Lifespan Test #1 Evolve
A postoperative client reports, "I have pain from a mild headache." Which PRN medication does the nurse administer?
Acetaminophen (Tylenol)
A client with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this client?
Adding duloxetine (Cymbalta) as adjuvant therapy
A client with cancer is receiving low-dose oral morphine but is reporting both "breakthrough" pain and constipation. What intervention does the nurse implement first?
Administers ordered docusate sodium (Colace) and gabapentin (Neurontin)
Which is the best referral that the nurse can suggest to a client who has been newly diagnosed with diabetes?
American Diabetes Association
The nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and re-positioning clients in a long-term care setting. Which client requires extreme caution and is at greatest risk for a skin tear?
An 85-year-old client with breathing problems receiving daily doses of prednisone
A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first?
Anticipate an order to discontinue the intraosseous IV and start an epidural IV.
The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? (Select all that apply.)
Apply povidone-iodine to clean skin, dry for 2 minutes. Clean the skin around the site. Prepare the skin with 70% alcohol or chlorhexidine.
The home health aide reports that a 70-year-old client is nonadherent in taking prescribed medications. What does the nurse do to solve this problem?
Asks what the barriers are to taking the medications
The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially?
Assess the insertion site
Which nursing action can the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes?
Assist the client with washing the feet and applying moisturizing lotion
The RN has delegated nursing actions to experienced unlicensed assistive personnel (UAP) working in a long-term care facility. Which actions require direct supervision by the RN? (Select all that apply.)
Assisting a 70-year-old client who has new-onset leg pain when ambulating. Re-positioning a 69-year-old client who has recently become unconscious.
The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants. Which of these nursing actions does the RN delegate to a nursing assistant?
Assisting a client with chronic joint stiffness to ambulate
The nurse is talking to a group of parents about different types of play in which children engage. Which statement made by a parent would indicate a correct understanding of the teaching?
"Cooperative play is organized, and children play in a group with other children."
The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further?
"For protein in my diet, I like to get the fish sandwich at the fast-food drive-through at least three times a week."
The nurse is providing discharge teaching to a client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching?
"I can break in my shoes by wearing them all day."
The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education?
"I can continue my 20-mile running schedule as I have for the past 10 years."
The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective?
"I must inspect my shoes for foreign objects before putting them on."
The nurse is teaching a client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching?
"I should begin exercising for at least an hour a day."
The nurse is teaching a client about the manifestations and emergency treatment of hypoglycemia. In assessing the client's knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates a correct understanding of hypoglycemia management?
"I should eat three graham crackers."
The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data?
"I usually drink two vodkas to help me get to sleep each night."
The nurse is providing discharge teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet?
"If I become hypoglycemic, I could become unconscious."
A postoperative client is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the client before administering the medication?
"Is your pain controlled between doses?"
The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond?
"Let's ask your father about your request."
A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response?
"Let's tackle it piece by piece. What is most scary to you?"
The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure?
"My hand tingles when you poke me."
A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What does the nurse say to the visitor?
"Please allow the client to push the button when needed."
The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety?
"Stop driving when your vision, motor skills, and confidence begin to diminish."
A 70-year-old client whose spouse died the previous year says to the nurse, "Life is not fun anymore." How does the nurse respond?
"Tell me about your support network, such as friends or family."
A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." How does the nurse respond?
"That sounds like a great plan; can you tell me more about it?"
A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond?
"They minimize health care workers' exposure to contaminated needles."
A diabetic client has a glycosylated hemoglobin (HbA1C) level of 9.4%. What does the nurse say to the client regarding this finding?
"What are you doing differently?"
When assessing a client for pain, acute or chronic, what question does the nurse ask the client to obtain the most data?
"When does it hurt?"
A client with osteoarthritis pain tells the nurse, "I take two arthritis-strength Tylenol (650 mg) every 8 hours." How does the nurse respond?
"You will need to have routine liver and kidney function laboratory tests."
A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action does the nurse plan to take next?
"Your body is under more stress, so you'll need insulin to support your medication."
A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client should be monitored for hypoglycemia at which time?
11:00 am
A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution?
18
The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone (Percocet) orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing?
4:30 pm
Which of these clients with diabetes does the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit?
70-year-old who needs blood glucose monitoring and insulin before each meal
Which client does the RN arriving for duty assess first?
A 56-year-old with acute pancreatitis who reports increasing abdominal pain
The RN is arriving for night duty at an acute care hospital. Which client does the RN assess first?
A 72-year-old who was admitted to the unit with postoperative delirium
Which best describes Piaget's cognitive stage of formal operations?
Deductive and abstract reasoning
The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son's comments and assessing the client, which cognitive problem does the nurse suspect the client may have?
Dementia
A client reports increasing pain during dressing changes. Which interventions are recommended for the client? (Select all that apply.)
Distraction. Music therapy Premedication
A client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess in the client before providing instruction about the disease and its management?
Educational and literacy level
The nurse is establishing a plan of care for a hospitalized client with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant?
Engagement in conversation about the client's family to distract the client
The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?
Ensures that another qualified health care professional checks the unit before administering
In the role of client advocate, what does the nurse do first for a client who reports pain?
Believes the client's report of pain
A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line?
Capillary refill and pulse
A client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family?
Causes and treatment of hypoglycemia
The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often?
Cephalic vein of the forearm
A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take?
Change the set in about 4 hours
The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety?
Check for blood return
A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action does the nurse take first?
Check the blood glucose
The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first?
Client taking glyburide (Diabeta) who is dizzy and sweaty
The nurse has just received change-of-shift report on the endocrine unit. Which client does the nurse see first?
Client with type 1 diabetes whose insulin pump is beeping "occlusion"
The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? (Select all that apply.)
Client's response to the insertion. Date and time inserted. Type and size of device. Type of dressing applied. Vein used for insertion.
Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN?
Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care
The nurse checking an IV fluid order questions its accuracy. What does the nurse do first?
Contacts the health care provider who ordered it
An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure ulcers, and limb contractures. What does the nurse do first?
Contacts the hospital social worker
The nurse is completing a hospital admission assessment on an 86-year-old client with renal impairment. The client's daughter gives the nurse a long list of drugs that the client is taking at home, both prescription and over-the-counter. What does the nurse do next?
Copies the list to the assessment data form
The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone (Dilaudid) IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What action does the nurse take initially?
Gives the client a dose of naloxone (Narcan) 0.4 mg IV
A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical manifestations of pain. What does the nurse do next?
Gives the pain medication as requested
A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch in length and streak formation. How does the nurse classify this client's phlebitis?
Grade 3
A 72-year-old client admitted to the hospital for congestive heart failure has a history of a fractured hip due to a previous fall. The client is taking oxycodone-acetaminophen (Tylox) as needed for pain secondary to a recent dental procedure. Which risk factor puts this client at greatest risk for a fall?
History of a fall
A hospitalized client anticipates a daily painful dressing change. Which complementary and alternative medicine therapy might the nurse offer before the procedure?
Imagery
A hospitalized client expresses satisfaction after using a recommended complementary and alternative medicine (CAM) therapy, saying that pain was diminished and anxiety reduced. Which CAM did the client most likely use?
Imagery
At a follow-up visit after repair of a fractured radial bone, an older adult client states, "I am not sleeping at all during the night." The client's partner reports that the client is sleeping all day. Which intervention does the nurse suggest?
Increasing the client's daytime activities
A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution?
Infusion pump
A postoperative client is vomiting and states, "I am having a lot of pain—about a 7 on a scale of 0 to 10." Which route of administration does the nurse choose to administer an analgesic to the client?
Intravenous
The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions will be most helpful for them? (Select all that apply.)
Joining a peer group with a common learning goal. Learning a new skill. Starting a new physical activity.
A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client?
Midline catheter
A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client?
Midline catheter
The nurse is preparing a client for home care pain management following discharge. Which intervention does the nurse implement?
Offer flexibility in home management of the client's current regimen.
What is the fastest-growing subgroup of older adults?
Old old
Which statement is true about assessing pain in an older adult client?
Older adults are at great risk for undertreated pain
Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN?
Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours
The nurse caring for four diabetic clients has all of these activities to perform. Which is appropriate to delegate to unlicensed assistive personnel (UAP)?
Perform hourly bedside blood glucose checks for a client with hyperglycemia
A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have?
Physical dependence
The nurse manager for an oncology unit is evaluating a newly hired staff nurse. Which action by the nurse is of greatest concern to the nurse manager?
Preparing to administer a placebo to a client with chronic back pain
Which action is correct when drawing up a single dose of insulin?
Pull back plunger to draw air into the syringe equal to the insulin dose.
During change-of-shift report, the day shift staff learns that a client who had back surgery has been reporting increasing lower back pain during the night. It is most appropriate for which day staff member to assess the client's pain?
RN team leader who is responsible for updating the care plan for the client
A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task?
RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day
An 80-year-old client is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome?
Re-orienting the client frequently to his or her new location
A postoperative client is receiving epidural analgesia and reports itching. What does the nurse do next?
Reduces the analgesic dose
A client with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client?
Releasing the restraints at least every 2 hours
An older adult client who is admitted to the medical-surgical unit with a diagnosis of heart failure states to the nurse, "I am of no use to anyone. I just want to die." What does the nurse do to ensure this client's safety?
Report the client's statement to the health care provider
Which statement is true about the special needs of older adults receiving IV therapy?
Skin integrity can be compromised easily by the application of tape or dressings
A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first?
Slow the rate of the IV infusion.
When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first?
Stop flushing and try to aspirate blood from the line
The RN manager of a skilled nursing facility wants to assign a staff member to assess the nutritional needs of an emaciated client with pressure ulcers. Which of these team members is appropriate?
The RN team leader responsible for care planning
A newly admitted client who was in an automobile accident has a concussion and is reporting pain from a fractured femur and broken fingers. Which staff member does the charge nurse on the orthopedic unit assign to care for this client?
The neurology unit RN who has floated to the orthopedic unit
The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention?
The vein feels hard and cordlike above the insertion site.
The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.)
Thorough hand hygiene (i.e., no quick scrub) before insertion. Using chlorhexidine for skin disinfection. Immediately removing the client's venous access device (VAD) when it is no longer needed.
Which explanation best assists a client in differentiating type 1 diabetes from type 2 diabetes?
Those with type 2 diabetes make insulin, but in inadequate amounts.
The nurse manager on the surgical unit is making assignments for the day. Who is assigned to check and program the patient-controlled analgesia (PCA) pumps on the unit?
Two registered nurses (RNs)
Which result is frequently seen in older adults who have undiagnosed depression?
Under-nutrition
A client had a hip replacement 2 days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 0-to-10 scale" of intensity. What intervention has the highest priority in the client's nursing care plan?
Using pre-emptive analgesia
A client recently admitted with new-onset type 2 diabetes will be discharged with a self-monitoring blood glucose machine. When is the best time for the nurse to explain to the client the proper use of the machine?
While performing the test in the hospital
Which older adult client's living situation typically presents highest risk for abuse?
With adult daughter and grandchildren
Parents are often confused by the terms growth and development and use the terms interchangeably. Based on the nurse's knowledge of growth and development, the most appropriate explanation of development is:
a child learns to throw a ball overhand
