11/25/22, 12:03 PM
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An older client had a hemiarthroplasty of the left hip yesterday due to
a fracture resulting from a fall. In reviewing hip precautions with the
client, which instruction should the nurse include in this client's
teaching plan?
In 8 weeks you will be able to bend at the waist to reach items on the floor.
Place a pillow between your knees while lying in bed to prevent hip
dislocation.
It is safe to use a walker to get out of bed, but you need assistance when
walking.
Take pain medication 30 minutes after your physical therapy sessions.
Rationale
The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of
dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation
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include placing a pillow between the knees to maintain abduction of the hips. Clients should be
instructed to avoid bending at the waist, to seek assistance for both standing and walking until they
are stable on a walker or cane, and to take pain medication 20 to 30 minutes prior to physical therapy
sessions, rather than waiting until the pain level is high after their therapy.
The nurse is assessing the nutritional status of several clients. Which
client has the greatest nutritional need for additional intake of
protein?
A college-age track runner with a sprained ankle.
A lactating woman nursing her 3-day-old infant.
A school-aged child with Type 2 diabetes.
An elderly man being treated for a peptic ulcer.
Rationale
A lactating woman has the greatest need for additional protein intake. Orthopedic injuries, typoe 2
diabetes, and peptic ulcers are all conditions that require protein, but do not have the increased
metabolic protein demands of lactation.
A resident in a skilled nursing facility for short-term rehabilitation
after a hip replacement tells the nurse, "I don't want any more blood
taken for those useless tests." Which narrative documentation should
the nurse enter in the client's medical record?
Healthcare provider notified of failure to collect specimens for prescribed
blood studies.
Blood specimens not collected because client no longer wants blood tests
performed.
Healthcare provider notified of client's refusal to have blood specimens
collected for testing.
Client irritable, uncooperative, and refuses to have blood collected. Healthcare
provider notified.
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Rationale
When a client refuses a treatment, the exact words of the client regarding the client's refusal of care
should be documented in a narrative format. The nurse should not editorialize, make judgments, or
document assumptions about the client's wishes.
Three days following surgery, a male client observes his colostomy for
the first time. He becomes quite upset and tells the nurse that it is
much bigger than he expected. What is the best response by the
nurse?
Reassure the client that he will become accustomed to the stoma appearance
in time.
Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
Offer to contact a member of the local ostomy support group to help him with
his concerns.
Encourage the client to handle the stoma equipment to gain confidence with
the procedure.
Rationale
Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the
stoma will become smaller when the swelling is diminished. This will help reduce the client's anxiety
and promote acceptance of the colostomy.
An older client with a fractured left hip is on strict bedrest. Which
nursing measure is essential to the client's nursing care?
Massage any reddened areas for at least five minutes.
Encourage active range of motion exercises on extremities.
Position the client laterally, prone, and dorsally in sequence.
Gently lift the client when moving into a desired position.
Rationale
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To avoid shearing forces when repositioning, the client should be lifted gently across a surface.
Reddened areas should not be massaged since this may increase the damage to already traumatized
skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg.
At the time of the first dressing change, the client refuses to look at
her mastectomy incision. The nurse tells the client that the incision is
healing well, but the client refuses to talk about it. Which is the best
response to this client's silence?
"It is normal to feel angry and depressed, but the sooner you deal with this
surgery, the better you will feel."
"Looking at your incision can be frightening, but facing this fear is a necessary
part of your recovery."
"It is OK if you don't want to talk about your surgery. I will be available when
you are ready."
"I will ask a woman who has had a mastectomy to come by and share her
experiences with you."
Rationale
When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse
should reflect that these feelings are OK and that the nurse is available when the client is ready. Such
a response displays sensitivity and understanding without judging the client. On the other hand,
telling a client how she should feel is judgmental and insensitive.
The nurse observes an unlicensed assistive personnel (UAP) checking a
client's blood pressure with a cuff that is too small, but the blood
pressure reading obtained is within the client's usual range. Which
action is most important for the nurse to implement?
Tell the UAP to use a larger cuff at the next scheduled assessment.
Reassess the client's blood pressure using a larger cuff.
Have the unit educator review this procedure with the UAPs.
Teach the UAP the correct technique for assessing blood pressure.
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Rationale
An unlicensed assistive personnel (UAP) is using the wrong sized cuff to check a blood pressure. The
most important action is to ensure that an accurate blood pressure reading is obtained. The nurse
should reassess the blood pressure with the correct size cuff. Reassessment should not be
postponed.
A client with pneumonia has a decrease in oxygen saturation from
94% to 88% while ambulating. Based on these findings, which
intervention should the nurse implement first?
Assist the ambulating client back to the bed.
Encourage the client to ambulate to resolve pneumonia.
Obtain a prescription for portable oxygen while ambulating.
Move the oximetry probe from the finger to the earlobe.
Rationale
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be
assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs to
prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen
saturation of the blood. Increased activity increases respiratory effort, and oxygen may be necessary
to continue ambulation, but first the client should return to bed to rest.
After completing an assessment and determining that a client has a
problem, which action should the nurse perform next?
Determine the etiology of the problem.
Prioritize nursing care interventions.
Plan appropriate interventions.
Collaborate with the client to set goals.
Rationale
Before planning care, the nurse should determine the etiology, or cause, of the problem, because
this will help determine goals, plan of care and priorities of interventions.
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During shift change report, the nurse receives report that a client has
abnormal heart sounds. Which placement of the stethoscope should
the nurse use to hear the client's heart sounds?
Place the stethoscope bell at random points on the posterior chest.
Use the stethoscope bell over the valvular areas of the anterior chest.
Move the diaphragm of the stethoscope over the left anterior chest.
Position the diaphragm of the stethoscope at Erb's point on the chest.
Rationale
Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched
sounds, that is placed at points on the anterior chest.
A female client asks the nurse to find someone who can translate her
treatment concerns into her native language. Which action should the
nurse take?
Explain that anyone who speaks her language can answer her questions.
Provide a translator only in an emergency situation.
Ask a family member or friend of the client to translate.
Request and document the name of the certified translator.
Rationale
A certified translator should be requested to ensure the exchanged information is reliable and
unaltered. To adhere to legal requirements in some states, the name of the translator should be
documented. Client information that is translated is private and protected under HIPAA rules, so
enaging anyone as a translator is not the best action. Family members are not preferred translators
as they may skew information and not translate the exact information.
The nurse is developing a plan of care for a client with dementia.
Which feature of confusion in the elderly is accurate?
Bewilderment is to be expected, and progresses with age.
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Disorientation often follows relocation to new surroundings.
Uncertainty is a result of irreversible brain pathology.
Being perplexed can be prevented with adequate sleep.
Rationale
Relocation often results in confusion among elderly clients, moving is stressful for anyone.
Advancing confusion with age is a stereotypical judgment. Stress in the elderly often manifests itself
as confusion. Adequate sleep is not a prevention for confusion.
Twenty minutes after beginning a heat application, the client states
that the heating pad no longer feels warm enough. What is the best
response by the nurse?
"That means you have derived the maximum benefit, and the heat can be
removed."
"Your blood vessels are becoming dilated and removing the heat from the
site."
"We will increase the temperature 5 degrees when the pad no longer feels
warm."
"The body's receptors adapt over time as they are exposed to heat."
Rationale
Thermal adaptation occurs 20 to 30 minutes after heat application. This means the client may not
feel the same level of heat as at the start of the treatment. The nurse should not increase the heat
setting.
What is the most important reason for starting intravenous infusions
in the upper extremities rather than the lower extremities of adults?
It is more difficult to find a superficial vein in the feet and ankles.
A decreased flow rate could result in the formation of a thrombosis.
A cannulated extremity is more difficult to move when the leg or foot is used.
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Veins are located deep in the feet and ankles, resulting in a more painful
procedure.
Rationale
Venous return is usually better in the upper extremities. Cannulation of the veins in the lower
extremities increases the risk of thrombus formation which, if dislodged, could be life-threatening.
Superficial veins are often very easy to find in the feet and legs. Handling a leg or foot with an IV is
probably not any more difficult than handling an arm or hand. Even if the nurse believes moving a
cannulated leg is more difficult, this is not the most important reason for using the upper
extremities. Pain is not a consideration.
A client with multiple sclerosis is prescribed Dantrolene
1
(Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in
100 mg capsules. How many capsules should the nurse administer?
(Enter numeric value only.)
Rationale
Using the conversion of 1 gram = 1000 mg:
0.1 gram = 100 mg
100 mg = 1 capsule
The nurse is assisting an 82-year-old client to ambulate. Which is the
center of gravity for an elderly person?
Arms.
Upper torso.
Head.
Feet.
Rationale
The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is
common because of the changes from osteoporosis and normal bone degeneration, and the knees,
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hips, and elbows flex. This stooped posture results in the upper torso becoming the center of gravity
for older persons. Although arms are part, or an extension of the upper torso, this is not the best and
most complete answer.
An older client who is a resident in a long term care facility has been
bedridden for a week. Which finding should the nurse identify as a
client risk factor for pressure ulcers?
Generalized dry skin.
Localized dry skin on lower extremities.
Red flush over entire skin surface.
Rashes in the axillary, groin, and skin fold regions.
Rationale
Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air
flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin
breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of
inflammation and tissue integrity.
When evaluating a client's plan of care, the nurse determines that a
desired outcome was not achieved. Which action should the nurse
implement first?
Establish a new nursing diagnosis.
Note which actions were not implemented.
Add additional nursing orders to the plan.
Collaborate with the healthcare provider to make changes.
Rationale
First, the nurse should review which actions in the original plan were not implemented in order to
determine why the original plan did not produce the desired outcome. Appropriate revisions can
then be made, which may include revising the expected outcome, or identifying a new nursing
diagnosis.
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An older client who requires frequent monitoring fell and fractured a
hip. Which nurse is at greatest risk for a malpractice judgment?
The nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing
notes.
The nurse assigned to care for the client who was at lunch at the time of the
fall.
The nurse who transferred the client to the chair when the fall occurred.
The charge nurse who completed rounds 30 minutes before the fall occurred.
Rationale
The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized
standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual
injury and the standard of care was "frequent monitoring." The nurse most at risk for malpractice is
the one in which duty was owed (transferring the client safely) and the injury occurred while the
nurse was in charge of the client's care.
Which response by a client with a nursing diagnosis of "Spiritual
distress," indicates to the nurse that a desired outcome measure has
been met?
Expresses concern about the meaning and importance of life.
Remains angry at God for the continuation of the illness.
Accepts that punishment from God is not related to illness.
Refuses to participate in religious rituals that have no meaning.
Rationale
Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of
resolution of spiritual distress.
A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled
for surgery the next day. Which question is most important for the
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nurse to include during the preoperative assessment?
"What is your daily calorie consumption?"
"What vitamin and mineral supplements do you take?"
"Do you feel that you are overweight?"
"Will a clear liquid diet be okay after surgery?"
Rationale
In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral
supplements. These products may impact medications used during the operative period. The nature
of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's
preference. Addressing long-term diet therapy is best done after surgery and recovery.
Which assessment data provides the most accurate determination of
proper placement of a nasogastric tube?
Aspirating gastric contents to assure a pH value of 4 or less.
Hearing air pass in the stomach after injecting air into the tubing.
Examining a chest x-ray obtained after the tubing was inserted.
Checking the remaining length of tubing to ensure that the correct length was
inserted.
Rationale
Assessing the pH of gastric contents and listening for air in the stomach are both methods used to
determine proper placement of the nasogatric tube. However, the best indicator that the tube is
properly placed is confirming with a chest x-ray.
A postoperative client will need to perform daily dressing changes
after discharge. Which outcome response best demonstrates the
client's readiness to manage wound care after discharge?
Asking relevant questions regarding the dressing change.
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Stating theability to complete the wound care regimen.
Demonstrating the wound care procedure correctly.
Showing all the necessary supplies for wound care.
Rationale
A return demonstration of a procedure provides an objective assessment of a client's ability to
perform a task, while client statements or questions are subjective measures.Showing that the client
possesses the necessary supplies is important, but it is less of a priority prior to discharge than the
nurse's assessment of the client's ability to complete the wound care.
A male client tells the nurse that he does not know where he is or what
year it is. What data should the nurse document that is most accurate?
Demonstrates loss of remote memory.
Exhibits expressive dysphasia.
Has a diminished attention span.
Is disoriented to place and time.
Rationale
The client is exhibiting disorientation. Loss of remote memory refers to memory of the distant past.
The client is able to express himself without difficulty, and does not demonstrate a diminished
attention span.
The nurse observes that a male client has removed the covering from
an ice pack applied to his knee. What action should the nurse take
first?
Observe the appearance of the skin under the ice pack.
Instruct the client regarding the need for the covering.
Reapply the covering after filling with fresh ice.
Ask the client how long the ice was applied to the skin.
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Rationale
The client has been using an ice pack without the protective covering. The first action the nurse
should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred,
the nurse can then explain the need for a cover and reapply the ice pack with the cover in place.
On admission, a client presents a signed living will that includes a Do
Not Resuscitate (DNR) prescription. When the client stops breathing,
the nurse performs cardiopulmonary resuscitation (CPR) and
successfully revives the client. What legal issues could be brought
against the nurse?
Assault.
Battery.
Malpractice.
False imprisonment.
Rationale
Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat
to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure
against the client’s wishes can potentially create a legal issue, such as battery, even if the procedure
is of questionable benefit to the client.
A male client with a history of hypertension tells the nurse that he is
tired of taking antihypertensive medications and is going to try
spiritual meditation instead. What should be the nurse's first
response?
"It is important that you continue your medication while learning to meditate."
"Spiritual meditation requires a time commitment of 15 to 20 minutes daily."
"Obtain your healthcare provider's permission before starting meditation."
"Complementary therapy and western medicine can be effective for you."
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Rationale
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications.
However, the medications must be continued while the physiologic response to meditation is
monitored. The healthcare provider should be informed, but permission is not required to meditate.
Although it is true that this complementary therapy might be effective, it is essential that the client
continue with antihypertensive medications until the effect of meditation can be measured.
The nurse is teaching a client with numerous allergies how to avoid
allergens. Which instruction should be included in this teaching plan?
Avoid any types of sprays, powders, and perfumes.
Wearing a mask while cleaning will not help to avoid allergens.
Purchase any type of clothing, but be sure it is washed before wearing it.
Pollen count is related to hay fever, not to allergens.
Rationale
The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors,
sprays, powders, and perfumes. The client should be encouraged to wear a mask when working
around dust or pollen. Clients with allergies should avoid any clothing that causes itching; washing
clothes will not prevent an allergic reaction to some fabrics. Pollen count is related to allergens, and
the client should be instructed to stay indoors when the pollen count is high.
The nurse is using a genogram while conducting a client's health
assessment and past medical history. What information should the
genogram provide?
Inherited familial health disorders.
Chronic health problems.
Reason for seeking health care.
Undetected disorders.
Rationale
A genogram that is used during the health assessment process identifies genetic and familial health
disorders. It may not identify the client's chronic health problems. A genogram is not a diagnostic
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tool to detect disorders, such as those based on pathological findings or DNA.
A hospitalized male client is receiving nasogastric tube feedings via a
small-bore tube and a continuous pump infusion. He reports that he
had a bad bout of severe coughing a few minutes ago, but feels fine
now. What action is best for the nurse to take?
Record the coughing incident. No further action is required at this time.
Stop the feeding, explain to the family why it is being stopped, and notify the
healthcare provider.
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from
the tube.
Inject 30 ml of air into the tube while auscultating the epigastrium for
gurgling.
Rationale
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding
tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the
sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach)
or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess
tube placement in this way prior to taking any other action. The auscultating method has been found
to be unreliable for small-bore feeding tubes.
The nurse plans to obtain health assessment information from a
primary source. Which option is a primary source for the completion
of the health assessment?
Client.
Healthcare provider.
A family member.
Previous medical records.
Rationale
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A primary source of information for a health assessment is the client. Family members, the medical
record, and the healthcare provider are considered secondary sources about the client's health
history, but other details, such as subjective data, can only be provided directly from the client.
1.5
A client is receiving alprazolam (Xanax) 0.75 mg PO bid
for anxiety. Alprazolam is available in 0.5 mg scored tablets. How many
tablets should the nurse administer? (Enter numeric value only.)
Rationale
Using the formula, Desired / Available x 1 tablet =
0.75 mg / 0.5 mg x 1 = 1.5 tablets
Which intervention is most important for the nurse to implement for a
male client who is experiencing urinary retention?
Apply a condom catheter.
Apply a skin protectant.
Encourage increased fluid intake.
Assess for bladder distention.
Rationale
Urinary retention is the inability to void all urine collected in the bladder, which leads to
uncomfortable bladder distention. Assessing for distention is more important than applying a
catheter or applying skin protectant.
During a visit to the outpatient clinic, the nurse assesses a client with
severe osteoarthritis using a goniometer. Which finding should the
nurse expect to measure?
Adequate venous blood flow to the lower extremities.
Estimated amount of body fat by an underarm skinfold.
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Degree of flexion and extension of the client's knee joint.
Change in the circumference of the joint in centimeters.
Rationale
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring
device that is placed over a joint as the individual extends or flexes the joint to measure the degrees
of flexion and extension on the protractor. On the other hand, a doppler is used to measure blood
flow; calipers are used to measure body fat; and a tape measure is used to measure circumference of
body parts.
A client who is in hospice care reports increasing amounts of pain. The
healthcare provider prescribes an analgesic every four hours as
needed. Which action should the nurse implement?
Give an around-the-clock schedule for administration of analgesics.
Administer analgesic medication as needed when the pain is severe.
Provide medication to keep the client sedated and unaware of stimuli.
Offer a medication-free period so that the client can do daily activities.
Rationale
The most effective management of pain is achieved using an around-the-clock schedule that
provides analgesic medications on a regular basis and in a timely manner. Analgesics are less
effective if pain persists until it is severe, so an analgesic medication should be administered before
the client's pain peaks. Providing comfort is a priority for the client who is dying, but sedation that
impairs the client's ability to interact and experience the time before life ends should be minimized.
Offering a medication-free period allows the serum drug level to fall, which is not an effective
method to manage chronic pain.
A Sub-Saharan African widowed immigrant woman lives with her
deceased husband's brother and his family, which includes the
brother-in-law's children and the widow's adult children. Each family
member speaks fluent English. Surgery is recommended for this
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client. What is the best plan to obtain consent for surgery for this
client?
Obtain an interpreter to explain the procedure to the client.
Encourage the client to make her own decision regarding surgery.
Ask the family members to provide a clarification of the surgeon's explanation
to the client.
Tell the surgeon that the brother-in-law will decide after explanation of the
proposed surgery is provided to him and the widow.
Rationale
Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the
widow becomes the inherited wife of the her husband's brother. In those rural areas women live in a
patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the
decision for his inherited wife, so it is important to provide the surgeon with culturally sensitive
information. Since all family members speak fluent English, there is no need for a translator. It is
culturally insensitive to encourage the woman to go against her wishes to follow her cultural
worldview.
1
A client's daily PO prescription for aripiprazole (Abilify) is
increased from 15 mg to 30 mg. The medication is available in 15 mg
tablets, and the client already received one tablet today. How many
additional tablets should the nurse administer so the client receives
the total newly prescribed dose for the day? (Enter numeric value only.)
Rationale
30 mg (total dose) - 15 mg (dose already administered) = 15 mg that still needs to be administered.
Using the Desired/Have formula:
15 mg/15 mg = 1 tablet
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The nurse is performing nasotracheal suctioning. After suctioning the
client's trachea for fifteen seconds, large amounts of thick yellow
secretions return. What action should the nurse implement next?
Encourage the client to cough to help loosen secretions.
Advise the client to increase the intake of oral fluids.
Rotate the suction catheter to obtain any remaining secretions.
Re-oxygenate the client before attempting to suction again.
Rationale
Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the
client's oxygenation is compromised during this time. Additional suctioning may continue after the
client has received oxygen.
An African-American grandmother tells the nurse that her 4-year-old
grandson is suffering with "miseries." Based on this statement, which
focused assessment should the nurse conduct?
Inquire about the source and type of pain.
Examine the nose for congestion and discharge.
Take vital signs for temperature elevation.
Explore the abdominal area for distension.
Rationale
Different cultural groups often have their own terms for health conditions. African-American clients
may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a
focused assessment on the source and type of pain.
Which nutritional assessment data should the nurse collect to best
reflect total muscle mass in an adolescent?
Height in inches or centimeters.
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Weight in kilograms or pounds.
Triceps skin fold thickness.
Upper arm circumference.
Rationale
Upper arm circumference is an indirect measure of muscle mass.Height and weight do not
distinguish between fat (adipose) and muscularity.Triceps skin fold thickness is a measure of body fat.
The nurse notices that the mother of a 9-year-old Vietnamese child
always looks at the floor when she talks to the nurse. What action
should the nurse take?
Talk directly to the child instead of the mother.
Continue asking the mother questions about the child.
Ask another nurse to interview the mother now.
Tell the mother politely to look at you when answering.
Rationale
Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western
cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form
of respect, so the nurse should continue to ask the mother questions about the child.
An older resident of a long-term care facility is no longer able to
perform self-care and is becoming progressively weaker. The resident
previously requested that no resuscitative efforts be performed, and
the family requests hospice care. What action should the nurse
implement first?
Reaffirm the client's desire for no resuscitative efforts.
Transfer the client to a hospice inpatient facility.
Prepare the family for the client's impending death.
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Notify the healthcare provider of the family's request.
Rationale
When a family requests hospice care, the nurse should first communicate with the healthcare
provider. Hospice care is provided for clients with a limited life expectancy, which must be identified
by the healthcare provider. Once the healthcare provider supports the transfer to hospice care, the
nurse can collaborate with the hospice staff and healthcare provider to determine what additional
care should be implemented.
When assessing a client with wrist restraints, the nurse observes that
the fingers on the right hand are blue. What action should the nurse
implement first?
Loosen the right wrist restraint.
Apply a pulse oximeter to the right hand.
Compare hand color bilaterally.
Palpate the right radial pulse.
Rationale
The nurse has observed that a client's fingers are blue distal to a wrist restraint. The priority nursing
action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates
decreased circulation. Assessing the depth of color change and the radial pulse are also important
nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry
measures the saturation of hemoglobin with oxygen and is not indicated in situations where the
cyanosis is related to mechanical compression (the restraints).
2
A client who has a sinus infection is receiving a
prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg
PO q8 hours. The available form is 250 mg amoxicillin/125mg
clavulanate tablets. How many tablets should the nurse administer for
each dose? (Enter numeric value only.)
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Rationale
Using Desired/Available formula:
500 mg/250 mg x 1 tablet = 2
A male client being discharged with a prescription for the
bronchodilator theophylline tells the nurse that he understands he is
to take three doses of the medication each day. Since, at the time of
discharge, timed-release capsules are not available, which dosing
schedule should the nurse advise the client to follow?
9 a.m., 1 p.m., and 5 p.m.
8 a.m., 4 p.m., and midnight.
Before breakfast, before lunch, and before dinner.
With breakfast, with lunch, and with dinner.
Rationale
Theophylline should be administered on a regular, around-the-clock schedule to provide the best
bronchodilating effect and to reduce the potential for adverse effects. Food may alter absorption of
the medication, so it should not be taken with meals.
The nurse is instructing a client with high cholesterol about diet and
life style modification. What comment from the client indicates that
the teaching has been effective?
"If I exercise at least two times weekly for one hour, I will lower my
cholesterol."
"I need to avoid eating proteins, including red meat."
"I will limit my intake of beef to 4 ounces per week."
"My blood level of low density lipoproteins needs to increase."
Rationale
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Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important
diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should
exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need
to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller
portions (2-ounce servings). The low density lipoproteins need to decrease rather than increase.
The nurse is teaching a client proper use of an inhaler. When should
the client administer the inhaler-delivered medication to demonstrate
correct use of the inhaler?
Immediately after exhalation.
During the inhalation.
At the end of three inhalations.
Immediately after inhalation.
Rationale
The client should be instructed to deliver medication through a metered inhaler during the last part
of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping
his/her lips closed and hold the breath for several seconds to allow for distribution of the medication.
Which snack food is best for the nurse to provide a client with
myasthenia gravis who is at risk for altered nutritional status?
Chocolate pudding.
Graham crackers.
Sugar free gelatin.
Apple slices.
Rationale
The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle
weakness resulting in dysphagia. Snacks that are semisolid, such as pudding are easy to swallow,
require minimal chewing effort, and provide calories and protein.Gelatin does not provide any
nutritional value and the other options require energy to chew and are more difficult to swallow than
pudding.
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A female client with a nasogastric tube attached to low suction states
that she is nauseated. The nurse assesses that there has been no
drainage through the nasogastric tube in the last two hours. Which
action should the nurse take first?
Irrigate the nasogastric tube with sterile normal saline.
Reposition the client on her side.
Advance the nasogastric tube an additional five centimeters.
Administer an intravenous antiemetic prescribed for PRN use.
Rationale
The nurse has identified two things suggesting the the nasogastric tube is not functioning properly;
the client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to
determine if the tube is functioning correctly, which would then relieve the client's nausea. The least
invasive intervention should be attempted first. This includes repositioning the client to her side. The
tube may need to be irrigated or advanced but these actions should follow repositioning the client.
A client with chronic kidney disease (CKD) selects a scrambled egg for
his breakfast. Which action should the nurse take?
Commend the client for selecting a high biologic value protein.
Remind the client that protein in the diet should be avoided.
Suggest that the client also select orange juice, to promote absorption.
Encourage the client to attend classes on dietary management of CKD.
Rationale
Foods such as eggs and milk are high biologic proteins which are allowed because they are complete
proteins and supply the essential amino acids that are necessary for growth and cell repair. Although
a low-protein diet is followed, some protein is essential. Orange juice is rich in potassium, and
should not be encouraged. The client has made a good diet choice, so classes on dietary
management is not necessary.
During the daily nursing assessment, a client begins to cry and states
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that the majority of family and friends have stopped calling and
visiting. What action should the nurse take?
Listen and show interest as the client expresses these feelings.
Reinforce that this behavior means they were not true friends.
Ask the healthcare provider for a psychiatric consult.
Continue with the assessment and tell the client not to worry.
Rationale
When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and
show interest as the client expresses feelings (A). (B) is not a therapeutic option and the nurse does
not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic
and offers false hope.
An unlicensed assistive personnel (UAP) places a client in a left lateral
position prior to administering a soap suds enema. Which instruction
should the nurse provide the UAP?
Position the client on the right side of the bed in reverse Trendelenburg.
Fill the enema container with 1000 mL of warm water and 5 mL of castile
soap.
Reposition in a Sims' position with the client's weight on the anterior ilium.
Raise the side rails on both sides of the bed and elevate the bed to waist level.
Rationale
The left-sided Sims' position allows the enema solution to follow the anatomical course of the
intestines and allows the best overall results, so the UAP should reposition the client in the Sims'
position, which distributes the client's weight to the anterior ilium. The reverse Trendelenburg is
inaccurate. The other options should be implemented once the client is positioned.
During the admission interview, which technique is most efficient for
the nurse to use when obtaining information about signs and
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symptoms of a client's primary health problem?
Restatement of responses.
Open-ended questions.
Closed-ended questions.
Problem-seeking responses.
Rationale
Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific
information, the nurse should use closed-ended questions that focus on common signs and
symptoms about a client’s health problem.Other question types are used when therapeutically
interacting and should be used after specific information is obtained from the client.
The nurse is examining a male client who reports itching on his right
arm, The nurse observes a rash made up of multiple flat areas of
redness ranging from pinpoint to 0.5 cm in diameter. How should the
nurse record this finding?
Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to
0.5 cm.
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
Rationale
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording
such a finding the nurse should describe the appearance rather than simply naming the condition.
Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to
purple skin discolorations that do not itch.
The nurse assigns an unlicensed assistive personnel (UAP) to obtain
vital signs from a very anxious client. What instructions should the
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nurse give the UAP?
Remain calm with the client and record abnormal results in the chart.
Notify the medication nurse immediately if the pulse or blood pressure is low.
Report the results of the vital signs to the nurse.
Reassure the client that the vital signs are normal.
Rationale
Interpretation of vital signs is the responsibility of the nurse, so the unlicensed assistive personnel
(UAP) should report vital sign measurements to the nurse. Any instructions requiring the UAP to
interpret the vital signs causes the UAP to function beyond the scope of the UAP's authority.
A client who is a Jehovah's Witness is admitted to the nursing unit.
Which concern should the nurse have for planning care in terms of the
client's beliefs?
Autopsy of the body is prohibited.
Blood transfusions are forbidden.
Alcohol use in any form is not allowed.
A vegetarian diet must be followed.
Rationale
Blood transfusions are forbidden in the Jehovah's Witness religion. Judaism prohibits autopsies and
Buddhism forbids the use of alcohol and drugs. Many of these sects follow a vegetarian diet, but the
direct impact on nursing care concerns beliefs about transfusions.
A client with acute hemorrhagic anemia is to receive four units of
packed red blood cells (RBCs) as rapidly as possible. Which
intervention is most important for the nurse to implement?
Obtain the pre-transfusion hemoglobin level.
Prime the tubing and prepare a blood pump set-up.
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Monitor vital signs every 15 minutes for the first hour.
Ensure the accuracy of the blood type match.
Rationale
Any time blood is administered, the nurse should ensure the accuracy of the blood type match in
order to prevent a possible hemolytic reaction. Preparing the tubing, checking the baseline
hemoglobin, and monitoring vital signs should also be implemented prior to administering blood,
but checking the blood type has the highest priority.
A client's spouse is learning passive range-of-motion for the client's
contracted shoulder. The nurse observes that the spouse is holding
the client's arm above and below the elbow. Which nursing action
should the nurse implement?
Acknowledge that the spouse is supporting the arm correctly.
Encourage the spouse to keep the joint covered to maintain warmth.
Reinforce the need to grip directly under the joint for better support.
Instruct the spouse to grip directly over the joint for better motion.
Rationale
The client's spouse is correctly holding the arm above and below the elbow to perform passive rangeof motion to the contracted shoulder. The nurse should acknowledge this fact. The joint that is being
exercised should be uncovered while the rest of the body should remain covered for warmth and
privacy.
A male client with obesity discusses with the nurse his plans to begin a
long-term weight loss regimen. In addition to dietary changes, he
plans to begin an intensive aerobic exercise program 3 to 4 times a
week and to take stress management classes. After praising the client
for his decision, which instruction is most important for the nurse to
provide?
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"Be sure to have a complete physical examination before beginning your
planned exercise program."
"Be careful that the exercise program doesn't simply add to your stress level,
making you want to eat more."
"Increased exercise helps to reduce stress, so you may not need to spend
money on a stress management class."
"Make sure to monitor your weight loss regularly to provide a sense of
accomplishment and motivation."
Rationale
A client with obesity who intends to begin a weight loss and exercise program may be at risk for
cardiovascular complications. The most important teaching is to encourage the client to have a
complete medical evaluation so that the client will not begin a dangerous level of exercise when he is
not sufficiently fit. Vigorous exercise may result in chest pain, a heart attack, or stroke.
The nurse is evaluating a client learning about a low-sodium diet.
Selection of which meal would indicate to the nurse that this client
understands the dietary restrictions?
Tossed salad, low-sodium dressing, bacon and tomato sandwich.
New England clam chowder, no-salt crackers, fresh fruit salad.
Skim milk, turkey salad, roll, vanilla ice cream.
Macaroni and cheese, diet Coke, a slice of cherry pie.
Rationale
Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium
foods. Bacon, canned soups (especially those with seafood), hard cheeses, macaroni, and most diet
drinks are very high in sodium.
A client is in the radiology department at 0900 when the prescription
levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be
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administered. The client returns to the unit at 1300. What is the best
intervention for the nurse to implement?
Contact the healthcare provider and complete a medication variance form.
Administer the Levaquin at 1300 and resume the 0900 schedule in the
morning.
Notify the charge nurse and complete an incident report to explain the missed
dose.
Give the missed dose at 1300 and change the schedule to administer daily at
1300.
Rationale
To ensure that a therapeutic level of medication is maintained, the nurse should administer the
missed dose as soon as possible, and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the bloodstream. The nurse should document
the reason for the late dose, but contacting the healthcare provider or the charge nurse are not
warranted.
A nurse is preparing to give medications through a nasogastric feeding
tube. Which nursing action should prevent complications during
administration?
Mix each medication individually.
Use sterile gloves for the procedure.
Monitor vital signs before giving medications.
Mix all medications together to facilitate administration.
Rationale
When administering medications through a nasogastric feeding tube, the medications should be
mixed separately to prevent clumping.
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1.5
Secobarbital (Seconal) 150 mg is prescribed at bedtime
for a male client who is scheduled for surgery in the morning. The
scored tablets are labeled 0.1 gram/tablet. How many tablets should
the nurse administer? (Enter the numerical value only. If rounding is
required, round to the nearest tenth.)
Rationale
1, 000 mg : 1 gram :: X mg : 0.1 gram
X = 100 mg
D/H = 150/100 = 1.5 tablets
The nurse is administering medications through a nasogastric tube
(NGT) which is connected to suction. After ensuring correct tube
placement, which action should the nurse take next?
Clamp the tube for 20 minutes.
Flush the tube with water.
Administer the medications as prescribed.
Crush the tablets and dissolve in sterile water.
Rationale
The NGT should be flushed before, after, and in between each medication administered. Once all
medications are administered, the NGT should be clamped for 20 minutes.Other options may be
implemented only after the tubing has been flushed.
At the beginning of the shift, the nurse assesses a client who is
admitted from the post-anesthesia care unit (PACU). When should the
nurse document the client's findings?
At the beginning, middle, and end of the shift.
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After client priorities are identified for the development of the nursing care
plan.
At the end of the shift so full attention can be given to the client's needs.
Immediately after the assessments are completed.
Rationale
Documentation of client findings should occur immediately after any component of the nursing
process, so assessments should be entered in the client's medical record as readily as findings are
obtained.
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn)
7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How many tablets
should the nurse plan to administer?
1/2 tablet.
1 tablet.
1 1/2 tablets.
2 tablets.
Rationale
D/H X Q = 7.5/5 X 1 tablet = 1 1/2 tablets.
The nurse notices that the Hispanic parents of a toddler who returns
from surgery offer the child only the broth that comes on the clear
liquid tray. Other liquids, including gelatin, popsicles, and juices,
remain untouched. What explanation is most appropriate for this
behavior?
The belief is held that the "evil eye" enters the child if anything cold is
ingested.
After surgery the child probably has refused all foods except broth.
Eating broth strengthens the child's innate energy called "chi."
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"Hot" remedies restore balance after surgery, which is considered a "cold"
condition.
Rationale
Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures
classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain
health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot"
remedies, such as soup, should be used to restore the healthy balance within the body.
The nurse is completing a mental assessment for a client who is
demonstrating slow thought processes, personality changes, and
emotional lability. Which area of the brain controls these neurocognitive functions?
Thalamus.
Hypothalamus.
Frontal lobe.
Parietal lobe.
Rationale
The frontal lobe of the cerebrum controls higher mental activities, such as memory, intellect,
language, emotions, and personality. On the other hand, the thalamus is an afferent relay center in
the brain that directs impulses to the cerebral cortex. The hypothalamus regulates body temperature,
appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and
endocrine systems, such as the pituitary. The parietal lobe is the location of sensory and motor
functions.
2
A client receives a prescription for azithromycin
(Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg
scored tablets. How many tablets should the nurse administer per
dose? (Enter the numerical value only.)
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Rationale
Using the formula, D/H
500 mg/250 mg = 2 tablets
A client with type 2 diabetes is receiving metformin
2
(Glucophage) 1 gram PO twice daily. The medication is available in 500
mg tablets. How many tablets should the nurse administer? (Enter
numeric value only.)
Rationale
Using the known equivalent, 1 gram = 1000 mg, the nurse should first convert the dose to the same
unit of measurement, which is 1 gram = 1000 mg.
Using the formula, Desired / Available x 1 tablets:
1000 mg / 500 mg x 1 = 2 tablets
The unlicensed assistive personnel (UAP) working on a chronic neuro
unit asks the nurse to help determine the safest way to transfer an
older client with left-sided weakness from the bed to the chair. Which
method describes the correct transfer procedure for this client?
Place the chair at a right angle to the bed on the client's left side before
moving.
Assist the client to a standing position, then place the right hand on the
armrest.
Have the client place the left foot next to the chair and pivot to the left before
sitting.
Move the chair parallel to the right side of the bed, and stand the client on the
right foot.
Rationale
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When positioning a client for transfer from bed to chair when the client has left-sided weakness, use
the client's stronger side, the right side, for weight-bearing during the transfer. In this case, the
client should stand on the right foot during the transfer.
During the initial morning assessment, a male client denies dysuria
but reports that his urine appears dark amber. Which intervention
should the nurse implement?
Provide additional coffee on the client's breakfast tray.
Exchange the client's grape juice for cranberry juice.
Bring the client additional fruit at mid-morning.
Encourage additional oral intake of juices and water.
Rationale
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to
increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit.
Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract
infection. The client needs to restore fluid volume more than solid foods (C).
3
Docusate sodium (Colace) 0.3 grams is prescribed for a
client who has frequent constipation. Each capsule contains 100 mg.
How many capsules should the nurse administer?
Rationale
Using the known equivalent, 1 gram = 1000 mg, the nurse should first convert the dose to the same
unit of measurement, which is 0.3 gram = 300 milligram. Using the formula, Desired / Available x 1
capsule = 300/100 x 1 = 3 capsules.
2
A client with pericardial effusion has phrenic nerve
compression resulting in recurrent hiccups. The healthcare provider
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prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours.
Reglan is available as 5 mg/5 ml. A measuring device marked in
teaspoons is being used. How many teaspoons should the nurse
administer?
Rationale
First, using the formula, Desired dose/dose on Hand x Quantity of volume on hand (D/H x Q),
10 mg / 5 mg x 5ml = 10 ml
Next using the known conversion of 5 ml = 1 tsp:
5 ml : 1 tsp :: 10 ml : X
5 / 10 : 1 / X
5X = 10
X=2
An older client who is unresponsive following a cerebral vascular
accident (CVA) is receiving bolus enteral feedings through a
gastrostomy tube (GT). What is the best position for the client for
administration of the bolus tube feedings?
Prone.
Fowler's.
Sims'.
Supine.
Rationale
A gastrostomy tube (GT), known as a PEG tube, due to placement by a percutaneous endoscopic
gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for
long-term administration of nutrition and hydration in the debilitated client. The unresponsive client
should be positioned in a semi-sitting (Fowler's) position during feeding through a gastrostomy tube
to decrease the occurrence of aspiration. In prone or Sims' positions, the client is placed on the
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abdomen, an unsafe position for feeding. Placing the client in supine position increases the risk of
aspiration.
When conducting an admission assessment, the nurse should ask the
client about the use of complementary healing practices. Which
statement is accurate regarding the use of these practices?
Complementary healing practices interfere with the efficacy of the medical
model of treatment.
Conventional medications are likely to interact with folk remedies and cause
adverse effects.
Many complementary healing practices can be used in conjunction with
conventional practices.
Conventional medical practices will ultimately replace the use of
complementary healing practices.
Rationale
Conventional approaches to health care can be depersonalizing and often fail to take into
consideration all aspects of an individual, including body, mind, and spirit. Often complementary
healing practices can be used in conjunction with conventional medical practices, rather than
interfering with conventional practices, causing adverse effects, or replacing conventional medical
care.
The nurse witnesses the signature of a client who has signed an
informed consent. Which statement best explains this nursing
responsibility?
The client voluntarily signed the form.
The client fully understands the procedure.
The client agrees with the procedure to be done.
The client authorizes continued treatment.
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Rationale
The nurse signs the consent form to witness that the client voluntarily signs the consent, that the
client’s signature is authentic, and that the client is otherwise competent to give consent. It is the
healthcare provider's responsibility to ensure that the client fully understands the procedure. The
nurse’s signature does not indicate that the client agrees to or authorizes treatment.
Which action is most important for the nurse to implement when
donning sterile gloves?
Maintain thumb at a ninety degree angle.
Hold hands with fingers down while gloving.
Keep gloved hands above the elbows.
Put the glove on the dominant hand first.
Rationale
Gloved hands held below waist level are considered unsterile. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis.
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