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150 Cards in this Set

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During an admission interview, a patient tells the nurse about a six-year history of heart failure. Which of the following requires an immediate intervention by the nurse?

1. The patient’s feet are cool with 2+ pitting edema.

2. The patient complains of abdominal pain.

3. The patient has a productive cough of pink-tinged sputum.

4. The patient’s abdomen is bloated and tympanic.
Strategy: “Requires an immediate intervention” indicates a complication.
1) suggestive of right-sided heart failure; edema may be a chronic problem
2) may indicate right-sided failure; does not require an immediate intervention
3) CORRECT— indicates fluid in lungs, which will decrease respiratory ability; may be life-threatening; administer cardiac glycosides and diuretics, record I and O, oxygen therapy
4) may indicate right-sided failure
A severe storm has blown out the windows on a 30-bed medical/surgical unit. The nurse determines that clients have to be evacuated to other rooms throughout the hospital. Which of the following clients should the nurse transfer FIRST?

1. A 40-year-old client admitted with exacerbation of asthma who is receiving nebulizer treatments.

2. A 56-year-old client with unstable type 1 diabetes and a recent blood glucose of 124 mg/dL.

3. A 58-year-old client transferred from cardiac intensive care earlier in the day post-myocardial infarction.

4. A 60-year-old client with a peptic ulcer who is receiving a blood transfusion.
Strategy: Determine the most unstable client.
1) CORRECT— client is at risk of ineffective airway clearance due to particles in the air from storm debris and damage to the windows
2) blood sugar within normal limits
3) may be anxious; does not take priority over the client with asthma
4) second most unstable client; requires frequent monitoring due to blood transfusion
The nurse assists the physician to perform a lumbar puncture on a patient with a high fever. At the completion of the procedure, the nurse should instruct the patient to remain in which of the following positions?

1. Semi-Fowler’s position.

2. Flat supine position.

3. Reverse Trendelenburg position.

4. High Fowler’s position.
Strategy: Determine the outcome of each answer. Is it desired?
1) may cause leaking of CSF at the site, resulting in a headache
2) CORRECT— prevents headache and leaking of CSF at the site
3) may cause leaking of CSF at the site, resulting in a headache
4) may cause leaking of CSF at the site, resulting in a headache
The nurse leads an in-service on ethical issues. The nurse accurately describes which of the following situations as an example of the ethical concept of beneficence?

1. The nurse makes a treatment decision for the patient.

2. The nurse does not tell the patient his accurate diagnosis.

3. The nurse slaps a patient’s face.

4. The nurse remains at the bedside comforting an anxious patient.
Strategy: Think about each answer.
1) nurse recognizes clients have the right to determine a course of action and is fundamental to the practice of nursing
2) according to the ANA code of ethics, nurses tell the truth; client has the right to determine course of action based on accurate information
3) example of battery; any intentional touching with the client’s permission
4) CORRECT— beneficence is taking positive actions to help others
The psychiatric home health nurse visits the home of a patient diagnosed with middle-stage Alzheimer’s disease. The patient lives with his daughter and son-in-law, who both insist he stay with them for as long as possible. Which of the following observations MOST concerns the nurse?

1. There are extension cords on the floors behind furniture.

2. There is a bowl of artificial fruit on a glass coffee table.

3. There is a blow-dryer on a hook on the bathroom wall.

4. The door locks are at the tops of the doors.
Strategy: The topic of the question is unstated.
(1.) appropriate action; prevents tripping hazard in any home, especially one with elderly residents who may have visual and musculoskeletal conditions predisposing them to fall; telephone and other cords should be put behind furniture, not across open spaces
(2.) concerning but not priority; patient may think the artificial fruit is real and try to eat it; also, glass coffee table could present an injury hazard due to its height (can be bumped into) and substance (glass); if kept, the table could be put out of the way of any traffic, have its edges padded, and be covered with lightweight objects
(3.) CORRECT—the dryer itself could be hazardous to this patient in terms of misperceptions of what it is—e.g., a gun—or in terms of improper use causing burns or other injuries; also, having it in bathroom can increase potential for electric shock by patient having contact with water while holding the device when it is turned on
(4.) appropriate action; wandering is a frequent behavior of Alzheimer’s patients; by the time patients are in the middle to late stages of the disorder, are unable to look up and reach upward; door locks that are complex are best for Alzheimer’s patients at any time
The nurse cares for a patient who is complaining of pain at the IV site. Upon assessment, the nurse notes tenderness and redness at the IV insertion site and redness proximally along the vein. It is MOST important for the nurse to take which of the following actions?

1. Slow the infusion rate and monitor patient’s response.

2. Stop the infusion and notify the physician.

3. Remove the IV and apply a pressure dressing.

4. Remove the IV and apply warm soaks.
Strategy: "MOST important" indicates discrimination is required to answer the question.
(1.) symptoms are likely caused by phlebitis and will only progress with continued infusion
(2.) catheter should be removed and warm soaks applied; notify physician if the signs and symptoms are severe, if they persist, or as indicated by the facility’s policy; otherwise, nurse should document patient’s chart appropriately and monitor the site
(3.) warm soak required
(4.) CORRECT—IV catheter should be removed to prevent further damage to the vein; warm soaks decrease inflammation, swelling, and discomfort
An older man is hospitalized for abdominal surgery. The client has a history of Alzheimer’s disease. Two days after surgery the nurse enters the room to discover that the client had altered the IV flow regulator. Rather than receiving 125 cc/h of 0.9% NaCl as ordered, the client had received 400 cc of IV fluid during the previous hour. Which of the following assessments, if made by the nurse, indicates fluid volume overload?

1. Distended hand veins, elevated BP, and moist crackles on auscultation.

2. Increased peripheral pulses, postural hypotension, and hyperthermia.

3. Diminished bowel sounds, regular pulse, and warm dry skin.

4. Decreased urinary output, thirst, and changes in sensorium.
Strategy: All parts of the answer have to be correct.
1) CORRECT— signs of fluid volume overload include dependent edema, rapid weight gain, rapid pulse, dyspnea, skin pale and cool, and headache
2) usually see hypertension and bounding pulses; hyperthermia not seen
3) pulse will be full, GI tract may show increased motility, skin pale and cool
4) indicates fluid volume deficit; other symptoms include increased, thready pulse, decreased BP, postural hypotension, increased rate and depth of respirations, poor skin turgor
The nurse cares for clients on the urology unit. After assessing the clients, it is MOST important for the nurse to instruct the support staff to monitor which of the following clients?

1. A client diagnosed with diabetic retinopathy and hypertension.

2. A client with a blood urea nitrogen (BUN) of 35 mg/dL and serum creatinine of 2.5 mg/dL.

3. A client with urinary albumin of 30 mg/24 h.

4. A client with a urinary output of 3,000 mL/24 h.
Strategy: “MOST important” indicates priority.
1) although diabetic retinopathy with hypertension may indicate renal failure, these are not definitive diagnostic tools
2) CORRECT— indicates renal failure
3) normal >30 mg/24 h
4) may or may not indicate renal failure; composition of urine would determine client status
The clinic nurse instructs a client newly diagnosed with Raynaud Syndrome. Which of the following statements if made by the client to the nurse indicates the need for further teaching?

1. “I will warm up my car before I get in and start to drive.”

2. “I am going to my yoga class after I leave the clinic.”

3. “I will first place my fingers in warm, then cool, then cold water three times a day.”

4. “I am going to make coffee and cigarettes a thing of the past.”
Strategy: “Need for further teaching” indicates incorrect information.
1) appropriate action; heating the core of the body prevents chilling and consequential shunting of blood to the trunk from the extremities
2) appropriate action; helps decrease stress that can cause vasospasm; also may help increase circulation
3) CORRECT— may think will help the fingers adapt to different temperatures; cold causes vasoconstriction; instruct client to stay indoors in cold weather, keep the home warm, wear wool gloves, clothes, and socks
4) appropriate action; smoking causes vasoconstriction; limit caffeine
The nurse cares for children on the pediatric unit. A physician orders doxycycline (Vibramycin) 4.4 mg/kg IV once per day for a child weighing 88 lb. Record the correct amount of medication, in mg, that the child should receive for each dose. Type the correct answer into the blank.
Your Response:
Strategy: 2.2 lb = 1 kg
Correct answer: 176
As the health care provider removes the peripherally inserted central catheter (PICC) from a patient, a portion of the catheter breaks. Which of the following actions should the nurse take FIRST?

1. Check the patient’s radial pulse.

2. Turn the patient to the right side.

3. Apply a tourniquet to the upper right arm.

4. Instruct the unit secretary to call for a STAT x-ray.
Strategy: “FIRST” indicates priority.
1) second action; if tourniquet is too tight, a radial pulse will not be detected
2) do not move client to prevent movement of broken catheter piece
3) CORRECT— place close to axilla; prevents catheter piece from advancing into right atrium; after tourniquet is applied, check for presence of radial pulse; keep in place until x-ray obtained and surgical retrieval attempted
4) will x-ray; priority is to prevent catheter from advancing
The nursing staff at the new pediatric hospital discusses instituting a community education program regarding mental retardation, particularly prevention. It is MOST beneficial for the nurses to emphasize which of the following areas?

1. Alcoholism treatment.

2. Phenylketonuria (PKU) screening.

3. Nutritional supplementation.

4. Prenatal classes.
Strategy: "MOST beneficial" indicates that discrimination is required to answer the question.
(1.) CORRECT—alcohol is recognized as the leading cause of preventable mental retardation; mental retardation is included in the fetal alcohol syndrome (FAS) complex of symptoms
(2.) very important, but not priority; screening for PKU occurs in newborns
(3.) important, but not best
(4.) timing is close to the birth; tendencies toward mental retardation have already been established
The charge nurse in the emergency department receives a call from EMS that they are en route with four patients involved in a motor vehicle collision. Based on the report from EMS, the nurse plans to see which of the following clients FIRST?

1. An adult with an obvious deformity to the left knee, weak pedal pulses bilaterally, and complaining of pain.

2. An adult without obvious injuries, a decreased level of consciousness, and a heart rate of 126.

3. A child with an obvious deformity to the right forearm, a strong radial pulse, and complaints of pain.

4. A child, crying uncontrollable, with an abrasion on the forehead and a heart rate of 112.
Strategy: Determine the most unstable client.
1) likely a dislocation or fracture, pulses are equal and this is likely the client’s baseline assessment
2) CORRECT— may be experiencing hypovolemic shock related to an unknown hemorrhagic injury
3) likely a fracture, distal circulation is intact; risk for hemorrhage takes precedence
4) may be at risk for neurological deficit from head injury, crying indicates appropriate level of consciousness at this time; elevated heart rate is likely caused by patient crying; requires evaluation; however, risk for hemorrhage takes precedence
The nurse assesses an elderly client receiving dexamethasone (Decadron) 1.5 mg PO tid. The nurse is MOST concerned if the client states which of the following?

1. “I take my medication with meals.”

2. “I have this little sore on my leg that won’t go away.”

3. “I should take a brisk walk several times a week.”

4. “I avoid public places during the flu season.”
Strategy: “Nurse is MOST concerned” indicates a potential complication.
1) appropriate action; given with meals to decrease gastrointestinal irritation
2) CORRECT— steroids suppress the immune response; should report non-healing sores
3) elderly more susceptible to osteoporosis, which is exacerbated by oral steroids; encourage exercise
4) corticosteroids cause immunosuppression
The nurse cares for patients on the medical/surgical unit. The nurse notes that a patient is anxious and in respiratory distress. It is MOST important for the nurse to place the patient in which of the following positions?

1. Flat on back with thighs flexed and leg abducted.

2. Lying with the head of the bed elevated 15 °–30°.

3. Lying on side with legs bent.

4. Lying with the head of the bed elevated 60 °–90°.
Strategy: Determine the outcome of each answer.
1) describes lithotomy position; increases vaginal opening for examination
2) describes low-Fowler’s position; head of bed not elevated enough to promote optimal lung expansion
3) describes Sim’s position; decreases abdominal tension and allows drainage of oral secretions
4) CORRECT— allows optimal pulmonary expansion; decreases venous return which assists in lowering the ventricle’s output and pulmonary congestion
The charge nurse meets with the head nurse to discuss the staff’s concerns about implementing a new delivery of care model. The charge nurse gives the head nurse a document providing extensive rationales about why the staff has voted not to implement the new model. Which of the following actions by the head nurse is MOST appropriate?

1. Inform the charge nurse that the process was inappropriately initiated.

2. Reprimand the charge nurse in writing for insubordination.

3. Instruct nurse to inform the staff that the delivery model will be implemented.

4. Meet with the staff to obtain feedback regarding their concerns about the delivery model.
Strategy: Topic of question is unstated.
1) CORRECT— the role of the charge nurse is to support agency decisions; charge nurse should have informed staff that voting would not negate the process
2) insubordination is disobedience to authority; charge nurse made a mistake in allowing staff to vote
3) does not deal with the charge nurse’s decision
4) does not deal with the charge nurse’s decision
Caring for clients in the pediatric clinic, the nurse performs an assessment of a 9-month-old infant. The nurse expects which of the following findings?
Select all that apply:

1. The infant sits unsupported.

2. The infant pulls himself to a standing position.

3. The infant attempts to build a two-block tower.

4. The infant responds to simple verbal commands.

5. The infant can say three to five words.

6. The infant hugs his mother on request.
Strategy: Picture a 9-month-old infant.
1) CORRECT— can sit without support for prolonged period of time
2) CORRECT— can also stand while holding onto furniture
3) appropriate for a 12-month-old; a 9-month-old compares two cubes
4) CORRECT— comprehends “no-no”
5) appropriate for a 12-month-old
6) does show interest in pleasing parents; hugging parent on request more appropriate for a 12-month-old
The nurse in the outpatient clinic assesses a female client complaining of “burning with urination.” It is MOST important for the nurse to take which of the following actions?

1. Ask the client if she has experienced this before.

2. Encourage the client to drink cranberry juice.

3. Examine the urethral meatus and vaginal introitus.

4. Instruct the client to wear loose-fitting cotton underwear.
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) appropriate question but not the priority action
2) helps to acidify the urine; assess before implementing
3) CORRECT— client may have normal acidic urine that causes burning if labial tissues are inflamed because of vaginal infection
4) appropriate action to prevent UTI; assess before implementing
The nurse cares for clients on the cardiovascular unit. As the nurse is administering medications to the clients, a nursing assistant approaches the nurse to report that a client has a large amount of thick, dry mucus on one side of the tracheostomy tube. Which of the following responses by the nurse to the nursing assistant is MOST appropriate?

1. “Please take this tray of medications into the medication room for me.”

2. “Is the client having difficulty breathing?”

3. “Take a sterile cotton swab and remove the mucus using sterile technique.”

4. “Please find another nurse to take care of the client.”
Strategy: “MOST appropriate” indicates discrimination may be required to answer the question.
1) passing medication is the nurse’s responsibility; nurse is responsible for managing tray of medications
2) CORRECT— nursing assistant can observe whether or not client is in distress; many cardiovascular drugs require administration in a timely manner; assess before implementing
3) sterile procedures not within the scope of practice for a nursing assistant; risk pushing the mucus into the airway
4) inappropriate delegation
The nurse cares for a client with an internal radium implant. It is MOST important for the nurse to take which of the following actions?

1. Restrict visitors with upper respiratory infections.

2. Assign the client to male caregivers.

3. Plan nursing activities to decrease time spent in the client’s room.

4. Wear a lead-lined apron when caring for the client.
Strategy: Determine the outcome of each answer.
1) all visitors should limit time spent in the room because of the radiation therapy
2) radiation is as harmful to males as females
3) CORRECT— nurse should decrease the time spent in close contact with the client; do not stand in direct line of the radiation therapy
4) not required for routine care
What is the MOST effective way for the nurse to prevent unnecessary complications for a patient receiving medications in the acute care setting?

1. Encourage the patient to report any new or unusual symptoms to the nurse or physician immediately.

2. Obtain information regarding the patient’s allergies and document in the chart and an allergy armband.

3. Monitor the patient’s response to prescribed medications.

4. Offer patient information regarding medications before administration.
Strategy: “MOST effective” indicates discrimination is required to answer the question.
1) appropriate action; however, an allergic reaction is completely preventable if appropriate history is obtained and documented correctly
2) CORRECT— first line defense in preventing unnecessary reactions
3) appropriate action; however, must first know patient allergies
4) appropriate action; however, must first know patient allergies
The nurse performs a physical assessment on an 80-year-old female. The nurse expects to find which of the following findings?
Select all that apply:

1. The client has increased flexibility

2. The client’s height has decreased by 1 inch.

3. The client has increased range of motion.

4. The client has increased endurance.

5. The client has diminished muscle tone.

6. The client has joint stiffness.
Strategy: Think about each answer.
1) will have decreased flexibility due progressive deterioration of cartilage
2) CORRECT— caused by decreased bone density in vertebrae
3) has diminished range of motion due to progressive deterioration of cartilage
4) has decreased endurance due to atrophy of muscles
5) CORRECT— due to diminished size of muscles
6) CORRECT— due to changes in cartilage
The home care nurse visits an elderly client diagnosed with depression. The client’s daughter states that it is difficult for her mother to complete activities of daily living. It is MOST appropriate for the nurse to suggest which of the following?

1. Medicate the client before beginning activities.

2. Write a schedule of activities and allow extra time for the client to complete the activities.

3. Assist the client with all grooming activities.

4. Provide frequent forceful directions to keep the client focused on the activities.
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) will not increase client’s independence
2) CORRECT— communicates to client what is expected and then gives her the time to accomplish her tasks; depression causes decreased attention span and concentration
3) maintain client’s independence by allowing her time to complete activities
4) communicating clear expectations and giving client time to complete activities are more useful
The wife of a combat veteran tearfully tells the home health nurse that recently her husband gets upset about nothing in particular and shouts at her, “Get away from me!” or “Don’t bother me!” The wife states that she does not know what she has done wrong or what she should do. Which of the following responses by the nurse is BEST?

1. “You have not done anything wrong. He is probably just dealing with some war memories.”

2. “Do what he says. Make the environment quiet and keep your distance until he is less upset.”

3. “Approach him calmly and slowly, saying your name and where he is.”

4. “Touch his arm gently and ask him what he is so upset about.”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) not best response; false reassurance; may be post-traumatic stress disorder (PTSD) and he may be having flashbacks; wife may unknowingly trigger a PTSD experience
2) CORRECT— probably having PTSD flashbacks; when combat veteran is having a flashback, she/he is psychologically in a war zone reliving a trauma as if it were occurring now and may misidentify people as a threat; maintain a safe distance and limit stimuli
3) calm, slow approach is useful when client is diagnosed with PTSD, but not during flashback
4) client is giving clear directions to stay away; approaching client may agitate him further and cause probable injury; do not ask “why” questions
During a routine prenatal visit, the nurse assesses a client at 38 weeks’ gestation. The nurse auscultates the fetal heart rate (FHR) and notes that the fetal position is right occiput posterior (ROP). Identify the point of maximum intensity of the fetal heart tone.
Strategy: Identify the mother’s right side.
ROP indicates vertex presenting part with fetal occiput on the mother’s right side toward the back of her pelvis; because infant is vertex, FHT heard below the umbilicus.
The charge nurse on the medical unit reviews physician’s orders for four newly admitted patients. The nurse should question which of the following orders?

1. A CT scan for a patient with suspected intracranial bleeding.

2. A bone imaging study for a patient with multiple myeloma.

3. A chest X-ray for a patient with a positive tuberculin skin test.

4. An upper GI tract endoscopy for a patient with cirrhosis.
Strategy: "Nurse should question" indicates a complication.
(1.) appropriate order; computed tomography (CT) scanning used to identify extent of a brain injury, including intracranial bleeding and presence of lesions requiring surgery, such as epidural or subdural hematomas
(2.) CORRECT—every contrast medium has a risk for causing reactions; benefit vs. risk should be considered; multiple myeloma involves overproduction of plasma cells, with resultant destruction of bone and of bone marrow products; multiple myeloma is unique as a neoplastic condition that is better detected with a plain radiograph than with a nuclear scan; if a bone scan is done, false-negative results occur
(3.) appropriate order; chest x-ray is appropriate follow-up to a positive PPD to further diagnose possible TB
(4.) appropriate order; upper GI tract endoscopy, especially esophagogastroduodenoscopy, examines the esophagus, stomach, and duodenum to identify factors that can complicate the care of a patient with cirrhosis, such as esophageal varices or gastric or duodenal irritation, ulcerations, or bleeding
While working at a local welding plant, a piece of metal penetrates an employee’s right eye. The nurse admits the client to the emergency department. Which of the following responses by the nurse is MOST appropriate?

1. “Can you tell me exactly what happened?”

2. “I thought the Occupational and Health Safety Act (OSHA) required you to wear eye protection.”

3. “Did the plant have safety guidelines in place?”

4. “Do you know what type of material entered your eye?”
Strategy: “MOST appropriate” indicates priority.
1) does need to be documented, but not necessary to determine the client’s immediate need
2) priority is determining client’s immediate needs; safety discussion can happen at a later time
3) yes/no question that is not relevant to assessing the client’s current condition
4) CORRECT— some materials (copper, iron, steel) can result in intense inflammatory reaction; information assists the staff to determine the extent of the injury
At 5:00 pm, the nurse notes that the last entry in a patient’s chart was at 9:00 am. The nurse on the previous shift did not complete the chart and did not sign the nurses’ notes. Which of the following actions by the nurse is BEST?

1. Leave a note on the front of the chart asking the nurse to make a late entry and begin charting on the line below the last entry in the nurses’ notes.

2. Leave enough space for the previous nurse to complete charting when the nurse returns the next day.

3. The evening nurse withholds all charting until the previous nurse returns to complete charting for care delivered.

4. Contact the nurse from the previous shift and ask for a report so the evening nurse can complete the charting.
Strategy: Determine the outcome of each answer.
1) CORRECT— charting should be timely and accurate; begin charting on the next line
2) inappropriate action
3) charting should be timely
4) nurse should begin charting on the next line; should document date and time that care provided
The nurse in the prenatal clinic assesses a client at 7 weeks’ gestation. The client is 5'7" tall and weighs 125 lb. She relates to the nurse that she is concerned about gaining too much weight in pregnancy. Which of the following responses by the nurse is BEST?

1. “You seem to be concerned about gaining weight. It’s too early to think about that now.”

2. “You are already thin. You will not have any problems with gaining too much weight.”

3. “Don’t worry about your weight gain. I’m sure you’re used to eating balanced meals.”

4. First trimester weight gain is 3–5 pounds. You need to increase your intake of calcium, protein, and iron.
Strategy: Determine the outcome of each answer.
1) acknowledges the client’s concerns but then dismisses them
2) judgmental and dismisses the client’s concerns
3) dismissive of the client
4) CORRECT— should gain less than 5 lb in the first trimester; focus on nutrition required during the first trimester
The nurse cares for a client diagnosed with substance abuse. The client states he wouldn’t drink if his wife didn’t irritate him. The nurse recognizes the client is using which of the following defense mechanisms?

1. Rationalization.

2. Projection.

3. Denial.

4. Intellectualization.
Strategy: Think about each answer.
1) justification for an unreasonable act or idea to make it appear reasonable
2) CORRECT— attributing to others one’s feelings, impulses, thoughts, or wishes (blaming or scapegoating)
3) failure to acknowledge an intolerable thought, feeling, experience, or reality
4) excessive use of reasoning or logic to prevent person from feeling
A community health nurse conducts a prevention program for suicide at a high school. The nurse discusses high-risk groups for suicide. The nurse knows that further teaching is necessary if students from the group verbalize which of the following?

1. “Adolescents are at risk to commit suicide.”

2. “Depressed people are at risk to commit suicide.”

3. “History of previous suicide attempts put people at risk.”

4. “People grieving a loss for 9 months are at risk.”
Strategy: “Further teaching is necessary” indicates an incorrect statement.
1) males over 50 and adolescents ages 15–19 are at risk
2) indications of depression include low self-esteem, feelings of helplessness/hopelessness, sense of doom or failure; are at risk to commit suicide
3) true statement; turn aggression and rage toward self
4) CORRECT— grief is a normal human response that occurs in response to loss; the entire grieving process may take up to 3 years
The nurse notes a physician has ordered a diet consisting of increased amounts of fresh fruits and vegetables, chicken, and whole grain breads for a 45-year-old man. Which of the following findings does the nurse expect to see on the client’s chart?

1. Blood pressure of 128/80 lying and 134/84 standing.

2. Hematocrit of 40% and a hemoglobin of 11.2 mg/dL.

3. AST (SGOT) 30 U/mL and ALT (SGPT) 35 U/mL.

4. creatinine 12.2 mg/dL and BUN 25 mg/dL.
Strategy: Determine the significance of each answer.
1) normal BP; if had hypertension, would require diet low in salt and fat with limited protein
2) CORRECT— normal hematocrit for a man is 42- 52%, normal hemoglobin for a man is 13 - 18 mg/dL; both reduced with anemia; clients diagnosed with anemia need a diet high in protein, iron, and vitamins
3) normal AST for males is 8 to 40 U/mL and ALT for males is 8 to 40 U/mL; both elevated with liver disease, clients with liver disease need diet of increased carbohydrates, low protein, and low sodium
4) normal creatinine is 0.7 to 1.4 mg/dL; normal BUN is 7 - 18 mg/dL, under 60 years; both elevatedwith renal disease; ckients with renal disease need a diet with limited protein and restricted potassium, sodium, and phosphorous
A client is placed on gentamicin sulfate (Garamycin) IV q 8 hours. It is MOST important for the nurse to respond to which of the following statements made by the client?

1. “My wife tells me my hearing has changed.”

2. “My vision is blurred when I read the paper.”

3. “Food just doesn’t taste as good to me.”

4. “Look at this rash on my arms.”
Strategy: “MOST important to respond” indicates a potential complication.
1) CORRECT— decreased hearing and vertigo occur as a result of involvement of the eighth cranial nerve, which is caused by gentamicin (Garamycin) toxicity
2) gentamicin is an aminoglycoside; nephrotoxic
3) not toxic effect of this antibiotic
4) rash may indicate hypersensitivity reaction; more important to respond to changes in hearing
The nurse plans care for a client diagnosed with meningitis due to Haemophilus influenza . It is MOST important for the nurse to include which of the following in the client’s plan of care?

1. Place the client in protective isolation for 24 hours.

2. Monitor vital signs and perform neurological checks every 4 to 6 hours.

3. Dim the lights and minimize environmental stimuli.

4. Encourage oral fluids.
Strategy: Determine the outcome of each answer. Is it desired?
1) place on droplet precautions until 24 hours after antibiotics started
2) assess more frequently; assess for increasing ICP and shock
3) CORRECT— prevents complication of seizures
4) may be on fluid restriction due to ICP
The nurse instructs a client with right-sided weakness how to use a cane. Which of the following behaviors, if demonstrated by the client, indicates to the nurse that teaching is successful?

1. The client holds the cane in his right hand, moves it forward followed by his right leg, and then his left leg.

2. The client holds the cane in his right hand, moves the cane forward followed by his left leg, and then his right leg.

3. The client holds the cane in his left hand, moves the cane forward followed by his right leg, and then his left leg.

4. The client holds the cane in his left hand, moves the cane forward followed by his left leg, and then his right leg.
Strategy: Each part of the answer has to be correct for the entire answer to be correct.
1) hold the cane on the side opposite the affected extremity (left side)
2) the purpose of the cane it to support the weak side; it is advanced at the same time the weak extremity is advanced
3) CORRECT— the cane acts as support and aids in weight-bearing for the weaker right leg; elbow should be flexed 30° and tip of cane should be 15 cm lateral to the base of the fifth toe
4) cane is advanced at the same time the weak extremity advances and client leans on cane
The nurse observes staff caring for clients on the medical/surgical unit. The nurse determines care is appropriate if which of the following is observed?

1. The practical nurse cares for a client with a stage 1 pressure ulcer by wearing gloves.

2. The nurse assistant wears gloves while ambulating a client with an indwelling urinary catheter.

3. A registered nurse wears clean, non-sterile gloves when removing a Foley catheter.

4. A nursing assistant caring for a client on droplet precautions removes the mask prior to removing the gloves.
Strategy: "Care is appropriate" indicates appropriate nursing actions; topic of question unstated.
(1.) skin is reddened but intact; gloves not required
(2.) not necessary; glove required if contact expected with blood, body fluids, secretions, excretions, contaminated items, mucous membranes, or nonintact skin
(3.) CORRECT—appropriate action; sterile gloves required for catheter insertion
(4.) incorrect action; when exiting room, untie gown, remove gloves, remove mask, take gown off working from inside
The mother of a 2-year-old boy asks the pediatric clinic nurse, “Do you have any suggestions for what I can say to get my child to go to bed without a fuss?” Which of the following suggestions by the nurse is BEST?

1. Ask your child, “Do you want to go to sleep now?”

2. Say to your toddler, “After we read this story, it will be time for sleep.”

3. Say to your toddler, “It’s time to go to sleep.”

4. Ask your child, “Would you like to take your bear or elephant to bed with you?”
Strategy: “BEST” indicates discrimination required to answer the question.
1) giving toddler a choice about bedtime is inappropriate
2) CORRECT— avoids asking toddler’s permission to go to sleep; sets clear and reasonable limits; allows time for adjustment; builds trust when parent follows through; bedtime is paired with an enjoyable, calming activity; provides a ritual
3) likely to be met with a tantrum or other negativism
4) does allow appropriate and limited choices; does not create sufficient ritual or transition time
The nurse supervises care for a patient on the hospice unit who practices orthodox Judaism. The nurse determines care is appropriate if which of the following is observed?

1. An unleavened wafer is placed on the tongue of the patient.

2. The patient has a continuous intravenous morphine infusion.

3. The patient is turned to face east as signs of death appear.

4. The patient’s forehead is anointed with oil.
Strategy: "Care is appropriate" indicates correct nursing actions.
(1.) wafer known as the Eucharist is offered to Roman Catholic patients and may be given by lay persons; not appropriate for an orthodox Jewish patient
(2.) CORRECT—control of pain (palliative treatment) during end of life is most important to Jewish persons
(3.) end of life care in the Islam religion requires the dying to face east towards Mecca
(4.) anointing with oil is performed in many Christian religions
A 21-year-old college student diagnosed with asthma falls on the running track while preparing for a track meet. Use of the inhaler restores breathing and equilibrium. Since this is the third time this has occurred in 3 weeks, the college health center nurse is called to the scene. The student is conscious, alert, and oriented. Blood pressure is 120/82 mm Hg, pulse is 84 bpm, and respirations are 14/min. The coach asks the student to go to the emergency department to obtain medical evaluation to assess whether continued training is safe. The student refuses to seek medical evaluation. It is MOST appropriate for the nurse to take which of the following actions?

1. Contact the student’s parents to obtain consent for hospital evaluation and any needed treatment.

2. Call an ambulance and ask the student who he wants to accompany him to the hospital.

3. Tell the student he does not have to seek medical evaluation if he does not want to.

4. Suggest the coach remove the student from the training roster unless the student consents to be medically evaluated.
Strategy: "MOST appropriate" indicates that discrimination is required to answer the question.
(1.) student has the right to refuse treatment; he is of legal age, living away from home, conscious and oriented
(2.) student has the right to refuse treatment
(3.) CORRECT—student is of legal age to refuse treatment; even if he were not, he is living away from home so may be considered an emancipated minor with rights equivalent to legal age; a competent adult can refuse emergency treatment, and that refusal must be respected by all
(4.) may be appropriate response to the coach but nurse should direct comments to the student, who has the right to refuse treatment
The nurse evaluates a client diagnosed with myxedema. The nurse determines that treatment is effective if which of the following is observed?

1. The client wears multiple layers of clothing.

2. The client discusses the family’s finances with his wife.

3. The client becomes short of breath after climbing the stairs.

4. The client takes his medication every day.
Strategy: “Treatment is effective” indicates an improvement in the client’s condition.
1) indicates client still feeling excessively cold, which indicates hypothyroidism
2) CORRECT— hypothyroidism causes slowed mental functioning; improved thought processes indicate improvement
3) indicates hypothyroidism
4) vital that client takes medication as prescribed, but does not indicate that client’s condition is improving
The nurse assesses a client in the outpatient clinic for treatment of multiple sclerosis (MS). The nurse should assess for which of the following clinical manifestations?
Select all that apply.

1. Urinary retention.

2. Decreased level of consciousness.

3. Hypoactive deep tendon reflexes.

4. Intestinal obstruction.

5. Numbness or tingling sensation.

6. Decreased short-term memory.
Strategy: Determine how each answer relates to MS.
1) CORRECT— causes progressive demyelination of spinal cord, will see gradual weakness leading to paralysis, alteration in innervation of bladder and urinary tract
2) caused by CNS involvement, not seen with MS
3) hyperreflexia of extremities caused by demyelination of motor nerve fibers
4) peristalsis is not controlled by motor nerve fibers
5) CORRECT— client will also experience decreased sensitivity to pain, facial pain, and decreased temperature perception
6) CORRECT— cognitive changes are seen late in the disease and include decreased concentration, decreased ability to perform calculations, impaired judgment
The nurse prepares a client for a barium enema. It is MOST important for the nurse to include which of the following instructions?

1. “Your stool will be light-colored for 2 to 3 days after the test.”

2. “Once the test is over and you go to the toilet, you will be able to resume normal activities.”

3. “The x-ray table will be tilted so you can assume various positions.”

4. “During the test, it is crucial that you take slow, deep breaths through your mouth.”
Strategy: “MOST important” indicates priority.
1) accurate information but not the most important
2) after the rectal tube is removed and client evacuates the bowels, additional x-rays are taken; due to the bowel prep and procedure, most clients require a period of rest after the test
3) accurate information but not the most important; reassure client that he will be secure on the table during the x-rays
4) CORRECT— for test to be successful, client must retain barium; as barium is introduced, client may have the urge to defecate; slow, deep breathing will help ease the discomfort
A patient is admitted to the psychiatric unit for assaultive behavior toward others. The nurse notes that the patient has been involuntarily admitted. The patient is demanding to leave the hospital today. Which of the following responses by the nurse is BEST?

1. “Because you may be unsafe to yourself and others, you will need to stay for further observation.”

2. “Since you signed yourself in, you will be able to leave after your physician talks to you.”

3. “You applied to be admitted and will be able to leave after your physician talks with your family.”

4. “You asked to be hospitalized, but you can leave if you want.”
Strategy: Think about each answer choice
1) CORRECT— involuntary admission is made without the patient’s consent; patient is admitted in this way when he is a danger to self/others and is unable to meet his own basic needs
2) voluntary clients have the right to demand and obtain release; staff may reevaluate patient’s condition to determine if conversion to involuntary status is appropriate
3) voluntary clients have the right to demand and obtain release; staff may reevaluate patient’s condition to determine if conversion to involuntary status is appropriate
4) voluntary clients have the right to demand and obtain release; staff may reevaluate patient’s condition to determine if conversion to involuntary status is appropriate
The medical unit charge nurse plans assignments of the staff, which consists of three RNs, one LPN/LVN, and one nursing assistant. The charge nurse determines assignments are correct if the nursing assistant is assigned to which of the following clients?

1. A patient with a 5-day-old ostomy requiring stoma care and application of an ostomy appliance.

2. A patient diagnosed in a coma after suffering a head injury requiring cranial nerve assessment and Glasgow coma scale evaluation.

3. A patient diagnosed with a spinal cord injury requiring range of motion (ROM) exercises and instruction about autonomic dysreflexia.

4. A patient diagnosed with COPD and type 1 diabetes requiring a sputum collection for culture and sensitivity and blood glucose glucometer reading.
Strategy: Nursing assistance is assigned to stable clients with expected outcomes.
(1.) care of newly created ostomy assigned to RN; assessment required
(2.) assessment and judgment required
(3.) instruction about autonomic dysreflexia should be done by RN
(4.) CORRECT—standard, unchanging procedures; RN should instruct nursing assistant about type of specimen to collect, timing, proper collection container, and appropriate labeling of specimen
The nurse cares for a patient after a thoracotomy. The patient has a Pleur-Evac drainage system in place. Which of the following observations MOST concerns the nurse?

1. The water in the suction control chamber bubbles constantly.

2. There are 700 mL of drainage in the collection chamber.

3. The level of the fluid in the water seal chamber remains stable.

4. There are air bubbles in the water seal chamber when the patient exhales.
Strategy: "MOST concerns the nurse" indicates that something is wrong.
(1.) should be continuous gentle, slow but steady bubbling in the suction control chamber
(2.) first 24 hours after chest surgery, as much as 500–1,000 mL of drainage can occur, with 100–300 mL being in the first 2 hours and then a progressive decline in amount
(3.) CORRECT—the fluid in the water seal chamber should fluctuate with the respirations of the patient, rising with inspiration and falling with expiration; absence of fluctuation indicates either that the lung has re-expanded (which is desired) or that there is an obstruction of the chest drainage tubes (which is not desired); most common cause of tubing obstruction is the patient lying on the tubing; other causes are kinking, dependent loops, clots, or fibrin
(4.) should be bubbles in the water seal chamber when the patient exhales (on expiration phase or respiration cycle) and when coughing or sneezing; these bubbles indicate the system is removing air from the pleural space
The nurse educator prepares a class on crisis management. It is MOST important for the nurse to emphasize which of the following principles?

1. The most charismatic person should assume leadership during a crisis.

2. During a crisis, leadership should be equally shared by the team members.

3. A well-prepared team does not require leadership during a crisis.

4. One person should be in charge during a crisis.
Strategy: "MOST important" indicates discrimination is required to answer the question.
(1.) charisma is a type of personal magnetism with an exceptional ability to win the devotion of large numbers of people; not the deciding factor about leadership during a crisis
(2.) not effective during a crisis
(3.) good preparation helps in a crisis, but no leadership is not appropriate during a crisis
(4.) CORRECT—autocratic or directive leadership where leader maintains strong control and issues commands rather than makes suggestions or seeks input is appropriate in a crisis or emergency situation
A mother brings her 2-year-old girl to the clinic. The nurse notes that the child has honey-colored crusts, vesicles, and reddish macules around her mouth. Which statement, if made by the nurse, is BEST?

1. Your child has developed an irritation because she continues to use a pacifier.

2. Your child has an infection that can be treated with antibiotics.

3. Your child has developed a food allergy and you should restrict her diet.

4. Your child has been exposed to a sick child and should be isolated for a few days.
Strategy: “BEST” indicates discrimination is required to answer the question.
1) describes impetigo, not an irritation
2) CORRECT— describes the skin eruptions found with impetigo; symptoms of impetigo include reddish macule becoming vesicle, then crusts, pruritus; caused by Staphylococcus , Streptococcus
3) symptoms suggestive of impetigo, not food allergy
4) unnecessary to isolate child; should use skin isolation and good handwashing techniques; antibiotics: may be topical ointment (Garamycin, Neosporin) and/or PO; loosen scabs with Burow solution compresses, remove gently, restraints if necessary; mitts for infants to prevent secondary infection; monitor for acute glomerulonephritis (complication of untreated impetigo)
The nurse gives a report to the next shift. During the report, a client’s ventilator alarm is activated. Which of the following actions should the nurse take FIRST?

1. Notify the respiratory therapist.

2. Observe the ventilator tubing for excessive fluid.

3. Deactivate the alarm and check the spirometer.

4. Auscultate breath sounds.
Strategy: “FIRST” indicates priority.
1) nurse should first assess client; even if the ventilator is the problem, client’s respiratory functioning must be supported
2) assess the client first and then the equipment
3) can silence the alarm, but do not deactivate
4) CORRECT—must support client while identifying and correcting ventilator problem; obtain vital signs, observe rate and quality of respirations, and assess for hypoxia
The nurse evaluates a patient diagnosed with schizoaffective disorder. Which of the following outcomes BEST describes a favorable response to psychological intervention?

1. The patient has a high level of psychomotor activity and no longer hears voices.

2. The patient’s facial expression is blunted and he/she walks slowly lacking arm swing.

3. The patient performs appropriate self-grooming when prompted, and speech is coherent.

4. The patient walks with an arched back, and delusions of persecution are no longer expressed.
Strategy: "BEST" indicates discrimination is required to answer the question.
(1.) suggestive of akathisia and restlessness, which are extrapyramidal side effects (EPS) of antipsychogotics used to treat schizoaffective disorder
(2.) signs of drug-induced Parkinsonism, another form of EPS, which are unfavorable responses
(3.) CORRECT—cooperative behavior and improved thought processes as evidenced by coherent speech is the expected therapeutic response to antipsychogotics; no evidence of EPS
(4.) indications of dystonic reaction, a form of EPS, another unfavorable response to medication
The nurse determines which of the following patients is at highest risk of developing colorectal cancer?

1. A 33–year–old African American female elementary–school teacher diagnosed with endometriosis.

2. A 47–year–old Chinese male who owns a restaurant and has a history of a ruptured appendix.

3. A 50–year–old Caucasian male cattle farmer diagnosed with ulcerative colitis.

4. A 70–year–old Caucasian female who is a retired bus driver and has an inguinal hernia.
Strategy: Think about each answer
1) no risk factors for colorectal cancer
2) age over 40 is a risk factor
3) CORRECT— risk factors include age over 40 and history of ulcerative colitis; diet for ulcerative colitis is high protein, high calorie and low residue; diet high in fat, high in protein, and low in residue is a risk factor for colorectal cancer
4) age is a risk factor
Two days after her menses began, a 17-year-old high school student experienced sudden, severe, intermittent, left lower quadrant (LLQ) pain. Her mother drives her to a local outpatient clinic and tells the triage nurse her daughter needs something for menstrual cramps so she can participate in cheerleading tryouts. Which of the following responses by the nurse is BEST?

1. “You will need to discuss that with the physician.”

2. “She probably should not be trying out for the cheerleading squad today.”

3. “Her signs/symptoms sound as if they involve more than her menstrual period.”

4. “You appear very concerned about your daughter’s condition.”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) passing the buck; teen will see the physician, but the nurse is knowledgeable and is capable of responding to the mother
2) should focus on the signs/symptoms
3) CORRECT— sudden onset of severe pain could indicate tissue injury or rupture of an organ
4) mother has expressed concern about cheerleader tryouts, nurse should focus on safety of teen
The home care nurse visits a client diagnosed with lupus erythematous. When instructing the client, it is MOST important for the nurse to include which of the following?

1. “Ask your physician to order a lipid profile and a urinalysis with the yearly examination.”

2. “Ask your physician to include a blood urea nitrogen (BUN) with the examination.”

3. “Seek psychological support with a support group if you get depressed.”

4. “Vigorous exercise will help with the aching and stiffness in your joints.”
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) CORRECT— proteinuria and hyperlipidemia are common with systemic lupus erythematous; instructing the client empowers him/her to assume responsibility for health
2) usually normal
3) probably should explore personal preferences with client
4) should balance rest and activity
The psychiatric nurse on the inpatient unit identifies which of the following patient situations as MOST requiring the nurse’s immediate attention?

1. A patient taking clozapine (Clozaril) for 2 months comes to the nursing station and complains of feeling hot and having a sore throat.

2. A patient taking diazepam (Valium) PRN for anxiety asks for the medication on an increasingly regular basis.

3. A patient taking lithium carbonate (Eskalith) for 10 days is observed to be thirsty and has fine hand tremors, mild nausea, and frequent urination.

4. A patient taking haloperidol (Haldol) for 4 days has a temperature of 102°F (38.9°C).
Strategy: Determine the MOST unstable patient.
(1.) is of very definite concern, but not first; may indicate flu, but may also indicate the very serious adverse effect of this drug, which is agranulocytosis
(2.) may indicate that the Valium and/or other medications being taken for anxiety are not being effective; may also indicate beginning dependence on the drug, which is a benzodiazepine
(3.) fine hand tremors, polyuria, and polydipsia are expected minor side effects from therapeutic levels of lithium; therapeutic levels are usually reached in 7 to 14 days
(4.) CORRECT—may indicate impending neuroleptic malignant syndrome (NMS); NMS is a potentially lethal side effect of antipsychotic medications, especially high-potency drugs such as Haldol; medical emergency
The home care nurse instructs a client diagnosed with Bell’s palsy. Which of the following statements, if made by the client to the nurse, indicates further teaching is necessary?

1. “I should place an eye shield over the affected eye at bedtime.”

2. “I should avoid sudden movement when bending over.”

3. “I should not go out when there is a cold wind.”

4. “I should use heat on the affected side of my face.”
Strategy: “further teaching is necessary” indicates an incorrect statement.
1) appropriate action; prevents corneal irritation; use artificial tears
2) CORRECT— required if client has problems with increased intraocular pressure
3) appropriate action due to sensitivity of nerve endings
4) appropriate action
The nurse on a medical/surgical unit admits a young adult suspected of having acute glomerulonephritis. Which of the following questions should the nurse ask FIRST?

1. “Have you had a sore throat within the last few weeks?”

2. “Have you noticed a significant weight gain?”

3. “Has your appetite decreased within the last few weeks?”

4. “Have you noticed an increase in fatigue over the last few weeks?”
Strategy: “FIRST” indicates priority.
1) CORRECT— infection often occurs before the onset of acute glomerulonephritis; sore throat caused by group A beta-hemolytic Streptococcus is a common cause; infections
2) sodium retention resulting in weight gain does occur; during admission, nurse is obtaining as much information as possible to validate possible cause
3) common sign/symptom but not the first question asked
4) common sign/symptom but not the first data needed to validate diagnosis
The nurse in the outpatient psychiatric clinic is meeting in a room with a client. Without warning, another client diagnosed with antisocial personality disorder comes into the room and sits down. Which of the following responses by the nurse is MOST appropriate?

1. “If you sit quietly, you may stay in the room.”

2. “Is there something that you need?”

3. “How do you feel about another client joining us?”

4. “I am talking with this client. Please return to the waiting room.”
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) firm limit-setting required; confront behavior consistently
2) do not allow client to infringe on others’ rights
3) not appropriate for client to interrupt
4) CORRECT— sets limits on behavior in a nonjudgmental way
A patient is to begin taking beclomethasone dipropionate (Vanceril) by metered dose inhaler (MDI) for control of asthma. Which of the following statements, if made by the patient to the nurse, indicates that teaching is successful?

1. "Once I see that the canister floats on top of a container filled with water, I know it is time to have the prescription refilled."

2. "I will rinse my mouth and throat with water each time I am done with the treatment."

3. "I will be sure not to shake the canister before I use it."

4. "If the treatment does not seem to be working with the dose that usually works, I will try a bit more and let the physician know the results."
Strategy: "Teaching is successful" indicates correction information.
(1.) once canister floats like this it is probably near empty; should not wait until it is empty because there is an imbalance in the amounts of medication and propellant at this time, and the last several doses are therefore frequently below therapeutic level
(2.) CORRECT—Vanceril is a corticosteroid; inhaled corticosteroids can predispose to fungal oropharynx infection (candidiasis); rinsing mouth and gargling with warm water when each treatment is completed is imperative to remove residual medication and to delay or prevent onset of infection
(3.) canister should be shaken thoroughly before use to disperse and mix the medication with the propellant
(4.) dangerous; the medication should be used exactly as it was prescribed; if more (quantity or frequency) seems to be needed, physician should be consulted first; an overdose could result in hypertension, palpitations, angina, dysrhythmias
The nurse cares for a client receiving potassium chloride 25 mEq IV piggyback. The potassium chloride is labeled 10 ml = 40 mEq. Record the number of milliliters of potassium chloride that the nurse should add to the IV solution.
Strategy: Set up a ratio.
Correct answer: 6.25
The parish nurse knows that it is MOST important to encourage which of the following men to obtain screening for prostate cancer?

1. A 24-year-old Caucasian computer programmer diagnosed with cryptorchidism.

2. A 42-year-old Asian American restaurant owner diagnosed with ulcerative colitis.

3. A 55-year-old African American factory worker in automobile tire manufacturing.

4. A 62-year-old Caucasian retired house painter who has been smoking for 40 years.
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) no risk factors for prostate cancer; age, race, and cryptorchidism (undescended testicle) are all risk factors for testicular cancer
(2.) no risk factors for prostate cancer; inflammatory bowel diseases such as Crohn disease or ulcerative colitis are risk factors for colorectal cancer, especially if disease course has been long and severe
(3.) CORRECT—three major risk factors: age, race, employment; prostate cancer is found most commonly in men age 50 and over; African Americans are affected more than other ethnic groups; occupation and environment are other definite risk factors, particularly exposure to carcinogens found in urban areas (higher incidence of prostate cancer) and in occupations such as fertilizer, rubber, and textile industries, as well as in places with heavy metals such as cadmium; cadmium used in low-friction, fatigue-resistant alloys, in nickel-cadmium batteries, and in rustproof electroplating
(4.) risk factors are for lung or bladder cancer
The nurse counsels a client diagnosed with a seizure disorder. The client has just won a national beauty pageant and will be frequently traveling during the next year. It is MOST important for the nurse to include which of the following instructions?

1. “Travel with a person experienced in handling health problems.”

2. “Place your medication in a carry-on bag.”

3. “Ask for hotel rooms on the first floor.”

4. “Avoid flashing lights.”
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) constant supervision not required for health management; client should carry medical alert bracelet or card
2) CORRECT— take medication as prescribed to keep drug levels constant to prevent seizures; should carry medication because luggage can get lost
3) should avoid exercise in excessive heat; room location not a priority
4) priority is carrying anti-seizure medication
The nurse identifies which of the following behaviors as associated with a dysfunctional family process related to impaired communication?

1. Acknowledgment of personal needs and role responsibilities.

2. Congruence between verbal and nonverbal messages.

3. Appropriate response to other family members’ needs.

4. Inability to meet the emotional needs of other family members.
Strategy: Think about each answer.
1) indicates a functional family unit; one of the functions of the family unit is to assist the members to meet their physiological, emotional, and safety needs
2) occurs in a functional family unit
3) occurs in a functional family unit
4) CORRECT— a functional family unit helps the family members meet their physical, psychosocial, and safety needs
Hospital administration decides the psychiatric unit will move to a former medical-surgical unit in 2 months. The psychiatric nurse manager goes to the new unit to assess its structure. Which of the following MOST concerns the nurse?

1. The lights and floor coverings in the hallways.

2. The location of the nursing station in relationship to the patient rooms.

3. The fixtures in the bathrooms in patient rooms.

4. The availability of a large central room for unit meetings and socialization.
Strategy: "MOST concerns the nurse" indicates that something is wrong.
(1.) if the lighting is breakable glass, needs to be addressed prior to the unit move
(2.) of concern, but not most; can adapt to whatever configuration is available
(3.) CORRECT—fixtures such as towel bars, shower bars, safety rails should be made of materials that break away from weight of patient attempting to kill him/herself by hanging or jumping; shower nozzles should be breakaway or recessed; toilets should be low flush pressure; lighting must be unbreakable
(4.) a dayroom is very important for a psychiatric unit so that community meetings as well as informal socialization and visitation can occur; safety takes priority
The nurse discusses skateboard safety with a group of parents. It is MOST important for the nurse to include which of the following statements?

1. “If your children are younger than 5, always observe them while they are skateboarding.”

2. “Carefully check the surface where your child will be skateboarding.”

3. “It does not matter what type of skateboard you get for your child.”

4. “Instruct your child to keep as close to the curb as possible.”
Strategy: Determine the outcome of each answer. Is it desired?
1) children younger than 5 should not skateboard; developmentally they have difficulty protecting themselves from injury
2) CORRECT— check for holes, bumps, rocks, and debris
3) skateboards are designed for various uses (slalom, freestyle, or speed); know how you child plans to use the skateboard
4) never ride a skateboard in the street
The nurse teaches the mother of an infant about how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?

1. “Feed the infant with a newborn nipple while holding him in the recumbent position.”

2. “Clean the suture site with a cotton-tipped swab soaked in Betadine.”

3. “Place the infant in the prone position after feeding.”

4. “Feed the infant with a rubber-tipped syringe and bubble frequently.”
Strategy: Determine the outcome of each answer. Is it desired?
1) unsafe because of aspiration; hold infant’s head in an upright position
2) site is cleansed with saline or hydrogen peroxide after feeding; position infant on back or side or in an infant seat to prevent trauma to suture line
3) incorrect positioning; place upright
4) CORRECT— rubber tip can be placed at the side of the mouth to avoid the operative area and to prevent sucking on the tubing; infants with cleft lip swallow excessive amounts of air, so they require frequent bubbling
The home care nurse visits a client diagnosed with cardiomyopathy. The client asks the nurse how he will know if he is “overdoing it.” Which of the following responses by the nurse is BEST?

1. “If you feel fatigued, you have done too much.”

2. “Follow the list that your physician gave you.”

3. “Coughing up more sputum is a good indication.”

4. “To prevent doing too much, allow your family to help you.”
Strategy: Determine the outcome of each answer. Is it desired?
1) CORRECT—fatigue is a useful guide in gauging activity tolerance in patients with decreased cardiac output; cardiomyopathy is subacute or chronic enlargement of heart
2) does not answer client’s question
3) may indicate pulmonary edema; client should discontinue activities at this point
4) encourage client to be as independent as possible
The nurse at the preschool learns that a child has developed hepatitis A. The nurse instructs the staff about signs and symptoms of hepatitis A. The nurse informs the staff that which of the following is the MOST likely symptom of hepatitis A in young children?

1. Anorexia.

2. Jaundice.

3. Arthralgia.

4. Clay-colored stools.
Strategy: “MOST likely” indicates discrimination may be required to answer the question.
1) CORRECT— anorexia, malaise, lethargy and easy fatigability are most common symptoms
2) only 1 in 12 young children with acute viral hepatitis develops jaundice
3) more common with hepatitis B
4) will occur if child develops jaundice
Upon assessment of a patient admitted for dehydration, the nurse observes that the patient appears restless and complains of difficulty breathing. Upon auscultation of the patient’s lungs, the nurse notes bibasilar crackles. Which of the following actions should the nurse take FIRST?

1. Place the patient on 2 liters of oxygen per nasal cannula and auscultate the lungs.

2. Elevate the head of the bed and stop the infusion.

3. Decrease the IV flow rate and administer Lasix as ordered.

4. Stop the infusion and notify the physician.
Strategy: "FIRST" indicates priority.
(1.) appropriate action; however, by immediately positioning patient for maximum lung expansion with minimal effort, more rapid improvement of ventilation will occur while preparing other interventions
(2.) CORRECT—signs and symptoms suggest fluid overload; elevating the head of the bed maximizes respiration; stopping the infusion prevents further overload and progressive complications
(3.) inadequate response; will likely stop IV fluids and administer a diuretic, but first elevate the head of the bed
(4.) appropriate action; elevate the head of the bed before contacting physician
The nurse cares for a newborn diagnosed with a myelomeningocele. The nurse identifies that which of the following actions is MOST important?

1. Monitor for elevated temperature, irritability, and lethargy.

2. Perform range-of-motion exercises to feet, ankles, and knee joints.

3. Apply lotion to healthy skin and gently massage skin.

4. Measure occipitofrontal circumference daily.
Strategy: “MOST important” indicates priority.
1) CORRECT— infant is at risk to develop infection (meningitis) because of myelomeningocele sac; change dressing every 2–4 hours using aseptic technique
2) prevents contractures; risk for infection takes priority
3) prevents skin irritation; keep perineal area clean and dry; place on pressure-reducing surface; risk for infection takes priority
4) at risk for impaired circulation of cerebrospinal fluid; risk for infection takes priority
The nurse in the psychiatric day hospital program cares for a patient diagnosed with recurrent depression. The referring therapist recommends a cognitive therapy approach. The nurse doing the initial assessment knows it is MOST important to focus the assessment on which of the following?

1. The patient’s use of language.

2. The patient’s insight into the depression.

3. The patient’s socialization history and skills.

4. The patient’s attitude toward medications.
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) CORRECT—cognitive viewpoint on depression sees it as stemming from errors in thinking, which may be negative, illogical, and/or irrational; language is used in thought as well as in speech; speech or writing is used to express thoughts and thereby is an indicator of the patient’s automatic thoughts, their schemata or cognitive structure about themselves and the world, and their cognitive distortions
(2.) emphasis on insight is prominent in traditional psychoanalytic and psychodynamic therapies
(3.) emphasis on socialization is prominent in behavioral therapies, milieu therapies, and some interpersonal psychotherapies
(4.) emphasis on medications is prominent in biochemical and psychologic therapies
A mother of a 7-year-old girl and 2 1/2–year-old boy tells the clinic nurse that she works full-time, loves to garden in her spare time, and has lots of house plants. She relates to the nurse that her 2 1/2-year-old is “into everything all the time and drives me to distraction!” Which of the following responses by the nurse is BEST?

1. “What kind of plants do you have?”

2. “Who is available to care for your son when you need a break?”

3. “Was your daughter like this when she was his age?”

4. “It must be hard balancing work and children.”
Strategy: Topic of question is unstated.
1) CORRECT— addresses safety issues; some plants are poisonous and/or can cause a variety of symptoms, such as irritation of oropharynx and GI tract; respiratory, renal, and CNS symptoms; dermatitis; choking; allergic reactions
2) helps assess support system and also conveys legitimacy of needing a break; deal with safety issues first
3) yes/no question, nontherapeutic
4) deal with safety issues first
The nurse obtains a history from a client scheduled for a permanent pacemaker insertion. It is MOST important for the nurse to convey which information to the physician?

1. The client is diagnosed with obsessive-compulsive disorder.

2. The client wears a hearing aid in the left ear.

3. The client works as a computer programmer.

4. The client lives in a two-story house.
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) not most important; may impact teaching about pacemaker management, specific directions likely to be followed, especially if written, but anxieties about pacemaker function and safety may be intense
2) CORRECT— hearing aid battery may affect placement of pacemaker; should not be placed under the left clavicle in this client
3) equipment that is grounded and well maintained is not a problem
4) clients with pacemakers do not require stair-climbing restrictions unless heart rhythm shows marked variation in response to this activity
The nurse cares for a client diagnosed with ventricular tachycardia. It is MOST important for the nurse to administer which of the following medications?

1. Nitroglycerin (Nitrostat).

2. Morphine sulfate.

3. Lidocaine (Xylocaine).

4. Dopamine (Intropin).
Strategy: Think about the action of each medication.
1) coronary vasodilator; given to treat angina
2) decreases pain; given for chest pain caused by MI to reduce preload and afterload pressure
3) CORRECT— ventricular tachycardia indicates severe myocardial irritability and causes chest pain, dizziness, and fainting; lidocaine is an antiarrhythmic
4) augments cardiac output by increasing myocardial contractility and stroke volume
A nurse conducts a quality assurance review of a laboring client’s chart. Which of the following entries should the nurse reviewer bring to the attention of the nurse manager?

1. “Two minutes after epidural initiated B/P 80/48. Turned to left side.”

2. “Fetal heart rate 90–100 after epidural. O 2 by face mask at 10 L.”

3. “500 cc IV fluid bolus complete 0820. Epidural procedure begun 0930.”

4. “FHR 100 bpm. Lactated Ringer’s solution increased to wide open.”
Strategy: Identify incorrect nursing actions.
1) appropriate action; increases placental perfusion
2) appropriate action; oxygen is appropriate for fetal bradycardia
3) CORRECT— epidural begun 1 hour after the fluid bolus administered; fluid bolus counteracts potential vasodilatation secondary to the insertion of an epidural and should be administered over 20–30 minutes and the epidural procedure begun shortly thereafter
4) appropriate action; placental perfusion is increased when the client is turned to her left side; administration of fluid (without any medication) is appropriate for fetal bradycardia
The nurse admits a 75-year-old client diagnosed in the early stage of Alzheimer’s disease. The nurse should assess for which of the following symptoms?

1. Increased muscle tone and rigidity.

2. Restlessness and pacing.

3. Extension of the head and neck.

4. Shuffling gait.
Strategy: Think about each answer.
1) rigidity is a symptom of Parkinson’s
2) CORRECT— symptoms of early-stage Alzheimer’s include recent memory loss and changes in motor activity, such as continuous pacing, wandering, and agitation
3) in Alzheimer’s, head and neck may be flexed
4) propulsive gait a symptom of Parkinson’s
The nurse cares for a client admitted with malnutrition due to disorientation and confusion. The nurse determines that the client has responded positively to care when which of the following is observed?

1. The client states that he understands that he does not eat when he is confused.

2. The client correctly identifies the food groups.

3. The client states that he needs to drink more water.

4. The client feeds himself when the nurse offers cues.
Strategy: Think about each answer.
1) not realistic for a client who is confused
2) not realistic for a client who is confused
3) not realistic for a client who is confused
4) CORRECT— a disoriented, confused client who is unable to care for himself will require cues from the nurse in order to eat; goal is for client to feed self
The home care nurse makes an initial visit to a client diagnosed with heart failure. The client takes digoxin (Lanoxin) 0.25 mg daily and furosemide (Lasix) 40 mg daily. It is MOST important for the nurse to intervene if the client states which of the following?

1. "I take my digoxin in the morning."

2. "I eat a dish of ice cream for dessert every night."

3. "I take herbal licorice to keep my stomach ulcer from coming back."

4. "I take the furosemide (Lasix) at night."
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) appropriate action; cardiac glycoside
(2.) high in fat; not priority for nurse to intervene
(3.) CORRECT—licorice can increase potassium loss and may cause digoxin toxicity
(4.) should take in the morning to prevent diuresis from interfering with sleep; priority is the ingestion of licorice
The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed?
Select all that apply:

1. The nursing assistant aspirates and measures the amount of the gastric aspirate.

2. The nursing assistant elevates the head of the client’s bed 30 degrees.

3. The nursing assistant warms the formula to room temperature.

4. The nursing assistant measures the pH of the gastric aspirate.

5. The nursing assistant infuses the intermittent feeding in 20 minutes.

6. The nursing assistant clamps the proximal end of the feeding tube at the end of the feeding.
Strategy: Determine the outcome of each answer. Is it desired?
1) verifies placement of the tube and should be performed by the RN
2) CORRECT— prevents aspiration
3) CORRECT— prevents cramping
4) should be performed by a professional nurse
5) should infuse for a minimum of 30 minutes
6) CORRECT— prevents air from entering the stomach
A nurse driving home from work observes a car go off the road into a shallow embankment. When an ambulance arrives, the nurse advises the paramedics to transport which of the following patients to the hospital FIRST?

1. A crying infant restrained in a rear-facing child safety seat.

2. The restrained front seat passenger who has a laceration to the right side of his head.

3. The restrained rear seat adult passenger who has a deformity of the right forearm and who complains of pain at the site.

4. The restrained driver who has faint discoloration around the umbilicus and complains of abdominal pain.
Strategy: Determine the most unstable client.
1) infant properly restrained; crying indicates adequate respiratory function; requires evaluation, however, actual risk takes precedence over potential risk
2) requires evaluation; however, any bleeding that may occur can be controlled with pressure and risk for hemorrhage takes precedence over risk for neurological deficit related to a head injury
3) likely to have a fracture; risk of hemorrhage takes precedence
4) CORRECT— ecchymosis around the umbilicus or in either flank indicates retroperitoneal bleeding
The nurse answers a call light for a patient who is complaining of pain at the IV site. Upon assessment, the nurse notes the IV insertion site is pale, cool to the touch, and mildly swollen. It is MOST important for the nurse to take which of the following actions?

1. Slow the infusion rate and monitor the patient’s response.

2. Stop the infusion and notify the physician.

3. Remove the IV and apply a pressure dressing.

4. Remove the IV and place the patient’s arm on a pillow.
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) indicates infiltration of the IV; symptoms will progress if the infusion is continued
(2.) inadequate intervention; action appropriate, should elevate extremity to increase rate of re-absorption of the fluid
(3.) should remove IV and elevate arm
(4.) CORRECT—likely infiltrated; discontinue and restart at a new site; elevate extremity to increase the rate of re-absorption of the fluid
The nurse cares for a client in active labor. The client requests an epidural. The nurse anticipates an order for a 1,000-cc fluid bolus with which of the following fluids?

1. 5% dextrose in lactated Ringer’s solution.

2. 5% dextrose in water.

3. Lactated Ringer’s solution.

4. Normal saline.
Strategy: Think about the contents of each IV solution.
1) do not give solution containing dextrose as a pre-epidural bolus, because the glucose can be transferred to the fetus
2) do not give solution containing dextrose as a pre-epidural bolus, because the glucose can be transferred to the fetus
3) CORRECT— Lactated Ringer’s replaces electrolytes lost in the labor process and adds volume to expand the vascular bed to reduce the incidence of hypotension
4) normal saline does not replace any of the electrolytes lost during labor
The nurse prepares a client for surgery. Place the following preoperative activities in the correct sequence from FIRST action to LAST. All options must be used.

Strategy:
Determine the outcome of each answer when determining the order of nursing actions.

Verify that operative permit is signed: perform first before continuing preparation; confirm that lab results are posted

Obtain and record the vital signs: provides baseline for anesthesiologist

Administer preoperative medication: provide all nursing care prior to administering preoperative medication

Ask the client to empty the bladder: do not allow client to ambulate after receiving preoperative medication

Instruct the client to remain in bed: safety measure; raise side rails and put bed in low position
Strategy:
Determine the outcome of each answer when determining the order of nursing actions.
(1) Verify that operative permit is signed: perform first before continuing preparation; confirm that lab results are posted
(2) Obtain and record the vital signs: provides baseline for anesthesiologist
(3) Ask the client to empty the bladder: do not allow client to ambulate after receiving preoperative medication
(4) Instruct the client to remain in bed: safety measure; raise side rails and put bed in low position
(5) Administer preoperative medication: provide all nursing care prior to administering preoperative medication
The nurse is MOST likely to provide teaching regarding which of the following to a 10-year-old boy and his parents?

1. Proper nutrition.

2. Water safety.

3. Suicide prevention.

4. Sexual maturity.
Strategy: Think about each answer.
1) CORRECT— because of the threat of obesity and a diet-conscious society, children begin to diet; teach importance of body-building nutrients and regular physical activity
2) may reinforce depending on the patient and his usual activities; toddler and preschool age more likely to drown, whereas adolescents more likely to be involved in injuries related to recreational water sports
3) more of a concern with adolescents
4) may teach depending on the individual physical development of the patient; proper nutrition is a more acute concern for this age group
The nurse cares for a client receiving lithium (Lithane). It is MOST important for the nurse to include which of the following dietary instructions?

1. Restricted sodium diet with increased fluid intake.

2. High-calorie diet with restricted potassium intake.

3. Regular sodium intake with adequate fluid intake.

4. Decreased caloric intake with decreased fluid intake.
Strategy: Think about each answer.
1) lithium is a salt preparation and replaces sodium in the cells; low-sodium diet will precipitate lithium toxicity
2) no reason to increase calories and decrease potassium intake
3) CORRECT— should drink 2 to 3 liters per day and ingest adequate amounts of sodium; side effect include dizziness, headache, impaired vision, fine hand tremors, and reversible leukocytosis
4) should drink 2 to 3 liters per day; caloric intake does not impact lithium levels
The nurse responds to a call light and finds the patient’s IV tubing disconnected from the patient’s central line. The patient is restless and complains of difficulty breathing. After the nurse locks the open catheter, which of the following series of interventions should the nurse perform FIRST?

1. Place the patient in a flat supine position, initiate oxygen therapy, and notify the physician.

2. Place the patient in a high Fowler’s position, initiate oxygen therapy, and notify the physician.

3. Place the patient on the left side in Trendelenburg position, initiate oxygen therapy, and notify the physician.

4. Place the patient on the left side with the lower extremities elevated, initiate oxygen therapy, and notify the physician.
Strategy: Use the "comma, comma, and" rule.
(1.) signs and symptoms indicate air embolism; placing patient in this position increases the risk of the embolism moving to the heart or brain
(2.) position increases the risk of the embolism moving to the brain
(3.) CORRECT—- position decreases the likelihood that the air will enter the systemic circulation; is priority action
(4.) signs and symptoms indicate air embolism; placing patient in this position increases the risk of the embolism moving to the heart or brain
After the recent delivery of an infant girl, a women’s organization held a baby shower for the department head. During the opening of the gifts, the department head began sobbing and informed the group that the baby has polycystic kidney disease. The department head announces that because she is so afraid that the baby is going to die, she does not know how she can return to work. While the rest of the group is setting up the refreshments in the next room, the nurse and the grieving mother discussed the problem. Which of the following responses by the nurse is BEST?

1. “Finding out your baby has a serious health problem has to be very painful.”

2. “How does your husband feel about this problem?”

3. “How is the baby doing now?”

4. “What you need to do is to focus on the present.”
Strategy: Remember therapeutic communication.
1) CORRECT— acknowledges her pain; gives her an opportunity to talk more about her feelings privately; polycystic kidney disease is one of the most common inherited disorders
2) redirecting the conversation does not show sensitivity, is not the best response; perhaps later in the conversation could discuss available support systems
3) after addressing her feelings, could lead conversation to present positive things about the baby’s status
4) nontherapeutic; does not allow the client to verbalize
The nurse on the medical/surgical unit admits a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following?
Select all that apply.

1. Obtain the pulses in all four extremities.

2. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands.

3. Determine client’s orientation to person, place, and time.

4. Determine if the client has pain when walking.

5. Observe for the presence of Chadwick’s sign.

6. Assess the client’s pupillary response.
Strategy: Determine if each answer assesses neurological function
1) assesses cardiovascular system
2) CORRECT— assessing muscle strength; asking client to release fingers assesses client’s consciousness and the ability to follow commands
3) CORRECT— integral part of a neurological assessment
4) intermittent claudication, which is a peripheral vascular disease
5) probably sign of pregnancy
6) CORRECT— pupil should constrict when light shined in it; the other pupil should constrict slightly
Six months ago a nursing assistant was injured in an automobile accident. Her right leg was badly damaged and, after rehabilitation, the nursing assistant walks with an extreme limp and a slow, unstable gate. The nursing assistant prepares to return to work on an acute care surgical unit. When planning for the return of the nursing assistant, the nurse should take which of the following actions?

1. Survey other units for positions that are more suitable for the nursing assistant.

2. Recommend the nursing assistant take a leave of absence without pay until the nursing assistant receives disability benefits.

3. Transfer the nursing assistant to a shift during which the work on the surgical unit is less demanding.

4. Transfer a major portion of the nursing assistant’s duties to the other nursing assistants.
Strategy: Topic of question unstated.
1) CORRECT— ADA recommends that the nursing assistant be offered a position that is appropriate
2) ADA requires reasonable accommodations; if nursing assistant is returning to work after 6 months, either there are no disability benefits or the nursing assistant does not want them
3) regardless of shift, nursing assistant has to be able to perform the care required by surgical patients; unsteady gait makes nursing assistant unsafe
4) may jeopardize patient safety and reduce staff morale
A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The nurse should assign which of the following clients to the nursing assistant?

1. A client diagnosed with diabetes requiring a dressing change for a stasis ulcer.

2. A client diagnosed with terminal cancer being transferred to hospice home care.

3. A client diagnosed with cancer of the bone complaining of pain.

4. A client diagnosed with a fracture of the right leg asking to use the urinal.
Strategy: Think about the skill level involved in each patient’s care.
1) stable patient with an expected outcome; assign to the LPN/LVN
2) requires nursing judgment; RN is the appropriate caregiver
3) requires assessment; RN is the appropriate caregiver
4) CORRECT— standard unchanging procedure
A client undergoes a thyroidectomy. When the patient is returned to her room, the nurse should be MOST concerned if which of the following is observed?

1. There is a moderate amount of serosanguinous drainage on the neck dressing.

2. The woman complains of moderate pain at the incision site.

3. The woman experiences hand tremors and facial twitching.

4. The NG tube attached to the intermittent suction drains a moderate amount of clear fluid.
Strategy: “MOST concerned” indicates a complication.
1) hemorrhage is a complication, but moderate amount of drainage is expected due to placement of drain; check for drainage at back of neck
2) normal occurrence; pain medication usually prescribed
3) CORRECT— indicates tetany due to calcium imbalance
4) expected drainage from NG tube
A patient’s cardiac monitor reveals ventricular fibrillation, and the patient is prepared for defibrillation. Which of the following actions should the nurse take FIRST?

1. Set the machine to 50 joules.

2. Press the “synch” button on the machine.

3. Say “clear” before defibrillation.

4. Place gel pads on chest.
Strategy: “FIRST” indicates priority.
1) set at 200 joules, then 200–300 joules, then 360 joules; emergency treatment of ventricular fibrillation; completely depolarizes myocardial cells so SA node can reestablish as pacemaker
2) used for cardioversion to treat atrial flutter, atrial fibrillation, supraventricular tachycardial synchronizes shock with R wave
3) said by person with paddles
4) CORRECT— gel, cream, or saline-soaked gauze pads used; better contact means less resistance to current flow, prevents burns; paddles placed over right sternal border wand apex of heart; check monitor between shocks for rhythm
The community health nurse obtains laboratory test results for four clients. After evaluating the lab results, the nurse determines that which of the clients should be contacted FIRST?

1. Urine culture and sensitivity with colonization of E. coli .

2. Urinalysis with leukocytes.

3. Elevated serum antistreptolysin O (ASO) titer.

4. Cystourethrogram reveals vesicoureteral reflux.
Strategy: “FIRST” indicates priority.
1) validates urinary tract infection; not as threatening to health as glomerulonephritis
2) reflects urinary tract infection or contamination during specimen collection; no immediate significant threat to health
3) CORRECT— indicates glomerulonephritis, damage to glomerulus caused by an immunological reaction that results in proliferative and inflammatory changes within the glomerular structure
4) X-ray study of bladder and urethra; radiopaque dye injected, patient voids, x-rays taken during voiding
The pediatric clinic nurse conducts a parent education class related to disciplinary measures for young children. It is MOST important for the nurse to emphasize which of the following points?

1. Explain to the child why an act is wrong, especially if it relates to moral issues.

2. A good rule of thumb for time-outs is 1 minute for each year of the child’s age.

3. If a child cries and refuses a time-out, add another time-out period to the initial one.

4. Once the child has calmed down after disciplinary measures, review what occurred.
Strategy: Determine the outcome of each answer. Is it desired?
(1.) younger children are egocentric and, being in the preoperational cognitive developmental stage of thinking, are limited in ability to see the difference between their own point of view and the points of view of others
(2.) CORRECT—1 minute for each year of the child’s age is the recommended practice for time-outs; for toddlers, conception of time is limited and 1 minute can seem like hours; for preschoolers, time is still not fully understood and is interpreted within their own frame of reference; a kitchen timer with an audible bell can be useful so the child knows, and the parent does not forget, when the time-out is over
(3.) if disruptive behavior such as crying or refusal is shown when a time-out is to begin, the start of the time-out is delayed until the child becomes quiet; explain to the child in advance
(4.) once the child has experienced the consequences of his/her actions, the parent should not comment upon that situation because the tendency is for the child to try to blame the parent for imposing the rule
The nurse cares for a 4-month-old infant diagnosed with meningitis. Which assessment indicates increased intracranial pressure?

1. A positive Babinski reflex.

2. High-pitched cry.

3. Bulging posterior fontanelle.

4. Pinpoint pupils.
Strategy: Think about each answer.
1) positive during the first 6 months of life; dorsiflexion of great toe when sole of foot is stroked
2) CORRECT— one of the first signs of increased intracranial pressure; other signs include irritability, poor feeding, increased frontal occipital circumference
3) posterior fontanelle closes at 2 months
4) pupils respond slowly to light
The nurse cares for a patient after a laminectomy and spinal fusion. The patient receives both continuous IV infusion and PCA-mediated demand dosing of morphine. As the nurse takes vital signs, the patient, who appears to be sleeping comfortably, suddenly looks startled and says "Whoops, I keep forgetting to push this," and pushes the PCA pump button. Which of the following responses by the nurse is BEST?

1. "Good. The more you can keep the morphine at an even level, the better."

2. "Tell me where you are feeling pain and show me on this pain chart the level of pain you are feeling."

3. "You seem very comfortable using the pump."

4. "The combination of the surgery and the medication can temporarily affect the memory."
Strategy: "BEST" indicates that discrimination is required to answer the question.
(1.) continuous infusion of morphine should maintain an even level; PCA pump manages breakthrough pain
(2.) CORRECT—assessment of pain status and apparent discrepancy between patient’s having appeared comfortable and relaxed and suddenly "remembering" pain; patient’s response to nurse’s question may lead to needed patient teaching
(3.) patient may seem comfortable and knowledgeable about what to do mechanically, but may have faulty, even dangerous, understanding of the basic purpose of the pump
(4.) accurate, but does not address the patient’s possibly dangerous misunderstanding of how to use the pump
The fire alarm is ringing at a 50-bed nursing facility. Arrange the following actions by the nurse in the appropriate order from MOST important to LEAST. All options must be used.

Close all of the fireproof doors: prevents fire from spreading)

Move clients away from the fire: remember the acronym RACE (rescue/remove, alarm, confine/close, evacuate

Pull the fire alarm after removing clients

Locate all of the residents: appropriate if evacuation required
(1) Move clients away from the fire: remember the acronym RACE (rescue/remove, alarm, confine/close, evacuate)
(2) Pull the fire alarm after removing clients
(3) Close all of the fireproof doors: prevents fire from spreading
(4) Locate all of the residents: appropriate if evacuation required
The nurse cares for a client diagnosed with a draining abdominal abscess. What is the MOST important information for the nurse to assess?

1. Amount.

2. Character.

3. Consistency.

4. Amount of suction on system.
Strategy: Think about each answer.
1) important to measure amount of drainage
2) CORRECT— assessing whether the drainage is purulent, sanguinous, serosanguineous, etc.
3) character is most important
4) not relevant to the drainage
An off-duty nurse on a bus observes a mother who boards the bus with an older infant in a stroller. As the ride progresses, the infant throw its toy to the floor. The mother picks up the toy and gives it back to the infant. The infant throws it again. If the mother does not immediately return the toy, the infant cries loudly. The process keeps repeating and the nurse notes the mother becoming increasingly upset and angry. Which of the following responses by the nurse is BEST?

1. "Be sure to wipe the toy off each time before you give it back. These floors are filthy."

2. "Your baby is either stubborn or wants attention, I can’t figure out which."

3. "I remember when my own baby used to do that."

4. "I bet your baby is about 11 months old. This is normal behavior."
Strategy: "BEST" indicates that discrimination is required to answer the question.
(1.) valid concern, but patronizing; does not focus on mother’s feelings, and also implies she is not intelligent enough to recognize dirty floors or take care of her baby’s health
(2.) may encourage discussion but implies judgment, especially since no relationship has yet developed between nurse and mother
(3.) response focuses on the nurse
(4.) CORRECT—at 11 months, an infant drops an object deliberately in order that it be picked up; even if the infant is not 11 months, this equating a problematic behavior with a developmental norm can help decrease the mother’s probable sense of aloneness, inadequacy, embarrassment, and frustration, and her feeling like she has a "bad" baby
The home care nurse monitors the progress of a client after a laryngectomy. Which of the following observations, if made by the nurse, requires an intervention?

1. The client uses her finger to apply A & D ointment around the stoma.

2. The client inserts a few drops of water into the soma every evening.

3. The client leaves the stoma uncovered when taking a bubble bath.

4. The client covers the stoma with a cotton scarf when outside.
Strategy: Determine the outcome of each answer.
1) used to soften crusts so they can be removed with sterile tweezer
2) CORRECT— humidification should be provided with humidifier or nebulizer
3) humidification would help liquefy secretions; should cover when taking a shower to prevent water from entering the airway
4) provides protection and prevents mucus from soiling clothing
An order is written for "3,000 mL 5% D5NS every 24 hours by gravity infusion." The administration set delivers 15 drops/mL. What is the correct infusion rate/min for this solution?

1. 21 drops/min.

2. 31 drops/min.

3. 50 drops/min.

4. 96 drops/min.
Strategy: Total volume to infuse (mL) × drop factor / time (min) = drops per min.
(1.) drop factor is 15, not 10; this incorrect number is obtained by dividing 30,000 by 1,440
(2.) CORRECT—3,000 mL × 15 drops/mL/(24 × 60) = 45,000/1,400 = 31.25 = 31 drops/min
(3.) incorrect number is obtained by dividing 3,000 ml by 60 minutes
(4.) solution volume needs to be included in calculation; this incorrect number is obtained by dividing 1,440 by the drop factor of 15
The nurse conducts a neurologic assessment on a new patient in the neurology clinic. Assessment of the biceps and patellar deep tendon reflexes does not readily elicit a response. It is MOST important for the nurse to take which of the following actions?

1. Record the reflexes as either 0 or 1+ and proceed to assess the pulses of all four extremities with a Doppler ultrasound device.

2. Test again using the opposite side of the reflex (percussion) hammer and strike more firmly.

3. Retest the biceps while the patient clenches the teeth, and retest the patellar while the patient interlaces the fingers and pulls them against each other.

4. Tap the patient’s face just below and in front of the ear and leave a blood pressure cuff inflated on patient’s arm for 3 minutes.
Strategy: "MOST important" indicates discrimination is required to answer the question.
(1.) not sufficient to simply record reflexes; reflexes are graded on a 0 to 4+ scale, so 0 or 1 would be appropriate if they were very diminished or absent; no need to check all pulses with Doppler; no particular relationship with pulses and reflexes
(2.) no reason; to prevent pain, pointed end of triangular hammer should be used to strike over small areas, e.g., biceps; the flat end should be used to strike over larger areas, e.g., Achilles; striking should be done with a brisk, rapid wrist movement
(3.) CORRECT—these are known as reinforcement techniques; isometric contraction of other muscles can increase the generalized reflex response/activity of the body; distraction may also be a reason for this effectiveness, as tension can inhibit a reflex being elicited
(4.) tests to assess for hypocalcemia or tetany (Chvostek’s sign and Trousseau’s sign); it is hypercalcemia, not hypocalcemia, that could cause decreased deep tendon reflexes (DTRs)
The nurse examines the abdomen of a client complaining of acute abdominal pain with nausea and vomiting. The nurse auscultates the abdomen and hears 40 sounds in one minute. The nurse should chart which of the following?

1. “Absent bowel sounds on auscultation.”

2. “Hypoactive bowel sounds heard on auscultation.”

3. “Normal bowel sounds heard on auscultation.”

4. “Hyperactive bowel sounds heard on auscultation.”
Strategy: Think about each answer.
1) no sounds heard in 3 to 5 minutes; indicates late intestinal obstruction
2) one or two sounds heard in two minutes; indicates decreased motility of bowel
3) 5 to 30 sounds per minute
4) CORRECT— greater than 30 sounds per minute; indicates increased motility due to gastroenteritis, diarrhea, and laxative use
Providing well-child screening for toddlers in the day care facility, the nurse performs an assessment of a 24-month-old child. The nurse expects which of the following findings?
Select all that apply:

1. The child jumps with both feet.

2. The child kicks a ball without falling.

3. The child rides a tricycle.

4. The child builds a block tower of six blocks.

5. The child uses two-to-three-word phrases.

6. The child is able to state her first and last name.
Strategy: Picture the child.
1) more likely seen in a 30-month-old; can run fairly well
2) CORRECT— can also pick up an object without falling
3) gross motor skill more appropriate to a 3-year-old
4) CORRECT— can also turn doorknobs and unscrew lids
5) CORRECT— has a 300-word vocabulary
6) only able to state her first name; stating first and last name more appropriate for a 30-month-old
The nurse cares for a patient 2 days after the patient took an acetaminophen (Tylenol) overdose. It is MOST important for the nurse to monitor which of the following laboratory results?

1. ALT and AST.

2. Blood glucose.

3. BUN and creatinine.

4. Hemoglobin and hematocrit.
Strategy: Think about each answer.
(1.) CORRECT—hepatic toxicity is a serious complication resulting from an acute Tylenol overdose that manifests approximately 1 to 3 days after initial ingestion; there is an increase in the serum transaminase liver enzymes ALT and AST; PT should also be monitored, as Tylenol overdose prolongs it
(2.) no particular relationship with overdose, although Tylenol can interfere with home glucose monitoring, causing false decreases in glucose
(3.) not most important at this time; renal damage, as well as hepatotoxicity, can occur with chronic long-term ingestion of large Tylenol doses
(4.) no particular relationship with Tylenol overdose
The nurse cares for a client receiving TPN (total parenteral nutrition) for 2 weeks. The physician orders the TPN to be discontinued. The nurse expects the physician to order what type of IV fluids?

1. Ringer's lactate.

2. 0.9% NaCl.

3. 10% dextrose in water.

4. 0.45% NaCl.
Strategy: Determine the outcome of each answer. Is it desired?
1) isotonic solution; effective as volume expander
2) isotonic solution; used for fluid replacement; increases plasma volume
3) CORRECT— hypertonic dextrose solution similar to TPN is used to wean patient
4) hypotonic solution
While interviewing a young adult as part of the job application process, the nurse learns that the individual has a history of frequent nosebleeds that require health care intervention. Which of the following responses by the nurse is BEST?

1. “Have you been diagnosed with allergies?”

2. “Do you smoke cigarettes?”

3. “Do you take aspirin on a regular basis?”

4. “Have you been diagnosed with nasal polyps?”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) CORRECT— frequent use of nasal sprays to relieve allergic symptoms can result in vasoconstriction that causes atrophy of nasal membranes resulting in decreased integrity of blood vessels
2) not likely to cause nosebleeds
3) causes increased bleeding time; not likely to be a contributing factor
4) grape-like swellings in the mucus membranes of the sinuses; may cause obstruction and chronic infections
The office nurse makes a follow-up telephone call to a patient 3 days after extracapsular cataract extraction with intraocular lens implantation. Which of the following patient statements MOST concerns the nurse?

1. "I am going to the beauty shop to get my hair done tomorrow. It will be kind of like a celebration—getting my whole head back in shape!"

2. "I am feeling really good. As soon as I get off the phone I am going to do the vacuuming and then go out for a round of golf with my friends."

3. "My eye is itching a little, especially at night. There is also a dry, crusty white drainage on the eyelids and lashes."

4. "It may be hard for me to get a ride to my doctor follow-up visit next week because all my friends are busy that day."
Strategy: "MOST concerns the nurse" indicates a complication.
(1.) hair can be shampooed 1–2 days after surgery as long as head is tilted back; does not affect intraocular pressure (IOP), which is major complication during the post-op period
(2.) CORRECT—for the first several weeks light housekeeping is acceptable, but vacuuming involves too much forward flexion and jerky, rapid movement; golf also involves too much flexion, potential for strained rapid movement, and possibly excessive lifting related to equipment
(3.) mild itching caused by the stitches that are in place to close the incision and is normal; acetaminophen (Tylenol) used as a mild analgesic if necessary; aspirin should be avoided because of its effect on blood coagulability; eyes should not be rubbed or pressed
(4.) cataract surgery is usually done on an outpatient basis; patient returns to the ophthalmologist the next morning and then again at 1 week and 1 month; exploration of transportation options for patient can be done and/or the appointment date or time can be adjusted
The nurse cares for a client in labor. The fetal heart rate is 150–160. The nurse notes at the apex of a contraction that the fetal heart rate (FHR) is 125 and returns to baseline at the completion of the contraction. Which of the following actions should the nurse take FIRST?

1. Continue to monitor the FHR.

2. Turn the client to her left side.

3. Turn the client to her right side.

4. Administer O 2 by mask at 6 L/min.
Strategy: Determine the outcome of each answer.
1) CORRECT— indicates early deceleration; occurs because of head compression; reassuring fetal heart tone pattern
2) appropriate action for late deceleration; administer O 2 , increase IV flow rate
3) reassuring fetal heart tone pattern; no reason to reposition the client
4) appropriate for late deceleration or variable deceleration
The nurse identifies which of the following clients as being at HIGHEST risk for injury?

1. A 3-month-old child is in an infant seat that her mother has placed on the coffee table.

2. A 2-year-old is playing alone in the living room.

3. A 2 1/2-year-old with a tracheostomy is eating raisins.

4. A 10-year-old stays home alone for half an hour after school.
Strategy: Think about the developmental age of each client.
1) do not leave an infant unattended on a raised surface
2) doors and screens should be locked; place gates at top and bottom of stairs
3) CORRECT— child is in danger of putting foreign objects in the tracheostomy
4) appropriate; teach child to lock door, keep list of emergency numbers by the phone
A newly admitted client has been taking lithium carbonate (Lithane) for 2 years. The client’s serum lithium level is 1.5 mEq/L. Which of the following actions should the nurse take FIRST?

1. Administer the next dose on time.

2. Increase the client’s oral fluid intake.

3. Notify the physician.

4. Encourage the client to rest.
Strategy: Determine the outcome of each answer. Is it desired?
1) should be withheld
2) does not address issue of toxic level of medication; encourage client to drink 2,000–3,000 mL and have a moderate sodium intake
3) CORRECT—therapeutic level of lithium is 1–1.5 mEq/L; toxic manifestations may occur at levels greater than 1.5 mEq/L; physician should be notified
4) does not address issue of toxic level of medication; observe for vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, muscle twitching
The industrial nurse is called to see a worker who was exposed to an extensive level of radiation. The worker appears anxious and reports lower right, intermittent abdominal pain. Which of the following actions should the nurse take FIRST?

1. Assess the abdominal pain.

2. Encourage the client to relax.

3. Obtain an order for pain medication.

4. Begin the decontamination process.
Strategy: “FIRST” indicates priority.
1) CORRECT— clients contaminated with radiation do not pose a health risk to medical personnel; nurse must assess worker’s complaint before implementing
2) priority is assessing client’s complaint
3) do not obtain orders until assessment is complete
4) worker does not pose a health risk to the nurse; wear gloves, shoe covers, lab coat, and eye covering
The school nurse is performing health screening for scoliosis on a group of sixth-graders. The nurse would be MOST concerned if which of the following is observed?

1. A child complains of a painful right knee.

2. A child’s feet turn inward.

3. A child shifts his weight from the right foot to the left foot.

4. A child’s left shoulder is higher than her right shoulder.
Strategy: “MOST” concerned indicates something is wrong.
1) usually there is no complaint of pain with scoliosis; there may be a slight limp with scoliosis
2) does not indicate scoliosis
3) does not indicate scoliosis
4) CORRECT— nurse should also observe for asymmetry or prominence of rib cage and scapulae, curvature of spine; treatment is bracing and spinal fusion surgery
The nurse prepares to assist a physician with a patient requiring a paracentesis. It is MOST important for the nurse to place which of the following at the patient’s bedside?

1. A tape measure.

2. An emesis basin.

3. A blood pressure cuff.

4. A scale.
Strategy: "MOST important" indicates priority.
(1.) measure abdominal girth before and after procedure; not most important
(2.) not needed
(3.) CORRECT—place on patient’s arm prior to procedure and leave in place through immediate postprocedure time; shock may occur because of removal of fluid
(4.) patient weighed before and after procedure; blood pressure cuff is priority
A male patient is discharged from the emergency department after being diagnosed with a concussion sustained in a fall. Which of the following statements, if made by the patient’s wife to the nurse, indicates that further teaching is necessary?

1. "I will wake my husband up every 3 hours whenever sleeping and ask him his name, my name, and where he is."

2. "If my husband complains of a headache and needs aspirin, I will give it to him no more than every 4 hours."

3. "If my husband complains of blurry vision or has difficulty walking, I will bring him to the emergency department right away."

4. "I will talk to my husband’s friend about doing the coaching for the soccer team tomorrow."
Strategy: "Further teaching is necessary" indicates incorrect information.
(1.) appropriate action; provides patient’s spouse with essential information as to whether complications or deterioration are occurring and if patient thus needs to be returned immediately to the hospital
(2.) CORRECT—wrong action; patient should not receive aspirin, as it can prolong any bleeding that might occur; acetaminophen (Tylenol) every 4 hours as needed is what should be given
(3.) appropriate action; visual disturbance such as blurred or double vision, difficulty walking, weakness, numbness, clumsiness are symptoms that require immediate return of patient to the hospital
(4.) appropriate action; patient should not be involved in strenuous activity for at least 2 days; even coaching and not playing can be strenuous; driving, contact sports, swimming, use of power tools are examples of strenuous activities; resting and eating lightly should be encouraged
An ice storm paralyzes a community during the night. The two nurses on a 24-bed medical/surgical unit learn that it will be 12 to 15 hours before they can expect the next shift to arrive. Which of the following actions should the nurses take FIRST?

1. Each nurse takes a shower to refresh herself while the other nurse cares for all of the clients.

2. Instruct the nursing assistant to begin a.m. care at 0400 so care can be completed for all of the clients.

3. Make a list of all of the clients’ breathing treatments and IV medications for the next 12 to 15 hours.

4. Plan to administer all of the clients’ PRN pain medication before they ask for it.
Strategy: Determine the outcome of each answer.
1) nurses do need to ensure that they can provide care to client; leaving unit is unsafe for clients
2) priority is determining treatments and medications that are vital to the well-being of the clients
3) CORRECT— priority is determining treatments and medications that are vital to the well-being of the clients
4) do not make PRN medications routine
The nurse cares for a client at 7 months’ gestation diagnosed with preeclampsia. After initiating a magnesium sulfate IV at 2 g/hour, which of the following actions should the nurse perform NEXT?

1. Darken the client’s room.

2. Perform a vaginal exam.

3. Measure the deep tendon reflexes.

4. Assist the client to a comfortable position.
Strategy: “NEXT” indicates priority.
1) appropriate action for seizure precautions; more important to assess
2) no indication client in labor
3) CORRECT— magnesium sulfate given to prevent eclampsia; hypermagnesemia causes CNS depression; assess respirations
4) should lie on left side
The charge nurse learns that two staff members are requesting a 12-month leave of absence. One staff member has 5 years of service and is requesting the leave because of an adoption. The other staff member has 2 years of service and will care for a family member diagnosed with terminal cancer. The charge nurse is informed that only one staff member can receive the leave of absence. Which of the following actions should the nurse take FIRST?

1. After consulting agency policy, grant the leave to the nurse with the greatest seniority.

2. Schedule a meeting with the two staff members to discuss the available options.

3. Grant leave to the nurse with the terminally ill husband.

4. Persuade the staff member adopting the baby to waive her rights.
Strategy: “FIRST” indicates priority.
1) may resort to strict rule enforcement after other options have been explored
2) CORRECT— first step in problem resolution is to identify the problem and generate possible solutions
3) after generating possible solutions, the staff members should evaluate the possible solutions; don’t base decision on personal issues such as terminal illness
4) many times a combination of suggestions is the best solution; assess before implementing
The school nurse instructs a group of high-school students about the prevention of sexually transmitted diseases. Which of the following statements, if made by a student to the nurse, indicates teaching is successful?

1. "The use of condoms does not totally eliminate the risk of STDs"

2. "Because some STDs have no symptoms in women, they cannot be that serious."

3. "I have had plenty of sex already and have not gotten a single disease. I think I am immune."

4. "I am glad I use birth control pills. I do not have to worry about STDs."
Strategy: "Teaching is successful" indicates correct information.
(1.) CORRECT—condoms reduce but do not eliminate the risk of transmission of HIV and other STDs
(2.) Chlamydia and gonorrhea may be asymptomatic in females, pelvic inflammatory disease can develop if left untreated
(3.) no particular immunity to STDs; reflects the "It can’t happen to me" attitude characteristic of adolescents
(4.) birth control pills offer no protection against STDs
The nurse cares for a toddler diagnosed with pneumonia caused by Haemophilus influenzae, type b. The nurse should follow which of the following transmission-based precautions?

1. Standard precautions.

2. Airborne precautions.

3. Droplet precautions.

4. Contact precautions.
Strategy: Think about each answer.
1) barrier precautions used for all clients to prevent nosocomial infections
2) used with pathogens transmitted by airborne route
3) CORRECT— used with pathogens transmitted by infectious droplets; droplet precautions indicated for Haemophilus influenzae, type b pneumonia in infants and children
4) contact precautions required for all client care activities that require physical skin-to-skin contact or those that require contact with contaminated inanimate objects in the client’s environment
The nurse cares for a client hospitalized for treatment of uncontrollable aggressive impulses. Which of the following observations is MOST important for the nurse to record before beginning a behavior modification plan?

1. The client tells each nurse that she is his favorite nurse.

2. The client is flirtatious with female members of the staff.

3. The client threatened to hit two other clients within 2 hours.

4. The client appears insincere and superficial in his interactions.
Strategy: “MOST important indicates discrimination is required to answer the question
1) example of manipulative behavior
2) example of manipulative behavior
3) CORRECT— concrete evidence of aggressive behavior; intercede early, continue nonthreatening behavior, restrain client to protect himself and others
4) not related to aggression
The hospital nursing educator plans an inservice for staff on the topic of working with interpreters. Which of the following statements is MOST important for the nurse to include?

1. "Look directly at the interpreter while you are asking the questions."

2. "Keep your questions short and simple in structure and wording."

3. "Interrupt the patient and interpreter if they seem to be talking longer than the question requires."

4. "Focus primarily on the patient’s body language and tone of voice."
Strategy: Determine the outcome of each answer. Is it desired?
(1.) look directly at the patient; reinforces nurse’s interest in patient and allows for observation of nonverbal behaviors
(2.) CORRECT—easiest for interpreter to understand and translate and for patient to understand and answer; do not use medical jargon, slang, clichés, contractions, and pronouns; phrase questions so that they are focused on getting only one answer at a time
(3.) may take longer to directly say or explain something in non-English; occurs when word and/or concept has no equivalent in the other culture, when topic is seen by the other culture as embarrassing or taboo, when there are dialect differences
(4.) focus on words as they are translated to the nurse so the nurse can formulate a new question; do note patient’s body language and tone of voice
As a nurse prepares to assist a physician with an epidural patch for a client with a postlumbar puncture headache, the client tells the nurse he is an illegal alien. Which of the following actions should the nurse perform NEXT?

1. Position the client in a side lying position.

2. Notify immediate supervisor of the client’s citizenship status.

3. Notify the appropriate federal officials.

4. Place client in upright position.
Strategy: “NEXT” indicates priority.
1) CORRECT— appropriate position for procedure; citizenship status is not the priority
2) staff nurse does not address citizenship status; current need is proper position for procedure, along with equipment/supplies
3) agency would need to decide who should make contact; questions of privacy and confidentiality exist
4) more likely to result in severe headache; headache represents excessive loss of cerebral spinal fluid, resulting in brain settling while in upright position
As the night nurse makes rounds, an elderly client complains of cold feet. Which of the following actions should the nurse take FIRST?

1. Palpate pedal pulses.

2. Elevate the foot of the bed.

3. Place a heating pad on the client’s feet.

4. Offer the client a warm drink.
Strategy: Assess before implementing.
1) CORRECT— assess before implementing; client may have decreased circulation
2) assess before implementing
3) contraindicated for decreased circulation
4) may be helpful, but it is important to assess the circulation in the client’s feet
The nurse in the outpatient clinic receives a call from the parent of a teenager diagnosed with infectious mononucleosis. The mother complains that her child seems angry and depressed since developing mononucleosis. Which of the following responses by the nurse is MOST appropriate?

1. “Why do you think your child is angry?”

2. “Teens become frustrated because of feeling weak and fatigued.”

3. “Would you like the physician to talk with your child?”

4. “My child had mono and was crabby all the time.”
Strategy: Remember therapeutic communication.
1) nontherapeutic; do not ask “why” questions
2) CORRECT— because of teen’s active life style, may react with anger and depression to the weakness and fatigue; allow teen to vent and reassure teen that activities can be resumed after the acute phase
3) passing the buck; nurse should respond to the situation
4) nontherapeutic; focus is on nurse and not the client
The nurse identifies that which of the following client statements is a contraindication to receiving the influenza vaccine?

1. “I am allergic to neomycin.”

2. “I am allergic to penicillin.”

3. “I am allergic to shellfish.”

4. “I am allergic to eggs.”
Strategy: Think about each answer.
1) allergy to neomycin is contraindication to MMR, IPV, and varicella vaccines
2) potential cross-allergy to cephalosporins
3) contraindication to diagnostic testing using dyes
4) CORRECT— only contraindication to the flu vaccine is an allergy to eggs; should be given to adults 50 years and older, clients with chronic conditions, and persons traveling to foreign countries
While running a mountainous marathon, a runner falls over a cliff and hits her head. The runner is admitted to the local hospital. The physician asks the nurse to prepare the client for a lumbar puncture. Which of the following actions should the nurse take FIRST?

1. Obtain informed consent.

2. Obtain the client’s vital signs.

3. Explain procedure to client.

4. Procure lumbar puncture tray.
Strategy: “FIRST” indicates priority.
1) responsibility of the physician
2) CORRECT— change in vital signs could indicate increased intracranial pressure (ICP), which is contraindicated in lumbar puncture
3) physical needs take priority over psychosocial needs
4) priority is completing the assessment
The home health nurse visits the home of a client with a history of kidney stones. When instructing the client, it is MOST important for the nurse to include which of the following

1. “Drink at least 2000 to 3000 mL water per day.”

2. “Avoid drugs that cause elevated calcium levels.”

3. “Avoid foods that contain calcium.”

4. “Participate in a regular exercise program.”
Strategy: Determine the outcome of each answer choice. Is it desired?
1) CORRECT— high urine output dilutes the concentration of minerals and flushes them from the body
2) priority is diluting the urine
3) avoid foods that are high in oxalates such as spinach, asparagus, and cabbage
4) good health promotion habits; should increase fluids to prevent dehydration
The nurse overhears the supervisor reprimand the head nurse for not discussing feelings with a patient. Shortly after, a patient asks the head nurse for an extra blanket. The head nurse angrily responds, “Get it yourself!” The nurse recognizes the head nurse is displaying which of the following defense mechanisms?

1. Compensation.

2. Displacement.

3. Conversion.

4. Projection.
Strategy: Think about the answers.
1) an attempt to overcome real or imagined shortcomings
2) CORRECT— head nurse is displacing feelings of anger at the supervisor onto the patient who is less threatening
3) anxiety is repressed and converted into physical symptoms
4) attributing to others one’s feelings, impulses, thoughts, or wishes
Which of the following facts in the health history of an adult patient should cause the nurse to question an order for aspirin (acetylsalicylic acid)?

1. An allergy to tartrazine (FD&C yellow dye #5).

2. A history of lead poisoning in childhood.

3. Maternal grandfather died of complications from diabetes.

4. Allergies to bee venom and to milk.
Strategy: Think about each answer.
(1.) CORRECT—there is cross-sensitivity between tartrazine and aspirin; an allergic response to one indicates a possible allergic response to the other
(2.) no relationship with or contraindications to aspirin usage; usual body system most affected by lead poisoning is neurologic
(3.) no contraindication
(4.) no contraindications to the use of aspirin by the patient, taking aspirin with milk may decrease GI irritation
The triage nurse is prioritizing patients to be evaluated in the ER. Which of the following patients will the nurse see FIRST?

1. A 2-year-old with a temperature of 101°F (38°C).

2. A 5-year-old complaining of arm pain after falling off a chair.

3. A 32-year-old complaining of nausea and vomiting for the past several hours.

4. A 55-year-old with a persistent nosebleed.
Strategy: Determine the MOST unstable client.
(1.) obtain an order for an antipyretic and monitor patient until patient can be evaluated by physician
(2.) assess the neurovascular status of the effected extremity, then ice, splint, and elevate it until patient can be evaluated by physician
(3.) average healthy young adult’s body can adequately compensate for dehydration over the short term
(4.) CORRECT—compromised circulation takes precedence
The nurse cares for a 2-month-old infant immediately after a surgical procedure. Which of the following is a priority nursing action?

1. Minimize stimuli for the infant.

2. Restrain all extremities.

3. Encourage the parents to stroke the infant.

4. Explain to the mother how she can assist with her infant’s care.
Strategy: Determine the outcome of each answer.
1) sensory deprivation can cause failure to thrive
2) might cause failure to thrive
3) CORRECT— tactile stimulation is imperative for infant’s emotional development
4) important, but not as important as providing tactile stimulation to the infant
The nurse assigns the care of a client after a left mastectomy to an LPN/LVN. The RN reminds the LPN/LVN to take the client’s blood pressure on the right arm. Later in the shift, the RN notes that the deflated blood pressure cuff is on the client’s left arm. Which of the following actions should the nurse take FIRST?

1. Talk with the LPN after the shift is over.

2. Ask the LPN why she did not follow directions.

3. Review with the LPN the importance of taking the blood pressure on the right side.

4. Write a report about the incident and place it in the LPN/LVN’s personnel folder.
Strategy: “FIRST” indicates priority.
1) would cause continued harm to client
2) do not ask “why” on the licensure exam
3) CORRECT— NCLEX ® -RN exam is a “here and now” test; take care of problem now to prevent harm to client
4) priority action is protecting the safety of the client
The nurse observes a preschooler interact with her mother. Which of the following observations by the nurse indicate a potential disturbed family interaction?

1. The mother explains that injections will burn like a bee sting.

2. The mother tells the preschooler that if she doesn’t behave, the mother will leave the child there.

3. The mother offers to let her child sit in her lap while the nurse administers an injection.

4. The mother tells her child that it is okay to cry.
Strategy: Think about the behaviors.
1) does not indicate a disturbed interaction
2) CORRECT— threatening abandonment will destroy the child’s trust in the family
3) does not indicate disturbed interaction
4) indicates healthy interaction
The nurse supervises care on a medical/surgical unit. The nurse notes that after a lab technician has drawn a blood specimen from a client, there are drops of blood on the floor and the wall next to the needle container. Which of the following actions should the nurse take FIRST?

1. Contact the laboratory supervisor to report the incident.

2. Contact the nurse manager to report the incident.

3. Call housekeeping to clean and disinfect the area.

4. Counsel the laboratory technician about appropriate technique.
Strategy: Determine the outcome of each answer.
1) nurse should stay in chain of command and notify the nurse’s supervisor
2) second action; nurse’s responsibility to communicate to the nurse manager
3) CORRECT— priority is cleaning up the contaminated area
4) responsibility of the laboratory supervisor
The nurse cares for clients in the neurological trauma unit. The nurse learns that a new admission was responsible for the death of a neighbor during a robbery. The nurse says to the head nurse, “I don’t think that I can care for that client.” Which of the following responses by the head nurse is BEST?

1. “I will talk with the supervisor about your situation.”

2. “Would you like to transfer to another unit?”

3. “Please share with me your concerns.”

4. “You are a professional and will care for the client.”
Strategy: Remember therapeutic communication.
1) passing the buck
2) yes/no question; nontherapeutic
3) CORRECT— therapeutic; allows nurse to express concerns
4) authoritarian response; head nurse does have the authority to assign nurse to clients but should find more information before making a decision
The nurse cares for a patient who has undergone right total knee replacement. Which of the following assessments requires an intervention by the nurse?

1. The patient’s temperature is 99.4°F (37.4°C).

2. The patient’s heart rate is 58 and regular.

3. The patient’s pedal pulses are palpable but weak bilaterally.

4. The patient notes cramping in the right calf.
Strategy: "Requires an intervention" indicates a complication.
(1.) no evaluation or intervention is needed for a temperature at this level
(2.) though it falls outside the "normal" range of 60–100 bpm, it is unlikely that any intervention would be indicated; continue to monitor patient closely for changes
(3.) since the pulses are equal and palpable, there is no need for intervention based on the information given
(4.) CORRECT—may indicate a blood clot and should be reported to physician immediately
The nurse on the psychiatric unit is caring for a patient who is taking fluvoxamine (Luvox) 100 mg PO at HS. Stat A.M. laboratory results reveal Na+124 mEq, K+ 4.6 mEq, Cl– 96 mEq, and serum osmolality 275 mOsm. Which of the following actions should the nurse take FIRST?

1. Place the patient on one-to-one suicide precautions.

2. Prepare to administer NaCl 0.45% IV.

3. Initiate seizure precautions with constant observation.

4. Ask the patient about side effects experienced during the night.
Strategy: "FIRST" indicates priority.
(1.) must assess for suicide before implementing precautions; fluvoxamine (Luvox) for OCD, side effect of dry mouth; although patient may be at risk for self-harm, no evidence that patient is intentionally harming self
(2.) patient has hypo-osmolar imbalance; hypotonic fluids will worsen medical condition
(3.) CORRECT—lab results suggest dilutional hyponatremia from obsessive-compulsive water intake (aka psychogenic polydipsia); at high risk for convulsions and cerebral edema; also needs monitoring to prevent further water intake
(4.) safety needs must be met first
A patient is discharged from the orthopedic unit after receiving treatment for low-back pain. The nurse counsels the patient about how to prevent further back injury. Which of the following statements, if made by the patient to the nurse, indicates correct understanding of appropriate preventive measures?

1. "It is all right to reach up for things, but if I am picking something up from the floor, I will squat rather than bend and reach down."

2. "I will sleep on my side or abdomen rather than lie flat on my back."

3. "If my back starts to hurt, I will immediately stop what I am doing."

4. "I will sit as far back from the pedals on my car as my legs can comfortably stretch, and I will use a firm backrest."
Strategy: All parts of the answer must be correct for the answer to be correct.
(1.) partially correct; it is not safe to strain to reach things
(2.) prone (abdomen) position should be avoided in order to maintain proper body alignment
(3.) CORRECT—pain is the body’s signal that there is a potential for physical harm and that the patient needs to withdraw from the pain-producing situation
(4.) to prevent back strain when driving a car, patient should sit close to the pedals, in part to avoid knee and hip extension; a seat belt and firm backrest should be used for back support
The nurse prepares a client for computerized axial tomography (CAT) scan without the use of contrast dye. It is MOST important for the nurse to assess for which of the following?

1. Problem client may have with being in a closed space.

2. Allergies to medication.

3. Intact swallow and gag reflex.

4. Range of motion of all extremities.
Strategy: “MOST important” indicates priority.
1) CORRECT— provides three-dimensional assessment of the lungs and thorax; if client is claustrophobic, scan may cause severe anxiety
2) not important
3) not necessary
4) client has to lie still for half an hour
The nurse cares for clients on a cruise ship. The nurse interviews several clients who are experiencing severe vertigo that is unrelieved by dimenhydrinate (Dramamine). After assessing the clients, the nurse determines that which of the following clients should see the physician FIRST?

1. A client with a temperature of 100°F (38°C) complains of hearing loss in the right ear.

2. A client complains that objects seem to be moving around him.

3. A client complains of a full feeling in her ear followed by a crackling and popping sound.

4. A client complains of ringing in his ears and occasional vertigo.
Strategy: “FIRST” indicates priority.
1) CORRECT— symptoms indicate infection; this is the priority client
2) describes vertigo; client with possible infection takes priority
3) describes serous otitis media related to eustachian tube obstruction; can occur due to flying or scuba-diving, does not require treatment unless infection is present
4) cause for tinnitus should be determined; client with possible infection takes priority
A patient who is diagnosed with leukemia and has a platelet count of 1,000/mm3 is scheduled to receive a platelet transfusion. The new graduate nurse reviews with the nurse manager the plans for the transfusion. It is MOST important for the manager to respond to which of the following statements made by the new graduate nurse?

1. "I will stop the IV amphotericin B (Amphotec) while the transfusion is taking place."

2. "I will be sure to have a standard transfusion set ready before I call the blood bank."

3. "I will have normal saline IV solution available for use with the transfusion."

4. "I will monitor the patient closely for the first 15 to 30 minutes, especially for a fever."
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) appropriate action; amphotericin B (Amphotec, Fungizone) is an antifungal agent often given to leukemic patients; can cause severe allergic reactions, which makes it difficult to distinguish whether a reaction is caused by medication or transfusion; this and other medications capable of causing allergic reactions should not be administered immediately before, during, or after a transfusion; at least 1 hour should pass after the transfusion before the amphotericin is re-started
(2.) CORRECT—all equipment should be ready before blood is ordered from the blood bank; however, standard transfusion sets are not used for platelet administration because the filter traps the platelets, and also there is increased adherence of platelets to the lumen of the longer tubing; an administration set particularly designed for platelets must be used; it has a smaller filter and shorter tubing
(3.) appropriate action; normal saline is isotonic and the only appropriate solution to use in blood administration
(4.) appropriate action; if a transfusion reaction occurs, it is most likely to manifest within the first 30 minutes, often within the first 10–15 minutes; a febrile, nonhemolytic reaction is the type of transfusion reaction most common with platelet, WBC, or plasma protein administration; sudden chills and a temperature increase occur, along with headache, anxiety, muscle pain, and flushing; usually treated with antipyretics
The nurse plans a physical assessment of an 8-month-old infant. The infant sits quietly in the parent’s lap as the student nurse approaches. Arrange the following assessments in the proper sequence from FIRST to LAST. All options must be used.

Examine eyes, ears, and mouth: perform immediately before testing Moro reflex; if infant begins crying earlier in the exam, examine mouth first

Record heart and respiratory rates after auscultating heart, lungs, and abdomen

Auscultate heart and lungs: performed initially when child is quiet

Elicit the Moro reflex last

Palpate and percuss the abdomen: proceed in head-to-toe direction; palpate and percuss after auscultating
Strategy:
Determine how each action will affect an infant.
(1) Auscultate heart and lungs: performed initially when child is quiet
(2) Record heart and respiratory rates after auscultating heart, lungs, and abdomen.
(3) Palpate and percuss the abdomen: proceed in head-to-toe direction; palpate and percuss after auscultating
(4) Examine eyes, ears, and mouth: perform immediately before testing Moro reflex; if infant begins crying earlier in the exam, examine mouth first
(5) Elicit the Moro reflex last
The nurse cares for clients on the psychiatric unit. A client begins to pace and continuously wrings his hands, and the nurse notes that the client’s voice is becoming increasingly louder and angrier. Which of the following actions should the nurse take FIRST?

1. Utilize an organized team to place the client in seclusion.

2. Leave the client alone in his room.

3. Redirect the client to a quiet activity.

4. Assist the client to express feelings of anger and frustration.
Strategy: “FIRST” indicates priority
1) behavior indicates increased agitation and anxiety and may indicate impending violence; speak calmly and in a normal tone of voice; appropriate action if nurse determine that client will hurt himself or others
2) do not leave the client alone; use nonthreatening body language; don’t block exit; decrease stimuli
3) inappropriate
4) CORRECT— help client to verbalize feelings; avoid disagreeing with or threatening patient; remove threatening objects or people
The nurse admits a patient to his room following a thyroidectomy. It is MOST important for the nurse to assess for which of the following?

1. Muscle flaccidity.

2. Numbness in the fingers.

3. Pain in the lower extremities.

4. Confusion.
Strategy: Determine how each answer relates to thyroidectomy.
1) complications of thyroidectomy include hypocalcemia; muscle flaccidity results from hypercalcemia; other indications of hypercalcemia include lack of coordination, confusion, depressed or absent tendon reflexes
2) CORRECT— injury to parathyroid glands causes decrease in serum calcium, assess for tingling around mouth, toes, fingers, and muscular twitching
3) not a complication of thyroidectomy; other complications include hemorrhage, respiratory distress, laryngeal nerve damage, and thyroid storm
4) confusion is an indication of hyperthyroidism
The nurse cares for a client diagnosed with paranoid schizophrenia. The client tells the nurse, “There are really strange people in the corner laughing and saying bad things about me.” Which of the following responses by the nurse is BEST?

1. “I don’t see anything, and you have nothing to be ashamed of.”

2. “I don’t hear voices, but it appears to frighten you.”

3. “What are they saying to you?”

4. “Your imagination is playing tricks on you because you are upset.”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) don’t argue with the client
2) CORRECT— present reality and acknowledge client’s feelings; protect client’s ego by not humiliating him
3) do not validate the hallucination
4) response should validate reality
The nurse cares for clients on the medical/surgical floor. Because of a staffing shortage, an RN has been reassigned from postpartum. Which of the following clients should the nurse give to the reassigned nurse?

1. A client admitted with facial trauma after an auto accident.

2. A client diagnosed with a heat stroke.

3. A client having a systemic reaction to latex.

4. A client with progressive systemic sclerosis experiencing Raynaud’s phenomenon.
Strategy: Assign stable clients with expected outcomes.
1) requires close monitoring to assess for a patent airway; assess eye functioning, observe for neurological changes; not a stable client
2) dehydration and hyperthermia, place in air-conditioned room, lie flat with legs elevated, administer oxygen; not a stable client
3) potential anaphylactic reaction; not a stable client
4) CORRECT— chronic connective tissue disease that caused inflammation, fibrosis, and sclerosis of the skin and vital organs; stable client who can be assigned to the reassigned RN
Four patients arrive in the emergency department within minutes of one another. Which patient should the nurse see FIRST?

1. A patient, pale and diaphoretic, who is complaining of sudden and severe pain radiating from the flank to the scrotum.

2. A patient with right lower quadrant (RLQ) abdominal pain of 24 hours’ duration and which is relieved by drawing the legs up and remaining still.

3. A patient, jaundiced and nauseated, who is complaining of pain in the right shoulder and has a temperature of 100°F (37.8°C).

4. A patient with sudden epigastric pain and nausea who reports vomiting blood and has an odor of alcohol on the breath.
Strategy: Determine the most unstable patient.
(1.) symptoms of renal colic; requires quick attention to diagnose and manage the pain; not first patient to see
(2.) symptoms of probable appendicitis; confirm with physical assessment (especially abdomen and temperature) and diagnostic tests; appendectomy should be done within 24 to 48 hours of symptom onset; delay usually causes rupture of the appendix and results in peritonitis
(3.) symptoms of chronic cholecystitis; insidious symptoms may occur with this disorder, resulting in patient not seeking medical help until late symptoms appear, such as jaundice, dark urine, clay-colored stools
(4.) CORRECT—symptoms of acute gastritis; vomiting and hematemesis may be seen with gastritis stemming from alcohol abuse; other symptoms are epigastric pain or discomfort, cramping, nausea and vomiting
The hospital has just received word that a major disaster has occurred and a large influx of clients is expected in less than 1 hour. The nurse considers which of the following clients MOST appropriate for immediate discharge?

1. An 84-year-old admitted 4 days ago with a diagnosis of a stage 3-pressure ulcer.

2. A 72-year-old admitted 12 hours ago with a diagnosis of pyelonephritis.

3. A 66-year-old client 5 days postop after a total hip replacement.

4. A 45-year-old client 24 hours postop after a vaginal hysterectomy.
Strategy: Determine the most stable client.
1) full-thickness skin loss involving damage or necrosis of SQ tissue, looks like a deep crater; requires aggressive treatment
2) pyelonephritis is inflammation of kidney due to bacteria; treated with IV antibiotics
3) CORRECT— most stable client; clients with total hip replacements discharged on postop day 3 to 6 to rehab facility or home
4) second most stable client
The nurse supervises care for a client diagnosed with a stage III pressure ulcer of the sacrum with foul smelling purulent drainage. The nurse should intervene if which of the following is observed?

1. The LPN/LVN enters the room wearing a gown and gloves.

2. The nursing assistant enters the room wearing a mask.

3. The client’s family offers him a milkshake.

4. The staff lifts the client to reposition him.
Strategy: “Nurse should intervene” indicates an incorrect behavior.
1) contact precautions required for infected decubitus ulcer; private room if possible
2) CORRECT— masks not required and door does not need to be closed
3) maintain positive nitrogen balance, offer high protein diet with protein supplements
4) lifting prevents shearing force
A patient is being discharged after a liver transplant with cyclosporine (Sandimmune) oral solution as one of the prescribed medications. Which of the following statements, if made by the patient to the nurse, indicates further teaching is necessary?

1. "I will report cold symptoms to my physician."

2. "I will store cyclosporine solution at room temperature in a tightly closed container."

3. "I will take the cyclosporine with meals exactly as my physician prescribed."

4. "I will mix the cyclosporine in a glass of grapefruit juice, stir, and drink it immediately."
Strategy: "Further teaching is necessary" indicates incorrect information.
(1.) cold symptoms such as fever, sore throat, fatigue can be symptoms of infection in an immunosuppressed patient and should be reported immediately
(2.) solution should be stored at room temperature, (59 to 86 degrees); correct that it should be kept in a tightly closed container and protected from light
(3.) prevents nausea, vomiting, GI irritation; take exactly as physician ordered; effectiveness of the drug depends greatly on following manufacturer’s directions for mixing and administering
(4.) CORRECT—grapefruit juice and cyclosporine should not be taken together because the juice causes the bioavailability of cyclosporine to increase by 20 to 200%; it is even advised by some that no drinking of grapefruit juice should occur when a patient is on this drug
A woman is scheduled to have a transabdominal pelvic ultrasound for evaluation of a uterine mass. The office nurse knows that which of the following statements is MOST important to include when preparing the patient for the procedure?

1. "Do not eat anything for at least 8 hours before the test."

2. "You may feel a stinging sensation as the machine moves over your skin."

3. "Drink four glasses of water 1 hour before the test and do not urinate."

4. "Be prepared for the test to take about 1 hour."
Strategy: "MOST important" indicates that discrimination is required when answering the question.
(1.) does not require fasting
(2.) no discomfort or pain with this test
(3.) CORRECT—a full bladder is necessary for this test for several reasons; included in these are that it serves as a window for the ultrasound beam transmission and that it provides a less obstructed view by pushing the uterus away from the pubic symphysis and by pushing the intestine out of the pelvis
(4.) examination time is approximately one-half hour; most ultrasounds take 20 to 45 minutes, not including preparation and waiting times