Hurst Readiness Exam 3: Nursing Care Questions and Answers, Exams of Nursing

Download Hurst Readiness Exam 3: Nursing Care Questions and Answers and more Exams Nursing in PDF only on Docsity! Hurst Readiness Exam4, Hurst Readiness Exam 3 Latest Exam Questions with Correct Answers 2023 A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to unlicensed assistive personnel (UAP)? 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 ml/hr. on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client. - Correct answer 3, 4 What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation? 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 4. A mild laxative is recommended to alleviate constipation. 5. The client needs to increase fluid intake. Rationale - Correct answer 1,2,3,5 What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bed rest? 1. "Clients on bed rest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." P a g e 1 | 77 5. "The incontinent client will be kept clean and dry." - Correct answer 1,3,4,5 The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Monteux test. What precautions should the nurse take when administering the Monteux test? 1. Don sterile gloves. 2. Place the client on reverse isolation. 3. Wear a particulate respirator 4. Obtain a consent form. 5. Initiate airborne precautions. - Correct answer 3, 5 Which finding should a nurse expect when assessing a healthy 65 year old client? 1. Anomia 2. Presbyopia 3. BP 156/88 4. Apraxia - Correct answer 2 The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed? 1. "Prior to suctioning, I will hyper-oxygenate the client." 2. "I will instill normal saline bullets to liquefy secretions." 3. "I will allow at least 20 seconds between suctioning passes." 4. "Suctioning will be limited to a maximum of three catheter passes." - Correct answer 2 P a g e 2 | 77 Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks - Correct answer This is the correct order A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? 1. Call the respiratory department to have the ventilator removed. 2. Notify the facility's pastoral personnel. 3. Contact the regional organ procurement team. 4. Ask the family to select a funeral home. - Correct answer 3 A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "My child has not been able to sleep since being put on methyphenidate." What is the best response for the nurse to make? 1. "I will discuss this with the primary healthcare provider. A different medication may be prescribed." 2. "The insomnia will get better over time. Just wait it out." 3. "To prevent insomnia, give your child the last daily dose at least 6 hours before bedtime." 4. "Your child may have overdosed on the medication. Go to the emergency department now." - Correct answer 3 A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms? P a g e 5 | 77 1. Weight gain 2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia - Correct answer 2,3,4,5 A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube. - Correct answer This is the correct order A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident. - Correct answer 1 A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate? P a g e 6 | 77 1. Administer oxygen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm 5. Debride wounds - Correct answer 1,2,3,4 A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should take my needles to the nearest hospital for disposal. " - Correct answer 3 Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)? 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after eating. - Correct answer 1,2,3,4 A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag? 1. Traumatic amputation to the left lower leg. 2. 2nd and 3rd degree burns over 75 % of the body. 3. Fracture of the humerus. P a g e 7 | 77 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives." - Correct answer 1,2,4,5 A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding? 1. Perianal irritation from frequent diarrhea 2. Fistula formation with an abscess 3. Stricture formation 4. Impaired immunologic response to infectious microorganisms - Correct answer 2 Which factor would most likely predispose a client to developing shock following a fracture of the femur? 1. Pooling of the blood in the lower leg 2. Generalized vasoconstriction in the lower extremities 3. Loss of blood into soft tissues surrounding the fracture 4. Depression of the adrenal gland by toxins released at the injury - Correct answer 3 The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels - Correct answer 3 A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a P a g e 10 | 77 fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of Normal Saline. 3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department. - Correct answer 2 What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully. - Correct answer 1,3,4,5,6 A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Assess bilateral radial pulses - Correct answer 4 While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding? P a g e 11 | 77 1. Breech presentation 2. Edema of cervix 3. Closed cervix 4. Bulging membranes - Correct answer 1 A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry. - Correct answer 1,3,4,5 Which home routines help reduce the risk of skin damage in a client with impaired sensation? 1. Using a hot water bottle to help warm up when first going to bed. 2. Hot water heater set at a temperature of 140 °F (60 °C) 3. Open flame heaters in the living areas of the home. 4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Check condition of all equipment used in the home. - Correct answer 4,5 An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. P a g e 12 | 77 5. There is a risk for dependence on this medication. - Correct answer 1,2,4,5 A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions. - Correct answer 1 A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises. - Correct answer 3 A nurse is planning to teach a group of men about their sildenafil prescription. What information should the nurse include? 1. Notify primary healthcare provider if prescribed an alpha-adrenergic blocker. 2. This medication protects against sexually transmitted diseases. 3. Sildenafil should be taken only once per day if needed. 4. This medication is most effective if taken with grapefruit juice. 5. The most common side effects are flushing, headache, and dyspepsia. - Correct answer 1,3,5 P a g e 15 | 77 The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post- delivery to compensate for the increased energy requirements of lactation? 1. 1000 2. 300 3. 500 4. 800 - Correct answer 3 A client with a history of increasing dyspnea over the past week comes to the emergency department. After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to document? 1. The client had not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is sitting in upright position. - Correct answer 2 A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers? 1. Types of contact sports played 2. Amount of acetaminophen intake 3. Recent sore throat 4. Recent exposure to salmonella - Correct answer 3 A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? P a g e 16 | 77 1. Surgical scrub 2. Time-out 3. Sponge and instrument count 4. Inspection of the surgical site - Correct answer 2 Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collects a urine specimen from an indwelling catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence. - Correct answer 2,4,6 A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect? 1. Kinesis 2. Neuroleptic malignant syndrome 3. Pseudo parkinsonism 4. Oculogyric crisis - Correct answer 3 A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority? P a g e 17 | 77 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath. - Correct answer 1,2 A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? 1. "Hello Dry, I am calling about one of your clients." 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Rasp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?" - Correct answer 2,3,4,5 The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements? 1. "I should start feeling better in two or three days." 2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements." 5. "I need to keep the medication in a closed container in the refrigerator." - Correct answer 2,3,4 P a g e 20 | 77 The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client? 1. One diminishes the side effects of the other. 2. Hepatoxicity is reduced. 3. Bacterial resistance is decreased. 4. One kills the live bacteria, and the other the spores. - Correct answer 3 The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct? 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and beta dine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold. - Correct answer 3,4,5 The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi- private room would be appropriate for the charge nurse to have this client share? 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 3. Client who has a fractured hip. 4. Client diagnosed with bronchitis. - Correct answer 3 A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include? P a g e 21 | 77 1. Fever greater than 100.4° F (38° C) for 2 or more days. 2. Change in lochia from rubric to serosa. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn. 6. Able to provide self-care. - Correct answer 1,3,4,5 A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen - Correct answer 1,2,4,5 A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective? 1. Swelling in the legs 2. Increase in urinary output 3. Proteinuria 4. Increase in waist measurement - Correct answer 2 Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. P a g e 22 | 77 5. Use "needleless" devices whenever possible. - Correct answer 4,5 A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response? 1. "Why do you want to take kava-kava?" 2. "I really doubt your primary healthcare provider will approve you taking kava-kava." 3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 4. "Do not take Kava-kava for more than a year without a primary healthcare provider's supervision." - Correct answer 3 The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients. - Correct answer 3 Based on the Parkland formula, the primary healthcare provider has determined that a burn victim needs 9,250 mL of LR intravenously over the first 24 hours. How many milliliters of LR should the nurse administer over the first eight hours? Round answer to the nearest whole number. - Correct answer 4625 A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? P a g e 25 | 77 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences. - Correct answer 1,4,5 Which tasks would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures. - Correct answer 1,2,5,6 The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber. - Correct answer 4 A client at 36 weeks gestation is receiving magnesium sulfate for treatment of pre- eclampsia. Which finding by the nurse requires immediate action? 1. Respiratory rate of 12 2. Deep tendon reflexes (DTR) of 3+ 3. Urinary output (UOP) of 100cc/4hours 4. Fetal heart rate (FHR) of 120 - Correct answer 3 P a g e 26 | 77 Post thyroidectomy, the nurse assesses the client for complications by performing which assessment? 1. Perform blood glucose monitoring every 6 hours 2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr - Correct answer 2,3,4 What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid between the cheek and gum for greater absorption. - Correct answer 1 Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) - Correct answer 4 The nurse is working at the triage station. Which client should the nurse triage first? P a g e 27 | 77 4. Urine description and output. - Correct answer 2 The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment? 1. Frequent low-calorie snacks. 2. Strict monitoring of intake and output. 3. Use of sweeping gaze when walking. 4. Setting the alarm clock for medication times. - Correct answer 4 The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees. - Correct answer 3 The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment? 1. Co-dependency 2. Denial 3. Depression 4. Stigma - Correct answer 2 The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take? P a g e 30 | 77 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider. - Correct answer 2 What should a nurse teach a client who has been diagnosed with hepatitis A? 1. Hepatitis A is spread through blood and body fluid. 2. Chronic liver disease is a common complication of hepatitis A. 3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice. 4. Treatment includes alpha-interferon and ribavirin. - Correct answer 3 The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?" 1. It will increase the level of serotonin in the brain. 2. It will decrease the production of noradrenaline. 3. It will lower your level of the brain hormone norepinephrine. 4. It will balance blood glucose and dopamine levels in your head. - Correct answer 1 A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent? 1. The primary healthcare provider will want to start your child on a central nervous system (CNS) depressant in order to decrease hyperactivity and improve attention. 2. You will need to admit your child to the psychiatric behavioral unit so that group therapy can be initiated. 3. Children are often placed on central nervous system stimulants that improve behavior associated with ADHD. P a g e 31 | 77 4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy. - Correct answer 4 The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit - Correct answer 1,3 The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting - Correct answer 1,3,5 The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. P a g e 32 | 77 3. Massage therapist 4. Occupational therapist - Correct answer 3 What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 3. Client's plan for transportation and care at home. 4. Client's plan to spend the night at the surgical center. - Correct answer 3 The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first? 1. Apply warm compresses. 2. Slow the infusion. 3. Inspect the IV site. 4. Stop the infusion. - Correct answer 4 A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition? 1. A known allergy to gelatin. 2. A family history of autism. 3. In infants with diarrhea. 4. A known allergy to sulfonamides. - Correct answer 1 P a g e 35 | 77 A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance. - Correct answer 1,2,4,5 A nurse is teaching a client about the prescription aripiprazole discmelt. The nurse documents that teaching has been effective when the client makes which statement? 1. "If I start to have shakiness and sweating I need to call my primary healthcare provider at once." 2. "I must be certain to take this medication with food to eliminate vomiting." 3. "If I miss a dose of medication, I need to take an extra dose to make up for the missed dose." 4. "I will allow the tablet to dissolve in my mouth." - Correct answer 4 In what position should the nurse place a client post liver biopsy? 1. Left Sims' 2. Reverse Trendelenburg 3. Semi-Fowler's 4. Right Lateral Decubitus - Correct answer 4 The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? P a g e 36 | 77 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. 2. A client admitted with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound. 3. A client with ulcerative colitis exhibiting diarrhea. 4. A client with a fever of 99.1º F (37.2° C) two days post gastrectomy. - Correct answer 1 A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok." - Correct answer 1 A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? 1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted 6. Infusing rate of IV fluid - Correct answer 1,2,3,4,5 The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate? P a g e 37 | 77 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia - Correct answer 1,2,3,5 A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy (ECT). The client asks the nurse, "How many of these treatments do you think I will need?" What is the nurse's best response? 1. That is a question you need to discuss with your primary healthcare provider. 2. Everyone responds differently, but on average clients need 6-12 treatments. 3. You will need to take a treatment every month for at least a year. 4. Let's just take one treatment at a time, shall we? - Correct answer 2 The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? 1. Use personal handkerchief to wipe the eye of discharge. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water. - Correct answer 2,3,4,5 A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? 1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. P a g e 40 | 77 4. Headache occurs after recovering from a headache treated with narcotics. - Correct answer 1 Which statements should a nurse make when educating a client about advance directives? 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions. - Correct answer 2,3,4 After reviewing the nursing notes on a client receiving a unit of packed red blood cells, what action should the charge nurse take? Exhibit 1. Decrease the transfusion rate to 50 mL/hour. 2. Assess the client for a transfusion reaction. 3. Check primary healthcare provider prescription for prescribed administration time. 4. Stop the transfusion and send blood bag to the lab. - Correct answer 4 Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia P a g e 41 | 77 4. Diarrhea - Correct answer 2 Which prescriptions would the nurse recognize as being appropriate for the client with shingles? 1. Private room 2. Negative pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room - Correct answer 1,2,3 The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive- compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client? 1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom. - Correct answer 1,2,5 When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse? 1. Have the client sign the permit, as he verbalizes understanding. 2. Witness the form after having the client sign it. 3. Have his wife sign the form as she witnessed his statement that he understands. 4. Call the surgical area and explain that the surgery will have to be cancelled. - Correct answer 4 P a g e 42 | 77 1. "Are you hearing voices today?" 2. "What are the voices saying?" 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 5. "Are the voices telling you to harm yourself or anyone else?" - Correct answer 1,2,5 A client had an abnormal maternal serum Alfa fetoprotein (MSAFP) at 18 weeks gestation. She is now 22 weeks gestation, and an amniocentesis has just been completed for genetic analysis. Which nursing action has priority? 1. Monitor the needle entry site for signs of infection. 2. Encourage the client to express her feelings. 3. Assess the maternal blood pressure for hypertension. 4. Monitor fetal heart tones and uterine activity. - Correct answer 4 A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction? 1. Relieve nausea 2. Reduce pancreatic secretions 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants - Correct answer 2 The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication. 2. 24 hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. P a g e 45 | 77 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes. - Correct answer 1,2,3 The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan? 1. Identification of safe zones. 2. Methods for accounting for all people present in the building. 3. Warning system activation. 4. Identification of the gymnasium as the routine safe place. 5. Regular practice protocols. - Correct answer 1,2,3,5 A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse? 1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 3. Six year old admitted for evaluation of possible sexual abuse by a parent 4. Two month old with bronchopulmonary dysplasia being admitted for reflux. - Correct answer 3 A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves. - Correct answer 4 The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider? P a g e 46 | 77 1. Document the prescription prior to the end of the shift. 2. Explain to the pimary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds. - Correct answer 3,4 The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? 1. Empathize with the client and listen to feelings. 2. Inform the family and ask them to remove the guns. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation. - Correct answer 2 A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse's initial action? 1. Tell the client to stay calm, and that treatment will be provided soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Find a safe place away from the client and then notify security. - Correct answer 4 What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs? P a g e 47 | 77 Which snack selection by a client receiving chemotherapy would indicate to the nurse that teaching has been successful? 1. Fresh salad with cucumbers, carrots, and tomatoes. 2. Orange slices with yogurt. 3. Strawberries with whipped cream. 4. Milk shake with a packet of instant breakfast added. - Correct answer 4 A home health nurse inspects the home of a client scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness. What safety interventions should the nurse recommend based on findings within the home? Exhibit 1. Place ramp over the front steps. 2. Move client's bedroom downstairs. 3. Remove throw rugs. 4. Secure furniture so client can use for support. 5. Apply nonskid strips to shower stall. - Correct answer 1,2,3,5 A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment? 1. Fever and shivering 2. Agitation 3. Decreased body temperature 4. Constipation 5. Increased heart rate - Correct answer 1,2,5 P a g e 50 | 77 On the third postoperative day, a client develops a fever of 103.3ºF (39.6ºC) shivering and nausea. The primary healthcare provider writes these prescriptions. Which should the nurse do first? 1. Apply cooling blanket for fever. 2. Give ceftriaxone 1 gram IVPB stat. 3. Draw blood cultures. 4. Give promazine 50 mg po PRN for nausea. - Correct answer 3 A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing? 1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium - Correct answer 4 Which factors should the nurse include when teaching a parent about risk factors for otitis media? 1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5 - Correct answer 2,3,4 The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at P a g e 51 | 77 greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM - Correct answer 2 The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye. - Correct answer 4 How would the nurse determine the correct size oropharyngeal airway for a client? 1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth. - Correct answer 4 What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? 1. Evaluate results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. P a g e 52 | 77 4. Medical records must stay within the facility unless requested by another primary healthcare provider. - Correct answer 3 Which client will the charge nurse intervene on behalf when making rounds? 1. The client turned to left side 1 ½ hour ago. 2. Client who has been sitting in a chair for 2 ½ hours. 3. Client who is day one postop from hip replacement with abduction pillow in place. 4. The client who is in buck's traction with foot boots. - Correct answer 2 The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting? 1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L) - Correct answer 3 The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care? 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days. - Correct answer 3 The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no P a g e 55 | 77 documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal. - Correct answer 2 The nurse is teaching the Type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for which test? 1. Glucose tolerance test 2. Glycosylated hemoglobin 3. Glucose-6-phosphate dehydrogenase 4. Fasting blood glucose - Correct answer 2 Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time? 1. Call the primary healthcare provider. 2. Reposition the client. 3. Increase the suction level. 4. Irrigate the tube. - Correct answer 1 The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection by the client would indicate understanding of an acceptable food to eat? 1. Smoked turkey and dressing, sweet peas and carrots and milk. P a g e 56 | 77 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water. - Correct answer 3 What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood. - Correct answer 3 During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit. - Correct answer 2 The charge nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 3. Going between client rooms wearing the same pair of gloves to collect I&O reports. 4. Cleaning a blood pressure cuff with a disinfectant. - Correct answer 3 The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin? P a g e 57 | 77 A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school. - Correct answer 2 The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle? 1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again. - Correct answer 2 Which assessment finding by a nurse would best indicate a positive Mantoux tuberculin skin test in a client? 1. Formation of a vesicle that is 4 mm in diameter 2. A sharply demarcated region of erythema of 10 mm 3. A central area of induration of 15 mm surrounded by erythema 4. A circle of blanched skin surrounding the injection site - Correct answer 3 The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? P a g e 60 | 77 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication. - Correct answer 1 The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior? 1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion. - Correct answer 2 A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include? 1. Do not keep secrets for the suicidal person. 2. Express concern for a person expressing thoughts of suicide. 3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well. 4. Inform group of suicide intervention sources. 5. Do not leave a suicidal person alone. - Correct answer 1,2,4,5 What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung? 1. Place in semi-Fowler's position. 2. Connect to oxygen saturation monitor. 3. Assess respiratory status every 2 hours. P a g e 61 | 77 4. Prevent dependent loops in closed drainage unit tubing. 5. Maintain closed drainage unit at the level of the client's chest. - Correct answer 1,2,3,4 To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed - Correct answer 1,3,4,5 The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen? 1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Place the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed. - Correct answer 3 A client, admitted in Sickle Cell Crisis, is started on oxygen at 2L/NC and given a narcotic analgesic for pain control. What additional prescription is a priority for the nurse to initiate? 1. A high protein, low fat diet 2. Administration of a thrombolytic, such as streptokinase 3. Implementation of bleeding precautions 4. Administration of IV fluids for hydration - Correct answer 4 P a g e 62 | 77 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26 - Correct answer 1 A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client? 1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living - Correct answer 2 A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order. Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin. - Correct answer That is the correct order A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen - Correct answer 1,2,4,5 P a g e 65 | 77 A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What is the best indicator that this client has an actual fluid deficit? 1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily intake of 2400 mL and an output of 1600 mL, plus diarrheal stools. - Correct answer 3 What should the nurse tell the parents of a newborn about a Guthrie test? 1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when your baby is 6 weeks old. - Correct answer 1,2,3 A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse - Correct answer 3 A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription? P a g e 66 | 77 1. Promotes diuresis 2. Prevents injury 3. Promotes rest 4. Stimulates RBC production - Correct answer 1 Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients? 1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Client with abdominal discomfort and a rigid abdomen on palpation. - Correct answer 4 A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation? 1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs. - Correct answer 1,2,3,5 A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? 1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower. - Correct answer 2 P a g e 67 | 77 3. Bleeding time and coagulation studies 4. Serum potassium and urine sodium - Correct answer 3 What information should a nurse include when educating a client regarding buccal administration of a medication? 1. This route allows the medication to get into the blood stream faster than the oral route. 2. Stinging may occur after placing the medication in the cheek. 3. If swallowed, the medication may be inactivated by gastric secretions. 4. The buccal dose of medication will need to be increased from the oral dose. 5. Remove the tablet from buccal area after 15 seconds. - Correct answer 1,2,3 The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse? 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis. - Correct answer 2 A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent? 1. 102° F (38.89° C) temperature that started 2 days previously. 2. History of pharyngitis approximately 4 weeks ago. 3. Vomiting for 3 days. 4. A cough that started about 1 week earlier. - Correct answer 2 P a g e 70 | 77 The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication? 1. 1 minute 2. 2 minutes 3. 5 minutes 4. 10 minutes - Correct answer 2 A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? 1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide three meals per day 6. Dangle legs - Correct answer 1,2,3,4 A client's last two central venous pressure (CVP) readings were 13 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? 1. Dry oral mucus membranes 2. Tachypnea 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain - Correct answer 2,4,5,6 P a g e 71 | 77 A client has sustained a major head injury as a result of a motor vehicle accident. The emergency department nurse is assessing the client's neurological status every 15 minutes. Which sign would the nurse recognize as an early indicator of an increased intracranial pressure (ICP)? 1. Dilated and unresponsive pupils 2. Cheyne-Stokes respirations 3. Cushing's triad 4. Change in level of consciousness (LOC) - Correct answer 4 The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? 1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training. - Correct answer 1,2,3 A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make? 1. "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive." 2. "We will need to increase your dose of captopril once you become pregnant." 3. "In order to prevent neural tube defects, start taking folic acid." 4. "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. " - Correct answer 4 P a g e 72 | 77 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 4. "What prescription medications are you taking?" 5. "What alternative therapies have you used?" - Correct answer 1,2,3,5 The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout. - Correct answer 2 During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best? 1. No, they do not hate you. 2. What did you do to make others not like you? 3. Just don't pay attention to what others think of you. 4. I can't speak for the other people, but I don't hate you. - Correct answer 4 The nurse should question which prescription for a client diagnosed with acute heart failure? 1. 2 gram of sodium (Na) diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Start IV with NS at 125 mL/hr. - Correct answer 4 A nurse, assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the charge nurse take first? P a g e 75 | 77 1. Re-assign the client to a nurse who does not mind caring for HIV positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV positive clients. - Correct answer 2 A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin? 1. Frontal headache 2. Orthostatic hypotension 3. Decrease in intensity of chest pain 4. Cool, clammy skin - Correct answer 4 A client diagnosed with rheumatoid arthritis has been prescribed celecoxib. What should the nurse include in the client's education regarding this medication? 1. Do not take celecoxib with ibuprofen. 2. GI complaints and headache are among the most common side effects. 3. Drink a lot of water to offset the dehydration that may occur. 4. Notify the healthcare provider immediately if black stools are noted. 5. This medication provides relief of pain and swelling so you can perform normal daily activities. - Correct answer 1,2,4,5 The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include? 1. Providing a back massage P a g e 76 | 77 2. Administering pain medication when pain is rated at 5 out of 10 3. Distracting with music 4. Exercise 5. Prayer - Correct answer 1,2,5 The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis. - Correct answer 4 P a g e 77 | 77