Kaplan predictor A
The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the
nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST
appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.
1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration;
cuff position and pressure should be assessed frequently; swallowing and breathing will cause
tracheostomy tube movement
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain
into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm
H2O); risk of trauma to trachea with higher pressures
4) Implementation: outcome not desired; increases the risk of trauma to lower airways
A young adult brings a friend to the emergency department and states that the friend has been
using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date.
1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin
overdose
2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be
seen; not priority
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?"
1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be appropriate; should be assessed for further
teaching
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases
heart rate and myocardial oxygen consumption; increased risk of angina and myocardial
infarction
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and
gums; may stain dental work
The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
determines that the client has pressed the button 11 times and received 6 doses of morphine
during the last hour. Which is the MOST appropriate action for the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain.
1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is
activated
2) Assessment: outcome may be appropriate but not priority; more important to determine pain
level, description of the pain, region and radiation of the pain, and relieving factors
3) Implementation: outcome not desired; more important to assess severity of pain and pain relief
first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before
implementation
A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse
is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated.
1) Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac
output; fetal pressure on inferior vena cava reduced
4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal
pressure on vena cava will prevent blood return to heart
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which
finding BEST indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82.
1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone
secreted; urine output decreased and concentrated
2) Assessment: outcome not priority; indicates that blood is hemoconcentrated
3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is 120/80
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the
morning. Which medication should the nurse question giving to the client?
1. 20 mg oral escitalopram (Celexa) in the morning.
2. 40 mg oral furosemide (Lasix) in the morning.
3. 300 mg of oral gabapentin (Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at bedtime.
1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI
antidepressant
2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis;
first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation;
combination of vasodilation and diuresis increases risk of orthostatic hypotension
3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure
medication; off-label use for neuropathic pain
4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors
The home care nurse visits a client with a halo fixator traction device. Which client statement
MOST concerns the nurse?
1. "My wife looks at the pin sites every day."
2. "I like to bathe in the tub."
3. "I drove to the library yesterday."
4. "I drink with a straw."
1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of
inflammation and infection
2) Implementation: outcome desired; showers increase risk of infection at pin sites
3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to
turn with halo device; increases the risk of injury to self and others
4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized
neck
The nurse cares for a client diagnosed with depression. Which statement by the client indicates
improvement?
1. "I have been sleeping 6 hours at night."
2. "I have lost 2 lbs in the past week."
3. "Lately, I have trouble watching television."
4. "I have much less muscle tension now."
1) CORRECT - Assessment: outcome desired; clients with depression may have increased or
decreased sleep time
2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression
3) Assessment: outcome not desired; lack of concentration is sign of depression
4) Assessment: outcome not desired; is a sign of anxiety
The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The
nurse considers which transfer client appropriate?
1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.
2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer.
3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
4. A 74-year-old client who has received intravenous antibiotics for 7 days.
1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious
2) Implementation: outcome not desired; possible skin damage and suppression of bone marrow
with decreased white-blood-cell levels; increased risk for infection
3) Implementation: outcome not desired; generalized skin infection of deeper connective tissue;
usually caused by Streptococcus or Staphylococcus; increased risk for infection
4) Implementation: outcome not desired; elderly clients receiving long-term antibiotic therapy
are at risk for Clostridium difficile infection; highly contagious; increased risk for infection
The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST
important for the nurse to make which of these statements?
1. "Your parents are going to leave a half hour before the surgery."
2. "You're going to talk with some other children who had this surgery."
3. "If you have this surgery, your parents will buy you a new toy."
4. "Take this doll and show me where the operation will be done."
1) Implementation: outcome not desired; parents are encouraged to remain with child
2) Implementation: outcome not desired; appropriate only for school-aged and adolescent
children
3) Implementation: outcome not desired; not appropriate
4) CORRECT - Implementation: outcome desired; encourage expression of feelings (e.g., anger);
fear mutilation; allow child to play with models of equipment
The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and
incontinent of urine. What is the MOST important action for the nurse to take?
1. Insert an indwelling urinary drainage catheter.
2. Perform intermittent catheterization every 4 hours.
3. Offer the bedpan to the client every 2 hours.
4. Assist the client to a bedside commode every 2 hours.
1) Implementation: outcome not desired; increases risk of infection; catheter-related infections
are most common hospital-acquired infection
2) Implementation: outcome not desired; increases chance of infection
3) Implementation: outcome appropriate but not priority; does not keep client independent and
active
4) CORRECT - Implementation: outcome desired; keeps client active and independent
The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the
surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose
is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should
be administered. Which of the following is the FIRST action the nurse should take?
1. Check the client records to see if insulin was given prior to surgery.
2. Administer the 6 units of regular insulin subcutaneously.
3. Administer the insulin when oral fluids are tolerated.
4. Contact the healthcare provider.
1) Assessment: outcome desired but not priority; client needs insulin coverage now
2) CORRECT - Implementation: outcome desired; sliding scale-receives predetermined amount
of insulin according to glucose level; surgery and infection increase insulin needs
3) Implementation: outcome not desired; needs insulin regardless of oral intake due to elevated
blood glucose
4) Implementation: outcome not desired; no reason to contact healthcare provider; order is valid
and appropriate for situation
During the admission interview, the client reports a red, itchy raised rash on the chest and lip
swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as
tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of
expected breath sounds heard during auscultation?
1. Administer the Ceclor as ordered; do not administer the naproxen.
2. Administer the naproxen as ordered; do not administer the Ceclor.
3. Administer both the Ceclor and naproxen as ordered; document the client's response.
4. Do not administer the Ceclor or naproxen; notify the healthcare provider.
1) Implementation: outcome not desired; cephalosporins have cross-allergies with penicillins
2) Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin
allergies
3) Implementation: outcome not desired; both medications should be withheld due to allergies
4) CORRECT - Implementation: outcome desired; both medications should be withheld; risk of
hypersensitivity reaction
The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the
client to the nurse, indicates further teaching is needed?
1. "The skin around the stoma should be cleaned with warm water and thoroughly dried."
2. "The appliance should fit snugly around the ileostomy opening."
3. "I should take polyethylene glycol (MiraLax) with a large glass of water."
4. "I will continue to take a daily multi-vitamin."
1) Implementation: outcome desired; standard of care for ileostomy
2) Implementation: outcome desired; ileostomy drainage is liquid and very alkaline; great risk of
skin irritation
3) CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated;
avoid enteric-coated or capsule medication, which may not be absorbed through GI tract
4) Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy
The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease.
The nurse expects to assess which of these breath sounds?
1. Continuous, high-pitched musical sounds heard on expiration.
2. Soft, high-pitched interrupted sounds heard on inspiration.
3. Deep, low-pitched rumbling sounds are heard mainly on expiration.
4. Harsh, grating sounds heard best during inspiration.
1) Assessment: outcome not expected; sibilant wheezes, heard with asthma, caused by narrow
bronchioles
2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF, caused by fluid
in the alveoli
3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus
in the airways; excessive mucous production is primary symptom
4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed pleura or
pericarditis
The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the
MOST important action for the nurse to take prior to administration of the medication?
1. Request a daily hemoglobin and hematocrit test.
2. Monitor the serum BUN and creatinine.
3. Request a highly-sensitive C-reactive protein (hs-CRP) test.
4. Monitor the erythrocyte sedimentation rate (ESR).
1) Assessment: outcome not priority; may cause anemia, but not usually seen
2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria,
hematuria, thirst, increased BUN, decreased creatine clearance
3) Assessment: outcome not priority; will be increased in inflammation and rheumatoid arthritis
4) Assessment: outcome not priority; will be increased with any inflammatory process
The nurse cares for the client in the labor unit. During the transitional phase of labor, the
umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action?
1. Place the client on her back with thighs flexed on her abdomen.
2. Place the client on her left side with legs flexed.
3. Place the client supine with the head of the bed elevated 30°.
4. Place the client supine with the foot of the bed elevated.
1) Implementation: outcome not desired; lithotomy position; will not decrease pressure on
umbilical cord
2) Implementation: outcome not desired; position used to remove weight of fetus from vena cava
to prevent maternal hypotension; will not help with prolapsed cord
3) Implementation: outcome not desired; would aggravate prolapsed cord pressure
4) CORRECT - Implementation: outcome desired; Trendelenburg or knee chest position desired
to decrease pressure on umbilical cord
The nurse cares for the client diagnosed with lung cancer. The family states that the client has
become confused and that urinary output has decreased during the previous 24 hours. Which
finding MOST concerns the nurse?
1. 2+ pitting pretibial edema.
2. Sodium 128 mEq/L.
3. Weight gain of 2 kg in 24 hours.
4. Urine specific gravity 1.008.
1) Assessment: outcome desired but not priority; edema not seen with SIADH even though water
is retained; needs to be monitored
2) CORRECT - Assessment: outcome desired and priority; normal sodium range is 135-145
mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased
risk of seizures
3) Asssessment: outcome desired but not priority; indicates fluid retention, not as important as
hyponatremia; important to watch trends in weight
4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with SIADH, urine
will have high concentration and specific gravity due to excess ADH secretion
The home care nurse cares for a client who is diagnosed with hypertension and mild depression.
The client's daughter states that her mother has been falling frequently. WWhich response by the
nurse is BEST?
1. "Let's get your mother a walker."
2. "Do you think it's time to put your mother in a nursing home?"
3. "When does your mother fall?"
4. "Does your mother seem to be more confused lately?"
1) Implementation: outcome not desired; need to assess first
2) Assessment: outcome not priority; "yes/no" question; doesn't help determine the problem
3) CORRECT - Assessment: outcome priority; nurse needs to determine what the problem is
before implementing; recent history of falling is most important contributor to increased risk of
falls
4) Assessment: outcome not priority; "yes/no" question is non-therapeutic; need to assess; may
be a contributing factor
A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which
action prior to the angiogram?
1. Clean and shave the catheter insertion-site area.
2. Locate and note the presence of peripheral pulses.
3. Encourage the client to increase oral fluid intake.
4. Teach coughing and deep-breathing exercises.
1) Implementation: outcome not desired; cleansing may be done according to facility policy;
shaving may not be recommended due to possible abrasions and increased risk of infection
2) CORRECT - Assessment: outcome desired and priority; pulse location may be marked
according to facility policy; important to get baseline assessment of color, motion, temperature
and sensitivity of extremities as well as strength and equality of pulses
3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause possible
nausea; fluid intake should be increased after procedure to clear dye and reduce risk of renal
toxicity
4) Implementation: outcome desired but not highest priority; not at greatly increased risk for
atelectasis
A child sustains a crushing chest injury in a car accident. In the emergency room, an
endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the
child in respiratory distress. It is MOST important for the nurse to take which action prior to the
angiogram?
1. Observe the color of the client's fingernail beds.
2. Assess the client's blood pressure in both arms.
3. Listen to the client's breath sounds.
4. Assess for intercostal retractions.
1) Assessment: outcome desired but not priority; cyanosis is a late sign of respiratory distress;
central cyanosis will occur later than peripheral cyanosis
2) Assessment: outcome not desired; priority is to assess respiratory status; blood pressure may
change due to decreased arterial oxygen levels; priority is to correct underlying problem
3) CORRECT - Assessment: outcome priority; will give early and clearest indication of
respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax
4) Assessment: outcome desired but not priority; late indication of respiratory distress;
intercostal muscles are accessory muscles
The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important
for the nurse to take which action?
1. Leave the television on all day in the client's room.
2. Frequently inform the client of the room and bathroom location.
3. Provide the client with newspapers and magazines.
4. Assign a staff member to check on the client every 15 minutes.
1) Implementation: outcome not desired; does not address orientation needs; risk of
overstimulation; television should be on intermittently
2) CORRECT - Implementation: outcome desired; provides for safety needs and frequent
orientation
3) Implementation: outcome not priority; does not address safety needs or orientation
4) Implementation: outcome desired not priority; addresses safety but not orientation or
stimulation needs
The nurse is responsible for triage of injured residents of an apartment building that collapsed
during a tornado. Which client should the emergency personnel see FIRST?
1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse
92/minute, shallow respirations at 16/minute.
2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood
pressure 142/90, pulse 88/minute, shallow respirations at 20/minute.
3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute,
irregular respirations at 12/minute.
4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood
pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute.
1) Potential for hemorrhage or fatty embolism; eliminate second
2) Potential pneumothorax; see second
3) CORRECT - Real problem; vitals signs indicate significant increase in intracranial pressure;
most unstable client
4) Most stable client; eliminate first
The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about
diet. Which menu selection indicates to the nurse that teaching is effective?
1. Cheeseburger on a whole-wheat bun, french fries, and an apple.
2. Tomato soup, saltines, and a slice of unfrosted angel food cake.
3. Baked cod, biscuit without butter, fruit roll-up.
4. Macaroni and cheese, coleslaw, 2 macaroon cookies.
1) Implementation: outcome not desired; high-fat, high-protein, high-residue; high-residue
contraindicated
2) Implementation: outcome not desired; low-fat, low-protein, low-residue
3) CORRECT - Implementation: outcome desired; low-fat, high-protein, low-residue,
nonirritating, high in calories, minerals
4) Implementation: outcome not desired; high-fat, low-protein, high-residue; may cause diarrhea
The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel
(NAPs). Which assignment is MOST appropriate for the LPN/LVN?
1. A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis
therapy.
2. A 72-year-old client admitted yesterday with a 10-day history of oral antibiotic therapy and a
24-hour history of watery diarrhea.
3. A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago.
4. A 86-year-old client just admitted with malaise, a productive cough, and WBC 17,000 mm3.
1) Outcome not desired; requires frequent assessment of neuromuscular function and monitoring
response to therapy
2) Outcome not desired; elderly clients are at risk for clostridium difficile infection due to
antibiotic therapy; client would need frequent assessment and evaluation
3) CORRECT - Outcome desired; LPN/LVN can care for stable clients with expected outcomes;
nothing in question indicates instability; as cerebral edema resolves, the condition will improve
4) Outcome: not desired; client requires frequent assessment and evaluation; WBC indicates
possible infection
The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the
client tells the nurse that she has started to menstruate. Which action by the nurse is MOST
appropriate?
1. Inform the health care provider that the client is menstruating.
2. Send the urine collected prior to the onset of the client's menstruation to the lab.
3. Insert an indwelling bladder catheter during the remainder of the collection period.
4. Request a separate urine collection container from the laboratory to be used during the
remainder of the urine collection period.
1) CORRECT - Implementation: outcome desired; menstruation may last several days to a week;
protein and red cells may alter the results of the urinalysis
2) Implementation: outcome not desired; all urine must be collected for accuracy
3) Implementation: outcome not desired; invasive procedure should be avoided if possible
4) Implementation: outcome not desired; would change the results of the 24-hour urine sample;
all urine must be collected for accuracy
The nurse cares for the client in the recovery room after a knee surgery procedure. The client has
an oral airway in place. Which is the BEST indicator that the oral airway can be removed?
1. The client has a forceful cough during repositioning.
2. The client tries to chew on the oral airway..
3. The client tries to push the airway out with his tongue.
4. The client is able to swallow.
1) Assessment: outcome not priority; may cough due to irritation of the airway; does not reflect
client responsiveness
2) CORRECT - Assessment: outcome priority; client is alert and able to maintain his own airway
3) Assessment: outcome not priority; client needs to be responsive before airway is removed;
may be a reflexive action
4) Assessment: outcome not priority; client will be able to swallow before he is responsive
The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST?
1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test.
2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema.
3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate.
4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal
movement.
1) Outcome not priority; indicates that Rh antibodies present; needs further investigation
2) CORRECT - Outcome priority; indicates pre-eclampsia; requires immediate evaluation; is at
risk for complications
3) Outcome not priority; colostrum may leak from breast during pregnancy; normal finding
4) Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in
primagravidas; 20 weeks in multigravidas
The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone
(Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further
instruction?
1. "I should weigh myself every morning and call the health care provider if I gain more than a
couple of pounds in a few days."
2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty
breathing with normal activities."
3. "I plan to use salt substitutes now that I have to limit my sodium intake."
4. "I should read food and nonprescription medication labels to check the ingredients."
1) Implementation: outcome desired; would indicate fluid retention
2) Implementation: outcome desired; symptoms of digitalis toxicity, CHF
3) CORRECT - Implementation: outcome not desired; salt substitutes contain potassium;
spironolactone is a potassium-sparing diuretic
4) Implementation: outcome desired; some medications may contain sodium and potassium
The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When the nurse
approaches the client with the informed consent form, the client says, "I don't need to talk to
anybody about this procedure. I already know everything I need to know about it." Which
response by the nurse is BEST?
1. "After I explain the operation to you, both of us will sign the form for legal purposes and it
will be placed in your chart."
2. "Tell me what the healthcare provider told you about the risks and benefits of this operation."
3. "Can I answer any questions that you have about the procedure?"
4. "You should read all these materials to be sure that you understand everything about this
procedure."
1) Implementation: outcome not desired; nurse should not explain the procedure; the health care
provider doing the procedure should explain the risks and benefits
2) CORRECT - Assessment: outcome desired; nurse should determine if client understands risks
and benefits of the procedure before the client and nurse sign the informed consent form
3) Implementation: outcome not desired; yes/no question non-therapeutic response
4) Implementation: outcome desired but not priority; reading materials do not ensure that client
understands risks and benefits of the procedure
A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a
monogamous relationship. Which statement by the nurse is BEST?
1. "You will need to wear a condom when having sexual intercourse for 6 weeks following the
vasectomy."
2. "No other form of birth control is necessary for you or your wife at this time."
3. "You do not need to wear a condom when having sexual intercourse for the next few weeks,
but your wife should use spermicidal jelly."
4. "Always wear a condom when having sexual intercourse because not all vasectomies are
successful."
1) CORRECT - Implementation: outcome desired; sperm count decreased after the vasectomy;
some sperm may remain in the vas deferens
2) Implementation: outcome not desired; sperm stored in vas deferens may be ejaculated for
several weeks after the vasectomy
3) Implementation: outcome not desired; not effective enough
4) Implementation: outcome not desired; considered successful after 2 negative sperm counts
The nurse prepares to assign a client requiring a capillary blood glucose test to a newly hired
nursing assistive personnel. Which action should the nurse take FIRST?
1. "Show me how you check a capillary glucose level."
2. "How many of these glucose checks have you done in the past?"
3. "Would you like for me to go with you when you do the glucose test?"
4. "Was this procedure covered during your nursing assistive personnel class?"
1) CORRECT - Assessment: outcome priority; must evaluate competency of the UAP; nurse is
accountable for UAP's actions during delegation process
2) Assessment: outcome not priority; number of procedures done is not as important as
demonstrated competency
3) Assessment: outcome not priority; nurse should be able to delegate procedure if UAP is
competent
4) Assessment: outcome not priority; obtaining a capillary glucose sample is within UAP scope
of practice
A 12-year-old diagnosed boy with a fractured right femur is placed in balanced suspension
traction with a Thomas splint and Pearson attachment. The nurse is MOST concerned by which
client statement?
1. "I will experience more muscle spasms and pain while my leg is in traction."
2. "I can lift my body up while I grab the overhead trapeze and bend my left leg."
3. "The health care provider told me it is okay to move the head of my bed up and down by
myself."
4. "I need to put the phone where I can reach for it without moving onto my side."
1) CORRECT - Implementation: outcome not desired; muscle spasm should decrease with
traction; if muscle spasm pain increases, the amount of traction weight should be assessed
2) Implementation: outcome desired; vertical movement is allowed as long as line of pull is
maintained
3) Implementation: outcome desired; balanced suspension traction not affected by movement of
bed; not affected by client movement unless line of pull affected
4) Implementation: outcome desired; can move up and down only, moving side-to-side changes
line of pull of traction
The nurse prioritizes the needs of a client who has been raped. Which nursing action is MOST
important?
1. Observe the client for withdrawn, tearful behavior.
2. Determine if the client sustained any injuries.
3. Obtain information about events which preceded the rape.
4. Accurately document the client's comments about the rape.
1) Assessment: outcome not priority; psychosocial assessment; eliminate; address physical needs
first
2) CORRECT - Assessment: outcome priority; physical needs are highest priority
3) Assessment: outcome desired but not highest priority; address physical needs first
4) Implementation: outcome not highest priority; legal documentation is not the highest priority
A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is
MOST appropriate?
1. Get Doppler studies to check the pulse.
2. Notify the healthcare provider.
3. Determine if the cast is dry.
4. Check the client's vital signs.
1) Assessment: outcome desired but not priority; question stem tells you that assessment has
been done; changes in pulse, color, sensation should be reported immediately to the healthcare
provider
2) CORRECT - Implementation: outcome priority and desired; diminished pulses indicates
change in circulation
3) Assessment: outcome desired but not priority; should report changes in circulation
4) Assessment: outcome not desired; symptoms suggest changes in circulation to extremity;
more important to report change in distal circulation
The nurse reviews medications with a 35-year-old female. The client takes 200 mg
carbamazepine (Tegretol) orally twice daily. The client asks the nurse about future pregnancies.
Which statement by the nurse is MOST appropriate?
1. "If you take 5 mg folic acid daily while trying to conceive, you should be able to get
pregnant."
2. "It is recommended that you take carbamazepine suspension instead of the tablets when trying
to get pregnant."
3. "You should contact your health care provider and discuss your concerns about pregnancy."
4. "If you avoid drinking grapefruit juice, there should be no problem with conception."
1) Implementation: outcome not desired; carbamazepine and valproic acid increase risk of birth
defects; daily folic acid decreases risk of neural tube defects if taken during pregnancy; folic acid
will not increase fertility
2) Implementation: outcome not desired; possible birth defects due to action of the medication;
route of administration does not matter
3) CORRECT - Implementation: outcome desired; carbamazepine may be teratogenic; the health
care provider should discuss risks and benefits with client
4) Implementation: outcome not desired; grapefruit juice can increase serum levels of
carbamazepine as much as 40%
The nurse cares for the client 3 days after a stroke. It is MOST important for the nurse to take
which action?
1. Instruct the client to push with the feet while moving client up in bed.
2. Offer the client soft foods on request.
3. Auscultate the client's lungs every 4 hours.
4. Observe the client's legs for warm, reddened, and tender areas every 4 hours.
1) Implementation: outcome not desired; if client holds breath, may increase intracranial pressure
2) Implementation: outcome not desired; need to assess risk for aspiration first before any oral
fluids or foods given
3) CORRECT - Assessment: outcome desired and priority; decreased oxygen levels will increase
intracranial pressure, client at high risk for aspiration
4) Assessment: outcome desired but not priority; at risk for thrombophlebitis due to immobility
The nurse cares for the client diagnosed with schizophrenia. Which question is MOST important
for the nurse to ask the client's spouse?
1. "Have you noticed loud talking and excessive restlessness lately?"
2. "Has your spouse seemed withdrawn and less responsive to you during the last few weeks?"
3. "How would you describe your spouse's daily consumption of alcohol?"
4. "Does your spouse appear to have lost weight recently?"
1) Assessment: outcome not priority; manic client (bipolar disorder); symptoms include
inappropriate dress, excessive talking, lack of inhibition, inability to stop moving, disorientation
2) CORRECT - Assessment: outcome priority; may withdraw from previous relationships or
regress to previous behavior levels
3) Assessment: outcome not priority; no data to support relationship
4) Assessment: outcome not priority; secondary to withdrawn behavior; common with other
psychiatric problems
The nurse cares for the client immediately after an ileostomy procedure. Which is the best
INITIAL action for the nurse to take during client teaching?
1. Schedule the teaching demonstrations during family visits.
2. Encourage the client to discuss any concerns and to ask questions.
3. Show a video demonstrating ileostomy care.
4. Perform care for the ileostomy until the client is able to do it herself.
1) Implementation: outcome not desired; must assess client's readiness to learn first
2) CORRECT - Assessment: outcome desired; ventilate feelings and assess readiness to learn
3) Implementation: outcome not desired; needs to be ready to learn
4) Implementation: outcome not desired; won't assist in adjustment
The nurse cares for an 84-year-old man who appears disheveled, restless and confused. The
nurse prepares to administer medication and observes that the client's armband is missing. Which
is the MOST appropriate action for the nurse to take?
1. Ask the client's roommate to identify the client.
2. Ask the client to state his name.
3. Ask another nurse to identify the client.
4. Look in the chart at the picture of the client.
1) Implementation: outcome not desired; "passing the buck;" mental status of roommate
unknown
2) Implementation: outcome not desired; client confused
3) Implementation: outcome not desired; "passing the buck"; must check identification
4) CORRECT - Implementation: outcome desired; only way to positively identify client
The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if which of
the by which observation?
1. The respiratory rate is 40 per minute with short periods of apnea.
2. The heart rate is 140 beats per minute with variation during sleeping and waking states.
3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows.
4. Stroking the outer sole of the infant's foot upward causes his toes to curl downward.
1) Assessment: outcome not a problem; 30-60 breaths/min with periods of apnea; normal
2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake
3) Assessment: outcome not a problem; startle reflex; normal until 4 months
4) CORRECT - Assessment: outcome not expected and is a problem; Babinski reflex; in
newborn, should see dorsiflexion of big toe
The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled for a renal
computed tomography scan with contrast media at 10 a.m. The nurse is MOST concerned if the
client makes which statement?
1. "My blood sugar was 124 mg/dL this morning."
2. "I drank a glass of water at midnight."
3. "Sometimes I get dizzy when I first get out of bed."
4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."
1) Assessment: outcome not desired but not priority; further assessment needed
2) Implementation: outcome not a problem; NPO for 8 hours prior to scan
3) Assessment: outcome not desired but not priority; possible orthostatic hypotension; further
assessment needed
4) Correct - Implementation: outcome not desired and priority; metformin should be held for 48
hours prior to tomography with contrast media; risk lactic acidosis with potential renal damage
The nurse cares for clients in a mental health center. The nurse observes the client, formerly
homeless and malnourished, diagnosed with chronic schizophrenia putting food from lunch into
a plastic bag. Which statement by the nurse is MOST appropriate?
1. "We don't allow people to take food from the dining room."
2. "What are you going to do with the food?"
3. "We will be serving snacks and juice at 3 P.M."
4. "Let's go watch a movie with the others."
1) Implementation: outcome not desired; judgmental; non-therapeutic communication
2) Assessment: outcome not desired; non-therapeutic; "why" questions make client defensive,
feel threatened
3) CORRECT - Implementation: outcome desired; reality orientation; talk with client in nonthreatening way about her needs
4) Implementation: outcome not desired; misses opportunity to reality test; distraction used for
small children and manic clients
The nurse plans care for a client admitted with fever, vomiting, and diarrhea. Which laboratory
value demonstrates an improvement in the client's condition?
1. Specific gravity of urine 1.020 and hematocrit 42%.
2. Specific gravity of urine 1.039 and hematocrit 50%.
3. Specific gravity of urine 1.010 and hematocrit 52%.
4. Specific gravity of urine 1.030 and hematocrit 35%.
1) CORRECT - Assessment: outcome expected; normal specific gravity of urine, normal
hematocrit; specific gravity and hematocrit increase with dehydration
2) Assessment: outcome not expected; increased specific gravity of urine, increased hematocrit;
suggests ongoing fluid volume deficit
3) Assessment: outcome not expected; decreased specific gravity of urine, increased hematocrit;
does not indicate improvement
4) Assessment: outcome not expected; increased specific gravity of urine, decreased hematocrit;
does not indicate improvement
The nurse cares for a client who is to receive thrombolytic therapy with tissue plasminogen
activator (rtPA). The nurse is MOST concerned if the client makes which of the following
statements?
1. "I take a multivitamin tablet daily for cold and flu prevention."
2. "I had major abdominal surgery a year ago."
3. "I get some stomach pain when I eat spicy foods."
4. "I hit my head and lost consciousness during a car accident 2 months ago."
1) Implementation: outcome not a problem; no interaction
2) Implementation: outcome not a problem; surgery within 3 weeks is potential contraindication
3) Implementation: outcome not a problem; active peptic ulcer disease is potential
contraindication; needs further investigation
4) CORRECT-Implementation: outcome a problem; significant traumatic head injury within 3
months is an absolute contraindication for thrombolytic therapy
A 60-year-old client comes to the outclient clinic to receive the influenza vaccine. Which of the
following questions, if asked by the nurse, is BEST?
1. "Have you had the flu in the past month?"
2. "Do you have any food allergies?"
3. "Has anyone in your family been sick?"
4. "Are you allergic to any medication?"
1) Assessment: outcome not priority; immunization deferred in presence of acute respiratory
disease or other acute infection
2) CORRECT-Assessment: outcome priority; allergy to eggs is a contraindication to receiving
flu vaccine
3) Assessment: outcome not priority; immunization deferred only if client has active infection
4) Assessment: outcome not priority; medication allergy not pertinent
The home care nurse is visiting an alert, oriented woman living with her daughter. The client is
malnourished and has multiple bruises on her body, and the situation is reported to the
appropriate authority. After counseling the client and daughter, the nurse notes the situation has
not improved. The client decides to remain with her daughter. Which action, if taken by the
nurse, is MOST appropriate?
1. Respect the client's decision to stay in her daughter's home.
2. Insist the client move in with her other child.
3. Begin guardianship procedures.
4. Place live-in help in the home.
1) CORRECT-Implementation: outcome desired; intervention not possible without consent of
the senior if person is legally competent; further assessment needed to determine cause of bruises
2) Implementation: outcome not desired; legally competent senior can choose where to live and
with whom
3) Implementation: outcome not desired; appropriate if senior is legally incompetent and in
immediate danger
4) Implementation: outcome not desired; must have consent of client
A news reporter and camera person arrive on the nursing unit to videotape an interview of a
client. When the nurse refuses their request, the reporter references his First Amendment rights.
Which statement, if made by the nurse, is MOST appropriate?
1. "Why do you want to talk with the client?"
2. "I'll ask the client if he is ready to speak with you."
3. "I will need to call the nurse manager about your request."
4. "Does the client know that you are coming?"
1) Assessment: outcome not priority; don't ask "why" questions on the NCLEX-RN®; "why"
questions are considered to be confrontational
2) Implementation: outcome not desired; confirms client presence; breaches confidentiality;
report to nursing supervisor
3) CORRECT- Follows the chain of command within the facility.
4) Verified the client's admission, violates client's confidentiality.
A client receives an IV heparin infusion at 22 mL/hr through an infusion pump. The IV bag
contains 25,000 units of heparin in 500 mL of 5% dextrose in water. How many units of heparin
is the client receiving during an 8-hour shift?
Calculate and record the answer in the box.
Your Response:
Correct Response: 8800
units
50 units heparin/1 mL
50 units x 22 = 1100 units per hour
1100 units x 8 = 8800 units heparin
The nurse teaches a client who had an above-knee amputation (AKA) 2 days ago about how to
care for the residual limb. Which statement, if made by the client, indicates to the nurse that the
teaching is effective?
1. "I shall apply cream to the residual limb to soften the skin."
2. "I should rewrap my residual limb with elastic bandages 3 times a day."
3. "I will not be able to sleep on my stomach from now on."
4. "I will no longer be able to sit in straight back chairs at home."
1) Implementation: outcome not desired; skin needs to be toughened if prosthesis is going to be
used; no lotions, creams, or powders should be used unless prescribed
2) CORRECT-Implementation: outcome desired; bandages may be loose; expose to air 20
min/day; inspect residual limb for redness, irritation
3) Implementation: outcome not desired; the prone position will decrease the risk of flexion
contractures
4) Implementation: outcome not desired; client can sit in straight back chair; time should be
restricted to 1 hour or less
The husband of an elderly client who is incontinent asks the nurse whether his wife will have to
wear diapers. Which response, if made by the nurse, is MOST appropriate?
1. "Let's discuss your specific concerns about your wife."
2. "Have you tried any type of incontinence pads in the past?"
3. "Let's wait and see if incontinence pads are necessary."
4. "There are many brands of adult diapers available for you to try."
1) CORRECT-Outcome desired; open-ended; client can verbalize concerns
2) Outcome not priority; need to address husband's immediate concerns; is "yes/no" answer
3) Outcome not desired; need to deal with the "here and now"
4) Outcome not desired; non-therapeutic; dismisses concerns
The school nurse teaches accident-prevention to the parents of school-aged children. Which
statement, if made by a parent to the nurse, indicates teaching is effective?
1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his
bike."
2. "I keep my guns and ammunition in a locked cabinet in the basement."
3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the
monkey bars."
4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."
1) Implementation: outcome not desired; only bicycle helmet is recommended; additional
protective gear with skateboarding or rollerblading
2) Implementation: outcome not desired; guns and ammunition should be kept in separate locked
areas
3) CORRECT-Implementation: outcome desired; injury prevention facilitated by age-appropriate
safety education
4) Implementation: outcome not desired; school-aged children are developmentally ready for less
supervision; parents should encourage interaction with peers
The nurse cares for a client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The
client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate
22 per minute. Which order should the nurse question?
1. 0.9% sodium chloride water infusion at 150 mL/hour.
2. Epinephrine (Adrenalin) 1 mg bolus intravenously.
3. Monitor urinary output hourly for 24 hours.
4. 50 mL 25% albumin (human) 50 mL intravenously.
1) Implementation: outcome desired; is isotonic; will replace lost blood volume
2) CORRECT-Implementation: outcome not desired; effect is vasoconstriction with further
decrease of blood flow to vital organs; used to treat anaphylactic shock
3) Implementation: outcome desired; measuring urinary output meaures renal perfusion;
appropriate activity
4) Implementation: outcome desired; is a crystalloid; will expand plasma volume rapidly; must
carefully monitor response
A nurse from the surgical floor is reassigned to the pediatric unit. Which of the following client
assignment is MOST appropriate for this nurse?
1. A 5-month-old infant after a cast application on the left extremity due to club foot.
2. A 4-year-old boy with right abdominal swelling and a decreased appetite.
3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C).
4. A 10-year-old girl with newly diagnosed type 1 diabetes.
1) CORRECT-Implementation: outcome desired; stable client with predictable outcome; serial
casting used to correct congenital club foot
2) Implementation: outcome unstable client; needs assessment and evaluation; possible teaching
interventions needed
3) Implementation: outcome not desired; unstable client; require frequent assessment and
evaluation
4) Implementation: outcome not desired; unstable client; required assessment, evaluation,
teaching and judgment
The home care nurse observes an elderly woman on a low-sodium diet eating a dill pickle that
her son gave her with lunch. Which response by the nurse is MOST appropriate?
1. "Giving your mother salty food will only make her condition worse."
2. "Didn't your mother tell you she's on a low-sodium diet?"
3. "Tell me what you know about your mother's diet."
4. "Let's make an appointment for you to meet with a dietician."
1) Implementation: outcome desired but not priority; non-therapeutic; closed statement
2) Assessment: outcome not desired; "yes/no" question; non-therapeutic
3) CORRECT-Assessment: outcome desired; teaching opportunity; includes family in teaching
4) Implementation: outcome not desired; "passing the buck"
The client is admitted to the hospital with chest pain when taking deep breaths and peripheral
edema. The health care provider's order for the client reads; "Digoxin 0.25 mg orally now.
Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse, is MOST
appropriate?
1. Do not administer the second dose of digoxin.
2. Call the health care provider to clarify the order.
3. Administer half the prescribed second dose of digoxin.
4. Administer the first and second dose of digoxin as ordered.
1) Implementation: outcome not desired; medication should be given; if nurse questions the
order, the health care provider should be contacted
2) Implementation: outcome not desired; unnecessary; 1 milligram of digoxin is a digitalizing
dose; digitalizing dose is necessary to reach therapeutic blood levels
3) Implementation: outcome not desired; nurse can never change prescribed dose
4) CORRECT-Implementation: outcome desired; loading dose to achieve therapeutic blood
levels; if loading dose not given, therapeutic levels are not reached for 6 days
The nurse observes a student nurse examine a client's chest. Which action requires an
intervention by the nurse?
1. The student nurse auscultates heart sounds and then palpates for tactile fremitus.
2. The student nurse uses the diaphragm of the stethoscope to listen to heart sounds.
3. The student nurse places the stethoscope firmly against the skin surface.
4. The student nurse inspects the chest before performing palpation.
1) CORRECT-Assessment: outcome desired; order for physical assessment is inspection,
palpation, percussion, and auscultation; tactile fremitus is vibration produced when client says
"99"
2) Assessment: outcome desired; used to listen for high-pitched sounds such as vesicular breath
sounds
3) Assessment: outcome desired; a tight seal increases accuracy
4) Assessment: outcome desired; the order for physical assessment is inspection, palpation,
percussion, and auscultation
The nurse cares for clients on an acute-care surgical area. Which client should the nurse see
FIRST?
1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the chest
drainage system.
2. The nursing assistive personnel reports that a client who had a thyroidectomy 24 hours ago
refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden).
3. The family of a client who had a small bowel resection 48 hours ago reports the client is more
confused than yesterday.
4. A client who had an ileostomy 3 days ago complains of "aching legs."
1) Not priority; further assessment required; see second
2) Not priority; may be safety issue; further assessment needed; see last
3) CORRECT-Priority; may have decreased cerebral blood flow or oxygenation; see first
4) Not priority; client is at risk for thrombophlebitis; further assessment and evaluation needed;
see third
The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery
diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching is successful if
the family makes which statement?
1. "We wear a fresh pair of clean gloves with each diaper change."
2. "We are not allowing our other children to be in the same room with the baby."
3. The grandmother wears a mask when changing the baby's diaper.
4. The mother wears an apron when changing the baby's diaper.
1) CORRECT-Implementation: outcome desired; contact precautions; Clostridium difficile
infection may develop after antibiotic treatment
2) Implementation: outcome not desired; unnecessary; should use stool and enteric precautions
3) Implementation: outcome not desired; mask unnecessary; used for airborne infection
4) Implementation: outcome not desired; need to use contact precautions, gown only if soiling
likely
A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her husband is
coaching her during labor. During the transitional phase of labor, the client begins to scream and
grab the side rails with each contraction. Which action, if taken by the nurse, is MOST effective?
1. Offer the client pain medication before her next contraction.
2. Assist the client to a side-lying position with her knees flexed and a pillow between her legs.
3. Establish eye contact with the client and breathe with her.
4. Suggest to the client that she watch television between contractions.
1) Implementation: outcome not desired; not used during transition; not effective and may
interfere with mother's cooperation; may cause respiratory depression in infant
2) Implementation: outcome desired but not priority; priority action is to assist client to get
control
3) CORRECT-Implementation: outcome desired and priority; slow breathing, reorient; model
appropriate behaviors; this will assist client to get control and reduce muscle tension
4) Implementation: outcome desired but not priority; meet physical needs first
The client with with a 5-year history of alcohol abuse is treated in the emergency room for acute
alcohol intoxication. The client is agitated and verbally abusive. Admission orders include
chlordiazepoxide (Librium) 50 mg IM or PO every 4-6 hours for agitation. Which action by the
nurse is MOST appropriate?
1. Place the client in chest restraints.
2. Assist the client to the bathroom every 2 hours.
3. Assign a licensed practical nurse to stay with the client.
4. Administer disulfram (Antabuse) 500 mg every 12 hours.
1) Implementation: outcome not desired; last resort unless safety is an issue
2) Implementation: outcome desired but not priority; safety is a priority
3) CORRECT - Implementation: outcome desired; nurse should delegate and give specific
instructions to LPN/LVN
4) Implementation: outcome not desired; administered to assist the client to refrain from drinking
first dose administered at least 12 hours after the last alcohol consumed
The nurse reviews health assessments completed by student nurses. Which assessment warrants
further investigation?
1. An 11-year-old female who states that she has had 3 periods in the past 6 months.
2. A 13-year-old male with intermittent voice changes.
3. A 14-year-old male with bilateral breast enlargement.
4. A 15-year-old female with bilateral breast buds.
1) Assessment: outcome expected; irregular menstrual periods common during the first year or
two after menarche
2) Assessment: outcome expected; age-appropriate and common
3) Assessment: outcome expected; temporary, age-appropriate phenomenon
4) CORRECT-Assessment: outcome not expected; one of the earliest changes of puberty; occurs
from age 9-13
An elderly woman is being seen by the home care nurse following a partial gastrectomy for
cancer. Which statement, if made by the client, requires further teaching?
1. "The healthcare provider told me to come in once a month for vitamin B12 injections."
2. "I eat frequently throughout the day."
3. "I do not eat concentrated sweets."
4. "I drink several glasses of iced tea with my meals."
1) Implementation: outcome desired; required monthly to prevent pernicious anemia
2) Implementation: outcome desired; small, frequent feeding prevents dumping syndrome
3) Implementation: outcome desired; prevents dumping syndrome
4) CORRECT-Implementation: outcome not desired; drinking fluids with meals causes stomach
content to empty too rapidly into the jejunum
A client had a right kidney transplant 1 week ago. Which symptom, if experienced by the client,
indicates to the nurse that the client is experiencing rejection?
1. The client complains of generalized muscle weakness.
2. The client complains of diffuse pain over the right abdomen.
3. The client gets up twice each night to void.
4. The client has lost 3 pounds.
1) Assessment: outcome not priority; seen with electrolyte imbalance, not rejection
2) CORRECT-Assessment: outcome priority and expected with kidney rejection; tenderness over
kidney is sign of rejection
3) Assessment: outcome not expected; oliguria is seen with rejection due to failing kidney
4) Assessment: outcome not expected; edema and weight gain are seen with rejection
A client is brought to the clinic by the spouse. The client's lab results are Na+ 156 mEq/L, Cl100 mEq/L, K+ 4.0 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Which is the MOST
appropriate action for the nurse to take?
1. Assess for muscle weakness and dysrhythmias.
2. Assess for confusion and tachycardia.
3. Check for peripheral edema and lung crackles.
4. Determine if muscular twitching and muscle weakness are present.
1) Assessment: outcome not priority; symptoms of hypokalemia
2) CORRECT-Assessment: outcome priority; elevated Na+ and elevated BUN, other values are
normal; elevated Na+ and BUN seen with dehydration
3) Assessment: outcome not priority; symptoms of fluid volume overload
4) Assessment: outcome not priority; symptoms of hyponatremia; hypernatremia seen with
dehydration
A client is prescribed prednisone and asks about possible adverse effects. The nurse teaches the
client about which common adverse effects of prednisone?
Select all that apply
1. (1.) Osteoporosis.
2. (2.) Decreased white count.
3. (3.) Low blood sugar.
4. (4.) Low serum potassium.
5. (5.) Retinal detachment.
6. (6.) Fluid retention
(1.) CORRECT-Glucocorticoids decrease bone density; calcium and vitamin D supplements or
biphosphonates will decrease risk
(2.) Glucocorticoids depress the immune response, but not the white cell count
(3.) Glucorticoids cause hyperglycemia and glyxosuria
(4.) CORRECT-Glucocorticoids cause hypokalemia and hypernatremia
(5.) Glucocorticoids increase the risk of cataracts and glaucoma
(6.) CORRECT-Glucocorticoids cause sodium and water retention
A woman with a diagnosis of Alzheimer's disease is admitted to the hospital for treatment of an
upper respiratory tract infection. On admission, she is incontinent of urine. When assigning the
client to a room on the nursing unit, which location would be BEST?
1. A semi-private room near the nurse's station.
2. A private room near the nurse's station.
3. A private room away from the nurse's station.
4. A semi-private room away from the nurse's station.
1) CORRECT-Implementation: outcome desired and priority; stimulation helps with orientation;
allows for frequent assessment
2) Implementation: outcome not desired; meets safety needs but lacks environmental stimulation
3) Implementation: outcome not desired; client should be frequently assessed and needs
stimulation
4) Implementation: outcome not desired; does provide environmental stimulation but client
should be frequently assessed
A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic nurse that she
was exposed to rubella 2 days ago. Which statement, if made by the nurse, is MOST
appropriate?
1. "You need to see the health care provider today, but come in after hours."
2. "Come in this afternoon for your regularly scheduled appointment."
3. "You will receive the rubella vaccine during your regularly scheduled appointment."
4. "Please cancel today's appointment and reschedule for next month."
1) Implementation: outcome not desired; incubation period is 14-21 days, not communicable at
this time; if woman develops rubella infection during the first trimester, abortion may be
considered
2) CORRECT-Implementation: outcome desired; communicability is approximately 7 days
before to 5 days following onset of rash; client needs to be evaluated
3) Implementation: outcome: not desired; vaccination contraindicated for pregnant women;
increased risk of fetal complications
4) Implementation: outcome not desired; needs to be seen by the healthcare provider
A 7-year-old boy is brought to the emergency room by his mother following a fall from his
bicycle. X-ray reveals healed fractures of the ribs. The child's mother states, "My son is such a
careless child; he's always having accidents or fights with his brother." Which response by the
nurse would be MOST appropriate?
1. "When I document information about these injuries, it will be on your son's hospital record
forever."
2. "How would you describe your son's relationship with his brothers and sisters?"
3. "What I see suggests that someone has been abusing your son."
4. "I will need to talk to the nurse manager about this situation before you leave."
1) Implementation: outcome not desired and not priority; documentation of suspected abuse
should contain facts and be nonjudgmental
2) Assessment: outcome not priority; priority action is to report potential abuse to nurse manager
3) Implementation: outcome not desired; close-ended statement; confrontational
4) CORRECT-Implementation: outcome desired; follows chain of command; potential abuse
situation
The parents of a newborn boy ask the nurse whether they should have their son circumcised.
Which response by the nurse is MOST appropriate?
1. "The benefits of the procedure usually outweigh the risks of bleeding and infection."
2. "You should ask your obstetrician or pediatrician to advise you."
3. "It is not mandatory that your son have a circumcision. What are your concerns?"
4. "Some parents worry about the pain associated with circumcision, but there is actually very
little discomfort."
1) Implementation: outcome not desired; program of good hygiene provides advantages without
risks of circumcision
2) Implementation: outcome not desired; passing the buck
3) CORRECT-Assessment: outcome priority; open communication; initial assessment:
acknowledges parents' feelings
4) Implementation: outcome not desired; closed communication; nurse assumes that pain is the
issue
The home health nurse is planning client visits for the day. Which of the following clients should
the nurse see FIRST?
1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week.
2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft
surgery (CABG).
3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours.
4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain
medication.
1) Follow-up required, but not priority; see second
2) Will require assessment and teaching, but no immediate care indicated; see third
3) CORRECT-Rapid weight gain indicates fluid retention, which could exacerbate CHF; see first
4) Stable client; pain control will be addressed but not first; see last
The home care nurse instructs the daughter of a client diagnosed with congestive heart failure.
The daughter states her father is taking digoxin (Lanoxin) 0.25 mg and the healthcare provider
just prescribed furosemide (Lasix) 40 mg. Which statement, if made by the daughter to the nurse,
indicates teaching is successful?
1. "I'm glad that Dad doesn't have to change his diet."
2. "Dad is going to have to eat more cottage cheese and add some more salt to his diet."
3. "Dad must increase his intake of cheese and yogurt."
4. "I should encourage Dad to eat more fresh fruits and vegetables."
1) Implementation: outcome not desired; Lasix is a potassium-wasting diuretic, hypokalemia
may precipitate digitalis toxicity
2) Implementation: outcome not desired; high in sodium, would increase fluid retention
3) Implementation: outcome not desired; high in calcium, no indication to increase calcium in
the diet; dairy products are high in sodium
4) CORRECT-Implementation: outcome desired; good source of potassium, decreased potassium
can predispose to digitalis toxicity
Heparin 5,000 units subcutaneously is ordered every 12 hours for a client. The result of the
client's most recent PTT is 55 seconds. Which action by the nurse is MOST appropriate?
1. Document the result and administer the heparin.
2. Withhold the heparin.
3. Notify the healthcare provider.
4. Have the test repeated.
1) CORRECT- Implementation: outcome desired; PTT lower limit of normal 20 - 25 seconds,
upper limit of normal 32 to 39 seconds, therapeutic range 1.5 to 2 times normal, 5 seconds is
within therapeutic range
2) Implementation: outcome medication should be given; PTT is in therapeutic range
3) Implementation: outcome not desired; unnecessary
4) Implementation: outcome not desired; unnecessary
The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to
compression fractures of the 5th and 6th cervical vertebrae. The client reports a sudden onset of
sweating and has a flushed face and chest. Which action should the nurse take FIRST?
1. Perform a digital rectal examination.
2. Check the color and temperature of the extremities.
3. Place the client in high-Fowler's position.
4. Administer hydralazine (Apresoline) 20 mg intravenously.
1) Assessment: outcome not priority; immediate action to decrease blood pressure is priority;
rectal stimulation may increase autonomic dysreflexia
2) Assessment: outcome not priority; immediate need is to reduce blood pressure and prevent
hemorrhage
3) CORRECT-Implementation: outcome desired; immediate effect; decrease venous return to
heart, decrease stroke volume, and decrease in blood pressure
4) Implementation: outcome not desired as initial action; causes vasodilation; more immediate
effect with position change; if cause of autonomic dysreflexia removed, sudden drop in blood
pressure could occur
A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He
has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL
balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in
his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take
FIRST?
1. Check the patency of the catheter.
2. Assess residual urine volume using bladder ultrasonography.
3. Assess the amount of drainage in the urinary drainage bag.
4. Decrease the tension on the catheter.
1) CORRECT-Assessment: outcome priority; catheter may be blocked or client may be having
bladder spasms
2) Assessment: outcome not priority; need to check patency of tubing first
3) Assessment: outcome not priority; more important to look for obstruction in tubing
4) Implementation: outcome not desired; decrease in traction against bladder neck could cause
bleeding; is a healthcare provider order and should not be changed
A client with suspected active tuberculosis is scheduled for a chest x-ray. Which action, if taken
by the nurse, is MOST appropriate?
1. Instruct the staff transporting the client to wear a gown and mask.
2. Place a face mask on the client.
3. Request that the x-ray be postponed.
4. Give the client an emesis basin and tissues.
1) Implementation: outcome not desired; mask is placed on client to prevent transmission of
airborne pathogen
2) CORRECT-Implementation: outcome desired and priority; client must wear a standard
isolation mask if out of room
3) Implementation: outcome not desired; no reason to postpone, place mask on client
4) Implementation: outcome desired but not priority; mask worn to prevent transmission of
airborne pathogen
The nurse cares for an 80-year-old client taking medication for the treatment of hypertension and
heart failure. Which action is MOST important for the nurse to take?
1. Check the client's blood pressure and heart rate immediately after ambulation.
2. Instruct the client to use a walker at all times during ambulation.
3. Encourage the client to walk with the feet as close together as possible.
4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.
1) Assessment: outcome not desired; blood pressure and heart rate should be assessed prior to
ambulation; more important to assess for shortness of breath and activity tolerance
2) Implementation: outcome not desired; avoid soft-soled shoes; remove barriers; orthostatic
precautions are priority; no indication in the question that a walker is needed
3) Implementation: outcome not desired; should have wide-based gait to distribute center of
gravity; may be unsafe ambulation
4) CORRECT-Implementation: outcome desired and priority; elderly have decreased cerebral
perfusion; antihypertensives and medications used to treat heart failure cause vasodilation
The nurse monitors the activities of a 9-year-old girl with juvenile rheumatoid arthritis (JA).
Which activity is MOST appropriate?
1. The girl is jumping rope.
2. The girl is skipping.
3. The girl jumps off the end of a slide.
4. The girl participates on a swim team.
1) Implementation: outcome not desired; too traumatic to the joints
2) Implementation: outcome not desired; too traumatic to the joints
3) Implementation: outcome not desired; too traumatic to the joints
4) CORRECT-Implementation: outcome desired; good moving and stretching activity; also,
throwing or kicking a ball, riding a bicycle, swimming
Haloperidol (Haldol) 5 mg IM every 4 hours PRN is prescribed for a client. Which observation
requires an IMMEDIATE intervention by the nurse?
1. Patient reports dizziness; heart rate 58 beats per minute.
2. Patient has tongue protrusion and muscle rigidity.
3. Patient has a facial rash and periorbital edema.
4. Patient reports sensitivity to light and blurred vision.
1) Assessment: outcome a concern but not priority; can cause tachycardia
2) CORRECT-Assessment: outcome not expected and priority; extrapyramidal reactions usually
dose-related; controlled by dose-reduction or antiparkinsonian medications (benztropine)
3) Assessment: outcome a concern but not priority; possible maculopapular rash
4) Assessment: outcome a concern but not priority; intolerance to light not seen; blurred vision
not commonly seen
The nurse teaches the client how to perform a colostomy irrigation. During the teaching, the
client states, "I can't do this." Which response, if made by the nurse, is BEST?
1. "Sure you can do this. You just need to have more practice."
2. "I'll do it for you this time, but you must perform the irrigation the next time."
3. "You seem to be frustrated. What are your specific concerns?"
4. "Most of the other clients learn this without any difficulty. Let's try it again."
1) Implementation: outcome not desired; false reassurance; need to assess first
2) Implementation: outcome not desired; fosters dependence
3) CORRECT-Implementation: outcome not desired; reflects feelings; allows nurse to assess
4) Implementation: outcome not desired; implies deficiency in the client
A man comes into the outclient rheumatology clinic for follow-up care after an episode of acute
gouty arthritis. The nurse would be MOST concerned if the client made which of the following
statements?
1. "I don't eat shrimp and scallops anymore."
2. "I play softball twice a week without any problem."
3. "I don't go to bars on Friday nights anymore."
4. "I have been drinking SlimFast for breakfast and lunch each day."
1) Implementation: outcome not desired; foods high in purines cause hyperuricemia
2) Implementation: outcome not desired; activity does not precipitate a gout attack
3) Implementation: outcome not desired; excessive drinking precipitates gout
4) CORRECT-Implementation: outcome desired; hyperuricemia may result from prolonged
fasting; increases production of ketones, which inhibit normal excretion of uric acid
A nurse is performing triage in the emergency department. Which of the following clients should
the nurse see FIRST?
1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C).
2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C).
3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C).
4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F
(37.4° C).
1) See last; most stable client
2) See second; unstable client; cardiovascular; requires further assessment and antihypertensive
medication
3) CORRECT-See first; unstable client; upper airway injury possibly due to inhalation injury
4) See third; vital signs consistent with dehydration, rapid respiration is Kussmaul's and expected
The home care nurse makes an initial visit to an 80-year-old client. The client's daughter states
that her mother has a history of colon cancer and has been restless and confused for about a
week. It is MOST important for the nurse to obtain an answer to which question?
1. "What medication is your mother taking?"
2. "Is there a family history of diabetes?"
3. "Describe your mother's usual diet."
4. "Does your mother complain of difficulty urinating?"
1) CORRECT-Assessment: outcome desired and priority; confusion can be caused by drug
toxicity and polypharmacy; decreased renal function may increase risk
2) Assessment: outcome desired but not priority; hypoglycemia may be a factor
3) Assessment: outcome desired but not priority; is a good open-ended question
4) Assessment: outcome desired but not priority; not most important; urinary tract infections
cause acute confusion in elderly
The nurse cares for a client in active labor. The client's membranes rupture spontaneously at 6
centimeters of dilation. Which action actions should the nurse take FIRST?
1. Check the fetal monitor.
2. Place the client on her right side.
3. Auscultate fetal heart rate.
4. Check the client's heart rate and blood pressure.
1) Assessment: outcome not desired; check client, not equipment; fetal monitor may give
incorrect information
2) Implementation: outcome not desired; position on left side if needed to prevent pressure on
vena cava; no information in question indicates fetal hypoxia
3) CORRECT-Assessment: outcome priority; check for possible prolapsed cord; recheck in 10
minutes; fetal assessment is priority during labor
4) Assessment: outcome not priority; provides no information about baby
The nurse identifies which client is at risk to develop metabolic acidosis?
Select all that apply
1. (1.) A client diagnosed with type 1 diabetes mellitus.
2. (2.) A client diagnosed with salicylate toxicity.
3. (3.) A client diagnosed with bilateral bacterial pneumonia.
4. (4.) A client diagnosed with acute renal failure.
5. (5.) A client diagnosed with continuous nasogastric drainage.
6. (6.) A client diagnosed with severe diarrhea.
(1.) CORRECT - At risk for diabetic ketoacidosis
(2.) CORRECT - Acidic medication
(3.) At risk for respiratory acidosis
(4.) CORRECT - Kidneys not able to excrete acids or absorb bases
(5.) At risk for metabolic alkalosis; lose acids
(6.) CORRECT - Lose base in diarrhea
The nurse receives a phone call from the mother of a 10-year old child taking methylphenidate
(Ritalin) daily. The mother reports the child has lost 2 pounds in the last 2 weeks. Which is the
MOST appropriate response by the nurse?
1. "How much does your child exercise on a daily basis?"
2. "Stop giving the Ritalin for several days to see if the appetite improves."
3. "At what time do you give your child the Ritalin medication?"
4. "What is your child's bedtime and when does he usually awaken?"
1) Assessment: outcome desired but not priority; methylphenidate has appetite suppressant
effects
2) Implementation: outcome not desired; Ritalin should be tapered
3) CORRECT-Assessment: outcome desired and priority; long-acting Ritalin should be given
after breakfast to decrease appetite-suppressant effects
4) Assessment: outcome not priority; more important to assess effect of medication on appetite
A client is admitted to the hospital with a diagnosis of chronic bronchitis. Which action should
the nurse take FIRST?
1. Weigh the client.
2. Place cardiac telemetry leads.
3. Place pulse oximetry on finger.
4. Obtain a sputum specimen
1) Assessment: outcome not priority; right heart failure and weight gain seen with chronic
bronchitis; priority is to assess oxygenation
2) Assessment: outcome not priority; dysrhythmias occur due to right heart failure; priority is
oxygenation
3) CORRECT-Assessment: outcome desired; priority is to establish oxygenation status
4) Assessment: outcome not priority; common reason for worsening status is respiratory
infection; more important to establish respiratory status first
The home care nurse visits a client diagnosed with Parkinson's disease. The nurse is MOST
concerned if which of the following is observed?
1. The client has soft, monotonous speech.
2. The client is drooling.
3. The client rolls the left thumb against the fingers.
4. The client ambulates with a stooped posture.
1) Assessment: outcome expected, hypotonia; speech may be hard to understand
2) CORRECT-Assessment: outcome not expected; at risk for aspiration due to difficulty
swallowing and the accumulation of saliva
3) Assessment: outcome expected, present at rest; may disappear with purposeful movement
4) Assessment: outcome expected, teach postural exercises to minimize this effect
The nurse discusses an appropriate diet with a client diagnosed with iron-deficiency anemia.
Which meal, if selected by the client, indicates to the nurse, that teaching is effective?
1. Spaghetti with a sauce of ground beef, cheese, and garlic bread.
2. Baked sausage casserole with rice and sliced tomato.
3. Frankfurter, baked beans, and chopped cabbage salad.
4. Lamb chop, baked potato, and tossed green salad.
1) Implementation: outcome not desired; only beef is a good source
2) Implementation: outcome not desired; only sausage is good source
3) Implementation: outcome not desired; low in iron
4) CORRECT-Implementation: outcome desired; contains 24-30 mg; vitamin C from potato and
salad enhance iron availability
The nurse cares for a client 4 hours after admission to the hospital for treatment of an anterior
wall myocardial infarction. The client suddenly reports difficulty breathing and appears very
anxious. Which action should the nurse take FIRST?
1. Evaluate the client's cardiac rhythm.
2. Check for cyanosis of the hands and the toes.
3. Auscultate the client's posterior lung fields.
4. Listen to the apical heart rate.
1) Assessment: outcome desired but not priority; ABCs apply here
2) Assessment: outcome not desired; peripheral cyanosis is a late sign of hypoxemia
3) CORRECT-Assessment: outcome priority; anterior wall MI high risk for heart failure; assess
client first and then equipment
4) Assessment: outcome desired but not priority; should be assessed, but ABCs apply here
A woman delivers a 6-lb and 2-oz infant. The Apgar scores at 1 and 5 minutes are 8 and 9,
respectively. Which action is MOST appropriate for the nurse to take?
1. Perform nasopharyngeal suctioning.
2. Document the Apgar score.
3. Administer O2 per mask.
4. Rub the infant's back.
1) Implementation: outcome not desired; if Apgar less than 8 and infant is in respiratory distress
nasopharyngeal suctioning may be indicated.
2) CORRECT-Implementation: outcome desired; Apgar score of 8 to 10 is considered to be good
3) Implementation: outcome not desired; done if respirations absent or inadequate
4) Implementation: outcome not desired; resuscitative measure, used to stimulate infant
The nurse cares for a client 72 hours after a right-below-knee amputation. Which is the MOST
important action for the nurse to take?
1. Lay the client prone for 25 minutes every 3-4 hours.
2. Dangle the client's residual limb over the side of the bed.
3. Abduct the client's residual limb by placing pillows between the legs.
4. Elevate the client's residual limb on a pillow.
1) CORRECT-Implementation: outcome desired; prevents hip flexion contracture
2) Implementation: outcome not desired; will increase edema
3) Implementation: outcome not desired; legs should be adducted to prevent flexion contractures
4) Implementation: outcome not desired; done for the first 24 hours; increases venous return;
prevents edema; promotes comfort
The nurse presents a class on herbal medications at a community health care seminar. Which
statement should be included in the class?
Select all that apply
1. (1.) The potency of herbal preparations varies between manufacturers.
2. (2.) The FDA tests and regulates herbal preparations.
3. (3.) Herbal preparations are classified as dietary supplements.
4. (4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure.
5. (5.) Herbal preparations are used in the treatment of immune system dysfunction.
(1.) CORRECT - read labels carefully to determine the exact amount of herbs in the preparation
(2.) herbal preparations are classified as dietary supplements; adverse reactions may be reported
after use
(3.) CORRECT - the FDA does not research or regulate herbal preparations because they are
classified as dietary supplements
(4.) CORRECT - read labels carefully to determine what the herbal preparation contains
(5.) label should state that the herbal preparation will "decrease inflammation or support the
immune system"; label cannot say that the preparation "protects against cancer"
The nurse feeds the client in a chair when the client suddenly begins to choke on food. The client
is conscious but unable to speak. Which action is MOST appropriate for the nurse to take?
1. Encourage the client to cough and breathe deeply.
2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind.
3. Return the client to the bed and apply vigorous abdominal or chest thrusts while straddling the
client's thighs.
4. Apply several vigorous back blows until the food dislodges.
1) Implementation: outcome not desired; can't inhale, can't exert enough pressure
2) CORRECT-Implementation: outcome desired; abdominal thrust maneuver appropriate when
client not moving air
3) Implementation: outcome not desired; no time to do this
4) Implementation: outcome not desired; could cause increased problems; food could migrate
further into respiratory tract
While playing on the floor in the hospital room, a 2-year-old has a tonic-clonic seizure. Which
action should the nurse take FIRST?
1. Begin oxygen at 2 liters per minute through a nasal cannula.
2. Place a pillow under the client's head.
3. Administer diazepam (Diastat) 5 mg rectally.
4. Turn the client to the side.
1) Implementation: outcome not desired; more important to protect from injury during the
seizure; no indication oxygen is needed
2) CORRECT-Implementation: outcome desired; protects client from injuries; stay with client
3) Implementation: outcome not desired; rectal diazepam used to treat status epilepticus in
children; not indicated for single seizure
4) Implementation: outcome not desired; turn client to side after the seizure to reduce risk of
aspiration; should protect extremities during seizure
The nurse describes to a male client how to collect a clean-catch urine for culture and sensitivity.
Which explanation, if made by the nurse, is MOST accurate?
1. "The urinary meatus is cleansed with an antiseptic solution, and then a urinary drainage
catheter is inserted to obtain urine."
2. "You will be asked to empty your bladder one half-hour before the test; you will then be asked
to void into a container."
3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is then
voided into a sterile container; the container must not touch the penis."
4. "You must void a few drops of urine, and then stop; then void the remaining urine into a clean
container which should be immediately covered."
1) Implementation: outcome not desired; unnecessary to use catheter
2) This is the procedure for a double void specimen and the question is for a clean catch
specimen.
3) CORRECT-Implementation: outcome desired; a culture and sensitivity urinalysis is a sterile
specimen
4) Implementation: outcome not desired; need sterile container
An LPN/LVN informs the nurse that aspirin 325 mg was given to a client even though 80 mg
aspirin had been ordered once daily. The LPN/LVN asks the nurse if it is necessary to complete a
medication-error form since "no harm was done." Which statement, if made by the nurse, is
BEST?
1. "What do you mean, "no harm was done"?
2. "A medication-error form must be completed whenever the wrong preparation of a medication
is given."
3. "I will call the health care provider and ask what should be done to deal with this error."
4. "It is not necessary to complete an incident report with over-the-counter medications."
1) Assessment: outcome not priority; assessment of client must be done by nurse; question is not
necessary
2) CORRECT-Implementation: outcome desired; contains full description of situation, error
committed, condition of client, remedial steps taken; medication error form must be completed
for all variances
3) Implementation: outcome not desired; it is a nursing responsibility; health care provider
should be informed
4) Implementation: outcome not desired; always complete form for any medication error
The nurse counsels a woman at 36 weeks gestation who has attended childbirth class in
preparation for labor and delivery. Which statement by the client requires an intervention by the
nurse?
1. "I now know when to expect discomfort during labor and delivery and the things I can do to
decrease the discomfort."
2. "My husband is still concerned that he is not sure what to do during the labor process."
3. "Even though I learned pain control techniques, I still may need some pain medication during
labor and delivery."
4. "The breathing patterns I learned in class will decrease the amount of time I spend in labor."
1) Implementation: outcome desired; purpose of childbirth class is to eliminate fear of the
unknown
2) Implementation: outcome not desired but not priority; focus of class is on fetus and mother;
further assessment needed
3) Implementation: outcome desired; anxiety and pain reduction techniques included in class, but
mothers are encouraged to use analgesia if needed
4) CORRECT-Implementation: outcome not desired; breathing techniques may decrease anxiety
and pain but have no effect on time of labor
The nurse cares for a client with suspected subarachnoid hemorrhage who had a bilateral carotid
angiogram 2 hours ago. Which finding requires an intervention by the nurse?
1. The client requests a large glass of water.
2. The client lies quietly in bed with a cloth placed over the forehead and eyes.
3. The head of the bed is elevated 30° and the client's legs are bent at the knee.
4. The urine specific gravity is 1.025.
1) Implementation: outcome desired; client is NPO before the procedure; risk of dye-induced
nausea and vomiting; encourage fluid to decrease risk of dye-induced nephrotoxicity after the
procedure
2) Implementation: outcome desired; photophobia common after subarachnoid hemorrhage
3) CORRECT-Implementation: outcome not desired and is priority; leg should be extended and
in a neutral position after femoral angiogram
4) Assessment: outcome not desired but not priority; urine is concentrated; fluids encouraged to
flush dye through kidneys
A client calls the healthcare provider's office reporting a rash, intermittent fever, headache,
fatigue, muscle pain, and stiff neck. It is MOST important for the nurse to ask which question?
1. "Have you ever felt this way before?"
2. "Have you noticed any swollen areas on your neck?"
3. "Have you recently noticed any flea bites?"
4. "Have you noticed any tick bites recently?"
1) Assessment: outcome not priority; question too general
2) Assessment: outcome not priority; enlarged lymph glands indicate an inflammatory response
or neoplastic disorder
3) Assessment: outcome not priority; causes papular urticaria, not systemic symptoms
4) CORRECT-Assessment: outcome priority; symptoms of Lyme disease; causes localized and
systemic symptoms
The nurse observes a student nurse caring for a client with a tracheostomy and humidified
oxygen. Which of the following actions taken by the student nurse requires an intervention by
the nurse?
1. The student nurse sets the wall suction to 160 mm Hg pressure prior to suctioning.
2. The student nurse increases the oxygen level to 100% prior to suctioning.
3. The student nurse uses a catheter half the size of the tracheostomy opening.
4. The student nurse tells the client to breathe normally as the catheter is inserted.
1) CORRECT-Implementation: outcome not desired; will cause trauma to tracheobronchial
mucosa; suction should be set at 80-120 mm Hg
2) Implementation: outcome desired; will decrease the risk of tissue hypoxia; is standard of care;
must remember to decrease oxygen level to ordered concentration after suctioning
3) Implementation: outcome desired; a larger catheter will obstruct the lumen and increase the
risk of trauma
4) Implementation: outcome desired; should breathe normally during suctioning
A man diagnosed with a stroke develops dysphagia. Before allowing the client to eat, which
action should the nurse take FIRST?
1. Place client in semi-Fowler's position.
2. Auscultate bowel sounds.
3. Check client's gag reflex.
4. Offer to cut client's food.
1) Implementation: outcome not desired but not priority; should be in high-Fowler's position
during and 30 minutes after eating; not first action; assessment should be done first
2) Assessment: outcome desired but not priority; should be assessed, but is not first action
3) CORRECT-Assessment: outcome desired and priority; touch tongue depressor to back of
throat; first priority to determine risk of aspiration
4) Implementation: outcome not desired; should keep independent
The nurse teaches a client who is lactose-intolerant about some alternative ways to maintain an
adequate diet. The nurse will suggest the client include which food items in the diet?
1. Tofu and green leafy vegetables.
2. Beef and tomato salad.
3. Cottage cheese and yogurt.
4. Custard and mashed potatoes.
1) CORRECT-Implementation: outcome desired; good sources of calcium
2) Implementation: outcome not desired; contain no calcium
3) Implementation: outcome not desired; contain lactose
4) Implementation: outcome not desired; made with milk; contain lactose
A client contaminated with an unidentified hazardous material arrives by ambulance at a local
hospital. Which action should the nurse take FIRST?
1. Determine the decontamination that occurred in the field.
2. Reassure the client that he will receive excellent care.
3. Identify the type of hazardous material.
4. Remove all the client's clothing.
1) CORRECT-Assessment: outcome desired; nurse needs to determine if the situation is a threat
to the caregiver; important to prevent the spread of contamination; flushing with water dilutes or
reduces the amount of hazardous material
2) Implementation: not a priority; attend to the physical needs of client and staff
3) Assessment: outcome not desired; will be done by other health professionals; more important
to determine level of decontamination in field
4) Implementation: outcome desired but not a priority; will reduce 80 to 90% contamination;
more important to determine if decontamination occurred to ensure safety of client and staff
The nurse assesses the fetal monitor of a client in labor. Which fetal heart rate pattern requires an
intervention by the nurse?
1. A baseline rate of 140-150 between contractions with moderate variability.
2. Consistent heart rate accelerations that coincide with fetal movements.
3. A heart rate that slows following the peak of the contraction and returns to baseline after the
contraction ends.
4. Gradual slowing of the heart rate that begins with the onset of the contraction and returns
quickly to the baseline.
1) Assessment: outcome expected; normal
2) Assessment: outcome expected; reassuring sign of fetal well-being
3) CORRECT-Assessment: outcome not expected; late deceleration; indicates fetal distress and
uteroplacental insufficiency; treatment-position on left side, give O2, IVs, notify healthcare
provider
4) Assessment: outcome expected; early deceleration; good fetal outcome
One afternoon in the hospital day room, the nurse overhears a woman with chronic schizophrenia
say to another other client, "I hate you, get away from me or I'll kill you." Which of the
following responses, if made by the nurse, is MOST appropriate?
1. "I will not let that client hurt you."
2. "There is no reason for you to be angry with that client."
3. "You seem to be frightened by that client."
4. "You don't really want to kill that client."
1) Non-therapeutic; false reassurance
2) Non-therapeutic; assumes client is angry because she is feeling threatened
3) CORRECT-Therapeutic; acknowledges feelings
4) Non-therapeutic; don't argue with client
A woman is admitted to the hospital with a diagnosis of ovarian cancer. She has been treated
with surgery and chemotherapy. The client states that she has no appetite and has lost 10 lbs in
the last 4 weeks. Which statement, if made by the nurse, is MOST important?
1. "Have you noticed a decrease in your energy levels lately?"
2. "Do you notice any swelling of your hands and feet?"
3. "Describe your normal daily food intake."
4. "What are your favorite foods?"
1) Assessment: outcome desired but not priority; energy level decreased with malnutrition; is
also adverse effect of chemotherapy
2) Assessment: outcome desired but not priority; protein deficiency may cause peripheral edema
3) Assessment: outcome desired but not priority; more important to provide nutrition
4) CORRECT-Assessment: outcome desired and priority; offer favorite foods to deal with the
"here and now"
At 7 A.M., the nurse administers 10 mg glipizide (Glucotrol XL) to a 75-year-old client. At 11
A.M., the nurse notes that the client is drowsy, pale, and has cold, clammy skin. Which is the
INITIAL action the nurse will take?
1. Administer 1 mg glucagon subcutaneously.
2. Give the client 1 cup of fruit juice to drink.
3. Determine if the client ate breakfast.
4. Notify the healthcare provider.
1) Implementation: outcome not desired; glucagon used with severe hypoglycemia or when
client cannot take oral fluids
2) CORRECT-Implementation: outcome desired; symptoms of moderate hypoglycemia; client
can drink juice
3) Assessment: outcome desired but not priority; more important to increase blood glucose level
4) Implementation: outcome desired but not priority; should take action to correct hypoglycemia
first
The nurse assesses the IV site before administering vancomycin. The nurse notes that the area
around the IV infusion site is pale and feels cool. Which INITIAL action will the nurse perform?
1. Remove the intravenous catheter and elevate the arm on 1 or 2 pillows.
2. Begin the vancomycin infusion and reassess the infusion site in 15 minutes.
3. Withhold the vancomycin infusion and notify the healthcare provider.
4. Apply warm, moist compresses to the infusion site for 30 minutes and then administer the
medication.
1) CORRECT-Implementation: outcome desired; possible infiltration; high risk of tissue damage
and thrombophlebitis during vancomycin administration
2) Implementation: outcome not desired; priority is to discontinue infusion and prevent harm to
client
3) Implementation: outcome not desired; medication should be given; no need to notify
healthcare provider
4) Implementation: outcome not desired; warmth indicated for thrombophlebitis, not infiltration
The nurse teaches reality orientation to the husband of a woman with Alzheimer's disease and a
moderate hearing loss. Which statement, if made by the client's husband, indicates that he
understands this technique?
1. "I should ask my wife about current events we have discussed."
2. "I should reminisce with my wife about past events."
3. "I should frequently ask my wife for the date and time."
4. "I should place a calendar and clock in an obvious place."
1) Implementation: outcome not desired; short-term memory affected; unable to remember
2) Implementation: outcome not desired; will not reorient
3) Implementation: outcome not desired; can cause confusion, anxiety
4) CORRECT-Implementation: outcome desired and priority; use of memory aids and cues to
help orientation; gives sense of security
The nurse observes a man standing with his adult children after the unexpected death of his wife.
Which statement by the nurse is MOST appropriate?
1. "I'm sorry about your wife. I'm sure you will miss her."
2. "This must be a difficult time for you; I will stay with you."
3. "I know you're going to miss your wife; would you like to talk about some memories you both
shared?"
4. "Is there anything I can get for you?"
1) Implementation: outcome not desired; should focus on husband, not nursing staff; assumes
husband's feelings
2) CORRECT-Implementation: outcome desired; nurse stays with client; open-ended; responds
to feeling tone
3) Implementation: outcome not desired; should focus on here and now; assumes husband's
feelings
4) Assessment: outcome desired but not priority; "yes/no" question; does not respond to feeling
tone
The nurse teaches a wellness class to a group of women. The nurse knows that which of the
following clients is MOST at risk for developing cervical cancer?
1. A woman who began menstruating at age 9.
2. A woman who used oral contraceptives for 8 years.
3. A woman diagnosed with endometriosis at age 20.
4. A woman who has had approximately 10 sexual partners.
1) Assessment: outcome not priority; increases risk of breast cancer
2) Assessment: outcome not priority; increases risk of estrogen-dependent cancers
3) Assessment: outcome not priority; not related to cervical cancer
4) CORRECT-Assessment: outcome priority; multiple sexual partners increases risk of cervical
cancer
A 26-year-old woman comes to the emergency room for a possible ruptured ectopic pregnancy.
On admission, the client's vital signs are pulse 90, blood pressure 110/70, respirations 20. A halfhour later, her vital signs are pulse 120, blood pressure 86/50, respirations 26. Which of the
following is the MOST appropriate initial action for the nurse to take?
1. Administer pain medication.
2. Increase the rate of the IV fluids.
3. Ask the client to identify where she is.
4. Check the client's white cell count.
1) Implementation: outcome not desired; address ABCs first; analgesic medication may cause
further decrease in blood pressure
2) CORRECT-Implementation: outcome desired and priority; increased pulse, decreased BP
indicates decreased intravascular volume; symptoms of hypovolemic shock
3) Assessment: outcome desired but not priority; client in shock, implementation required
4) Assessment: outcome desired but not priority; usually won't change unless infection is causing
septic shock
On the third day after a thyroidectomy, the nurse notes that the client has developed tremors.
Which of the following is the MOST appropriate action for the nurse to take?
1. Check the client's calcium level.
2. Check the client's glucose level.
3. Check the client's potassium level.
4. Check the client's sodium level.
1) CORRECT-Assessment: outcome priority; parathyroid gland may be injured, causing
hormone levels to decrease; causes decrease in blood calcium; early signs include tingling of
fingers, toes, lips
2) Assessment: outcome desired but not priority; blood glucose below 50 mg/dL; symptoms
include sweating, trembling, anxiety, hunger, weakness
3) Assessment: outcome desired but not priority; K+ below 3.5 mEq/L; symptoms include
fatigue, vomiting, muscle weakness, dysrhythmias
4) Assessment: outcome desired but not priority; if Na+ below 135 mEq/L; symptoms include
muscle cramps, lethargy, hemiparesis (paralysis of one side of body)
The nurse cares for a client with Addison's disease who is taking 20 mg hydrocortisone (Cortef)
daily. Which statement by the client requires an intervention by the nurse?
1. "I will need to have my blood sugar levels checked while on this medication."
2. "I may have episodes of low blood pressure while taking this medication."
3. "I need to weigh myself twice a week and keep a record of my weight."
4. "I should notify my health care provider if I am running a fever."
1) Assessment: outcome expected; glucocorticoids can increase serum glucose levels
2) CORRECT- Assessment: outcome not expected; hypertension due to sodium and water
retention expected
3) Assessment: outcome expected; weight gain due to sodium and water retention expected
4) Implementation: outcome desired; glucocorticoids have immunosuppressant effect; client at
high risk for infection
The nurse cares for a client being maintained on a ventilator. The client suddenly becomes
distressed and agitated. Which of the following is the MOST appropriate action for the nurse to
take?
1. Obtain an order for a tranquilizer.
2. Restrain the client.
3. Check the last arterial blood gas result.
4. Assess the client's breathing pattern in relation to the ventilator.
1) Implementation: outcome not desired; priority is to determine cause of distress
2) Implementation: outcome not desired; physical restraints are a last resort
3) Incorrect. A current ABG is needed to make any type of decision.
4) CORRECT-Assessment: outcome desired and priority; is client "fighting" the ventilator;
symptoms of respiratory distress include restlessness, agitation, apprehension, irritability, pallor,
use of accessory muscles, increased pulse; check airway, vital signs, and ABGs
The nurse cares for a client with chronic renal failure who has an arteriovenous fistula in the left
arm. Which of the following should be included in the care of the client?
Select all that apply
1. (1.) Assess and compare blood pressure in both arms.
2. (2.) Auscultate for "whooshing" sound over the fistula.
3. (3.) Palpate for warmth and tenderness over the area of the fistula.
4. (4.) Instruct the client to avoid getting the left arm wet.
5. (5.) Instruct the client to sleep with the left arm in the dependent position.
6. (6.) Instruct the client to avoid carrying heavy objects with the left arm.
(1.) no constriction of the arm with the fistula; may damage fistula
(2.) CORRECT - Bruit should be heard over the area of the fistula due to increased blood flow; if
no bruit heard, notify healthcare provider
(3.) CORRECT - Increased risk of infection in the fistula area; possible infection should be
reported to healthcare provider
(4.) fistula is internal; no risk of infection from exposure to water
(5.) no weight should be placed on the extremity with the fistula
(6.) CORRECT - increases the risk of fistula damage
The nurse teaches a client about foods and beverages that may be consumed on a low- sodium
diet. Which beverage, if selected by the client, indicates an understanding of the instructions?
1. Lemonade.
2. Skim milk.
3. Ginger ale.
4. Tomato juice.
1) CORRECT- Implementation: outcome desired; 1 cup = 2 mg Na+
2) Implementation: outcome not desired; 1 cup = 125 mg; high Na+ in milk products
3) Implementation: outcome not desired; 1 cup = 60 mg; high Na+ in carbonated beverages
4) Implementation: outcome not desired; 1 cup = 500 mg; extremely high Na+
The nurse cares for a 24-year-old female client admitted to an inclient treatment unit with a
diagnosis of purging-type bulimia. It is MOST important for the nurse to take which action?
1. Encourage the client to verbalize feelings about eating disorders.
2. Sit with the client in silence as she discusses her daily life and eating habits.
3. Ask the family to describe the client's eating habits prior to admission.
4. Ask the client about any emotional distress she may be experiencing.
1) Implementation: outcome desired but not priority; priority is to establish trust
2) CORRECT- Implementation: outcome desired; establishing trust relationship is first priority
3) Assessment: outcome not desired; more important to establish trust
4) Assessment: outcome desired but not priority; may be done after trust relationship established
A 22-year-old woman at term comes to the hospital in labor. Two hours after admission, the
client remains 4 centimeters dilated, and her contractions are weak. The healthcare provider
orders oxytocin (Pitocin). Which finding would require an intervention by the nurse?
1. Contractions every 2 minutes, lasting 90 seconds.
2. Contractions every 3-4 minutes, lasting 60 seconds.
3. Fetal heart rate of 110 beats per minute at the peak of a contraction.
4. Fetal heart rate of 158 bpm at the end of a contraction.
1) CORRECT- Assessment: outcome priority; only 30 seconds between contractions; hypertonic
labor pattern; results in fetal distress
2) Assessment: outcome not priority; normal frequency and duration
3) Assessment: outcome not priority; reassuring fetal heart tones
4) Assessment: outcome not priority; reassuring fetal heart tone
The nurse cares for a client after a lumbar laminectomy. Which action by the nurse is MOST
important?
1. Elevate the head of the bed 30° and then turn the client.
2. Place a pillow between the client's legs and then turn the client.
3. Have the client grasp the side rail on the opposite side of the bed and then assist the client to
turn.
4. Instruct the client to bend the knees and then assist the client to turn.
1) Implementation: outcome not desired; must stay flat to maintain alignment
2) CORRECT-Implementation: outcome desired; log roll repositioning maintains proper
alignment of spine
3) Implementation: outcome not desired; no twisting allowed
4) Implementation: outcome not desired; no twisting allowed
An adolescent is admitted to the hospital with a diagnosis of bacterial meningitis. Which of the
following actions, if observed by the nurse, would require an intervention?
1. The LPN/LVN enters the client's room and leaves the door open.
2. The nursing assistive personnel leaves the client's room with the face mask hanging from the
neck.
3. The student nurse washes hands and puts on gloves.
4. The client's mother stands away from the client while talking to the client.
1) Implementation: outcome desired; droplet precautions necessary, door may be left open
2) CORRECT- Implementation: outcome not desired; used masks should be discarded inside the
client's room
3) Implementation: outcome desired; standard precautions used with all clients
4) Implementation: outcome desired; maintain 3-foot separation from infected client
A woman is admitted to the hospital complaining of diarrhea and vomiting for 3 days. The blood
pressure is 90/60, apical heart rate 96, and respiratory rate 22 with shallow respirations.
Laboratory results include Na+ 147 mEq/L, K+ 5.6 mEq/L, hematocrit 52%, hemoglobin 14
g/dL. The client is receiving 5% dextrose in 0.45% normal saline with K+ 20 mEq at 125 mL/hr.
Prior to calling the healthcare provider, it is MOST important for the nurse to take which of these
actions?
1. Change IV fluids to 5% dextrose in 0.45% normal saline.
2. Increase IV flow rate to 150 mL/hour.
3. Check the hourly urine output.
4. Observe the client for muscle weakness.
1) CORRECT- Implementation: outcome desired; potassium removed due to hyperkalemia;
hypotonic solution used to correct dehydration
2) Implementation: outcome not desired; will increase serum potassium
3) Assessment: outcome not priority; client is dehydrated; intervention required
4) Assessment: outcome not priority; lab values indicate hyperkalemia
The nurse cares for a client 4 hours after admission to the neuroscience unit due to a closed-head
injury. Which is the MOST important action for the nurse to take?
1. Assess pupil shape and reactivity.
2. Take the client's rectal temperature.
3. Assess blood pressure and apical heart rate.
4. Observe the client's oxygen saturation level.
1) CORRECT- Assessment: outcome desired and priority; change in pupil size, shape, or
reactivity is an early sign of increased intracranial pressure; report to healthcare provider
immediately
2) Assessment: outcome not priority; increased temperature late sign of increased intracranial
pressure; temperature elevation may be due to other injuries
3) Assessment: outcome not priority; changes in vital signs are late sign of increased intracranial
pressure
4) Assessment: outcome desired but not priority; increased carbon dioxide level will increase
intracranial pressure
The husband of a woman at 39 weeks gestation calls the clinic nurse and states, "My wife's water
just broke, and I think she's going to have the baby!" Which statement, if made by the nurse, is
BEST?
1. "Look at your wife's vaginal area and tell me what you see."
2. "Time the contractions for 5 minutes."
3. "Tell your wife to pant between contractions."
4. "I will instruct you about how to deliver the baby."
1) CORRECT- Assessment: outcome desired and priority; determine if presenting part is
crowning
2) Assessment: outcome desired but not priority; need to determine stage of labor first
3) Implementation: outcome not desired; need to determine stage of labor first
4) Implementation: outcome not desired; need to assess first
A 60-year-old male client awakens frightened and agitated. He climbs out of bed, removes his
indwelling urinary drainage catheter, and runs down the hall screaming. Which of the following
is the FIRST action the nurse should take?
1. Notify the healthcare provider.
2. Restrain the client.
3. Replace the urinary catheter.
4. Check for injuries.
1) Implementation: outcome desired but not priority; assessment needed
2) Implementation: outcome not desired; restraint is last resort; needs reorientation
3) Implementation: outcome desired but not priority
4) CORRECT- Assessment: outcome desired and priority; will guide further assessment and
interventions; will gather needed information to tell health care provider
The nurse plans care for a 4-year-old girl who has been sexually abused by her grandfather. Play
therapy is scheduled as part of the treatment plan. Which statement, if made by the child's
parents, indicates understanding of the primary purpose of play therapy?
1. "The main goal of play therapy is for our child to deal with any anger that she has."
2. "During these play sessions, our child will be encouraged to communicate at her own level."
3. "Our child's developmental level will be evaluated by a child development specialist during
these sessions."
4. "The main purpose of play therapy is to determine exactly what type of abuse occurred."
1) Implementation: outcome not desired; expression of anger may occur; main goal is
communication
2) CORRECT- Implementation: outcome desired; child may not be able to express her
perception of the events verbally; play with dolls will facilitate communication
3) Implementation: outcome not desired; not primary goal of play session; assessment of
developmental level may occur
4) Implementation: outcome not desired; may occur, but not the primary purpose
The nurse cares for a client with suspected Neisseria meningitidis infection. Which action is
MOST important for the nurse to take?
1. Wear a gown when entering the room.
2. Place the client in a negative-pressure isolation room.
3. Wear a face mask while assisting the client with activities of daily living.
4. Wash hands with soap and water for 3 to 4 minutes when exiting the room.
1) Implementation: outcome not desired; gown not required with droplet precautions unless risk
contact with body fluids
2) Implementation: outcome not desired; negative-pressure isolation room used for airborne
precautions
3) CORRECT- Implementation: outcome desired; place on droplet precautions because organism
spread by larger droplets
4) Implementation: outcome not desired; length of hand-washing does not need to be extended
A client is brought to the mental health center reporting severe headaches, insomnia, and poor
appetite. Each time a question is asked, the client provides a lengthy, detailed description of
events. Which of the following is the MOST important action for the nurse to take?
1. Remind the client of the time.
2. Tell the client that people are there to take care of her.
3. Sit and listen to the client.
4. Ask the client to be brief.
1) Implementation: outcome not desired; should allow client the time to express needs; nontherapeutic response
2) Implementation: outcome not desired; false reassurance; blocks communication
3) CORRECT- Implementation: outcome desired; assess first to meet client needs, allow client to
express needs
4) Implementation: outcome not desired; non-therapeutic; nurse is controlling the interview
Based on the nurse's knowledge of the goal of diuretic therapy for a client with heart failure,
which assessment BEST indicates that the client's condition is improving?
1. The client's weight has decreased 2 pounds.
2. The client's systolic blood pressure has decreased.
3. The client has fewer crackles heard during auscultation.
4. The client's urinary output has increased.
1) Assessment: outcome expected but not priority; could be due to changes in appetite, no time
frame given in question
2) Assessment: outcome expected but not priority; could be due to other causes such as change in
position
3) CORRECT- Assessment: outcome priority; reason for diuretics; diuretic reduces alveolar
edema and pulmonary venous pressure
4) Assessment: outcome expected but not priority; will increase due to diuretic but may not
change heart failure
The home care nurse performs a health screening at the local mall. The nurse knows that which
of the following clients is at HIGHEST risk for developing a stroke?
1. A 32-year-old Caucasian female who has a history of type 1 diabetes mellitus and has used
oral contraceptive for 8 years.
2. A 49-year-old Caucasian male who works as an account executive at an ad agency and has a
cholesterol level of 250 mg/dL.
3. A 56-year-old African-American female who consumes 1 to 2 alcoholic beverages weekly and
has smoked cigarettes for 30 years.
4. A 69-year-old African-American male who has a history of hypertension and is 30 pounds
overweight.
1) Assessment: outcome not priority; risk factors include diabetes and oral contraceptive use
2) Assessment: outcome not priority; risk factors include high cholesterol; no demonstrated
relationship between occupation and stroke
3) Assessment: not priority; risk factors include race and smoking; daily consumption of 2 or
more alcoholic beverages a day increases risk of hypertension and stroke
4) CORRECT- Assessment: priority; risk factors include age, race, hypertension, and obesity
The nurse supervises the distribution of meal trays on a medical unit. Which tray will should be
given to a client who has requested a kosher diet?
1. Cheeseburger, sliced tomato, french fries, and a milkshake.
2. Pork chops, applesauce, baked potato, and ginger ale.
3. Shrimp salad, sliced avocado, bread, and coffee.
4. Fruit salad, cottage cheese, crackers, and tea.
1) Implementation: outcome not desired; cannot eat dairy and meat at the same meal; eat dairy 6
hours after meat meal
2) Implementation: outcome not desired; cannot eat pork products (bacon, ham, animal
shortening, gelatin or foods containing gelatin, e.g., marshmallows)
3) Implementation: outcome not desired; cannot eat shellfish or scavenger fish; fish must have
scales
4) CORRECT- Implementation: outcome desired; kosher diet follows Jewish law; no meat or
poultry at the same meal as dairy, or using the same utensils; no pork products; no scavenger fish
A 56-year-old man is scheduled for an MRI (magnetic resonance imaging). His history indicates
that he suffered an injury during the Vietnam War. Which question is MOST important for the
nurse to ask the client?
1. Where was your injury?
2. When were you wounded?
3. Did your injury involve shrapnel?
4. Were you exposed to chemical warfare?
1) Assessment: outcome not priority; not significant for MRI
2) Assessment: outcome not priority; not significant for MRI
3) CORRECT- Assessment: outcome desired and priority; MRI contraindicated with metal
prosthesis or implanted metal
4) Assessment: outcome not priority; defoliant used in war, not significant for MRI
The home care nurse is visiting a client terminally ill with pancreatic cancer who wishes to die at
home. Which question, if asked by the nurse, is MOST appropriate?
1. "Are you sure you want to die at home?"
2. "Where will you put the hospital bed?"
3. "Would you like your minister to visit you?"
4. "Who will take care of you?"
1) Assessment: outcome not desired; psychosocial, yes-no question, non-therapeutic
2) Assessment: outcome desired but not priority; important to obtain the needed equipment, but
is very specific
3) Assessment: outcome not priority; passing the buck, yes-no question, non-therapeutic
4) CORRECT- Assessment: outcome desired and priority; physical need, meet basic needs first
before psychosocial
A client returns to the unit following a thyroidectomy. Which assessment finding requires an
intervention by the nurse?
1. The client makes noises when breathing.
2. The client reports pain at the surgical site.
3. The client asks for liquids to drink.
4. The client is sleepy from anesthesia.
1) CORRECT- Assessment: outcome not expected and priority; sign of tracheal compression
caused by hemorrhage or edema
2) Assessment: outcome expected; use analgesics, semi-Fowler's position
3) Assessment: outcome expected; NPO status prior to surgery
4) Assessment: outcome expected
A 52-year-old homeless woman is admitted to the psychiatric unit for treatment of chronic
schizophrenia. The nursing assistive personnel reports to the nurse that when attempting to bathe
the client, the client became uncooperative and demanded coffee and a snack. Which suggestion
will the nurse give to the nursing assistive personnel?
1. Remind the client that too much caffeine is bad for her health.
2. Tell the client that she may have coffee and a snack when her bath is complete.
3. Remove the client from the bath and return her to bed.
4. Get help from other staff members to complete the bath.
1) Implementation: outcome not desired; not effective with this client
2) CORRECT- Implementation: outcome desired; would meet client's immediate needs; is
factual answer
3) Implementation: outcome not desired; needs physical needs met; need to develop trusting
relationship; action may increase distress
4) Implementation: outcome not desired; shouldn't use force; client should feel environment is
safe; action may increase distress
A 39-year-old man is admitted with a diagnosis of Acquired Immune Deficiency Syndrome
(AIDS). His lab results are hemoglobin 9.3 g/dL, hematocrit 25%, platelets 50,000/mm3, white
cell count 1,500/mm3. Which order will should the nurse implement FIRST?
1. "Infuse 2 units of packed red cells."
2. "High-protein, high-carbohydrate diet as tolerated."
3. "Administer 2 units platelets."
4. "Place the client on neutropenic precautions."
1) Implementation: outcome desired but not priority; given when hemoglobin is down to 8 g/dL
2) Implementation: outcome desired but lower priority
3) Implementation: outcome desired but lower priority; risk of spontaneous bleeding when
platelets 20,000/mm3 or below
4) CORRECT- Implementation: outcome desired and high priority; at risk for acquiring lifethreatening infection due to leukopenia
To locate the point of maximum impulse (PMI) of a client's heart, the nurse's hand (fingertips)
should be placed over which location?
1. A
2. B
3. C
4. D
QUESTION - Where do you find the PMI?
STRATEGY - Picture the anatomy of the heart and its position in the body.
NEEDED INFO - PMI: forward thrust of left ventricle during systole produces normal pulsation
on chest wall. Indicates size and position of heart. Should be felt in 5th intercostal space. If
apical impulse appears in more than one intercostal space, may indicate ventricular enlargement.
CORRECT ANSWER - (3) The fifth intercostal space at the midclavicular line. (1) Wrong
position. (2) Wrong position. (4) Incorrect.
The nurse is caring for an elderly client admitted for type 1 diabetes mellitus. The nurse notes
that the client appears to have difficulty understanding what is said. Which of the following
actions, if taken by the nurse, is MOST appropriate?
1. Ask the client if cotton-tipped applicators are used for ear cleaning.
2. Perform the Weber hearing test.
3. Check the client's ear canals for cerumen.
4. Use facial expressions and speak in a high frequency tone of voice.
1) Assessment: outcome not priority; most common cause is cerumen in elderly
2) Assessment: outcome not priority; cerumen most likely cause
3) CORRECT- Assessment: outcome priority; physical, ear wax becomes drier in elderly; can
block ear canal and cause decreased hearing
4) Implementation: outcome not priority; nonverbal cues useful when speaking to hearingimpaired; need low tones; high frequency tones are problem for elderly
A client with an 8-year history of ulcerative colitis is admitted to the hospital with severe
abdominal cramping and diarrhea. The client has experienced 18 to 20 stools a day for the last 4
days. The nurse is MOST concerned by which finding?
1. The client's diastolic blood pressure decreases 20 mm when the client rises to a standing
position.
2. The client's urinary specific gravity is 1.020.
3. The client has lost 3 pounds since her last admission.
4. The client appears pale and thin.
1) CORRECT- Assessment: outcome priority; indicates fluid volume deficit, check blood
pressure supine, sitting and standing; other symptoms include concentrated urine and weak, rapid
pulse
2) Assessment: outcome not priority; normal 1.010-1.030
3) Assessment: outcome not priority; don't know when client was last hospitalized
4) Assessment: outcome not priority; more concerned about fluid volume deficit
The nurse performs dietary teaching for a client taking lithium carbonate (Lithonate). Which
snack, if selected by the client, indicates that teaching is effective?
1. Four carrot sticks.
2. 8 oz of ice tea.
3. A whole banana.
4. 12 oz of lemonade.
1) Implementation: outcome not desired; should provide increased fluid intake
2) Implementation: outcome not desired; contains caffeine, which is a natural diuretic and
stimulant; should avoid fluids containing caffeine
3) Implementation: outcome not desired; should provide increased fluid intake
4) CORRECT-Implementation: outcome desired; provides for increased fluid intake; lithium can
cause nephrogenic diabetes insipidus; those on lithium experience thirst and polyuria; need
2,500-3,000 mL/day with adequate salt intake
A child is admitted to the hospital with a diagnosis of status asthmaticus. The nurse is MOST
concerned if which of the following is observed?
1. SaO2 91%.
2. Expiratory wheezing.
3. Intercostal retractions.
4. Arterial pH 7.25.
1) Assessment: outcome expected; minimal acceptable level
2) Assessment: outcome expected; continuous high-pitched musical sound; expected with asthma
3) Assessment: outcome expected; usually present with severe asthma
4) CORRECT- Assessment: outcome not expected; indicates severe respiratory acidosis,
accumulation of CO2 is danger sign of impending respiratory failure and cardiac arrest
The nurse cares for a client who returned 4 hours ago after a subtotal thyroidectomy procedure.
The nurse notes that the client sounds more hoarse when speaking than he did 1 hour ago. Which
of the following is the MOST appropriate action for the nurse to take?
1. Check the gag and swallow reflex.
2. Instruct the client to chew small amounts of ice chips.
3. Notify the healthcare provider.
4. Instruct the client to cough and breathe deeply every 15 minutes.
1) Assessment: outcome desired but not priority; not best test for laryngeal damage
2) Implementation: outcome not desired; will not decrease hoarseness
3) CORRECT- Implementation: outcome priority and desired; possible laryngeal damage;
further assessment and possible treatment indicated; do not assume that hoarseness is caused by
endotracheal tube
4) Implementation: outcome not desired; may further damage operative site
A mother brings her 15-month-old infant to the pediatric clinic for immunizations. The mother
tells the nurse that the infant has been diagnosed with cancer and is being treated with
chemotherapy. The nurse should question the administration of immunization?
1. Hepatitis B (HB).
2. Measles/mumps/rubella (MMR).
3. Inactivated polio (IPV).
4. Diphtheria, tetanus toxoid, and acellular pertussis (DTaP).
1) Implementation: outcome desired; no contraindication
2) CORRECT- Implementation: outcome not desired; live virus, not given to immunosuppressed
clients
3) Implementation: outcome desired; no contraindication
4) Implementation: outcome desired; contraindication includes encephalopathy within 7 days
The nurse reviews room assignments for 4 clients admitted to the unit. The nurse should question
which room assignment?
1. A child with chickenpox placed in a private room at the end of the hall.
2. A child with meningitis placed in a private room across from the nurses' station.
3. A client with cellulitis of the right leg placed in a semi-private room with a client diagnosed
with type 1 diabetes.
4. A client with essential hypertension placed in a semi-private room with a client who has
pancreatitis.
1) Implementation: outcome desired; communicable disease, appropriate room placemen
2) Implementation: outcome desired; communicable disease, requires frequent assessment; client
at risk for seizures
3) CORRECT- Implementation: outcome not desired; don't put a client with infection (cellulitis)
with a client who is at risk for infection
4) Implementation: outcome desired; appropriate placement, no cross-contamination
Levodopa (L-Dopa) is prescribed for a 61-year-old woman. Which statement, if made by the
client to the nurse, would indicate that the client needs further instruction?
1. "While I take this medication, I should eat a high-protein diet."
2. "I should change positions slowly at first so I don't get dizzy."
3. "If I have muscle twitching, I should report it to my health care provider."
4. "I should check with my health care provider before taking any over-the-counter medications."
1) CORRECT- Implementation: outcome not desired; take with low-protein diet to decrease GI
upset
2) Implementation: outcome desired; true; orthostatic hypotension is common with Parkinson's
disease
3) Implementation: outcome desired; true; blepharospasms (twitching eyelid) are early signs of
overdosage
4) Implementation: outcome desired; true; multivitamins can reverse actions, especially vitamin
B6
The nurse cares for clients in the pediatric clinic. The nurse would be MOST concerned if which
of the following was observed?
1. A 3-month-old infant's back is rounded.
2. A 4-year-old has a blood pressure of 90/60.
3. A 5-year-old has a pulse of 88.
4. The hem of the skirt on a 10-year-old is longer on one side than the other.
1) Assessment: outcome expected; normal finding
2) Assessment: outcome expected; normal finding
3) Assessment: outcome expected; normal finding
4) CORRECT-Assessment: outcome not expected; symptom of scoliosis
The nurse observes a peer self-administering fentanyl (Sublimaze) after removing it from the
narcotic cabinet. Which is the MOST appropriate action for the nurse to take?
1. Tell the nurse what was observed.
2. Report the observation to the supervisor.
3. Complete an incident report.
4. Discuss the incident with another nurse.
1) Implementation: outcome not desired; inappropriate; is confrontational
2) CORRECT- Implementation: outcome desired; use chain of command
3) Implementation: outcome not desired; not appropriate for situation
4) Implementation: outcome not desired; inappropriate; confidential information
The nursing team consists of two RNs, one LPN/LVN, and one nursing assistive personnel. The
nurse should consider the assignment appropriate if the LPN/LVN is required to complete which
task?
1. Ambulate a client 8 hours after a thoracotomy.
2. Give an enema to a client prior to a colonoscopy.
3. Complete a bed bath for a client with burns on the arms and legs.
4. Perform a dressing change on a client 3 days after a cholecystectomy.
1) Implementation: outcome not desired; RN needs to frequently assess and evaluate
2) Implementation: outcome not desired; standard, unchanging procedure, assign to
assistive personnel
3) Implementation: outcome not desired: high risk of infection and sepsis, RN can do
thorough assessment during bath
4) CORRECT- Implementation: outcome desired; stable client with an expected outcome