the client's skin integrity b. Reviewing the preoperative instructions c. Administering general anesthetic to the client d. Placing the client in the correct position on the operating table
ANS = C
The nurse is providing care to a client with a neck & spinal cord injury. Which is the priority when moving this client during the assessment process? a. Removing the cervical spine collar b. Monitoring for autonomic dysreflexia c. Implementing the logrolling technique d. Administering the prescribed pain medication
ANS = D
The nurse is providing care to several clients in the emergency department (ED). Which client is the priority when using the three-tiered triage system? a. A client with a simple fracture b. A client experiencing renal colic c. A client with severe abdominal pain d. A client with chest pain & diaphoresis
ANS = A
The nurse is providing post-procedure care to a client who had a cardiac catheterization. The client begins to manifest signs & symptoms associated with embolization. Which action should the nurse take? a. Notify the primary healthcare provider immediately b. Apply a warm, moist compress to the incision site c. Increase the intravenous fluid rate by 20 mL/hr d. Monitor vital signs more frequently
ANS = D
The nurse is providing postoperative care for a college student who has undergone a knee arthroscopy for a tendon repair. The client is scheduled to be discharged in a few hours & plans to return to the college dormitory & spend the weekend there before returning to class in 2 days. What is most important for the nurse to include in the client's discharge plans? a. Arrange for a taxi to return the client to the dormitory b. Instruct the client to restrict activities for at least several days c. Suggest the client spend the weekend in a motel near the hospital d. Ask the client who is available in the dormitory to provide assistance
ANS = B
The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? a. Prevent a client from pulling out an IV when there is concern that the client cannot follow instructions or is confused b. Prevent an adult client from getting up at night when there is insufficient staffing on the unit c. Maintain immobilization of a client's leg to prevent dislodging a skin graft d. Keep an older adult client from falling out of bed following a surgical procedure
ANS = A, D, E
The nurse is trained to work as a member of a disaster preparedness team. Which activities should the nurse be prepared to perform if a disaster were to occur? (Select all that apply) a. Triage b. Palliative care c. Home visits to newborns d. Decontamination procedures e. Evaluation of the disaster plan
ANS = C
The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to do what? a. Call the security guard b. Tell the nurse manager to go home c. Have the supervisor validate the observation d. Offer the nurse manager a large cup of coffee
ANS = B
The nurse provides teaching to a client who has received a prescription for oral pancreatic enzymes, pancrelipase. The nurse evaluates that teaching is understood when the client identifies which time for medication scheduling? a. At bedtime b. With meals c. One hour before meals d. On arising each morning
ANS = C
The nurse starts a new job & recognizes that the patient population is very diverse. What action will help the nurse to provide culturally competent care? a. Read about all of the cultural groups in the local population b. Treat all of the patients the same, regardless of their cultural background c. Increase self-awareness of cultural identity, cultural knowledge, & potential biases d. Attempt to remain culturally neutral while treating patients of a different culture
ANS = B
The nurse uses which principles of body mechanics when caring for immobilized clients? a. Bending at the waist to provide the power for lifting b. Placing the feet apart to increase the stability of the body c. Keeping the body straight when lifting to reduce pressure on the abdomen d. Relaxing the abdominal muscles while using the extremities to prevent strain
ANS = D
The nursing team is involved in effective pain management. Which task would be performed by a registered nurse (RN) in this case? a. Performing hygiene tasks b. Taking & reporting vital signs c. Administering oral pain medications d. Developing a treatment plan for client's pain
ANS = C
The plan of care for the client was to lose 7 lbs by the end of the month. The client only lost 3 lbs. How should the nurse respond? a. Assume that the client has been cheating on the diet b. Increase the goal for next month to keep the client on track c. Reevaluate the plan of care for appropriateness d. Discontinue the plan of care because it did not work
ANS = C
The primary healthcare provider instructs the nurse to manage fluid replacement therapy in a patient with cancer. What type of care is the patient receiving? a. Palliative care b. Comfort care c. Supportive care d. End-of-life care
ANS = A
The professional obligation of a nurse to assume responsibility for actions is referred to as what? a. Accountability b. Individuality c. Responsibility d. Bioethics
ANS = C
The registered nurse (RN) administers IV fluids to a client who was in a motorcycle accident. Which assessments made by the nurse would be appropriate based on the principle of right task of delegation? a. Environmental conditions b. Resources required for drug administration c. Institutional policies of drug administration d. Client's condition prior to drug administration
ANS = B, D, E
The registered nurse (RN) assigns a task to a licensed practical nurse (LPN) to take care of a client admitted with severe burns. Which tasks are being performed by the LPN in this situation? (Select all that apply) a. Performing hygiene tasks b. Monitoring the heart rate c. Evaluating the medical reports d. Monitoring the blood pressure e. Administering the oral medication
ANS = C
The registered nurse (RN) delegates a task to a licensed practical nurse (LPN) to take care of the client who underwent a tracheostomy. Which task should be performed by the LPN in this situation? a. Developing a plan to avoid aspiration b. Assessing the client's condition after tracheostomy c. Providing tracheostomy care using sterile techniques d. Teaching a client and caregiver about home tracheostomy care
ANS = B
The registered nurse (RN) delegates a task to a licensed practical nurse (LPN). Which client task can be assigned to the LPN? a. Client A b. Client B c. Client C d. Client D
ANS = A, B
The registered nurse (RN) is caring for a client who underwent a hysterectomy. Which tasks can be delegated to the unlicensed assistive personnel (UAP) to provide quality care to the client? (Select all that apply) a. Recording vital signs b. Assisting the client with bathing c. Administering oral medications d. Preparing the care plan for the client e. Administering IV antibiotics
ANS = B
The registered nurse (RN) is caring for a client who underwent surgery for a pituitary tumor. Which task can be delegated to unlicensed nursing personnel (UNP)? a. Teaching the client b. Monitoring vital signs c. Assessing laboratory reports d. Evaluating the status of the client
ANS = B
The registered nurse (RN) is caring for a client who was admitted to the hospital due to severe diarrhea. The RN assigns the unlicensed assistive personnel (UAP) to check on the client hourly & perform hygiene care as needed. Which concept best explains this situation? a. Leadership b. Delegation c. Supervision d. Assignment
ANS = C
The registered nurse (RN) is caring for a client with severe diarrhea. Which task of the client care plan can be safely delegated to the unlicensed assistive personnel (UAP) by the registered nurse? a. Administration of oral antidiarrheal b. Administration of IV antibiotics c. Administration of oral replacement fluids d. Administration of IV antiemetics
ANS = C
The registered nurse (RN) is caring for a pregnant client with malnutrition due to morning sickness. Which task can be safely performed by the licensed practical nurse (LPN) in this condition? a. Assessing hemoglobin levels b. Evaluating nutritional status c. Administering oral antiemetics d. Administering intravenous fluids
ANS = B, E
The registered nurse (RN) is planning to provide feedback to the licensed practical nurse(LPN). Which questions asked by the RN help in eliciting the LPN's work quality? (Select all that apply) a. "Are you feeling well today?" b. "How did the patient respond?" c. "Has the task been completed?" d. "Are you willing to perform the task?" e. "What changes were observed in the client?"
ANS = A
The registered nurse (RN) is the team leader for a group of clients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) & an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? a. Taking vital signs b. Providing wound care c. Conducting discharge teaching d. Administering oral medications
ANS = C
The registered nurse delegates a task to the unlicensed nursing personnel (UNP). Which client care is suitable for UNP? a. Client A b. Client B c. Client C d. Client D
ANS = C
The registered nurse delegates the task of feeding a 90-year-old client suffering from dysphagia to the unlicensed assistive personnel (UAP) who has previously performed this task. The client died of choking & aspiration after being fed by the UAP. Which right of delegation was violated for this client? a. Task b. Person c. Circumstance d. Communication
ANS = B, D
The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? (Select all that apply) a. Assessing the vital signs b. Performing all hygiene tasks c. Administering oral medications d. Helping the client in changing clothes e. Administering IV medications
ANS = A
The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? a. "Clients with decreased sensory perception of touch should be carefully monitored for infection." b. "Clients with recent memory loss should be taught by repetition & by using memory aids that provide recurrent alerts." c. "Clients with slower processing time should be provided with sufficient time to respond to questions or directions." d. "Clients with decreased coordination should be instructed to hold handrails when ambulating."
ANS = C
Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment? a. Apical heart rate b. Electrolyte levels c. Signs of bleeding d. Tissue compatibility
ANS = C
To reduce a fracture of the hip, a client is placed in Buck traction before surgery. Because the client keeps slipping down in bed, increased countertraction is prescribed. What should the nurse do to increase countertraction? a. Add more weight to the traction b. Elevate the head of the client's bed c. Use a slight Trendelenburg position d. Apply a chest restraint around the client
ANS = B
Two 14-year-old girls are best friends & always eat lunch together at school. One of the girls eats rapidly & then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do? a. Confront her friend with her suspicions b. Talk to the school nurse about her concerns c. Inform the girl's mother about her daughter's behavior d. Watch a while longer before doing anything that might ruin the friendship
ANS = D
Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? a. Instruct the client to position one arm on each shoulder of the nurses b. Direct the client to extend the legs & remain still during the procedure c. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed d. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, & then move the client
ANS = A, B
What are the overall purposes of delegation? (Select all that apply) a. To achieve nursing goals b. To improve client outcomes c. To develop critical judgment skills d. To understand the art of delegation e. To apply delegation decision in clinical nursing practice
ANS = A, C, D
What are the three strategies that the nurse can perform while assisting other nurses in making delegation decisions? (Select all that apply) a. Doing b. Telling c. Asking d. Offering e. Participating
ANS = C, E
What interventions should the nurse perform while caring for an actively dying patient? (Select all that apply). a. Admit the patient in hospice care b. Perform aggressive laboratory tests c. Provide patient & family reassurance d. Keep the patient undisturbed for long time e. Perform symptom management in the patient
ANS = D
What is a goal for a client who has difficulty with verbal communication precipitated by psychologic barriers? a. The client will be free of injury b. The client will demonstrate decreased acting-out behavior c. The client will identify consequences of acting-out behavior d. The client will interact with other people in the environment
ANS = C
What is most important for the nurse to do to assist a couple to cope with their feelings about the husband's terminal illness? a. Referring the husband to a psychotherapist for help in dealing with his anger b. Placing the couple in a couples' therapy group that addresses terminal illness c. Helping the couple express to each other their feelings about his terminal illness d. Encouraging the wife to verbalize her feelings to a therapist during individual therapy sessions
ANS = A
What is the duty of a nurse while caring for a client? a. The nurse should determine the client's care preferences b. The nurse should hide serious information from the family c. The nurse should inform the family after taking the required steps d. The nurse should instruct the family to keep the client from doing things himself or herself
ANS = A
What is the priority in preparing health care professionals for any type of disaster? a. Identification of hazards b. Cooperation with state authorities c. Collaboration with local authorities d. Implementation of federal mandates
ANS = B
What is the professional nurse's legal responsibility regarding child abuse? a. Honor the request of the parents not to report the suspected abuse b. Report any suspected abuse to local law enforcement authorities c. Return the child to the legal parent even if he or she is suspected of abuse d. Provide the parents with a copy of the child's medical record
ANS = A, B
What is true about psychosocial changes observed in adolescents? (Select all that apply) a. "They search for personal identity." b. "They develop their own ethical systems." c. "They consider themselves invincible." d. "They think of their parents as materialistic." e. "They get emotionally dependent on their parents."
ANS = D
What legal complications might a nurse face for using a restraint without a legal warrant on a client? a. The nurse may be charged with libel b. The nurse may be charged with negligence c. The nurse may be charged with malpractice d. The nurse may be charged with false imprisonment
ANS = C
What makes a crisis access hospital (CAH) different from an intensive care unit (ICU)? a. It offers 24-hour emergency care b. It offers health care to acutely ill people c. It provides temporary care for 96 hours or less d. It provides the most expensive health care delivery
ANS = A, C, E
What must triage nurses employ when prioritizing care with any model? (Select all that apply) a. A caring ethic b. Intensive care experience c. A systematic approach to care d. A baccalaureate degree in nursing e. Solid clinical decision-making skills
ANS = B
What nursing action will most help a client obtain maximum benefits after postural drainage? a. Administer oxygen as needed b. Encourage coughing deeply c. Place the client in a sitting position d. Encourage the client to rest for a half hour
ANS = A, B, C
What points should a nurse keep in mind when caring for a client who belongs to a different culture? (Select all that apply). a. The nurse should be aware of his or her own cultural values and behavior patterns b. The nurse should focus on understanding the client's traditions, values, & beliefs c. The nurse should understand that unique cultural perceptions exist regarding health practices d. The nurse should know that every client strictly adheres to his or her cultural beliefs and traditions e. The nurse should know that a client's cultural background does not influence the nurse-client relationship
ANS = A
What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting? a. The nurse should focus on doing no harm b. The nurse should keep promises made to clients c. The nurse should respect the autonomy of clients d. The nurse should keep the best interests of the client in mind
ANS = D
What should a nurse recommend to best help a client during the period immediately after a spouse's death? a. Crisis counseling b. Family counseling c. Marital counseling d. Bereavement counseling
ANS = D
What should the nurse do initially when obtaining consent for surgery? a. Describe the risks involved in the surgery b. Explain that obtaining the signature is routine for any surgery c. Witness the client's signature, which the nurse's signature will document d. Determine whether the client's knowledge level is sufficient to give consent
ANS = A
What should the nurse teach a client who is taking Warfarin? a. Report episodes of spontaneous bleeding b. Increase the dose with prolonged inactivity c. Take antibiotics, if injured, to prevent infection d. Eat a diet with an increased quantity of green vegetables
ANS = D
What stage of Kohlberg's theory of moral development defines "right" by the decision of the conscience? a. Social contract orientation b. Society-maintaining orientation c. Instrumental relativist orientation d. Universal ethical principle orientation
ANS = D
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the semi-Fowler position with the knees slightly bent & encourages the client to lie still. What is the next nursing action? a. Obtain vital signs b. Notify the healthcare provider c. Reinsert the protruding organs using aseptic technique d. Cover the wound with a sterile towel moistened with normal saline
ANS = A
When caring for a client who adheres to a kosher diet, which important thing should the nurse make sure to exclude from the client's meals? a. Pork & shellfish b. Blood-containing food c. All meat, fish, & poultry d. Animal & dairy products during Lent
ANS = A
When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? a. Elevate the head of the bed between 30 & 45 degrees b. Decrease flow rate at night c. Check for residual daily d. Irrigate regularly with warm tap water
ANS = C
When caring for a client with venous insufficiency, the nurse would implement which nursing measure? a. Apply abdominal girdle as needed b. Remove compression stockings for client ambulation c. Elevate the client's legs above heart level d. Keep the upper extremities elevated
ANS = A, B, C, D
When compared with their non-Hispanic white counterparts, which factors contribute to the health disparities Hispanic older adults face? (Select all that apply). a. Value differences b. Language barrier c. Lack of health care facility d. Inadequate health insurance e. Poor diet & nutrition
ANS = A
When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. When teaching when to call the primary healthcare provider, what statement made by the client shows that teaching was effective? a. "I should call the primary healthcare provider for dry hair & an intolerance to cold." b. "I should call the primary healthcare provider for muscle cramping & sluggishness." c. "I should call the primary healthcare provider for fatigue & an increased pulse rate." d. "I should call the primary healthcare provider for tachycardia & an increase in weight."
ANS = C
When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs & symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? a. Substernal chest pain b. Episodes of palpitation c. Severe shortness of breath d. Dizziness when standing up
ANS = B, C, D
When should the nurse consider family members as the primary source of information? (Select all that apply) a. The client is an elderly adult b. The client is an infant or child c. The client is brought in as an emergency d. The client is critically ill and disoriented e. The client visits the outpatient department
ANS = A, B, C, D
When using the AMPLE memory aid to conduct a health history during the emergency assessment, which questions will the nurse ask? (Select all that apply). a. "Do you smoke or drink?" b. "When was your last meal?" c. "Do you have any drug allergies?" d. "When was your last tetanus shot?" e. "How would you describe your current pain?"
ANS = C
Which action involving client needs may a nurse delegate to an unlicensed health care worker? a. Assessing a newly admitted client's contraction pattern b. Discussing pain management options with a laboring client c. Providing ice chips to a primigravida in early labor per the primary healthcare provider's prescription d. Obtaining a sterile urine specimen for a suspected urinary tract infection
ANS = A
Which action should be the nurse's first priority for a client with major burns? a. Assessing airway patency b. Checking the client from head to toe c. Administering oxygen as needed d. Elevating the extremities if no fractures are noticed
ANS = A, B, D
Which actions by the nurse help set the stage for a patient-centered interview during the first visit after admission to the healthcare facility? (Select all that apply) a. Close the door after entering the room b. Greet the client using his or her last name c. Open the curtains to allow plenty of light in the room d. Introduce oneself with a smile & explain the reason for the visit e. Obtain an authorization from the client after the interview
ANS = B
Which amount of time is appropriate for a nurse to spend triaging each patient during a mass casualty incident? a. Less than 10 seconds b. Less than 15 seconds c. Less than 30 seconds d. Less than 60 seconds
ANS = A, B, E
Which are disadvantages to the functional system of care delivery? (Select all that apply) a. Poor communication b. Fragmentation of care c. Efficiency with specific tasks d. Fixed number of registered nurses e. Changes in client status go unnoticed
ANS = A, D
Which are examples of internal disasters that must be accounted for when formulating a disaster response plan? (Select all that apply) a. Fire b. Hurricane c. Earthquake d. Power outage e. Act of terrorism
ANS = A, C, E
Which care activities would be involved in a correct delegation process? (Select all that apply) a. Licensed practical nurse (LPN) cleans the client's body b. Unlicensed assistive personnel (UAP) provides medication to the client c. Unlicensed assistive personnel (UAP) assist the client with oral feedings d. Licensed practical nurse(LPN) evaluates the client's temperature condition e. Registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature
ANS = B
Which client care activity may a nurse safely delegate to an unlicensed health care worker? a. Assessing a client's mastectomy incision for signs of inflammation b. Assisting a client who is recovering from an abdominal hysterectomy to the bathroom c. Providing information about side effects to a client receiving chemotherapy for breast cancer d. Evaluating the effectiveness of an antiemetic that was administered to a client to relieve nausea
ANS = A
Which client care can be safely delegated to the unlicensed nursing personnel (UNP) to provide oral hygiene? a. Client A b. Client B c. Client C d. Client D
ANS = D
Which client is most appropriate to be delegated to unlicensed assistive personnel (UAP) based on the given data? a. Client A b. Client B c. Client C d. Client D
ANS = D
Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? a. Choking b. Redness c. Gagging d. Cyanosis
ANS = D
Which client situation may benefit from the nurse issuing a contract regarding the plan of care? a. An infant's parents prior to hospital discharge b. A preschool-age child requiring immunizations c. A school-age child who is active in afterschool sports d. An adolescent who is seeking information regarding birth control
ANS = C
Which client's healthcare requirements cannot be delegated? a. Client A b. Client B c. Client C d. Client D
ANS = B
Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? a. Nausea b. Dyspnea c. Orthopnea d. Paresthesia
ANS = B
Which color of CSF may indicate subarachnoid hemorrhage in the client? a. Hazy b. Yellow c. Brown d. Colorless
ANS = B
Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation? a. Red b. Black c. Green d. Yellow
ANS = A, B, C, E
Which colors are often included in an organizational disaster plan for use during triage? (Select all that apply) a. Red b. Black c. Green d. White e. Yellow
ANS = C, E
Which delegation actions may be performed by unlicensed nursing personnel while caring for a client? (Select all that apply) a. Teaching the care plan to the client b. Infusing intravenous fluids into the client c. Asking the client to wash the hands before meals d. Instructing the client to take specific medications e. Instructing the client to wear footwear while walking
ANS = A
Which description by the nurse is a correct explanation of delegation? a. The transfer of responsibility for the performance of an activity b. The person's responsibility & accountability for individual actions or omissions c. The active process of directing, guiding, & influencing the outcome of an individual d. The transfer of both the accountability & responsibility from one person to another
ANS = A, C
Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? (Select all that apply) a. Paramedics b. Unlicensed assistive personnel c. Nurses appointed to a field team d. A physician who survives the incident e. Community response team members
ANS = B
Which ethical principle is violated when the nurse forgets to give a painkiller to a patient as promised? a. Justice b. Fidelity c. Veracity d. Nonmaleficence
ANS = C
Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? a. Irish Americans b. African Americans c. Chinese Americans d. Egyptian Americans
ANS = C
Which health care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? a. Medical unit nurse b. Police officer c. Critical care nurse d. Unlicensed assistive personnel
ANS = C
Which hospital department plays a primary role in disaster preparedness? a. Medical department b. Surgical department c. Emergency department d. Mental health department
ANS = B
Which instruction would be most beneficial for an aging African-American client with hypertension? a. "Check the pulse daily." b. "Have an annual urinalysis." c. "Record blood pressure weekly." d. "Visit an ophthalmologist monthly."
ANS = D
Which internal variable influences health beliefs & practices? a. Family practices b. Cultural background c. Socioeconomic factors d. Intellectual background
ANS = B
Which intervention does the nurse implement to develop a caring relationship with the client's family? a. Deciding healthcare options for the client b. Identifying the client's family members & their roles c. Declining to inform the client's family after performing a procedure d. Refraining from discussing the client's health with the family
ANS = D
Which is the priority nursing action to decrease the risk for a client developing a hospital-acquired infection? a. Using droplet precautions b. Using contact precautions c. Using airborne precautions d. Using standard precautions
ANS = A
Which is the priority nursing action to include in a disaster plan for the radioactive dust & smoke that can cause illness from a radiologic dispersal device (RDD)? a. Covering the nose b. Protecting the eyes c. Decontaminating the skin d. Administering prophylactic antibiotics
ANS = A
Which member of the health care team is accountable for initial assessment & ongoing evaluation of client care? a. Registered nurse b. Licensed practical nurse c. Primary health care provider d. Unlicensed nursing personnel
ANS = D
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? a. Face tent b. Venturi mask c. Nasal cannula d. Nonrebreather mask
ANS = A
Which noninvasive assessment & management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS)
ANS = C
Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care? a. Avoiding manipulation of the client's limbs b. Asking a family member about any client drug allergies c. Cutting fabric that is stuck to the client's skin with scissors d. Auscultating heart and lung sounds through the client's clothing
ANS = D
Which nursing action indicates that the nurse is actively listening to the client? a. The nurse states his or her own opinions when the client is speaking b. The nurse refrains from telling his or her own story to the client c. The nurse reads the client's health record during the conversation d. The nurse interprets what the client is saying & reiterates in his or her own words
ANS = C
Which nursing action should be included in the plan of care for a client who has a permanent fixed (asynchronous) pacemaker inserted? a. Instruct the client that it is better to sleep on two pillows b. Encourage the client to reduce activity from former levels c. Teach the client to keep daily accurate records of the pulse d. Inform the client that the pacemaker functions when the heart rate drops below a preset rate
ANS = B
Which nursing intervention is employed to encourage the client to fully reveal the nature of their health problem? a. The nurse takes down notes while the client is talking b. The nurse leans forward attentively during the discussion c. The nurse refrains from pausing enough after each question d. The nurse asks questions that can be answered as "yes" or "no"
ANS = C
Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a. Providing oxygen b. Encouraging carbohydrates c. Administering fluid replacement d. Teaching facts about dietary principles
ANS = A, B, C
Which nursing interventions are examples of the nurse as a caregiver? (Select all that apply) a. Encouraging the client to exercise daily b. Setting goals for the client to reduce weight c. Arranging for the client to meet a spiritual advisor d. Evaluating the client's understanding of prescribed diet e. Demonstrating the procedure to self-administer insulin injection
ANS = A, B, E
Which nursing interventions enhance comfort in an imminently dying patient in the hospital? (Select all that apply). a. Frequently repositioning the patient b. Maintaining oral hygiene in the patient c. Limiting frequent visits of the family members d. Measuring the vital signs of patient frequently e. Applying body lotion to the patient's skin daily
ANS = D
Which of the following legal defenses are the most important for a nurse to develop? a. Dedication b. Certification c. Assertiveness d. Accountability
ANS = C, D
Which of these clients can be provided care safely by unlicensed nursing personnel? (Select all that apply) a. A client with pain b. A client who is upset c. A client who is stable d. A client who is recovering e. A client with suicidal intention
ANS = C
Which parameter monitoring should be the nurse's priority while caring for a client with hypothyroidism? a. Pulse rate b. Blood pressure c. Respiratory rate d. Body temperature
ANS = D
Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? a. Right task b. Right person c. Right supervision d. Right communication
ANS = A
Which statement made by the nurse indicates that the client interview is coming to a close? a. "I have just one more question for you." b. "I hope you are comfortable & not in pain." c. "I would like to spend some time to understand your concerns." d. "I assure you that information I gather now will be confidential."
ANS = D
Which step in the nursing process would involve promoting a safe environment for the client? a. Planning b. Diagnosis c. Assessment d. Implementation
ANS = D, E
Which task can be delegated to the licensed vocational nurse (LVN)? (Select all that apply) a. Analyzing vital signs b. Maintaining oral hygiene c. Administering intravenous drugs d. Administering oral hypoglycemic agents e. Administering intramuscular medications
ANS = A, B, D
Which threats, included in the term "NBC", lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? (Select all that apply) a. Nuclear b. Biologic c. Botulism d. Chemical e. Nipha virus
ANS = C
Which treatment for anthrax should be included in the biologic agent portion of a disaster plan for terrorist attacks? a. Antivirals b. Antitoxins c. Antibiotics d. Vaccinations
ANS = A
Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? a. A motor vehicle accident involving 5 cars b. A tornado destroying 50 homes & businesses c. An act of terrorism injuring & killing hundreds of people d. A hurricane causing flooding & displacing thousands of people
ANS = C
While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? a. Administer nitroglycerin & aspirin b. Slow the rate & monitor the vital signs c. Stop the transfusion & administer normal saline through new IV tubing d. Ask the client to further describe the feeling & rate the pain
ANS = C
Who supervises unlicensed nursing personnel (UNPs) in providing care to the client? a. Charge nurse b. Nurse manager c. Registered nurse d. Patient care associate