PNC Questions

35. A client is scheduled to receive 1 L of total parenteral nutrition (TPN) every 12 hours. The primary nursing responsibility is to monitor the client's: A. Electrolytes B. Urinary output C. Blood pressure D. Serum glucose levels

Correct Answer: D Serum glucose levels are essential because the solution is hyperosmolar, and a concentrated source of glucose can result in hyperglycemia.

13. A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client appears to be an angry, demanding person. One day the unlicensed assistive personnel (UAP) tells the nurse, "I've had it with that client's demands. I'm not going in that room again." The nurse's best response to this statement is: A. "The client is frightened. Let's think about the best approach we can take." B. "You need to try to be patient with the client who is going through a lot right now." C. "I'll talk with the client. Maybe I can figure out the best way for us to handle this." D. "Just ignore the client and get on with the rest of your work. Let someone else take a turn."

Correct Answer: A The response "The client is frightened. Let's think about the best approach we can take." interprets the client's behavior without belittling the UAP's feelings; it encourages the UAP to get involved with plans for future care.

29. The nurse is caring for a client who is receiving intermittent IV piggyback doses of vancomycin (Vancocin) every 12 hours. The primary health care provider prescribes trough levels of the antibiotic. The nurse recognizes that the blood sample should be obtained: A. just before the medication is administered. B. between 30 and 60 minutes after the infusion is completed. C. six hours after the dose is completely infused. D. in the morning before the client eats breakfast

Correct Answer: A Trough levels are measured in relation to the time a drug is administered. The trough level for a drug is drawn just before a drug is given, when the drug's level is at its lowest

24. A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? A. Procedures used to implement client care B. Sequence of steps used to meet the client's needs C. Activities employed to identify a client's problem D. Mechanisms applied to determine nursing goals for the client

Correct Answer: B The nursing process is a step-by-step method that scientifically provides for a client's nursing needs.

19. A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? A. Eating beef and veal is prohibited. B. Consumption of fish with scales is forbidden. C. Meat and milk at the same meal are forbidden. D. Consuming alcohol, coffee, and tea are prohibited.

Correct Answer: C Jewish dietary laws prohibit any combination of milk and meat at the same meal.

4. Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? A. Primary nurse B. Nurse clinician C. Nurse coordinator D. Clinical nurse specialist

Correct Answer: A The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or health care provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. A clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.

23. What actions should the nurse include when planning for the long-term care of a client with expressive aphasia? A. Begin helping the client to write. B. Encourage the client to acknowledge that this disability is permanent. C. Wait for communication to be initiated by the client even if it takes a long time. D. Assist family members to accept the fact that they cannot communicate verbally with the client.

Correct Answer: A Clients with expressive aphasia have understanding of speech, but are unable to communicate verbally. Writing can be difficult, but the client may be able to write.

7. A spouse of a client, while visiting at the hospital, slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse that witnessed the occurrence take? A. Initiate an agency incident report. B. Report the fall to the state health department. C. Write a brief description of the incident to be kept by the nurse manager. D. Determine that no documentation is needed because the visitor is not a client in the hospital.

Correct Answer: A Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited

28. A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk factor for the development of a pulmonary embolus? A. Atrial fibrillation B. Forearm laceration C. Migraine headache D. Respiratory infection

Correct Answer: A Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli.

15. When should the nurse begin discharge planning for a client who will be transferred to a nursing home after discharge? A. Immediately upon admission B. After a family member gives permission C. As soon as the transfer is approved D. When the client talks about future plans

Correct Answer: A Preparation of clients for discharge to either their own home or a nursing home should begin the day of admission.

34. A nurse is planning care for a depressed client. Which approach is most therapeutic? A. Allowing the client time to complete activities B. Helping the client focus on the family support system C. Encouraging the client to perform repetitious menial tasks D. Telling the client repeatedly that the staff views the client as worthwhile

Correct Answer: A Routines should be kept simple, and no demands should be made that the client cannot meet. The client is depressed, and all reactions will be slow. Putting pressure on the client will increase anxiety and feelings of worthlessness.

21. A nurse reviews the postoperative plan of care for a client who is scheduled for a ligation of hemorrhoids with latex bands. To decrease local discomfort after the procedure, the nurse expects a prescription for: A. Sitz baths. B. Water-soluble jelly. C. Inflatable doughnut. D. Medicated suppository

Correct Answer: A Sitz baths may be cool or warm. Warm baths dilate blood vessels and promote circulation, relieving local inflammation and itching. Cool sitz baths constrict blood vessels, limiting bleeding and edema.

12. Which client care activity may a nurse safely delegate to a nursing assistant? A. Assessing a client's mastectomy incision for signs of inflammation B. Assisting a client who is recovering from an abdominal hysterectomy to the bathroom C. Providing information about side effects to a client receiving chemotherapy for breast cancer D. Evaluating the effectiveness of an antiemetic that was administered to a client to relieve nausea

Correct Answer: B A nursing assistant is taught how to safely ambulate clients; this activity does not require extensive nursing knowledge or expert clinical judgment. Assessment, teaching, and evaluation of client responses to care all require clinical judgment and a license to practice nursing.

26. When planning continuing care for a moderately depressed client, the nurse should: A. Encourage the client to determine leisure time activities. B. Offer the client the opportunity to make some decisions. C. Relieve the client of the responsibility of making any decisions. D. Allow the client time to be alone to decide in which activities to engage.

Correct Answer: B Allowing the client to make decisions that can be handled helps improve confidence. The client is depressed, and this can result in total inactivity.

11. The postpartum nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task should the nurse delegate to UAP? A. Evaluation of a postpartum client's lochia B. Vital signs on a client 4 hours after delivery C. Assessment of a postpartum client's episiotomy D. Assisting the postpartum client to breastfeed for the first time

Correct Answer: B Evaluating the client's lochia, assess the client's episiotomy, and helping the client breastfeed for the first time would involve assessment, teaching, or evaluation and should not be delegated. The only task that does not require any of these is taking vital signs 4 hours after delivery.

6. The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. What action should the nurse take? A. Monitor vital signs more frequently B. Notify the primary health care provider immediately C. Apply a warm moist compress to the incision site D. Increase the intravenous fluid rate by 20 mL/hr

Correct Answer: B The health care provider must be notified immediately so that anticoagulation therapy can be instituted. Although monitoring vital signs is appropriate, it is an insufficient intervention; the health care provider must be notified so that anticoagulants can be prescribed. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, warm, moist compresses may be applied with a health care provider's prescription.

1. A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. The best initial response by the nurse is: A. "Why did you sign the consent?" B. "Can you tell me why you decided to refuse the procedure?" C. "You are obviously afraid about something concerning the procedure." D. "Although the procedure is very important, I understand why you changed your mind."

Correct Answer: B The response "Can you tell me why you decided to refuse the procedure?" attempts to explore why the client is refusing the procedure; it promotes communication.

31. Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment? A. Apical pulse rate B. Electrolyte levels C. Signs of bleeding D. Tissue compatibility

Correct Answer: C Assessment for bleeding is a priority when administering a thrombolytic agent because it may lead to hemorrhage. The heart rate is not affected. Electrolyte levels are not affected. Tissue compatibility is not necessary.

33. A client has a bone marrow aspiration performed. After the procedure, what is the first nursing action? A. Position the client on the affected side. B. Cleanse the site with an antiseptic solution. C. Briefly apply pressure over the aspiration site. D. Begin frequent monitoring of the client's vital signs

Correct Answer: C Brief pressure generally is enough to prevent bleeding. No special positioning is required

25. A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? A. Insert a urinary catheter. B. Initiate droplet precautions. C. Move the client to a private room. D. Use a high efficiency particulate air (HEPA) respirator during care.

Correct Answer: C Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room.

16. What factors are most important for the nurse to consider when delegating responsibilities? A. Preferences of the clients and staff B. Physical layout of the unit and client rooms C. Staff member's level of education and expertise D. Client's diagnosis and length of time in the hospital

Correct Answer: C Delegation should provide for client safety based on staff capabilities as determined by level of education and experience.

10. Which nursing behavior is an intentional tort? A. Miscounting gauze pads during a client's surgery B. Causing a burn when applying a wet dressing to a client's extremity C. Divulging private information about a client's health status to the media D. Failing to monitor a client's blood pressure before administering an antihypertensive

Correct Answer: C Divulging private information is an invasion of privacy, which is an intentional tort. Miscounting gauze pads during a client's surgery, causing a burn when applying a wet dressing to a client's extremity, and failing to monitor a client's blood pressure before administering an antihypertensive are examples of professional negligence (malpractice).

5. A nurse from the pediatric clinic who is strongly opposed to any chemical or mechanical method of birth control is asked to work in the family planning clinic. What is the most professional response that this nurse could give to the requesting supervisor? A. "I will go, but it is against my beliefs and values." B. "I won't do it, because I do not believe in birth control at all." C. "I would prefer another assignment that is not contrary to my beliefs." D. "I will have to stress that the rhythm method is the method of choice."

Correct Answer: C Expressing a preference for another assignment that is not contrary to the nurse's beliefs is a positive negotiation to be reassigned to an area where the nurse's personal values will not pose a problem. Fulfilling the request even though it is against the nurse's beliefs is an ineffective way to resolve value conflict; undoubtedly a client would sense this conflict.

22. A client with cirrhosis of the liver and ascites fails to respond to chlorothiazide (Diuril), a thiazide diuretic. Spironolactone (Aldactone) is prescribed in addition to the chlorothiazide. What should the nurse explain to the client about why spironolactone was added to the medication regimen? A. Promotes water excretion B. Stimulates sodium excretion C. Helps prevent potassium loss D. Reduces arterial blood pressure

Correct Answer: C Spironolactone is a potassium-sparing diuretic often used in conjunction with thiazide diuretics.

8. As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? A. Moving the client's bedside table closer to the bed B. Encouraging the client to take an available sedative C. Instructing the client to call the nurse before going to the bathroom D. Assisting the client to telephone home to say goodnight to the spouse

Correct Answer: C Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to the bathroom unassisted.

9. A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? A. The oxygen had not been prescribed and therefore should not have been administered. B. The symptoms were too vague for the nurse to determine a need for administering oxygen. C. The nurse's observations were sufficient, and therefore oxygen should have been administered. D. The health care provider should have been called for a prescription before the nurse administered the oxygen.

Correct Answer: C The Nurse Practice Act states that nurses diagnose and treat human responses to actual or potential health problems. Administration of oxygen in an emergency situation is within the scope of nursing practice. Because the client's clinical manifestations reflected an immediate need for oxygen, postponement of treatment could have resulted in further deterioration of the client's condition.

3. A nurse understands that when a client is a member of a different ethnic community it is important to: A. Ensure that the nurse's biases are understood by the family. B. Make plans to counteract the client's misconceptions about therapies. C. Offer a therapeutic regimen compatible with the lifestyle of the family . D. Recognize that the client's responses will be similar to other clients' responses

Correct Answer: C The client cannot be expected to accept or even respond to a plan that is incompatible with the family's lifestyle.

18. A registered nurse (RN) in charge of a mental health unit has two additional staff members: a licensed practical nurse (LPN) and a nursing assistant (NA). The unit has 20 clients, with one client on constant observation for acute suicidality. What should the nurse in charge do when making the daily assignments? A. Administer medications and assign the LPN to maintain observation of the suicidal client and the nursing assistant to provide client care. B. Maintain constant observation of the suicidal client and assign the LPN to administer medications and the nursing assistant to provide client care. C. Perform client care and administrative duties and assign the nursing assistant to administer medications and the LPN to maintain observation of the suicidal client. D. Provide client care and administrative duties and assign the LPN to administer medications and the nursing assistant to maintain constant observation of the suicidal client.

Correct Answer: D Assigning the LPN to administer medications utilizes the LPN's skills; providing constant observation of a client is within the role of NAs and frees the RN to perform client care and administrative duties.

27. Which client intervention should the nurse perform to prevent the development of lower extremity contractures in a paralyzed patient? A. Deep massage B. Active exercise C. Use of a tilt board D. Proper positioning

Correct Answer: D Correct positioning maintains functional alignment, which helps prevent contracture formation. The tilt board is used primarily to prevent orthostatic hypotension or bone demineralization.

32. A nurse is delegating tasks to the school health office aide. What task should be left for the nurse to perform? A. Recording data on health forms B. Obtaining the weights of students C. Measuring the heights of students D. Interpreting body mass index readings

Correct Answer: D It is the nurse's responsibility to interpret data and to inform the parents if a reading is outside the expected range.

30. Which statement by a female client with a non-weight-bearing long leg cast indicates the need for the nurse to reinforce discharge teaching? A. "The cast can be wrapped in plastic when I take a shower." B. "I called my office to let them know I will be back at work next week." C. "The physical therapist is going to teach me how to walk with crutches." D. "I am going to give myself a pedicure with red nail polish when I get home."

Correct Answer: D Red nail polish will interfere with the ability to assess the toes for capillary refill; effective capillary refill, after releasing compression of the toenail, ensures that the cast is not compromising circulation to the distal part of the extremity.

2. A physician is admitted to the psychiatric unit of a community hospital. The client, who was restless, loud, aggressive, and resistive during the admission procedure, announces, "I'll take my own blood pressure." What is the most therapeutic response by the nurse? A. "Right now you're just another client." B. "If you would rather, I'm sure you will do it correctly." C. "I'll get the attendants to assist me if you won't cooperate." D. "I'm sorry, but I can't allow that, because I have to take your blood pressure."

Correct Answer: D Telling the client that the nurse cannot allow him to take his own blood pressure simply states facts without getting involved in role conflict.

17. An older, confused client is being cared for at home by an adult child who works full-time. The client has lost weight and is wearing soiled and inappropriate clothing. The home care nurse suspects elder neglect. What should the nurse do? A. Discuss the situation with the adult child. B. Ask the client whether the adult child is neglectful. C. Avoid reporting the situation to prevent alienation of the adult child. D. Report the suspicion of neglect by the adult child to adult protective services

Correct Answer: D The nurse has a legal responsibility to report suspicions of neglect to adult protective services; failure to do so can result in the bringing of charges against the nurse.

14. On a home visit to an older adult with chronic heart failure, the nurse notes that a 6-month-old grandchild lies quietly in a crib, rarely smiles or babbles, and barely has basic needs attended. The client is the primary caregiver for the infant. The nurse should: A. Advise the purchase of appropriate toys designed for this age level. B. Inform the client that the child will be cognitively impaired if he is not stimulated. C. Explain the need for the family to hire a mother's helper for the home. D. Initiate a referral to an appropriate agency to assess the need for a home health aide and schedule a family conference.

Correct Answer: D Initiating a referral to an appropriate agency to assess the need for a home health aide and scheduling a family meeting will ensure that a thorough assessment of the family's needs is made and the appropriate assistance initiated.

20. The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply. A. Performing a bed bath for a client on bed rest B. Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) C. Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered D. Assisting a client who has patient-controlled analgesia (PCA) to the bathroom E. Assessing the wound integrity of a client recovering from an abdominal laparotomy

Correct Answers: A and D Performing a bed bath for a client on bed rest is within the scope of practice of the UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of the UAP.