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1. A client is being discharged home
after a routine hip replacement
surgery. The nurse is instructing the
client on how to prevent postoperative complications. What statements by the client would indicate
the need for further teaching? Select all that apply.
"Limiting fiber is necessary to
avoid diarrhea."
"I should empty my bladder when I
feel the urge."
"Avoiding pain medication will prevent constipation."
"I should drink plenty of liquids like
iced tea or coffee."
"I should continue with my physical
therapy and walking."
2. The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse
do to ensure the client and family
receives the most accurate information? Select all that apply.
Provide culturally sensitive education.
Encourage family members to obtain a tuberculosis skin test.
Provide written instructions in English for the client to reference.
Encourage the client and family to
wash all dishes by hand to prevent
the spread of infection.
Urge all family and close contact community members to seek
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A, C, D
Rationale: Constipation is common after surgery due to pain medication,
decreased movement, and anesthesia. Fiber intake should be encouraged as it promotes the prevention of
stool retention. Although pain medication can cause constipation, it should
not be avoided in the post-operative
period. Drinking plenty of fluids is encouraged for both bowel and bladder maintenance, but the client should
choose non-caffeinated options. Physical therapy, walking, and exercise will
help prevent constipation. Emptying
the bladder when the urge is present
can help prevent urinary tract infections.
A, B, E
Rationale: As always, the nurse must
provide culturally sensitive education.
Because tuberculosis is highly contagious, all family members and close
community members should have a
tuberculosis skin test, seek treatment,
and remain compliant. A full course of
6 to 9 months of treatment is needed to
prevent re-infection. Instructions written in English are not helpful for the
client with limited English skills. Washing dishes by hand is not the best way
to prevent infection; rather a dishwasher should be used if available.
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and complete treatment to enhance
compliance.
3. A client with anxiety has just been
seen by the health care provider
and has been prescribed alprazolam. A week later, the client is
brought to the emergency room, after consuming a large number of
tablets in an attempt to overdose.
The client is unresponsive and has
gasping respirations. Which action
should the nurse take first?
C
Rationale: The client requires immediate intubation because of the gasping respirations and unresponsiveness. Flumazenil is the antidote for an
overdose of benzodiazepines; however, the priority is securing the airway.
Naloxone is the antidote for an opiate
overdose. Assisting with insertion of a
central venous line is not the priority
Administer the antidote naloxone and would involve a great deal of time
Administer the antidote flumazenil while the client is gasping to breathe.
Assist with intubation of the client
Assist with insertion of a central venous line
4. The nurse is observing the carA
diac monitor of a client and notes
this cardiac rhythm (refer to figure). Rationale: Ventricular tachycardia can
What is the initial nursing action? be stable or unstable depending on
[V-Tach]
whether the client has a pulse or not. In
this case, assessing the client's pulse
Check for a pulse
is the initial action. Obtaining a 12
Notify the health care provider
lead ECG and notifying the health care
Obtain a 12 lead electrocardiogram provider may be necessary but are not
(ECG)
initial actions. Initiating CPR may be
Begin cardiopulmonary resuscita- necessary of the ventricular tachycartion (CPR)
dia becomes unstable and cardiac arrest occurs.
5. A mother brings her 9-month-old
child to see the pediatrician and has
concerns that the child may have
a developmental delay because the
child cannot roll over yet. for the
2 / 39
C,D, E, F
Rationale: Developmental delays can
occur at any age; however, it is most
commonly seen in infancy through
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nurse should ask the mother about
which risk factors associated with
a developmental delay? Select all
that apply.
Age
Race
Income
Chronic illness
Low birth weight
Environmental exposure to toxins
adolescence. Developmental delays
can occur regardless of race. Children
living in poverty, those with chronic illnesses, low birth weight, or exposure
to environmental exposure to toxins
are at a higher risk for developmental
delays.
6. The nurse in a pediatric unit is plan- A, D
ning the staff assignments for children with developmental delays.
Rationale: A developmental delay is
When planning the assignment, the defined as not meeting the expected
nurse decides to assign those chil- developmental level. Social and emodren who have social or emotion- tional developmental delays include
al delays amongst different nurses. those affecting personality, emotion, or
Which children should be assigned behaviors. Two examples are autism
to different nurses? Select all that and generalized anxiety disorder. Atapply.
tention deficit disorder and fetal alcohol syndrome are classified as cogA child with autism
nitive developmental delays, and exAn infant with fetal alcohol synpressive language disorder is a comdrome
munication developmental delay.
A child with attention deficit disorder
A child with generalized anxiety disorder
A child with expressive language
disorder
7. The client has been prescribed
0.5
amoxiciilin 250 mg three times daily for sinusitis. The medication is
supplied in a 500 mg tablet. How
many tablet(s) would the nurse prepare every 8 hours to administer
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the correct dose? Fill in the blank.
Record the answer using one decimal place. _____________ tablet(s)
8. The nurse is caring for a client
admitted to the hospital for shortness of breath and edema in both
lower extremities. The client is prescribed furosemide 40 mg by the
intravenous route once daily. What
information in the chart would warrant the nurse to verify continuing the prescription with the health
care provider (HCP)? Refer to chart.
Expiratory rales
Atorvastatin prescription
Peripheral vascular disease
Potassium level of 3.5 mEq/L (3.5
mmol/L)
9. A nurse employed at a long-term
care facility is caring for a client
who has recently been transferred
from the hospital. The client is confused and is acting out. The nurse
suspects the client is suffering from
relocation stress. The nurse should
include which helpful actions in the
plan of care? Select all that apply.
D
Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5 mEq/L (3.5 mmol/L)
is on the lower limit of normal, and
the nurse should anticipate that the
potassium level would drop with the
administration of furosemide. Therefore, the nurse should verify continuing
the prescription if this potassium level
was noted. Expiratory rales are an expected finding with fluid overload and
furosemide would be an appropriate
treatment. Atorvastatin and peripheral
vascular disease are not impacted by
the administration of furosemide.
A, B, D
Rationale: Relocation stress can occur
when a client is removed from their
usual surrounding such as home. In
order to provide safe and quality care,
encourage friends and family to visit
the client often and establish a trusting
relationship with the client as soon as
possible. It is important for the client
Encourage friends and family to
to have an active role in decision-makvisit frequently.
ing. In order to lessen confusion, the
Establish a trusting relationship
nurse should provide the client time
with the client as soon as possible. to become familiar with the immediate
Change rooms frequently to presurroundings such as his or her room
vent the client from becoming
before allowing or encouraging ambubored.
lation to new surroundings; allowing
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Ensure the client is an active part
of decision making regarding their
care.
Allow the client to move around the
halls as desired to decrease the
confusion and acting-out.
the client to move around the halls as
desired may increase confusion and
acting-out behaviors. Likewise, changing the client's room frequently may
increase confusion.
10. The nurse is caring for a client
in the hospital and is reconciling
the client's home medications. The
client is taking Lactobacillus, a probiotic over-the-counter medication.
The nurse is discussing the supplement with the client. What statement by the client would warrant
the need for further teaching? Select all that apply.
A, C, D
11. The nurse educator is presenting
a lecture on child neglect. Which
statement by one of the students indicates that the teaching has been
effective? Select all that apply.
A, C, D, E
Rationale: Probiotics are live microorganisms that are similar to those found
naturally occurring in the gastrointestinal tract. Probiotics should be taken as
directed, usually with a meal, and can
have a side effect of gas and bloating.
If gas and bloating do occur, the client
should be advised to try a different
type of probiotic. Probiotics are rec"I can take my probiotic at any time ommended for those clients who are
of day or night."
lactose intolerant. Probiotics are found
"Probiotics can be found in yogurt in foods such as yogurts and some
and some juices."
juices and can be helpful to treat an"I should take this supplement to tibiotic-associated diarrhea.
prevent gas and bloating."
"Because I'm lactose intolerant, a
probiotic would not benefit me."
"This supplement will help me
avoid getting diarrhea from antibiotics."
Rationale: Neglect has serious consequences for children. Basically, there
are 5 types of child neglect: physical neglect; psychological or emotion"A sign of neglect are bruises on al neglect; medical neglect; mental
the child's body."
health neglect; and educational ne"Neglected children show aggres- glect. One sign of physical neglect
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sion after age 10."
"Neglect is parental failure to meet
a child's basic needs."
"Neglected children often have
learning problems and low self-esteem."
"Neglect occurs when a parent
does not seek medical attention for
a sick child."
12. The nurse is obtaining the medical
history from an older client with a
black eye and bruising to the head.
The nurse suspects that the client
has been abused, and that there
may be a history of abuse. Which
statement by the client indicates
the need for further questioning by
a social worker? Select all that apply.
"Perhaps I somehow did this to myself."
"I tripped over a rug and now I have
a black eye."
"I got into a car accident yesterday
and the airbag deployed."
"Well, I don't remember anything
that would have caused the injuries."
"Sometimes my grandson becomes
angry with me when I can't give him
money."
6 / 39
is bruising on the child's body. Neglect is the parental failure to meet
a child's basic needs such as: food,
shelter, comfort, love, and medical attention. Consequences of neglect include: learning problems, low self-esteem, developmental delays, passivity and juvenile delinquency. Children
who are neglected often show signs of
aggression before the age of 2.
A, B, D, E
Rationale: There are certain elements
in the medical history that raise concern for physical abuse. Perpetrators
may provide a history of events that
are incomplete or inconsistent with
injuries seen. Many individuals who
experience interpersonal violence are
unable or afraid to provide an accurate
account of events. Often individuals
will provide a history of trauma that is
inconsistent with the physical examination. It is unlikely that these injuries
were self-inflicted or the result of tripping over a rug. Having no recollection
of how an injury occurred should be
an alert to the nurse, as well as statements that another person caused the
injury. The nurse should immediately
report this to the appropriate legal authorities, a health care provider and
the social worker so that proper intervention and follow-up can be arranged.
A car accident with air bag deployment
could reasonably cause the injuries to
the client, and could be easily verifed.
The nurse should continue on with as-
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sessment, treatment and arrange follow-up care for the client.
13. The nurse is meeting with an older client who was brought into the
health care facility for evaluation.
According to the family member,
the client has lost a large amount
of weight recently and does not
eat much. Which actions would be
the most important for the nurse to
take? Select all that apply.
A, D, E
Rationale: Older adults in the community or in any health care setting
are most at risk for poor nutrition.
The nurse should review the medical
history to determine the possibility of
increased metabolic needs or nutritional losses, chronic disease, trauma,
recent surgery of the gastrointestinal
Assess the client's eyesight.
tract, drug and alcohol abuse, and reQuestion the client about urinary cent significant weight loss. Each of
habits.
these conditions can contribute to malReview the list of the client's pre- nutrition. As part of a thorough asscribed medications only.
sessment, the nurse should assess
Determine the fit of the client's den- the client's eyesight. Clients with poor
tures.
vision are often not able to drive to obAssess the client for mental status tain groceries or cook for themselves.
changes.
The nurse should also obtain a list
of the client's medications, both prescription and over-the-counter. Certain
medications can alter the taste perception and decrease the desire to
eat. It is also important for the nurse
to determine the fit of the client's
dentures. Poor fitting dentures can
lead to painful sores, which lead to
a decrease in food intake. The nurse
should also include an assessment of
the client's mental status, observing
for behavoir that may be abnormal for
the client. Utilizing the family member's
knowledge of the client's typical behavior will be important in the treatment of this client. While the client's
urinary status is important to assess,
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it is not the most important action for
the nurse to take at this time because
it is not directly related to weight loss.
14. The nurse is caring for a malnourished client with dementia and a
history of rheumatoid arthritis, and
is creating a plan of care for the
client's nutrition. Which nursing actions are most appropriate for increasing the client's caloric intake?
Select all that apply.
A, B, C
Rationale: Malnutrition results from inadequate nutrient intake, increased
nutrient losses, and increased nutrient requirements. Inadequate nutrient
intake can be linked to poverty, lack
of education, substance abuse, decreased appetite, and a decline in
Provide pain medications as need- functional ability to eat independently,
ed.
particularly in older adults. In order to
Play soft, calming music during
support the client, the nurse should
mealtimes.
provide pain medication as needed so
Serve the food at the appropriate that the client is comfortable during
temperature.
meal times. The nurse can make mealProvide the client with three large time positive by providing a quiet envimeals per day.
ronment, which is conducive to eating.
Encourage the client to eat quickly, Soft music may calm those with adto prevent fatigue.
vanced dementia or delirium. It is important that the nurse serve the client's
food at the appropriate temperature, in
order to make the food appealing to
the client. Arranging for the client to
eat six small meals per day, instead
of three large meals, may increase the
client's desire to eat, and prevent the
client from being overwhelmed by a
large amount of food at each meal. It is
important that the nurse avoid rushing
the client through a meal, but allow as
much time as needed.
15. The nurse is educating a client on D, E
obesity. Which statements by the
client indicate a need for further
Rationale: After receiving education
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teaching? Select all that apply.
from the nurse, the client should be
able to state that complications and
"Type 2 diabetes is a complication risks of obesity such as type 2 diaof obesity".
betes and peripheral artery disease
"I will likely develop obstructive
and other cardiovascular and respirasleep apnea".
tory system complications such as ob"Physical inactivity is one of the
structive sleep apnea. It is also imporcauses of obesity".
tant that the nurse discuss the causes
"My heart and lungs are mildly af- of obesity, which include physical infected by obesity".
activity. Encouraging the client to exer"It is unlikely that I will develop pe- cise 20 minutes per day can decrease
ripheral artery disease".
the risk of obesity and life threatening
illnesses.
16. The nurse is attending a teaching
session on communicating with the
ill child. Which statement by the
nurse indicates that the teaching
has been effective? Select all that
apply.
"I will strive to maintain honesty
and trust with each child."
"Children frequently ask multiple
questions, even when they fear the
answers."
"Providing as much information as
possible will help ease the child's
fears."
"Complete honesty may cause
problems for some family and staff
members."
"To prevent misunderstandings, I
should ask the child to explain what
is known."
9 / 39
A, D, E
Rationale: After listening to the lecture on communication with the ill
child, the nurse should understand the
need to strive to maintain honesty and
trust with each child. Lack of honesty and trust can hinder care and
leave the child feeling frightened. The
nurse should also understand that children often are reluctant to ask questions when they fear the answers. The
nurse should keep the child informed,
while clarifying any questions the child
has. Clarifying questions can help the
nurse avoid providing more information than the child wants or can handle emotionally. Providing too much information may be overwhelming and
frightening to the child. It may also
inhibit future questions and interaction with the nurse. It is important for
the nurse to consider that not everyone agrees with complete honesty; at
times, parents may directly ask the
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nurse to withhold information from the
child. It is important that the nurse
maintain honesty, using terms that the
parents agree upon. One of the most
important aspects of communicating
with a child is to have the child explain what is already known to them
about their illness. The nurse can then
answer questions accordingly without
overwhelming the child with information.
17. A client is being assessed for
post-partum depression. Which actions by the client would indicate
a need for follow-up by the nurse?
Select all that apply.
Not responding to the infant's cries.
Crying after talking with spouse on
the phone.
Stating that family was not supportive of the pregnancy.
Making statements about being fat
and unattractive now.
Stating that the infant latched on
properly during a feeding.
10 / 39
A, B, C, D
Rationale: The weeks following the
birth are a time of vulnerability to psychiatric disorders, such as depression
for many women, causing significant
distress for the mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional and social
development. It is important that the
nurse frequently assess the client for
post-partum depression. Ignoring the
infant's cries should alert the nurse
that further assessment is needed.
Crying after talking with a spouse of
the phone could indicate a problem
at home. Statements of non-supportive family members need to be addressed by the nurse, for the safety
and well-being of the client and infant. The nurse should also address
the client's statements about body image, educating the client about what is
normal and what is not normal in the
post-partum period. Stating that the infant latched on during a feeding is a
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positive action and would not indicate
the need for further assessment.
18. The nurse is evaluating a client who
is four weeks post-partum. Which
statement by the client would indicate a need for intervention? Select
all that apply.
A, B, C
19. The client is being discharged
home after the delivery of a healthy
infant. The nurse is educating the
client on how to prevent postpartum depression. Which activities
are the most appropriate for the
nurse to suggest? Select all that apply.
A, B, D
Rationale: Post-partum depression is
an intense and pervasive sadness with
severe and labile mood swings and is
more serious and persistent than post"I feel like giving up."
partum blues. Intense fears, anger,
"My husband never helps me with anxiety, and despondency that persist
the baby."
in the new mother past the baby's first
"My baby will not stop crying and I few weeks of life are not a normal part
can't take it anymore."
of postpartum blues. These symptoms
"I wish I could get more than four rarely disappear without professionhours of sleep at a time."
al help. The nurse should be aware
"My milk has come in and my baby of statements that could place the
is nursing every 2 hours."
well-being of the client and infant at
risk, such as wanting to give up or reporting lack of support from a spouse.
An inconsolable infant should be evaluated to determine the cause of crying. Most clients in the post-partum
period struggle with sleep due to the
infant waking up for feedings, which is
a normal part of infant life in the first
few weeks. An infant who nurses every
two hours at four weeks of life is a
normal finding and does not require an
intervention.
11 / 39
Rationale: The postpartum nurse must
observe the new mother carefully for
any signs of tearfulness and conduct
further assessments as necessary.
Nurses must discuss post-partum depression to prepare new parents for
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potential problems in the postpartum
Exercise on a regular schedule
period. The nurse can provide activiEat a healthy, well-balanced diet
ties and recommendations to improve
Try to do housework when the baby the client's health and well-bring. Exersleeps
cising on a regular basis will help the
Don't overcommit yourself to activ- client feel better and maintain physiities that will be tiring
cal health, as well as eating a healthy
Stay home with the baby as much diet. The nurse should also suggest
as possible, to promote bonding
avoiding over commitment to activities
that will tire the new mother. The nurse
should advise the client to sleep when
the infant sleeps. While it is important
for the client to bond with the infant,
the client should not be isolated from
friends and family.
20. The nurse is preparing to discharge
a child who was treated in the emergency department. Which should
the nurse consider when planning
medication discharge instructions
for the client's parents? Select all
that apply.
Provide the child's parents with a
simple dosing schedule.
Create a medication schedule that
fits the parent's lifestyle.
Assist the child's parents in obtaining the medication at an affordable
cost.
Ensure that the child's family is able
to read the written discharge instructions.
Refer the family to the pharmacist
with questions about medication
side effects.
21.
12 / 39
A, B, C, D
Rationale: It is important that the nurse
create a medication schedule that fits
the family's lifestyle and provide the
family with a simple dosing chart. This
helps to ensure that the child receives proper medication dosing and
prevents medication errors. The nurse
should consider cost of prescribed
medications and providing the family
with resources as needed. During the
discharge process, the nurse should
verify that the family can read the written discharge instructions and answer
any questions about the prescribed
medications, including side effects.
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The nurse is preparing to administer blood to a client. Which actions
by the nurse are the most appropriate before administration of the
blood? Select all that apply.
A, B, C, E
Rationale: Before administering any
blood product, review the agency's
policies and procedures. The nurse
should take care to ensure that the
Assess laboratory values.
client is adequately prepared to reObtain and assess vital signs.
ceive the blood. This is accomplished
Evaluate the client's venous acby assessing the client's laboratocess.
ry values, in order to determine the
Identify the client by room number client's need for intervention. The
and bed.
nurse should also obtain and asCheck the health care provider's
sess the client's vital signs, prior to
prescriptions with another nurse. blood administration. This is completed so that the nurse can detect any
change from the client's baseline during the administration. The client's venous access should be assessed prior to the blood administration, ensuring that at least a 20 gauge IV is in
place and patent. Checking the health
care provider's prescription with another nurse is a crucial step that must
be completed. The nurse should not
simply identify the client by room number and bed.
22. The nurse is evaluating a medication prescription written by the
health care provider. Which pieces
of information should the nurse verify has been included in the prescription? Select all that apply.
C, D, E
Rationale: Medication safety is extremely important in all health care settings. The nurse should be prepared to
evaluate each medication prescription
to ensure that the proper information
The routine dosage
is included, and intervene when necThe client's home address
essary to provide safe client care. The
The generic medication name
information should include: the specifThe length of time for the adminis- ic dosage (rather than just the routine
tration
dosage), generic drug name, length
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The route and frequency of admin- of drug administration and route and
istration
frequency of administration. The medication prescription does not need to
include the client's home address.
23. The nurse is caring for a postoperative client with a patient controlled
analgesia (PCA) pump. When creating the client's plan of care, which
opiate-induced side effects should
the nurse monitor? Select all that
apply.
Sedation
High blood glucose
Increased appetite
Nausea and vomiting
Elevated cardiac enzymes
24. The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should
the nurse give to the client? Select
all that apply.
A, D
Rationale: Patient-controlled analgesia (PCA) is a common way to address
the problem of inadequate analgesia
by allowing the client to control the
dosage of opioid received. When creating the plan of care, the nurse should
anticipate opiate-induced side effects,
and be prepared to monitor for them
and manage them. These side effects
include sedation, nausea, and vomiting. High blood glucose, increased appetite and elevated cardiac enzymes
are not typical opiate-induced side effects.
A, D, E
Rationale: When creating and providing discharge instructions, it is important that the nurse include accurate information about leflunomide.
The nurse should educate that the
"You may lose your hair."
client that hair loss and diarrhea (not
"It is ok to drink alcohol."
constipation) are possible. Women of
"Constipation is a common side ef- child-bearing age should use a reliable
fect."
method of birth control, as the med"It has been shown that leflunomide ication can cause birth defects. The
can cause birth defects."
client should be educated that while
"Leflunomide is a potent medica- leflunomide is a potent medication, it
tion that is generally tolerated."
is generally well tolerated.
25.
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The nurse is caring for a client
who has been admitted to the intensive care unit with acute pulmonary
edema. After assessing the client,
the nurse administers furosemide
as prescribed. Which actions by the
nurse are the most important after
administering the medication? Select all that apply.
A, B , C
26. The nurse preceptor is orienting
a new nurse on an acute medical-surgical unit and educating the
nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an
understanding of a PICC? Select all
that apply.
A, C, D
Rationale: The client with pulmonary
edema needs aggressive treatment
and continuous cardiac monitoring.
The most important interventions for
the nurse to take after administration
of the medication include: assessing
the client lung sounds and vital signs
and measuring the urine output. These
Assess lung sounds
interventions will assist in evaluating
Measure urine output
client status and response to treatObtain and monitor vital signs
ment and alert the nurse to any deDocument the client's meal intake terioration in the client's health. DocAssess the client for pitting edema umenting the client's meal intake and
assessing for pedal edema are not the
most important actions to take after
administering the medication.
Rationale: A peripherally inserted central catheter (PICC) is a catheter inserted through a vein of the antecubitcal fossa (inner aspect of the bend
of the arm) or the middle of the upper
arm. When educating the new nurse
on the purpose and use of PICC lines,
"The tip of the PICC line sits in the the nurse preceptor should discuss
superior vena cava."
the placement of the PICC line, in"Insertion of the PICC line occurs in cluding where the PICC line is placed
the operating room."
in the body. The nurse should explain
"PICCs can accommodate infuthat PICC line insertions are typicalsions of all types of therapy."
ly done at the client's bedside, by a
"PICCs with a lumen size of 14
nurse with specialized training. PICC
Gauge or larger can be used for
lines can accommodate infusions of
blood sampling."
all types of therapy because the tip
"PICCs are the most appropriate for sits in the superior vena cava, where
the rapid blood flow quickly dilutes the
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client's who require short-term an- infusion. The nurse preceptor should
tibiotics."
include information about blood sampling, such as only sampling blood
from a PICC line with a lumen size of
a 14 Gauge or larger. The new nurse
should also recognize that PICC lines
are often used for client's who require
long-term antibiotics, in order to protect the vein and skin tissue.
27. The nurse is assigned to care for
a client who needs an intravenous
(IV) catheter inserted and will receive an IV infusion of a vesicant
medication. When creating a plan of
care for the client, which interventions should the nurse include in
the plan? Select all that apply.
A, B, D, E
28. The nurse is preparing to administer oral potassium chloride to a
client. What should the nurse keep
in mind about this medication? Select all that apply.
C, D
Rationale: It is important that the nurse
take time to prepare for the IV infusion before administering any medication. The nurse should assess the
client's skin integrity prior to selecting an IV site. The nurse should avoid
placing the IV at an area of flexion,
Assess the skin integrity
such as in the antecubital space, or
Monitor the site frequently
any other space that will limit or prePlace the IV at an area of flexion
vent the client's range of motion. The
Educate the client about the signs nurse should plan to monitor the site
and symptoms of infiltration
frequently for signs of infiltration. The
Understand the vesicant potential nurse should also educate the client
before administering the infusion about the signs and symptoms of infiltration and inform the client to alert the
if any signs such as discomfort occur.
Prior to administering the infusion, the
nurse should understand the vesicant
potential.
Rationale: When preparing to administer potassium to the client, the nurse
should keep in mind that potassium
has a strong, unpleasant taste that
Potassium has a generally pleasant is often difficult to mask. The client
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taste.
Potassium can only be mixed with
water.
Potassium may be taken in a liquid
or solid form.
Potassium chloride can cause nausea and vomiting.
Potassium may be given as an intramuscular (IM) injection.
should be made aware of this beforehand. Oral potassium may be taken
as either a liquid or a solid. The nurse
should be aware that potassium chloride can cause nausea and vomiting,
therefore it is recommended that the
client take the medication with food.
Potassium can be mixed with a variety
of liquids, in order to make the medication more pleasant for the client. Potassium should never be administered IM,
because it is a severe tissue irritant.
29. The nurse is caring for a client with D
a latex allergy. Upon entering the
client's room, the nurse should plan Rationale: A sensitivity or allergy to
to take which action as the priority? certain substances alerts the nurse
to other possible cross allergies. The
Perform a skin assessment
nurse should be aware of this and prePerform a physical assessment
vent allergic reactions whenever posAsk if the client needs pain medica- sible. The nurse should know that the
tion
client with an allergy to latex, may also
Remove the banana from the
be allergic to bananas. The priority acclient's breakfast tray
tion that the nurse should plan to take
when entering the client's room, is to
remove the banana from the client's
breakfast tray. The other actions can
be completed once the risk of allergic
reaction has been removed.
30. The nurse has been assigned to
care for an older client with a hip
fracture who had surgical repair.
After receiving report, the nurse
learns that the health care provider
has prescribed meperidine for pain
management. Which action should
the nurse take first?
17 / 39
D
Rationale: The nurse should immediately recognize that meperidine is contraindicated for the older client because it has toxic metabolites that can
cause seizures and other complications. The first step the nurse should
take is to clarify the prescription with
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Prepare the medication
Verify the dosage of meperidine
Assess the client's pain score before administration.
Clarify the medication prescription
with the health care provider.
the health care provider. The other
steps should not be done.Test-Taking
Strategy: Focus on the strategic word,
"first," and focus on the data in the
question and that the client is an older client. Determine which step the
nurse should take first when receiving
the medication order. Eliminate the options of preparing the medication, verifying the dosage and assessing the
pain score, because this medication
should not be given to an older client.
31. The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular
stent graft. What priority actions
should the nurse include in the plan
of care? Select all that apply.
A, B, C, E
32. The nurse notices that an older
client's skin is very dry. What actions would be appropriate for the
nurse to implement into the care
plan? Select all that apply.
A, C
Rationale: A priority nursing action after an AAA repair with a graft is to
ensure patency of the graft. In order
to do this, the nurse would monitor
vital signs, pedal pulses, urinary outAssess for pedal pulses
put, and extremity color at least hourly.
Monitor urinary output
Pain medication is administered as
Administer analgesics as needed needed and as prescribed and adminKeep the head of the bed elevated istered regularly for better pain manto at least 60 degrees
agement. The head of the bed is mainEncourage use of an abdominal pil- tained at 45 degrees or less to prevent
low when coughing or deep breath- flexion of the graft. The client should be
ing
instructed to use an abdominal pillow
when coughing or deep breathing to
prevent incision splitting.
Rationale: Ensuring adequate hydration can help hydrate the skin from the
inside out. Dehydration is avoided by
eliminating substances such as cafEnsure adequate hydration
feine and alcohol. Lotion can be benWait 15 minutes after bathing to ap- eficial if applied 2 to 3 minutes after
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ply lotion
Instruct the client to avoid caffeine
and alcohol
Rub skin surfaces dry in order to
remove dead skin
Use lavender scented lotion, which
can help add moisture to the skin
bathing when skin still has moisture.
Rubbing the skin can further dry the
skin. Scented soaps, lotions, and oils
can dry out the skin.
33. The nurse is caring for an older Japanese American man being
treated in the oncology unit for
prostate cancer. In order to provide culturally competent care, the
nurse should include what actions
in the care plan? Select all that apply.
B, C, D
34. The nurse is caring for a client in
the emergency department who is
being treated for major burns and
smoke exposure. What information
in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to
chart.
B
Rationale: The client of Japanese descent often remains quiet and stoic,
and therefore may not voice pain and
should be assessed frequently. The
nurse should pay attention to non-verbal signs of pain. Providing personal space boundaries may help alleAddress client by first name to pro- viate tension and allowing family to
mote a trusting relationship
partake in decision-making is an inteRoutinely assess for pain, as
gral part of providing culturally compeJapanese Americans often remain tent care. Some Japanese American
stoic
clients may be offended if called by
Provide personal space boundaries their first name, and may not wish to
if client is in a semi-private room
talk frequently.
Allow for family to visit and participate in the decision-making
process
Encourage the client to verbally express their feelings and thoughts
often
19 / 39
Rationale: Clients with major burns are
at risk for respiratory compromise. A
hoarse voice is an impending sign that
the client may soon lose his airway due
to obstruction or swelling. This would
indicate the need to immediately acti-
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Asthma
Hoarse voice
Blood pressure of 98/62 mmHg
Blood glucose of 68 mg/dL (3.7
mmol/L)
vate the rapid response team as intubation is required. A history of asthma
may impact respiratory status, however, the presence of asthma alone
does not warrant a call to the rapid
response team. The client's blood glucose reading is low, and should be
treated, however, this can be done by
the RN assigned to the client and does
not warrant a rapid response team.
Hypovolemia is associated with burns
and would explain the low blood pressure reading.
35. The nurse is caring for a 55-pound 625
child on the pediatric medical surgical unit being treated for Lyme disease. The health care provider has
prescribed ceftriaxone intramuscular 50 mg/kg/day in two divided
doses. The nurse should administer
how many milligrams per dose? Fill
in the blank. ________ mg
36. The nurse is caring for a client
with joint pain and is educating the
client on pharmacological management of pain with acetaminophen.
What statements made by the client
would indicate a need for further
teaching? Select all that apply.
B, C, D
Rationale: Acetaminophen works by
blocking pain receptors. Grapefruit
does not impact the ability of this medication and can be taken together.
Dosing can occur every 4 to 6 hours as
long as a daily maximum of 4000 mg
"This medication is safe to take with is not exceeded. Gastrointestinal side
my warfarin."
effects are not common with this med"I should avoid eating grapefruit
ication, and therefore, can be taken
while taking this medication."
on an empty stomach. Acetaminophen
"I should not take this medication does not inhibit platelet aggregation
more often than 3 times per day." and can safely be taken with anticoag"To prevent a stomach ache, I
ulants. Side effects such as liver toxici20 / 39
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should take this medication with
ty, which include skin itching or yellowfood."
ing of the skin should be reported im"I should report any skin itching or mediately to the healthcare provider.
yellowing of the skin to my healthcare provider."
37. The nurse is providing discharge
education to a client who was admitted for treatment with Addison's
crisis and is reviewing the medication hydrocortisone. What statements made by the client would indicate teaching was effective. Select all that apply.
A, E
38. The nurse is caring for a client
in active labor. The nurse notices
that the fetal heart rate pattern is
demonstrating late decelerations.
Which position should the nurse
assist the client into? Refer to figures 1-4.
B
Rationale: Hydrocortisone is used in
the treatment of Addison's disease.
Adverse effects such as weight gain,
moon face, and fluid retention are not
expected and may indicate over-correction and a dose adjustment is needed. This medication can be taken once
"I should take this medication twice or twice daily, and should not be doua day."
bled if a dose is missed.
"Weight gain is common and I
should expect it."
"If I forget a dose, I should take two
pills the next time."
"I may notice my cheeks become fat
and rounded but this is okay."
"If I notice any swelling or fluid retention, I should notify my healthcare provider."
Prone
Lateral recumbent
Knee-chest
Dorsal recumbent
21 / 39
Rationale: Late decelerations are a
nonreassuring fetal heart rate that implies a decrease in placental sufficiency. To promote adequate oxygenation
and blood flow to the fetus, the client
should be assisted to a side lying position. Re-positioning may improve perfusion and the fetal heart rate. Positions such as prone and dorsal recumbent should be avoided to prevent
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compression of the vena cava and decreased blood flow. Knee-chest position may improve comfort, but side lying is best for perfusion.
39. A client is being treated on the medical surgical unit for a deep vein
thrombosis (DVT). The client will be
discharged home on oral anticoagulants. What information in the
client's medical record would warrant the need for teaching? Refer to
chart.
Sodium result
D-Dimer result
Vitamin D 400 IU daily
10 pack year history of smoking
D
Rationale: A deep vein thrombosis
(DVT) is the most common type of venous thromboembolism (VTE). DVTs
occur most often in the legs, but can
also occur in the upper arms. Smoking increases the risk of DVT formation, and clients should educated on
the importance of quitting. The sodium
result is within normal limits. The positive d-dimer result is expected, as it
is a marker for DVTs. Vitamin D supplementation does not impact DVTs or
anticoagulation therapy.
40. The post-operative client is experi- 0.4
encing moderate pain and requests
pain medication from the nurse.
The prescription reads: morphine
4 mg intravenous (IV) push every
three hours as needed. The morphine is supplied in an ampule of 10
mg/mL. How many milliliters should
the nurse administer? Fill in the
blank and record your answer using
the one decimal place. ________ mL
41. The nurse is caring for an older client who is being treated for
malnutrition. Which actions by the
nurse would be the most appropriate when providing for this client's
care and comfort? Select all that
22 / 39
A, B, C, D
Rationale: Malnutrition or nutrition-related problems can occur in older
adults when their nutritional needs are
not met. When caring for the malnour-
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apply.
ished client, the nurse should evaluate the client's living situation. Older
Ask if the client lives alone.
clients, who live alone, are more likely
Evaluate the fit of the client's den- to become malnourished. The nurse
tures.
should also evaluate the fit and comEducate the client on how to
fort of dentures. The client is less likechoose healthy foods.
ly to eat if dentures are poor fitting.
Determine if the client qualifies for The nurse should be prepared to deany food services.
termine the client's level of knowledge
Recommend that the client choose and educate as necessary. Food serover-the-counter medications for vices, such as meals on wheels, proailments.
vide food to the older client who may
not be able to obtain food on their own.
The nurse should assess the client
to determine if this assistance would
be an option. Over-the-counter medications can cause changes in taste,
placing the client at a greater risk for a
decreased appetite. The client should
speak with the health-care provider
before beginning any over-the-counter
medication.
42. The nurse is planning care for a
client who is confused. The nurse
should include which actions in the
client's care plan? Select all that apply.
A, B, C, D
Rationale: The nurse should plan care
that keeps the client as comfortable
and peaceful as possible. If possible,
the nurse should allow a pet visit. The
Allow a pet visit
nurse should also ensure a comforting
Play soft, calming music
environment. Many times clients who
Toilet the client every 2 to 3 hours are confused are unable to express
Evaluate the client for signs of pain the need to be toileted, which can inApply restraints as needed if the
crease agitation. It is also important
client becomes agitated
that the nurse evaluate the client for
pain, and treat the pain immediately.
Applying restraints should be a last
option. Restraints often increase agi23 / 39
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tation and lead to the client becoming
violent.
43. The nurse is working in the emergency department when a client
with heat exhaustion is brought in.
Which actions would be the appropriate in order to effectively treat
the client? Select all that apply.
A, C, D, E
44. The nurse is caring for a client
who has just come in to the emergency department to receive treatment. The client reports a bite from
a brown recluse spider. The nurse
assesses the bite mark and notes
that it is possibly infected. Which
actions should the nurse take? Select all that apply.
A, D, E
Rationale: If untreated, heat exhaustion can lead to heat stroke. The nurse
should reduce the client's temperature immediately. This can be done
by applying cool water soaks to the
Remove any restrictive clothing.
client, removing any restrictive clothAdminister salt tablets to the client. ing, orally rehydrating the client with
Apply cool water soaks to the client. a sports drink or rehydrating solution,
Give the client an oral rehydrating and applying cool packs to the client's
solution.
body. The nurse should avoid giving
Apply cool packs to the client's
the client salt tablets, as these can
neck and groin.
cause stomach irritation, nausea, and
vomiting—which can lead to further
dehydration. In addition, they can alter
the electrolyte balance.
Rationale: Brown recluse spider venom causes cell damage. The central
bite site may appear as a bleb or vesicle surrounded by edema and erythema, which may expand over the
course of hours as the toxin spreads to
surrounding tissues. The nurse should
take immediate action to prevent furApply ice to the site.
ther damage to the bitten area. ApContact a surgeon immediately.
plying ice to the site helps decrease
Apply a non-sterile dressing to the the enzyme activity of the venom and
site.
assists in decreasing swelling of the
Cleanse the area with a topical anti- tissue. Cleansing the area with a topseptic.
ical antiseptic and applying a sterile
Assess the date of the client's last dressing can help decrease the risk of
tetanus immunization.
infection, and prevent a current infec24 / 39
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tion from worsening. The nurse should
also assess the date of the client's last
tetanus immunization, and prepare to
administer the vaccine if necessary. It
is not necessary to contact a surgeon
immediately. If necrosis is present then
a surgeon may be needed for debridement.
45. The nurse is educating a client on
how to prevent altitude sickness.
Which statements indicate that the
teaching has been effective? Select
all that apply.
B, D, E
Rationale: High altitude illness, also
known as high altitude sickness or
altitude sickness, cause pathophysiologic responses in the body as a re"I will limit my fluid intake."
sult of exposure to low partial pres"I will wear sunscreen and high
sure of oxygen at high elevations. The
quality goggles."
nurse should educate the client on
"I will plan a quick ascent when
how to recognize and prevent altitude
changing to a higher altitude."
sickness and basic measures to treat
"I will refrain from consuming alco- sickness, until help can be obtained.
hol when I am at a high altitude." The nurse can determine that teach"I will pay attention to the manifes- ing has been effective when the client
tations of altitude-related illness- identifies the following as being imes."
portant: remaining hydrated, wearing
sunscreen, using high quality goggles,
refraining from alcohol use and recognizing the symptoms of altitude-related sickness. The client should prepare for a slow ascent, rather than a
quick ascent. This allows the client to
become acclimated to the altitude
46. The nurse is educating a child's par- D
ents on using the behavior modification technique of discipline.
Rationale:The behavior modification
Which statement should the nurse technique of discipline rewards posimake to the parents?
tive behavior and ignores negative behavior. This technique requires par25 / 39
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"All behaviors should be acknowledged."
"Rewards are given at the end of the
training period only."
"Negative behaviors are recorded
where the child can see them."
"Corporal punishment should not
be used to encourage good behaviors."
ents to choose selected behaviors,
preferably only one at a time, that
they desire to stop. They choose others that they want to encourage. The
basic technique is useful for any
age from toddlerhood through adolescence. Corporal punishment can
lead to child abuse if the disciplinarian loses control. When educating
the paents, the nurse should provide
accurate information such as: ignoring negative behaviors, giving rewards
throughout and at the end of the training period and recording negative behaviors out of the client's view.
47. The nurse is caring for a client
who has been diagnosed with bladder cancer. Which action should
the nurse take as a priority when
planning psychosocial care for this
client?
C
48. A client has come to the emergency
department complaining of burning with urination. What should the
nurse consider a priority when providing care in order to maintain the
client's psychosocial integrity?
B
Rationale: When planning care that
includes the psychosocial needs, the
priority action for the nurse should be
to assess the client's ability to cope
with the cancer diagnosis. Other imAssess all urine for the presence of portant aspects of caring for this client
blood
are to assess the urine and determine
Question the client about insurance the client's medical history, including
coverage
family history of cancer but these are
Assess the client's ability to cope physiological aspects. Questioning the
with the diagnosis
client's insurance coverage is not typiAsk the client if there is a history of cally a nursing function.
cancer in the family
26 / 39
Rationale: Providing the client with
as much privacy as possible during
the examination is the best way to
maintain psychosocial integrity and
should be considered a priority by the
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Use medical terminology when
speaking to the client.
Provide the client with as much privacy as possible during the examination.
Explain to the client that all questions will be answered at the time of
discharge.
Administer medications as soon as
they are prescribed by the health
care provider.
nurse. Using medical terminology may
be confusing to the client. The nurse
should explain all actions and procedures to the client before they occur.
Administering medications as soon as
prescribed is important, but does not
necessarily maintain the client's psychosocial integrity in this situation
49. The nurse is educating an older
client on sources of stress. Which
statements by the client indicate
that the teaching has been effective? Select all that apply.
A, B, C
50. The nurse is caring for a client with
bipolar disorder. When creating a
care plan for this individual, which
should the nurse include as appropriate goals? Select all that apply.
A, C, D, E
Rationale: Stress can accelerate the
aging process over time, or it can lead
to diseases that increase the rate of
degeneration. Although no period of
"Relocating to a nursing home
the life cycle is free from stress, the
causes stress."
later years can be a time of especially
"Financial hardships can be a
high risk. While educating the client
cause of stress."
on sources of stress, the nurse should
"A lifestyle change such as retiring evaluate the knowledge of the client.
can cause stress."
It is important that the client under"A history of anxiety can be a
stand the sources of stress, so that
source of stress in the older per- they can be avoided when possible.
son."
Sources of stress for the older client in"The birth of a new grandchild is of- clude: relocation, financial hardships,
ten a source of stress for the older and lifestyle changes. A history of anxperson."
iety is not often a source of stress for
the older client. The birth of a new
grandchild is often a joyous experience for the older client.
27 / 39
Rationale: While caring for the bipolar
client, it is important that the nurse create a plan of care, in order for the client
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to have the best outcome. The nurse
The client will understand what
should ensure that the client underbipolar disorder is.
stands important concepts such as:
The client will ask the nurse to refill what bipolar disorder is, how to manthe prescriptions each month.
age the symptoms and the importance
The client will be able to manage the of taking medications as they are presymptoms of bipolar disorder.
scribed. The nurse should also assess
The client will perform activities of the client's ability to realistically solve
daily living (ADLs) independently. problems of daily living, such as obThe client will state the importaining more medications. The client
tance of taking medications as pre- should be able to call the pharmacy to
scribed.
refill medications, instead of relying on
the nurse.
51. The nurse is creating a plan of care
for a client that will undergo a total
joint replacement. What should the
nurse include in the client's plan of
care? Select all that apply.
A, B, C
Rationale: The client's readiness for
surgery is critical to the outcome. Preoperative care focuses on preparing
the client for the surgery and client
Teach interventions to reduce client safety. The nurse should include activianxiety
ties in the plan of care that will focus on
Educate the client on what to expect preparing the client for surgery such
after surgery
as interventions that will reduce the
Complete a physical assessment client's level of anxiety and education
before the surgery
on what to expect after surgery. The
Ask the client's family to wait in the nurse should perform a physical aswaiting room before surgery
sessment and alert the surgeon to any
Allow time for the surgeon to ad- findings that would interfere with the
dress questions after the surgery surgery. When possible, the client's
family should be with the client before
surgery to reduce the client's anxiety.
The nurse should allow time for the
surgeon to meet with the client and
family before (not after) the surgery to
address any questions or concerns.
52. The nurse is caring for a client with A, D, E
a blood pressure of 80/54 mmHg.
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Which actions should the nurse
Rationale: Hypovolemic shock occurs
take because of the risk of hypov- when there is a decrease in the circuolemic shock? Select all that apply. lating blood volume in the body. When
treating a client in hypovolemic shock,
Insert a large-bore intravenous (IV) the nurse should insert a large-bore
line
IV line, administer Ringer's lactate or
Position the client into high
0.9 % normal saline solutions, perFowler's position
form assessments and monitor the
Keep intravenous fluids to be ad- client closely. These treatments will
ministered cold
restore circulating blood volume to
Anticipate administering Ringer's the client. Positioning the client in
lactate solution
high Fowler's position could further
Perform assessments and monitor decrease the blood pressure. Intrathe client closely
venous fluids should be warmed prior
to administration to the client.
53. The nurse is providing care to a
client. After assessing the client,
the nurse determines that the
client's self ability to change position is compromised. Which actions
should the nurse take to reduce the
risk of skin break down? Select all
that apply.
B, D, E
Rationale: If a client is unable to
change positions the nurse should
take special care in protecting skin
integrity and preventing breakdown.
After assessing the client, the nurse
should implement a turning schedule
for this client. The nurse should creAssess the skin daily
ate a plan of care and document skin
Implement a turning schedule
breakdown prevention measures so
Gently massage reddened skin
that other members of the health care
Keep the client's skin clean and dry team can continue care for this client.
Document skin breakdown preven- It is important that the nurse keep
tion measures in the plan of care the client's skin clean and dry at all
times, changing soiled linens whenever needed. Massaging reddened areas could damage fragile underlying tissues. The nurse should plan
to assess the client's skin frequently
to determine if there have been any
changes to integrity; checking daily is
too infrequent.
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54. The nurse is creating a plan of care
for a client with a respiratory infection. Which actions should the
nurse include in the plan of care
to prevent the spread of infection?
Select all that apply.
A, D, E
55. The nurse is caring for a client with
cancer who has a sealed implant of
a radioactive source. Which actions
should the nurse take to promote
safety for staff and visitors? Select
all that apply.
A, C
Rationale: Infection control within a
health care facility is designed to reduce the risk for health-care associated infections (HAI). The nurse must
implement measures to prevent the
Clean the client's room daily
spread of infection. The nurse should
Wash hands when they are soiled include the following in a plan of care
Wear gloves to apply fresh linen to for the client: daily room cleaning to rethe bed
move infectious material; keeping finKeep fingernails short and without gernails short and without nail polish
nail polish
because of the risk of harboring bactePlace a mask on the client's face
ria; and use of a mask when the client
when transporting to other depart- is transported to other departments to
ments
prevent spread. In addition, other departments that the client is being transported to should be aware of the risk of
respiratory infection. The nurse should
wash hands after every client contact
or more frequently if needed, not just
when they are soiled. Often hands may
not look soiled, but can have infectious
material on them. It is not necessary to
use gloves to apply fresh bed linens.
Rationale: Solid or sealed radiation
sources are implanted within or near
the tumor. These sources can be temporary or permanent. Most implants
emit continuous, low-energy radiation
Keep the client's door closed
to tumor tissues. Safety for staff and
Limit each visitor to 1 hour per day visitors should be a priority for the
Wear a lead apron while providing nurse and are focused on preventcare
ing exposure to the radiation. ThereAssign the client to a semi-private fore, ways to promote safety include
room
wearing a lead apron while providing
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Remove dressings and linens from care. The nurse should always keep
the room as they are soiled
the lead facing the client, never turning
away from the client. The door to the
client's room should be kept closed.
Visitors should be limited to one-half
hour a day, and should remain 6 feet
(1.8 meters) from the source of radiation. The client should be assigned to a
private room with a private bathroom,
and not in a semi-private room. All
dressings and linens should be kept in
the room until the source of radiation
has been removed.
56. The nurse provides information to A, C, D
an assistive personnel (AP) about
caring for a client with neutropenia. Rationale: Monitoring for manifestaWhich statements by the AP indi- tions of infection is critical for the hoscate that teaching has been effec- pitalized client with neutropenia. The
tive? Select all that apply.
nurse should communicate the importance of this to the AP, and actions
"I should practice good hand wash- that can be taken to reduce infection.
ing."
The AP should state the importance
"The client needs mouth care at
of taking precautions to protect the
least every 24 hours."
client from potential infections. The AP
"The client may not have a high
should be able to state the need to
fever if infection occurs."
practice good hand washing, as well
"Any sores or skin irritations
as the client's need for mouth care
should be reported right away."
at least every 12 hours, not every 24
"I need to take precautions to pro- hours. The AP should understand that
tect myself from the client's illany rashes or open sores should be
ness."
reported right away, and that the client
may not have the classic signs of infection, such as a high fever, due to the
decrease in white blood cells (WBCs)
that occurs in neutropenia.
57. The nurse is caring for a client who A, B, C
expresses an interest in alternative
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therapies to reduce the risk of illness and disease. What noninvasive activities should the nurse recommend to the client? Select all
that apply.
Yoga
Meditation
Biofeedback
Acupuncture
Herbal therapy
Rationale: Integrative health care encompasses complementary and alternative therapies in combination with
conventional Western modalities of
treatment. Many popular alternative
healing modalities offer human-centered care based on philosophies that
recognize the value of the client's input
and honor the individual's cultural beliefs, values, and desires. When caring
for this client, the nurse should recommend noninvasive activities such
as yoga, meditation, and the use of
biofeedback. Acupuncture and herbal
therapies are invasive modalities.
58. The nurse is educating a new regis- A, D, E
tered nurse (RN) about the Healthy
People 2020 goals. Which stateRationale: Healthy People 2020 proments by the RN indicate that teach- vides science-based 10-year nationing has been effective? Select all al objectives for improving health
that apply.
and preventing disease in the United
States. The nurse should evaluate the
"Healthy People 2020 aims to pro- new RN's understanding of the informote healthy behaviors."
mation, and provide additional educa"Healthy People 2020 aims to make tion as needed. The teaching has been
health care more affordable."
effective when the new RN can state
"Healthy People 2020 aims to im- that Healthy People 2020 aims to proprove the health of the geriatric
mote healthy behaviors, eliminate prepopulation."
ventable disease, disability, injury, and
"Healthy People 2020 aims to elimi- preventable death; as well as to create
nate preventable disease, disability, social and physical environments that
injury, and preventable death."
promote good health for all. Healthy
"Healthy People 2020 aims to create People 2020 strives to create a socisocial and physical environments ety that is healthy for all populations,
that promote good health for all." however, the objectives do not include
making health care affordable.
59.
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The nurse is completing a health
history on a client who is 12 weeks
pregnant. Which findings should
alert the nurse to the risk of potential parenting problems? Select all
that apply.
A, D, E
Rationale: Situational factors such as
the family's ethnic and cultural background and socioeconomic status are
assessed while the history is obtained.
The nurse should be alert to how the
The client reports feeling declient is currently feeling about the
pressed
pregnancy, as well as the client's risk
The client has new health insurance or actual appearance of depression.
The client states that she likes hos- The nurse should also determine if the
pitals
family is supportive of the pregnancy;
The client states that the father is lack of support can lead to parentnot supportive
ing problems later on. The homeless
The client is homeless and often
client is at a high risk of parenting
stays in local shelters
problems due to the lack of permanent
residence; the nurse should address
this problem immediately for the best
outcome.
60. When conducting the preoperaD
tive interview with the client, the
client reports an allergy to shellfish. Rationale: The nurse should anticipate
Which agent is most likely to cause this client to have an allergic reacan allergic reaction in this client? tion to providone-iodine, also known
as betadine. It is important that the
Latex
nurse report the allergy to shellfish to
Penicillin
the surgeon right away so that anMedical tape
other method of skin cleansing can
Providone-Iodine
be chosen. Latex, penicillin, and medical-tape are not considered cross allergens for shellfish.
61. Which actions should the nurse
A, D, E
take to adequately prepare a client
for a thoracentesis? Select all that Rationale: Thoracentesis is the aspiraapply.
tion of pleural fluid or air from the pleural space. It can be used for diagnosis
Explain the procedure to the client or treatment. In preparing the client for
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Instruct the client to cough when
asked to do so
Teach the client to take slow, deep
breaths during the procedure
Tell the client to expect a stinging
sensation from the anesthetic
Inform the client that it is common
to feel pressure from the needle insertion
a thoracentesis, the nurse should thoroughly explain the procedure to the
client, allowing time for the client to
ask questions. The nurse should also
instruct the client not to move during the procedure, and therefore the
client should not cough or take deep
breaths, in order to avoid puncture of
the lungs or pleura. The client should
be informed to expect a stinging sensation and pressure as the needle is
inserted.
62. The nurse is presenting information
to a new nursing employee regarding a thoracentesis that will take
place later today. Which instructions should the nurse provide regarding signs/symptoms of a pneumothorax? Select all that apply.
A, B, E
63. The nurse is caring for a client on a
ventilator. Which symptoms should
alert the nurse to the possibility of
absorption atelectasis? Select all
that apply.
A, B
Rationale: The nurse should explain
that pneumothorax is a complication of
a thoracentesis. Signs and symptoms
of a pneumothorax include: cyanosis,
often noticed around the lips; pain on
the affected side, frequent coughing,
"Frequent coughing should be re- a feeling of air hunger, and a slanted
ported."
trachea. Clients with these signs and
"Be sure and report any bluish col- symptoms will need to be evaluated
or to the skin."
right away. Discomfort on the unaffect"Having air hunger is to be expect- ed side is not associated with a thoraed."
centesis or pneumothorax.
"Discomfort on the unaffected side
should be evaluated immediately."
"Presents of a slanted trachea in
the neck region need to be reported."
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Rationale: Nitrogen in the air helps
maintain patent airways and alveoli.
Making up 79% of room air, nitrogen
prevents alveolar collapse because it
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Crackles in the lungs
Diminished lung sounds
Decrease in blood pressure
Increase in red blood cell count
High oxygen saturation readings
64. The nurse is caring for a client with
heat stroke, who is being cooled
with a cooling blanket. Which actions should the nurse take to ensure that the intervention is effective? Select all that apply.
Administer antipyretics
Gradually lower the core temperature
Monitor temperature continuously
until it is stable
Monitor for patency of the airway
and prepare for intubation if necessary
Prepare to insert an intravenous
line for administration of fluids as
needed
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does not cross the alveolar-capillary
membranes and remains in the airways and alveoli. When high oxygen
levels are delivered, nitrogen is diluted, oxygen diffuses from the alveoli
into the circulation, and the alveoli collapse. Collapsed alveoli cause atelectasis (called absorption atelectasis),
which is detected by auscultation. The
nurse providing care to the ventilated client should be alert for signs of
absorption atelectasis. These symptoms include: crackles in the lungs and
diminished lung sounds. The nurse
should intervene when these symptoms are present. High oxygen saturation, decreased blood pressure, and
an increase in the red blood cell count
are not typical signs of absorption atelectasis.
C, D, E
Rationale: Victims of heat stroke have
a profoundly elevated body temperature (above 104° F [40° C]) and need
to be treated immediately with cooling measures to rapidly, not gradually,
lower the body temperature. The nurse
would monitor the temperature continuously using a rectal thermometer
or other acceptable temperature measuring method. An intravenous line is
inserted to administer fluids such as
5% dextrose in the event of hypoglycemia that can occur as a complication. The nurse should not administer
antipyretics. Antipyretics can interrupt
the change in the hypothalamic set
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point and are not expected to work on
a healthy hypothalamus that has been
overloaded, as in the case of heatstroke. In addition, they can be harmful
in some situations.
65. Which interventions should be in- B, D, E
cluded in the care of a client with a
chest tube? Select all that apply.
Rationale: The chest tube site should
be assessed for signs of infection and
Change the chest tube each shift. the drainage system should always
Assess the insertion site for signs be kept below the level of the client's
of infection.
chest to ensure adequate drainage. If
Assess the water seal chamber for drainage stops in the first 24 hours,
a continuous, strong bubbling.
the HCP should be notified immediKeep the drainage system lower
ately because there could be a blockthan the level of the client's chest. age in the tube. The chest tube is not
Alert the health care provider (HCP) changed each shift and the system
if drainage in the tube stops in the needs to remain closed and patent. A
first 24 hours.
continuous strong bubbling in the water seal chamber indicates an air leak,
requiring further investigation.
66. The nurse is providing care to a
client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the
nurse to the onset of an acute arterial occlusion? Select all that apply.
A,B,D
Rationale: Although chronic peripheral arterial disease (PAD) progresses
slowly, the onset of acute arterial occlusions may be sudden and dramatic.
Acute arterial occlusion is serious and
Cyanosis of the skin in the affected occurs when blood flow in a leg artery
extremity
stops suddenly. If blood flow to the toe,
Skin temperature cool to touch in foot, or leg is completely blocked, the
the affected extremity
tissue begins to die and can lead to
Client complaints of stiffness in the gangrene. Intervention is needed imjoints of the affected extremity
mediately to restore blood flow. ManComplaints of sudden and severe ifestations of acute arterial occlusion
pain in the affected extremity
are due to a lack of blood flow and inBounding pulse in the affected ex- clude cyanosis, cool skin temperature,
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tremity below the level of the occlu- severe pain, problems moving the afsion
fected extremity, and a lack of a pulse.
There would be no pulse as a result
of the occlusion and blocked artery.
Stiffness in the joints of the affected
extremity is not a finding associated
with acute arterial occlusion.
67. Which manifestations are specif- B, D, E
ically noted in a client with
right-sided heart failure.? Select all Rationale: Right ventricular failure
that apply.
is associated with increased systemic venous pressure and congesWet cough
tion. Therefore, manifestations are notHepatomegaly
ed in the systemic circulation and can
Breathlessness
include ascites, hepatomegaly, depenDependent edema
dent edema and neck vein distention.
Neck vein distention
Breathlessness, a cough, and other
pulmonary manifestations are often a
sign of left-sided heart failure
68. The client with heart failure is
preparing to be discharged from
the hospital. Which interventions
should the nurse include in the
client's discharge teaching plan?
Select all that apply.
Encourage the client to rest in bed
Develop a regular exercise program
Educate the client about dietary restrictions
Give the client a minimal role in the
self-management program
Provide the client with a list of current medications and dosing times
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B, C, E
Rationale: Any client discharged from
the hospital should be encouraged to
become involved in as much self-care
as possible and the client's condition
allows. An exercise program is also important to maintain strength and circulation. Dietary restrictions may be necessary for the client with heart failure
and may include fluid restrictions and
sodium restrictions. Clients need to
clearly understand how to administer
prescribed medications and a written
list of instructions is extremely helpful
to ensure safety and compliance. It is
unnecessary for the client to rest in
bed.
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69. The nurse is educating a client on
how to self-manage care at home,
following an admission to the hospital for heart failure. Which statements by the client indicate that
teaching has been effective? Select
all that apply.
B, C
70. The client has been diagnosed with
valvular disease. Which interventions should the nurse be prepared
to discuss with the client? Select all
that apply.
A, D, E
Rationale: Health teaching is essential for promoting self-management.
Many clients with heart failure are
readmitted to hospitals because they
do not maintain their prescribed treatment plan, including lifestyle changes.
"I will weigh myself monthly."
The client should state the importance
"I will wear my oxygen at night as of daily weights, not monthly, to monprescribed."
itor for increases indicating fluid re"I will follow up with my health care tention, wearing oxygen at night to
provider (HCP) as scheduled."
prevent hypoxia, keeping follow-up ap"I will report new signs and symp- pointments for monitoring status, and
toms to my home care nurse when having medications and dosages writshe visits."
ten down and available for review and
"I have my medications and
administration. The client should not
dosages memorized, and I recog- wait for the home care nurse to report
nize my pills by color."
new signs and symptoms, but should
report them immediately to the HCP in
charge of care. Waiting could lead to
worsening heart failure and complications such as pulmonary edema.
Surgical management
Required dietary changes
Encouraging oral fluid intake
Placing limits on physical activity
Monitoring for an irregular heart
rhythm
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Rationale: Management of valvular
heart disease depends on which valve
is affected and the degree of valve
impairment. When caring for a client
with valvular disease the nurse should
be prepared to discuss interventions.
These include surgical and medication
management, as well as placing limits
on physical activity. Monitoring for an
irregular heart rhythm is also a common intervention for clients with valvular disease. Required dietary changes
is not specific to valvular heart dis-
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ease although diet changes would
be necessary for other cardiac disorders such as coronary artery disease.
Valvular diseases can result in heart
failure, and fluids may be restricted,
not encouraged.
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