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A client is being transported to radiology from an inpatient nursing unit. The unlicensed assistive personnel (UAP) and a family member accompany the client to radiology. To whom should a nurse assign responsibility for the client's medical record during transport? 1. The unlicensed assistive personnel (UAP) 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client's family member 4. The medical record should not be transported with the client

A new nurse is preparing an injection from an ampule. What action by the new nurse would require the precepting nurse to intervene? 1. Snaps the neck of the ampule gently towards the body. 2. Uses a filter needle when drawing up the ampule contents. 3. Folds gauze around the ampule neck before snapping open. 4. Avoids touching edges of the ampule when inserting needle.

A nurse is reinforcing the teaching to a client with a somatization disorder in an outpatient pyschitric treatment program. Which statement by the client indicates that reinforcement of teaching has been successful? 1. "I will keep a diary of times of stress and the appearance of physical symptoms." 2. "I will simply ignore any physical symptoms I get from now on." 3. "The best way for me to stop having physical symptoms is to avoid all the stress in my life." 4. "I will take a sedative when I start having physical symptoms."

A psychiatric nurse, caring for several clients, recognizes that which client presents the greatest risk for violence toward others? 1. Twenty-four year old man with paranoid delusions. 2. Sixty-two year old woman with bi-polar disorder 3. Seventy year old man with major depression. 4. Twenty-eight year old woman with borderline personality disorder

Which tasks could the LPN/VN working on a telemetry unit assign to an unlicensed assistive personnel (UAP)? 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Assist with a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen.

1,2,3,5

A child has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? 1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 3. Administer aspirin for fever. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.

1,2,4,5

Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? 1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound before applying the dressing. 5. Use sterile forceps when cleaning the wound.

1,2,5

The clinic nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What response by the nurse is appropriate? 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Someone is calling 911 for an ambulance."

1,3,4,5

A nurse is planning to discuss steps that senior citizens can take to keep the brain healthy. What should the nurse include? 1. Memorize poetry. 2. Eat foods low in Omega 3, fatty acids. 3. Brush teeth with nondominant hand. 4. Do crossword puzzles. 5. Learn a new language. 6. Volunteer.

1,3,4,5,6

A client is being scheduled for a cat scan (CT) of the abdomen with contrast. When considering client safety, what should be the priority action for the nurse to implement? 1. Verify that informed consent has been provided. 2. Confirm with client the accuracy of allergies listed. 3. Force fluids following procedure. 4. Monitor output following procedure.

Which statement by the parents of a 9 month old baby with otitis media infection indicates to the nurse that follow up is necessary? 1. "Our baby should sit up for feedings." 2. "It is fine to prop up a juice bottle for our baby to drink at night." 3. "Since our baby has ear tubes, ear plugs should be worn when swimming." 4. "We need to keep our baby away from people who are smoking."

When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.

2,3,4

The nurse is teaching a group of adults how to check skin lesions for signs of melanoma. What should the nurse include? 1. Symmetrical shape 2. Multiple colors with a lesion 3. Odd looking lesion 4. Poorly defined border of lesion 5. Diameter of lesion 6 mm

2,3,4,5

The nurse is caring for a client on the psychiatric unit. The client is prescribed fluphenazine 10 mg. The drug is available as an elixir: 2.5 mg / 5 mL. How many mL will the nurse give to the client? Round answer to the nearest whole number.

A client has just found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected date of confinement? 1. December 3 2. December 7 3. December 10 4. December 13

A nurse is evaluating a unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off the floor. Which action by the UAP requires follow up? 1. Test the object's weight to determine if additional assistance is needed. 2. Keep feet shoulder width apart. 3. Bend from the waist to pick up the object. 4. Hold object close to body upon rising.

The nurse on a large surgical unit needs to collect data on several clients returning from procedures. Which client should the nurse monitor first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

A 3 year old child is being treated for asthma. The child weighs 31.5 lb (14.3 kg). The primary healthcare provider has prescribed Albuterol syrup 5 mg PO every 8 hours. What action should the nurse take? 1. Administer the dose immediately to relieve respiratory efforts. 2. Split the dose in two equal parts and administer every 4 hours. 3. Notify the charge nurse that the child needs a different type medication. 4. Notify the primary healthcare provider.

A child who fractured the ulna and radius following a fall is experiencing itching under the cast. What would be an appropriate nursing intervention to help alleviate the itching? 1. Apply a small amount of hydrocortisone cream with a cotton tip applicator. 2. Use a soft, sterile, cotton tip applicator to gently rub area under the cast. 3. Apply warm, dry heat to the outside of the cast with a lightweight heating pad. 4. Circulate air under the cast utilizing a blow dryer on the cool setting.

A client is brought into the emergency department (ED) with nausea, vomiting and diarrhea after eating chicken at a picnic. The nurse suspects that this client has most likely contracted which infection? 1. Shigella 2. Escherichia coli 3. Clostridium Difficile 4. Salmonella

A client is to be discharged following treatment for hepatitis A. The nurse knows teaching was successful when the client makes what statement? 1. "I should never eat fresh salad in a restaurant." 2. "I must wait two years before traveling abroad." 3. "I will need blood work once a month for a year." 4. "I will be able to donate blood when I am well."

A clinic nurse is collecting data from a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? 1. "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him." 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"

The parents of a preschooler have been told the child has primary tuberculosis. An LPN enters the room when the primary healthcare provider leaves to write prescriptions. The LPN knows what is the priority action? 1. Discuss the importance of dietary modifications. 2. Prepare child for immediate transfer to isolation. 3. Review important medications and respiratory aids. 4. Encourage parents to verbalize fears and concerns.

Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."

The LPN/VN is preparing to transfer a client from the delivery room to the postpartum unit. Which statement by the client would be the priority for the LPN/VN to notify the charge nurse? 1. "I just felt something gush." 2. "I feel like I am still having contractions." 3. "When I stand up, I feel dizzy for several moments" 4. "My hemorrhoids are hurting."

The nurse is caring for a client in the outpatient mental health clinic. The client recounts several incidences of spousal abuse. The client says to the nurse, "I know that he loves me. Sometimes I can be quite irritating." Which response is most appropriate by the nurse? 1. "You are not responsible for the abuse." 2. "Sometimes we can irritate our spouses." 3. "The worst is over now." 4. "You should think about leaving him."

The nurse wants to promote comfort and relaxation after giving the client a bed bath. Which action best meets this goal? 1. Providing the client with a back rub. 2. Dimming the lights in the room. 3. Providing warm milk and cookies. 4. Playing soft music.

What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis? 1. Abnormal gait 2. Blindness 3. Hyperreflexia 4. Stiff neck 5. Hearing loss

1,2

The nurse is providing foot care to the client who has diabetes. The nurse reinforces teaching with the client about proper care of the feet. What should the nurse include in the discussion? 1. Inspect the feet daily for abrasions or pressure areas. 2. Check water temperature with the hands before getting into tub. 3. Do not use heating pads on the feet or lower legs. 4. Thoroughly dry the feet, especially between the toes. 5. Cut toenails rather than file them. 6. Cut nails in a rounded fashion.

1,2,3,4

Which are modifiable risk factors for developing a stroke? 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

1,2,4,5,6

The LPN/VN could safely accept which client assignments? 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1,2,5,6

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? 1. Weigh daily. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1,4,5

A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate? 1. Apply splint nightly to affected extremities. 2. Approach client from the right side. 3. Provide full range of motion once a shift. 4. Elevate left extremities on a pillow. 5. Place pillow in the right axilla. 6. Wrap affected hand into a fist.

1,5

The client reports just not feeling good and like something is wrong. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next? 1. Administer PRN anxiolytic. 2. Check O2 sat and administer oxygen. 3. Reassure the client that everything is okay. 4. Determine the Glascow coma scale.

The nursing staff have not been able to control the outbursts of a violent adult client. The primary healthcare provider prescribes physical restraints to be applied for the next 8 hours. What is the nurse's best action? 1. Apply the restraints for the 8 hours, with a trial release every 2 hours. 2. Explain to the primary healthcare provider that the prescription will have to be reissued in 4 hours. 3. Refuse to place the client in restraints unless the primary healthcare provider gets a permit signed from the family. 4. Apply the restraints, and observe the client hourly.

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

Which assigned client should the nurse see first? 1. Diagnosed with urinary tract infection 2 days ago who is to be discharged. 2. Admitted last night with a diagnosis of severe pneumonia. 3. 45 year old who had a hernia repair 24 hours ago. 4. Scheduled for an endoscopy in two hours.

Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? 1. "I want to make my mark on the world." 2. "I am satisfied with my life so far." 3. "I wish I could go back and fix the mistakes I have made." 4. "Life is too short. I have more living to do."

The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have client grab the wheelchair with the right arm. 6. Have client grab the wheelchair with the left arm.

2,4,6

The nurse is assisting the community health nurse to plan a discussion on how to prevent pesticide ingestion at a local health fair. What should the nurse include in this discussion? 1. Discard the outer leaves of lettuce. 2. Wash fruits and vegetables with dish soap. 3. Buy organic produce. 4. Peel fruits prior to eating. 5. Dry produce thoroughly with disposable paper towels after washing. 6. Use a scrub brush when washing fresh fruits and vegetables.

1,3,4,5,6

A pregnant teenage client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say? 1. What does the baby's father think about an abortion? 2. I know this is a difficult decision. 3. What are your thoughts about abortion? 4. There are many options other than abortion.

he nurse is contributing to the plan of care for a client with severe anxiety and new onset panic attacks following the loss of a spouse. Which factor is most important to recommend for the plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms

Which foods should the nurse encourage a client to avoid when prescribed a diet limiting purine rich foods? 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops

4,5

The nurse is caring for a client taking spironolactone. Which needed dietary change should the nurse reinforce to the client? 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.

The nurse prepares a sterile field for a procedure. Fifteen minutes later, the nurse is informed that there will be a 20 minute delay before the primary healthcare provider will arrive. What action should the nurse take? 1. Cover the sterile field with a sterile drape 2. Close and tape the doors so that no one may enter. 3. Monitor the sterile field while awaiting the primary healthcare provider. 4. Take down the sterile field.

The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM. Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give? Round your answer to the nearest whole number.

Which response by the nurse is appropriate when admitting a 5 year old child who is crying and hugging a stuffed animal? 1. "Hello, I am your nurse. I am going to show you to your room." 2. "Don't cry. Let's go to the playroom where you can meet other children." 3. "You are upset. I see you have your stuffed animal." 4. "Can I hold your stuffed animal? Then, would you like to put your stuffed animal in the bed?"

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is most important to monitor at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

The nurse is reinforcing instructions for the spouse of a home care client recently diagnosed with Alzheimer's Disease. The nurse acknowledges that previous teaching was successful when the spouse makes what statement? 1. "Activities that provide stimulation will help to reorient my spouse". 2. "With medications and therapy, my spouse will begin to improve". 3. "Keeping the rooms dark and quiet will be calming for my spouse". 4. "As the disease progresses, I need to review safety issues at home".

The nurse observes a primary healthcare provider removing gloves after performing an invasive procedure on a client, and then entering another client's room without washing hands. What should be the nurse's action? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

The nurse, caring for an 8 month old infant, should recognize which major stressor of hospitalization for this infant? 1. Fear of unknown 2. Loss of daily routine 3. Body image disturbance 4. Separation anxiety

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

Which nursing actions are correct for a client in a Halo Traction? 1. Observe for signs of serous drainage. 2. Inspect skin under the halo vest. 3. Use sterile technique to clean pin sites. 4. Tape a torque screwdriver to the headboard. 5. Tighten a loose pin with a torque screwdriver.

2,3,4

A client reports a diminished ability to visually focus on close objects and has also noticed a need for a well lit environment to enhance vision. To what does the nurse attribute these changes? 1. Normal changes associated with aging. 2. Cataract formation. 3. A brain tumor. 4. Diabetic retinopathy.

A young client comes to the mental health center reporting the need to sleep excessively, and states, "I cry at the drop of a hat." How should the nurse interpret this information? 1. Further screening for a mood problem is needed. 2. Anxiety assessment is warranted. 3. Symptoms of disordered thinking is being experienced. 4. Screening should be done for social isolation.

Which intervention would the nurse recognize as in best helping to relieve joint stiffness in a client with rheumatoid arthritis? 1. Take a warm shower prior to performing activities of daily living. 2. Take an aspirin after activity to help decrease inflammation. 3. Lose 10 pounds of weight. 4. Apply cold compresses to joints for 30-45 minutes.

A client who is scheduled for a total hip replacement surgery in the morning begins to verbalize anxiety related to the surgery. Arrange the client's comments in order as the client's anxiety advances beginning with mild to panic anxiety. "Can I wear my wedding ring during the surgery?" "I know those hip exercises after the surgery are painful." "Having trouble thinking about anything, but the surgeon cutting on my hip." "My Dad died on the operating table, and I keep thinking I will die too."

"Can I wear my wedding ring during the surgery?" "I know those hip exercises after the surgery are painful." "Having trouble thinking about anything, but the surgeon cutting on my hip." "My Dad died on the operating table, and I keep thinking I will die too."

The nurse knows which are signs and symptoms of ovarian cancer? 1. Urinary frequency. 2. Menorrhagia with breast tenderness. 3. Watery vaginal discharge. 4. Increasing abdominal girth. 5. Fullness after a heavy meal.

1,2,4

The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point.

0.5

A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs

A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholic Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group

A client hospitalized in the mental health unit asks if she can receive mail from her mother and sister. Which statement by the nurse indicates adequate understanding of client rights? 1. "All clients can receive and send mail, but staff must check for hazards." 2. "Clients are not allowed to receive mail while hospitalized." 3. "Receiving mail from family is not encouraged on inpatient units." 4. "I will check with the nursing supervisor about this."

A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse notes coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symptoms being most indicative of? 1. Chronic Arterial Insufficiency 2. Chronic Venous Insufficiency 3. Chronic Unstable Angina 4. Chronic Coronary Artery Disease

A client who has schizophrenia tells the nurse, "I am Jesus and I am here to save the world". The client is warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What action should the nurse take? 1. Set limits and send the client to room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client, "Share with the group how you know that you are Jesus."

A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the most appropriate action by the nurse? 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure for this client? 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent monitoring of level of consciousness

A person contacts a nurse at the hospital asking about the extent of injuries of a friend. What is the most appropriate response by the nurse? 1. The client's health information is confidential and protected by law. 2. I will look the information up, but do not tell anyone that I did. 3. The x-ray reports are abnormal, you should contact the family. 4. Call the emergency department and see if they will give you any information.

A psychiatric nurse, caring for several clients, recognizes that which client presents the greatest risk for violence toward others? 1. Twenty four year old man with paranoid delusions. 2. Sixty two year old woman with bi-polar disorder 3. Seventy year old man with major depression. 4. Twenty eight year old woman with borderline personality disorder

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

The nurse is assigned a group of clients on the inpatient psychiatric unit. Which client presents the greatest risk for violence toward others? 1. 24 year old man with paranoid delusions 2. 62 year old woman with bipolar disorder 3. 72 year old man with major depression 4. 28 year old woman with borderline personality disorder

The nurse is caring for a client admitted with acute gastritis. Which client information is most significant? 1. Takes ibuprofen for arthritis pain. 2. Had an upper respiratory infection two weeks ago. 3. Has a stressful job. 4. Enjoys spicy food.

The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse "I am sweating more than ever!" What is the nurse's best response? 1. This is a common side effect of antidepressant medications. 2. Excessive sweating can have many causes. 3. You should report this side effect to your primary healthcare provider. 4. This symptom should go away within a few days.

The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine. 2. No, do not bring the sleep apnea machine. 3. It is your choice. 4. Call your primary healthcare provider.

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

The nurse is taking care of a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). What should the nurse recognize as the child's likely view of this illness? 1. Punishment 2. Disturbance to body image 3. Rejection from parents 4. Change in routine with friends

The nurse should see the client with which problem first? 1. Recurring crushing chest pain 2. Needing an IVPB going to surgery in 5 minutes 3. Needing pain control post hysterectomy 4. Waiting to get back to bed after sitting in a chair for 30 minutes.

The nurse suspects that the neighbors are abusing their child. The nurse has noticed bruises on the face, the backs of the hands and the tops of the feet of the child. When questioned, the parents state their child is just clumsy. The nurse reports possible abuse to Child Protective Services. How would a nurse peer evaluate this nursing action? 1. The nurse is serving as advocate for the child. 2. The nurse is becoming involved in the personal business of the neighbors. 3. The nurse has no right to interfere with private issues. 4. The nurse should speak to the parents privately about the concerns.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.

Which action, if done by a new LPN/VN, needs to be interrupted by the precepting LPN/VN? 1. Mixes diazepam and hydromorphone in one syringe. 2. Administers diazepam before meals. 3. Raises side rails after administering hydromorphone. 4. Instructs client to call for assistance getting out of bed after administration of diazepam.

Which client should the nurse see first after receiving report on assigned clients? 1. Having dyspnea after surgery. 2. Needing vitals signs taken before the administration of blood. 3. Crying with pain after back surgery. 4. Vomiting dark brown, granular material.

Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."

Which information should the nurse reinforce to family members of a client diagnosed with hepatitis B to decrease their risk of exposure? 1. Do not share personal items with the client, such as razors or toothbrushes. 2. Wash dishes in separate water to decrease the risk of contamination. 3. Do not hug or kiss the client. 4. Use a separate bathroom from the client.

Which movements should the nurse expect to observe when evaluating the developmental stage of a 2 year old? 1. Stands on tiptoes. 2. Hops on one foot up to five seconds. 3. Goes upstairs without support. 4. Kicks ball forward.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Totaling I & O records on five clients at the end of the shift. 2. Assessing VS on a client who was admitted 30 minutes ago. 3. Administering nasogastric (NG) tube feeding. 4. Changing an abdominal surgical dressing on a client that is 3 days post op.

The nurse is reinforcing teaching to a group of parents about transmission of the chickenpox virus and the importance of vaccination. Which modes of transmission for chickenpox should be included in the discussion? 1. Direct contact 2. Indirect contact 3. Airborne 4. Droplet 5. Common vehicle

1,2,3

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children to receive at 6 months? 1. Diphtheria 2. Hib 3. Influenza 4. Measles 5. Mumps 6. Rubella

1,2,3

What information should be reinforced for parents regarding the promotion of adequate bowel elimination in their toddler? 1. Include adequate fiber in the diet through whole grains and fruits. 2. Increase intake of water daily. 3. Provide toileting opportunities that are free from distractions. 4. Encourage the toddler to go to the bathroom at least three times daily. 5. Take away attention from the toddler unable to potty.

1,2,3

A client who has diabetes calls the nurse at the clinic reporting shakiness, nervousness, and palpitations. Which questions would yield information that would assist the nurse to gather data to share with the primary healthcare provider? 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?

1,2,3,4

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? 1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion 5. Low level altitude

1,2,3,4

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon

1,2,3,4

What developmental milestone does the nurse expect to see in an 18 month old toddler? 1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. 5. Kicks a ball. 6. Walks up and down stairs holding on.

1,2,3,4

Which is a therapeutic technique that can be utilized by the nurse for clients with anxiety disorders? You answered this question Incorrectly 1. Activity assignments 2. Careful monitoring 3. Goal setting 4. Relaxation techniques 5. Group activities

1,2,3,4

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? Select all that apply 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1,2,3,4,5

An LPN/LVN has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the nurse take regarding this issue? 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

1,2,3,4,6

What should the nurse document after a client has died? 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility

1,2,3,4,6

The nurse has a duty to act as client advocate. What are the consequences of failure to act as a client advocate? 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or health care facility. 3. Suspension of license or loss of license to practice nursing. 4. Suspension of license or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.

1,2,3,5

What risk factors does the nurse know for developing varicose veins? 1. Sitting for prolonged periods 2. Obesity 3. Female 4. Leg exercises 5. Wearing high-heeled shoes

1,2,3,5

What actions should the nurse take when administering fentanyl? 1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 3. Shave hair where fentanyl patch will be applied. 4. Place fentanyl patch over dry skin. 5. Apply adhesive dressing over the fentanyl patch. 6. Dispose of fentanyl patch in trash.

1,2,4

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

1,2,4,5

A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? 1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron

1,2,4,5

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

1,2,4,5

The nurse is caring for a client admitted with a diagnosis of pheochromocytoma. What sign/symptom does the nurse expect during an acute episode? 1. Profuse sweating 2. Hypertension 3. Hypoglycemia 4. Tachycardia 5. Palpitations

1,2,4,5

The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? 1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 3. Select a day care center that provides physical activity opportunities every 4 hours. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.

1,2,4,5

Which client assignment would be appropriate for the LPN to accept? 1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client one day post kidney transplant. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis.

1,2,4,5

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

1,2,5

How should the nurse prepare a client for a paracentesis? 1. Place client in the Fowler's position. 2. Position client flat with right arm behind the head. 3. Ask the client to empty bladder. 4. Obtain client's vital signs every 4 hours. 5. Maintain NPO status for 4 hours pre-procedure.

1,3

A client has been admitted to a psychiatric unit for severe depression after attempting suicide. Which interventions should the nurse include in this client's plan of care? 1. Provide constant visual observation. 2. Assign client to a private room. 3. Supervise closely during meals. 4. Provide simple, concrete instructions for getting dressed each morning. 5. Allow client to sleep as long as desired for the first three days.

1,3,4

Which actions should the nurse encourage a client diagnosed with cirrhosis to do? 1. Use a shower chair when performing hygiene. 2. Limit alcohol intake. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.

1,3,4,5

The nurse enters the client's room and finds the client having a seizure on the floor. Which nursing interventions should the nurse implement? 1. Loosen tight shirt or jacket. 2. Move the client to the couch. 3. Place a pillow under the head. 4. Position the head tilted forward. 5. Insert a wash cloth between the teeth.

1,4

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

1,4

Which discussion points should a LPN/VN plan to reinforce when talking with a group of college students on prevention of sexually transmitted infections (STI)? 1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of birth control pills 4. Sexual abstinence 5. Vaccinations for STIs

1,4,5

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take? 1. Notify the infection control nurse. 2. Continue to care for client as varicella and herpes zoster are not related. 3. Go to the lab to have a Tzanck smear performed. 4. Obtain herpes zoster vaccine for protection from this exposure. 5. Receive the varicella-zoster immune globulin within 96 hours of exposure.

1,5

The charge nurse of a large medical-surgical unit is admitting several clients requiring specific infection control precautions. The LPN/VN is aware that droplet precautions are necessary for which client diagnosis? 1. Mumps 2. Methicillin resistant Staphylococcus aureus (MRSA) 3. Shingles (Herpes Zoster) 4. Human immunodeficiency virus (HIV) 5. Pertussis

1,5

The nurse is teaching a group of parents how to promote healthy teeth in their newborn. What should the nurse include? 1. Clean gums with a damp washcloth after feedings. 2. Use a firm-bristled toothbrush once teeth have erupted. 3. Beginning at birth use toothpaste the size of a pea. 4. Allow only milk bottles in bed. 5. Wean from bottle by 15 months.

1,5

What nursing interventions should the nurse implement for a client with Addison's disease? 1. Administer potassium supplements as prescribed. 2. Assist the client to select foods high in sodium. 3. Administer Fludrocortisone as prescribed. 4. Monitor intake and output. 5. Record daily weight.

2,3,4,5

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What information should the nurse reinforce to help reduce this side effect? 1. Stop taking the medication. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. An antacid should be taken with the medication. Rationale

A client with diabetes has a history of ignoring the primary healthcare provider's prescription for daily medication management of the illness. The client has been working toward increased adherence to prescribed medication regimen. Which finding suggests that the client has increased adhearance to the regimen? 1. Client has lost five pounds. 2. Client takes medication as prescribed. 3. Client has been hospitalized twice for complications of diabetes. 4. Client walks one mile per day.

A nurse drops a glass bottle, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.

After obtaining vital signs, which prescribed medication should the nurse hold when caring for a client on the cardiac unit? 1. Rosuvastatin 2. Enalapril 3. Digoxin 4. Clopidogrel

During a clinic checkup, the mother of two sons confides the 8 year old has been acting out since the younger sibling, diagnosed with cerebral palsy, requires more attention. What suggestion by the LPN will most likely help the mother deal with the older child? 1. "Have you tried involving the older child in the care of his little brother?" 2. "Perhaps you could schedule quality time just for you and the older son." 3. "Your 8 year old is too young to understand the needs of a child with cerebral palsy." 4. "I can talk to your child and explain why he gets less attention right now."

The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.

The driver of a motor vehicle was driving while intoxicated with a friend in the passenger seat. Both clients are admitted to the Intensive Care Unit. The nurse is caring for the driver of the vehicle who states, "I'm so scared. What if the car accident is my fault and my friend dies?" What is the most appropriate response from the nurse? 1. "I wouldn't worry about that; everything will be all right." 2. "You are worried that you may be responsible for your friend's condition?" 3. "How come you were drinking and driving?" 4. "Let's not talk about that right now."

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? 1. BP 150/108 decreases to 138/86 2. Weight gain of 5 pounds (2.27 kg) in one week 3. Urinary output of 1450 mL in 12 hours 4. Apical pulse of 90/min

The nurse is participating in educating a group of parents about the importance of immunizing their daughters against the human papillomavirus (HPV) in an effort to prevent the development of which cancer? 1. Breast 2. Cervical 3. Ovarian 4. Uterine

The nurse is providing morning care to a client who has pneumonia. The client has shortness of breath on exertion and fatigues easily. What alterations in routine may be needed to complete the hygienic needs of the client? 1. Perform all of the hygiene needs for the client. 2. Allow periods for rest as the care is provided. 3. Leave equipment at the bedside to allow client to go at his own pace. 4. Omit the morning hygiene routine for the present time.

The primary healthcare provider has prescribed hydromorphone 2 mg intravenously (IV) every 4 hours as needed for pain. When should the nurse plan to administer the medication to the client? 1. Only when requested. 2. Prior to onset of intense pain. 3. With reports of acute pain lasting for at least one hour. 4. Continuously every 4 hours to keep the client pain free.

What does a non-stress test tell the nurse about a pregnant client? 1. That the baby is going to be a boy or girl 2. The baby is doing well and the placenta is providing enough oxygen at this time 3. That the baby's heart is healthy and there are no birth defects 4. That the mother is strong enough to undergo vaginal delivery

What information should the nurse reinforce about decreasing the risk of spreading influenza? 1. Influenza is transmitted via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing if tissue is not available. 3. Tissues are not effective in decreasing the spread of influenza. 4. Antibiotics are effective in treating influenza.

When reinforcing teaching, what symptom would the nurse include as being the most common initial visual change associated with glaucoma? 1. Central vision is lost. 2. Progressive tunnel vision occurs. 3. Sudden flashes of light in the eyes.

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

What should the nurse include when reinforcing teaching to a female client prescribed doxycycline for the treatment of acne? 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.

2,3,4

A licensed practical nurse (LPN) is planning client assignments prior to the beginning of a shift. Which client assignments would be appropriate for an unlicensed assistive personnel (UAP)? 1. A new postoperative client who requires dressing changes. 2. A 3 day postoperative client who needs assistance with ambulation. 3. A diabetic client who requires insulin several times daily. 4. A client who requires a 24-hour urine collection. 5. A client who is under suicide precautions.

2,4

Which assignments would be most appropriate for the LPN/VN to accept from the RN? 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.

2,4,5

What symptoms would the nurse anticipate in a client with a calcium level of 3.2 mg/dL (0.80 mmol/L)? 1. Slowed deep tendon reflexes 2. Muscle rigidity and cramping 3. Hypoactive bowel sounds 4. Positive Chvostek's sign 5. Seizures 6. Laryngospasms

2,4,5,6

A client being prepared for surgery is to be given a pre-operative medication. What is the nurse's priority action when administering the medication? 1. Verify client has signed all consent forms. 2. Escort the client to the bathroom to void. 3. Check that identification band is in place. 4. Raise side rails and put call bell in place.

The nurse is preparing to administer 500 mL Normal Saline to a client over the next two hours per infusion pump. What number should the nurse set the pump at to deliver the prescribed amount per hour?

250

A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement? 1. Administer an osmotic diuretic. 2. Complete a neurological assessment. 3. Maintain the head of the bed at 30 degrees. 4. Instruct the client to take a stool softener daily.

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? 1. Anger 2. Acceptance 3. Bargaining 4. Depression

A client has been diagnosed with cutaneous anthrax in a cut on the right hand. What should the nurse do for self protection while caring for this client? 1. Wear mask only. 2. There are no precautions necessary. 3. Universal precautions. 4. Limit interactions with client.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

A nurse is caring for a client who had a total hip replacement 2 days ago. What observation would be a priority concern for the nurse? 1. Small amount of red drainage on the surgical dressing. 2. Continues to report pain in hip when being repositioned. 3. Temperature of 101.8°F (38.7°C). 4. Slight swelling in the leg on the affected side.

When preparing an intramuscular injection for a neonate, which needle should a nurse select? 1. 18 G, 7/8 inch . 21 G, 1 inch 3. 25 G, 5/8 inch 4. 25 G, 1.5 inch

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever

The nurse is inserting an indwelling catheter into a confused client. After cleansing the area, the nurse is getting ready to insert the catheter. As the nurse's hand moves toward the urinary meatus, the client moves and the catheter touches the sheets on the bed. What should the nurse do? 1. Continue with the catheter insertion. 2. Cleanse the catheter tip with the cleansing solution. 3. Obtain a new catheter. 4. Reposition the client and insert the catheter.

The nurse is reinforcing proper use of the walker with partial weight-bearing to a client with a total hip arthroplasty. Which action would indicate to the nurse that the client is using the walker correctly? 1. Leaning over the walker. 2. Using a walker with 4 wheels. 3. Elbows positioned at 30 degrees. 4. Lifts the walker when climbing steps.

The nurse is working on an in-patient psychiatric unit. The nursing care plan includes teaching a client about assertiveness. The client has a long history of being manipulated by the employer and spouse. What is the best rationale for including assertiveness training in this client's treatment plan? 1. All clients should have assertiveness skills. 2. The client has low self-esteem. 3. The client is being taught self-advocacy. 4. No client deserves to be manipulated by an employer.

What is the priority treatment for carbon monoxide poisoning? 1. O2 saturation monitoring 2. Hyperventilation 3. Matching ventilation/perfusion in lungs 4. Administer 100% O2

The parents of a toddler ask the nurse how to stop their child's temper tantrums when they occur. What is the best advice the nurse should provide? 1. Spank the child gently when the tantrum occurs. 2. Promise the child a new toy if the child stops the tantrum. 3. Ignore the tantrum if the child is safe. 4. Restrain the child during a tantrum.

What action should the nurse take after entering the room of a client who becomes agitated and combative? 1. Administer prn sedative. 2. Notify the family of client behavior. 3. Speak softly to the client. 4. Apply wrist restraints.

What nursing intervention takes priority for the client one day postoperative bowel resection reporting pain of a 6 on a 0 to 10 pain scale? 1. Assist the client in changing positions. 2. Use a distraction technique. 3. Administer the prescribed analgesic. 4. Encourage the client to walk.

Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake

Which nursing action takes priority once a term infant has delivered vaginally? 1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints

The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which findings? 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst

3,4

The nurse is preparing a client for a renal biopsy. Which data is most important to gather prior to this procedure? 1. BUN 2. NPO status 3. Prothrombin time (PT) 4. Serum potassium 5. Activated partial thromboplastin time (aPTT)

3,5

A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now? 1. Cancel physical therapy and allow client to leave. 2. Ask client to stand with crutches to check the size. 3. Tell client insurance will not permit use of old crutches. 4. Send client with crutches to physical therapy for evaluation.

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

A female client who identifies herself as a Muslim arrives at the outpatient clinic with abdominal pain. Which initial question should the nurse ask to obtain cultural information? 1. "Do you need a family member in the room with you?" 2. "What can you tell me about your culture?" 3. "Have I positioned you so that you are facing toward Mecca?" 4. "Are you comfortable being cared for by a male primary healthcare provider?"

An LPN working on pediatric oncology unit has been assigned to a five year old terminal client. The mother is concerned that the child, who is expressing excitement to see the family's deceased dog, does not understand the permanence of death. What comment by the LPN would be most helpful at this time? 1. "It is okay to allow your child to believe death is only temporary." 2. "This age group is too young to understand the concepts of death." 3. "Sometimes children use imagination to deal with scary situations." 4. "It is difficult for this age group to understand death is permanent."

An LPN/LVN from the maternity unit is pulled to the medical unit for the first four hours of the shift. Which client should the LPN/LVN explain to the charge nurse would be an inappropriate assignment? 1. Client with rheumatic fever. 2. Client scheduled for an appendectomy. 3. Client one day post cardiac catheterization. 4. Client diagnosed with Methicillin-Resistant Staphylococcus Aureus.

As the nurse removes the IV line from a client, a small drop of blood spills onto the nurse's arm. What should the nurse do first? 1. Call for assistance from another nurse. 2. Report the exposure to employee health and infection control department. 3. Request baseline lab work to be completed. 4. Remove the blood by thoroughly washing the area with soap and water.

Post cataract removal, a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which additional sign or symptom would cause the greatest concern? 1. Nasal congestion 2. Hiccups 3. Blood glucose of 130 4. Muscle spasms

The nurse is caring for a client diagnosed with schizophrenia. What action would the nurse consider a priority for this client? 1. Schedule alone time for client to relax. 2. Frequently reorient the client to surroundings. 3. Encourage participation in all social activities. 4. Assign same staff to provide client care daily.

The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia

The nurse is caring for a client with myasthenia gravis. What teaching is essential for the nurse to reinforce with this client regarding treatment? 1. Frequent low-calorie snacks. 2. Strict monitoring of intake and output. 3. Use of sweeping gaze when walking. 4. Setting the alarm clock for medication times.

The nurse is reinforcing teaching to a client who has been prescribed glucocorticoids for the treatment of Addison's disease. What points should the nurse emphasize? 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy.

The nurse is working with a new unlicensed assistive personnel (UAP) on a postoperative floor. The first vital sign check on a new postoperative client was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the postoperative client, the nurse decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on clients. 3. The nurse's role includes assessment of vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

The parents of a 1 month old report that their baby wakes up startled and stretches out the arms throughout the night. What suggestion should the nurse provide to the parents to decrease this reflex? 1. Rock to sleep. 2. Place in a baby swing. 3. Provide a pacifier. 4. Swaddle the baby.

Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bracelets. Because of similar appearance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify family to come in and identify clients in person.

Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take? 1. Do nothing since this is normal. 2. Decrease the amount of suction. 3. Replace CDU unit with another one. 4. Notify primary healthcare provider.

Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? 1. Give parent a small dog for company and comfort. 2. Reset the water heater to 125 degrees Fahrenheit (51.67 degree Celsius) to prevent burns. 3. Place mirrors in multiple locations so parent sees images of self. 4. Make floors and walls different colors.

Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility? 1 1. Offer multiple environmental stimuli at the same time to provide distraction. 2. Encourage the client to participate in activities such as board games. 3. Restrain the client in a chair to prevent falls when sundowning occurs. 4. Involve the client in supervised walking as a routine.

Which pain scale should the nurse use to monitor the pain level of a 3-year old client after surgery? 1. Numerical scale 2. Verbal descriptive scale 3. Visual analog scale 4. FACES scale

Which statement made by the client using an inhaler would indicate the need for a follow up? 1. "I should shake the inhaler well before use." 2. "I should breathe out slowly and completely through my mouth before placing the mouthpiece of the inhaler in my mouth." 3. "I should hold my breath for approximately 8-10 seconds before exhaling slowly." 4. "I should administer the two puffs that are ordered in rapid sequence."

The nurse asks if the client has an advance directive. The client responds by saying, "What is an advance directive?" What is the nurse's best response to the client's question? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. Specifies your wishes regarding healthcare and treatment options should you become incapacitated. 5. The person signing the advanced directive must be competent.

4,5

The primary healthcare provider prescribed lactulose 30g orally once a day. Available is lactulose labeled 10g per 15 mL. How many mL will the nurse administer? Round to nearest whole number.

The nurse is performing peritoneal dialysis on a client diagnosed with renal injury. In what order should the nurse perform this procedure? Warm dialysate. Infuse dialysate through peritoneal catheter. Provide 30 minute dwell time. Drain fluid for 30 minutes. Turn client from side to side.

Warm dialysate. Infuse dialysate through peritoneal catheter. Turn client from side to side. Provide 30 minute dwell time. Drain fluid for 30 minutes.

The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? 1. Ventrogluteal 2. Vastus lateralis 3. Rectus Femoris 4. Deltoid

Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

A newly hired nurse has been instructed by the preceptor nurse on burn dressing techniques. The nurse knows teaching has been effective when the new nurse performs wound care in what order? Medicate client with pain medication. Wash hands and apply clean gloves. Set up sterile field and open packages. Remove the old dressing and discard. Wash hands and apply sterile gloves. Clean burn and place sterile dressing.

Wash hands and apply clean gloves. Set up sterile field and open packages. Remove the old dressing and discard. Wash hands and apply sterile gloves. Clean burn and place sterile dressing.

A client comes to an obstetric clinic for a routine prenatal checkup at 32 weeks gestation. The nurse palpates the client's abdomen to determine fetal position so that fetal heart tones can be auscultated. It is determined that the fetal position is left occipital anterior (LOA). Where should the nurse place the Doppler to hear fetal heart sounds? 1. Below the umbilicus, on the mother's left side. 2. Below the umbilicus, on the mother's right side. 3. Above the umbilicus, on the mother's right side. 4. Above the umbilicus, on the mother's left side.

A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first? 1. Go to the client to collect data for signs and symptoms of decreased cardiac output. 2. Call the primary healthcare provider to report that the client had an episode of VF so medication adjustments can be made. 3. Notify the "on call" person in the cath lab to re-charge the ICD in the event that the client has a recurrence. 4. Document the incident on the code report form and follow up regularly.

Which room assignment would be most therapeutic for the nurse to make for a client with bipolar disorder in manic phase who is hyperactive and has difficulty sleeping? 1. A private bedroom. 2. A semi private room with a roommate who has a similar problem. 3. Either a private or a semi private room. 4. Direct admission to the seclusion room until his activity level becomes more subdued.

When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.

1,3,4

The nurse has completed newborn discharge teaching with the parents. Which statements by the parents would indicate accurate understanding of proper CPR for infants? 1. Place the infant on a firm, flat surface. 2. Use the palm of one hand to do compressions. 3. Give compressions at a rate of at least 1 per second. 4. Compress about one third the anterior-posterior diameter of the chest. 5. Give one breath after every 15 compressions. 6. Time to give breaths should not take longer than 10 seconds.

1,4,6

A client diagnosed Alzheimer's disease has been prescribed memantine. The nurse is reinforcing education about this medication. What points should the client know about this medication? Select all that apply 1. When beginning this medication provide ambulatory assistance. 2. This medication is prescribed to help improve mild dementia. 3. This medication must be taken without food. 4. If a dose is missed, double the next dose. 5. If the client cannot swallow the capsule you sprinkle on applesauce.

1,5

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Backache 5. Severe headaches rated 9/10

1,5

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

1,5

A client with asthma uses a corticoid inhaler. What teaching should the nurse reinforce to decrease the risk of an oral fungal infection? 1. Lessen the exposure of the oral mucosa to the corticoid inhaler by exhaling rapidly. 2. Rinse the mouth completely and brush teeth following the use of the corticoid inhaler. 3. Use alcohol based mouth rinses with corticoid inhaler. 4. Drink water prior to using the corticoid inhaler.

A nurse working in a long term care facility observes a resident who is eating in the dining hall. Suddenly, the resident crosses her hands at her neck. What action should the nurse perform first? 1. Forcefully hit the resident between the scapula with an open hand. 2. Ask the resident if she can cough. 3. Apply 5 abdominal thrusts quickly and firmly. 4. Sweep back of mouth with crossed fingers.

Following report, which newborn infant should the nursery nurse monitor first? 1. Positive Babinski reflex noted. 2. Has circumoral cyanosis. 3. Negative Ortolani's sign noted. 4. Has telangiectatic nevi.

Two healthcare personnel are talking about a client by name in the facility elevator. The conversation is overheard by visitors in the same elevator. Which client right is violated? 1. Right to be treated with respect. 2. Right to privacy. 3. Right to not be discriminated against. 4. Right to be informed of one's condition.

The nurse is identifying home safety issues to prevent injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this process? 1. Episodes of mild anxiety 2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes

2,3,4,5

A client is diagnosed with seizures. Which nursing interventions should the nurse implement? 1. Have an unlicensed assistive personnel stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help to ambulate.

2,3,5

A client who has Parkinson's disease has a new prescription for benztropine. What does the nurse reinforce to the client about this medication? 1. This medication blocks dopamine in the brain to decrease tremors and muscle stiffness. 2. The client should notify their primary healthcare provider if urinary retention develops. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 4. No lab tests are needed while taking this medication. 5. Sit up or stand up slowly to prevent lightheadedness.

2,3,5

The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.

The nurse is assessing an adolescent newly diagnosed with obsessive compulsive disorder (OCD). The client is nervously rearranging papers on the desk and stating "why can't I stop this?" What would be the most therapeutic response(s) by the nurse at this time? 1. "We can help you control impulses, but you will never be cured." 2. "You will feel much better after beginning your family therapy." 3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help."

3,4,5

Which task would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Obtain a sterile urine specimen from an indwelling catheter. 2. Insert an in-and-out catheter on a postpartum client. 3. Take vital signs on a client 12 hours postpartum. 4. Remove an indwelling catheter on a postpartum client. 5. Perform perineal care on a client with an episiotomy.

3,5

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

A client with diabetes is hospitalized for debridement of a non-healing foot ulcer. Following the procedure, the nurse notes that the client has become confused and combative. The family expresses concern with the behavioral changes and requests that the client be restrained in bed. What is the nurse's priority action? 1. Notify the primary healthcare provider. 2. Apply a vest restraint as requested by family. 3. Move client to a room near the nurse's desk. 4. Obtain a finger-stick blood glucose level.

Client satisfaction is a key factor for quality assurance in the health care setting. Which nursing action is likely to improve satisfaction and demonstrates acts of beneficence? 1. Allowing clients to make their own decision about care. 2. Answering all questions posted by the client in an honest manner. 3. Reporting faulty equipment to the proper departments. 4. Sitting at the bedside and listening to an elderly client.

The adult client requires ear drops. Place the steps of ear drop administration in order. Warm medication under running water Place client in side-lying position Pull pinna up and back Wipe out gently any cerumen or drainage in outer ear canal Instill prescribed drops Apply pressure to tragus of ear Maintain in side lying position for 5-10 minutes

Warm medication under running water Place client in side-lying position Pull pinna up and back Wipe out gently any cerumen or drainage in outer ear canal Instill prescribed drops Apply pressure to tragus of ear Maintain in side lying position for 5-10 minutes

The nurse should monitor the results of which laboratory test for a client taking atorvastatin? 1. Complete blood count 2. Serum triglyceride levels 3. Troponin level 4. Cardiac enzymes

A client consumes a lacto-ovo-vegetarian diet. Since admission, the client has only consumed about 60% meals. Which foods are appropriate to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk. 2. Boiled eggs but no dairy products. 3. Fish sticks and cocktail sausages. 4. Fresh vegetables but no milk or eggs.

A client has been on the medical unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client wishes to leave. 2. Make arrangements for a commitment hearing as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.

After completing several rounds of chemotherapy, a client's laboratory results indicate severe neutropenia. After admission, what is the nurse's priority action for this client? 1. Notify dietary no fresh, unpeeled fruits or vegetables. 2. Avoid all venipunctures or IM injections. 3. Have client wear mask when leaving room. 4. Instruct client to use a soft toothbrush.

Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should be placed in the waste basket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Provide personnel for assistance with completing an advance directive. 4. Encourage client to complete advance directive as soon as possible. 5. Determine if the client's daughter agrees with the client's decision.

1,2,3

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1,2,3,4

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1,2,3,5,6

The client has the need for droplet precautions due to a respiratory illness. When providing care for this client, when is it appropriate for the nurse to wear a mask? 1. Performing tracheostomy care. 2. Delivering mail to the client's room. 3. Bathing the client. 4. Feeding the client. 5. Making routine room checks.

1,3,4

The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

2,3,4,5

The client, who recently started college, tells the nurse, "I am having trouble studying for my tests. Every time I try to study, my mind begins to wander." What is the nurse's best response? 1. "Stop making excuses and make a study schedule you will follow." 2. "I wouldn't worry. You are smart enough to pass college." 3. "You are having difficulty concentrating?" 4. "What do you mean you can't study?"

The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens? 1. Obesity among teens is often accompanied by psychologic issues like poor self-esteem. 2. Weight issues among teens are often due to excess eating out of boredom or stress. 3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 4. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.

The nurse is looking at the plan of care for a child with a fractured femur in Bryant's traction. The nurse is aware that planned interventions should focus on preventing what major complication? 1. Infection at the pin sites. 2. Slipping counter traction. 3. Neurovascular impairment. 4. Skin breakdown and decubiti.

The nurse is setting up the sterile field for the primary healthcare provider and another nurse to use. As the nurse and primary healthcare provider enter the room, they don sterile gowns and gloves. As the procedure begins, the nurse observes that the other nurse in the room has turned her back on the sterile field. What should the observing nurse do first? 1. Nothing, as everyone is individually accountable for their practice. 2. Provide the nurse with another gown and sterile gloves. 3. Inform the primary healthcare provider and the nurse that the sterile field may have been compromised. 4. Remind the nurse not turn back on a sterile field.

A client has an intestinal obstruction and a NG tube to low suction. Blood gases are ph 7.54, pCO2 40, HCO3 35. The client is weak, shaky, and reports tingling of the fingers. The nurse knows that this client is most likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease? 1. "I can be treated and then no one else is at risk." 2. "Using condoms will keep my sex partner from acquiring the disease." 3. "If I have no sores, I am not contagious to anyone." 4. "My sex partner should be tested because we have not always used condoms."

The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? 1. Ask the client to lie down and place the stockings on the legs. 2. Ask the client to sit on the bedside and place the stockings on the legs. 3. Tell the client that the nurse will return later to assist with the application. 4. Elevate the extremities in bed for 30 minutes before application.

The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Minimally swollen eyelid 2. Mild discomfort of the eye 3. Slight red appearance of the eye 4. Extreme pain in the eye

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report.

Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report.

Which victim would the nurse decontaminate first in a biological terrorist event? 1. Client who was exposed but is exhibiting no symptoms 2. Client who has an open leg fracture and head injury 3. Client who is not breathing and has no palpable pulse 4. Client with minor cuts and abrasions

What discharge instructions should the nurse reinforce to the client post abdominal hysterectomy? 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider of a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.

1,2,4

What food should the nurse include when reinforcing teaching to an older adult about increasing vitamin B12 intake? 1. Calf liver 2. Feta cheese 3. Fresh spinach 4. Shrimp 5. Tuna 6. Tofu

1,2,4,5

The nurse is to administer a client's first dose of lithium. Prior to giving the medication, the nurse should verify that what tests have been completed? 1. Blood urea nitrogen (BUN) 2. Thyroid stimulating hormone (TSH) 3. Electroencephalogram (EEG) 4. Alanine Aminotransferase (ALT) 5. Electrocardiogram (ECG)

1,2,5

A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs

1,3,4,5

1,3,4,5,6

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

1,3,4,6

What risk factors should the nurse identify when screening individuals for type 2 diabetes mellitus? 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

1,5

What statement by a new LPN would indicate an understanding of how to maintain skin integrity for a client on bedrest? 1. "Clients on bedrest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."

1., 3., 4., & 5

Which is a risk factor for developing breast cancer in women? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Menarche at age 10

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination. 2. Second diphtheria vaccination. 3. Third Hib vaccination. 4. Influenza vaccination.

Which vaccines would a clinic nurse encourage a 65 year-old adult to receive? 1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine 6. Measles, mumps, and rubella (MMR)

1,2,3,4,5

A client who is obese and paraplegic needs to be repositioned in the bed. What actions should the nurse take? 1. Obtain assistance from a coworker. 2. Place the bed in the lowest position with the client close. 3. Adjust the bed to a workable position and move close to the client. 4. Use a draw sheet with the assistance of a coworker and pivot the hips while pulling the draw sheet upward. 5. Use the client's arms and pull to head of bed to aid positioning.

1,3,4

A nurse in an inpatient facility is serving as an advocate for a client who is being prepared for surgery. Which communication by the nurse is the best example of advocacy? 1. Convincing the client to accept medical treatments that the health care team recommends for the client. 2. Respecting the client's rights and facilitating communication between the client and the health care team. 3. Reassuring the client that a surgical procedure will be successful and will achieve the desired outcome. 4. Encouraging the client to refuse medical treatment that the nurse believes to be unnecessary.

A nurse is caring for a Mexican-American client post stroke. While in the client's room, a curandero visits at the request of client. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Reinforce client care with the client and curandero. 3. Ask the curandero to leave so that the client can be observed. 4. Explain to the client that the curandero is not a reliable healthcare option.

An LPN is providing care for a post-Cesarean section client with a history of cardiac disease. When reviewing home dietary plans, the LPN realizes further instruction is needed when the client makes what statement? 1. "I should eat extra fiber to prevent constipation." 2. "I must drink lots of fluid to increase breast milk." 3. "I will check my weight and record it every day." 4. "I need to rest frequently throughout the day."

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation? 1. The client is probably having an extramarital affair. 2. The developmental task at this stage is adjusting to the needs of more than two family members. 3. A relative or close friend should be consulted for help so the client can pursue activities outside the home. 4. The client should be referred to a psychotherapist for evaluation and care.

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing care should be included in this immediate post-treatment period? 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.

2,3

A client asks a nurse about the Health Insurance Portability and Accountability Act (HIPAA). When reinforcing teaching to the client about HIPAA regulations, which provisions should the nurse include? 1. HIPAA guarantees individual access to health insurance. 2. Clients have the right to request a copy of their personal health information. 3. Health care agencies must keep a client's personal health information confidential. 4. A client's personal health information may be released to obtain health insurance benefits for the client. 5. All staff members have legal access to a client's medical record while the client is receiving medical care in a facility.

2,3,4

Prior to administering medications, the nurse must identify the client using which identifiers? 1. Room number 2. Date of birth 3. Identification band 4. Client correctly states name 5. Visitor stating client's name

2,3,4

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? 1. Abstract reasoning 2. Waxy flexibility 3. Grandiose delusions 4. Anxiety 5. Agitated behavior

2,3,4,5

A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.

To determine the standards of care for the institution, the nurse should consult which document? 1. Organizational Chart 2. Personnel policies 3. Policies and procedure manual 4. Job descriptions

A client is admitted to the hospital due to a deep vein thrombosis (DVT). Which intervention should the nurse initiate? 1. Ambulate client around room every 2 hours. 2. Assess Homans' sign every 8 hours. 3. Place sequential compression device on both legs. 4. Apply intermittent warm, moist soaks to affected area.

A client in the inpatient mental health unit has been determined not suicidal. The client is requesting to leave against medical advice (AMA). What should the nurse do first? 1. Inform the primary healthcare provider that the client is wishing to leave. 2. Make arrangements for a commitment hearing 3. Tell her that she must stay until her primary healthcare provider discharges her. 4. Call the primary healthcare provider and request a discharge order.

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space

A client who is suicidal confides to the night nurse, "I will try again when I get out of this place." What is the nurse's best response? 1. "What do you plan to do?" 2. "You will try what again?" 3. "Why would you want to do that? You have everything to live for." 4. "Are you trying to get back at your family for sending you here?"

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

A client who presents with severe epigastric pain, reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation? 1. pH - 7.49, pCO2 - 40, HCO3 - 30 2. pH - 7.32, pCO2 - 48, HCO3 - 20 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26

A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? 1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"

A client with acquired immunodeficiency syndrome (AIDS) is admitted to an emergency department in respiratory arrest. There is no advanced directive in the client's medical record. Which action should a nurse take? 1. Activate the code protocol and resuscitate the client. 2. Resuscitate the client only with primary healthcare provider authorization. 3. Remain with the client and document the client's vital signs. 4. Ask the client's family if the client has an advanced directive.

A female client with a history of frequent exacerbations of asthma asks the nurse why she is at greater risk for fractures than other women her age. What is the nurse's best response? 1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." 2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "Asthma should not put you at increased risk for fractures but you are at risk for decreased blood glucose levels."

A nurse observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client most likely experiencing? 1. Auditory hallucinations 2. Delusions 3. Catatonic excitement 4. Anergia

A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."

A young client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." Which statement by the nurse is appropriate? 1. "That is inappropriate behavior and you will need to go to your room." 2. "You've got to be kidding! You can't get me fired." 3. "I don't want to hear that again; don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it."

Following surgery, a client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed for this client to prevent an adverse reaction related to methylprednisolone? 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid

Immediately after a liver biopsy, a client is placed on the right side for 60-90 minutes. What is the rationale for placing the client in this position? 1. Helps stop bleeding if any occurs. 2. Restores circulating blood volume. 3. This is the position of greatest comfort. 4. Helps reduce fluid trapped in the biliary ducts.

The client has been taking divalproex for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test? 1. Alanine aminotransferase (ALT) 2. Serum glucose 3. Serum creatinine 4. Serum electrolytes

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse meets with the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

The nurse is assisting the client in changing clothes. The client says, "Stop. I don't want you or anyone touching me." What should the nurse do? 1. Stop assisting the client if he does not want it. 2. Inform the client that she is just helping him to get into hospital gown. 3. Tell the client that it is okay. The nurse just wants to help. 4. Say, "Nurses help clients all the time. There is nothing wrong with it."

The wife of a client in the hospital inquires if cardio pulmonary resuscitation (CPR) will be done if the client stops breathing. The client has suffered from a terminal illness, and it appears that death is imminent. The client has a living will which requests "do not resuscitate". What should the nurse say to the wife? 1. "No, the living will requests that no resuscitation efforts be performed." 2. "We will respond slowly with resuscitation efforts." 3. "We will begin the CPR, but the house primary healthcare provider will stop within a few minutes." 4. "We will only perform CPR, no defibrillation."

What should the nurse do to prevent ageism when working with older adult clients? 1. Understand the normal aging process, while maintaining contact with healthy, independent, older clients. 2. Speak slowly with increased volume while providing educational pamphlets and brochures to older clients. 3. Limit the client's activities to prevent injury and promote rest. 4. Involve the family in decision making and financial concerns.

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

Which nursing task would be appropriate for the LPN/VN to complete? 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Update plan of care for a client. 4. Initiate client teaching on ostomy care.

Which primary healthcare prescription should the nurse perform first? 1. Insert intermittent catheter in client who has not voided in 8 hours. 2. Administer a bolus feeding via a client's gastrostomy tube. 3. Reinsert nasogastric tube (NG) that was pulled out. 4. Remove wound sutures.

Which statement about acquiring the Ebola virus by a client would indicate to the nurse that follow up is necessary? 1. "I can get a vaccine to prevent getting the Ebola virus." 2. "Ebola is not spread through casual contact, so my risk of getting the virus is low." 3. "The Ebola virus is passed from person to person through blood and body fluid." 4. "Ebola viruses are mainly found in primates in Africa."

Which statement by the client with children ages 5 months to 8 years old requires follow up by the clinic nurse? 1. "I give all my children a spoonful of honey at night when they have a cough." 2. "I serve my 8 year old a glass of orange juice with breakfast before school." 3. "I have children use Lavender scented soap to wash their hands before they eat. 4. "I play music for my children when it is time for them to take a nap."

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

1,2

The night nurse has reported to the day nurse that a client has not had a bowel movement in 2 consecutive days. What actions should the day nurse take? 1. Write prescription to initiate "Bowel Protocol" per standing order. 2. Offer client 120 mL prune juice. 3. Give Milk of Magnesia (MOM) 30 mL po. 4. Administer bisacodyl suppository. 5. Provide sodium phosphate enema.

1,2

The nurse is participating in a presentation regarding adolescent violence to middle and high school faculty and staff. What risk factors for violence should the nurse include? 1. Attention deficit disorder 2. Diminished economic opportunities 3. Authoritative parenting style 4. Active in school sports 5. High parental involvement

1,2

A nurse is administering medications to a client and notes that a newly prescribed medication is on the client's list of allergies. When advocating for this client, which actions should the nurse take to ensure the client's safety? 1. Check the client's allergies against the list of client allergies documented in the medical record. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Discontinue the medication on the client's medication administration record (MAR). 4. Give the medication as ordered by the primary healthcare provider and administer diphenhydramine to the client. 5. Hold the medication and administer diphenhydramine to the client.

1,2,3

A client with chronic obstructive pulmonary disease (COPD) learns about the importance of a nutritious diet to avoid weight loss. Which food selections for a breakfast menu show understanding by the client? 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1,2,3,4

A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? 1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby 5. Allows baby to cry vigorously for 15 minutes

1,2,3,4

What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation. 1. Document current functional status. 2. Have the primary healthcare provider receive acceptance for transfer from receiving agency. 3. Transfer appropriate parts of medical record to the receiving facility. 4. Phone report to the receiving nurse. 5. Send a day's worth of medications with the client to the receiving facility.

1,2,3,4

The homecare nurse is reinforcing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptations should the nurse emphasize for the family to initiate? 1. Install grab bars on tub walls. 2. Place nightlights in hallways. 3. Add bran and fiber to daily diet. 4. Remove scatter rugs or loose cords. 5. Keep bedroom dark, cool and quiet. 6. Put tennis balls on legs of walker.

1,2,3,4,5

The nurse is caring for a client receiving digoxin. What information should be reinforced by the nurse to the client about this medication? Select all that apply 1. Check your pulse daily before taking the medication. 2. Report a marked decline in pulse rate. 3. Consume foods high in potassium to maintain adequate serum potassium levels. 4. Report pulse rate of 64 or more. 5. Report symptoms of nausea, loss of appetite, or visual disturbances.

1,2,3,5

What risk factors should the nurse include when teaching a group of clients about osteoarthritis? 1. Sports injury to joint 2. Genetic predisposition 3. Obesity 4. Male sex 5. Repetitive joint stress

1,2,3,5

1,2,3,5,6

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? You answered this question Incorrectly 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1,2,3,5,6

Which tasks can the LPN/VN complete when assisting with the care of a client scheduled for an adrenalectomy? You answered this question Incorrectly 1. Check finger stick glucose level. 2. Administer regular insulin SQ based on sliding scale prescription. 3. Assess client's cardiac rhythm. 4. Reinforce teaching regarding postoperative care. 5. Review client's pre-surgical laboratory values.

1,2,4

1,2,4,5

A nurse, serving on the quality assurance (QA) committee, is asked to collect data regarding the implementation of fall precautions on at risk clients. What methods of collection would be appropriate? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1,2,4,5

A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? 1. Turn the client to the left side. 2. Administer oxygen. 3. Start an intravenous line. 4. Prep the mother for cesarian section. 5. Notify the primary healthcare provider.

1,2,5

A client is admitted to the psychiatric unit with a diagnosis of obsessive-compulsive disorder with frequent hand washing rituals. Which nursing interventions would be advisable at the time of admit? 1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 3. Provide a structured schedule of activities for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom.

1,2,5

A client is seen in an outpatient clinic for anxiety after losing the family home in a hurricane. What actions would be appropriate for the nurse to make? 1. Reinforce teaching the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 3. Suggest that the client might recover faster by moving away from the coastal area. 4. Refer the client to the family primary healthcare provider for a complete physical examination. 5. Allow the client time to talk about the loss.

1,2,5

What physical changes should the nurse discuss with a client who is entering menopause? 1. Loss of bone density 2. Loss of muscle mass 3. Improved skin elasticity 4. A reduction in waist size 5. Increased fat tissue

1,2,5

Following a total hip replacement, the nurse reinforces discharge teaching to the client. The nurse knows that reinforcement of teaching was effective when the client states which activities are safe to perform? 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

1,3,4

What does a Durable Power of Attorney for Health Care as a legal document provide? 1. Direction about treatment choices in certain circumstances such as an advance directive. 2. A surrogate decision-maker for the client's financial matters in the event that the client becomes incapacitated. 3. A surrogate decision-maker in the event the client becomes incapacitated or unable to make informed health care decisions. 4. A permanent part of the client's medical record. 5. A surrogate decision-maker for the client's burial wishes.

1,3,4

1,3,4,5

A nurse is caring for a client diagnosed with Alzheimer's disease. What actions should the nurse initiate? 1. Monitor client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client.

1,3,4,5

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

1,3,4,5

The nurse should reinforce which instructions given to the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder.

1,3,4,5

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.

1,3,4,5

Which interventions are appropriate to reduce symptoms of neck and back strain and repetitive movement pain from long periods of computer work? 1. Suggest that the workers place the keyboard and mouse close to the body. 2. Adjust computer screen to below eye level. 3. Drop and roll shoulders periodically. 4. Type with forearms parallel to the floor. 5. Keep elbows at the side when typing.

1,3,4,5

The nurse, caring for a client diagnosed with Alzheimer's disease (AD), notices the client becoming agitated. What nursing intervention would be appropriate for the nurse to initiate? 1. Provide a snack for the client. 2. Tell the client to stop the unwanted behavior. 3. Take client for a walk. 4. Ask the client to sweep the floor. 5. Inform the client that restraints will be used if behavior continues. 6. Turn on the client's favorite music.

1,3,4,6

A unlicensed assistive personnel (UAP) enters the unit with artificial fingernails in place. What should the nurse explain to the UAP? 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial fingernails are allowed to be worn on the unit. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of infection to the client. 4. A more vigorous handwashing is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands.

1,3,5

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

1,3,5

The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? 1. Obtain client likes and dislikes from family members. 2. Expose the client with data regarding the forgotten past. 3. Expose client to stimuli that was a happy memory of the past. 4. Hypnotize the client to help restoration of memory. 5. Ensure client safety.

1,3,5

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

1,3,5

A nurse in a long-term care facility is reinforcing teaching to newly-unlicensed assistive personnel (UAP) about advance directives. Which statements by the nurse regarding a Health Care Power of Attorney are correct? 1. "The Health Care Power of Attorney identifies the person designated to make end-of-life care decisions on a client's behalf." 2. "The Health Care Power of Attorney identifies the health care providers that are permitted to care for the client." 3. "The Health Care Power of Attorney identifies the person designated to make financial decisions for the client if the client is incapacitated." 4. "The Health Care Power of Attorney identifies the person designated to make health care decisions for the client if the client is incapacitated." 5. "The Health Care Power of Attorney identifies the person designated to make funeral arrangements for the client if the client dies."

1,4

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? 1. Weigh daily at the same time each day. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1,4,5

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that instructions were successful? 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

A 68 year old client was admitted two days ago to a long term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/min by nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? 1. Unlicensed assistive personnel (UAP) 2. LPN/LVN 3. RN 4. Charge Nurse

A child has been admitted to a busy pediatric unit diagnosed with dehydration secondary to nausea and vomiting. An LPN has been assigned to assist with the admission. Which task is priority for the LPN? 1. Collect blood for cultures and electrolytes. 2. Weigh child and compare to normal weight. 3. Offer cool oral fluids to begin re-hydration. 4. Inform parents about visiting hours and rules.

A client asks a nurse to view his/her medical records. Which response by the nurse regarding this request is best? 1. "You will need to contact the medical records department in order to view your medical records. Here is their phone number." 2. "You have the right to view your medical records and to have those records explained to you. Let's schedule a time to go over them." 3. "You may view your medical records only if a primary healthcare provider is present. I will let him/her know that you would like to see them." 4. "You are not allowed to view your medical records. They are confidential and for hospital use only."

A client with schizophrenia tells the nurse, "I want you to take me to the uniphorum". Which statement would be most appropriate for the nurse to make? 1. "You don't even know what you are saying. Stop making up words". 2. "I don't understand what you mean by that. Would you please explain it to me"? 3. "Think about what you are trying to say, then try again". 4. "I will take you after I finish handing out medications".

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look great today, so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."

A client with tuberculosis (TB) has been coming to the health department for directly observed therapy (DOT) for the past month. Today, the client states, "I don't think I need to come back anymore. I am feeling much better now." What should the nurse tell the client? 1. "You have taken your medication long enough so, the primary healthcare provider should discontinue it today." 2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured." 3. "I will be required to have you arrested if you do not come back for further treatment." 4. "Just let us decide when you should stop taking the medication."

A client, hospitalized for a respiratory infection, must leave the room for a test procedure. What intervention is appropriate for the nurse to perform so that spread of infection is less likely? 1. Ask the primary healthcare provider if the test can be performed in the room. 2. Ask the client to wear a mask when out of the room. 3. Make sure that all staff wear masks when providing care. 4. No special precautions are needed.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.

A hospitalized client using a K-pad on an injured muscle reports the pad is not warming up. What should be the nurse's initial action? 1. Unplug unit and plug into another wall outlet. 2. Check temperature setting on the heating unit. 3. Call maintenance to repair unit immediately. 4. Increase temperature on unit till pad heats up.

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? 1. "Vaccinations give antibodies to your baby to protect them from disease." 2. "Vaccinations will help your baby produce antibodies against disease causing organisms." 3. "Federal law requires that your baby receive recommended vaccinations." 4. "There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur."

A nurse prepares a client for a colonoscopy and presents the consent form to the client. The client states, "I don't know what a colonoscopy is." Which is the best action for the nurse to take? 1. Explain the procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Inform the primary healthcare provider that the client requests additional information related to the procedure. 3. Give the client an information pamphlet about the procedure and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed.

A nurse's neighbor, who is suspected of having acquired immunodeficiency syndrome (AIDS), is hospitalized. The nurse is curious and accesses the neighbor's medical record. How should the nurse's supervisor evaluate this action? 1. This action is okay as the nurse is one of many employees at the hospital. 2. The action is unethical and violates client privacy. 3. The action demonstrates curiosity, but no problem exists. 4. The action is okay as long as the nurse does not share the information.

A schizophrenic client tells the nurse, "The President of the United States just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What is the nurse's best response? 1. The voice you heard is because of your illness and will go away in time. 2. I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here. 3. I find it hard to believe that you have talked to the President of the United States. This is not the White House! 4. I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices.

An LPN is assisting at a pediatric clinic. The parents of a 2 month old infant have just been informed the baby has cerebral palsy. The mother brings to cry, taking personal blame for this diagnosis. What comment by the LPN would be most therapeutic for the mother? 1. "Your child can still live a relatively normal lifestyle." 2. "I can see you are distressed about this new diagnosis." 3. "There is medication to improve strength and function." 4. "Early intervention programs can help speech and mobility."

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.

The nurse has identified that a client receiving oxygen has nasal irritation. Which client action would require the nurse to intervene? 1. Application of gauze padding beneath the tubing. 2. Use of petroleum jelly on the nares and cheeks. 3. Mouth and nose care every 4 hours as needed. 4. Placement of the oxygen mask straps well above the ears.

The nurse has just inserted an indwelling catheter into the hospitalized client. The nurse has cleared the items from the client's bed, disposed of them, and removed the gloves. What should the nurse do next? 1. Record output. 2. Wash hands. 3. Inspect tubing for obstructions. 4. Tape the catheter in place.

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks.

The nurse is caring for a client on the skilled nursing unit. The client has lost 8 pounds (3.6 kg) since admission 3 months ago. Which strategy may help to improve the client's caloric intake? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the nursing tech to feed the client at each meal.

The nurse is caring for a client who was admitted to the inpatient psychiatric unit five days ago for exacerbation of psychotic symptoms, as evidenced by delusions of grandeur. Which type of client remarks indicate continued delusions of grandeur? 1. Comments with fear as a theme. 2. Comments with a theme of being powerful. 3. Comments related to missing body organs. 4. Comments related to being under someone else's control.

The nurse is caring for a primipara client at 27 weeks gestation. Which client signs and symptoms are priority at this stage of pregnancy for the nurse to tell the client to report? 1. Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care

The nurse is caring for a primipara client at 27 weeks gestation. Which client signs and symptoms are priority at this stage of pregnancy for the nurse to tell the client to report? . Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care

The nurse is discussing with a client information about herbal therapy. What is the main goal of herbal therapy? 1. To treat a specific disease or symptom by taking prescription medications. 2. To restore balance within the body by supporting the client's self-healing ability. 3. To avoid the use of toxic chemicals within the body. 4. To incorporate Eastern healing practices into Western medicine.

The nurse is reinforcing information about car accident prevention to a group of high school students. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that carpool to the senior prom. 4. Female students who drive to weekly football games.

The nurse on an inpatient psychiatric unit has been assigned to care for a group of clients. Which client should receive priority during morning rounds? 1. 40 year old woman who is being discharged today. 2. 80 year old man with suicidal thinking. 3. 45 year old man who has suicidal thinking. 4. 50 year old woman with history of acute panic attacks.

The nurse on an inpatient psychiatric unit has been assigned to care for a group of clients. Which client should receive priority? 1. Forty year old woman who is being discharged today. 2. Eighty year old man with a history of suicidal thinking. 3. Forty-five year old man who has a history of paranoid thinking. 4. Fifty year old woman with history of acute panic attacks.

The psychiatric nurse notices a new client sitting alone in the dayroom, shaking and muttering indistinguishable words. What statement by the nurse is appropriate? 1. "Who are you talking to?" 2. "You look like you are cold." 3. "It is always cold in this room." 4. "Do you want to get a sweater?"

What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? 1. Turn the screen facing the client rooms so that healthcare personnel can access the information easily. 2. Have the screen placed facing away from any visitor or client care area. 3. Turn the computer monitors off when the computer is not in use. 4. The computer should be kept in a secured, locked area.

Which action by a new nurse indicates to the supervising nurse that the sterile field has been contaminated? 1. Maintains the sterile field above the level of the waist. 2. Places sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for damage.

Which baseline data would tell the nurse that a school aged child is at risk for obesity? 1. Spends one hour playing sports or swimming daily. 2. Spends at least two hours watching TV after dinner each day. 3. Assists mom in preparing low carb snacks for the family. 4. Participates in the marching band at school.

Which menu selection by the client diagnosed with nephrotic syndrome indicates that reinforcement of dietary teaching was understood? 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea

Which nursing intervention can the LPN/LVN safely perform? 1. Assess a client for a hearing loss. 2. Reinforce hand-washing with the client who has bacterial conjunctivitis. 3. Evaluate a client's ability to instill eye medication. 4. Create the plan of care for a client post cataract surgery.

Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Alternate applying warm and cold compresses. 4. Instruct on importance of turning, coughing, and deep breathing.

Which nursing intervention should the nurse implement when administering a medication through a nasogastric (NG) tube? 1. Place the client in a high-Fowler's position for medication administration. 2. Flush the tubing between administering medications 3. Turn the client onto their left side after medication administration. 4. Mix the medication directly into the tube feeding

A nurse educator is providing an inservice regarding the Health Insurance Portability and Accountability Act (HIPAA). When explaining this federal act, which provisions should the educator include? 1. HIPAA guarantees individual access to health insurance. 2. Health care agencies must keep a client's personal health information confidential. 3. Clients have the right to request a copy of their personal health information. 4. A client's personal health information may be released to obtain health insurance benefits for the client. 5. All staff members have legal access to a client's medical record while the client is receiving medical care in a facility.

2,3,4

A nurse is calling the primary healthcare provider about a client who is experiencing a migraine. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? 1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is reporting a migraine." 3. "Jane Doe was admitted two days ago. Pulse is 92, BP 152/80, Resp 22." 4. "From my data collection, she states she has a hx of migraines and is prescribed sumatriptan for relief." 5. "I recommend that she recieve a dose of sumatripten. Do you agree?"

2,3,4,5

The nurse is reinforcing teaching to a client who has been prescribed fluticasone/salmeterol. What points are important for the client to understand? 1. Swallow the capsule when having an acute asthma episode. 2. Rinse mouth after medication administration to decrease infection. 3. Take this medication every day, even on days when breathing fine. 4. Administer by inhalation device twice daily. 5. Carry a rescue inhaler, such as albuterol, when leaving home.

2,3,4,5

Which signs/symptoms would indicate to the nurse that a client with cancer needs follow up care? 1. Unexplained weight gain of 10 pounds 2. Leukoplakia 3. Prolonged hoarseness 4. Hematuria 5. Persistent abdominal bloating

2,3,4,5

The client shares that her husband died 2 months ago. She stays at home at least 3 times per week and cries most of the day. Which interventions for dealing with loss would the nurse initiate? You answered this question Correctly 1. Resume previous social activities right away. 2. Establish a structure of daily activities. 3. Reinforce that dreaming about the loved one is positive. 4. Recommend immediate professional assistance. 5. Encourage communicating feelings during grief process.

2,3,5

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment has not been effective? 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented

2,3,5

Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months? 1. Weight loss 2. Decreased wound healing 3. Hypertension 4. Decreased facial hair 5. Moon face

2,3,5

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which actions should be included when caring for this client? 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Use alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2,4

Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? 1. Ask the client diagnosed with dementia memory-testing questions. 2. Collect the urinary output hourly on the client with renal disease. 3. Demonstrate pursed lipped breathing to the client who has emphysema. 4. Give a tepid sponge bath to the client who has a fever. 5. Assess oxygen saturation on a client experiencing angina.

2,4

Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? 1. Monitor client for signs of skin breakdown. 2. Take client's vital signs after ambulating. 3. Apply bacitracin ointment to right forearm. 4. Obtain a stool specimen. 5. Determine what activities the client can do independently.

2,4

A LPN/VN is caring for a client who reports a pain level of 8 on a numeric scale of 1-10. The LPN/VN reports the client's pain level to the RN and administers pain medication as prescribed. Which actions should a nurse take to advocate for this client? 1. Notify the primary healthcare provider. 2. Ensure that bed side rails are raised and locked. 3. Administer naloxone within 30 minutes. 4. Advise the client to call for assistance before getting out of bed. 5. Monitor the client's pain level after administering medication.

2,4,5

What interventions should the LPN/VN include when reinforcing teaching with a client on how to prevent and treat fungal infections of the feet? 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

2,4,5,6

Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C) 6. Use of tablecloths

2,4,5,6

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

2,5

A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? You answered this question Correctly 1. Sodium 135 mEq/L (135 mmol/L) 2. Potassium 5.8 mEq/L (5.8 mmol/L) 3. BP 100/70 4. No weight loss 5. Calcium 8.0 mg/dL (2 mmol/L)

2,5

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? 1. Consult with the primary healthcare provider. 2. Monitor the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

2,5

Which clients would be appropriate for the LPN/VN to be assigned by the charge nurse? 1. Client admitted with exacerbation of asthma. 2. Client needing oral antibiotics for a diagnosis of gastroenteritis. 3. Client 4 hours post lobectomy. 4. Client with terminal cancer refusing pain medication. 5. Client with arthritis who needs scheduled pain medication around the clock. 6. Client who has a chronic graft versus host disease.

2,5,6

You have an order to administer a pediatric medication according to the client's weight in kilograms (kg). The client's weight this morning was 64 pounds (lb). You would calculate the medication dosage after determining that this client's weight in kg is? (Round to the nearest tenth)

29.1

A client admitted in the manic phase of bipolar disorder approaches the nursing station in the middle of the night, demanding the therapist be called immediately. What response by the nurse is appropriate? 1. "Calm down first, and then I will call your therapist." 2. "It's against the rules to call in the middle of the night." 3. "You must be distressed to want to talk at this late hour." 4. "That's a valid request, but it must wait until morning."

A client at a rehabilitation facility states, "No one asked me which rehabilitation facility I preferred. I feel as if this entire process took place without my involvement. I was not informed of alternative options." Which client right is being violated? 1. The right to considerate and respectful care 2. The right to self-determination 3. The right to participate in the plan of care 4. The right to review medical records related to care and treatment.

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

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Convince the client to proceed with the plans for surgery. 2. Notify the surgery department to cancel surgery. 3. Notify the primary healthcare provider of the client's decision. 4. Suggest that the client talk over the decision with family members.

A client with altered level of consciousness is admitted to a medical unit, the nurse finds the client with no pulse and initiates CPR. The primary healthcare provider instructs the respiratory therapist to prepare for intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client's wrist during the initial assessment. Which immediate action should the nurse take to advocate appropriately for this client? 1. Assist the respiratory therapist to prepare the client for immediate intubation. 2. Attempt to contact the client's family. 3. Notify the primary healthcare provider immediately of the client's DNR bracelet. 4. Notify the charge nurse immediately of the client's DNR bracelet.

A female client has used Depo-Provera injections for birth control for several years. For the past 6 months, attempts to become pregnant have been unsuccessful. What information should the nurse provide the client? 1. A primary healthcare provider who specializes in this problem should be seen. 2. Have a sperm count performed on the client's partner. 3. Ovulation may not occur for many months after using Depo-Provera. 4. Ensure proper nutrition, rest, and establish an exercise program.

A nurse has reinforced teaching to a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.

A nurse is caring for a client admitted with a diagnosis of depression and suicidal thoughts. The client states, "My husband doesn't love me anymore, and so life is just not the same." What would be the most appropriate response by the nurse? 1. "Even though your husband does not love you, life can still be very meaningful." 2. "Many couples go through difficult times in their marriage, but you should not assume that he does not love you anymore." 3. "Tell me what has led you to believe that your husband doesn't love you anymore." 4. "You really need to try not to let your husband make you depressed and feel that life is not worth living."

A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? 1. Rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures. 2. Rubella is the most common cause of meningitis and acquired deafness. 3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect. 4. Rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis or meningitis and can lead to death.

A school age child has been admitted with acute rheumatic fever. The mother states the child gets bored easily and asks what toys could be brought from home. What is the most appropriate child activity for the nurse to tell the mother? 1. Play board games with another child. 2. Encourage school friends to come visit. 3. Listen to music or watch television. 4. Solitary play of handheld video games.

A school nurse is caring for a child who fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention? 1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week.

A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."

After shift report, which client should the nurse see first? 1. Eight year old that is in skeletal traction. 2. Six year old who is 5 hours postop appendectomy. 3. Unattended two year old admitted for a sleep study. 4. Four year old cerebral palsy child with a urinary tract infection (UTI). Rationale

After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the charge nurse that the mother refuses the autopsy. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.

Clients have the right to confidentiality when treated by medical professionals. Which situation is the exception to this rule? 1. The family of the client is visiting from out-of-town and requests information. 2. The family of the psychiatric client calls the nursing unit and requests condition information. 3. The nurse suspects abuse of a child or elder. 4. A nurse and friend from another hospital unit inquire about a client's condition.

During a treatment team meeting, a client who recently had a mastectomy shares that she can no longer stand to look at herself in the mirror and does not want her husband to see her without clothes. Which statement by the nurse on the team would be most appropriate? 1. "Try looking at yourself in the mirror 5 minutes four times daily until you feel more comfortable." 2. "I'm sure that your husband loves you just the way you are." 3. "Trying to adjust to the change in your body image must be very hard for you." 4. "You look great! Also, when the swelling goes down, you will look even better!"

During the hospital discharge instructions a client asks the nurse, "What do you think I should do about my husband's smoking?" Which statement by the nurse is appropriate? 1. "Why are you asking me for advice?" 2. "I think you should talk to your husband." 3. "What do you think you should do?" 4. "You need to support him through his addiction."

The nurse discovers that a client diagnosed with severe depression formerly taught art classes at a local school. The nurse offers to obtain needed supplies if the client would instruct a few interested clients on simple painting techniques. The nurse is aware this type of intervention may help the client achieve what outcome? 1. Distract client from depressive thoughts of hopelessness. 2. Encourage client to begin communicating with others. 3. Utilize client's own strengths to increase self-esteem. 4. Establish the trusting nurse/client relationship.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

The nurse is monitoring a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important follow up at this time? 1. Blood glucose level 2. Ankles for edema 3. Twenty-four hour diet recall 4. Confirmation of last menstrual period

The nurse is working with the interdisciplinary team in developing a plan of care focused on weight gain for an anorexic client. What intervention would be ineffective for reaching that outcome? 1. Refrain from being critical of client during meals. 2. Permit client to make own food selections on menu. 3. Reward the client with private time for a meal completely eaten. 4. Provide positive reinforcement for each pound gained.

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8 - 12 hours of sleep per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories. 4. Encourage preschooler to sleep without a toy.

The nurse overhears an unlicensed assistive personnel (UAP) speaking rudely to a client. Acting as the client's advocate, the nurse tells the employee privately that all clients are to be treated with equal respect and dignity. Which client right has the nurse protected? 1. Free speech 2. Privacy 3. Respectful care 4. Confidentiality

The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse implement? 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal.

Two hours following a lumbar puncture, the client stands up to void and reports a headache rated 8 out of 10 on a pain scale. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces (240 mL) of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.

What important principle should the nurse reinforce with the client performing intermittent self-catheterization? 1. Inserted in an emergency department. 2. Used to treat urinary catheter infections. 3. Is a clean procedure. 4. Requires use of sterile gloves.

What information should be reinforced when a LPN/VN is talking with a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)? 1. HIV is transmitted via toilet seats whereas hepatitis B is not. 2. HIV is transmitted by sexual contact whereas hepatitis B is not. 3. Hepatitis B is more readily transmitted via needle sticks than HIV. 4. Neither virus is transmitted via body fluids.

What is the only acceptable use of restraints by the nurse? 1. An elderly male client had a chest restraint applied after crawling over the bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV. 4. A dementia client is in a Geri-chair with lap belt at nurse's station at night.

What response from the nurse would be most appropriate for a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors."

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? 1. Perform neurological checks. 2. Collect data for health history. 3. Institute droplet precautions. 4. Orient client to the room and procedures.

What task would be most appropriate to assign to the UAP when caring for a client with ulcerative colitis? 1. Sharing successful anxiety reduction measures. 2. Encouraging the client to express concerns about an ileostomy. 3. Reminding the client to avoid cold foods and smoking. 4. Explaining the rationale for needing a low residue diet.

Which task would be appropriate for the LPN/VN to accept from the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse? 1. Administer IV pain medication to a client three days postopertive cesarean section. 2. Draw a trough vancomycin level on a client 3 days postpartum with bilateral mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Draw admission labs on a client admitted in final stages of labor.

Which task would be appropriate for the LPN/VN to complete? 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Feeding a client through a percutaneous endoscopic gastrostomy (PEG). 4. Reinserting a PICC line that was pulled out by the client.

Which task would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Obtaining a sterile urine specimen from a Foley catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing a Foley catheter on a client postpartum.

A busy LPN instructs an unlicensed assistive personnel (UAP) to obtain daily weights on a client. The LPN provides initial direction for the task, monitors that the task is successfully completed, reviews the results of the daily weight, and reports the results to the RN. Which action has the LPN taken? 1. Failed to supervise the actions of the UAP. 2. Improperly assigned a client care task. 3. Appropriately assigned a client care task. 4. Supervised the performance of a client care task. 5. Functioned outside of the LPN scope of practice.

3,4

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse reinforce with the client prior to discharge? 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

3,4

The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is this client utilizing? 1. Sublimation 2. Somatization 3. Symbolism 4. Projection 5. Conversion

3,4

A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate? 1. Assign the client to a private room away from nurses station. 2. Make rounds to assess the client at regular intervals. 3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Ask the client to sign a no harm contract.

3,4,5

A licensed practical nurse (LPN) is utilizing the nursing process to care for assigned clients. Which nursing actions should the LPN relate to the implementation step of the nursing process? 1. Collecting client data for a nursing history. 2. Reporting client response to a new medication. 3. Procuring equipment for a planned medical procedure. 4. Assigning client care activities to unlicensed assistive personnel. 5. Delivering skilled nursing care according to an established health care plan.

3,4,5

A nurse is reinforcing information given to a child's parents about prevention of allergic rhinitis. What preventive measures should the nurse be sure to include? 1. Vacuum rugs daily. 2. Importance of using 12 hour nasal decongestant spray. 3. Place stuffed animals in the freezer for 24 hours prior to washing. 4. Wash pets weekly. 5. Remove carpet from the home.

3,4,5

The nurse is caring for a client admitted with an episode of bleeding esophogeal varices. What should the nurse monitor for after administering propranolol to this client? 1. Increased systolic BP 2. Hypokalemia 3. Bradycardia 4. Wheezing 5. Decreased hematemesis

3,4,5

A client diagnosed with Celiac disease is on a gluten-free diet. What statement by the client would indicate to the nurse that reinforcing of diet instructions is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."

A client diagnosed with alcoholism was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What action should the nurse take? 1. Hide the client's clothes so that the client cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that reinforcement of teaching about this medication is successful when the client makes what statement? 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.

A client is brought to the after hours clinic with a stab wound to the left leg, reporting it as "accidental". The nurse notes the odor of alcohol and marijuana on the client. The nurse is aware that client privacy rights do not apply to what action? 1. The right to refuse photos of the wound. 2. The right to refuse a blood alcohol test. 3. The right to refuse a tetanus injection. 4. The right to refuse police notification.

A client is seen in the clinic expressing feelings of hopelessness and despair after losing his wife two months ago. He tells the nurse, "I think I am ready to go meet her. Please don't tell anyone." How should the nurse respond? 1. "I can see that you miss your wife very much." 2. "Tell me about your wife." 3. "I will keep your secret if you promise me you won't do anything until we talk again." 4. "I can't keep a secret like that. Are you planning to harm yourself?"

A client who is in the manic phase of bipolar disorder was admitted to the psychiatric unit two days ago. Since admission, the client has been overly active, dressing bizarrely and sleeping very little. What type of activity should be planned for this client for the period following the evening meal? 1. Encourage the client to watch TV with the other clients on the unit. 2. Engage the client in a game of ping pong. 3. Suggest that the client play monopoly with other clients. 4. Provide soft lighting in the client's room for reading.

A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the nurse to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? 1. Advocacy 2. Ability to decline participation in experimental treatments. 3. Expectation of reasonable continuity of care. 4. To make decisions about the plan of care

A client with schizophrenia is admitted with a bowel obstruction, and a nasogastric (NG) tube is inserted. The client describes the pain as a 7/10. What would be the appropriate action by the nurse? 1. Decrease the stimuli and observe frequently 2. Administer the prn sedative 3. Call the primary healthcare provider immediately 4. Administer the prn pain medication

A homecare LPN is visiting a 6 month old with a new colostomy for Hirschsprung's disease. The mother expresses concerns about caring for the colostomy throughout the child's lifetime. What is the best response by the LPN? 1. "Your child is too young to worry about appearance." 2. "I will have the ostomy team stop by with information." 3. "You seem very concerned about your child's future." 4. "This ostomy may be temporary and might be reversed."

A medical-surgical nurse cares for a postoperative client who has undergone a percutaneous endoscopic gastrostomy (PEG). With which interdisciplinary team member is the nurse most likely to collaborate? 1. Occupational therapist 2. Respiratory therapist 3. Physical therapist 4. Nutritionist

A neighbor of a client asks the nurse how the woman is doing with her respiratory problems. How should the nurse respond to the neighbor? 1. "That woman is doing well and she will be home soon." 2. "It is nice of you to be concerned." 3. "I can't tell you about her condition." 4. "I am sorry, but I can't say who is or is not on the unit."

A nurse is caring for a client who complains of fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. The nurse immediately puts the client in isolation. The nurse suspects that the client is suffering from which condition? 1. Bronchitis 2. Pneumonia 3. Pneumothorax 4. Tuberculosis

A police officer brings a confused and agitated client to an emergency department. The client's urine is sent for a stat urine drug screen and the police officer asks the nurse for a copy of the results, believing that the client is under the influence of an illegal substance. Which action indicates that the nurse understands the Health Insurance Portability and Accountability Act (HIPAA)? 1. The nurse provides a copy of the client's urine drug screen to the police officer as requested. 2. The nurse obtains permission from the primary healthcare provider to provide a copy of the client's urine drug screen to the police officer. 3. The nurse leaves the client's drug screen results on the counter and walks away, thus allowing the officer possible access to the document. 4. The nurse refuses the police officer's request because the client is unable to consent to the release of personal medical information.

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. Ambulate in the room 2. Perform crede' exercises 3. Reassess the fundus in 30 minutes. 4. Massage the fundus.

A teenage client is anxious about the intravenous line (IV) that has been prescribed. A nurse takes the time to explain how the IV is inserted and why it is needed to care for the client. How did the nurse exhibit client advocacy? 1. By promoting client privacy. 2. By ensuring client safety. 3. By convincing the client that the IV is needed. 4. By providing appropriate information to the client

An elderly client with a history of mild dementia and incontinence tells a nurse that an unlicensed assistive personnel (UAP) touched her private body parts in an inappropriate way. Which response by the nurse is most appropriate? 1. Inform the client that the UAP will be terminated. 2. Remind the client that dementia causes confusion, so this probably did not occur. 3. Tell the client that you are sure the UAP was just performing required care. 4. Reassure the client that you will report this concern to the charge nurse and personally supervise care yourself.

At a well-baby check, the parents of a 14 month old report how the child is doing and then excitedly share that they have purchased and are moving into a "fixer-up" home that was built in the mid-1960s. Based on the parent's report, what would be the priority concern for the nurse to address with the parents? 1. Fall risk due to increased mobility 2. Increased anxiety due to change in the environment 3. Speech consisting of only 4 words 4. Potential for lead poisoning

Client's satisfaction is a key factor for quality assurance in the health care setting. Which nursing action is likely to improve satisfaction and demonstrates acts of beneficence? 1. Allowing clients to make their own decision about care. 2. Answering all questions posted by the client in an honest manner. 3. Reporting faulty equipment to the proper departments. 4. Sitting at the bedside and listening to an elderly client.

During morning report, the nurse learns that a client's call bell is not working and maintenance cannot do repairs until tomorrow. The nurse is aware that the safest temporary method for the client to signal staff is what? 1. Provide a hand-held bell for client to ring. 2. Ask family to stay with client to alert staff. 3. Tell client to call out loudly to the staff. 4. Have staff visit client's room every 15 minutes.

Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only? 1. The client with chicken pox. 2. The client with rubeola. 3. The client with impetigo. 4. The client with pancreatitis.

How should the nurse assist a post-operative client in transferring from the bed to a chair? 1. Have the client look down and watch their feet as they move. 2. Tell the client to bend at the waist to lower the center of gravity. 3. Place a walker away from the bed so the client can lean forward while standing. 4. Ensure the client's feet are as wide apart as the hips.

The LPN is caring for a four month old infant diagnosed with respiratory syncytial virus (RSV) and placed in contact isolation. What personal protection equipment (PPEs) should the LPN use when providing care to the baby? 1. Double glove when changing the infant's soiled diapers. 2. Place face mask on infant when transported for x-rays. 3. Only gloves are necessary in order to provide infant care. 4. Wear gown and mask during feeding or burping of the baby.

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

The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? 1. Keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 93%. 2. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. 3. Let the client sleep until he has rested, then discuss abuse potential of narcotics. 4. Call the primary healthcare provider and report client findings.

The nurse is making rounds on the psychiatric unit at the beginning of the shift. Which client should be seen first? 1. Client with somatoform disorder. 2. Client with depression. 3. Client with panic attacks. 4. Client with hallucinations.

The nurse is preparing the sterile field to assist the primary healthcare provider with a procedure. Which flap of the sterile pack should the nurse open first? 1. Closest to the nurse. 2. To the left of the nurse. 3. To the right of the nurse. 4. Farthest from the nurse.

The nurse is preparing to make an occupied bed. Which action by the nurse is important to preserve client's self-esteem during this procedure? 1. Remove the top sheet first and replace with a clean one. 2. Inform the client that they will be uncovered only for a short time. 3. Ask the client to relax as the top sheet is removed and the bottom sheet is changed. 4. Cover the client with a bath blanket before removing any of the sheets on the bed.

The nurse is reviewing morning laboratory results on four clients. Which lab finding should the nurse report to the primary healthcare provider immediately? 1. aPTT 2. WBC 3. Sed rate 4. K+

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children at 12 months? 1. Pertussis 2. Rotovirus 3. Tuberculosis 4. Varicella

The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O

The nurse monitors a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.

What is the most important factor the nurse can reinforce to prevent chronic obstruction pulmonary disease (COPD)? 1. Controlling asthma. 2. Receiving an influenza shot annually. 3. Taking daily multivitamins containing antioxidants. 4. Ceasing cigarette smoking.

What should the nurse calculate as the estimated due date of a pregnant client, whose last menstrual period started on August 31st? 1. July 1st 2. May 6th 3. May 31st 4. June 7th

Which finding should take priority when the nurse is collecting data about the skin of a client diagnosed with diabetes? 1. Vitiligo of the chest. 2. Scleroderma to scapula and posterior neck region. 3. Redness of face and upper chest. 4. Small abrasion on great toe.

Which medication should the nurse administer first after receiving the morning shift report? 1. Levothyroxine to the client with hypothyroidism and a thyroid stimulating hormone (TSH) level of 2.8 mU/L 2. Amlodipine to the client with hypertension and a blood pressure of 150/86 3. Regular insulin sliding scale dose to the client with diabetes and a 210 mg/dL (11.7 mmol/L)blood glucose level. 4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3 (12 (10^9L)

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? 1. Sit with the client during meals and encourage the client to eat all foods on the tray. 2. Assess the client's food preferences and provide only those foods for the client at meal time. 3. Allow the client to eat in the dining room with other clients. 4. Provide high-protein, high calorie snacks to the client between meals.

While preparing an information sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.

post-op client has received morphine for pain. A few minutes later, the nurse notes the following: B/P 110/76, Pulse 68, Respirations 8, Pain level of 5, dressing dry and intact. Which of the recorded data warrants further action? 1. Blood pressure 2. Pulse rate 3. Pain level 4. Respiratory rate

The charge nurse is making client assignments. Which assignments are appropriate for a licensed practical nurse to perform? 1. Assessment of newly admitted diabetic. 2. Prepare discharge planning for a client diagnosed with Parkinson's disease. 3. Provide care to client requiring multiple blood transfusions. 4. Care for a one day post op mastectomy client. 5. Insert an indwelling urinary catheter for the client scheduled for surgery.

4,5

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.

Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. Client's tracheostomy needs to be suctioned. Client with oxygen saturation of 90% needing a nebulizer treatment. UAP reports a heart rate of 40/min in a client. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria.

Client's tracheostomy needs to be suctioned. Client with oxygen saturation of 90% needing a nebulizer treatment. UAP reports a heart rate of 40/min in a client. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria.

Medicate client with pain medication. Wash hands and apply clean gloves. Set up sterile field and open packages. Remove the old dressing and discard. Wash hands and apply sterile gloves. Clean burn and place sterile dressing.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. Monitor the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room.

Monitor the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room.

Place the steps in order that the nurse should take to administer a subcutaneous injection. Perform hand hygiene Apply gloves and locate the injection site Cleanse site with antiseptic swab Remove the needle cap by pulling it straight off Hold syringe and pinch the skin with nondominant hand Inject the needle and administer the medication Dispose the syringe in sharps container

Perform hand hygiene Apply gloves and locate the injection site Cleanse site with antiseptic swab Remove the needle cap by pulling it straight off Hold syringe and pinch the skin with nondominant hand Inject the needle and administer the medication Dispose the syringe in sharps container

HURST

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