1.An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C.
To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range
2.The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Admi
The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.
Correct Answ
3.A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of anal
The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medi
4.When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare han
The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry
5.The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.
Correct Answer: B
6.A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?
A. Contact th
To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloods
7.While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
A. Ackno
The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not pro
8.What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result i
Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in t
9.The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to impleme
The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the
10.A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to del
The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 � 60 /20x 1= 300/20=150
Correct Answer: 150
11.Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your bloo
(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client.
Correct Answer: D
12.The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?
A. If I exercise at least two times weekly for one hour, I will lower my choles
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 ti
13.The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?
A. Plac
(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.
Correct Answer: D
14.An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenbur
The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the ante
15.A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in an
Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B).
Correct Answer: B
16.The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the co
The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed.
Correct Answer: A
17.The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?
A. 31 gtt/min.
B. 6
(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg � 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg
18.A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to tak
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing
19.A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available,
Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the
20.A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
A. 13 ml/hour.
B. 63 ml/hour.
C. 80 ml/hour.
D. 125 ml/hour.
(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour.
Correct Answer: B
21.An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After p
The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less prio
22.The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
A. Immediately after exhalation.
B. During the inhalation.
C. At the end of three inh
The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for dist
23.The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer?
A. � tablet.
B. 1 tablet.
C. 1� tablets.
D. 2 tablets.
(C) is the correct calculation: D/H � Q = 7.5/5 � 1 tablet = 1� tablets.
Correct Answer: C
24.The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer?
A. 1 ml.
B. 1.5 ml.
C. 1.75 ml.
D. 2 ml.
(B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1� or 1.5 ml.
Correct Answer: B
25.Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5� hours. How much heparin has the client received?
A. 11,000 units.
B. 13,000 units.
C. 15,000 units.
D. 17,000 units.
(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1
26.The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer?
A. 0.5 ml.
B. 1 ml.
C. 1.5 ml.
D. 2 ml.
Using ratio and proportion:
8mg: 1ml :: 4mg:Xml
8X=4
X=0.5
Correct Answer: A
27.The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute?
A. 80
B. 8
C. 21
D. 25
The accepted formula for figuring drops per minute is: amount to be infused in one hour � drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 � 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (
28.Which action is most important for the nurse to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant ha
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).
Correct Answer: C
29.A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial acti
Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually f
30.An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?
A. Prone.
B. Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted di
31.A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan?
A. In 8 weeks
The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain
32.A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?
A. Assist the ambulating client back to the bed.
B. Encourage the client to ambu
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client'
33.A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Sug
Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein i
34.A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral
Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D)
35.During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grap
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since th
36.Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
A. Apply a condom catheter.
B. Apply a skin protectant.
C. Encourage increased fluid intake.
D. Assess for bladder distention.
Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distenti
37.A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubin
All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction.
Correct
38.Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?
A. Chocolate pudding.
B. Graham crackers.
C. Sugar free gelatin.
D. Apple slices.
The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort, and provide calor
39.The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?
A. Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B. New England
Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium.
Correct Answe
40.Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?
A. Height in inches or centimeters.
B. Weight in kilograms or pounds.
C. Triceps skin fold thickness.
D. Upper arm circumference.
Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.
Correct Answer: D
41.An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What actio
The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider
42.After completing an assessment and determining that a client has a problem, which action should the nurse perform next?
A. Determine the etiology of the problem.
B. Prioritize nursing care interventions.
C. Plan appropriate interventions.
D. Collaborat
Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).
Correct Answer: A
43.An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care
The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monito
44.A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client
A. asks relevant questions regarding the dressing
A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of th
45.When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nurs
First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome,
46.The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. Th
gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min
Correct Answer: B
47.Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?
A. 0.5 tablet.
B. 1 tablet.
C. 1.5 tablets.
D. 2 tablets.
15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 � 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B).
Correct Answer: B
48.Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
A. Aspirating gastric contents to assure a pH value of 4 or less.
B. Hearing air pass in the stomach after injecting air into the tubing.
C.
Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement.
Correct Answer: C
49.The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available
TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The cl
50.When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the
A. Arms.
B. Upper torso.
C. Head.
D. Feet.
The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the
51.In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
A. is to be expected, and progresses with age.
B. often follows relocation to new surroundings.
C. is a result of irreversible brain pathol
Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confus
52.An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is
A. prone.
B. Fowler's.
C. Sims'.
D. supi
The client should be positioned in a semi-sitting or Fowler's (B) position during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often referred to as a PEG tube, is inserted directly into the stomach through an incision in the
53.The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?
A. Talk directly to the child instead of the mother.
B. Continue asking the mother questions about
Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother que
54.When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
A. Complimentary healing practices interfere with the efficacy
Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medi
55.A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?
A. Sexual activity patterns.
B. Nutritional history.
C. Leisure activities.
D. Financial stressors.
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of
56.Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?
A. Reassure the client that he will becom
Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not
57.At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client
(C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays
58.The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?
A. The client voluntarily signed the form.
B. The client fully understands the procedure.
C. The client agrees
The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure t
59.The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
B. Notify the medication nurse immediately if the pulse
Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority.
Correct Answ
60.An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?
A. It is important that you continu
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medicatio
61.Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding?
A. Multiple vesicular areas surrounded by re
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an
62.The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?
A. Thalamus.
B. Hypothalamus.
C. Fronta
The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperatu
63.A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?
A. demonstrates loss of remote memory.
B. exhibits expressive dysphasia.
C. has a diminished attention span.
The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C).
Correct Answer: D
64.An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump?
A. 30
B. 60
C. 120
D. 180
(D) is correct calculation: 180 ml/hr = 500 ml/5 mg � 1mg/1000 mcg � 30 mcg/min � 60 min/hr.
Correct Answer: D
65.An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct?
A. Inquire about the source and type of pain.
B. Examine the nose for
Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A).
66.The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most ap
Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surge
67.A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this
A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administrati
68.The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?
A. Encourage the client to cough to help loosen se
Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.
Correct
69.A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?
A. Irrigate th
The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is cont
70.During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
A. Adequate venous blood flow to the lower extremities.
B. Estimated amount of body fa
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A do
71.During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?
A. Request another nurse to complete the physical assessment.
B. Ask the client to stop crying and tell the nurse what is wrong.
C. Acknowledge the
Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings.
Correct Answer: C
72.A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
A. Explain that anyone who speaks her language can answer her questions.
B. Provide a translat
A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private
73.The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?
A. Avoid any types of sprays, powders, and perfumes.
B. Wearing a mask while cleaning will not help to avoid alle
The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should av