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150 Cards in this Set

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The nurse on the medical/surgical unit reviews lab results. The nurse notes that a client’s serum albumin level is 2.5 g/dL, fasting blood sugar is 110 mg/dL, potassium is 4.2 mEq/L, and sodium is 140 mEq/L. It is MOST important for the nurse to assess for which of the following?

1. Edema.

2. Nausea.

3. Muscle weakness.

4. Blurred vision.
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) CORRECT— normal serum albumin is 3.5 to 5.5 g/dL; albumin deficit decreases oncotic pressure and fluids shift from vascular area to tissue
2) can be caused by hypokalemia or hyponatremia; sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L
3) caused by changes in potassium level
4) caused by hypoglycemia, normal FBS is 60 to 110 mg/dL
The nurse prepares a client for a bone scan. Which of the following statements by the nurse to the client is MOST important?

1. “Be sure to drink lots of fluid in the time between the tracer injection and the test.”

2. “You will feel some discomfort as the tracer is injected into your muscle.”

3. “You will have to assume various positions on a tilting x-ray table.”

4. “The scan is painless and will be over before you know it.”
Strategy: “MOST important” indicates priority.
1) CORRECT— interval between injection of the tracer and the actual scanning is usually 1 to 3 hours; large amounts of fluid maintain hydration and decrease radiation dose to the bladder; client should void immediately before scan to prevent a distended bladder
2) tracer is administered IV, not IM
3) client does not change position; must lie still for bone scan
4) scan is painless, but may take about 1 hour; client required to lie still throughout the scan
The nurse cares for a client diagnosed with type 1 diabetes. The client has been taking NPH 40 units SQ at 7 am. The physician changed the client’s insulin to NPH 30 units regular insulin, 10 units at 7 am. The nurse should instruct the client that an insulin reaction may occur at which of the following times?

1. 7:00 AM

2. 11:00 AM

3. 1:00 PM

4. 9:00 PM
Strategy: Think about each answer.
1) onset of regular insulin is 30 to 60 minutes and it peaks in 2 to 3 hours; onset of NPH is 2 to 4 hours and it peaks in 6 to 12 hours; insulin has just been administered at 7 am
2) CORRECT— hypoglycemia will occur midmorning
3) after lunch, blood sugar will be elevated
4) when taking NPH insulin, hypoglycemia occurs early evening
The nurse in the medical clinic performs a chart review. The nurse identifies that which of the following clients have modifiable risk factors for coronary artery disease?
Select all that apply:

1. A 32-year-old African American.

2. A 44-year-old who has smoked for 25 years.

3. A 49-year-old who is 5'8" tall and weighs 242 pounds.

4. A 53-year-old whose father died at age 61 of a myocardial infarction.

5. A 66-year-old with a blood cholesterol of 255 mg/dL.

6. A 70-year-old who plays golf four times per week.
Strategy: Think about each answer.
1) incidence of heart disease is higher in African Americans but is a nonmodifiable risk factor
2) CORRECT— smoking is a modifiable risk factor
3) CORRECT— obesity is a modifiable risk factor
4) increasing age and family history are nonmodifiable risk factors
5) CORRECT— normal cholesterol is 150 to 200 mg/dL; elevated cholesterol is a modifiable risk factor
6) increasing age is a nonmodifiable risk factor; physical inactivity is a modifiable risk factor; playing golf four times per week is acceptable physical activity
The nurse cares for clients in the outpatient surgical center. Four clients scheduled for surgery present to the surgical center at the same time. Which of the following clients should the nurse see FIRST?

1. A 19-year-old scheduled for a tonsillectomy.

2. A 25-year-old scheduled for an inguinal hernia repair.

3. A 32-year-old scheduled for a mastoidectomy.

4. A 39-year-old scheduled for removal of nasal polyps.
Strategy: “FIRST” indicates priority.
1) not the priority client
2) stable client; not the priority
3) CORRECT— chronic ear infections often cause vertigo, priority client due to safety
4) stable client
The nurse cares for a client injured in a motor vehicle accident (MVA) that resulted in total blindness. The nurse assists the client with the lunch tray. Which of the following actions should the nurse take FIRST?

1. Place client’s hand on each food item and describe the specific foods.

2. Procure utensils specifically designed for visually impaired clients.

3. Cut up the client’s food.

4. Inform client of location of food items using an imaginary clock face.
Strategy: “FIRST” indicates priority.
1) most people eat with utensils; there is no value in asking the client to feel the food
2) familiar utensils more useful; client likely to reject anything that makes her/him different, especially if it is not necessary
3) priority is helping client locate food on the tray
4) CORRECT— client can use imagery to recall location of each food
Prior to the patient’s discharge, the nurse in the cardiac unit reviews dietary management with a patient diagnosed with hypertension. Which of the following statements, if made by the patient to the nurse, indicates further teaching is necessary?

1. "I will use a rack whenever I cook meats."

2. "I will ask for some nice pans with nonstick coating for my birthday."

3. "I will make stews and soups in advance and refrigerate them."

4. "I will use vegetable oils instead of butter to fry my foods."
Strategy: "Further teaching is necessary" indicates incorrect information.
(1.) allows the fat to drip off; lean cuts of meat are best and all visible fat should be trimmed first
(2.) decreases the need for shortening or oil
(3.) allows the fat to harden and then be skimmed off
(4.) CORRECT—low-fat, low-cholesterol diet is recommended for patients with hypertension, fried foods should be avoided; baking, roasting, boiling, or broiling are appropriate cooking methods
The nurse cares for a client receiving aluminum hydroxide gel (Amphojel). The nurse determines that teaching is effective if the client states which of the following?

1. I will only take this medication before bedtime.

2. I will decrease side effects by taking this medication before meals.

3. I will take the medication 1 hour after meals.

4. I will take the medication when I feel epigastric pain.
Strategy: “Teaching is effective” indicates correct information.
1) antacids are taken several times per day to be effective
2) most effective when taken after digestion has begun but before the stomach has emptied
3) CORRECT— antacids neutralize gastric acids, increase gastric pH, and inactivate pepsin; contains sodium, check if patient is on sodium-restricted diet
4) take medication to prevent epigastric pain
The home care nurse returns to the office to find four phone messages. Which of the following messages should the nurse return FIRST?

1. The daughter of a client diagnosed with lung cancer states that her father refuses chemotherapy today.

2. A client is asking when staples can be removed from his abdominal incision.

3. A client with a colostomy complains that the skin is raw around the stoma.

4. The wife of a client with a cerebrovascular accident states that her husband is refusing a bath.
Strategy: Determine the most unstable client.
1) CORRECT— assess whether client is experiencing side effects
2) should ask client if incision is red or if there is any drainage
3) second call to be returned; ensure that skin sealant does not contain alcohol and instruct client to use stoma powder or paste
4) stable client
The nurse determines that which of the following patients is MOST likely to need pyridoxine hydrochloride (vitamin B6) supplementation?

1. A patient diagnosed with tuberculosis.

2. A patient diagnosed with pernicious anemia.

3. A patient diagnosed with chronic alcoholism.

4. A patient at 12 weeks’ gestation.
Strategy: Think about each answer.
(1.) CORRECT—patient is likely to be taking isoniazid (INH); INH is a mainstay in prevention and treatment of tuberculosis, used in combination with other antitubercular drugs if the disease is active; vitamin B6 is given to prevent the peripheral neuropathy, dizziness, and ataxias that can occur with this drug
(2.) needs supplementation with vitamin B12
(3.) needs supplementation with all B vitamins, especially thiamine (vitamin B1); thiamine deficiency is the primary cause of alcohol-related changes such as Wernicke’s encephalopathy and Korsakoff’s syndrome
(4.) needs supplementation with folic acid (vitamin B9) to prevent neural tube defects in the fetus; supplementation is recommended for all women capable of becoming pregnant
The nurse observes a student nurse care for a client diagnosed with cerebrovascular accident (CVA). The nurse should intervene if which of the following is observed?

1. The student nurse places the client in an upright position to eat.

2. The student nurse auscultates breath sounds bilaterally.

3. The student nurse simultaneously palpates the carotid pulses.

4. The student nurse faces the client and speaks clearly.
Strategy: “Nurse should intervene” indicates an incorrect action.
1) appropriate action; in addition to sitting upright, encourage client to flex head slightly
2) appropriate action
3) CORRECT— palpating the carotid pulses together can cause a vagal response and slow the client’s heart rate
4) appropriate action; facilitates communication, allow client enough time to respond
The nurse instructs a client receiving prednisone (Deltasone) 10 mg QD for treatment of rheumatoid arthritis. The nurse determines that teaching is successful if the client makes which of the following statements?

1. “The physician will adjust the dosage until there is complete relief of my symptoms.”

2. “The dosage of prednisone will be increased and decreased gradually.”

3. “This drug may cause urinary incontinence and frequency as a side effect.”

4. “I should stop the medication if I experience any side effects.”
Strategy: “Teaching is successful” indicates correct information.
1) rheumatoid arthritis is a chronic, progressive, systemic inflammatory process; complete relief of symptoms is not possible
2) CORRECT— prednisone is an antiinflammatory and immunosuppressive drug; to minimize body’s reaction to sudden loss of exogenous steroids, drug is decreased gradually; side effects include euphoria, insomnia, peptic ulcer, acute adrenal insufficiency after increased stress or abrupt withdrawal
3) not a side effect of medication; symptoms of rheumatoid arthritis include joint pain, swelling, contracture deformity, ulnar drift
4) should not discontinue medication abruptly
The nurse assesses a client for signs and symptoms of carpal tunnel syndrome. It is MOST important for the nurse to include which of the following instructions?

1. “Put the back of your hands together and bend both wrists at the same time.”

2. “Place the fingernails of your ring fingers together and hold them up to the light.”

3. “Hold your arms out straight in front of you and push with your hands and wrists against the wall.”

4. “Put your hands with palms up and then palms down on each thigh, repeating as fast as you can.”
Strategy: Determine the outcome of each answer. Is it desired?
1) CORRECT— describes Phalen’s maneuver; produces paresthesia of the median nerve distribution within 60 seconds; 80% of clients diagnosed with carpal tunnel syndrome have a positive result
2) Schamroth method to detect clubbing; if diamond shape is visible between the nails, there is no clubbing; clubbing indicates oxygen deprivation from respiratory or cardiovascular conditions
3) isometric exercise not related to assessment of carpal tunnel syndrome
4) assesses cerebellar function, fine coordination of muscle activity
The nurse instructs the parents of a 6-year-old boy about the medications prescribed by the clinic physician. The physician’s order reads, “Phenobarbital 15 mg PO q12h, phenytoin sodium (Dilantin) 30 mg/5 ml BID.” Which of the following information is MOST important for the nurse to discuss with the parents?

1. Dilantin comes as a suspension and should be shaken.

2. Dilantin can cause a change in the growth of the boy’s gums.

3. Phenobarbital can cause a discoloration of the child’s urine.

4. Phenobarbital can affect the child’s vitamin D metabolism.
Strategy: Determine the outcome of each answer choice. Is it desired?
1) CORRECT— minimum information that should be taught for safety of patient; need to give prescription accurately
2) gingival hyperplasia is side effect of Dilantin; seen over long periods of time; minimized with frequent dental care
3) phenobarbital does not change color of urine, but may cause nausea, constipation, and epigastric pain; Dilantin may make urine pink, red, or red-brown
4) phenobarbital increases vitamin D metabolism, which can lead to subtherapeutic levels with prolonged therapy, but not most important
The nurse at a community health center is notified that a group of clients has been exposed to a hazardous chemical. Which of the following clients should the nurse see FIRST?

1. A client who says the chemical spilled onto his legs.

2. A client who says he inhaled the chemical.

3. A client who says she has hypertension and type 2 diabetes.

4. A client who says he swallowed the chemical.
Strategy: “FIRST” indicates priority.
1) although serious, skin exposure results in a slower absorption rate
2) CORRECT— results in immediate absorption and can impair oxygen exchange
3) no indication that client is unstable
4) not as life-threatening as impaired gas exchange
When intervening with a client who is in a state of crisis, which of the following statements by the nurse is MOST effective?

1. “Why is it you feel so upset in this situation?”

2. “What have you done before when you felt this anxious?”

3. “There is no way to prevent this from happening.”

4. “It seems as if this situation is very stressful for you.”
Strategy: “MOST effective” indicates discrimination is required to answer the question.
1) “why” questions imply disapproval
2) CORRECT— priority is to establish coping methods that have helped in the past; crisis intervention focuses on finding the client’s inner strengths to deal with the problem at hand
3) false reassurance
4) is a reflective statement; in crisis, more important to determine coping methods used in the past
An elderly alcoholic client receives a benzodiazepine (Librium) for 2 days for symptom management and reduction. The client says to the nurse, “Get those bugs off of me!” The nurse should assess for which of the following?

1. A reaction to the benzodiazepine (Librium).

2. Worsening course of withdrawal syndrome.

3. An exacerbation of schizophrenia.

4. The effects of delirium.
Strategy: Think about each answer.
1) not exhibiting symptoms of oversedation
2) CORRECT— has progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; symptoms include tremors, increased heart rate, fever, confusion, delusions, and hallucinations
3) incorrect
4) incorrect
The nurse cares for a client diagnosed with active tuberculosis. It is MOST important for the nurse to take which of the following actions?

1. Restrict visitors to immediate family only.

2. Wear a gown and gloves at all times.

3. Wear a mask and gloves when in direct contact with the client.

4. Dispose of waste articles more frequently.
Strategy: “MOST important” indicates priority.
1) immediate family has probably already been exposed to the client’s tuberculosis
2) requires airborne precautions; wear respiratory protection; place client in private room with monitored negative air pressure
3) CORRECT— airborne precautions required
4) appropriate action to prevent spread of TB; priority is for the staff to maintain airborne precautions
The nurse cares for patients in the emergency department. Four patients come to the ED at the same time. Which of the following patients should the nurse see FIRST?

1. A 1-year-old with vomiting and diarrhea.

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

3. A 20-year-old at 8 weeks’ gestation who is complaining of vaginal spotting.

4. A 32-year-old complaining of nausea and vomiting for the past several hours.
Strategy: Determine the MOST unstable patient.
(1.) CORRECT—at significant risk for dehydration, which may result in electrolyte imbalances, as well as shock, depending on the amount of fluid lost
(2.) obtain an order for an antipyretic and monitor until can be evaluated by physician
(3.) caused by drop the progesterone level, potential for spontaneous abortion; encourage patient to rest; offer reassurance until patient evaluated by physician
(4.) average healthy young adult’s body can adequately compensate for dehydration over the short term
The charge nurse demonstrates an understanding of appropriate delegation when an LPN/LVN is assigned to which of the following clients?

1. A client diagnosed with psychosis.

2. A client receiving chemotherapy.

3. A client in Buck’s traction.

4. A client receiving a blood transfusion.
Strategy: Assign stable clients with expected outcomes.
1) unstable client; requires skill of RN
2) unstable client; requires skill of RN
3) CORRECT—stable client with an expected outcome
4) unstable client; requires frequent assessment
The home care nurse visits a client after a prostatectomy with urinary incontinence. The client reports that he is changing incontinence pads every 2 hours. Which of the following actions by the nurse is MOST appropriate?

1. Encourage the client to drink 1000 mL per day.

2. Instruct the client to use artifical sweetener.

3. Instruct the client to so pelvic muscle strengtening exercises.

4. Administer terazosin (Hytrin) 1 mg orally.
Strategy: Assess before implementing.
1) no need to restrict fluids
2) artifical sweetener will irritate the bladder and may increase incontinence
3) CORRECTappropriate action for incontinence; will improve bladder control
4) is an alpha one adrenergic blocker; used for treatment of benign prostatic hypertrophy
The nurse cares for a client receiving carbidopa/levodopa (Sinemet). Which of the following statements, if made by the client’s wife to the nurse, indicates the medication is effective?

1. “My husband has gained 2 pounds in the last month.”

2. “My husband gets fewer upper respiratory infections.”

3. “My husband’s tremors have disappeared.”

4. “My husband is better able to ambulate.”
Strategy: Think about the answers.
1) Sinemet is used to treat symptoms of Parkinson’s disease; weight gain does not evaluate effectiveness of medication
2) does not indicate effectiveness of medication; instruct patient to take immediately before meals; high-protein meals may impair effectiveness of medication
3) medication is not a cure and tremors do not disappear
4) CORRECT— reduces rigidity and bradykinesis and facilitates client’s mobility
The nurse supervises care on the medical/surgical unit. Which of the following situations should the nurse attend to FIRST?

1. A nursing assistant enters the room of a client diagnosed with Pneumocystis carinii pneumonia wearing gown, mask, and gloves.

2. A client who has just returned to the unit after a right pneumonectomy is placed in a room with a client diagnosed with COPD.

3. The family of a client reports that the toilet is overflowing in the patient’s bathroom.

4. A client diagnosed with tuberculosis is ready for discharge and waiting for discharge instructions.
Strategy: Determine which situation will cause the most harm to a client.
1) should be using standard precautions; nursing assistant needs to be counseled on appropriate precautions; not the most unstable situation
2) CORRECT— postoperative clients are considered “clean” and should not be placed with a client that is considered “dirty”
3) potential problem; actual problems take priority
4) psychosocial need; physical needs take priority
The nurse on the surgical unit receives a call from the operating room to administer preoperative medication to a client scheduled for surgery. After administering the preoperative medication, the nurse discovers that the client has not signed the informed consent for the surgery. Which of the following actions should the nurse take NEXT?

1. Notify the physician.

2. Ask the client to sign the consent form.

3. Transfer the client to the operating room.

4. Inform the nursing supervisor.
Strategy: “NEXT” indicates priority.
1) nurse should stay within the chain of command
2) consent not valid if client has been drinking or has been premedicated
3) surgery performed without consent considered battery
4) CORRECT— nurse should follow chain of command; risks and benefits of the procedure must be explained by the person performing the procedure
The oncology nurse is caring for a patient diagnosed with lung cancer. Which of the following symptoms, if exhibited by the patient, MOST concerns the nurse?

1. Confusion, weight gain, urine output of 15 cc/hr.

2. Stomatitis, alopecia, skin rash.

3. Serum sodium of 140 mEq/L and serum calcium of 10.0 mg/dL.

4. Chest pain and blood-tinged sputum.
Strategy: "MOST concerns the nurse" indicates a complication.
(1.) CORRECT—signs and symptoms related to syndrome of inappropriate antidiuretic hormone (SIADH), the basic process of which is water retention due to excessive ADH; most common cause of SIADH is cancer, especially lung cancer, other causes include various pulmonary and CNS disorders and certain drugs
(2.) stomatitis and skin rash require further assessment and intervention; these are symptoms that can occur with cancer, especially as a result of chemotherapy and/or radiation
(3.) serum sodium is within normal range, which is 135–145 mEq/L; serum calcium is toward the high end of the normal narrow range of 9.0–10.5 mg/dL and would be watched, but is still within limits; hypercalcemia is a late sign of extensive malignancy, particularly bone metastases
(4.) manifestations of lung cancer; pain comes partly from the tumor invading perivascular nerves; blood-tinged sputum may come from bleeding from a malignant tumor
The nurse counsels a client diagnosed with tuberculosis. The client asks the nurse what he should do to prevent the spread of the disease. Which of the following recommendations should the nurse make FIRST?

1. “Take all of your medication exactly as prescribed by your health care provider.”

2. “Cover your mouth and nose when you sneeze.”

3. “Dispose of all of your tissues in a paper bag.”

4. “Keep all of your clinic appointments.”
Strategy: Determine the outcome of each answer. Is it desired?
1) CORRECT—combination drug therapy most effective to treat tuberculosis; to ensure compliance, assess for side effects
2) appropriate action; do not go to work or school until 3 negative sputum specimens
3) appropriate action; air out room frequently
4) appropriate action; health care provider will evaluate effectiveness of medication
The nurse performs a physical assessment on an infant. When assessing the infant, it is MOST important for the nurse to take which of the following actions LAST?

1. Evaluate genitalia.

2. Assess ears and mouth.

3. Assess deep tendon reflexes.

4. Obtain heart and respiratory rates.
Strategy: Determine outcome of each answer.
1) should proceed in a general head to toe direction
2) CORRECT— more traumatic/invasive, which may induce crying; nurse should perform auscultation and less aggressive assessments first while patient is calm and quiet
3) should be completed as each body part is examined
4) should be done while infant is calm and quiet
The nurse learns that a client recovering from an abdominal hysterectomy is being transferred from recovery to the medical/surgical unit. The nurse determines that the client’s room assignment is appropriate if the client is placed in a room with which of the following clients?

1. A client recovering from a craniotomy to treat a brain abscess.

2. A client diagnosed with cellulitis of the left leg.

3. A client diagnosed with an MSRA wound infection.

4. A client recovering from gastric bypass surgery.
Strategy: Place noninfected clients with noninfected clients.
1) not considered a “clean” client
2) not considered a “clean” client
3) place on contact precautions
4) CORRECT— place “clean” client with “clean” client
The parents of a 4-year-old girl bring their child to the emergency department. The parents state that the child has been complaining of abdominal pain, is nauseated and vomiting, and refuses to eat. The nurse knows it is flu season. It is MOST important for the nurse to ask the parents which of the following questions?

1. "Did your child have the flu shot this year?"

2. "What new foods has your child been eating lately?"

3. "How long has your child been feeling like this?"

4. "Which came first: the pain, or the nausea and vomiting?"
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) symptoms are not those of influenza
(2.) assumes symptoms may be related to food
(3.) important question, but not most important; if it is appendicitis, the information could assist in predicting possible perforation and peritonitis; physiologic differences in children (compared to adults) increase vulnerability to rapid progression to perforation and peritonitis; delay in appendicitis diagnosis in young children is frequent due to child’s inability to state symptoms and because clinical signs are similar to other conditions
(4.) CORRECT—the sequence of symptoms is the most reliable information from the history when assessing for possible appendicitis; the clinical symptoms with acute appendicitis are similar to those of many other medical conditions; in acute appendicitis, the pain usually comes prior to nausea and vomiting; nausea and vomiting that come before abdominal pain frequently indicate gastroenteritis
The nurse admits a 6-year-old child with an open wound that is methicillin-resistant Staphylococcus aureus (MRSA)-positive. It is MOST appropriate that the nurse assign this child to which of the following rooms?

1. A semiprivate room with a 2-year-old diagnosed with respiratory syncytial virus.

2. A semiprivate room with a 5-year-old diagnosed with acute respiratory virus.

3. A private room that is close to the nurse’s station.

4. Any private room that is available.
Strategy: Think about the outcome of each answer.
1) both illnesses require contact precautions; do not mix clients with different infections
2) both illnesses require contact precautions; do not mix clients with different infections
3) requires a private room, but there are no indications for close monitoring
4) CORRECT— requires a private room; semiprivate room is acceptable only when there are no other rooms to admit this client, and an MRSA client can room only with another client who is MRSA-positive
The nurse performs a physical assessment on a patient diagnosed with bulimia nervosa. Which of the following findings warrant an IMMEDIATE referral to the physician?

1. Bilateral parotid gland enlargement.

2. A hoarse voice that is barely audible.

3. Grey to black eroded teeth with foul odor.

4. Multiple papulopustular skin eruptions on face, chest, and back.
Strategy: "IMMEDIATE referral" indicates a complication.
(1.) hallmark sign of chronic vomiting; glands become clogged with foreign matter; not priority
(2.) CORRECT—at high risk for tracheoesophageal fistula from esophageal tear; laryngitis is danger sign
(3.) sign of chronic vomiting; gastric acid erodes teeth; needs eventual dental referral
(4.) sign of acne vulgaris related to bingeing on junk foods
The nurse cares for an elderly client 24 hours after an abdominal hysterectomy. The nurse asks the client if she is experiencing any pain. The client states, “No, I am just fine.” Which of the following responses by the nurse is BEST?

1. “That’s good. Please let me know if your abdomen starts hurting.”

2. “I see that you have not used your PCA pump. Are you sure that you aren’t in pain?”

3. “You are doing such a good job. If it were me, I would be using the pain medication.”

4. “Look at this faces pain scale. Point to the picture that shows how you feel now.”
Strategy: “BEST” indicates priority.
1) should validate client’s statement; client may be denying pain
2) second best answer; nurse is making observation about client’s use of PCA pump, but validates by asking a yes/no question
3) focus is on nurse and not client
4) CORRECT— allows nurse to assess client’s perception of pain and validate client’s denial of pain
Four children come to the office of the school nurse at the same time. After performing an assessment, the nurse determines that the parents of which of the following children should be contacted FIRST to come pick up their child?

1. A child with a red rash on the cheeks that makes the child’s face look like it has been slapped.

2. A child with a fever who complains of headache, malaise, anorexia, and an earache when chewing.

3. A child with an apparent upper respiratory infection (URI) and an inflamed conjunctiva with swollen eyelids and watery drainage.

4. A child with clusters of small, erythematous, intensely pruritic papules in the antecubital space.
Strategy: Determine the child who is most infectious.
(1.) indicates fifth disease; most contagious before rash appears, isolation not required once rash appears; child can attend school
(2.) CORRECT—indicates probable mumps; communicability greatest immediately before and after the swelling begins
(3.) symptoms are of viral conjunctivitis; not priority
(4.) describes eczema; not priority
A client diagnosed with lung cancer has gained 3 kg in 2 days. The nursing assessment reveals a regular heart rate and lungs are clear to auscultation. The client’s lab values include sodium 122 mEq/L, potassium 4.5 mEq/L, Cl 99 mEq/L, BUN 22 mg/dL, creatinine 1.0 g/dL, HCT 42%, WBC 5,000 mm 3 , urine specific gravity 1.008. The nurse identifies which of the following as the reason for the weight gain?

1. Syndrome of inappropriate antidiuretic hormone (SIADH).

2. Chemotherapy.

3. Renal failure.

4. Heart failure.
Strategy: Think about each answer.
1) CORRECT— lung cancer is a common cause of SIADH, which is abnormal secretion of ADH; results in increased water absorption and dilutional hyponatremia
2) will cause a decreased HGB and WBC
3) BUN increased and creatinine within normal limits; BUN would be decreased with hypervolemia due to increased ADH secretion
4) does not cause hyponatremia; may cause pulmonary edema and crackles
During a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which of the following actions should the nurse take NEXT?

1. Place an identification bracelet on each child.

2. Go back for an adequate supply of water.

3. Notify the parents of the children’s location.

4. Comfort children who are anxious.
Strategy: Determine the outcome of each answer.
1) CORRECT— aids in communication after rescue or recovery
2) nurse should not leave the children alone
3) identification takes priority over notification
4) priority is assuring that each child can be identified
The nurse manager on the unit is fiscally responsible for meeting goals related to personnel and the supply and expense part of the budget. To meet budget expectations, it is MOST important for the nurse manager to take which of the following actions?

1. Share budget expectations with the personnel on the unit.

2. Designate a staff nurse to assist with budget planning.

3. Post the budget on the bulletin board.

4. Ensure that provider needs are met.
Strategy: Determine the outcome of each answer. Is it desired?
1) CORRECT— sharing the budget and monitoring activities with staff allows the staff to develop cost-conscious nursing practices
2) staff nurses help meet budget expectations but are not directly accountable for the budget process
3) not appropriate
4) when making budget decisions, make sure that patient needs are being met
The nurse in the cardiac care unit monitors a patient who is recovering from coronary artery bypass graft surgery (CABG). Which of the following occurrences MOST concerns the nurse?

1. The jugular veins are distended; the lung sounds are clear.

2. The patient complains of sharp localized pain over the sternum.

3. The serum electrolytes show potassium 4.6 mEq/L, calcium 9.4 mg/dL, magnesium 1.6 mg/dL.

4. The core body temperature is 97.2°F (37°C).
Strategy: "MOST concerns" indicates a complication.
(1.) CORRECT—jugular vein distention symptom of cardiac tamponade, a potential complication after a CABG caused by blood accumulating around the heart (from bleeding and nonpatent mediastinal tubes) and compressing the myocardium, atria, and ventricles
(2.) expected after CABG since the heart has been accessed through the sternum, and is treated with pain medications
(3.) all within normal limits; normal potassium is 3.5–5.0 mEq/L, Ca ranges 8.5–10.5 mg/dL, Mg ranges 1.5–2.5 mg/dL
(4.) hypothermia is usual after CABG because of induced hypothermia during surgery and heat loss from the open chest
The nurse instructs a student nurse about the correct way to set up a sterile field. The nurse determines that teaching is effective if which of the following is observed?

1. The student nurse places the supplies at the edge of the sterile field.

2. The student nurse wears a gown and gloves at all times.

3. The student nurse sets up the sterile field above waist level.

4. The student nurse opens supplies with sterile gloves.
Strategy: Determine the outcome of each answer.
1) carefully place sterile items on the field; any object placed on the outer 1 inch of the field must be discarded
2) set up field before donning sterile gloves
3) CORRECT— below waist level is considered contaminated; face sterile field; prepare field immediately before the scheduled procedure
4) contaminates the gloves; supplies can be opened with bare hands
The nurse cares for clients in the Emergency Department (ED). The nurse is approached by transport personnel asking the nurse to sign out a client for transport for magnetic resonance imaging (MRI). The client states “I was in a car accident and there is something wrong with my left eye.” Which of the following responses by the nurse to the transport personnel is MOST appropriate?

1. “I’ll call to make sure that they are ready for the client.”

2. “Is there a family member who can go with the client to the MRI?”

3. “I’ll locate the chart to make sure that the physician has ordered the MRI.”

4. “You have to talk with the nurse assigned to the client.”
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) immediate concern is contacting the nurse assigned to the client
2) appropriate for family to accompany the client, but client safety takes priority
3) should be completed by the nurse assigned to the client
4) CORRECT— MRI is contraindicated for clients with actual or suspected metallic foreign body in the eye; client was in an auto accident and has the potential for eye injury that involves metal; assigned nurse would know if prior tests have eliminated a possible metal object
The nurse answers the call light of a patient who is complaining of a severe headache 30 minutes after undergoing a lumbar puncture. Which of the following actions should the nurse take FIRST?

1. Assess the puncture site.

2. Administer an analgesic as ordered.

3. Assess the patient’s blood pressure.

4. Encourage the patient to lie flat.
Strategy: "FIRST" indicates priority.
(1.) CORRECT—headaches are a common side effect of a lumbar puncture procedure, however assessing for leakage of cerebrospinal fluid or the presence of a hematoma that may increase the likelihood of complications is required to determine if further intervention is indicated
(2.) appropriate action; assess before intervening
(3.) assessment of vital signs is an appropriate action, but assessment of the site takes precedence because it may be directly linked to the patient’s symptoms
(4.) appropriate action if the patient is not following the pre- and post-procedure instructions given by the nurse; assess before intervening
The nurse makes patient assignments on the medical/surgical unit. The nurse assigns an LPN/LVN to a patient diagnosed with localized herpes zoster. The LPN/LVN mentions to the nurse that she has never had the chickenpox. Which of the following statements by the nurse is MOST appropriate?

1. “Use standard precautions when caring for the patient.”

2. “You will be fine, because the patient is on airborne precautions.”

3. “I will assign the patient to another nurse.”

4. “Are you concerned about caring for the patient?”
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) localized herpes zoster does require standard precautions; because LPN/LVN has not had the chickenpox, should not enter room
2) requires standard precautions
3) CORRECT— should assign patient to an immune caregiver
4) no reason to explore LPN/LVN’s concerns; nurse should assign patient to an immune caregiver
The triage nurse at a busy urgent care center prioritizes clients for evaluation. The nurse determines that which of the following clients should be seen FIRST?

1. A woman at 6 weeks’ gestation who complains of left lower quadrant abdominal pain and vaginal spotting.

2. A toddler whose parents report nausea and vomiting for 2 hours and a fever of 102.8°F (39.0°C).

3. A patient diagnosed with renal disease who missed his dialysis appointment the day before and who complains of swelling in his feet and ankles.

4. A toddler who has a forehead laceration from a fall and who is smiling and playful.
Strategy: Determine the most unstable client.
1) CORRECT— symptoms of ectopic pregnancy, which may result in death if allowed to progress
2) though at risk for dehydration, short duration of the child’s symptoms indicate a potential and not actual risk at this time; nurse likely to obtain an order for an antipyretic while the patient waits for evaluation
3) likely requires dialysis; ectopic pregnancy is an actual risk
4) level of consciousness is appropriate
A male patient is brought to the emergency department by friends who state that he has been "hanging with the wrong crowd" and they are worried he is using drugs. The nurse notes that the patient stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. It is MOST important for the nurse to plan for which of the following?

1. Increased adventitious breath sounds.

2. Decreased blood pressure, temperature, and pulse.

3. Aggressive behaviors.

4. Nausea, vomiting, abdominal cramping.
Strategy: The topic of the question is unstated.
(1.) patient’s symptoms indicate phencyclidine piperidine (PCP) intoxication; breath sounds important to assess with any new patient but not priority; respiratory arrest can occur with PCP overdose
(2.) with PCP, blood pressure, temperature, and pulse are expected to increase, not decrease; overdose could even lead to a hypertensive crisis; hyperthermia can also occur
(3.) CORRECT symptoms of blank stare, rigid muscles, ataxia, and nystagmus that is both vertical and horizontal indicate probable phencyclidine piperidine (PCP) intoxication; another name for PCP is angel dust; aggression in all forms is another symptom that manifests with PCP; can take the form of assault, belligerence, impulsiveness, and/or suicidality, and is very often bizarre in nature; often occurs in unpredictable outbursts; interventions should be planned to monitor for aggressive symptoms, to prevent them, and to manage them should they occur; decreasing stimuli, avoiding trying to "talk the person down," securing potential injurious objects in the environment, having chemical and physical restraints (along with sufficient staff) available are all measures that can be planned in advance and utilized; PCP is used by itself, but is also frequently used as an adulterant with other drugs
(4.) no particular association with PCP; these are symptoms that occur with opiate withdrawal.
The nurse performs a physical assessment of the precordium on an adult male. Identify where the nurse should place the stethoscope to auscultate Erbs’ point.
Strategy: Locate landmarks.
Erb’s point is located in the third intercostal space just to the left of the sternum; both aortic and pulmonic murmurs may be auscultated at this location
The nurse observes that 1 minute after a newborn is delivered the heart rate is 124, central color is pink, hands are blue, moderate flexion is noted on the upper and lower extremities, cry is vigorous, and there is a slight response to a foot tap. What Apgar score should the nurse assign to the newborn?

1. 6

2. 7

3. 8

4. 9
Strategy: Think about each answer.
1) Apgar evaluates the physical condition of a newborn at birth; 2 points given for each of the following categories: heart rate, color, muscle tone, respiratory effort, and reflex irritability; this score isn’t correct
2) CORRECT— assign 2 points for heart rate, 1 point for color, 1 point for muscle tone, 2 points for respiratory effort, and 1 point for reflex irritability
3) inaccurate; score of 8–10 indicates newborn is in good condition; Apgar evaluated at 1 and 5 minutes
4) inaccurate
The nurse surveys patients midway through the evening shift. It is MOST important for the nurse to intervene in which of the following situations?

1. A patient diagnosed with emphysema and a smoker’s cough is watching television with a visitor who is wearing a mask and gloves.

2. A patient diagnosed with gastroesophageal reflux disease (GERD) is sitting in a chair sipping a can of ginger ale after eating dinner.

3. A patient diagnosed with peripheral arterial disease (PAD) is sitting on the side of the bed with legs crossed.

4. A patient diagnosed with myasthenia gravis is being assisted with dinner by the nursing assistant, who is cutting the food into small pieces.
Strategy: "Nurse to intervene" indicates that something is wrong.
(1.) intervention useful but not most important; emphysema not infectious and does not require particular infection control precautions such as mask, gloves, or gown
(2.) not most important for intervention, although intervention would be useful; patients with GERD should not drink carbonated beverages because they cause increased pressure in the stomach
(3.) CORRECT - patients with peripheral vascular disease (PVD), either venous or arterial, should sit with feet flat on the floor or comparable surface and avoid crossing legs or wearing constrictive clothing
(4.) no need for intervention; patients with myasthenia gravis have easy muscle fatigue, including muscles used for chewing and swallowing; as long as patient can swallow, food should be cut into small bites and patient encouraged to eat slowly
The nurse in the outpatient clinic cares for a client who experienced sudden visual loss in a portion of the visual field. A physician’s examination reveals age-related macular degeneration (ARMD). It is MOST important for the nurse to assess which of the following?

1. Allergies to medication and food.

2. Client’s feelings about permanent loss of vision.

3. History of hypertension.

4. History of smoking.
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) ARMD causes permanent loss of central vision; focus of treatment is augmenting remaining vision; obtaining information about allergies is not relevant to ARMD
2) CORRECT— because loss of vision is permanent, it is important for the nurse to allow the client to verbalize fears about the future and to assist the client to maximize remaining vision
3) not related to macular degeneration
4) cigarette smokers have significantly higher risk of developing ARMD; important information to obtain when counseling the public about how to decrease the risk of developing macular degeneration
The nurse cares for a client 2 days after the client sustained an injury in an auto accident. The client is placed in halo vest traction. The nurse is MOST concerned if the client states which of the following?

1. “It hurts when I chew.”

2. “My back itches.”

3. “I have a headache.”

4. “Why did this happen to me?”
Strategy: “MOST concerned” indicates a complication.
1) CORRECT— if pain occurs with jaw movement 24 to 48 hours after traction applied, may indicate that skull pins have slipped onto the thin temporal plate; notify physician immediately
2) wash chest and back daily and carefully dry; assess skin for pressure areas; dry damp sheepskin with hairdryer; apply light dusting of medicated powder or cornstarch to prevent itching
3) physician tightens screws 24 to 48 hours after halo is applied; offer analgesic
4) important to encourage client to express feelings; physical needs take priority over psychosocial needs
The nurse cares for a young adult female client diagnosed with type 1 diabetes. When teaching the client about measures to prevent long-term complications, the nurse should include which of the following?

1. Use a vaginal douche after each menstrual period.

2. Wipe the perineal area from front to back after voiding.

3. Avoid sexual intercourse.

4. Wear nylon undergarments.
Strategy: Determine the outcome of each answer. Is it desirable?
(1.) increases the risk of vaginal infections, especially yeast infections
(2.) CORRECT—prevents contamination of the vaginal and urethral areas and decreases the risk of vaginal and urinary tract infections
(3.) sexual intimacy is a natural part of being human; patient should be encouraged to maintain good hygiene and instructed to avoid intercourse if she or her partner is experiencing symptoms suggestive of infection
(4.) cotton undergarments tend to absorb moisture more effectively than other materials and allow air to circulate better, decreasing the risk of infection
The nurse performs an initial assessment on a middle-aged male. It is MOST important for the nurse to follow up on which of the following client statements?

1. "My brother was just diagnosed with prostate cancer."

2. "I take enalapril maleate (Vasotec) 5 mg po daily."

3. "I had a lumbar laminectomy 2 years ago but still have some low back pain."

4. "Lately, I just don’t have as much desire to engage in sex."
Strategy: "MOST important" indicates discrimination is required to answer the question.
(1.) CORRECT—middle-aged male is at risk for prostate cancer; having a father or brother with this cancer increases the client’s risk by 50%
(2.) used to treat mild hypertension, no problem indicated
(3.) may be experiencing chronic pain; usually not life-threatening, requires further assessment
(4.) requires further assessment of underlying cause; may be physical or psychosocial
The nurse cares for a client in the outpatient clinic with a diagnosis of myxedema. During the initial assessment, the nurse should carefully observe for which of the following symptoms?

1. Tachycardia, fatigue, and intolerance to heat.

2. Polyphagia, nervousness, and dry hair.

3. Lethargy, weight gain, and intolerance to cold.

4. Tachycardia, hypertension, and tachypnea.
Strategy: Think about each symptom and how it relates to hypothyroidism.
1) signs of hyperthyroidism
2) indicates hyperthyroidism; even though appetite is increased, weight loss occurs; other emotional manifestations include decreased attention span, irritability, manic behavior
3) CORRECT— signs and symptoms of hypothyroidism; other assessments include dry hair, mask-like facial expression, thickened skin, enlarged tongue, and drooling
4) signs of hyperthyroidism
The nurse cares for a client receiving gentamycin (Garamycin) IV. The physician orders the medication to be administered IV piggyback in 100 mL D 5W over 30 minutes. The IV set delivers 15 drops per mL. Record the number of drops per minute the client should receive.
Type a whole number in the blank
Strategy:
Correct answer: 50

100*50/30 = 1,500/30

=50gtts/min
The nurse cares for clients in the long-term care facility. The nurse recognizes which of the following signs/symptoms may indicate that a client has developed dementia?

1. Impaired motor skills, lack of coordination, and mood changes.

2. Confusion, delirium, and hallucinations.

3. Weight loss, fatigue, and hopelessness.

4. Poor judgment, memory deficit, and irritability.
Strategy: Think about each answer.
1) may be the result of a CVA
2) describes delirium; rapid onset secondary to physical illness
3) symptoms of depression
4) CORRECT— characteristic symptoms of dementia; may also see apathy, indifference, pacing, restlessness, and agitation
When providing care for a client over the age of 65 years, the nurse knows that which of the following is the MOST reliable sign of infection?

1. Fever.

2. Hypotension.

3. Leukocytosis.

4. Tachypnea.
Strategy: Think about each answer.
1) absent in 25 to 30% of clients
2) is not a sign of infection
3) more than 20% of elderly clients with infection may present without leukocytosis
4) CORRECT— tachycardia, tachypnea, and confusion may be signs of infection in elderly patients
A nurse cares for children in the pediatric clinic. A mother tells the nurse that she thinks her 8 year-old son has attention deficit hyperactivity disorder (ADHD). Which of the following behaviors, if identified by the nurse, supports a diagnosis of ADHD?
Select all that apply:

1. When asked to sit in the waiting room, the child wanders in the hallway.

2. The child quietly looks at a book while his mother talks to the nurse.

3. The child looks out the window when the nurse is talking to him.

4. During the visit with the nurse, the child repeatedly demands to leave.

5. The mother reports that her son independently completes his homework

6. The mother states that her son was “always on the go as a toddler.”
Strategy: Think about each behavior and how it relates to ADHD.
1) CORRECT— not following directions and leaving seat when remaining seated is expected is indicative of ADHD
2) indicates that child is able to attend and follow directions
3) CORRECT— child with ADHD often does not seem to listen when someone speaks directly to him/her
4) CORRECT— often interrupts or intrudes on others
5) child with ADHD has difficulty following through on instructions or finishing schoolwork
6) CORRECT— parents report that child is often on the go or acts as if driven by a motor
The nursing assistant on an acute urology unit gives the nurse the intake and output sheet for a client diagnosed with chronic renal failure (CRF). The client’s output was measured on the day shift but not recorded on the evening shift. Which of the following actions should the charge nurse take FIRST?

1. Call the nurse assigned to the evening shift and request the information.

2. Complete an agency incident report.

3. Ask the client if he noticed the output last evening.

4. Notify immediate supervisor of the incident.
Strategy: “FIRST” indicates priority.
1) CORRECT— the goal is to make every effort to retrieve the data; knowledge of output used to support decision making about most appropriate interventions; nurses often carry notes home with them or store their work sheets in their lockers; this method seeks a possible resource
2) last step; information may be available; quality client care is first priority; don’t have problem yet
3) some clients notice the volume and some do not; is a possible resource, but is not the best resource; is nurse’s job to record output
4) focus is not maintaining system at this point; focus is on collection of prime data for management of client health needs
A 2-month-old child is brought to the clinic for a well-baby checkup and routine immunizations. The nurse should explain to the mother that the child may experience which of the following side effects due to the immunizations?

1. Vomiting and diarrhea.

2. Swelling of the lymph nodes and conjunctivitis.

3. Low-grade fever and irritability.

4. Anorexia and nystagmus.
Strategy: Think about each answer. Is it a side effect of DPT?
1) do not occur after immunization; may indicate infection; assess for s/s dehydration
2) not associated with immunizations; enlarged lymph nodes indicate infection; recurrent conjunctivitis may indicate tear-duct obstruction
3) CORRECT— slight elevation of temperature, localized response at injection site, and increased irritability are anticipated responses, usually occur within a few hours or days of immunization; more serious side effects: continuous screaming, convulsions, high fever, loss of consciousness; do not administer if there is a past history of serious reaction
4) not common side effects of immunizations; anorexia is a loss of appetite; nystagmus is constant, involuntary, cyclical movement of the eye and is common after birth
The clinic nurse anticipates the arrival of a Navajo Native American patient for follow-up care regarding type 2 diabetes. When planning care for the client, the nurse should expect which of the following behaviors?

1. The patient will not arrive at the appointed time.

2. The patient will be noncompliant with medication.

3. The patient will complain much about dietary restrictions.

4. The patient will offer a firm handshake.
Strategy: Think about each answer.
(1.) CORRECT—Native Americans are present oriented and do not live by the clock
(2.) do accept Western medicine along with traditional remedies
(3.) silent and reserved, more attuned to listening and observing body language
(4.) handshaking is considered aggressive; instead, a passing of the hands may occur
The nurse cares for a client receiving lithium carbonate (Eskalith) 300 mg PO TID. The nurse identifies that which of the following indicates early signs of toxicity?
Select all that apply.

1. Mild thirst.

2. Nausea and vomiting.

3. Coarse hand tremor.

4. Ataxia.

5. Slurred speech.

6. Muscle weakness.
Strategy: Think about each answer.
1) lithium is an antimanic used to treat bipolar disorder; mild thirst is expected side effect; other side effects include fine hand tremor, polyuria
2) CORRECT— early sign of toxicity; withhold medication, obtain blood lithium level, dose will be re-evaluated
3) indicates advanced sign of toxicity; other indications include persistent GI upset, mental confusion, incoordination
Following an exploratory laparotomy, the client requests analgesia for pain. While the nurse is preparing the medication, the nurse asks the nursing assistant to take the client’s vital signs. The client’s blood pressure is 97/62, pulse is 105, and respirations are 22. The client is alert and talking, and the skin is warm, dry, and pink. The nursing assistant asks the nurse, “How can the blood pressure be so low when the client states she is having severe pain?” Which of the following responses by the nurse is BEST?

1. “The rapid heart beat results in decreased cardiac output, resulting in hypotension.”

2. “You don’t need to worry about that.”

3. “I think there is another patient light on.”

4. “Did you check on the client in the next bed?”
Strategy: Remember therapeutic communication.
1) CORRECT— addresses the problem directly; ANA Standards of Practice indicate the nurse contributes to the development of support personnel, resulting in a higher quality of heath care
2) the more information the personnel has, the better care he/she can provide
3) respect for the personnel is imperative; is entitled to an answer; nurse is the individual with advanced knowledge; should communicate effectively with team members
4) evasiveness does not promote trust; ANA Standards of Practice indicate the nurse acts to establish and maintain trust among team members
The nurse cares for a client diagnosed with Hantavirus pulmonary syndrome (HPS). Which of the following actions by the nurse is MOST appropriate?

1. Set up seizure precautions.

2. Assess the client for signs/symptoms of renal failure.

3. Assess the client for signs/symptoms of thrombocytopenia.

4. Assess the client for signs/symptoms of pneumonia.
Strategy: Think about each answer.
1) Hantavirus pulmonary syndrome is caused by rodents; symptoms include fever, aching, and nausea; no seizure precautions necessary
2) may cause severe cardiopulmonary disease; teach clients in rural areas to avoid rodent droppings
3) CORRECT— caused by HPS; observe for hematuria, hematemesis, bleeding gums, and melena
4) may cause overhydration
The nurse prepares to change the dressing on the wound of a 4-year-old child. After explaining the procedure to the child, the child begins to cry and refuses to have the dressing changed. Which of the following responses by the nurse is BEST?

1. “When would you like to have the dressing changed?”

2. “I’ll come back later to change the dressing.”

3. “Your mom is going to be here with you.”

4. “It’s not going to hurt at all.”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) appropriate to offer the child choices, but this question allows the child to refuse or delay the treatment
2) allows child time to fantasize and worry about procedure
3) CORRECT— parents offer child comfort and security and reduce the child’s anxiety
4) more important to explain to child what they will experience and what they can do during the procedure; do not tell the child what they will not feel
The nurse cares for a client after a left below-the-knee amputation. Which of the following observations by the nurse requires immediate follow-up?

1. The client eats about half the food on his meal tray.

2. The client complains about inability to concentrate when reading a book.

3. Pulses are palpable above the operative site.

4. The client complains of persistent pain after receiving pain medication.
Strategy: “Requires immediate follow-up” indicates something is wrong.
1) not unusual during postoperative period; offer the client small, frequent feedings of favorite foods
2) may be due to stress of amputation; nurse should further assess, but this is not the priority
3) expected outcome; assess the closest proximal pulse and compare with the other extremity
4) CORRECT— may indicate inflammation or infection
The nurse in the outpatient clinic obtains a history on a 48-year-old client who has come in for a gynecological examination. The client’s B/P is 128/72 mm Hg, pulse is 76 bpm, temperature is 99.3°F (37.4°C). The client shares with the nurse that she is having pain during intercourse. The client denies experiencing syncope, headaches, or tremors. Which of the following actions should the nurse take FIRST?

1. “Explore the client’s personal menstrual history.”

2. “Explain to the client the need to obtain serum hormone levels.”

3. “Encourage the client to talk about her sexual experience.”

4. “Instruct the client to perform Kegel exercises several times per day.”
Strategy: “FIRST” indicates priority.
1) CORRECT— client probably experiencing dyspareunia caused by perimenopause/menopause; nurse should assess client’s menstrual status before determining the appropriate course of action
2) dyspareunia does not require serum hormone levels for diagnosis or treatment
3) may occur as part of a larger discussion on sexuality; initially, assessment should be targeted
4) increases blood flow to perineum and helps maintain vaginal tone; nurse should assess before implementing
The nurse cares for a patient diagnosed with COPD who is brought to the hospital by EMS for increasing shortness of breath. The patient is placed on a cardiac monitor and an IV access is established. The patient’s vital signs are: B/P 130/70, HR 84, RR 26, and oxygen saturation is 100% on 6 L oxygen per nasal cannula. Which of the following interventions should the nurse perform FIRST?

1. Attempt to wean the patient’s supplemental oxygen.

2. Elevate the head of the bed to 45°.

3. Administer aminophylline (Truphylline).

4. Obtain arterial blood gases as ordered.
Strategy: “FIRST” indicates priority.
1) appropriate action because high oxygen flow rate may decrease the COPD patient’s stimulus for breathing; proper positioning improves respiratory functioning; if positioned incorrectly, other interventions would be less effective
2) CORRECT— proper positioning maximizes respiration and decreases respiratory effort
3) appropriate action but is less effective without proper positioning
4) appropriate action; however, proper positioning maximizes respiration and decreases respiratory effort while additional interventions are performed
The nurse leads a family therapy session for the family of an adolescent diagnosed with depression. During the first session, the teen’s mother dominates the discussion. Which of the following responses by the nurse is MOST appropriate?

1. “Please let some of the other family members speak.”

2. “You appear to be frustrated about dealing with your teen.”

3. “You and I will speak privately after the session is over.”

4. “How do the rest of you feel about what your Mother is saying.”
Strategy: Remember therapeutic communication.
1) nontherapeutic response
2) is therapeutic; one purpose of family therapy is to help members develop their own sense of identity
3) important to give every member in the group a chance to talk as a group
4) CORRECT— allows every member of group to offer feedback about the effect the mother’s monopoly of the session has on each person
The nurse in the emergency department (ED) assesses a patient diagnosed with tonic-clonic epilepsy. The patient’s spouse states that the patient has been taking phenytoin (Dilantin) as prescribed but has not been feeling well lately. Which of the following observations of the patient MOST concerns the nurse?

1. Reddish-brown urine, and the patient complains of constipation.

2. Acne, hirsutism, gingival hyperplasia.

3. Ataxia, slurred speech, nystagmus.

4. The left arm is in a sling and the patient walks with a limp.
Strategy: "MOST concerns the nurse" indicates a complication. Discrimination is required to answer the question.
(1.) common occurrences with Dilantin; may turn urine pink, red, or reddish-brown, and is a harmless effect; constipation or diarrhea may occur with Dilantin
(2.) seen with long-term Dilantin therapy; meticulous personal and professional dental care can help prevent or ameliorate gingival hypertrophy; acne and hirsutism may require referral to a dermatologist; patient may also benefit from psychological counseling related to body image
(3.) CORRECT—these are common signs of Dilantin overdose/toxicity; usual therapeutic concentration of the drug in the plasma is 10–20 g/mL; nystagmus is usually evident at >20 g/mL, and ataxia and slurred speech are usually evident at >30 g/mL
(4.) may indicate osteomalacia, which may occur with Dilantin unless sufficient vitamin D is given; Dilantin interferes with normal vitamin D metabolism
The nurse cares for a client diagnosed with obsessive-compulsive disorder. The nurse notes the client has difficulty getting to meals on time because of frequent handwashing. Which of the following statements by the nurse is MOST appropriate?

1. “Why don’t you eat your meals in your room.”

2. “I know you are feeling anxious but you have to get to meals on time.”

3. “I will call you for meals 15 minutes earlier.”

4. “Please discuss this with your physician.”
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) contract with client about how to deal with excessive handwashing
2) acknowledges feelings but doesn’t give client direction about how to deal with handwashing
3) CORRECT— allows client time for ritual; communicates acceptance of the client
4) passing the buck
The nurse in the long-term care facility cares for clients during an outbreak of Legionnaires’ disease. The nurse recognizes that which of the following clients is MOST at risk to develop the disease?

1. A 95-year-old client diagnosed with a fractured right hip.

2. An 85-year-old client diagnosed with a right-sided cerebrovascular accident.

3. A 75-year-old client diagnosed with Alzheimer’s.

4. A 65-year-old client diagnosed with end-stage renal disease.
Strategy: Think about each answer.
1) clients with Legionnaires’ disease develop pneumonia caused by Legionella pneumophila ; risk factors include advancing age and severe immunosuppression
2) age is a risk factor
3) advancing age is a risk factor
4) CORRECT— risk factors include advanced age, severe immunosuppression, end-stage renal disease, diabetes, smoking, and pulmonary disease
The nurse is leading a class for student nurses about immunizations. Which of the following statements by the student nurse indicates an appropriate understanding of immunizations?

1. “The influenza vaccine is contraindicated if the client is allergic to pork.”

2. “The pneumococcal and influenza vaccine can be administered at the same time.”

3. “The pneumococcal vaccine prevents any complications from a chronic illness.”

4. “Vaccinations have not shown to decrease the hospitalizations for older adults.”
Strategy: Determine the outcome of each answer.
1) contraindicated if allergic to eggs
2) CORRECT— can be administered at the same time in different sites
3) may decrease complications but no guarantee that it will prevent complications
4) hospitalizations decrease with immunizations
A woman delivers an 8 lb, 1 oz, infant via spontaneous vaginal delivery. The nurse assists the patient with her first breast-feeding experience. Which of the following should be the priority action of the nurse?

1. Instruct the mother to use an antiseptic soap on her breasts.

2. Teach the mother how to position the baby.

3. Allow the mother and the baby time alone.

4. Include the infant’s father or other caregiver.
Strategy: All the answer choices are implementations. Determine the outcome of each answer. Is it desired?
1) implementation; should just use water on the breasts because soap can be drying; dry thoroughly; expose to air
2) CORRECT— implementation; can use side-lying, sitting upright, or with infant facing mother (tailor position); rotate breast-feeding positions; position nipple so that infant’s mouth covers a large portion of the areola and release infant’s mouth from nipple by inserting finger to break suction
3) implementation; stay with the patient; should assess effectiveness of newborn’s suck, swallow, gag reflex; instruct mother how to position baby and nipple
4) implementation; not highest priority
A home health nurse makes an initial visit to a client diagnosed as legally blind. Which of the following recommendations should the nurse make FIRST?

1. Call a plumber to set the hot-water tank’s thermostat at 100 degrees.

2. Use battery-operated appliances rather than electrical appliances.

3. Remove most of the furniture from the home

4. Purchase clothing that is easy for the client to don.
Strategy: “FIRST” indicates priority.
1) CORRECT— reduces possibility of burns by hot water
2) can be taught to use electrical appliances safely
3) no reason to remove furniture; articles and furniture should be kept in the same positions so that client knows where they are
4) client can learn to dress self; does not necessarily require special clothing
The nurse reviews dietary guidelines with a client diagnosed with gastroesophageal reflux disease (GERD). The nurse determines teaching is successful if the client states which of the following?

1. “If my stomach feels bloated, I will drink peppermint tea.”

2. “I will switch from orange juice to tomato juice at breakfast.”

3. “I will eat three meals per day and not snack between meals.”

4. “I will sleep on my left side with my head elevated about 12 inches.”
Strategy: “Teaching is successful” indicates correct information.
1) peppermint exacerbates reflux; caffeine also exacerbates reflux
2) both juices are acidic and exacerbate reflux; apple juice is an appropriate alternative
3) big meals exacerbate reflux by increasing volume and pressure in the stomach as well as delay gastric emptying
4) CORRECT— recumbent position significantly impairs esophageal clearance; head should be elevated 6 to 12 inches to prevent nighttime reflux
A 75-year-old man is admitted with altered mental status and a urinary tract infection. The physician writes an order for use of a Posey vest restraint. Which of the following actions by the nurse is BEST?

1. Perform some of the patient’s care so he doesn’t feel that the restraint is a punishment.

2. Ask the physician to change the order to wrist restraints to allow the patient some movement in bed.

3. Explain the use of the restraint to the patient and ask for permission to apply it.

4. Reevaluate the need for the restraint every 4 hours.
Strategy: The answer choices are a mix of assessments and implementations. Is validation required? Yes.
1) should encourage independent functioning; try less restrictive alternative first
2) would increase agitation more than a vest restraint; nurse must try less restrictive alternatives
3) should explain use of restraint to patient, but should not ask patient for permission to apply restraints due to patient’s altered mental status; if client is unable to consent to use of restraints, then consent of proxy must be obtained after full disclosure of risks and benefits
4) CORRECT— nurse should assess for and document need for continue use of restraints; order for restraint is time-limited to 4 hours
The nurse cares for a patient who has just been intubated in preparation for mechanical ventilation. Which of the following actions should the nurse take NEXT?

1. Assess lung sounds.

2. Call for a stat x-ray.

3. Obtain arterial blood gasses.

4. Suction the endotracheal tube.
Strategy: Assess before implementing.
1) CORRECT— priority is to assess for bilateral lung sounds and bilateral chest excursions; assess before implementing
2) more important to assess lung sounds
3) more important to determine that there are bilateral breath sounds
4) priority is to determine if client has a patent airway
A nurse on the psychiatric unit overhears one client yelling at another client, “You are always borrowing my things. Stay out of my way!” Which of the following responses by the nurse is BEST?

1. “You both seem very upset with each other.”

2. “You sound very angry with the other client.”

3. “We will have to make a plan to prevent this from happening.”

4. “You must leave this room immediately because you are out of control.”
Strategy: Determine the outcome of each answer. Is it appropriate?
1) nurse should address the aggressor; important to set limits by explaining expected behaviors
2) CORRECT— address the aggressor to try to diffuse the anger
3) contracting is appropriate, but first de-escalate the situation
4) will further escalate the situation
The nurse in the outpatient clinic assesses a client diagnosed with a seizure disorder. The client states that her seizures are controlled by carbamazepine (Tegretol), and she also takes oral hormonal contraceptives and levothyroxine (Synthroid). Which of the following responses by the nurse is MOST important?

1. “Do you take the medications at the same time every day?”

2. “Let’s talk about other forms of contraceptives.”

3. “Wear sunscreen when you go outdoors.”

4. “Taking the medication with food will decrease gastric irritation.”
Strategy: Determine the outcome of each answer. Is it desired?
1) each medication should be taken at the same time to maintain blood levels
2) CORRECT— Tegretol interferes with action of hormonal contraceptives; client should use another form of birth control
3) important due to Tegretol (photosensitivity) and hormonal contraceptives (increased pigmentation)
4) Synthroid (thyroid preparation should be administered at breakfast to prevent insomnia)
The nurse from the medical unit is floated to the psychiatric unit. During medication administration, a patient yells at the nurse, "You are a terrorist with poison pills!" Which of the following responses by the nurse is BEST?

1. "I am not a terrorist."

2. "Is it your feeling that I am trying to poison you?"

3. "This is your medication, which you have to take now."

4. "I am a nurse from another unit in this hospital."
Strategy: "BEST" indicates discrimination is required to answer the question.
(1.) nontherapeutic defensiveness; reinforces delusion
(2.) inappropriate use of reflection; reinforces delusion
(3.) does not address patient’s concern about who the nurse is; may be misinterpreted as a threat
(4.) CORRECT—reality orientation; addresses patient’s concern without reinforcing delusion
An infant is treated in the newborn nursery for hyperbilirubinemia using phototherapy lights. It is MOST important for the nurse to intervene in which of the following situations?

1. The mother turns off the phototherapy lights and removes the infant’s eye patches in preparation for feeding.

2. The mother is worried because the infant experiences frequent loose, greenish stools and increased urine output.

3. A laboratory technician turns off the phototherapy lights to draw blood.

4. The jaundice observed around the infant’s eyes has begun to disappear.
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) no intervention required; turning off the light and removing the eye patches before oral feeding is appropriate
(2.) loose, greenish stools and increased urine output reflect increased excretion of bilirubin and are possible minor side effects
(3.) appropriate action; phototherapy lights must be turned off when blood is drawn to ensure accurate bilirubin levels
(4.) CORRECT—indicates that the eye patches are not adequately placed or are not of adequate opaqueness and are allowing light to enter; with phototherapy, eyes must be completely shielded with patches or an opaque mask in order to prevent exposure to the light, which could result in eye damage, especially of the retina
A 15-year-old girl sustains a spinal cord injury at the level of L1 in a motor vehicle accident. The adolescent returns to school after rehabilitation and tells the school nurse, “I am determined to lead a normal life.” To assist the adolescent to achieve this goal, which of the following activities by the school nurse is MOST appropriate?

1. Reinforce teaching about the Cred é maneuver.

2. Provide privacy for change of protective undergarments.

3. Refer the adolescent to school counselor.

4. Procure urinary catheter trays.
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) CORRECT— applying manual pressure to bladder aids in emptying the bladder completely; results in reduced risk for infection; performing the Cred é maneuver at the same times every day can result in bladder control
2) make sure protective undergarments are available, but client’s goal is to lead normal life; continence would contribute to this goal achievement; federal requirements provide disabled public toilet for her with privacy to manage personal hygiene
3) do not pass the buck
4) first teach the Cred é and Valsalva maneuvers
The nurse on the psychiatric inpatient unit is notified in report of four admissions expected on that shift. There is only one private room available. Which of the following patients should the nurse admit to the private room?

1. A patient diagnosed with chronic undifferentiated schizophrenia.

2. A patient diagnosed with bipolar disorder in the manic phase.

3. A patient diagnosed with obsessive-compulsive disorder.

4. A patient diagnosed with major depression and suicidal ideation.
Strategy: Determine the outcome of each answer. Is it desired?
(1.) patient does not need a private room; odd, disorganized, and restless behaviors, careless dress and appearance, and fragmented thought processes are not likely to harm patient or others and do not require intense monitoring or withdrawal from others
(2.) CORRECT—patients experiencing mania need a quiet environment with decreased stimuli; a private room provides this as a refuge (and a staff time-out limit-setting opportunity) from the stimuli of other patients and from the unit as a whole
(3.) does not need a private room; these patients’ behavior is usually focused on themselves; it is unlikely to affect a roommate unless there were issues related to focus of the obsessive-compulsive disorder, such as cleanliness concerns with a shared bathroom
(4.) does not need a private room; if anything, having a roommate could help patient feel less alone and also be safer should self-destructive behavior or suicidal thought be expressed at a time staff were not present
A patient is admitted to the medical unit for evaluation of headaches, epigastric pain that is relieved by food, anorexia, nausea and vomiting, and periods of both constipation and diarrhea. The physician orders several diagnostic tests. The nurse knows it is MOST important to schedule which of the following tests FIRST?

1. Upper GI series.

2. Small bowel series.

3. Lower GI series.

4. Lumbar puncture.
Strategy: "FIRST" indicates priority.
(1.) upper GI series includes esophagus, stomach, duodenum, and upper portion of jejunum; patient swallows barium sulfate
(2.) usually, is done in conjunction with upper GI series; sometimes is even referred to as small bowel follow-through (SBFT); encompasses duodenojejunal junction to ileocecal valve; patient swallows barium sulfate
(3.) CORRECT—often referred to as a barium enema examination, it is a radiographic visualization of the large intestine; encompasses rectum, sigmoid, descending, transverse, and ascending colon, going to the ileocecal valve; barium is administered through a rectal catheter which has an inflatable balloon; when both upper and lower GI series are ordered, the lower GI series should be done first; this is in order to avoid the barium from the upper GI exam traveling down the GI tract and interfering with the results of the lower GI series; signs/symptoms consistent with irritable bowel syndrome
(4.) no clear indications that this test is needed
The nurse cares for clients in the family planning clinic. A client comes to the clinic for a diaphragm fitting, and the nurse instructs her about use of the diaphragm. The nurse knows that teaching is effective when the client states which of the following?

1. “I’m glad a diaphragm protects me from AIDS.”

2. “I can remove the diaphragm 6 hours after intercourse.”

3. “I can only use spermicide cream with the diaphragm before insertion.”

4. “I need to be examined every 6 months to make sure the diaphragm fits.”
Strategy: “Teaching is effective” indicates correct information.
1) only offers protection from contraception
2) CORRECT— diaphragm must remain in the vagina at least 6 hours after intercourse; before insertion place 1 tsp spermicidal gel around rim and in the dome
3) if more than 4 hours elapses between the time the diaphragm is inserted and intercourse occurs, use additional spermicidal gel
4) should be rechecked for correct size annually, after childbirth, and if the client’s weight has changed by more than 15 lb
The charge nurse on the psychiatric unit observes that when a client is admitted with a history of sexual abuse, a certain nurse subtly, and sometimes overtly, verbally attacks the client. The charge nurse learns that the nurse was sexually abused as a child. When making assignments, the charge nurse should consider which of the following?

1. Assign the nurse to clients who have been sexually abused to promote therapeutic feedback to the client.

2. Assign the nurse to clients who have been sexually abused and request that the nurse begin therapy.

3. Assign the nurse to clients who do not have a history of sexual abuse because the nurse is able to interact therapeutically with these other clients.

4. Inform the nurse that she can no longer care for clients on the psychiatric unit because she has a history of being sexually abused.
Strategy: Think about the outcome of each answer
1) charge nurse should consider the abilities of each staff member; should not assign nurse to clients that the nurse is having difficulty caring for in a therapeutic way
2) nurse should receive counseling to deal with unresolved issues of the past
3) CORRECT— assign nurse to clients that she is able to deal with in a therapeutic way
4) not an appropriate action
The nurse reviews proper application of the condom catheter with a new nursing assistant. Which of the following statements by the nurse assistant indicates to the nurse that further teaching is required?

1. “I will clip the hair at the base of the penis before I apply the condom.”

2. “I will wrap an adhesive strip around the penis in a circular, overlapping pattern.”

3. “I will leave 2 inches between the tip of the penis and the end of the catheter.”

4. “I will secure the urinary drainage collection bag to the bed frame.”
Strategy: “Further teaching is required” indicates incorrect information.
1) appropriate action; hair will adhere to the condom and become caught as the condom is applied or removed
2) CORRECT— elastic adhesive strip should be wrapped in a spiral pattern without overlapping onto itself to ensure circulation to the penis is not impaired; tape should be snug but not too tight
3) appropriate action; 1 to 2 inches of space should be left between the end of the condom catheter and the tip of the glans penis
4) appropriate action; collection bag is attached to the bed frame and the drainage tubing is brought up through the side rails onto the bed
The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse observes the student nurse enter wearing a gown, gloves, and a facemask. The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?

1. An infant diagnosed with respiratory syncytial virus.

2. A school-aged child diagnosed with hepatitis A.

3. A teenager diagnosed with toxic shock syndrome.

4. A teenager diagnosed with influenza.
Strategy: Remember transmission-based precautions.
1) requires contact precautions, no mask
2) requires standard precautions
3) standard precautions
4) CORRECT— droplet precautions used for organisms that can be transmitted by face-to-face contact; door may remain ope
A 6-year-old girl is brought to the well-child clinic for a checkup by her mother. While the child is playing in the clinic playroom, the nurse observes her behavior. Which of the following activities demonstrates to the nurse that the child has musculoskeletal development that is age-appropriate but not advanced for her age?

1. The child runs after a rolling ball.

2. The child walks up and down the stairs.

3. The child hops and skips.

4. The child neatly ties her shoelaces.
Strategy: Picture a 6 year old.
1) appropriate for child of 2 years
2) develops 2–4 years of age
3) CORRECT— appropriate skills for 4–6 years of age
4) advanced motor skill accomplished after age 6
Which of the following statements if made by the client BEST indicates to the nurse the client understands teaching to prevent hypokalemia?

1. “I should take the potassium supplements on an empty stomach.”

2. “I should crush the potassium tablets if I can’t swallow them.”

3. “I should eat more bananas as well as take the potassium supplement.”

4. “I should avoid salt substitutes while taking the potassium supplement.”
Strategy: “BEST” indicates discrimination is required to answer the question. read answers first before answering question; topic is client education about potassium supplementation
1) potassium supplements should be taken with meals
2) do not crush, may affect the potency or action of the drug
3) bananas are a good source of potassium; increasing natural potassium intake while on a potassium supplement may result in hyperkalemia
4) CORRECT— many salt substitutes are potassium-based, which combined with the prescribed potassium supplement may result in hyperkalemia
The medical nurse enters the room of a confused patient diagnosed with angina pectoris in order to remove the patient’s nitroglycerin patch for the night. Upon opening the patient’s gown, the nurse sees that the patch is not evident where charting indicated it was placed. What is the FIRST action the nurse should take?

1. Find the patch.

2. Clean the site and secure a new patch in place for the night.

3. Ask the patient what happened to the patch.

4. Administer 1 nitroglycerin tablet sublingually.
Strategy: "FIRST" indicates priority.
(1.) CORRECT—patient who is confused may move a transdermal patch elsewhere on the body or remove it; if it remains in the new location and another patch is applied elsewhere, tolerance and loss of angina-relieving response could occur; also, discarded patches still have sufficient active ingredients to be of harm to persons having contact with them
(2.) the site does need to be cleaned thoroughly because nitroglycerin is irritating to the skin and also should not continue to be absorbed after the patch is removed; however, a new site should be chosen for each new patch
(3.) patient is confused and may not be able to respond accurately
(4.) no indication given that this is needed
The nurse understands that debates over abortion rights are MOST often based on conflict between which of the following pairs of ethical principles?

1. Beneficence and justice.

2. Veracity and fidelity.

3. Autonomy and nonmaleficence.

4. Paternalism and restitution.
Strategy: Think about each answer.
(1.) beneficence refers to doing good and justice refers to being fair to all people, including—but not limited to—distribution of benefits and resources
(2.) veracity refers to truthfulness and fidelity refers to being faithful and loyal to honoring commitments made to self or others
(3.) CORRECT—autonomy refers to the independence of the individual and the right to have her/his own opinions, make her/his own choices, and take action based on personal beliefs and values; nonmaleficence refers to preventing harm to others, harm being interfering with the physical or mental well-being of others; nonmaleficence includes both harm and the risk of harm, whether that harm may be intentional or unintentional
(4.) paternalism refers to interfering with the liberty of another, under the assumption that the interferer knows better than the other what is best for the other; restitution is not an ethical principle, it is a legal remedy in contract disputes which returns property or the financial value of a loss to the owner
The nurse cares for clients in the hospital. Which of the following clients should the nurse see FIRST?

1. A client complaining of pain 2 hours after a liver biopsy.

2. A client with a long leg cast complaining of pain after taking medication.

3. A client 2 days postpartum complaining of pain during breast-feeding.

4. A young child complaining of a sore throat after a tonsillectomy.
Strategy: Determine the most unstable client.
1) some discomfort is expected after liver biopsy
2) CORRECT— may indicate compartment syndrome
3) expected outcome; breast-feeding causes release of oxytocin
4) expected outcome
The nurse in the emergency department assesses an elderly client. The client’s daughter states that her mother has glaucoma, is extremely hard of hearing, and has been experiencing abdominal pain for the past 24 hours. Which of the following actions by the nurse is MOST appropriate?

1. Using a numeric rating scale, determine the intensity of the client’s pain.

2. Ask the client if she wears hearing aids.

3. Administer pain medication.

4. Ascertain when the client last saw a physician.
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) appropriate action; priority is to ensure that client is able to understand what the nurse is asking
2) CORRECT— tools used for rating pain are ineffective if client can’t hear what is being asked or if the client can’t see the pain rating scale
3) assess before implementing
4) priority is to ensure that nurse can effectively communicate with the client
A 55-year-old woman comes to the outpatient clinic. The client has been receiving estrogenic substances, conjugated (Prem Pro), for 3 months. Which statement, if made by the client to the nurse, requires immediate follow-up?

1. “I frequently have trouble falling asleep at night.”

2. “I have gained 5 pounds since I have started taking this medication.”

3. “My left leg is sore behind the knee.”

4. “I am still having hot flashes several times a week.”
Strategy: “requires immediate follow-up” indicates a complication.
1) assessment; insomnia is a common complaint during menopause
2) assessment; weight gain is a common side effect
3) CORRECT— assessment could indicate thrombophlebitis; other side effects include nausea, skin rashes, pruritus, breast secretion
4) assessment; symptoms of menopause may persist with use of ERT; symptoms related to hormone changes: vasomotor instability, emotional disturbances, atrophy of genitalia, uterine prolapse
The home care nurse visits a client with a long leg cast on the right leg due to a fracture of the tibia. The client complains of feeling a hot spot under the cast. Which of the following actions should the nurse take FIRST?

1. Assess the circulation in the right leg.

2. Suggest that the client change position.

3. Obtain the client’s temperature.

4. Apply ice over the area that is hot.
Strategy: “FIRST” indicates priority.
1) CORRECT— heat is a sign of pressure; nurse should perform neurovascular assessment before choosing a course of action
2) changing position may relieve the pressure but nurse should first assess
3) follow the ABCs, assess circulation
4) ice is applied directly over fracture site for first 24 hours; heat indicates pressure
The nurse performs a physical assessment of the precordium on an adult male. Identify where the nurse should place the stethoscope to auscultate the tricuspid area.
Strategy: Locate landmarks.
Located in the fifth intercostal space at the lower left of the sternal border; auscultate for S1.
An 8-year-old with a history of asthma is brought to the emergency department by his mother. The child tells the nurse that he was wheezing earlier and now feels worse. The nurse should be MOST concerned with which of the following findings?

1. The child states that his chest feels tight.

2. The nurse auscultates wheezing at the end of each expiration.

3. The nurse auscultates decreasing breath sounds.

4. The child coughs while lying on the stretcher.
Strategy: “MOST concerned” indicates a complication
1) common complaint with asthma, but does not necessarily indicate severe respiratory impairment
2) indicates mild respiratory impairment; asthma attack produces dyspnea, audible wheezing, coughing, chest tightness, feeling of suffocation
3) CORRECT— with severe spasm or obstruction, breath sounds and crackles may become inaudible
4) indicates ability to breathe in the recumbent position
After completing charting on a patient’s record, the nurse realizes that the charting has been placed in the wrong patient’s chart. Which of the following actions by the nurse is MOST appropriate?

1. Complete an incident report and place a copy in the client’s file.

2. Draw a single line through each line of the incorrect entry and write a new note explaining what occurred.

3. Use correction fluid to delete the wrong entry and write in the space that the note was obliterated due to patient confidentiality.

4. Copy the note into the correct patient’s chart and indicate that it was erroneously put in the wrong patient’s chart.
Strategy: Determine the outcome of each answer. Is it desired?
1) incident report is not included in the patient’s record
2) CORRECT— does not obliterate or alter what was written; new note should be entered into patient’s record and should include time and signature
3) mistaken entries should never be obliterated
4) error needs to be corrected
The nurse admits a patient diagnosed with bipolar disorder. Which of these assessments requires IMMEDIATE attention by the nurse?

1. The patient has not eaten breakfast and lunch.

2. The patient has been pacing the hallway for the last 15 minutes.

3. The patient is not wearing a bra.

4. The patient believes she has a lot of money and power.
Strategy: “IMMEDIATE attention” indicates priority
1) CORRECT— must be addressed immediately; physical vs. psychological; because of the patient’s poor judgment, dehydration and poor nutrition put the patient at risk for injury
2) indicative of mania; other indications include talking excessively, joking, easily stimulated by environment; encourage fluids and give patient high-calorie finger foods
3) may indicate lack of inhibition; priority is offering food and fluids
4) delusions of grandeur; do not argue or try to convince patient they are not real
During the summer, the nurse visits an assisted living facility for seniors. Which of the following observations requires an intervention by the nurse?

1. A resident wears knee-high nylon stockings.

2. A resident wears a long-sleeved knit sweater.

3. A resident wears a rectangular floral neck scarf.

4. A resident wears walking shoes with laces.
Strategy: “Requires an intervention” indicates something is wrong.
1) CORRECT— constricts circulation to extremities and promotes venous stasis; can cause thrombi and pulmonary emboli
2) elderly often have impaired tolerance for cold temperatures due to changes in circulation; does not require an intervention
3) does not require intervention; is a concern if aggression or suicide is an issue; scarves can add cheerfulness and individualization
4) best for preventing falls; laces ensure shoes can be adjusted properly and securely for individual’s feet
The nurse cares for clients in the emergency department. A client is brought to the emergency department by his friend after the client was in an auto accident. The nurse is MOST concerned if which of the following is observed?

1. Blood pressure of 96/50, pulse 112.

2. Nausea and vomiting.

3. Abrasions on the client’s abdomen.

4. Staggering gait.
Strategy: “MOST concerned” indicates something is wrong.
1) CORRECT— tachycardia and hypotension indicative of shock
2) possible shock takes priority
3) provide clues as to location and force of injury; possible shock takes priority
4) may be related to possible shock
The home care nurse makes an initial visit to a client diagnosed in the early stages of COPD. The nurse plans to discuss the client’s perception about the disease. Which of the following responses by the nurse is BEST?

1. “I have brought some materials for you to read.”

2. “Tell me what you understand about the disease.”

3. “The focus of this visit is to get to know you.”

4. “How has the COPD changed your life?”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) nurse needs to assess before implementing
2) allows client to verbalize but narrows the focus to the disease process
3) closed statement that does not allow the client to respond
4) CORRECT—allows client to explain the impact of the disease on his life; information will help nurse plan client’s care
The nurse cares for an older client diagnosed with partial thickness and full thickness burns over 75% of his body. Which of the following assessments indicates to the nurse the client is developing shock?

1. Epigastric pain and seizures.

2. Widening pulse pressure and bradycardia.

3. Cool, clammy skin and tachypnea.

4. Kussmaul respirations and lethargy.
Strategy: Think about each answer.
1) epigastric pain is a warning sign of seizures in the pre-eclamptic client
2) occurs with cardiac problems
3) CORRECT— body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for loss of fluid
4) occurs in ketoacidosis
The middle of the evening shift on the inpatient psychiatric unit is unusually hectic, with a large census, high acuity level, three admissions in two hours, and a fourth admission on the way. The unit secretary goes down to the emergency department to get some needed paperwork for one patient. When she gets back to the unit, she angrily and repeatedly exclaims about the ongoing rudeness of the emergency department staff, including their not providing the necessary documents. She states, "I am going home!" and starts to go toward the coatroom. What is the BEST response by the charge nurse?

1. "Take a deep breath. Give it some thought and let me know what you decide."

2. "You must stay here and do your job. If you leave, that will be insubordination."

3. "Calm down. Overreacting does not do you or anyone else any good."

4. "We are not the ones who were rude to you. Do not leave us, because we need you."
Strategy: "BEST" indicates that discrimination is required to answer the question.
(1.) does not solve the immediate need for the unit’s functioning calmly and safely; also does not set a clear limit which could then later be used if disciplinary actions were to be taken
(2.) not best; clear limit-setting and factual; it would be insubordination or defiance because the secretary would not be recognizing or accepting the authority of a superior; however, it does not acknowledge secretary’s feelings or possible validity of her concerns, and as such may seem impersonal and nonsupportive
(3.) not best; use of the word "overreacting" is certain to trigger an angry response because it implies that something is wrong with the unit secretary and that the emergency department incident was not serious; "calm down" can also convey these feelings
(4.) CORRECT—priority is getting through the immediate situation on the unit; points out reality; conveys genuineness, empathy, and positive regard, factors that help people to grow; accepts secretary’s judgment and does not set up conflict by disagreeing or challenging by choice of words
The industrial nurse receives a visit from a worker diagnosed in the early stages of chronic renal failure. The client relates to the nurse that he does not understand why the physician thinks he is “having trouble” with his kidneys when they are working better than they have in the past. He states that he urinates large volumes of urine all day and gets up to go to the bathroom all through the night. Which of the following response by the nurse is BEST?

1. “Did you tell the physician you are putting out lots of urine?”

2. “If you manage your diabetes well, there should be no further damage.”

3. “You seem to be very upset about this.”

4. “A high volume of urine indicates your kidneys are releasing too much fluid.”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) yes/no question; nontherapeutic
2) does not address the client’s misunderstand about the symptoms
3) can be appropriate lead statement when exploring subject; has enough information to have structured discussion
4) CORRECT— hypertrophy of renal tissue results in increased surface available for urinary excretion
It is MOST important for the nurse to consider which of the following concepts when planning nursing care for a client from a culture other than the United States?

1. The distance from the United States and the duration of time the client has been in the United States.

2. The climate and topography of the client’s native country.

3. The concept of time and the organization of society in the client’s native country.

4. The client’s financial status and physical characteristics.
Strategy: Think about the answers.
1) may impact how comfortable client is with the living in the United States, not most important
2) familiar client and landscape may contribute to comfort level but not most important
3) CORRECT— time orientation varies among cultural groups. Some cultures are more oriented toward the present than the future; social environment in which a person is raised is an essential part of the person’s cultural development and identification
4) not most important to provide good care to a client from another country and culture
The nurse cares for a comatose client. The nurse is unable to elicit a reaction after applying the trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub. Which of the following actions should the nurse take NEXT?

1. Administer diuretics as ordered.

2. Lower the head of the bed.

3. Press a pencil to a finger or toe of each limb.

4. Begin cardiopulmonary resuscitation.
Strategy: Assess before implementing.
1) complete assessment first; may help decrease ICP if contributing to comatose state
2) first, complete assessment; head of bed should be elevated to decrease ICP; assess before implementing
3) CORRECT— when assessing a client’s response to pain, begin with least noxious stimulation (speak to client) and proceed to more painful stimulation; trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub are central stimulation; if no response to central stimulation demonstrating brain function, apply peripheral stimulus to the extremities; client’s finger or toe should be braced on nurse’s thumb and pencil placed sideways on top of nail bed at base of cuticle and pushed down hard; use peripheral assessment only on extremity that did not move
4) first, complete assessment; not responding to painful stimuli indicates brain is not responding; does not indicate client has arrested
The office nurse meets with a high-school graduate who will be starting at a residential college in the fall. It is MOST important for the nurse to address which of the following immunizations?

1. DTaP.

2. Pneumococcal.

3. Meningitis.

4. Varicella.
Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) diphtheria, tetanus toxoid, and attenuated pertussis vaccine; 10 years after kindergarten need booster of tetanus and diphtheria (Td) vaccine
(2.) pneumococcal vaccine available since 1983 to prevent pneumonia; in terms of age group, the highest risk is with older adults; the other risk factors are unlikely in a college-bound student
(3.) CORRECT—the meningitis vaccine is not currently required for college freshmen, but information about the importance and reasons for vaccinations against meningococcal disease should be given to all adolescents who are bound for college and to their parents, especially if the students will be living on campus in residence halls or dormitories
(4.) chickenpox vaccine given to people over 13 years of age if they are susceptible because they have not had the disease and have not been immunized
A sequential compression device (SCD) is ordered for a patient recovering from a retropubic prostatectomy. It will be the first time for the nurse to apply such a device. Which of the following statements by the nurse to the nursing manager best reflects correct understanding of the proper procedure?

1. "I will wrap the sleeves snugly, but I will be certain I can fit one finger between each one and the leg."

2. "I will put the antiembolism stockings on before I wrap and secure the sleeves."

3. "I will start by positioning each sleeve under the leg so that the opening is at the ankle."

4. "I will measure the circumference of the midcalf and the midthigh to ensure that the sleeves are the correct size."
Strategy: Determine the outcome of each answer. Is it desired?
(1.) incorrect action; need to be able to fit two fingers, not just one, between the sleeve and the leg; correct fit prevents irritation to the leg; it also allows for the device to reach adequate inflation pressure and prevents slipping out of position when deflation occurs; the fit can be checked by inserting two fingers in the knee opening
(2.) CORRECT—correct action; it is acceptable, though not essential, to apply antiembolism stockings prior to applying the sequential compression device sleeves; the stockings can decrease the itching, sweating, and heat that can build up under the plastic sleeves and thereby cause discomfort and skin irritation
(3.) incorrect action; the opening should be at the knee (in front) and at the popliteal pulse point (in back)
During a routine prenatal visit, the nurse assesses a client at 37 weeks’ gestation. The nurse auscultates the fetal heart rate (FHR) and notes that the fetal position is left sacrum anterior (LSA). Identify the point of maximum intensity of the fetal heart tone.
Strategy: Identify the mother’s left side.
LSA indicates that the presenting part is the sacrum (breech) and the fetal back is on the mother’s left side; because infant is breech, FHT heard at or above the umbilicus.
The nurse obtains a health history from a 72-year-old Caucasian female. It is MOST important for the nurse to ask which of the following questions?

1. “What kind of coffee do you drink?”

2. “When did your mother go through menopause.”

3. “Is there a family history of osteoporosis?”

4. “Do you take calcium supplements?”
Strategy: “MOST important” indicates priority.
1) client at risk to develop osteoporosis; excessive caffeine intake is a risk factor; caffeine should be ingested in moderation
2) primary osteoporosis occurs in woman after menopause; prevention is the key
3) no known familial relationship
4) CORRECT— small-framed non-obese Caucasian women are at risk; not only has a 72-year-old woman lost bone mass, but the elderly also absorb calcium less efficiently; should take regular calcium supplements
The nurse cares for a 7-year-old child hospitalized with a diagnosis of staphylococcal pneumonia. It is MOST important for the nurse to encourage the child to perform which of the following activities?

1. Blowing bubbles using a hand-held wand.

2. Watching a movie while lying in bed.

3. Going to the activity room to play with a puzzle.

4. Coloring pictures of other children on the unit.
Strategy: Determine the outcome of each activity.
1) CORRECT— blowing bubbles will promote lung expansion while not overexerting the child and not exposing him/her to other children on the unit
2) watching a movie may be appropriate due to fatigue; does little for lung expansion
3) exposes other children to the pneumonia
4) developmentally appropriate, but is a sedentary activity; most important to promote lung expansion
The nurse cares for a client diagnosed with full-thickness burns. In planning the d é bridement of the burn, the nurse should give priority to which of the following actions?

1. Assemble all necessary supplies and medications.

2. Organize time for the dressing change and provide emotional support.

3. Prepare the client and family for the pain the client will experience during and after the procedure.

4. Limit visitors before the procedure.
Strategy: Determine the outcome of each answer.
1) take care of the patient first, not the equipment; important to organize and assemble all that is required; more important to offer support to client
2) CORRECT— administer analgesic 30 minutes before wound care; d é bridement is the removal of nonviable tissue; may be preceded by hydrotherapy; encourage expression of feelings and demonstrate acceptance of the client
3) appropriate, but more important to carefully plan time for the dressing change
4) assist client’s family to adjust to changed appearance
Because of persistent absenteeism and decreased performance, a 35-year-old African American woman who works at a national cell telephone company is referred to the occupational nurse’s office. The client tells the nurse that she feels tired all of the time and has headaches unrelieved by acetaminophen (Extra Strength Tylenol) tab ii. It is MOST important for the nurse to take which of the following actions?

1. Obtain the client’s blood pressure.

2. Schedule an appointment with the nephrologist.

3. Ask the client when she last saw her personal physician.

4. Instruct the client to schedule an appointment with her personal physician.
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) CORRECT— race, age, gender, and signs/symptoms are reflective of hypertension; fatigue may indicate early development of renal disease
2) requires more data
3) important question; priority is to complete the assessment
4) assess before implementing
The nurse reviews discharge instructions with a patient receiving risperidone (Risperdal) 4 mg po bid. Which of the following statements, if made by the patient to the nurse, indicates the need for further teaching?

1. "I know I have to take it even though I am no longer depressed."

2. "I will report any changes in my sleeping habits."

3. "I will avoid exposure to extreme heat conditions."

4. "I will use caution when I change positions."
Strategy: "Need for further teaching" indicates incorrect information.
(1.) CORRECT—drug is an antipsychotic, patient has right to know indication for medication
(2.) high incidence of sleep disturbances reported; abnormal dreams, insomnia, and oversedation
(3.) photosensitivity and impaired temperature regulation as with most antipsychogotics
(4.) high risk for orthostatic hypotension, use caution with sudden position changes
The nurse on the medical unit reviews laboratory results on four patients. The nurse should notify the physician about which of the following results?

1. Theophylline (Theobid) level 15 mcg/mL.

2. Digoxin (Lanoxin) level 2.5 ng/mL.

3. Intermational Normalized Ratio (INR) 2.5 for a client who takes warfarin (Coumadin)

4. Lithium (Lithobid) level of 1.2 mEq/L for a client with bipolar disorder
Strategy: Determine the abnormal lab results.
(1.) therapeutic range 10–20 mcg/mL; toxicity occurs with levels over 20 mcg/mL; theophylline is xanthine-derivative bronchodilator
(2.) CORRECT—toxic levels for digoxin are over 2 ng/mL; normal therapeutic level of digoxin in the blood is between 0.5 and 2 ng/mL
(3.) optimal dose of Coumadin prolongs the PT and maintains the INR at 2 to 3
(4.) should read: within normal limits, lithium dosage is adjusted to maintain a serum lithium level of 1.0 - 1.5 mEq/L, particularly in acute mania
The nurse makes a prenatal visit to the home of a woman who is pregnant with her first child. It is MOST important for the nurse to intervene if which of the following is observed?

1. A cat is sleeping peacefully on the windowsill.

2. Cleaning supplies are in an unlocked cabinet under the kitchen sink.

3. There are throw rugs on the living room floor.

4. The smoke detector is chirping intermittently.
Strategy: Think about the outcome of each answer.
(1.) CORRECT—cat presents a toxoplasmosis risk to the pregnant woman and her unborn/newborn infant; toxoplasmosis is a parasitic disease transmitted in the feces of cats who have eaten infected mice and animals; preventive measures include handwashing after touching cats, have the litter box changed daily (it takes about 48 degrees for the cat’s feces to become infectious) by someone other than the pregnant woman, prevent cats from eating raw meat or wild animals, wear gloves when gardening, do not garden in areas frequented by cats, avoid undercooked meat and contact with stray animals
(2.) will be an issue for future teaching prior to yet-unborn infant becoming a toddler
(3.) could be a falling hazard for the woman; priority is follow-up about the cat
(4.) indicates that battery needs changing, or that unit is defective
The home care nurse visits a client receiving chlordiazepoxide (Librium). The nurse is MOST concerned if which of the following is observed?

1. Shuffling gait and rigidity.

2. Drowsiness and blurred vision.

3. Photosensitivity and jerky movements.

4. Hypertension and slurred speech.
Strategy: “MOST concerned” indicates something is wrong.
1) side effects of antipsychotic drugs
2) CORRECT— Librium is an antianxiety; additional side effects include constipation, slurred speech, dermatitis, anorexia, polyuria, pancytopenia, and thrombocytopenia; administer after meals or with milk to decrease GI irritation
3) side effects of antipsychotic drugs
4) side effects of MAO inhibitor
The nurse admits four clients to labor and delivery. Which of the following clients should the nurse see FIRST?

1. A primigravida woman, cervix 5 cm dilated, baseline fetal heart tones 125 bpm with decelerations to 100 bpm at the apex of the contraction.

2. A multigravida woman, cervix 4 cm dilated and 60% effaced, baseline fetal heart tones of 150 bpm increasing to 170 bpm mirroring uterine contractions.

3. A multigravida woman, cervix 6 cm dilated, fetal presenting part at +1, fetal heart tones 160 bpm in lower left quadrant.

4. A primigravida woman, 7 cm dilated, baseline fetal heart tones 136 bpm with periodic decelerations of 20 beats below baseline independent of uterine contractions.
Strategy: Determine the most unstable client.
1) caused by head compression and is considered a normal finding
2) accelerations may indicate fetal well-being or may indicate an occlusion of umbilical vein; see this client second
3) indicates healthy fetus in vertex position during first phase of labor
4) CORRECT— repetitive variable deceleration; indicates umbilical cord occlusion that needs to be resolved
The nurse instructs a client about the correct way to take oral contraceptives. The nurse determines that teaching is effective if the client states which of the following?

1. “The pill is most effective if I take it at the same time each day.”

2. “If I miss 1 pill I will wait and take it with the next day’s pill.”

3. “As long as I take the pill at the same time each day, the pill has a 99% rate of effectiveness.”

4. “I will continue to use my diaphragm through the first week of the pill pack.”
Strategy: “Teaching is effective” indicates correct information.
1) CORRECT— blood level of hormones may decrease and ovulation may occur if the pill is not taken at the same time daily
2) if a pill is missed, it should be taken as soon as it is remembered or 2 taken the next day; if 2 pills are missed, a barrier method of birth control should be used for the rest of the month
3) timing of the pill contributes to effectiveness; however, if oral contraceptive is taken with antibiotics, effectiveness decreases
4) use barrier method of birth control for the first 3 weeks
The nurse evaluates care given by a nursing assistant. The nursing assistant ambulates a client to the bathroom, and the nurse overhears the nursing assistant ask a family member to stand with a client while the nursing assistant cares for another client. Which of the following responses by the nurse is BEST?

1. “Why did you ask the family member to stay with the client?”

2. “Please stay with the client and call me if the client becomes dizzy.”

3. “Do not ask a family member to do your job.”

4. “Did the client ask you to leave?”
Strategy: “BEST” indicates discrimination is required to answer the question.
1) do not ask “why” questions; priority is client safety
2) CORRECT— priority at this time is client safety; after client is safely back in bed, nurse should review proper procedure with the nursing assistant
3) priority is to ensure the client is safe
4) yes/no question; address client safety first before determining why the incident occurred
The nurse prepares to complete an assessment of cranial nerves IX and X. To complete the assessment, the nurse should obtain which of the following supplies?

1. A cotton ball.

2. A penlight.

3. An ophthalmoscope.

4. A tongue depressor and flashlight.
Strategy: Think about each answer.
1) not used
2) not used
3) not used
4) CORRECT— assessing the glossopharyngeal and vagus nerve; assessing client’s ability to swallow and the gag reflex
The nurse admits a client with nuchal rigidity and photophobia. Which of the following actions should the nurse take FIRST?

1. Place client on droplet precautions.

2. Monitor for increased intracranial pressure.

3. Prepare the client for a lumbar puncture.

4. Set up seizure precautions.
Strategy: “FIRST” indicates priority.
1) CORRECT— has symptoms of meningitis; Haemophilus influenzae and Neisseria meningitidis (either known or suspected) require droplet precautions; place client on droplet precautions until diagnosis is confirmed or eliminated to protect other clients and staff
2) caused by accumulation of purulent exudate; important to assess for changes in LOC; preventing spread of infection takes priority
3) bacterial culture and Gram staining of CSF is done
4) important to protect client from injury; priority is preventing spread of infection
Which of the following skin manifestations in an infant MOST concerns the nurse?

1. Irregularly shaped pink patches on the back of the neck.

2. Diffuse bluish-purple, bruised-looking areas on the buttocks.

3. Large, irregular, flat macular patch on one side of the face.

4. Red, raised, rough-surfaced, clearly delineated nodules.
Strategy: Think about each answer.
(1.) telangiectatic nevi or "stork bites"; may be pink or red and are often on the nape of the neck (the lower occipital bone) and/or on the eyelids, between the eyebrows, on the nose or upper lip; fade as the infant gets older
(2.) Mongolian spots; may be bluish-black or gray-blue or purple; may be mistaken as bruises and should be documented in the chart, as should all birthmarks; usually appear in sacral and/or gluteal area, back, shoulders; common in newborns of African, Asian, Native American, or Hispanic descent; gradually fade during first or second year of life
(3.) CORRECT—this is a nevus flammeus (port wine stain); its color ranges from pink to red to purple and it may appear purple-black in Africans; grows proportionately as the child grows; does not fade; a laser pulse device is used to significantly lighten or completely clear the stain when the child is older
(4.) strawberry hemangiomas; benign cutaneous capillary tumors which gradually disappear, usually by the first year of life
A patient is to receive 1,000 cc of TPN infused over a 24-hour period. When it is time for the nurse to change the solution, there is 200 cc remaining in the bottle. Which of the following actions, if taken by the nurse, is MOST appropriate?

1. Quickly infuse the remaining solution over the next half-hour.

2. Slowly infuse the remaining solution over the next two hours.

3. Change the infusion as scheduled.

4. Call the physician for further instructions.
Strategy: Determine the outcome of each answer.
1) too rapid; would cause hyperglycemia and hyperosmolar diuresis
2) should hang no longer than 24 h; slowing rate will cause rebound hypoglycemia
3) CORRECT— decrease the chance of infection; unused solution always discarded; site of catheter changed every 4 weeks, change IV tubing and filers every 24 h
4) “passing the buck”
The ICU nurse cares for a patient diagnosed with septic shock. Which of the following observations MOST concerns the nurse?

1. The peripheral pulses are strong and bounding and the respiratory rate is 26 breaths per minute.

2. The white blood cell differential results indicate that there are predominantly band neutrophils rather than segmented neutrophils.

3. The skin changes from warm, dry, and flushed to cool, clammy, and pale.

4. There is blood at a venipuncture site and around an IV catheter.
Strategy: Think about the implications of each question.
(1.) strong bounding peripheral pulses occur in the early hyperdynamic stage of septic shock; peripheral pulses are weak or absent in the late stage of septic shock; tachypnea (>20 breaths/min) and hyperventilation occur in the early stages, decreased (>12 breaths/min) rate and depth in the later stages
(2.) indicates infection, in this case septic shock; segmented neutrophils are mature cells, whereas band neutrophils are immature cells; normally, the bone marrow releases mostly mature neutrophils; if immature neutrophils predominate, it indicates that the bone marrow cannot produce enough mature neutrophils to cope with microorganisms present and is releasing immature neutrophils
(3.) indicates that shock has progressed from initial hyperdynamic phase of septic shock (symptoms mostly opposite to symptoms seen in other types of shock) to hypodynamic or late stages of septic shock (wherein symptoms are like those of later stages of all forms of shock).
(4.) CORRECT—this is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem; sepsis is the most frequent cause of DIC
As part of a wellness program, the high-school nurse gives a series of classes on the five senses. In the session on hearing, a student complains, "My parents are always yelling at me about my loud music and that I will go deaf. I tell them that when I get old, if I need a hearing aid I will just get one. After all, I already wear glasses." What is the BEST initial response by the nurse?

1. "It sounds as though your parents really care about you."

2. "Let me explain about the two main kinds of hearing loss."

3. "It is not that simple. Hearing aids are quite different from glasses."

4. "You seem really upset about this issue with your parents."
Strategy: Remember therapeutic communication.
(1.) not best; even if true, is likely to be provocative to an adolescent, who is usually dealing with trying to be independent from parents; this often takes the form of rebellion; this response by the nurse could seem patronizing, or like the nurse is allying with the parents
(2.) CORRECT—adolescents can think abstractly and logically, and this response provides important information from an adult outside the family; hearing loss includes conductive, sensorineural, and mixed (both conductive and sensorineural); sensorineural type can be caused by prolonged exposure to noise, such as loud music; it is this type that is usually permanent and not helped with medical or surgical treatment
(3.) not best; is correct information but hearing aids are unlikely to be of much, if any, help in sensorineural hearing loss
(4.) reflective empathic statement that misses opportunity for direct health teaching about hearing
The nurse observes a nursing assistant providing care on the medical/surgical unit. The nurse should intervene if which of the following is observed?

1. The nursing assistant performs perineal care for a client diagnosed with a cerebrovascular accident.

2. The nursing assistant removes dead leaves from a plant in the client’s room.

3. The nursing assistant removes the contact lenses from a client with right-sided weakness.

4. The nursing assistant collects a clean catch urine specimen from a client diagnosed with pneumonia.
Strategy: “Nurse should intervene” indicates something is wrong.
1) appropriate action; instruct to report any drainage, excoriation, or rash
2) CORRECT— caregivers should not be caring for plants and clients; plants should be cared for by a different person
3) appropriate action; instruct nursing assistant about correct way to remove contacts so that client is not harmed and the contacts are not damaged
4) appropriate action
A patient receives isoniazid (INH), rifampin (Rifadin), and ethambutol (Myambutol). Which of the following statements, if made by the patient to the nurse, MOST concerns the nurse?

1. "I seem to be becoming color-blind—I can’t see green."

2. "My urine and sweat are reddish-orange."

3. "Sometimes I wonder what I did to deserve all this."

4. "My big toe has started hurting so I can hardly walk."
Strategy: "MOST concerns" indicates that discrimination is required to answer the question.
(1.) CORRECT—a major common adverse effect of ethambutol is optic neuritis, with reduced visual activity; lessened ability to see green is a possible initial sign
(2.) discoloration of body fluids—urine, sweat, tears, feces, and sputum—is a harmless side effect of rifampin (Rifadin); patient should be warned, though, that soft contact lenses may be permanently stained and therefore should not be worn; the stain will wash out of clothing
(3.) psychosocial; does indicate need for further exploring patient’s thoughts and emotions regarding causation and management of disease process, including assessing for possible depression, as medications prescribed indicate patient has tuberculosis
(4.) hyperuricemia can occur with pyrazinamide (PZA), resulting in acute gout symptoms, such as severe pain in the great toe; this indicates that the drug should be discontinued
The nurse instructs a client diagnosed with diverticulosis. The nurse determines that further teaching is needed if the client states which of the following?

1. “I will eat fruits and vegetables with every meal.”

2. “I will select meats that are low in fat.”

3. “I will add nuts and corn to my diet.”

4. “I will drink milk at least once per day.”
Strategy: “Further teaching is needed” indicates incorrect information.
1) appropriate action; will add fiber to diet which increases bulk in stool; avoid fiber if diverticulitis develops
2) good heath habit; no more than 30% of daily calories should come from fat
3) CORRECT— diverticulosis is diverticula in the colon without inflammation; foods with seeds or indigestible material may block a diverticula; should avoid seeds, nuts, corn, popcorn, cucumbers, tomatoes, figs, strawberries, and caraway seeds
4) appropriate action
The nurse is making client assignments on a medical/surgical unit. The staff includes one RN, an LPN/LVN, and a nursing assistant. Which of the following clients should be assigned to the LPN/LVN?

1. A client who had a detached retina surgically repaired 4 hours ago.

2. A client who requires assistance after receiving bowel prep for abdominal surgery.

3. A client 1 day postop after an appendectomy.

4. A client 2 days postop after a laminectomy with spinal fusion.
Strategy: Think about the skill level involved with each client’s care.
1) requires frequent assessment for hemorrhage, instruct client to avoid sneezing, coughing, or straining at stool
2) assign to the nursing assistant
3) CORRECT— stable patient with expected outcome
4) requires assessment and teaching; assign to the RN
The nurse cares for a client receiving hemodialysis three times per week. Today the client’s potassium is 6.5 mEq/L. The physician orders sodium polystyrene sulfonate (Kayexalate) 15 g PO today. Because the client finds the taste unpleasant, the client asks if the medication can be added to orange juice. Which of the following responses by the nurse is MOST appropriate?

1. Inform client that orange juice is likely to increase the blood sugar.

2. Explain to client that orange juice is contraindicated with this medication.

3. Remind the client that additions to diet supersede the prescribed regulations.

4. Discuss with the client the importance of managing her kidney disease.
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) true statement, but the priority is managing the hyperkalemia
2) CORRECT— Kayexalate is a cationic exchange resin used to treat hyperkalemia; normal potassium is 3.5 to 5.0 mEq/L
3) the rationale is related to the hyperkalemia and not the specific dietary restrictions; exchanges can be made if the client wanted the orange juice and hyperkalemia did not exist
4) is relevant for health problem; may have forgotten about the chemistry of orange juice; obviously needs reinforcement of prior teaching; current issue is the relationship between orange juice and hyperkalemia
The nurse on the medical/surgical unit notes a graduate nurse often seems rushed during the shift and is staying overtime without pay to complete work. The graduate nurse approaches the nurse and says, "I am having difficulty with time management." Which of the following INITIAL responses by the nurse is BEST?

1. "I have some ideas to help you better manage your time."

2. "How much practice did you get in school taking care of groups of patients?"

3. "What ideas do you have as to the reasons for your time management difficulties?"

4. "Tell me how you feel about time in general."
Strategy: Assess before implementing.
(1.) assess before implementing
(2.) relevant, but more important to first determine graduate’s perception about why there is a time management problem
(3.) CORRECT—best to initially assess graduate’s perception of difficulty before offering solutions; conveys respect, allows for free expression and analysis of problem
(4.) relevant but not best initial response; obtains information about larger framework and possible cultural issues; assessment should be focused
A child is learning rules and how to play with others. Based on these observations, the nurse knows that the client is in which of the following stages according to Erikson’s theory of personality development?

1. Autonomy vs. shame and doubt.

2. Initiative vs. guilt.

3. Industry vs. inferiority.

4. Trust vs. mistrust.
Strategy: Image the behavior.
1) 18 months–3 years of age (toddler)
2) 3–6 years of age (preschool)
3) CORRECT— school aged child (ages 6–12); during this stage a child learns to compete and cooperate with others
4) birth to 18 months
The nurse cares for a child receiving 40 drops of IV fluid per minute. The IV set has a drip factor of 60 drops per mL. At this rate, record how many hours it will take the nurse to infuse 400 mL?
If the IV set delivers 60 drops per minute, drops per minute equals mL per hour.
Correct answer: 10

40gtts/min = 40ml/hr

400ml/40ml/hr = 10
Which of the following observations of a patient who has a cuffed endotracheal tube inserted after a drug overdose MOST concerns the emergency department nurse?

1. The pilot balloon does not fill when air is injected.

2. The abdomen is distended and food-like material is in the tube.

3. The inner cannula is lying on the chest of the patient.

4. There is condensation in the endotracheal tube on exhalation.
Strategy: "MOST concern" indicates a complication. Discrimination is required to answer the question.
(1.) cause for concern but not priority since there is still an airway via the tube; pilot balloon indicates presence or absence of air in cuff; lack of balloon filling indicates cuff leak, which may have been caused by a tear or rupture in the cuff or pilot system; the tube needs to be replaced
(2.) CORRECT—indicates esophageal intubation and tube is in the stomach; there is no airway; the tube needs to be immediately removed and the patient hyperventilated to prevent hypoxia before attempting another intubation with a new sterile tube
(3.) there is no inner cannula in an endotracheal tube; inner cannulas are present in most tracheostomy tubes
(4.) indicates correct positioning of the tube in the trachea
The nurse cares for a client receiving 1,200 mL of TPN solution daily. The IV set delivers 10 drops per mL. The nurse should adjust the flow rate so that the client receives how many drops of fluid per minute? Type the correct answer into the blank. Round to the nearest mL.
total volume * drop factor/total time in minutes

1220x10/1440 *12000/1440 = 8gtts/min
The home care nurse counsels a client diagnosed with glaucoma. The nurse determines that teaching is successful if the client makes which of the following statements?

1. “Because of glaucoma, the correction in my eyeglasses needs to be changed”

2. “I will schedule appointments with my physician early in the morning.”

3. “I’m glad that surgery can reverse the damage caused by the glaucoma.”

4. “I will be happy when I don’t have to use the eyedrops anymore.”
Strategy: “Teaching is successful” indicates correction information.
1) glaucoma is an obstruction of the outflow of aqueous humor, causing increased intraocular pressure that causes permanent damage to the optic nerve; there is decreased visual acuity but it is not corrected by eyeglasses
2) CORRECT— IOP tends to be higher in the early morning hours; an early morning assessment is likely to be more accurate
3) damage resulting from sustained increased pressure cannot be corrected with surgery
4) glaucoma is a chronic health problem; blindness can be prevented by lifelong treatment
The nurse performs patient teaching for a client diagnosed with arteriosclerotic heart disease (ASHD) and heart failure. The nurse determines that teaching is effective if the client chooses which of the following menus?

1. Baked chicken, green vegetables, and fresh fruit.

2. Hot dog, cup of canned soup, and lettuce salad.

3. Baked fish, baked apples, and avocado salad.

4. Baked ham, rice, and fruit cup.
Strategy: “Teaching is effective” indicates correct information.
1) CORRECT— ASHD and heart failure requires low fat, low sodium diet; this diet meets both requirements
2) hot dog and canned soup are high in sodium
3) baked fish and apples are low in fat and sodium, avocado salad is high in fat
4) ham is high in sodium
The home health nurse evaluates the health status of a 78-year-old female. The nurse would be MOST concerned if the client states which of the following?

1. “I lie down at night, but sometimes I think about things and I can’t sleep.”

2. “Sometimes I don’t eat much because food doesn’t taste good to me.”

3. “My legs throb when I take my dog for a walk.”

4. “It seems like so many of my friends have either died or moved away.”
Strategy: “Most concerned” indicates something is wrong.
1) assessment; older adults report increased problems with falling asleep and staying asleep
2) assessment, older adults often experience decrease in taste sensation and desire additional salt or sugar to make food more appealing; decreased taste can lead to anorexia, reduced intake, and poor nutrition
3) CORRECT— assessment; may be indicative of a form of peripheral vascular disease; requires immediate follow-up
4) assessment; loneliness is not uncommon and is a response to losses of valued family members and friends; adults who may not have support systems in place to help cope with inevitable losses
The nurse receives a report from the previous shift. Which of the following patients should the nurse see FIRST?

1. A patient who had a lobectomy 24 hours ago and has a chest tube.

2. A patient who had a laryngectomy 12 hours ago.

3. A patient complaining of a headache.

4. A patient in Buck’s traction for a fracture of the R femur.
Strategy: Determine the most unstable patient.
1) no indication that patient is unstable
2) CORRECT— postop complications include respiratory difficulties
3) stable patient
4) assess for fat embolism; postop laryngectomy patient is priority
The nurse on the medical/surgical unit has just received report. Which of the following clients should the nurse see FIRST?

1. A 29-year-old woman undergoing peritoneal dialysis. The outflow appears bloody.

2. A 35-year-old man diagnosed with acute postinfectious glomerulonephritis. The client’s B/P is 150/90.

3. A 45-year-old woman diagnosed with P. jiroveci pneumonia. The client complains of a persistent dry cough.

4. A 56-year-old man diagnosed with angina. The client is scheduled for discharge today.
Strategy: Determine the most unstable client.
1) not unusual that because of tonicity of dialysate, endometrial lining may be pulled through the fallopian tubes
2) hypertension caused by volume overload; give antihypertensives and diuretics, restrict salt
3) CORRECT— opportunistic infection associated with AIDS; causes progressive hypoxemia and cyanosis
4) stable client; requires teaching regarding importance of weight reduction, regular exercise, and medication
To assess an adult for a pulse during cardiopulmonary resuscitation (CPR), the nurse should palpate

1. the inguinal area midway between the symphysis pubis and antero superior iliac spine.

2. the fourth to fifth intercostal space at the midclavicular line.

3. the medial edge of the sternocleidomastoid muscle in the neck.

4. the groove between the biceps and triceps muscle at the antecubital fossa.
Strategy: Think about anatomy.
1) femoral pulse; used to assess circulation of legs and other pulses; not palpable during cardiac arrest
2) apical pulse; used for auscultation of heart sounds
3) CORRECT— carotid pulse; used to assess character of pulse peripherally and during CPR
4) brachial pulse; used to assess circulation to lower arm and auscultate BP
The nurse assesses a client in the outpatient clinic reporting repeated severe headaches. Which of the following actions should the nurse take FIRST?

1. Obtain a description of the headache.

2. Determine how the client usually relieves headaches.

3. Ask how long the client has been having headaches.

4. Obtain a list of medication the client is currently taking.
Strategy: “FIRST” indicates priority.
1) CORRECT— ask client to describe headache in own words; headache is usually a symptom and not a disease; can be a result of neurological disease, caused by vasodilation, or skeletal muscle tension
2) is a part of the history, but the most important action is to ask the client to describe the headache
3) appropriate information to obtain
4) appropriate information to obtain; antihypertensives, diuretics, and anti-inflammatories can cause headaches
The nurse in the critical care unit reviews postoperative care for a patient after a supratentorial craniotomy. It is MOST important for the nurse to instruct the aide to do which of the following?

1. "Put an ice pack on the patient’s eyes and a cool compress on his forehead."

2. "Determine how much pain the patient is experiencing on a scale of 1 to 10 and report back to me."

3. "Keep the head of the bed flat, with the patient lying on his back."

4. "If the patient starts to have a seizure, place a padded tongue blade in his mouth right away and call for help."
Strategy: Topic of question is unstated.
(1.) CORRECT—appropriate to delegate to unlicensed assistive personnel (UAP) application of heat or cold to a closed inflamed or painful area; patient may have periorbital edema and burning after the surgery; ice will help with vasoconstriction and decrease of edema; cool compress is a comfort measure
(2.) incorrect delegation; pain assessment must be done regularly and routinely by the registered nurse
(3.) incorrect action; the head of the bed should be elevated 30 degrees to encourage venous drainage and help prevent increased intracranial pressure; patient may stay supine or be turned side to side; if the removed tumor was large, patient should be turned only to the nonoperative side in order to prevent gravity from displacing cranial contents
(4.) incorrect action; tongue blades are not used for seizure management; they are not needed and can cause injury to teeth, affect aspiration, or even obstruct airway
A client is scheduled for surgery in 10 days for removal of a pilonidal cyst. The nurse notes the client is diagnosed with adrenal insufficiency and has been taking prednisone 5 mg PO bid. The nurse expects the physician to take which of the following actions?

1. Continue the medication as prescribed before surgery.

2. Discontinue the medication before surgery.

3. Reduce the dosage of medication before surgery.

4. Increase the dosage of medication before surgery.
Strategy: Determine the outcome of each answer.
1) dosage should be changed
2) steroids should not be abruptly withdrawn
3) surgery increases the demand for corticosteroids
4) CORRECT— surgery increases the demand for corticosteroids; nurse should monitor vital signs and blood sugar, and check for infection and bleeding
A nurse notes a significant increase in client falls causing injury. To help resolve this problem, which of the following actions by the nurse is MOST appropriate?

1. Schedule an inservice about client safety.

2. Inform staff that pay raises will be withheld until incidents decrease.

3. Convey to the staff the nurse’s confidence in their abilities to provide safe care.

4. Form a group to design and implement a plan to prevent further incidents.
Strategy: “MOST appropriate” indicates discrimination is required to answer the question.
1) presumes that education is the solution
2) coercive techniques usually have temporary outcomes
3) charismatic power does little to address a safety problem; lacks problem solving
4) CORRECT— involvement of staff is likely to have more permanent effect; nurses have firsthand knowledge of why the problems are occurring
The nurse assesses a client diagnosed with M é ni è re’s disease. The client reports that even though he takes the prescribed medications regularly, he continues to have episodes of vertigo. It is MOST important for the nurse to ask which of the following questions?

1. “Tell me about your diet.”

2. “How are things going at work?”

3. “When was M é ni è re’s disease diagnosed?”

4. “What were the results of your last blood test?”
Strategy: “MOST important” indicates discrimination may be required to answer the question.
1) CORRECT— symptoms are usually controlled by adhering to a low-sodium diet (2000 mg/day); nurse should assess if client following diet
2) a psychological evaluation may be warranted if client anxious, fearful, or depressed; more important for nurse to determine if client adhering to medical regimen
3) priority is to determine if client is following the low-sodium diet
4) M é ni è re diagnosed through history and evaluation of cranial nerve VIII
The nurse cares for clients in the senior citizens facility. A client relates to the nurse that, “I had pneumonia once, and I don’t want to get it again.” To develop an effective teaching plan for this client, it is MOST important for the nurse to obtain an answer to which of the following questions?

1. “How often do you cough and deep breathe?”

2. “Have you received a flu shot this year?”

3. “Do you avoid crowds?”

4. “How much sleep do you receive each night?”
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) activity, coughing, and deep breathing helps prevent pneumonia; community-acquired pneumonia often follows viral infections or influenza
2) CORRECT— community-acquired pneumonia (most common form of pneumonia) often follows viral infections or influenza; also ask client status of pneumococcal vaccine
3) avoid crowds during periods of flu outbreak; priority is obtaining the flu vaccine
4) encourage client to get enough rest and sleep and eat balanced meals; primary prevention is priority
On assessment of a patient admitted for dehydration, the nurse notes the patient appears restless and complains of difficulty breathing. The nurse notes bibasilar crackles on auscultation of the patient’s lungs. Which of the following interventions should the nurse perform FIRST?

1. Place the patient on 2 liters oxygen per nasal cannula.

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

3. Stop the infusion and notify the physician.

4. Elevate the head of the bed and stop the infusion.
Strategy: “FIRST” indicates priority.
1) appropriate action, immediately reposition for maximum lung expansion with minimal effort, may rapidly improve patient ventilation while preparing other interventions
2) inadequate response, nurse will likely stop IV fluids and administer a diuretic; more important to position client correctly
3) appropriate action, priority is to elevate the head of the bed
4) CORRECT— signs and symptoms suggest fluid overload; elevating the head of the bed maximizes respiration while stopping the infusion prevents further overload and progressive complications
The nurse counsels a client diagnosed with rheumatoid arthritis. The client asks the nurse why he should perform range-of-motion (ROM) exercises. Which of the following responses by the nurse is BEST?

1. “They help make your muscles stronger.”

2. “They help prevent contractures.”

3. “They help keep your spirits up.”

4. “They will prevent respiratory complication.”
Strategy: Think about what the words mean.
1) it is important that the client increases muscle strength; will be done through isometric and resistive exercises
2) CORRECT— ROM exercises increase joint mobility and decrease pain; important that client take medication on time to ensure consistent blood levels, balance rest, and activity
3) if client has decreased pain and greater ROM, will feel better psychologically, but not the primary reason for ROM exercises; recreational exercise such as walking and swimming will increase muscle tone and increase psychological well being
4) not accurate; coughing and deep breathing will prevent respiratory complication