Which pain scale should the nurse use to monitor the pain level of a 3-year old client after surgery?
1. Numerical scale
2. Verbal descriptive scale
3. Visual analog scale
4. FACES scale
4. Correct: Monitoring pain in children requires special techniques. The nurse should use the FACES scale as a tool to assess this client's pain level. Children as young as 3 years of age can use the FACES scale to communicate their pain level to the medi
Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? (SATA)
1. Ask the client diagnosed with dementia memory-testing questions.
2. Collect the urinary output hourly on the client with renal disease.
3. Dem
2., & 4. Correct: The UAP can obtain hourly urine output on clients and can give a tepid sponge bath to a client. The LPN/VN must know what tasks can be assigned to the UAP.
1. Incorrect: The nurse cannot delegate assessment, evaluation, or teaching. This
What nursing interventions should the nurse implement for a client with Addison's disease? (SATA)
1. Administer potassium supplements as prescribed.
2. Assist the client to select foods high in sodium.
3. Administer Fludrocortisone as prescribed.
4. Monit
2., 3., 4. & 5. Correct: The client with Addison's disease needs sodium due to low levels of aldosterone. Fludrocortisone is a mineralocorticoid that the client will need to take for life. I&O and daily weights are needed to monitor fluid status.
1. Incor
A licensed practical nurse (LPN) is utilizing the nursing process to care for assigned clients. Which nursing actions should the LPN relate to the implementation step of the nursing process? (SATA)
1. Collecting client data for a nursing history.
2. Repor
3., 4., & 5. Correct: The nurse should relate procuring medical equipment, assigning client care activities, and delivering skilled nursing care to the implementation step of the nursing process. Implementation is the third step of the nursing process and
The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM. Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give? Round your answer to the nearest whole number.
Changing 0.6 g to mg equals 600 mg.
Then 200 mg : 1 mL = 600 mg : x mL
200x = 600
x = 3
The nurse should reinforce which instructions given to the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? (SATA)
1. Check catheter for kinks in the tubing when the client is
1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequ
What should the nurse document after a client has died? (SATA)
1. Time of death
2. Who pronounced the death
3. Disposition of personal articles
4. Destination of body
5. Primary healthcare provider's prescriptions
6. Time body left facility
1., 2., 3., 4., & 6. Correct: All of these are correct options that should be documented. In addition to these things, the nurse should also document consideration of and preparation for organ donation, family notified and decisions made, and location of
The client states, "I really do not want to have surgery. I have told my children this, but they still want me to go through with the surgery. I do not know what to do." What is the best response for the nurse as client advocate?
1. "Your children are con
4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy between the care or proposed care and the client's wishes regarding treatment. It is important to acknowledge the client's feelings and to demonstrate compassion and a w
The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best?
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O
4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains m
A nurse has reinforced teaching to a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique?
1. "The wound should be cleaned using a washcloth, soap, a
3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing.
1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has bee
When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? (SATA)
1. Apply compression hose.
2. Place pillow under knees while supine.
3. Assist client to perform active foot and leg e
1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises, as wel
Which action, if done by a new LPN/VN, needs to be interrupted by the precepting LPN/VN?
1. Mixes diazepam and hydromorphone in one syringe.
2. Administers diazepam before meals.
3. Raises side rails after administering hydromorphone.
4. Instructs client
1. Correct: In this question, you are looking for the answer that is unsafe and should not be done. Diazepam cannot be mixed with any other medication. The charge nurse should intervene.
2. Incorrect: This is an appropriate action. Food in the stomach del
A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse reinforce with the client prior to discharge? (SATA)
1. Avoid hot baths and showers.
2. Inc
3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase.
1
The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely?
1. Hypocalcemia
2. Hypomagnesemia
3. Hyponatremia
4. Hypokalemia
4. Correct: Hyperemesis gravidarum is characterized by persistent, severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally,
The nurse is preparing the sterile field to assist the primary healthcare provider with a procedure. Which flap of the sterile pack should the nurse open first?
1. Closest to the nurse.
2. To the left of the nurse.
3. To the right of the nurse.
4. Farthes
4. Correct: The flap farthest from the nurse should be opened first so that the nurse's arm or hand does not cross the sterile field.
1. Incorrect: The flap closest to the nurse should be opened last so that the sterile field is not crossed by the nurse's
When reinforcing teaching, what symptom would the nurse include as being the most common initial visual change associated with glaucoma?
1. Central vision is lost.
2. Progressive tunnel vision occurs.
3. Sudden flashes of light in the eyes.
4. Eye floater
2. Correct: If glaucoma is not diagnosed and treated early, an individual starts to lose peripheral vision, or the area of vision outside the central field of sight. People who have glaucoma experience tunnel vision and cannot see objects to the side, nea
The nurse is reinforcing teaching to a client who has been prescribed glucocorticoids for the treatment of Addison's disease. What points should the nurse emphasize?
1. Be aware of the development of hypoglycemia.
2. Test the urine for albumin or other pr
4. Correct: Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued.
1. Incorrect: Increased blood sugar is an adverse effect associated with glucocor
Which electrolyte imbalance would be the nurse's priority concern in the burn client?
1. Hypernatremia
2. Hyperkalemia
3. Hypoalbuminemia
4. Hypermagnesemia
2. Correct: Good job. When the cells lyse, they release potassium, and then the serum potassium goes up. And if the kidneys stop functioning, we are in real trouble.
1. Incorrect: Well, hypernatremia does occur when the client becomes very dehydrated, but
Which task would be appropriate for the LPN/VN to accept from the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse?
1. Administer IV pain medication to a client three days postopertive cesarean section.
2. Draw a trough vancomycin level on a clie
3. Correct: Client teaching may be reinforced by an LPN/VN on a stable client.
1. Incorrect: Administering IV pain medications is out of the scope of practice of LPN/VN.
2. Incorrect: This client with a severe infection who is only 3 days postpartum is co
Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse?
1. Lowers the side rails closest to them.
2. Places hands under client's axilla.
3. Lowers the head of bed.
4. Raises
2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring.
1. Incorrect: This is a correct action. The UAPs will need t
How should the nurse prepare a client for a paracentesis? (SATA)
1. Place client in the Fowler's position.
2. Position client flat with right arm behind the head.
3. Ask the client to empty bladder.
4. Obtain client's vital signs every 4 hours.
5. Maintai
1., & 3. Correct: The correct position is HOB elevated to allow fluid to pool in one spot for the paracentesis. The nurse knows this is a lower abdominal puncture and the bladder should be empty to avoid puncturing the bladder.
2. Incorrect: The optimal p
A client diagnosed with alcoholism was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What action should the nurse take?
1. Hide the client's clothes so tha
4. Correct: Always assess why the client wishes to leave first. This is the only way to fix the problem.
1. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment
Which comment by the client indicates understanding of possible complications of long term hypertension?
1. "I would like to have my serum creatinine checked at this visit."
2. "My blurred vision is part of getting older."
3. "I have leg pain caused by ex
1. Correct: Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications.
2. Inc
The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate f
1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advan
A nurse drops a glass bottle, which shatters on the floor in the hallway. What action should the nurse take?
1. Notify housekeeping to clean up the spill.
2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container.
3.
2. Correct: The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container.
1. Incorrect: While waiting for housekeeping, someon
The nurse is preparing to make an occupied bed. Which action by the nurse is important to preserve client's self-esteem during this procedure?
1. Remove the top sheet first and replace with a clean one.
2. Inform the client that they will be uncovered onl
4. Correct: The client should not be exposed during the bed change. Cover with a bath blanket as the top sheet is removed.
1. Incorrect: The client's self-esteem will not be preserved if uncovered during the procedure. Being exposed to the nurse is very t
The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse "I am sweating more than ever!" What is the nurse's best response?
1. This is a common side effect of antidepressant medications.
2. Excess
1. Correct: A common side effect of SSRIs is increased sweating. This option gives the client an explanation.
2. Incorrect: This response shows a lack of understanding of the side effects of antidepressant medications.
3. Incorrect: This option does not a
The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment has not been effective? (SATA)
1. Diuresis
2. Dyspnea on exertion
3. P
2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) a
The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next?
1. Notify the primary healthcare provider.
2.
3. Correct: Look at the clues: full thickness wound, small amount of blood, and wet to dry dressing. With a full thickness wound, there is destruction of the epidermis, dermis, and subcutaneous tissues going down to the bone. ?So you would expect to see a
A client diagnosed with Celiac disease is on a gluten-free diet. What statement by the client would indicate to the nurse that reinforcing of diet instructions is needed?
1. "I will still have occasional abdominal discomfort."
2. "I may need to take iron
4. Correct: The nurse is evaluating client statements for any lack of understanding and the need to provide further instruction. With Celiac disease, intestinal villi become inflamed whenever gluten is introduced to the gut through food intake. However, f
A busy LPN instructs an unlicensed assistive personnel (UAP) to obtain daily weights on a client. The LPN provides initial direction for the task, monitors that the task is successfully completed, reviews the results of the daily weight, and reports the r
3. & 4. Correct: The LPN appropriately assigned the performance of a client care task. The LPN appropriately supervised the performance of a client care task.
1. Incorrect: The LPN appropriately supervised the actions of the UAP.
2. Incorrect: The LPN app
Two hours following a lumbar puncture, the client stands up to void and reports a headache rated 8 out of 10 on a pain scale. What priority action should the nurse perform?
1. Instruct the client to drink at least 8 ounces (240 mL) of water.
2. Close room
3. Correct: The most frequent cause of headache following a lumbar puncture is loss of, or leaking, of cerebrospinal fluid from the puncture site. Positioning a client is an important nursing responsibility, particularly in this situation since the supine
A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client?
1. Assist client to take a cool bath.
2. Provide a back massage.
3. Administer prescribed triazolam.
4.
2. Correct: Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first.
1. Incorrect: A cool bath would wake a client, whereas, a warm bath would increase relaxation.
The clinic nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What response by the nurse is appropriate? (SATA)
1. "I want to help you to re
1., 3., 4. & 5. Correct: The nurse wants to establish a positive relationship with the client as quickly as possible. The nurse wants to recognize positive qualities. Keeping the client on the phone may prevent the client from taking the pain killers. The
Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? (SATA)
1. Weigh daily at the same time each day.
2. Allow only 20 minutes of exercise daily.
3. Allow the clien
1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale and clothes if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with a
What should the nurse calculate as the estimated due date of a pregnant client, whose last menstrual period started on August 31st?
1. July 1st
2. May 6th
3. May 31st
4. June 7th
4. Correct: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed. August 31st - 3 months would be May 31st. Add seven days. The estimated date of delivery would be June 7th.
1. Incorrect: Estim
The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response?
1. Yes, bring
1. Correct: A client with sleep apnea is at risk for cardiac and respiratory complications postop due to decreasing oxygenation. So yes, the client needs to use the CPAP machine. Remember this client will also be receiving narcotics for pain and have a de
What important principle should the nurse reinforce with the client performing intermittent self-catheterization?
1. Inserted in an emergency department.
2. Used to treat urinary catheter infections.
3. Is a clean procedure.
4. Requires use of sterile glo
3. Correct: Intermittent catheterization is a clean, not sterile, technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of a Foley catheter, as a Foley catheter increases client risk of urinar
A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse notes coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symp
1. Correct: These symptoms are indicative of arterial insufficiency as there is pain with walking that is relieved by rest. This pain is known as intermittent claudication. In addition, the pulses are decreased or may be absent with arterial insufficiency
What action should the nurse take after entering the room of a client who becomes agitated and combative?
1. Administer prn sedative.
2. Notify the family of client behavior.
3. Speak softly to the client.
4. Apply wrist restraints.
3. Correct: The nurse needs to present a calm manner and speak quietly to the client. This will build trust and decrease tension and stress in the client.
1. Incorrect: This is a form of restraint. The use of positive nursing actions can reduce the use of
In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last.
Apply clean gloves.
Remo
First, apply clean gloves.
Second, remove soiled dressings.
Third, discard soiled dressings and clean gloves in red bag.
Fourth, don sterile gloves.
Fifth, clean surgical wound with moistened sterile 4x4's.
Sixth, clean around Penrose drain using circular
Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? (SATA)
1. Monitor client for signs of skin breakdown.
2. Take client's vital signs after ambulating.
3. Apply bacitracin ointment to right forearm.
4. O
2., 4. Correct. These tasks are within the scope of practice for the UAP. The LPN/VN must know the tasks that are appropriate for the UAP in order to assign tasks.
1. Incorrect. The UAP cannot assess, evaluate, or plan care for the client. The LPN/VN know
Which task would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? (SATA)
1. Obtain a sterile urine specimen from an indwelling catheter.
2. Insert an in-and-out catheter on a postpartum client.
3. Take vital signs on
3., & 5. Correct: Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for reviewing the vital signs. Performing perineal care is within the scope of practice for the UAP. The nurse is responsible for assessing the
A client with schizophrenia tells the nurse, "I want you to take me to the uniphorum". Which statement would be most appropriate for the nurse to make?
1. "You don't even know what you are saying. Stop making up words".
2. "I don't understand what you mea
2. Correct: Attempt to decode incomprehensible communication patterns. Seek validation and clarification. These techniques reveal to the client how he or she is being perceived by others, and the responsibility for not understanding is accepted by the nur
Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence?
1. Allowing clients to make their own decisions about care
2. Answering all questions posed by client in an honest manner
3. Reporting faulty equipment to t
4. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and desiring to do good which are the core principles of client advocacy.
The nurse prepares a sterile field for a procedure. Fifteen minutes later, the nurse is informed that there will be a 20 minute delay before the primary healthcare provider will arrive. What action should the nurse take?
1. Cover the sterile field with a
3. Correct: The nurse should monitor the sterile field while awaiting the primary healthcare provider. This means keeping the sterile field in your site.
1. Incorrect: Sterile fields should not be covered. Although there are no research studies to support
The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider?
1. BP 150/108 decreases to 138/86
2. Weight gain of 5 pounds (2.27 kg) in one week
3. Urinary output of 1450
2. Correct: Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention.
1. Incorrect: This is an expected response of an ACE inhibitor. ACE inhibitors block the normal effects of renin-
A nurse is caring for a Mexican-American client post stroke. While in the client's room, a curandero visits at the request of client. What is the best action of the nurse?
1. Leave, and return once the curandero has left.
2. Reinforce client care with the
2. Correct: This is the best course of action for the nurse. The health and healing of a client come from many components, including spirituality, religion, folk remedies, alternative therapies, and modern medicine. Unless something is harmful to the clie
The nurse monitors a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority?
4. Correct: These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1
To determine the standards of care for the institution, the nurse should consult which document?
1. Organizational Chart
2. Personnel policies
3. Policies and procedure manual
4. Job descriptions
3. Correct: The standard of care for nurses is defined as what a prudent nurse would do in the same situation. The policies and procedure manual defines standards of care for an institution.
1. Incorrect: An organizational chart identifies which departmen
Place the steps in order that the nurse should take to administer a subcutaneous injection.
Perform hand hygiene
Apply gloves and locate the injection site
Cleanse site with antiseptic swab
Remove the needle cap by pulling it straight off
Hold syringe and
First perform hand hygiene. Then apply gloves and locate injection site using anatomical landmarks. Start at the center of the site and rotate outward in a circular direction to cleanse the site. Remove the needle cap by pulling the cap straight off. Next
After shift report, which client should the nurse see first?
1. Eight year old that is in skeletal traction.
2. Six year old who is 5 hours postop appendectomy.
3. Unattended two year old admitted for a sleep study.
4. Four year old cerebral palsy child w
3. Correct: The unattended child should be checked first to make sure he/she is safe and having no complications. A child this age is entirely dependent on someone else. Safety is priority here.
1. Incorrect: An eight year old in skeletal traction does no
The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate?
1. Sug
2. Correct: The nurse is using the expertise of other team members by requesting that the dietician visit the client. This is the most important measure to address the client's nutritional needs. The problem may be that the client simply does not like the
A nurse is caring for a client who had a total hip replacement 2 days ago. What observation would be a priority concern for the nurse?
1. Small amount of red drainage on the surgical dressing.
2. Continues to report pain in hip when being repositioned.
3.
3. Correct: A low grade fever is normal following hip surgery but a temperature of 101.8�F (38.7�C) two days postoperatively is higher than the expected slight increase and should be a priority concern. The development of an infection is one of the major
The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? (SATA)
1. Obtain client likes and dislikes from family members.
2. Expose the client with data regarding the forgotten pa
1., 3. & 5. Correct: Considering likes and dislikes may help the client to remember. Using information to expose the client to stimuli that were happy memories may help the client remember. The client's disorder may lead to inattention to safety. Think sa
Which foods should the nurse encourage a client to avoid when prescribed a diet limiting purine rich foods? (SATA)
1. Peanut butter
2. Potatoes
3. Apples
4. Venison
5. Scallops
4., & 5. Correct: Purines are found in many foods and produced naturally by the body. Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high
Which is a risk factor for developing breast cancer in women?
1. Menopause before the age of 50
2. Drinking one glass of wine daily
3. Multiparity
4. Menarche at age 10
4. Correct: Early menarche, before age 12, is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at the first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her li
The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration?
1. Ventrogluteal
2. Vastus lateralis
3. Rectus Femoris
4. Deltoid
1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle.
2. Incorrect: The vastus lateralis site could be used in adult
A LPN/VN is caring for a client who reports a pain level of 8 on a numeric scale of 1-10. The LPN/VN reports the client's pain level to the RN and administers pain medication as prescribed. Which actions should a nurse take to advocate for this client? (S
2., 4. & 5. Correct: To advocate for this client, the LPN/VN should ensure that client's bed side rails are up and in a locked position and should advise the client to call for assistance before getting out of bed, because pain medication increases the cl
A client who has schizophrenia tells the nurse, "I am Jesus and I am here to save the world". The client is warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What action should the nurse take?
1. Set l
1. Correct: Yes! You must set limits of where the client is allowed to preach. This is disrupting others, and the client needs to be redirected to the client's room for a cool down and then another activity shortly thereafter.
2. Incorrect: No, you should
What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis?
1. Perform neurological checks.
2. Collect data for health history.
3. Institute droplet precautions.
4. Orient client to the room
3. Correct: Although all the options are appropriate, you should first place the client on droplet precaution to prevent the spread of meningococcal meningitis.
1. Incorrect: Placing client in isolation should be done first (actually prior to arriving to
A client has an intestinal obstruction and a NG tube to low suction. Blood gases are ph 7.54, pCO2 40, HCO3 35. The client is weak, shaky, and reports tingling of the fingers. The nurse knows that this client is most likely in which acid base imbalance?
1
4. Correct: Metabolic alkalosis happens when there is a loss of acid or a gain in bicarbonate. Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium cha
The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which additional sign or symptom would cause the greatest concern?
1. Nasal congestion
2. Hiccups
3. Blood glucose of 130
4. Muscle spasms
4. Correct: This client could have preeclampsia and would be at risk for seizures.
1. Incorrect: This is a common occurrence during pregnancy and is not the greatest concern.
2. Incorrect: Hiccups would be the second best answer, indicating nerve/muscle i
Which baseline data would tell the nurse that a school aged child is at risk for obesity?
1. Spends one hour playing sports or swimming daily.
2. Spends at least two hours watching TV after dinner each day.
3. Assists mom in preparing low carb snacks for
2. Correct: Sedentary activities, such as watching television, playing video games, and using a computer to surf the internet or engage with friends can also contribute to obesity and cardiovascular health problems in later life.
1. Incorrect: The more ac
A psychiatric nurse, caring for several clients, recognizes that which client presents the greatest risk for violence toward others?
1. Twenty four year old man with paranoid delusions.
2. Sixty two year old woman with bi-polar disorder
3. Seventy year ol
1. Correct: This client has a diagnosis that is consistent with a risk of violence, and his age falls within the age range for males who are most likely to present a risk of violence toward others.
2. Incorrect: This client may be irritable; however, it i
A young client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." Which statement by the nurse is appropriate?
1. "That is inappropriate behavior and you will need to go to your room."
2.
1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated.
2. Incorrect: Do not argue with the client.
3. Incorrect: This is confrontational and does not set consequences.
4. Incorrect:
A client who presents with severe epigastric pain, reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation?
1. pH - 7.49, pCO2 - 40,
1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis.
2. Incorrect: The client is n
What information should the nurse reinforce about decreasing the risk of spreading influenza?
1. Influenza is transmitted via the influenza vaccine.
2. Use a shirtsleeve when coughing or sneezing if tissue is not available.
3. Tissues are not effective in
2. Correct: A shirtsleeve should be used as a barrier when coughing or sneezing if tissue is not available. This prevents germs being spread via the hands.
1. Incorrect: The vaccine contains a dead virus that is not capable of causing influenza. Clients m
The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit?
1. Expectorating pink frothy sputum
2. Sudden onset of mid-sternal chest pain
3. Jaundiced conjunctiva
4. Diaphoresis and fever
3. Correct: This is a sign of liver damage, which is caused by an overdose of acetaminophen.
1. Incorrect: This is a symptom of pulmonary edema, not liver damage.
2. Incorrect: This is a symptom of myocardial ischemia, not liver damage.
4. Incorrect: Acet
The LPN/VN is preparing to transfer a client from the delivery room to the postpartum unit. Which statement by the client would be the priority for the LPN/VN to notify the charge nurse?
1. "I just felt something gush."
2. "I feel like I am still having c
1. Correct. This could indicate postpartum hemorrhage (PPH) and requires immediate assessment by the nurse. PPH can be caused by the following: placenta previa, cervical lacerations, vaginal tear, or a ruptured or inverted uterus.
2. Incorrect. This is no
Following a total hip replacement, the nurse reinforces discharge teaching to the client. The nurse knows that reinforcement of teaching was effective when the client states which activities are safe to perform? (SATA)
1. Using an abduction pillow while s
1., 3., & 4. Correct: The client should use an abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering, rather than sitting in a tub, will pr
Which menu selection by the client diagnosed with nephrotic syndrome indicates that reinforcement of dietary teaching was understood?
1. Pancakes with whipped butter, syrup, bacon, apple juice
2. Scrambled eggs, sliced turkey, biscuit, whole milk
3. Grits
2. Correct: Client needs low sodium and increased proteins.
1. Incorrect: This selection is too high in sodium and fats.
3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clie
The nurse is participating in educating a group of parents about the importance of immunizing their daughters against the human papillomavirus (HPV) in an effort to prevent the development of which cancer?
1. Breast
2. Cervical
3. Ovarian
4. Uterine
2. Correct: A vaccine that offers protection from the virus responsible for most cases of cervical cancer is the latest addition to the official childhood immunization schedule. The HPV vaccine is recommended for boys and girls at age 11 or 12 so they are
A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What shou
3. Correct: Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem.
1. Incorrect: This is a correct answer, but remove the cat first.
2. Incorrect: This will help hyperventilation
A client has been on the medical unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do?
1. Inform the primary healthcare provider that the client wishe
1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA.
2. Incorrect: The client is not suicidal; however, the primary he
A client is diagnosed with seizures. Which nursing interventions should the nurse implement? (SATA)
1. Have an unlicensed assistive personnel stay with the client.
2. Pad the side rails with blankets.
3. Place the bed in low position.
4. Keep a padded ton
2., 3., & 5. Correct: Place a call light within reach, put the client close to the nurses' station, and pad the side rails. Have client call for assistance to BR, maintain bedrest until seizures are controlled, or ambulate with assistance to protect from
The nurse is caring for a client taking spironolactone. Which needed dietary change should the nurse reinforce to the client?
1. Eat extra helpings of bananas.
2. Increase intake of water.
3. Avoid salt substitutes.
4. Increase intake of green leafy veget
3. Correct: Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided.
1. Incorrect: Bananas have potassium and should be avoided to prevent hyperkalemia and life threatening arrhythmias.
2. In
What information should be reinforced for parents regarding the promotion of adequate bowel elimination in their toddler?
(SATA)
1. Include adequate fiber in the diet through whole grains and fruits.
2. Increase intake of water daily.
3. Provide toileting
1., 2. & 3. Correct: Fiber is important for achieving adequate bowel elimination. Fruits and whole grains may help. Water intake is important, coupled with adequate fiber. Distractions at toileting times may result in poor elimination results.
4. Incorrec
A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? (SATA)
1. Holds baby face to face
2. Talks about the baby's features
3. To
1., 2., 3., & 4. Correct: Positive behaviors that would indicate that maternal-infant bonding is occurring include making eye contact; assuming the in face position when holding the infant; pointing out common features; smiling and gazing at the infant; t
The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which findings? (SATA)
1. Continued lethargy
2. Heart rate 112/min
3. Decreasing shortness of breath
4. BP 114/78
5. Increased thirst
3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as the FVE is corrected, and BP should be normal.
1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain.
2. Incorrect: Heart rate should de
A client in the inpatient mental health unit has been determined not suicidal. The client is requesting to leave against medical advice (AMA). What should the nurse do first?
1. Inform the primary healthcare provider that the client is wishing to leave.
2
1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step involves calling the primary healthcare provider.
2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input int
The nurse, caring for an 8 month old infant, should recognize which major stressor of hospitalization for this infant?
1. Fear of unknown
2. Loss of daily routine
3. Body image disturbance
4. Separation anxiety
4. Correct: Yes, they are afraid of being without the caregiver. Separation anxiety develops after a child gains an understanding of object permanence. The infant may become unsettled after the parent leaves. Although some babies display object permanence
What risk factors should the nurse identify when screening individuals for type 2 diabetes mellitus? (SATA)
1. Fat distribution greater in abdomen than in hips.
2. Being underweight.
3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
1., & 5. Correct: If the body stores fat primarily in the abdomen, the risk of developing type 2 diabetes is greater than if the body stores fat elsewhere, such as the hips and thighs. Women with polycystic ovary syndrome have increased risk of developing
Which nursing intervention should receive priority after a client has returned from having had eye surgery?
1. Administer pain medication around the clock.
2. Maintain head of bed at 35�.
3. Alternate applying warm and cold compresses.
4. Instruct on impo
2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures,
The nurse is reinforcing teaching to a client who has been prescribed fluticasone/salmeterol. What points are important for the client to understand? (SATA)
1. Swallow the capsule when having an acute asthma episode.
2. Rinse mouth after medication admini
2., 3., 4., & 5. Correct: This medication contains a steroid which can increase the risk of oropharyngeal fungal infections. Rinsing will reduce this risk of infection and will also decrease mouth and throat irritation. The medication should be taken ever
A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings?
(SATA)
1. Sodium 135 mEq/L (135 mmol/L)
2. Potassium 5.8 mEq/L (5.8 mmol/L)
3. BP 100/70
4. No weight loss
5. Calc
2., 5. Correct: Normal K 3.5-5.0 mEq/L (3.5-5.0 mmol/L); Normal serum Ca 9.0-10.5 mg/dL (2.25-2.62 mmol/L)?. The abnormal lab results need to be reported. Hyperkalemia is a serious electrolyte disorder associated with chronic renal failure due to decrease
Which nursing intervention can the LPN/LVN safely perform?
1. Assess a client for a hearing loss.
2. Reinforce hand-washing with the client who has bacterial conjunctivitis.
3. Evaluate a client's ability to instill eye medication.
4. Create the plan of c
2. Correct: The LPN/VN can reinforce education. The LPN/VN must know the scope of practice of the LPN/VN
1. Incorrect: The LPN/VN cannot instruct, assess, evaluate, or create the plan of care. These are RN tasks only.
3. Incorrect: The LPN/VN cannot instr
Immediately after a liver biopsy, a client is placed on the right side for 60-90 minutes. What is the rationale for placing the client in this position?
1. Helps stop bleeding if any occurs.
2. Restores circulating blood volume.
3. This is the position of
1. Correct: Anyone who has a liver biopsy is at risk for bleeding. The clotting factors are produced in the liver, as is prothrombin. Any time a needle is inserted into the body and removed, bleeding can occur. Whenever there is a risk for bleeding, the p
A client who is obese and paraplegic needs to be repositioned in the bed. What actions should the nurse take? (SATA)
1. Obtain assistance from a coworker.
2. Place the bed in the lowest position with the client close.
3. Adjust the bed to a workable posit
1., 3. & 4. Correct: The nurse should solicit a coworker for help, adjust the bed to a workable position, move close to the client, use a draw sheet with the assistance of a coworker, and pivot the hips while pulling the draw sheet upward. These steps wil
Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time?
1. "You are lucky to have lived a very long life."
2. "We have youn
4. Correct: The nurse responds with an open-ended statement that reflects back to what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to
What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality?
1. Turn the screen facing the client rooms so that healthcare personnel can access the information easily.
2. Have the scree
2. Correct: Computer monitors that display client health information should be positioned away from the view of any visitors or unauthorized persons. Even a well-guarded computer monitor, with an authorized employee sitting in front of it, could be a pote
A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money?
1. Insist the money go home with the client's visitor.
2. Place the money in the client's bedside table
3. Correct: It is best to have two witnesses (preferably hospital staff) sign the inventory list. The best action by the nurse would be to itemize the valuables, place in an envelope with the record of the inventory, and have it put in the hospital safe.
A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? (SATA)
1. Puffy hands and face
2. Reports indigestion
3. Pedal edema
4. Backache
5. Severe headaches
1., & 5. Correct: Facial and upper extremity edema can be a sign of pre-eclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, oft
What should the nurse include when reinforcing teaching to a female client prescribed doxycycline for the treatment of acne?
(SATA)
1. Take this medication with food to maximize absorption.
2. Use a non-hormone method of birth control while taking this me
2., 3., & 4. Correct: Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, and/or spermicide) should be used to prevent pregnancy while using
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given?
1. "The action of the medication is complex
4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration.
1. Incorrect: The
Which nursing task would be appropriate for the LPN/VN to complete?
1. Obtain a wound culture from a client.
2. Administer regular insulin IV to a client in diabetic ketoacidosis.
3. Update plan of care for a client.
4. Initiate client teaching on ostomy
1. Correct: The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN.
2. Incorrect: The LPN/VN cannot administer IV medications to an unstable client. This client needs the RN for close monitori
A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that reinforcement of teaching about this medication is successful when the client makes what statement?
1. Alprazolam will take up to two week
4. Correct: Suddenly stopping alprazolam could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium.
1. Incorrect: Alprazolam works relatively quick
What symptoms would the nurse anticipate in a client with a calcium level of 3.2 mg/dL (0.80 mmol/L)? (SATA)
1. Slowed deep tendon reflexes
2. Muscle rigidity and cramping
3. Hypoactive bowel sounds
4. Positive Chvostek's sign
5. Seizures
6. Laryngospasms
2., 4., 5., & 6. Correct: Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report mu
Which task would be appropriate for the LPN/VN to complete?
1. Assessing a client who was just admitted to the unit.
2. Administering morphine IV push to a two day post-op client.
3. Feeding a client through a percutaneous endoscopic gastrostomy (PEG).
4.
3. Correct: Feeding by way of a PEG tube would be the best assignment for the LPN/VN. This is a nursing action that can be performed by the LPN/VN and does not require verification nor a co-signature by the RN.
1. Incorrect: The LPN/VN can collect data on
A nurse is caring for a client diagnosed with Alzheimer's disease. What actions should the nurse initiate?
(SATA)
1. Monitor client's ability to perform activities of daily living.
2. Perform activities of daily living for the client.
3. Place a clock and
1., 3., 4., & 5. Correct: All of these should be included in this client's care. Monitor the client's ability to perform activities of daily living and allow client to perform alone if capable. Facilitate orientation by placing items such as a clock, news
Which assignments would be most appropriate for the LPN/VN to accept from the RN? (SATA)
1. Six year old with new onset diabetes.
2. Ten year old with pneumonia admitted two days ago.
3. Three month old admitted with severe dehydration.
4. Four year old a
2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable.
1. I
The nurse is caring for a client on the psychiatric unit. The client is prescribed fluphenazine 10 mg. The drug is available as an elixir: 2.5 mg / 5 mL. How many mL will the nurse give to the client? Round answer to the nearest whole number.
2.5 mg : 5 mL = 10 mg : x mL
2.5 mg/x mL = 50 mg/mL
2.5 mg/x mL = 50 mg/mL
x = 20 mL
The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse?
1. Leave the client alone and remove clients from the day
2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent.
1. Incorrect: The client may cause self injury
The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8 - 12 hours of sleep per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler?
1. Offer a time o
3. Correct: Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep.
1. Incorrect: Stimulation of activity before bedtime impedes sleep.
2. Incorrect: The routine should be maintained eac
Following surgery, a client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed for this client to prevent an adverse reaction related to methylprednisolone?
1. Pantoprazole
2. Phenytoin
3. Imipramine HCI
1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect.
2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a
The nurse is preparing a client for a renal biopsy. Which data is most important to gather prior to this procedure? (SATA)
1. BUN
2. NPO status
3. Prothrombin time (PT)
4. Serum potassium
5. Activated partial thromboplastin time (aPTT)
3. & 5. Correct: Yes, before you insert a needle into an organ for a biopsy it would be best to know their bleeding time and coagulation studies. Prothrombin is a protein produced by the liver. The PT test measures how well and how long it takes for blood
The nurse, caring for a client diagnosed with Alzheimer's disease (AD), notices the client becoming agitated. What nursing intervention would be appropriate for the nurse to initiate?
(SATA)
1. Provide a snack for the client.
2. Tell the client to stop th
1., 3., 4., & 6. Correct: Nursing interventions that address difficult behavior include redirection, distraction, and reassurance as provided by these correct interventions.
2. Incorrect: These behaviors are often unpredictable and not intentional. Do not
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure for this client?
1. Observation and support of ventilation
2. Insertion of indwelling urinary catheter
3. Nasogastric suctioning
4. Frequ
1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis.
2. Incorrect: Insertion of an indwelling
A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What information should the nurse reinforce to help reduce this side effect?
1. Stop taking the medication.
2. Drink plenty of water
2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet.
1. Incorrect: There is no need to stop the medication due to mild
What discharge instructions should the nurse reinforce to the client post abdominal hysterectomy? (SATA)
1. Ambulate at least 3-4 times per day.
2. Notify the primary healthcare provider of a yellow discharge from the surgical wound.
3. Swimming is allowe
1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch, or has
The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time?
1. E
3. Correct: Depressed clients often have little energy to do or think. The depression can lead to a lack of self-care as the client lacks motivation and energy. Give short, simple commands during this time.
1. Incorrect: Not very therapeutic. This is diff
The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point.
Step 1: 1000 mg : 1 g = x mg: 0.5 g
x = 500 mg
Step 2: 500 mg: 1 tab = 250 mg : x tab
500 x = 250
X = 0.5
Which primary healthcare prescription should the nurse perform first?
1. Insert intermittent catheter in client who has not voided in 8 hours.
2. Administer a bolus feeding via a client's gastrostomy tube.
3. Reinsert nasogastric tube (NG) that was pulled
1. Correct: The client who has not voided after 8 hours needs to be catheterized. This is the priority since the bladder is likely full and could lead to backflow of urine to the kidneys.
2. Incorrect: Not the priority here. The feeding can be done after
A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the nurse to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right?
1. Ad
4. Correct: Under the Patient Self-Determination Act (PSDA), healthcare institutions provide clients with a summary of their rights when making health care decisions as well as the facility's policies regarding recognition of advanced directives. The clie
A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last.
Monitor the client's orientation.
Assist the client to sit on th
In order to keep a client safe, the nurse should first check the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Thi
The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication?
1. Minimally swollen eyelid
2. Mild discomfort of the eye
3. Slight red appearance of the
4. Correct. The postoperative cataract client usually experiences little to no pain, and it can be managed with mild analgesics. If the pain is severe, there may be an increase in intraocular pressure, hemorrhage, or infection, and the surgeon should be n
The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nur
4. Correct: The client should have extremities elevated to encourage venous return and reduce the risk of swelling before the stockings are applied.
1. Incorrect: To place the stockings on immediately will cause further venous stasis and swelling.
2. Inco
A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take?
(SATA)
1. Notify the infection control nurse.
2. Continue to care for client as varicella and herpes zoster are not related.
1., & 5. Correct: Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The i
Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)?
1. Totaling I & O records on five clients at the end of the shift.
2. Assessing VS on a client who was admitted 30 minutes ago.
3. Administering nasogastri
1. Correct: Totaling I & O is an appropriate task for a UAP to be assigned. This is within the scope of practice for the UAP.
2. Incorrect: New clients should be assessed by an RN; however, it is acceptable for the RN to get assistance with some of the in
The nurse is identifying home safety issues to prevent injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this process?
(SATA)
1. Episodes of mild anxiety
2. Rugs secured to the fl
2., 3., 4. & 5. Correct: Throw rugs may cause falls, as the client may trip. Diabetes may also impact sensation and the client may be unaware that there is a rug in place. Adequate lighting is important so that the client does not bump into furniture or m
A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake?
1. Chee
1. Correct: A lacto-ovo vegetarian diet is a vegetarian diet that does not include meat, but does contain eggs and dairy. The client can eat milk and dairy products along with grain products on this diet.
2. Incorrect: Dairy products and eggs are allowed
Prior to administering medications, the nurse must identify the client using which identifiers? (SATA)
1. Room number
2. Date of birth
3. Identification band
4. Client correctly states name
5. Visitor stating client's name
2., 3. & 4. Correct: The client's date of birth and the client's identification band can be used as the two identifiers per Joint Commission standards. The client may also state their name. Two identifiers must be used.
1. Incorrect: The client's room num
Which action by a new nurse indicates to the supervising nurse that the sterile field has been contaminated?
1. Maintains the sterile field above the level of the waist.
2. Places sterile gauze dressing within the one inch border of sterile field.
3. Rema
2. Correct: No sterile object should be within the one inch border of the sterile field, as the object is no longer considered sterile.
1. Incorrect: This is a correct action. Bacteria tend to settle below the level of the waist, so there is less contamin
Post cataract removal, a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority?
1. Administer morphine and ondansetron.
2. Reposition client to non-operative side.
3. Massage the canthus to unblock the lacri
4. Correct: Severe pain and nausea indicate an increase in intraocular pressure and must be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery.
1. I
Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility?
1. Offer multiple environmental stimuli at the same time to provide distraction.
2. Encourage the client to
4. Correct: A regular routine and physical activity help clients with Alzheimer's disease maintain abilities for a longer period of time. Physical activities promote strength, agility, and balance. The client's walking should be supervised for client safe