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NCLEX-RN Practice Set
Terms in this set (60)
A client is admitted to the emergency department (ED). The family reports the client had a sudden onset of left-sided facial droop and slurred speech at home. The nurse observes left-sided muscle weakness. Which is the most important question for the nurse to ask?
1. "What over-the-counter medications does your parent take?"
2. "What was your parent doing when the symptoms began?"
3. "When did you notice the onset of your parent's symptoms?"
4. "Does your parent have a history of high blood pressure?"
Rationale: Time is of the essence when providing care to a client who experiences ischemic stroke, as thrombolytic therapy is only effective for 4.5 to 6 hours from onset of sx. This is the priority assessment question as thrombolytic therapy can restore circulation for this client.
2:A hemorrhagic stroke may be precipitated by strenous activity. This question is important to differentiate whether the client is experiencing a hemorrhagic or ischemic stroke but not the priority.
4: HTN or high blood pressure is a common risk factor for all types of stroke. Although this is an appropriate assessment question, it does not address the here and now.
The nurse meets with the parent of an adolescent male who presents for an annual health maintenance visit. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct?
1. "Your son might have attention deficit hyperactivity disorder."
2. "I'll talk with the health care provider about assessing for subtle motor dysfunction."
3. "Your son's clumsiness is expected at this age."
4. "This may be an early sign of depression."
Rationale: Adolescent males experience a rapid rate of physical growth, which can cause clumsiness and a lack of coordination. This statement is accurate and addresses the parent's concern.
1,4: This is a false statement about clumsiness and lack of coordination in adolescent males, as these manifestations are not associated with attention deficit hyperactivity disorder (ADHD) nor depression. Therefore, this response by the the nurse is not correct.
2: Inappropriate for the nurse tos uggest to HCP the need to assess for subtle motor dysfunction.
*The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't know what to expect." Which statements will the nurse include when responding to the client's concerns? (Select all that apply.)
1. "We will move you to the operating room where the test is always performed."
2. "The bone in the front of your chest will be used for the biopsy specimen."
3. "A tight pressure dressing will be placed over the test site after the procedure."
4. "You will not feel any discomfort as the local anesthetic is injected."
5. "There is a risk of bleeding, so we will monitor the test site frequently."
Rationale: A bone marrow biopsy can cause bleeding and a pressure dressing is applied to reduce the risk of bleeding. Therefore, both are accurate and appropriate for the nurse t o include in teaching.
1: BMA/biopsy may be done in a client room or treatment room. OR is not required.
2: Sternum may be used for BMA but not enough marrow available for biopsy.
4: Client will feel some stinging and discomfort during bone marrow biopsy. This is false reassurance.
*The LPN/LVN reporting to the nurse says, "You may want to see the client recently diagnosed with pancreatic cancer. I am not sure how well things are going." The nurse enters the room and finds the client sitting quietly, looking out the window. As the nurse approaches the client, the client does not look at the nurse. Which is the most appropriate response by the nurse?
1. "Sleep problems are common during times of stress. Have you had difficulty sleeping?"
2. "Tell me what you know about your diagnosis and the treatment you will receive."
3. "How would you describe your overall health status up to this time of your life?"
4. "How have you handled any health problems you experienced in the past?"
Rationale: MOST imp't to determine client's perception of the health problem. Open-ended statement.
Strategy: need to address the problem and better to ask open-ended questions. It is more imp't to deal with the here and now.
*The nurse provides care for the client immediately after arrival in the emergency department (ED). Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the first action taken by the nurse?
1. Determine Glasgow Coma Scale (GCS) score.
2. Assess bilateral blood pressure.
3. Check bilateral pupillary response to light.
4. Determine oxygen saturation levels.
Rationale: When prioritizing care for a client, nurse uses the ABC's (airway, breathing, circulation). Oxygen saturation levels allow the nurse to monitor the client's airway (priority).
1: GCS is used to assess ABC and neuro status for clients c head trauma. It is appropriate but too broad and will take longer.
2: Assessing BP is monitoring for circulation. However, airway is priority and increases in arterial CO2 will increase ICP.
3: Nurse assesses neuro status (eg. PERRLA) after ABC.
At a rehabilitation center for clients with spinal cord injuries (SCIs), the nurse conducts an orientation session for a group of unlicensed assistive personnel (UAP). Which statement is most important for the nurse to include?
1. "The clients may appear angry at times."
2. "Obtain the client's permission before touching the client."
3. "Most clients arrive believing they will walk out of here."
4. "Personnel in this environment often need counseling."
Rationale: This statement provides the UAP c info needed to provide care for a client c SCI. Therefore, this isa priority when delegating tasks to the UAP who provides client care.
1,3,4: MAY be true but does not provide info regarding care for SCI patients.
*The home care nurse instructs a client diagnosed with multiple sclerosis (MS). The client states, "I have poor concentration and difficulty pronouncing words." The nurse notes that the client's speech is slow and slurred. Which client statement indicates to the nurse that further teaching is necessary?
1. "I will sit up straight when I talk and will feel confident."
2. "I will turn off the TV when speaking and look at the person with whom I am talking."
3. "During a conversation, I will carefully build up to my most important points."
4. "If words fail me, I will draw a picture."
Rationale: Verbal communication often causes fatigue for MS clients. Therefore, client is taught to make important points first prior to the onset of fatigue.
1,2,3: INDICATES appropriate understanding from the client.
A client diagnosed with malnutrition is prescribed continuous enteral feedings through a newly placed gastrostomy tube. Which actions will the nurse include in the client's plan of care? (Select all that apply.)
1. Cover the insertion site with an adhesive bandage.
2. Add 8 hours of feeding to the bag at a time.
3. Rotate the gastrostomy tube 360 degrees once daily.
4. Auscultate for whoosh of air through the gastrostomy tube.
5. Check for slight in-and-out movement of the gastrostomy tube.
Rationale: Gtube should be rotated 360 degrees daily (to reduce risk of skin irritation and breakdown) and a slight in-&-out mov't indicates that the GTube is not embedded in the stomach wall.
1: Gtube insertion site should be covered c a sterile bandage to reduce infection until the stoma is healed. AN adhesive bandage is not used, as this may cause the tube to become dislodged along with increasing risk of infection.
2: Only 4 hours of feeding should be added to the bag to reduce risk of bacterial contamination.
4: Insertion of air is not recommended for GTube placement assessment.
The nurse provides care to a client who is diagnosed with a stroke and is admitted to a rehabilitation center. The client has left-sided pronator drift and decreased dorsiflexion strength of the left extremity. The nurse notes the client bumps into the left wall when ambulating with a walker. The client leans to the left when sitting in a chair or wheelchair. Which is the most appropriate action for the nurse to take?
1. Place the client's favorite watch on the left wrist.
2. Provide a written list for the client to follow during morning care.
3. Instruct the client to choose a dress for the day.
4. Position the client so the right side faces the door of the room.
Rationale: Client has R side stroke c L side unilateral neglect syndrome. Therefore, the client cannot see out of the left side of both eyes. Safety is a priority when providing care. To enhance safety, the nurse positions the client for best vision so that the client is not scared or upset by approaching people.
2: Client recovering from stroke may have short attention span or visual difficulties, making reading with comprehension a difficult task. Nurse should provide verbal instructions c short sentences.
A client is brought to the emergency department (ED) by friends reporting a dry mouth, frequent urination, extreme thirst, and no fluid intake for the last 8 hours. The friends report the client may not have taken insulin during the last couple of days. The nurse reviews prescriptions from the health care provider. Which prescription does the nurse implement first?
1. Administer 20 mEq potassium chloride orally.
2. Begin regular insulin at 0.1 units/kg/hour.
3. Obtain a 12-lead electrocardiogram.
4. Begin infusion of 0.9 % NaCl at 1 L per hour.
Rationale: During DKA, osmotic diuresis occurs and the client is at significant risk for fluid volume deficit. Since this deficit impacts the ABCs (specifically circulation), this is the priority prescription for the nurse to implement.
1: Mild to moderate hyperkalemia is often seen during the initial phase of DKA. Once an insulin drip is initiated, causing potassium to move into the cells, a KCl prescription may be appropriate.
2: does not address ABC's Restoring volume is the priority for this client
3: This does not address the client's actual problem
*The nurse reviews the medical record of a client recently diagnosed with Guillain-Barré syndrome. The client has flaccid paralysis of both legs, a history of coronary artery bypass surgery 3 weeks ago, and a 20-year history of hypertension and hypercholesterolemia. The client was also recently diagnosed with type 2 diabetes mellitus (DM). The nurse prepares to apply anti-embolism stockings to both legs. Which priority action does the nurse implement?
1. Assess for bilateral pretibial edema.
2. Palpate both calves for pain.
3. Ask the client the reason for application of anti-embolism stockings.
4. Palpate bilateral pedal pulse strength.
Rationale: Best indication of PAD and circulation in the extremities is to monitor the client's pedal pulses. In addition, decreased circulation is a contraindication for an anti-embolism stockings.
1: Some edema is expected to an immobile client. Purpose of TED socks may be to reduce edema
2: Venous thromboembolism is a contraindication for anti-embolism stockings. However, client may not have calf pain c VTE in the deeper veins. Pain is also considered psychosocial.
A client returns to the recovery area after a colonoscopy procedure. Intravenous midazolam was administered during the procedure. The procedure was completed at 1115. The recovery room nurse reviews the sedation chart below. Based on this information, which is the most appropriate action for the nurse to take?
Pulse/Pain: 84, 0/10
Pulse/Pain: 76, 0/10
Pulse/Pain: 80, 0/10
LOC: Arouses to command
Pulse/Pain: 72, 1/10
LOC: Arouses to command
Pulse/Pain: 66, 1/10, nausea
1. Recheck blood pressure in 15 minutes.
2. Administer ondansetron 4 mg IV.
3. Obtain a 12-lead electrocardiogram (ECG).
4. Assist client to get dressed.
Rationale: VS should be within 20% of pre-procedure values. While midazolam more commonly causes hypotension, the elevated BP is greater than a 20% change in baseline values, indicating that the client is not stable.
2: Expected, nausea may occur p the procedure
3:ECG is done to determine heart rate changes and dysrythmias.
4: Client is not stable
The nurse in the emergency department (ED) assesses a client diagnosed with tonic-clonic epilepsy. The client's spouse states that the client has been taking phenytoin as prescribed, but has not been feeling well lately. Which client observation most concerns the nurse?
1. Reddish-brown urine, and the client reports constipation.
2. Acne, hirsutism, and gingival hyperplasia.
3. Ataxia, slurred speech, and nystagmus.
4. The left arm is in a sling and the client walks with a limp.
Rationale: Slurred speech and ataxia both present an airway concern.
1,2,4: Important manifestations but none impact the ABCs
The health care provider prescribes metoclopramide 2 mg/kg IV to be given to a client 30 minutes before the client receives cisplatin. The client asks the nurse why the metoclopramide is being given. Which response will the nurse give to the client?
1. "Metoclopramide prevents or reduces the side effects caused by cisplatin."
2. "Metoclopramide increases the effectiveness of the cisplatin."
3. "Cisplatin prevents or reduces the side effects of the metoclopramide."
4. "Cisplatin increases the effectiveness of metoclopramide."
1) CORRECT— Metoclopramide (Reglan) is prescribed to prevent or reduce the side effects (antiemetic) caused by cisplatin, an anti-neoplastic agent. Therefore, this is an accurate response by the nurse.
2) Metoclopramide does not increase the effectiveness of cisplatin. Therefore, this is not an accurate response by the nurse.
3) This is a false statement about the use of metoclopramide and cisplatin. Therefore, this is not an accurate response by the nurse.
4) This is a false statement about the use of metoclopramide and cisplatin. Therefore, this is not an accurate response by the nurse.
*A client diagnosed with rheumatoid arthritis (RA) is prescribed 50 mg etanercept subcutaneous weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both hands. Which finding does the nurse report to the health care provider?
1. White cell count 14,000/mm 3 (14 x 10 9/L).
2. C-reactive protein 1.2 mg/dL.
3. Serum hemoglobin 9 mg/dL (90 g/L).
4. Sedimentation rate 22 mm/hr.
Rationale: WBC of 14,000 may indicate active infection (normal: 4,500 to 10,500), which is a contraindication to etanercept.
2,3,4: Expected findings with moderate to severe RA clients.
Etanercept: DMARDs, MOA: binds to TNF (a mediator of inflammatory response) = decreased inflammation and slowed preogression of RA/spondylitis/psoriasis.
*The nurse provides medication instruction to a client who is prescribed 50 mcg/hour dose of transdermal fentanyl every 3 days. Which statement made by the client indicates understanding of the instructions?
1. "I should avoid placing a heating pad over the medication patch."
2. "If I develop a fever, less medication will be absorbed through my skin."
3. "The medication patch should be folded in half and put in the trash."
4. "I will leave the old patch on for a couple of hours after putting on the new one."
Rationale: ANY heat source, including hot baths & electric blankets, will increase the absorption of the medication thru the skin. Statement indicated correct understanding.
2: A fever increases med absorption thru the skin.
3: Med patch should be folded in half with the adhesive side on the inside and flushed down the toilet.
4: Med will continue to be absorbed from both patches, increasing the risk of adverse effects.
*A pediatric client is diagnosed with pneumonia and prescribed ampicillin 50 mg/kg oral suspension every 6 hours. The child weighs 18 lb (8.181818 kg). The ampicillin is available in 125 mg/5 mL. How many mL will the nurse administer for each dose? (Record your answer rounding at the end of your calculations to the nearest whole number.)
Correct: 16 mL
Client Dose: 50 x 8.181818 = 409.0909 mg
x mL = (5mL/125mg) x (50mg/1kg) x (1kg/2.2lbs) x 18lbs.
x mL = 4500/275
x mL = 16.3636364 ~ 16
The nurse reviews the medical record of a client diagnosed with acute kidney injury. It is most important for the nurse to review which lab value?
1. Fasting blood glucose.
2. Serum uric acid.
3. Serum protein.
4. Urine specific gravity.
Rationale: When providing care for a client diagnosed with acute kidney injury, it is important for the nurse to monitor circulation by reviewing the client's urine specific gravity, which is a good indicator of fluid volume.
1,2,3: Not necessary to review for acute kidney injury
The nurse provides care for the client diagnosed with a hypertensive emergency. The client is prescribed sodium nitroprusside 0.3 mcg/kg/min. The client weighs 176 lb (80 kg). The concentration of the sodium nitroprusside is 50 mg/250 mL. What rate will the nurse set for the per hour amount on the micro infusion pump? (Record your answer rounding at the end of the calculation using one decimal place.)
Correct: 7.2 mL/hr
x mL/hr = (250mL/50mg) x (1mg/1000mcg) x (24mcg/1min) x (60min/1hr)
The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client? (Select all that apply.)
2. Low back pain.
3. Wet breath sounds.
6. Severe shortness of breath
Rationale: CLIENT c hemolytic transfusion reaction will experience a drop in BP, low back pain and an elevated temp.
3,4: wet breath sounds and SOB/dyspnea is expected for a client c circulatory overload
5: urticaria/hives is expected c an allergic reaction
*The health care provider prescribes an increase in the parenteral nutrition (PN) infusion rate from 50 mL/hour to 100 mL/hour. The PN is infusing through a peripherally inserted central catheter (PICC) device. Which is the priority action for the nurse?
1. Assess hourly urine.
2. Evaluate total serum protein level.
3. Assess vital signs (VS) every 4 hours.
4. Evaluate aspartate aminotransferase (AST) test.
Rationale: PN is hyperosmolar and will pull fluid into the intravascular space, thereby causing osmotic diuresis. Fluid volume will affect the ABCs. Therefore, monitoring UO is the priority nursing action.
2: PN is high in protein, necessitating the need to monitor the total serum protein level. This will not impact ABC.
3: Changes in fluid volume may impact VS. However, this is too broad. Urine output is a better indicator of intravascular volume.
4: Not appropriate
The nurse provides care for a client who underwent a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the client develops dumping syndrome. Which client statement indicates to the nurse that further teaching is necessary?
1. "I should eat bread with each meal."
2. "I should eat smaller meals more frequently."
3. "I should lie down after eating."
4. "I should avoid drinking fluids with my meals."
Rationale: Carbohydrates increase the risk of dumping syndrome.
During a urinary bladder catheter insertion, with a size 16 French catheter on an older adult male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take?
1. Withdraw the catheter and apply more lubricant.
2. Instruct the client to take a deep breath and bear down.
3. Stop the insertion and instruct the client to take deep breaths.
4. Withdraw the catheter and notify the health care provider.
Rationale: Instructing the client to take deep breaths will relax the urethral muscles and facilitate passage thru the prostate gland.
4: the nurse determines if there is something that can resolve the issue prior to contacting the HCP
The nurse preceptor observes the novice nurse obtain blood through a peripherally inserted central catheter (PICC). Which observation requires an intervention by the nurse preceptor?
1. The nurse discards 1 mL of blood prior to obtaining the blood sample.
2. The nurse uses a 10 mL syringe to flush through the port of the catheter.
3. The nurse applies clean gloves prior to beginning the procedure.
4. The nurse uses the push-pause technique to flush the catheter.
Rationale: Novice nurse should discard 3-5 mL of blood to prevent contamination of a blood sample with IV fluids/meds.
2: 10 mL syringe is recommended to reduce pressure on the lumen of the PICC line during the flush.
3: Clean gloves are used when drawing blood from PICC line
4: The push-pause technique reduces the risk of clot formation and damage to the PICC line.
The nurse observes the unlicensed assistive personnel (UAP) obtain a capillary glucose sample. Which is the best location for obtaining a blood glucose sample?
Lateral aspect of finger; end of finger is not recommended d/t less blood flow and more nerve fibers.
The nurse provides care to a client who has a chest tube and pleural drainage system placed for the treatment of a right-sided pneumothorax. The suction control chamber is set at 20 cm and tubing is attached to the wall suction. Which finding will the nurse expect to observe after the insertion of the chest tube?
1. Bubbling in the water-seal chamber.
2. Serosanguinous drainage in the collection chamber.
3. Fluctuation in the suction control chamber during coughing.
4. One cm sterile water in the water-seal chamber.
Rationale: The water seal chamber bubbles d/t the pneumothorax
2: serosanguinous drainage is not anticipated, shouldn't have any drainage or very scant drainage
3: fluctuation is expected in the water seal chamber when the client forcefully coughs; not expected after the initial insertion
4: nurse expects 2 cm sterile water in the water seal chamber to prevent reentry of air into the pleural space
The nurse determines that a client's tracheostomy requires suctioning. Which action does the nurse take first?
1. Elevate the head of the client's bed to 90 degrees.
2. Quickly insert the suction catheter.
3. Preoxygenate the client.
4. Put on clean gloves.
1) A semi-Fowler, not high-Fowler, position is ideal for this client during tracheostomy suctioning.
2) The client requires preparation prior to inserting the suction catheter during this procedure.
3) CORRECT— In order to ensure the client does not experience hypoxia during tracheostomy suctioning, the nurse hyperoxygenates the client before and after each time the airway is entered for suctioning.
4) Sterile gloves are used for tracheostomy suctioning.
Upon assessment of a client admitted for dehydration, the nurse observes that the client appears restless and reports difficulty breathing. Upon auscultation of the client's lungs, the nurse notes bilateral basilar crackles. Which actions will the nurse take first?
1. Place the client on 2 L of oxygen by nasal cannula and auscultate the lungs.
2. Elevate the head of the bed and stop the IV infusion.
3. Decrease the IV flow rate and administer furosemide as prescribed.
4. Stop the IV infusion and notify the health care provider.
) Providing the client with oxygen via nasal cannula addresses breathing. However, there is another action the nurse will implement first.
2) CORRECT — Elevating the head of the bed will allow for a more open airway. This is the priority action.
3) Decreasing the IV flow rate and administering furosemide addresses circulation. However, there is another action the nurse will implement first.
4) Stopping the IV infusion addresses circulation. However, there is another action the nurse will implement first.
The nurse provides care for a client diagnosed with diastolic heart failure. The nurse observes the recent onset of the Atrial Fibrillation. Which is the most appropriate action for the nurse to take?
1. Administer digoxin 0.25 mg IV.
2. Instruct the client to take a deep breath and hold it.
3. Assess level of consciousness and orientation.
4. Auscultate posterior chest.
1) The nurse must assess before implementation in this situation. In addition, digoxin is not a first-line drug used to treat atrial fibrillation due to the risk of toxicity.
2) The Valsalva maneuver is not indicated in this situation, as it is used for supraventricular tachydysrhythmias.
3) CORRECT — Level of consciousness (LOC) and orientation are the best indicators regarding the effect of atrial fibrillation on cardiac output. A change in LOC and/or alertness is the earliest indication of poor cardiac output. Therefore, this is the priority action by the nurse.
4) This electrocardiogram strip indicates atrial fibrillation, which may contribute to left-sided heart failure. While it is appropriate to auscultate lung sounds, this is not the priority action in this situation.
The family member of a client diagnosed with a pneumothorax states, "I think something is wrong with that drainage device. It just got very noisy." The nurse observes that bubbling in the underwater seal is continuous compared to several hours ago. Which action does the nurse take first?
1. Clamp the chest tube at the insertion site.
2. Add sterile water to the underwater seal chamber.
3. Notify the health care provider.
4. Observe the connections of the drainage system.
1) The nurse must assess the system first and then assess the client. Clamping the chest tube at the insertion site is not an independent nursing action, as a health care provider prescription is required.
2) The water level should be at 2 cm. If a leak is present, continuous bubbling will still occur. This is not a priority action.
3) The nurse must perform an assessment prior to this action. If the system is not leaking, the nurse can call the health care provider to get additional prescriptions.
4) CORRECT — A leak in the drainage system can cause continuous bubbling. Therefore, the nurse should assess the equipment. This is the priority action.
When assessing the incision of a client 2 days postoperatively, the nurse notes a shiny pink area with underlying bowel visible. Which action does the nurse implement?
1. Cover the area with sterile gauze soaked in normal saline.
2. Cleanse the wound with hydrogen peroxide and apply a sterile dressing.
3. Pack the opened area with sterile 3/4 inch gauze soaked in normal saline.
4. Apply antibacterial ointment and cover with clear adhesive dressing.
1) CORRECT — The data indicates that the client is experiencing an evisceration. Therefore, the appropriate action from the nurse is to immediately cover the site with a sterile dressing soaked with normal saline and contact the health care provider.
2) It is not appropriate for the nurse to use hydrogen peroxide in this situation. Normal saline is used.
3) This is an inappropriate action by the nurse.
4) This is an inappropriate action by the nurse.
The nurse assesses a client diagnosed with Ménière disease. The client states, "I take my prescribed medications regularly, but I continue to have episodes of vertigo." Which response by the nurse is most important?
1. "Tell me about your diet."
2. "How are things going at work?"
3. "When was Ménière disease diagnosed?"
4. "What were the results of your last blood test?"
1) CORRECT— This statement allows the nurse to determine if there are dietary factors (food to medication interactions) that may be interfering with the action of the prescribed medication.
2) This response by the nurse does not allow for investigation into why the prescribed medications are not working as anticipated.
3) While it is important to document when the disease process was diagnosed, this information does not allow the nurse to investigate why the prescribed medications are not working as anticipated.
4) This question is too broad and does not allow the nurse to investigate the current situation experienced by the client.
**Meniere's disease: a chronic disoreder of the inner ear involving sensorineural hearing loss, sever vertigo and tinnitus.
Diet Mgmt: Low sodium (2000 mg/day), avoidance of etoh, nicotine and caffeine.
*A client who is diagnosed with end-stage kidney disease is prescribed hemodialysis treatments three times a week. After two weeks of treatment, the client states, "I have a headache when the dialysis finishes. Is this normal?" Which is the most appropriate response by the nurse?
1. "I have seen this a lot in clients. Don't worry too much about it."
2. "Headaches may occur at the beginning of treatment and should improve over time."
3. "Have you experienced any headaches similar to these in the past?"
4. "Why are you so worried about this? It is a common side effect."
Rationale: Nurse must provide correct info in a therapeutic way. Headache, nausea and fatigue may occur after hemodialysis d/t disequilibrium syndrome. This is caused by rapid removal of electrolytes and solutes from blood. A reduction of blood flow during dialysis decreases the risk of disequilibrium syndrome.
1: This response is about the nurse, not the client; this also negates client's concern
3: It is more imp't for the nurse to address the here and now versus if the client has experienced similar headaches in the past
4: "why" questions are not therapeutic
*The nurse receives a phone call from a client's adult child who states, "I just got here to see my elderly parent, and I think heat stroke has occurred. I think the air conditioning is not working and the house is very hot." The adult child reports that the parent is confused, very thirsty, nauseated, and in pain. Which is the most appropriate statement for the nurse to make?
1. "If perspiration is present, heat stroke has not occurred."
2. "Give your parent cool fluids to drink immediately."
3. "What medications does your parent take daily?"
4. "Remove any excess clothing immediately."
Rationale: Removing the parent's clothing will begin the cooling process, thereby enhancing circulation. Other measures to reduce temp can be implemented once this step occurs.
1: Provides education to family but does not address the immediate concern
2: Client is at risk for aspiration d/t altered mental status, should be NPO.
3: This is an assessment question but info is not immediately needed.
The nurse admits a client to the postpartum unit and provides instruction about the postpartum process. The nurse determines that teaching is effective if the client makes which statement?
1. "I will call for assistance the first time I want to get out of bed."
2. "I can expect to pass clots the size of golf balls for the first 24 hours."
3. "I will use lanolin on my nipples when I breast feed my baby."
4. "I will allow my baby to suck no more than 5 minutes on each breast."
Rationale: Only true statement regarding postpartum care.
*The nurse provides care for a client who is prescribed assist-control mechanical ventilation with positive end-expiratory pressure (PEEP) of 5 cm H 2O. Which actions will the nurse include in the client's plan of care? (Select all that apply.)
1. Strict handwashing before suctioning.
2. Brushing teeth every 12 hours.
3. Elevating the head of the bed 20 degrees.
4. Administering pantoprazole 40 mg intravenous daily.
5. Changing client position every 2 hours.
-Hand hygiene will reduce risk of VAP
-Pantoprazole, a proton pump inhibitor, will decrease the risk of aspiration of gastric contents.
-Repositioning and turning every 2 hours reduces the risk of atelectasis, PNA and skin breakdown
2: Oral care and teeth brushing should be at least every 8 hours.
3: HOB should be at least 30 degrees
The nurse supervisor is informed that three serious safety events occurred last month between 0730 and 0800. The last serious safety event occurred because the oncoming nursing shift did not know a client was receiving an IV insulin drip. Which is the priority action for the nurse supervisor to take?
1. Implement mandatory bedside reporting.
2. Discuss unsafe nursing practices with the local media.
3. Delay action until hospital risk manager has completed a full investigation.
4. Ask another nurse manager for suggestions.
1) CORRECT — The nurse supervisor needs to take action to ensure proper exchange of information during shift report, as it is essential for staff to have an opportunity for last-minute updates, to clarify information, or to receive information on care events or changes in a client's condition. Bedside report promotes staff accountability, intercepts errors, and allows nurses to better prioritize care.
2) This is not an appropriate action. The nurse supervisor's immediate priority is to proactively address safety concerns within the unit.
3) While the hospital risk manager should be involved, the nurse supervisor is responsible for client outcomes and ensuring proper exchange of information is being distributed during shift report.
4) While this may be an appropriate action by the nurse supervisor, it does not address the immediate safety issue.
The terminally ill client reports to the nurse that a do-not-resuscitate (DNR) prescription has been initiated. The client is concerned that family members do not accept this wish. Which is the best action made by the nurse?
1. Reassure the client that things will work themselves out.
2. Allow the next of kin to make final health care decisions.
3. Schedule a meeting with the client and family.
4. Contact the hospital social worker.
1) The nurse needs to proactively address the client's concerns, not provide reassurance that may not be appropriate.
2) The nurse needs to advocate for the client's wishes. There is no data indicating the client is unable or incapable of making this decision.
3) CORRECT — The client's family members need to acknowledge and understand the client's wishes. Therefore, a meeting with the client and family will open the lines of communication and allow time for questions/explanations.
4) The first action is to open lines of communication with the client and family. If a meeting to open the lines of communication is not effective, a social worker consult might be appropriate.
The nurse is supervising four unlicensed assistive personnel (UAP). The nurse will immediately intervene and provide assistance if which scope of practice violation is observed?
1. The UAP performs a routine blood glucose test on a client.
2. The UAP performs a point of care urine pregnancy test.
3. The UAP assists an older adult client with feeding.
4. The UAP restarts a client's IV fluids.
1) This action is not a scope of practice violation. The UAP can perform standard, unchanging procedures, such as a routine blood glucose test for a stable client.
2) This action is not a scope of practice violation. The UAP can perform standard, unchanging procedures (such as a urine pregnancy test) for stable clients.
3) This action is not a scope of practice violation. The UAP can perform standard, unchanging tasks (such as feeding a stable client).
4) CORRECT — This UAP action requires an intervention by the nurse. Intravenous (IV) line patency should be assessed by the nurse before restarting IV fluids, as assessment is not within the UAP's scope of practice.
The telemetry nurse is notified that the unit is receiving a new admission from the medical surgical unit. Which client currently on the telemetry unit should the nurse suggest be sent to the medical surgical unit?
1. Client with magnesium level 1.6 mg/dL (0.66 mmol/L).
2. Client scheduled for cardiac catheterization the next morning.
3. Client with digoxin level 2.4 ng/mL (3.1 nmol/L).
4. Client who reported chest discomfort during cardiac stress test.
1) CORRECT — This client is stable and can be moved to the medical surgical unit, as the magnesium level is within normal limits (1.3 to 2.3 mg/dL [0.53 to 0.95 mmol/L]).
2) This client is not stable. The client's cardiac rhythm should be monitored until the results of cardiac catheterization are known.
3) This client should remain on the telemetry unit, as the client may experience symptoms of digoxin toxicity. The normal digoxin level is 0.5 to 2.0 ng/mL (0.6 to 2.6 nmol/L).
4) Chest discomfort during a cardiac stress test indicates poor cardiovascular response to increased workload. This client is not stable and should remain on the telemetry unit.
The nurse evaluates client care assignments made by the student nurse. The nurse will intervene if the LPN/LVN is scheduled to care for which client?
1. Client who received methylprednisolone for lumbar radiculopathy.
2. Client who received racemic epinephrine for croup.
3. Client who received ketorolac for pleurisy.
4. Client who received tamsulosin for benign prostatic hyperplasia.
1) This is a stable client. Therefore, this assignment is within the LPN/LVN's scope of practice.
2) CORRECT — The nurse should care for this client, as the client will require frequent airway/breathing assessment.
3) This is a stable client. Therefore, this assignment is within the LPN/LVN's scope of practice.
4) This is a stable client. Therefore, this assignment is within the LPN/LVN's scope of practice.
*The nurse performs triage in the emergency department (ED). An unemancipated adolescent minor requests to be treated. The registration clerk states the adolescent requires guardian consent for treatment. Which action should the nurse take next?
1. Triage the client after guardian consent has been obtained.
2. Ask the unemancipated minor about the medical reason for seeking treatment.
3. Request that the health care provider perform a medical screening exam.
4. Notify the nursing supervisor.
Rationale: Unemancipated minors an consent to medical tx if they have a specific medical condition (i.e. pregnancy, pregnancy-related conditions, minor tx for custodial child, STI info & tx, substance abuse tx and mental health tx).
1: depending on why the minor is seeking treatment, guardian consent may not be necessary and could breach HIPAA guidelines
3: Every person who presents to the ED and requests tx should receive medical screening exam from HCP.
4: it is not appropriate
*The nurse works on the medical surgical unit. The nurse-to-client ratio is 1:10. Which action does the nurse take first?
1. Document the situation in writing.
2. Refuse the client assignment.
3. Delegate tasks to the LPN/LVN.
4. Notify the nursing supervisor.
Rationale: Thisi s the priority action, as the nurse-to-client ratio is proportionately high. This action alerts the nursing supervisor of the situation so nurses can be "floated" from other departments, if available.
1: Notifying the supervisor is the priority. Nurse should provide documentation to the nursing admin, but the documentation does not relieve the nurse of responsibility if clients suffer harm because of inattention. It does show that the nurse attempted to act appropriately.
2: Refusing the client assignment could be regarded as abandonment
3: Nurse maintains responsibility for client outcomes. Problem is nurse-to-client ratio.
*The nurse provides care for pregnant and postpartum clients. Which client does the nurse see first?
1. Client at 6 weeks' gestation, reporting that the LPN/LVN could not obtain fetal heart tones with a Doptone.
2. Client at 5 days postpartum, reporting bright red, bloody discharge.
3. Client at 22 weeks' gestation, reporting feeling fetal movement four times in the last hour.
4. Client at 2 days postpartum, reporting urinary incontinence.
Rationale: Lochia rubra (endometrial sloughing that is bloody with a fleshy odor) should last 1-3 days. Therefore, client is unstable. Nurse should assess the client's lochia amount and color in addition to monitoring VS.
1: Client is stable. Fetal heart tones cannot be heard with Doptone until 8-12 weeks gestation.
3: Reassuring sign of fetal well being; fewer than 3 fetal mov'ts in a 1 hour period would indicate a potential issue
4: Stable; urinary incontinence is common during the postpartum period. Nurse should teach the client to perform Kegel exercises to tighten pubococcygeal muscles and avoid diuretics.
*The nurse provides care for a young adult client requiring an emergent appendectomy. The health care provider explains to the client the risks and benefits of the procedure. However, the client refuses to sign the informed consent. The client states, "No one is removing any organs from my body because it is against my religious beliefs. I'm leaving!" The client's mother insists the client receive the operation. Which response does the nurse make to the client?
1. "I am going to apply soft wrist and ankle restraints."
2. "Let us contact the hospital chaplain to mitigate the situation."
3. "Intravenous diazepam will help calm your nerves before the procedure."
4. "It is your decision to refuse medical treatment."
Rationale: The competent client has the right to make personal choice without interference
1: false imprisonment
2: contacting the hospital chaplain violates the client's rights
3: use of diazepam in this situation would be considered a chemical restraint. Psychotropic drugs cannot be used to control behavior
The nurse completes documentation for a client and realizes the entry has been placed in the wrong client's medical record. Which action by the nurse is most appropriate?
1. Complete an incident report and place a copy in the client's medical record.
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 client confidentiality.
4. Copy the note into the correct client's record and indicate that it was erroneously put in the wrong client's record.
1) This is not an appropriate action by the nurse. An incident report is not placed in the client's medical record.
2) CORRECT— This is an appropriate action when correcting documentation in the client's medical record.
3) This is not an appropriate action by the nurse. Correction fluid is not used when a correction is needed to document in the medical record.
4) This is not an appropriate action by the nurse when care is documented in the wrong client's medical record.
The nurse provides care for an adolescent client reporting arm pain after a fall. The nurse notes bruising in multiple stages of healing. The nurse accesses the client's medical record and notes the client was treated twice last month for reported back pain after two separate falls. The client was treated two months ago for a perforated eardrum. Which action by the nurse is the priority?
1. Assess the client's anxiety level.
2. Use light touch to show support.
3. Contact social services.
4. Assess the client's pain level.
1) While the nurse should assess the client's anxiety level, a professional assessment of the client's situation takes priority over psychosocial nursing actions.
2) The use of touch may not be appropriate for this client, as it may make the client feel uneasy or threatened.
3) CORRECT — The adolescent client's history suggests that there may be abuse. The law mandates that the nurse report known or suspected child abuse by collaborating with social services and law enforcement. Therefore, this is the priority action.
4) The nurse should assess pain level. However, the professional assessment of the client takes priority over psychosocial issues, such as pain.
The nurse provides care for a hospitalized older adult client who has a body mass index (BMI) of 16.1. Which is the priority action by the nurse?
1. Document the client's BMI.
2. Decrease caloric intake to 1200 calories per day.
3. Confer with a dietician.
4. Plan a return visit in 1 week.
1) While it is appropriate for the nurse to document the client's BMI in the medical record, this is not the priority action.
2) Individuals who have a BMI lower than 18.5 are at increased risk for problems associated with poor nutritional status. The client's daily caloric intake should be increased, not decreased.
3) CORRECT — The nurse should refer the client to a dietician for further evaluation, as a low BMI is associated with higher mortality rate among hospitalized clients.
4) This client requires prompt evaluation. Delaying treatment for one week negates the potential seriousness of client's current condition.
Normal BMI: 18.5 to 24.9
The nurse speaks with a client and the spouse who have been undergoing family counseling. The client's spouse states, "You never take any responsibility for the messes you always cause!" Which response by the nurse is best?
1. "Why do you say that?"
2. "Blaming is not effective."
3. "Let's focus only on the positives."
4. "When is the last time you two had a vacation?"
1) The use of "why" questions is often considered confrontational and not therapeutic.
2) CORRECT — Family members often blame others for failures, errors, or negative consequences of an action to keep focus away from themselves. This response by the nurse is both accurate and therapeutic.
3) The nurse needs to correct unhealthy communication patterns. Only focusing on the positives will not correct unhealthy communication patterns.
4) The nurse needs to correct unhealthy communication patterns. Asking the client and spouse when they had a vacation does not correct unhealthy communication patterns.
*The nurse provides care for a client who is diagnosed with depression and anxiety. The client states, "I feel overwhelmed because I'm the only caregiver for my two children." Which response by the nurse is best?
1. "Do you participate in any religious or spiritual activities?"
2. "What can we do to help take your mind off things?"
3. "You do not plan to have any more children, do you?"
4. "Why do you not work outside the home?"
Rationale: Spirituality and religious beliefs have the potential to exert influence on how people understand the meaning and purpose in their lives. The beliefs can also impact the use of critical judgment and the ability to problem solve.
2: Distraction is not always the best technique. Nurse should assess the client's coping mechanisms
3: a judgmental question
4: "why" questions is confrontational and not therapeutic
The nurse discusses the client's plan of care with the student nurse. The student nurse states, "I know the client is from another country, but the client could at least look at me when I'm talking. That is so rude." Which response by the nurse is best?
1. "I am sorry the client made you feel that way."
2. "The client doesn't look at me when I speak either."
3. "Eye contact may be a sign of arrogance in the client's country."
4. "I will ask the family if anything is bothering the client."
1) The nurse should clarify the client's cultural norms, as eye contact interpretation is not universal.
2) The nurse should clarify the client's cultural norms, as eye contact interpretation is not universal.
3) CORRECT — The nurse recognizes that eye contact interpretation is not universal. In north America, maintaining eye contact during conversation communicates respect and willingness to listen. In some cultures, however, maintaining eye contact is considered intrusive, threatening, or shows arrogance.
4) The nurse should clarify the client's cultural norms, as eye contact interpretation is not universal.
*The community health nurse conducts a program for suicide prevention at a high school. The nurse discusses high-risk groups for suicide. The nurse determines that further teaching is necessary if students from the group make which statement?
1. "Adolescents are at risk to commit suicide."
2. "Depressed people are at risk to commit suicide."
3. "History of previous suicide attempts put people at risk."
4. "People grieving a loss for 9 months are at risk."
Rationale: Grief is a normal human response that occurs in response to loss. The entire grieving process may take up to 3 years. Therefore, this statement indicates the need for further instruction.
1) Males over the age of 50 years and adolescents ages 15 to 19 years are at risk for suicide. This statement indicates correct understanding of the information presented.
2) Indications of depression include low self-esteem, feelings of helplessness/hopelessness, and a sense of doom or failure. Individuals who are depressed are at an increased risk to commit suicide. This statement indicates correct understanding of the information presented.
3) A suicide attempt is the result of the client turning aggression and rage toward self. Anyone with a history of a previous suicide attempt is at risk for another attempt. This statement indicates correct understanding of the information presented.
The nurse assesses clients for potential spousal abuse. The nurse is most concerned if a client makes which statement?
1. "It's my fault because I push my spouse's buttons."
2. "My spouse and I often disagree on many subjects."
3. "We have talked about divorce multiple times."
4. "I used to be so happy, but now I'm not."
1) CORRECT — Individuals who experience spousal abuse often accept blame, become compliant, and feel helpless. This client statement is concerning to the nurse.
2) This is not typical abuser/victim behavior, as the victim is often compliant.
3) This is not typical abuser/victim behavior, as the victim is often compliant.
4) The nurse should ask the client to elaborate. However, this is not the most alarming statement of those presented.
The nurse makes client assignments on the medical surgical unit. The nurse assigns an LPN/LVN to a client diagnosed with localized herpes zoster. The LPN/LVN tells the nurse, "I have never had chickenpox." Which response by the nurse is most appropriate?
1. "Use standard precautions when providing care for the client."
2. "You will be fine, because the client is on airborne precautions."
3. "Your client assignment will be changed."
4. "Why are you concerned about providing care for the client?"
1) This is an incorrect statement and is not therapeutic.
2) This response trivializes the LPN/LVN's concern and is not therapeutic.
3) CORRECT— This is a true, therapeutic statement.
4) The use of "why" questions is confrontational and is not therapeutic.
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 action 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.
Rationale: Appropriate action and indicates accurate understanding of the sterile field
The nurse in the emergency department prepares to administer morphine sulfate to a client. Which action does the nurse take first?
1. Verify the client's name and date of birth.
2. Document the amount used on the medication record.
3. Determine if the client has a responsible driver.
4. Ensure the client's call light and belongings are within reach.
Rationale: Nurse must verify clients' identity before administering meds, at least with 2 identifiers
*The nurse provides care for an older adult client who is diagnosed with a fractured ulna. The client reports falling frequently. Which client statements require that the nurse collect more information? (Select all that apply.)
1. "I keep my bedroom pitch black at night."
2. "My adult child secured all electrical cords against the baseboards."
3. "The bottoms of my shoes have rubber soles."
4. "My sister gave me her cane before she died."
5. "I have my vision checked every 3 years."
6. "I prefer for my pants to fit loosely around my waist."
Rationale: These statements requires follow-up by the nurse
*Reducing fall risk:
-have a night light
-secure all electrical cords
-rubber soles on bottom of shoes
-cane should be in proper height with client
-visual examinations every 1-2 years
-no loose fitting pants on waist
The client approaches the triage desk in the emergency department (ED) and reports exposure to chemicals after a truck overturned. The client has powder and unknown liquid substances on the clothing. The client is diaphoretic and reports difficulty breathing. Which action does the nurse take first?
1. Escort the client to the decontamination room.
2. Notify the health care provider.
3. Put on appropriate protective gear.
4. Deliver high flow oxygen via a mask.
Rationale: The nurse's first priority is to protect self and put on the appropriate protective gear.
4: Action is appropriate after the nurse puts on protective gear, as the goal is to prevent the spread of contamination.
*The nurse reviews the medical record of a client who is confused. The client has soft wrist and ankle restraints in place. The nurse determines care is effective if which actions are documented? (Select all that apply.)
1. Restraints secured tightly to the skin.
2. Client placed in room next to the nursing station.
3. Restraints attached to side rails on the client's bed.
4. Informed consent for the restraints obtained from the client's spouse.
5. Client alert and oriented x 3.
6. Client placed in the prone position.
Rationale: An appropriate action that promotes client's safety, consent is obtained by proxy since the client is confused
1: tight application interferes c circulation and potentially can can neurovascular injury. Nurse should be able to insert 2 fingers under the restraint
3: restraints should be attached to the bed frame; client could be injured if restraint is secured to the side rail and it is lowered
5: restraints should be d/c as soon as client becomes alert and oriented
6: prone position while in restraints increases the client's risk of suffocation
The nurse provides care for a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse performs discharge teaching with the client. The nurse determines teaching is effective if the client makes which statements? (Select all that apply.)
1. "I will contact the health care provider if my bed sheets become drenched with perspiration."
2. "It is safe to share toothbrushes with others."
3. "It is safe to not use condoms since we both have HIV."
4. "I will be cured if I take zidovudine as prescribed by my health care provider."
5. "I will not go to the fall festival."
1) CORRECT — The client diagnosed with AIDS is at an increased risk for infection. Wet bed sheets can indicate the development of tuberculosis.
2) A client with AIDS should not share a toothbrush or a razor under any circumstances.
3) Cross-infection with the partner's virus can increase severity of infection.
4) Zidovudine is an anti-retroviral medication that slows disease progression. This medication is not curative.
5) CORRECT — The client diagnosed with AIDS should be instructed to avoid large crowds, as this increases the risk of infection.
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