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26 Cards in this Set
- Front
- Back
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The triage nurse receives a call from a client with a history of type 2 diabetes mellitus controlled by metformin. The client is reporting muscle pain and shortness of breath with exercise. Which of the following is the most appropriate response from the nurse? |
Select one: a. See the client’s primary health care provider today
b. Increase the amount of fluids to treat possible dehydration
c. Take ibuprofen 600 mg every 4-6 hours for the muscle pain
d. Breathe into a paper bag to control hyperventilation
Answer
c. See the client’s primary health care provider today The client needs to see a health care provider for further care. Lactic acidosis can occur when taking Metformin in the presence of dehydration and renal insufficiency, typically seen in type 2 diabetics. Manifestations of lactic acidosis include Kussmaul’s breathing and severe muscle pain caused by the buildup of lactic acid in the muscles.
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A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client? |
Select one: a. Seek the assistance of a nurse on the floor who is fluent in the client’s language.
b. Do nothing as this is the provider’s primary concern.
c. The nurse should explain the procedures using pictures and hand gestures.
d. Have the nurse respond to the client’s concerns so the provider can prepare for surgery.
Answer
a. Seek the assistance of a nurse on the floor who is fluent in the client’s language. The nurse is responsible for ensuring that the client understands the information provided regarding the procedure.
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A nurse is performing initial teaching with a client who will be receiving electroconvulsive therapy (ECT). Which statement by the client indicates a need for further teaching? |
Select one: a. “Before the procedure, I will have an EKG to assess for heart irregularities.”
b. “My Dilantin dose will be increased several days before the procedure.”
c. “I will stop taking my lithium for 2 weeks prior to my procedure.”
d. “I will need to continue taking my regular blood pressure medication.”
Answer
b. “My Dilantin dose will be increased several days before the procedure.” Because the therapeutic action of ECT is to induce seizures, any medications that affect the client’s seizure threshold must be decreased or discontinued several days before the procedure.
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A daughter of a client with a terminal illness pulls a nurse to the side and says, “Although my mother’s living will states she is not to be resuscitated, the family wants everything done to save her if she has a cardiac arrest.” How should the nurse respond? |
Select one: a. “I will contact the provider to make him aware of your request.”
b. “If your mother has a cardiac arrest, we will begin resuscitation if you wish.”
c. “The living will documents your mother’s wishes and must be followed.”
d. “Since the living will is a legal document a lawyer will have to make the changes.”
Answer
c. “The living will documents your mother’s wishes and must be followed.” A living will is a document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. The client’s wishes should be followed by the health care provider.
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A provider informs the wife of a comatose client with terminal cancer that she will need to sign the consent for insertion of a gastrostomy feeding tube. The nurse knows this is against the client’s wishes. What is the appropriate action by the nurse? |
Select one: a. Prepare the consent for the wife to sign.
b. Ask the provider for an order for a NG tube instead.
c. Inform the wife she cannot sign the consent
d. Consult the hospital’s ethics committee.
Answer
d. Consult the hospital’s ethics committee. If the nurse believes the provider’s actions are directly against the client’s wishes, the nurse should contact the hospital’s ethics committee. These committees are typically multidisciplinary and are organized to consciously and reflectively consider significant and often difficult issues related to client care. Any nurse can consult the hospital’s ethics committee when deemed necessary.
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A client is seeking treatment for stress related to unexpected loss of employment and is engaging in the stress management technique of cognitive reframing. Which of the following statements would indicate to the nurse that the client understands this stress management technique? |
Select one: a. “I can visualize the perfect interview and being offered a new job.”
b. “I have excellent job skills; I just need to find a new employer.”
c. “Once I decided what was most important to me, things got easier.”
d. “When I do my daily yoga exercises, I feel so much better.”
Answer
d. “I have excellent job skills; I just need to find a new employer.” Cognitive reframing is a simple and effective technique for reducing stress by looking at things in a more positive light in order to experience them as less stressful. Cognitive reframing for this client would involve building confidence in job skills and searching for a new job.
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A nurse is preparing a client with terminal illness for discharge to a nursing home when he states: “I don’t want to go to a nursing home to die. I would rather die at home.” What would be the most appropriate action by the nurse? |
Select one: a. Assess the client's reasons for feeling this way.
b. Continue to make the discharge arrangements.
c. Inform the provider of the client's decision.
d. Contact the client's case manager.
Answer
d. Contact the client's case manager. Contact the client’s case manager would be the most appropriate action by the nurse. The case manger would be able to determine if the client’s wishes could be carried out.
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The nurse is caring for a client admitted with diverticulitis. The client reports severe abdominal pain and assessment reveals that the client’s abdomen is rigid and tender. The client's vital signs are: T: 101.8 F (38C); HR: 120; B/P: 100/50. Urine output was less than 300 ml during the previous eight hours. The client states the pain is "worse than before". What is the priority nursing intervention for this client? |
Select one: a. Administer bisacodyl suppository as needed
b. Notify the client’s health care provider
c. Encourage the client to increase fluids
d. Administer the prescribed scheduled antibiotic
Answer
a. Notify the client’s health care provider The client is febrile, tachycardic and hypotensive with verbalization of increased worsening abdominal pain. These are signs of possible rupture of the diverticulum, pelvic abscess, or bowel obstruction
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A client is hospitalized for multiple rib fractures following a motor vehicle accident (MVA). The results of an arterial blood gas (ABG's) are; pH 7.30, pCO2 48, HCO3 26 and pO2 91 on 2 L/min of oxygen per nasal cannula. Which of the following interventions has the highest priority? |
Select one: a. Notify the health care provider of the abnormal ABG's.
b. Administer an anti-anxiety agent to calm the client.
c. Increase the client's O2 delivery to 4 L/min.
d. Assist the client to deep breathe, splinting with a pillow.
Answer
d. Assist the client to deep breathe, splinting with a pillow. The client is experiencing respiratory acidosis from hypoventilation caused by painful respirations due to fractured ribs. Splinting the chest wall with a pillow will decrease pain associated with deep breathing. Deeper breaths will allow for better gas exchange, which will correct the acidosis.
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The nurse is caring for a client admitted with diverticulitis. The client reports severe abdominal pain and assessment reveals that the client’s abdomen is rigid and tender. The client's vital signs are: T: 101.8 F (38C); HR: 120; B/P: 100/50. Urine output was less than 300 ml during the previous eight hours. The client states the pain is "worse than before". What is the priority nursing intervention for this client? |
Select one: a. Administer bisacodyl suppository as needed b. Notify the client’s health care provider c. Encourage the client to increase fluids d. Administer the prescribed scheduled antibiotic
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The nurse is caring for four clients receiving chemotherapy. Which of the following clients should the nurse see first? |
Select one: a. A client with cervical cancer and a hemoglobin level of 8.2 mg/dL
b. A client with ovarian cancer with a white blood cell count of 4,500 cells/mcL
c. A client with breast cancer and a sodium level of 115 mEq/L
d. A client with endometrial cancer and a potassium level of 5.0 mEq/L
Answer
d. A client with breast cancer and a sodium level of 115 mEq/L A sodium level less than 120 mEq/L is considered a medical emergency and needs immediate assessment and treatment.
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A community based nurse receives a client referral. Which of the following actions should be performed first? |
Select one: a. Collaborate with the health care team and the referring agency to assess client needs.
b. Educate the client about the community resources that are available
c. Obtain information about community resources accessible to the client.
d. Encourage the client to contact appropriate agencies.
Answer
a. Collaborate with the health care team and the referring agency to assess client needs. The nurses who receive the referrals need to work collaboratively with the health care team and the referring agency or persons. Continuous coordinated care among all health care providers involved in a client’s care is essential to avoid duplication of effort by the various personnel caring for the client. Understanding client needs is the first step in the referral process.
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At 0715 the nurse is assigned to care for the following four clients. Which of the following clients should the nurse plan to see first? |
Select one: a. A client who will be transferred to a skilled care facility at 0930.
b. A client scheduled for a bronchoscopy at the bedside at 0900.
c. A client with pneumonia scheduled for a portable chest x-ray at 0730.
d. A client with diabetes mellitus type I waiting for a breakfast tray at 0745.
Answer
d. A client with diabetes mellitus type I waiting for a breakfast tray at 0745. The diabetic client waiting for breakfast should be assessed first. Prior to breakfast the client's blood glucose needs to be drawn and if insulin coverage is required it is administered before breakfast. Once the client begins to eat and digest food they will be at risk for increasing blood glucose levels without their insulin coverage.
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A nurse is caring for a client who has been committed to an acute Mental Health facility with an involuntary emergency commitment order. What should the nurse include when orienting the client to the facility? |
Select one: a. The client has the right to refuse treatment, unless he has been judged to be incompetent.
b. Family will not be able to visit until their provider grants the visitation privileges.
c. The client can leave the facility at any time if they sign a medical release form.
d. Length of stay at the facility will be determined by the courts.
Answer
a. The client has the right to refuse treatment, unless he has been judged to be incompetent. Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, unless they have gone through a legal competency hearing and have been judged incompetent. The client who has been judged incompetent has a temporary or permanent guardian, usually a family member if possible, appointed by the court. The guardian can sign informed consent for the client. The guardian is expected to consider what the client would want if they were still competent.
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The following clients have been assessed in the emergency department. Which of the following clients requires immediate attention? |
Select one: a. A 48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's.
b. A 19 year-old client who is vomiting and complaining of new onset right lower quadrant pain with rebound tenderness.
c. An 81 year-old client with a history of heart failure and new onset pneumonia with a respiratory rate of 32 and a temp of 101 F (38).
d. A 6 year-old client with an open tibial fracture that occurred two hours ago after being hit by a car.
Answer
a. A 48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's.
While all of these clients require nursing care, the 48 year-old male with c/o chest pain and a cardiac rhythm of sinus tachycardia with occasional PVC’s needs immediate attention! Chest pain is an indication of myocardial ischemia and this client has other factors that put him at risk for sudden death: gender, age and PVC’s. PVC’s are not normal in a 48 year old. PVC’s occur when the myocardium is irritated, usually from hypoxia but also from electrolyte imbalance, usually involving K+. This client is young and as a result has not had sufficient time to develop adequate collateral circulation.
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A nurse is caring for four laboring clients. Each of the clients is requesting an epidural. Which of the following clients should receive her epidural first? |
Select one: a. Mulitipara with contractions occurring every 3 minutes, lasting 45 seconds. The cervical os is dilated 5 cms.
b. Primipara with contractions occurring every 10-15 minutes, lasting 15 seconds. The cervical os is dilated 3 cms.
c. Primipara with contractions occurring every 2 minutes, lasting 90 seconds. The cervical os is dilated 10 cms.
d. Mulitipara with contractions occurring every 2 minutes, lasting 130 seconds. The cervical os is dilated 8 cms.
Answer
c. Mulitipara with contractions occurring every 3 minutes, lasting 45 seconds. The cervical os is dilated 5 cms. An epidural is indicated in the active phase of labor. Active labor is defined as: cervical dilation of 4-7 cms, contractions occurring every 3-5 minutes and lasting 30-60 seconds.
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Match the following ethical principles to the correct definition:
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The care that is in the best interest of the client. Answer 1Choose... Justice, Veracity, Beneficence, Nonmaleficence, Autonomy, Fidelity
The nurse’s duty to tell the truth.
Answer 2Choose... Justice, Veracity, Beneficence, Nonmaleficence, Autonomy, Fidelity
Fair treatment in matters related to physical and psychosocial care and use of resources.
Answer 3Choose... Justice, Veracity, Beneficence, Nonmaleficence, Autonomy, Fidelity
Keeping one’s promise to the client about care that was offered.
Answer 4Choose... Justice, Veracity, Beneficence, Nonmaleficence, Autonomy, Fidelity
The ability of the client to make personal decisions, even when those decisions may not be in the client’s own best interest.
Answer 5Choose... Justice, Veracity, Beneficence, Nonmaleficence, Autonomy, Fidelity
The nurse’s obligation to avoid causing harm to the client.
Answer 6Choose... Justice, Veracity, Beneficence, Nonmaleficence, Autonomy, Fidelity
Answer
The care that is in the best interest of the client. – Beneficence, The nurse’s duty to tell the truth. – Veracity, Fair treatment in matters related to physical and psychosocial care and use of resources. – Justice, Keeping one’s promise to the client about care that was offered. – Fidelity, The ability of the client to make personal decisions, even when those decisions may not be in the client’s own best interest. – Autonomy, The nurse’s obligation to avoid causing harm to the client. – Nonmaleficence |
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A nurse is caring for a client recently diagnosed Hepatitis C. He asks the nurse to promise him his wife will find not out about his diagnosis. What is the best response by the nurse? |
Select one: a. “I’ll place a note in your chart concerning your request for your wife not to be informed.”
b. “Your medical information is considered confidential to be shared only if you agree.”
c. “I can’t promise you because your provider may inform her anyway.”
d. “Your wife has the right to know about your condition because she may be at increased risk.”
Answer
b. “Your medical information is considered confidential to be shared only if you agree.” The client must give consent for health care information, including laboratory results, diagnosis, and prognosis, to be shared with anyone that is not involved in the client’s care. This includes sharing the information with family members.
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A nurse is using silence to communicate with a client. Which of the following describes a therapeutic purpose of silence? |
Select one: a. Conveys the nurse’s understanding of the client and assists with clarification.
b. Communicates the nurse’s interest and concern for the well-being of the client.
c. Encourages the client to discuss central issues and keeps communication goal-oriented.
d. Allows the client time to gain insights and slows the pace of the interaction.
Answer
b. Allows the client time to gain insights and slows the pace of the interaction. Silence gives the client time to think and gain insights, slows the pace of the interaction, and encourages the client to initiate conversation, while conveying the nurse’s support, understanding, and acceptance.
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A client is admitted to the hospital for suspected infective endocarditis. The client is reporting chills, fatigue, myalgia and dyspnea upon exertion. When assessing the client the nurse notes a heart murmur and a temperature of 102.3 F (38.2 C). Which of the following orders should the nurse implement first? |
Select one: a. Order the EKG
b. Administer IV Penicillin G, 2 million units
c. Obtain the blood cultures from three sites
d. Administer acetaminophen 325 mg by mouth
Answer
c. Obtain the blood cultures from three sites. Obtaining blood cultures is the priority intervention. Cultures must be drawn prior to initiation of antibiotics so sensitivity results are not influenced. Obtaining specimens from three sites increases the reliability of the results. Clients at risk for endocarditis should be treated with prophylactic antibiotics prior to dental procedures; respiratory and GI diagnostic procedures; GU and Cardiac surgeries.
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A nurse has accepted a new position and is attending the general nursing orientation. Which of the following topics will most likely NOT be included in the orientation? |
Select one: a. Accident prevention
b. Health promotion
c. Fire safety
d. Rules of conduct
Answer
d. Rules of conduct
Orientation activities are more specific for the position, whereas general employee orientation provides the employees with general information about the organization. Rules of conduct are employee indoctrination content and are not part of the nurse’s orientation schedule
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An elderly client is three days post-operative an anterior and posterior colporrhaphy. Which of the following assessments has the highest priority in this client's care? |
Select one: a. Breath sounds decreased with fine crackles audible at bilateral bases.
b. Oral temperature 100.8 F (38.2 C).
c. Apical pulse 90 and slightly irregular.
d. Abdomen firm and tender to palpation above the symphysis pubis.
Answer
d. Abdomen firm and tender to palpation above the symphysis pubis. An assessment of an abdomen being firm and tender to palpation above the symphysis pubis has the most immediate implications for this post-op client. Urinary retention is possible complication of colporrhaphy and a firm and tender abdomen above the symphysis pubis is an indication of urine retention. The priority intervention for acute urinary retention is catheterization.
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A community based nurse receives a client referral. Which of the following actions should be performed first? |
Select one: a. Obtain information about community resources accessible to the client.
b. Collaborate with the health care team and the referring agency to assess client needs.
c. Educate the client about the community resources that are available
d. Encourage the client to contact appropriate agencies.
Answer
b. Collaborate with the health care team and the referring agency to assess client needs. The nurses who receive the referrals need to work collaboratively with the health care team and the referring agency or persons. Continuous coordinated care among all health care providers involved in a client’s care is essential to avoid duplication of effort by the various personnel caring for the client. Understanding client needs is the first step in the referral process.
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The nurse manager observes a nurse placing several packages of suction catheters in her pocket to use as the nurse provides treatments to several clients with tracheostomies. Which of the following recommendations should the nurse manager make? |
Select one: a. Place suction catheters in a treatment tray rather than in a pocket
b. Store suction catheters in a dedicated space at client’s bedside
c. Leave suction catheters in the supply room until needed
d. Carry catheters in pocket but note how many catheters are used for each client
Answer
d. Store suction catheters in a dedicated space at client’s bedside Storing suction catheters in a dedicated space at client’s bedside is the best choice. While the cost of supplies must be considered, clients with new tracheostomies for example require frequent suctioning and the client may be placed in jeopardy if the necessary equipment is not readily available. Resource allocation is a responsibility of the unit manager as well as every practicing nurse. Providing cost-effective client care should be balanced with quality care.
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A nurse is charting the morning assessments on the computer when a client calls for assistance from his room. What actions should the nurse take next? |
Select one: a. Complete the charting before assisting the client.
b. Log off of the computer before responding.
c. Have an assistive personnel stay with the computer.
d. Take the computer to the client’s door while assisting him.
Answer
b. Log off of the computer before responding. The nurse should always log off the computer when leaving the terminal to protect her user name as well as to protect client information.
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A nurse is managing the nursing staff on a medical-surgical unit. When evaluating client care, which of the following statements represents correct implementation of the five rights of delegation by the nursing staff? |
Select one: a. A licensed practical nurse delegates to the assistive personnel to teach the client about ambulating with a walker before discharge.
b. A licensed practical nurse creates the nursing care plan for a client experiencing post-operative pain 2 days after an appendectomy.
c. An RN asks the assistive personnel to record the intake and output of a client who is admitted to the unit with heart failure.
d. An RN asks the licensed practical nurse to administer total parenteral nutrition to a client who had minor surgery 2 days ago.
Answer
c. An RN asks the assistive personnel to record the intake and output of a client who is admitted to the unit with heart failure. Measuring intake and output is a task that can be delegated to assistive personnel.
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