A client with pulmonary tuberculosis (TB) asks the nurse how this disease was contracted. The nurse replies that TB is commonly spread by which of the following methods?
1. Sneezing
2. Shaking hands
3. Contact with stool
4. Contact with urine
1. Sneezing
Rationale: TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue. Therefore it is not spread by sha
A nurse is collecting data about the lethality risk of a suicidal client. Which of the following is the best question for the nurse to ask the client?
1. "Do you have a death wish?"
2. "Do you wish your life was over?"
3. "Do you ever think about ending i
4. "Have you ever thought of killing yourself?"
Rationale: A lethality assessment requires direct communication between the client and nurse. It is important to provide a question that is directly related to lethality. Options 1, 2 and 3 do not directly a
A physical assessment of the suicidal client is performed on admission to the inpatient unit. The nurse reviews the findings and recognizes that this is an important part of the admission process because it alerts the nurse to:
1. Baseline data
2. Abnorma
4. Evidence of physical self-harm
Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the formulation of a plan for the suicide attempt. Although all of the options are correct, optio
A nurse is collecting information from a client about the client's suicide risk. The nurse should ask the client which most significant question?
1. "Why do you want to hurt yourself?"
2. "Do you have a plan to commit suicide?"
3. " Has anyone in your fam
2. "Do you have a plan to commit suicide?"
Rationale: When collecting information about suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Options 1, 3 and 4 do not
A client is admitted to a long-term care facility with a diagnosis of Parkinson's disease. The nurse gives information about the client's condition to a visitor assumed to be a family member. The nurse has violated which legal concept of the nurse-client
2. Invasion of privacy
Rationale: Discussing a client's condition without the client's permission violates the client's right and places the nurse in legal jeopardy. This is an invasion of privacy and affects client's confidentiality. Incompetence could l
A client has an order for valproic acid (Depakene) 250 mg once daily. To maximize the client's safety, the nurse plans to schedule the medication:
1. With lunch.
2. At bedtime.
3. After breakfast.
4. Before breakfast.
2. At bedtime
Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. Its side effects include sedation, dizziness, ataxia and confusion. When the client is taking this medication as a single dose, administering
A client with a synthetic cast on the right leg tells the nurse that he wants to take a shower. Based on the review of the data related to the injury and type of cast, which of the following is the best response to ensure a safe environment?
1. "The cast
4. "It is not safe for you to shower at this time."
Rationale: It may be unsafe for a client to shower with a cast the leg because the client could slip and fall. Water does not damage the synthetic cast; however, the client should know that it may take a
A client is prepared to receive elective cardioversion to treat atrial fibrillation. Which of the following is an unsafe preprocedure observation?
1. The client's digoxin has been withheld for the last 48 hours.
2. The synchronizer on the defibrillator is
4. The client is wearing a nasal cannula delivering oxygen at 2 liters per minute.
Rationale: Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after counte
A nurse administers a fatal dose of digoxin (Lanoxin) to a client. During the subsequent investigation of error, it is determined that the nurse did not note the client's heart rate of 45 beats per minute before administering the medication. Failure to ad
3. Identifying the process for disciplinary action if standards of care are not met
Rationale: In this event, acceptable standards of care were not met (the nurse failed to adequately assess the client before administering a medication). Option 3 refers s
A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client?
1. The nursing assistant is speaking i
4. The nursing assistant is speaking directly into the impaired ear.
Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client whi
Which statement made by a nursing student indicates an understanding of the concepts associated with suicide and suicide intentions?
1. "Only psychotic individuals commit suicide."
2. "Suicide attempts are just attention-seeking behaviors."
3. "Suicide ru
4. "Many individuals who really do kill themselves have talked about their intentions to others."
Rationale: Most people who commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psy
A rehabilitation center nurse is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant?
1. A client who had a below-the-knee amputation
2. A client on a 24-hour urine collection who is
2. A client on a 24-hour urine collection who is on strict bed rest.
Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency.
A nurse has administered a dose of diazepam (Valium) to the client. The nurse should take which most important action before leaving the client's room?
1. Draw the shades closed
2. Give the client a bedpan
3. Put up the side rails on the bed
4. Turn the v
3. Put up the side rails on the bed
Rationale: Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not inju
A client with acquired immunodeficiency syndrome (AIDS) who has cytomegalovirus retinitis is receiving ganciclovir sodium (Cytovene). The nurse should plan to do which of the following while the client is taking this medication?
1. Monitor blood glucose l
4. Provide the client with a soft toothbrush and an electric razor
Rationale: Ganciclovir sodium causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client fro signs and symptoms of bleeding a
A client is scheduled to have insertion of an inferior vena cava (IVC) filter. The nurse should place highest priority on determining whether the surgeon wants which of the following medications held in the preoperative period?
1. Furosemide (Lasix)
2. Fa
4. Warfarin (Coumadin)
Rationale: The nurse is careful to question the surgeon about whether warfarin sodium should be administered in the preoperative period before insertion of an IVC filter. This medication is often withheld during the preoperative per
A client has cognitive-perceptual difficulties and problems with fine motor coordination. The nurse working with this client should read the progress notes from which of the following health team members to obtain suggestions for working with him or her?
4. Occupational therapist
Rationale: The occupational therapist focuses on the development or relearning of fine motor skills. Social workers, speech pathologists and recreational therapists do not address these types of client problems.
A postpartum client has been diagnosed with endometritis. The nurse who is reinforcing teaching about how to prevent the spread of infection to the newborn should tell the mother to:
1. Keep the newborn in the Isolette
2. Ask visitors not to hold the newb
4. Wash hands carefully before picking up the newborn
Rationale: Infectious diseases can be transmitted through contaminated items such as hands and bed liners in clients with endometritis. Hand washing is one of the most effective methods to prevent tran
A 2 month-old is admitted to the hospital. The nurse should take which of the following actions to maintain the infant's safety and to reduce the risk of sudden infant death syndrome (SIDS)?
1. Make sure that only plastic bottles and toys are used
2. Plac
2. Place the infant in a supine position in preparation for sleep
Rationale: The American Academy of Pediatrics recommends the supine position for sleep to reduce the risk of SIDS. Plastic bottles and toys are not needed yet because a 2 month-old cannot h
Sertraline (Zoloft) is prescribed to treat depression. The nurse reviews the client's record and consults the physician if which of the following is noted?
1. A history of diabetes mellitus
2. Use of phenelzine sulfate (Nardil)
3. A history of myocardial
2. Use of phenelzine sulfate (Nardil)
Rationale: Sertraline (Zoloft) is a serotonin reuptake inhibitor and antidepressant medication. Potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI
A nurse must give an injection to a client with acquired immunodeficiency syndrome (AIDS). The nurse does which of the following after giving the injection?
1. Breaks the needle and discards it
2. Recaps the needle and discards the syringe in the disposal
4. Places the uncapped needle and syringe in a labeled, rigid plastic container
Rationale: Standard precautions include specific guidelines for handling sharps and needles. Needles should not be recapped, bent, broken or cut after use; they should be disp
A licensed practical nurse (LPN) is assisting a registered nurse (RN) to develop a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following does the LPN suggest be included in the c
2. Place a radiation sign on the door of the client's room
Rationale: The client's room should be marked with appropriate signs stating the presence of radiation. Visitors are limited to 30 minutes. The client should be placed in a private room at the end
A nurse assigned to care for a 4-week-old infant who is scheduled for a pyloromyotomy. The nurse plans to do which of the following when caring for the infant?
1. Restrain the infant in a high chair
2. Feed the infant in a lying-down position
3. Feed the
4. Position the infant prone with the head of the bed elevated
Rationale: Before surgery the infant's status is nothing by mouth (NPO), and the infant is stabilized with intravenous fluids and electrolytes. The head of the bed is elevated, and the infant
A nurse employed in a long-term care facility has planned a get-together for clients and their families to celebrate the birthday of a client who is 100 years old. During the party, the nurse takes pictures of some of the clients and plans to develop the
3. Invasion of privacy
Rationale: Invasion of privacy takes place when an individual's private affairs are unreasonably invaded. Taking photographs of a client is an example of such a violation. Telling the client that he or she cannot leave the hospital
A nurse overhears a client ask the physician if the client the results of a biopsy indicated cancer. The physician tells the client that the results have not returned, when in fact the physician is aware that the results of the biopsy indicated the presen
3. Slander
Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a h
A nurse employed in a long-term care facility is preparing to administer medications to an assigned client and notes that order for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the physician to clarify the order and asks the p
2. Contact the nursing supervisor
Rationale: If the physician writes an order that requires clarification, it is the nurse's responsibility to contact the physician for clarification. If there is no resolution regarding the order because the order remains
The nurse is administering medications to a client and administers a dose of methyldopa (Aldomet) 250 mg orally instead of the prescribed 125 mg dose. The nurse discovers the error when documenting that the medication has been administered. Which of the f
3. Make a copy of the incident report for the physician
Rationale: An incident report needs to be completed whenever an unusual occurs. The incident report is confidential and privileged information and should not be copied, placed in the chart, or have a
A new nurse graduate asks another licensed practical nurse (LPN) about the need to obtain professional liability insurance. The appropriate response by the LPN is:
1. "The hospital insurance covers your actions."
2. "Nurses should have their own malpracti
2. "Nurses should have their own malpractice insurance."
Rationale: Nurses need their own liability insurance for protection against malpractice lawsuits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Us
A licensed practical nurse witnesses an accident in which a victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to the victim, who sustained a compound fracture of the femur. The victim is hospitalized and later
3. The Good Samaritan Law will protect the nurse if the care given at the scene is not negligent
Rationale: A Good Samaritan law is passed by the state legislature to encourage nurses and other health care providers to provide care to a person when an acc
A nurse working in a long-term care facility responds after hearing someone calling, "Help, the bed is on fire!" On entering the room, the nurse finds an older client slapping at the flames on the bedspread with a pillow. Both hands have been burned. Whic
3. Remove the client from the room
Rationale: In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim. The next steps are: activate the alarm, contain the fire, and then extinguish as needed. This is a univers
An adult client is brought to the emergency room by an ambulance after being hit by a car. The client is unconscious and in shock. A perforated spleen is suspected, and emergency surgery is required immediately to save the client's life. No family members
2. Transport the client to the operating room immediately
Rationale: Generally there are only two instances in which the informed consent of an adult is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obt
A nurse is asked to check the corneal reflex on an unconscious client. The nurse should use which of the following as the safest stimulus to touch the client's cornea?
1. Sterile glove
2. Wisp of cotton
3. Sterile drop of saline
4. Tip of a 1 mL syringe
3. Sterile drop of saline
Rationale: The client who is unconscious is at risk of corneal abrasion. The safest way to test the corneal reflex is by using a drop of sterile saline. Options 1, 2 and 4 can cause injury to the cornea.
A client tells the nurse that she has seen many articles in the health care section of the newspaper about case management and asks the nurse what this means. To provide the client with accurate information, the nurse tells the client which of the followi
1. "It represents an interdisciplinary health care delivery system."
Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenu
A client is scheduled for a bone marrow aspiration. The nurse plans to bring which of the following skin cleansing agents to the bedside before this procedure for skin cleansing to prevent infection as a result of the procedure?
1. Alcohol swabs
2. Soap a
3. Povidone-iodine
Rationale: Before bone marrow aspiration, the needle insertion site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin and decreases the risk of infection from the proce
A nurse arrives to work on the day shift and is assigned to care for a client with terminal cancer. The nurse notes that the client has been receiving a narcotic analgesic every 3 hours for pain. When entering the client's room, the client states, "I am s
2. Report the information to a supervisor
Rationale: The Nurse Practice Act requires reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. The su
A nurse is assisting in providing emergency treatment for a client in ventricular tachycardia. The licensed practical nurse understands that which action by the registered nurse provides for the safest environment during a defibrillation attempt?
1. Place
2. Performs a visual and verbal check of "all clear"
Rationale: Safety during defibrillation is essential for preventing injury to the client and to the personnel assisting with the procedure. The person performing the defibrillation ensures that all pers
A physician prescribes 1000 mL of normal saline to be infused over 12 hours. The drop factor is 15 drops per milliliter. To administer the infusion safely, the nurse adjusts the flow rate at how many drops?
1. 15 drops
2. 18 drops
3. 21 drops
4. 28 drops
3. 21 drops
Rationale: Use the formula for calculating intravenous (IV) drop rates. Formula:
Total volume in mL X drop factor/Time in minutes = Flow rate in drops per minute
1000 mL X 15 drops/720 minutes = 15000/720 = 20.8 or drops 21 drops per minute
An adolescent asks a nurse about the procedure to become an organ donor. The nurse most accurately tells the adolescent that:
1. Written consent is never required to become a donor
2. A donor must be 18 years or older to provide consent
3. An individual w
2. A donor must be 18 years or older to provide consent
Rationale: Any person 18 years of age or older may become an organ donor by indicating his or her consent in writing. In the absence of appropriate documentation, a family member or legal guardian ma
A nurse employed at a medical unit of a local hospital arrives at work and is told to report (float) to the pediatric unit for the day because there were several pediatric admissions during the night and the pediatric unit needs assistance in caring for t
4. Report to the pediatric unit and identify tasks that can be safely performed
Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract gu
A 22 year-old client who was struck by a car while jogging, is brought to the emergency room by the ambulance team. Emergency measures are instituted but are unsuccessful. The client's fiancee is with the client and tells the nurse that the client is an o
4. Elevate the head of the bed, close the deceased client's eyes, and place a small ice pack on the eyes
Rationale: When corneal donation is anticipated, the head of the bed is elevated, the deceased client's eyes are closed, and a small ice pack is place
A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks if the will needs to be updated. The most appropriate nursing res
4. "A living will should be reviewed yearly with your physician."
Rationale: The client should discuss the living will with the physician, and it should be reviewed annually to ensure that it contains the client's current wishes and desires. Options 1 and
A licensed practical nurse (LPN) is preparing to suction a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The LPN should gather which of the following supplies to perform this procedure safely?
1. Gloves, gown and mask
2. Gown, mask
3. Gloves, mask, and protective eyewear
Rationale: Standard precautions include the use of gloves whenever there is actual or potential contact with blood or body fluids. During suctioning the nurse wears gloves, a mask, and protective eyewear or a face s
A licensed practical nurse (LPN) employed in a long-term care facility is observing a nursing assistant ambulating a client with right-sided weakness. The LPN determines that the nursing assistant is performing the procedure safely if the LPN observes the
4. Standing on the right side of the client
Rationale: When working with a client, the nurse should stand on the client's affected side. The nurse should position the free hand on the client's shoulder so that the client can be pulled toward the nurse in
A nurse is caring for a client who is receiving a dose of an intramuscular antibiotic. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want to receiv
2. Battery
Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable the victim must be aware of the threat of harmful or offensive contact. Battery is the actual c
A licensed practical nurse (LPN) is reinforcing teaching done by a registered nurse (RN) to parents of a child with celiac disease. The LPN reminds the parents to do which of the following to ensure that the diet is safe based on the child's physical need
4. Read food labels carefully to avoid hidden sources of gluten
Rationale: Gluten is added to many foods such as hydrolyzed vegetable protein derived from cereal grains. Grains are also frequently added to processed foods as thickening or fillers. Because
A nurse notes that a child who has been diagnosed with intussusception has a formed brown bowel movement. The nurse should do which of the following at once to ensure that a safe plan of care is implemented for the child?
1. Prepare the child for hydrosta
4. Report the passage of the normal stool to the registered nurse (RN)
Rationale: Passage of a formed brown bowel movement usually indicates that an intussusception has reduced itself. The nurse immediately reports this data to the RN, who will in turn re
A psychotic client is belligerent and agitated, making aggressive gestures and pacing in the hallway. To ensure a safe environment, which of the following is the nurse's highest priority?
1. Assist other staff in restraining the client
2. Provide safety f
2. Provide safety for the client and other clients on the unit
Rationale: A psychotic client who is out of control may require seclusion to ensure the safety of the client and other clients in the unit. The correct option is the only one that addresses th
A client with Bell's palsy is scheduled for a magnetic resonance imaging (MRI). The nurse should implement which of the following standard orders to ensure a safe environment in preparation for this test?
1. Shave the groin area for insertion of a femoral
3. Remove all objects containing metal from the client
Rationale: An MRI uses magnetic fields to produce a diagnostic image. All metal objects such as rings, bracelets, hairpins and watches should be removed. The client's history should also be reviewed t
A nurse assisting in the care of a client who has been in a coma for more than a year is told by the physician to stop the tube feeding that is providing sustenance to the client. The nurse, who is aware of the legal basis needed for carrying out the orde
4. Authorization by the family to discontinue the treatment
Rationale: The family or a legal guardian can make treatment decisions, generally in collaboration with physicians, other health care workers, and other trusted advisors. The nurse first checks f
A nurse who is assisting a physician with insertion of a Miller-Abbott tube should do which of the following to ensure a safe environment and decrease the client's risk of aspiration?
1. Place the client in a high-Fowler's position
2. Assist with insertin
1. Place the client in a high-Fowler's position
Rationale: A miller-Abbott tube is a nasoenteric tube used to correct a bowel obstruction and decompress the intestine. A high-Fowler position decreases the risk of aspiration if vomiting occurs. A physician
A nurse who is assisting in the care of a client with cancer is following medication orders to manage the cancer pain. Which of the following strategies should the nurse follow to ensure adequate and safe pain control?
1. Try multiple simultaneous medicat
4. Start with low medication doses and gradually increase to a dose that relieves pain without exceeding the maximal daily dose
Rationale: The most appropriate approach is to begin with low doses and increase as needed to maintain a dose that relieves the
A licensed practical nurse (LPN) is reinforcing instructions given by a registered nurse (RN) to a client about how to take medications after discharge from the hospital. The LPN should use which of the following approaches to best ensure safe administrat
4. Allow the client to verbalize and demonstrate correct administration procedure
Rationale: The most effective method of teaching to ensure safe self-administration of medications in the home setting is to have the client verbalize and also demonstrate h
A client with thrombophlebitis is being treated with heparin sodium (Liquaemin) therapy. The registered nurse (RN) asks the licensed practical nurse (LPN) to check the medication supply to ensure that the antidote for this therapy is available. The nurse
1. Protamine sulfate
Rationale: Protamine sulfate is the antidote for heparin sodium. Streptokinase is a thrombolytic agent used to dissolve blood clots. Vitamin K is the antidote for warfarin (Coumadin). Amicar is an antifibrinolytic used to prevent the
A nurse who is assisting in the care of a client with cardiomyopathy should give priority to which of the following to ensure client safety>
1. Administering vasodilator medications
2. Conducting a thorough pain assessment
3. Taking measures to prevent or
3. Taking measures to prevent orthostatic changes when the client stands
Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of impaired venous return. These changes could lead to dizziness and client falls. Vasodilators
A licensed practical nurse (LPN) is reinforcing teaching done by the registered nurse (RN) with a client who has been diagnosed with endocarditis. The LPN explains that it is important for this client to use an electric razor rather than a straight razor
4. Any cuts or skin injury should be avoided while taking anticoagulants
Rationale: Clients with endocarditis are at risk for developing thrombi along the walls of the heart, which could become emboli leading to stroke. For this reason, clients with endoc
A licensed practical nurse (LPN) is assisting a registered nurse (RN) in caring for a client who just underwent cardiac catheterization using the femoral artery approach. The nurse should avoid taking which of the following actions in caring for this clie
2. Have the client sit upright for a meal
Rationale: For 6 hours after cardiac catheterization using the femoral approach (or per physician's orders), the client should not bend or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage
A nurse is delivering a meal tray to a client with heart failure. The nurse should remove which item from the tray before bringing it to the client's bedside because the food item would be unsafe for the client to consume?
1. Sherbet
2. Green beans
3. Bak
4. Saltine crackers
Rationale: Clients with heart failure should monitor and restrict sodium intake. Saltine crackers are high in sodium and should be avoided. Green beans and sherbet are low in sodium. Baked chicken would contain only physiological salin
An older client with diabetes mellitus is vomiting because of gastroenteritis. The nurse should do which of the following to maintain oral intake to safely minimize the risk of dehydration?
1. Give only sips of water until the client is able to tolerate s
4. Encourage the client to drink up to 8 to 12 ounces of fluid every hour while awake
Rationale: Small amounts of fluid may be tolerated even when vomiting is present. The client should be offered up to 8 to 12 ounces of liquid containing both glucose and
A client who does not have an artificial airway has a new order for a sputum culture. The nurse should avoid doing which of the following to obtain a suitable specimen?
1. Obtaining the specimen early in the morning
2. Having the client take deep breaths
4. Placing the culture container lid face down on the bedside table
Rationale: The lid would be contaminated if it is placed face down on the bedside table, which could lead to inaccurate test results. The client should rinse the mouth or brush the teeth
A nurse is implementing measures to prevent the spread of infection to other clients. The nurse understands that which of the following is the best way to prevent the spread of infection?
1. Use proper hand washing techniques
2. Use sterile technique with
1. Use proper hand washing techniques
Rationale: Proper hand washing is the best way to prevent the spread of infection. All procedures do not require sterile technique. Reading the policy and procedure manual does not guarantee that infection will not be
A nurse is carrying out an order to obtain a sputum sample, which must be obtained using the saline inhalation method. The nurse guides the client in using the nebulizer safely and effectively by encouraging the client to do which of the following?
1. Hol
2. Keep the lips closed lightly over the mouthpiece
Rationale: Inhaling vaporized saline is an effective means to assist a client to cough productively because the vapor condenses on respiratory mucosa, stimulating the cough reflex and the expectoration o
A client has a tracheostomy with a nondisposable inner cannula. After completing tracheostomy care, the nurse reinserts the inner cannula into the tracheostomy tube immediately after doing which of the following?
1. Suctioning the airway
2. Rinsing it in
4. Tapping it dry lightly against a sterile surface
Rationale: The nurse reinserts the inner cannula immediately after tapping it dry against a sterile surface. Once inserted, it is turned clockwise to lock it into place. It should not be dried with a cot
A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client?
1. Measuring the pH of
2. Submerging the NG tube in water to check for bubbling
Rationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration
An older client who has not been hospitalized previously is extremely anxious after hospital admission. To provide a safe environment for the client and minimize the stress of hospitalization, the nurse should do which of the following?
1. Keep visitors t
4. Allow the client to have as many choices related to care as possible
Rationale: Several general interventions will reduce the hospitalized client's level of stress. These include acknowledging the client's feelings, offering information, providing soci
A prenatal client who has acquired the sexually transmitted virus Condyloma acuminatum (human papilloma virus) asks the nurse to explain again the treatment for the infection. The nurse should reinforce additional information about which of the following
1. Laser therapy
Rationale: For the pregnant client, laser therapy is the most effective method of destroying the virus. This therapy is localized, whereas medications (which are considered toxic to the fetus) would have a systemic effect. The primary neo
A nurse is assisting in the care of a client in labor who has a history of sickle cell anemia. Knowing that the client has a high risk for sickling crisis during labor, the nurse should give priority to implementing which safe nursing action to prevent a
3. Ensure that the client uses oxygen during labor
Rationale: Administering oxygen as needed is an effective intervention to prevent sickle cell crisis during labor. During the labor process the client is at high risk for being unable to meet the oxygen d
A client who is admitted to the labor and delivery unit in active labor has active genital herpes lesions present in the genital tract. The licensed practical nurse should reinforce teaching done by the registered nurse about which of the following immedi
2. Preparation for a cesarean delivery
Rationale: Cesarean delivery reduces the risk of neonatal infection with a mother in labor who has either herpetic genital lesions or ruptured membranes. Options 3 and 4 would expose the fetus to the virus. Standard
A client with possible renal disease is scheduled to undergo diagnostic testing by intravenous pyelogram (IVP). To ensure client safety, the nurse should be certain to collect data from this client about a history of which of the following?
1. Allergy to
1. Allergy to shellfish
Rationale: A client undergoing diagnostic testing that uses a contrast medium such as IVP should be questioned about allergy to shellfish, seafood, or iodine. This would identify a potential allergic reaction to the contrast dye th
A nurse is carrying out an order for a 24-hour urine collection for a client with a suspected renal disorder. Which of the following actions should the nurse avoid to ensure proper collection technique?
1. Refrigerate the container or place it on ice
2. S
4. Ask the client to void at the start time, and place this specimen in the container
Rationale: To collect a 24-hour urine specimen, the nurse should ask the client to void at the beginning of the collection period and discard the urine sample. This is d
A licensed practical nurse (LPN) who is assisting a registered nurse (RN) in caring for a client in active labor should do which of the following to best prevent fetal heart rate decelerations?
1. Begin preparations for a cesarean delivery
2. Encourage up
2. Encourage upright or side-lying maternal position
Rationale: Side-lying and upright positions such as walking, standing and squatting can improve venous return and encourage effective uterine activity, which in turn will reduce the likelihood of fetal
A nurse employed in a clinic is assisting in the care of a client with diabetes mellitus who is 36 weeks' pregnant. The results of three previous weekly nonstress tests have been reactive. This week the test was nonreactive after 40 minutes. The nurse sho
1. A contraction stress test
Rationale: A nonreactive test requires further follow-up evaluation, indicating the need for a contraction stress test. To send the client home for 3 days could place the fetus in jeopardy. Hospitalizing the client for either
A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first?
1. Aspirate the tube
2. Flush the tube with warm water
3. Prepare to remove a
1. Aspirate the tube
Rationale: the nurse should first attempt to unclog the feeding tube by aspirating it. If this does not work, the nurse should try to flush the tube with warm water. Carbonated liquids such as cola may also be used, but only if agency
A client with depression who was admitted to the psychiatric unit the previous day suddenly begins smiling and stating that the current episode of depression has lifted. The client continues to be talkative and engages in conversation with other clients o
2. Increase the level of suicide precautions
Rationale: A depressed client hospitalized for only 1 day is unlikely to have a dramatic cure. A sudden elevation in mood probably indicates that the client has decided to harm himself or herself. An increase i
A nurse who is assisting in the care of suicidal clients in a psychiatric nursing unit should plan to implement special precautions at which of the following times of increased risk?
1. Day shift
2. Weekdays
3. Shift change
4. 8 am to 2 pm
3. Shift change
Rationale: During the change of shifts, fewer staff members may be available to observe clients. The staff in a psychiatric nursing unit should increase precautions during shift change for clients identified as suicidal. Other times of inc
A nurse is assisting in the admission of a postoperative client from the postanesthesia care unit to the surgical nursing unit. The nurse should do which of the following for the safety of the client?
1. Ask the client to slide from the stretcher to the b
3. Put the bed rails up after moving the client from the stretcher
Rationale: Because the client may still be experiencing residual effects of anesthesia, the nurse should raise the side rails after transferring the client from the stretcher to the bed. I
A nurse is caring for a child with a fever. The nurse implements which safe action when giving this child a tepid tub bath?
1. Add some alcohol to the bath water
2. Let the child soak in the tub for 10 minutes
3. Add cool water slowly to the warmer bath w
3. Add cool water slowly to the warmer bath water
Rationale: Cool water should be added to an already warm bath because this will cause the water temperature to slowly drop. The child will be able to gradually adjust to the changing water temperature and
A nurse is assisting in the care of a child who underwent surgical repair of a cleft lip the previous day. The nurse should implement which safe nursing intervention when caring for the surgical incision?
1. Clean the incision only if serous exudate forms
4. Rinse the incision with sterile water after using diluted hydrogen peroxide
Rationale: The incision should be rinsed with sterile water when it is cleaned with a solution other than water or saline. The Logan bar is intended to maintain integrity of th
A nurse is assigned to care for an older client who has been identified as a victim of physical abuse. In planning care for this client, the nurse's priority is focused toward:
1. Removing the client from any immediate danger
2. Adhering to the mandatory
1. Removing the client from any immediate danger
Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on determining whether the person is in any immediate danger. If so, emergency action must be taken to remov
A nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following will the nurse suggest to include in the client's plan of care?
1. Limit visiting time to 60
4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering
Rationale: the client's room should be marked with appropriate signs stating the need to speak to the nurse before entering because of the risk of e
A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client?
1. The nursing assistant is speaking i
4. The nursing assistant is speaking directly into the impaired ear
Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client whil
Ultraviolet light (UVL) therapy is prescribed in the treatment plan for a client with psoriasis. The nurse reinforces instructions to the client regarding safety measures related to the therapy. Which statement made by the client indicates a need for furt
1. "Each treatment will last 30 minutes."
Rationale: Safety precautions are required during UVL therapy. Most UVL treatments require the person to stand in a light treatment chamber for up to 15 minutes. It is best to expose only those areas requiring tre
A nurse is assigned to care for a client who sustained a burn injury. The nurse reviews the physician's orders and should question the registered nurse about which order?
1. Monitor weight daily
2. Monitor urine output hourly
3. Maintain the nasogastric t
4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain
Rationale: Oral, subcutaneous and intramuscular routes for administering medications are contraindicated in the burned client because of the poor absorption factor. When fluid
A nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, the nurse should avoid which of the following to minimize the chance for further injury?
1. Leaving the side rails down
2. Keeping the call bell in
1. Leaving the side rails down
Rationale: Safe nursing actions intended to prevent injury to the client include keeping the side rails up, keeping the bed in low position, and providing a call bell that is within the client's reach. Responding promptly to
A nurse has reinforced instructions to a parent regarding the safe methods to prevent Lyme disease. Which statement made by a parent would indicate the need for additional instructions?
1. "We should wear hats when we go on our hiking trip."
2. "Wearing l
4. "We should avoid insect repellents because they will attract the ticks."
Rationale: To prevent Lyme disease, individuals should be instructed to use insect repellent on the skin and clothes in areas where ticks are likely to be found. Long-sleeved tops
A client with paraplegia has a risk for injury related to spasticity of leg muscles. The nurse avoids which action that would be least helpful in dealing with this problem?
1. Using restraints to immobilize the limbs
2. Administering a PRN order for a mus
1. Using restraints to immobilize the limbs
Rationale: Using limb restraints will not alleviate spasticity and could harm the client. Their use should be avoided. Use of muscle relaxants may be helpful if the spasms cause discomfort to the client or pose
A client is admitted to the hospital with severe hypoparathyroidism. The nurse should do which of the following activities to promote client safety?
1. Keep the room slightly cool
2. Institute seizure precautions
3. Keep the head of bed lowered
4. Use a w
2. Institute seizure precautions
Rationale: Hypoparathyroidism results from insufficient parathyroid hormone, leading to low serum calcium levels. Hypocalcemia can cause tetany, which, if untreated can lead to seizures. The nurse should institute seizure
A nurse is assisting in preparing a plan of care for a client being admitted to the hospital for insertion of a cervical radiation implant. Which safe activity should the nurse suggest for this client following insertion of the implant?
1. Maintain bed re
1. Maintain bed rest
Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort.
A nurse is assigned to care for a client who has returned to the nursing unit after an oral cholecystogram. At this point in time, the nurse should question which of the following physician's orders in the medical record?
1. Assess for nausea and vomiting
3. Maintain a clear liquid status for 72 hours
Rationale: The client should be able to resume the usual diet once the nurse assured is assured the client that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on
A nurse employed in a physician's office is asked to check the client who is at low risk for contracting tuberculosis for the results of the purified derivative (PPD) implanted 72 hours previously. The nurse reads the PPD as measuring 11 mm induration in
1. Notify the physician
Rationale: An area of induration that measures 10 mm is considered a positive reading and indicates exposure to tuberculosis (TB). The nurse who observes a positive PPD reading notifies the physician immediately. The physician woul
A nurse reinforces information about the disease and recuperation to the client diagnosed with tuberculosis. The nurse determines that the client understands the information presented if the client states that it is possible to return to work when:
1. Fiv
2. Three sputum cultures are negative
Rationale: The client must have sputum cultures performed every 2 to 4 weeks after antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the
A registered nurse (RN) tells a licensed practical nurse (LPN) that a client who is suspected of having tuberculosis (TB) is being admitted to the hospital and asks the LPN to prepare a room for the client. The LPN prepares the room, knowing that this cli
4. Venting to the outside, six room air exchanges per hour, and ultraviolet light
Rationale: The client with tuberculosis must be admitted to a private room that provides at least six air exchanges per hour. The room should provide venting to the outside
A nurse is planning to give a subcutaneous injection of insulin. The nurse plans to do which of the following immediately after giving the injection?
1. Break the needle
2. Recap the needle
3. Place the needle and syringe in a labeled cardboard box
4. Pla
4. Place the needle and syringe in a labeled, rigid plastic container
Rationale: Standard precautions include specific guidelines for handling of sharps. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a label
A licensed practical nurse (LPN) is asked to prepare a room for a child who will be admitted to the pediatric unit with a diagnosis of tonic-colonic seizures. The LPN prepares the room and plans to place which of the following items at the bedside?
1. Suc
1. Suction apparatus and oxygen
Rationale: Tonic-clonic seizures cause tightening of all body muscles followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after a seizure. Suction apparatus, oxygen
An extremely angry and aggressive client in the mental health inpatient unit has been placed in restraints. When working with this client, the nurse should suggest removal of the restraints when the client:
1. Has been sedated and is still experiencing it
4. Initiates no aggressive acts for an hour after the release of two leg restraints
Rationale: The best indicator that the client's behavior is under control is when the client refrains from aggression after being partially releases from the restraints. R
A client who has been admitted to the mental health unit with obsessive compulsive disorder repeatedly cleans the bathroom fixtures. The client has become enraged and has started to bite and kick the roommate for occupying the bathroom. Which of the follo
3. Provide a safe environment for both clients
Rationale: The first action of the nurse is to provide an environment that is safe for both clients. This may take a variety of forms, depending on the individual circumstance, agency protocols, and written p
A physician orders a 12-lead electrocardiogram (CG) to be performed on a client. The client is concerned about the safety of the test, and the nurse provides information to the client. Which of the following would indicate that the client understands the
2. "I should lie still while the ECG is being done."
Rationale: good contact between the skin and electrodes is necessary to obtain a clear 12-lead ECG printout. Therefore the electrodes are placed on the flat surfaces of the skin just above the ankles an
A nurse is assisting in planning the discharge of a client with chronic anxiety and assists in selecting the goals that will promote a safe environment at home. The appropriate maintenance goal should focus on which of the following?
1. Ignoring feelings
2. Identifying anxiety-producing events
Rationale: Recognizing events that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing events, and this option d
A nurse is planning to reinforce instructions to a client with chronic vertigo about safety measures to prevent worsening of symptoms or injury. Which safety instruction should the nurse provide to the client?
1. Turn the head slowly when spoken to
2. Rem
2. Remove throw rugs and clutter in the home
Rationale: The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client
A nurse is assigned to care for a client with Parkinson's disease who has recently begun taking L-dopa (levodopa). Which of the following is most important to check before ambulating the client?
1. The client's history of falls
2. Assistive devices used b
3. The client's postural (orthostatic) vital signs
Rationale: Clients with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem worsens when L-dopa is introduced because the medication can also cause postur
A nurse is giving a bed bath to a client who is on strict bed rest. To safely increase venous return, the nurse bathes the client's extremities by using:
1. Long, firm strokes from distal to proximal areas
2. Short, patting strokes from distal to proximal
1. Long, firm strokes in the direction of venous flow promote venous return when the extremities are bathed. Circular strokes are used on the face. Short, patting strokes and light strokes are not as comfortable for the client and do not promote venous re
A nurse is preparing to give an intramuscular (IM) injection that is irritating to the subcutaneous tissues. The drug reference recomends that it be given using the Z-track technique. Which of the following procedural steps would cause tracking the medica
1. Massaging the site after injecting the medication
Rationale: The Z-track variation of the standard IM technique is use to administer IM medications that are highly irritating to subcutaneous and skin tissues. Attaching a new sterile needle is done so t
A nurse is preparing to transfer an average-sized client with right-sided hemiplegia from the bed to the wheelchair. The client is able to support weight on the unaffected side and the nurse plans to use the hemiplegic transfer technique. The client is si
2. Near the client's left leg
Rationale: Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client's unaffected
A nurse is preparing to suction a client's tracheostomy. To ideally promote deep breathing and coughing, in which position should the client be safely placed?
1. Supine
2. Lateral position
3. High-Fowler's position
4. Semi-Fowler's position
4. Semi-Fowler's position
Rationale: If it is not contraindicated, before suctioning a tracheostomy, the client is placed in semi-Fowler's position to promote deep breathing, maximum lung expansion, and productive coughing. With the client in this positio
The pregnant client is at full term. The fetal heart rate (FHR) is being monitored for a baseline rate. The nurse is satisfied with the results and tells the client that the baby is safe and that the baby's heart rate is within normal limits. The nurse ba
3. FHR of 140 beats per minute
Rationale: The average FHR is 140 beats per minute. The normal range is 110 to 160 beats per minute; therefore option 3 is the only correct option.
A nurse is caring for a client who is dying and is a potential organ donor. The nurse reviews the client's medical record and identifies a contraindication to organ donation if which of the following were documented in the client's record?
1. Age of 38 ye
2. Hepatitis B infection
Rationale: A potential organ donor must meet age eligibility requirements, which vary by organ. For example, age must not exceed 65 (kidney donation), 55 (pancreas and liver), or 40 (heart) years old. The client should be free of
A nurse is assigned to care for a client with cervical cancer who has an internal radiation implant. Which of the following required items should the nurse ensure is kept in the client's room during this treatment?
1. A lead shield
2. A bedside commode
3.
4. Long-handled forceps and a lead container
Rationale: In the case of dislodgement of an internal radiation implant, the radioactive source is never touched with the bare hands. It is retrieved with long-handled forceps and placed in the lead container k
A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has now been determined. The nurse assigned to assist in caring for the client prepares to carry out which of the following orders that will maint
4. Administration of intravenous (IV) fluids
Rationale: Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore the client who was previously dehydrated to control intracranial pres
A nurse is assisting in the emergency room of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. The nurse is asked to care for the client's personal belongings, which may be needed as legal evidence. Which of the foll
1. Giving the clothing and wallet to the family
Rationale: Basic rules for handling evidence include limiting the number of people with access to the evidence, initiating a chain of custody log to track handling and movement of evidence, and carefully rem
A nurse working on a medical nursing unit during an external disaster is called to assist with the care of clients coming into the emergency room and is asked to assist the triage nurse. Using principles of prioritizing, the nurse initiates care for a cli
3. Bright red bleeding from a neck wound
Rationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. According to the triage process, the client in this classification would be issued a red t
A nurse is orienting a nursing assistant to the clinical nursing unit. The nurse should intervene if the nursing assistant did which of the following during a routine hand washing procedure?
1. Kept the hands lower than the elbows
2. Washed continuously f
4. Dried the hands from the forearm down to the fingers
Rationale: Proper hand washing procedure involves wetting the hands and wrists and keeping the hands lower than the forearms so water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and
A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. The nurse assigned to care for the client plans to ensure that which of the following does not occur in the care of the client?
1. Admitting the client to a sem
1. Admitting the client to a semiprivate room
Rationale: The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a single room on the nursing unit. A sign indicating "See the Nurse before Entering" should be placed on
A client who received a dose of chemotherapy 12 hours ago is incontinent of urine while in bed. The nurse safely wears which of the following when cleaning the client?
1. Mask and gloves
2. Gown and gloves
3. Mask, gown and gloves
4. Gown, gloves and eyew
2. Gown and gloves
Rationale: The client who has received chemotherapy will have antineoplastic agents or their metabolites in body fluids and excreta for 48 hours. For this reason, the nurse should wear protection for likely sources of contamination. In
A clinic nurse is providing instructions to a mother of a child who was diagnosed with mumps. The mother is concerned about her other children and asks the nurse how the infection is transmitted. The nurse informs the mother that mumps is transmitted by:
2. Airborne droplets
Rationale: Mumps id transmitted via airborne droplets, salivary secretions, and possibly the urine. Options 1, 3 and 4 are incorrect.
A nurse is assisting in preparing a client scheduled for a bone marrow aspiration. The client asks the nurse if the procedure will be painful. To provide the client with accurate information, the nurse should incorporate which of the following in a respon
3. A local anesthetic is used, but there is some pain during aspiration
Rationale: A local anesthetic is used to anesthetize the skin and subcutaneous tissue to minimize tissue discomfort with needle insertion. The client will feel some pain briefly when
A nurse is preparing to assist a client from the bed to chair using a hydraulic lift. The nurse should do which of the following to move the client safely with this device?
1. Position the client in the center of the sling
2. Have three staff members avai
1. Position the client in the center of the sling
Rationale: One person may operate a hydraulic lift. The client is positioned in the center of the sling, which is then attached to chains or straps that connect the sling to the lift. The client is raised
An older client in a long-term care facility is at risk for injury because of confusion. Because the client's gait is stable, which method of restraint, if prescribed, would be best used by the nurse to prevent injury to the client?
1. Vest restraint
2. W
3. Alarm-activating bracelet
Rationale: If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm-activating bracelet, or "wandering bracelet." This allows the client to move about the residence freely