The nurse is preparing to administer four medications to the client with dysphagia. Which medication should be administered first?
A. Conjugated estrogen (Premarin)
B. Furosemide (Lasix)
C. Ceclor (cephaclor)
D. Diphenhydramine (Benadryl)
B. Furosemide (Lasix) is a diuretic commonly used to treat congestive heart failure and hypertension. This drug should be given first to ensure that the client receives medication to treat potential life-threatening condition. Answers A, C, and D are incorrect because these drugs can be given after the furosemide (Lasix).
The nurse is preparing to make rounds. Which client should be seen first?:
A 1-year-old with hand-and-foot syndrome
B 69-year-old with congestive heart failure
C 40-year-old with resolving pancreatitis
D 56-year-old with Cushing’s disease
B. The nurse should first see the client with congestive heart failure in order to evaluate the client’s respirations. This client is in the most immediate danger. Answer A is incorrect because the 1 year old with hand foot syndrome is experiencing swelling and pain in the joints related to sickle cell anemia. This client can be seen after the client in Answer B. Answers C and D are incorrect because the client with resolving pancreatitis and the client with Cushing’s disease is more stable than the client with congestive heart failure
A category four tornado has injured 50 people from the community. The nurse is responsible for in field triage. According to triage protocol, which client should betreated last?
A. The 30-year-old with lacerations to the neck and face
B. The 70-year-old with chest pain and shortness of breath.
C. The 6-year-old with fixed, dilated pupils who is nonresponsive
D. The 40-year-old with tachypnea and tachycardia
C. The six-year-old with fixed, dilated pupils who is unresponsive is unlikely to survive. According to disaster triage protocol, priority is given to those clients who are expected to survive with fewer resource expenditures. Answers A, B, and D are incorrect for this reason.
Which nurse should be assigned to care for the client who has recently returned from surgery following a coronary artery bypass graft?
A. The nurse with 2 years experience in surgery
B. The nurse with 1 year experience in oncology
C. The nurse with 10 years experience in neonatal intensive care
D. The nurse with 5 years experience in the emergency room
A. The nurse with experience in surgery is most qualified to care for the client recently returned from having a coronary artery bypass graft. Answers B, C, and D are incorrect because these nurses are less experienced in the care of the surgical client.
The charge nurse is responsible for assigning clients to share a semi-private room. Which two clients can be assigned to share the room?
A. The 15-year-old with pneumonia and a 10-year-old with human immunovirus
B. The 30-year-old with leukemia receiving chemotherapy and the 25-year-old with bronchitis
X. The 60-year-old with gastroenteritis and the 65-year-old with Cushing’s disease
X. The 70-year-old with diabetes and the 75-year-old with a fractured hip
Four clients arrive in the emergency room. Which client should receive priority?
A. The client with burns of the chest and neck
B. The client with gastroenteritis
C. The client with a migraine headache
D. The client with a fractured tibia
A. The client with burns of burns chest and neck should be seen first because he is at risk for airway obstruction. Answers B, C, and D are incorrect because these clients do not take priority over the client with potential airway obstruction.!
A nursing assistant has reported to work late for the last three days. Which action should be taken first?
A. Document the lateness in the employee’s record
B. Terminate the employee immediately
C. Discuss the problem with the employee
D. Confront the employee during the change of shift
C. Discussing the problem with the employee will allow the employee to explain the lateness. This action should be taken first. Answer A is incorrect because documentation will be done after the meeting. Answer B is incorrect because the employee should be given the opportunity to explain the lateness. The employee should also be told what action will be taken if the problem is not corrected. Answer D is incorrect because the employee should be confronted privately.!
Which task must be performed by the registered nurse?
A. Hanging a bag of total parenteral nutrition solution
B. Inserting an indwelling urinary catheter
C. Administering a vaginal suppository
D. Checking the weights used with skeletal traction
A. The registered nurse should be assigned to hang total parenteral nutrition solution. Total parenteral nutrition, administered by central line, contains lipids and other nutrients needed by the client in negative nitrogen balance. Answer B is incorrect because the licensed practical nurse can insert an indwelling urinary catheter. Answer C is incorrect because the licensed practical nurse can administer a vaginal suppository. Answer D is incorrect because the licensed practical nurse can check the weights used with skeletal traction.
Which task is best delegated to the licensed practical nurse?
A. Beginning an infusion of platelets
B. Inserting a nasogastric tube
C. Flushing a central venous catheter
D. Administering intravenous dexamethasone (Decadron)
B. The licensed practical nurse is skilled in the insertion of nasogastric feeding tubes. Answers A, C, and D are incorrect because these are tasks are best performed by the registered nurse. Some states allow the licensed practical nurse to obtain certification in intravenous administration; however, IV administration cannot be performed by licensed practical nurses in all states. Nurses should be familiar with the nurse practice act in the state in which they practice.!
The nurse observes the nursing assistant speaking harshly to an elderly client. Which action is most appropriate?
A. Ask the nursing assistant to speak in a lower tone because he is disturbing the other clients
B. Report the nursing assistant to the charge nurse
C. Reassign the nursing assistant to a younger client
D. Call the nursing assistant aside to discuss the observation
D. The best action is to call the nursing assistant aside and explore the reason for her harsh behavior toward the elderly client. The nurse’s priority action should be to protect the client. Answer A is incorrect because this answer does not address the problem. Answer B is incorrect because this answer does not foster a resolution of the problem. Answer C is incorrect because this answer does not ensure that the nursing assistant will behave differently toward a younger client.
The nurse realizes that the nursing assistant needs further teaching if she observes the nursing assistant:
A. Walking the postoperative client with leg pain
B. Bathing the client using soap and water
C. Changing the bed of the client in traction from top to bottom
D. Feeding the client using a disposable spoon and fork
A. The client with leg pain might be experiencing a deep vein thrombus. Activities that can dislodge the clot can result in pulmonary embolus. The client should be returned to bed immediately and the finding should be reported to the physician. Answer B is incorrect because there is no contraindication to using soap and water to bathe the client. If the client is in traction, it is often easier to change the bed from top to bottom; therefore, Answer C is incorrect. Answer D is incorrect because disposable utensils are suitable for use when feeding the client.
During morning report, the nurse is told that the postoperative client has complained of unremitting pain during the night. Although she has been given pain medication several times, there seems to be no change in the client’s condition. Which action should the nurse take at this time?
A. Call the doctor and ask for a change in the client’s medication
B. Perform a head-to-toe assessment
C. Administer another dose of the client’s prescribed analgesic
D. Ask the client whether she is addicted to pain medications
B. Because the client has had no relief from pain, even with administration of pain medication, the nurse should fully assess the cause of the pain. Answer A is incorrect because an assessment should be done prior to changing the medication. Answer C is incorrect because administration of an analgesic has done little to relieve the client’s pain during the night; therefore, it is unlikely that another dose will offer relief. Answer D is incorrect because there is no data to suggest that the client is addicted and implies an assumption on the part of the nurse.
The nurse observes a co-worker putting a contaminated dressing on the client’s bedside table. Which action is most appropriate?
A. Remove the contaminated dressing and clean the surface of the bedside table with a hypochlorite solution
B. Wait until after the co-worker finishes and then request housekeeping to completely clean the room
C. Remove the contaminated dressing and place it in the client’s waste can
D. Ask the co-worker why he placed the contaminated dressing on the client’s bedside table
A. The nurse should remove the contaminated dressing and clean the surface of the bed side table with a hypochlorite solution. A hypochlorite solution is one part bleach and ten parts water. Answer B is incorrect because there is no indication that the entire room needs cleaning. Answer C is incorrect because the dressing should be placed in a red bag before placing in the waste can. Answer D is incorrect because asking why is nontherapeutic. The nurse should discuss the proper disposal of contaminated articles with the co-worker.
The nurse observes a co-worker striking a client with Alzheimer’s disease. The coworker can be charged with:
A. Battery
B. Assault
C. Malpractice
D. Negligence
A. Battery, an intentional tort, refers to physical contact in an offensive manner without the intent to do harm. Striking the client is a form of battery. Answer B is incorrect because assault, also an intentional tort, refers to threatening or attempting violence without physical contact. Answer C is incorrect because malpractice refers to unreasonable lack of skill in performing professional duties that results in injury or death of the client. Answer D is incorrect because negligence refers to acts of omission or commission that results in injury to the client or the client’s property. Malpractice and negligence are examples of unintentional torts.
The nurse is making several room assignments. Which client should be placed in the private room near the nurse’s station?
A. The 75-year-old with emphysema and fever
B. The 70-year-old who is two days post appendectomy
C. The 65-year-old scheduled for surgery for suspected ovarian cancer
D. The 60-year-old who is one day post thyroidectomy
A. The client with emphysema with fever requires closer observation than the other four clients because of his chronic respiratory disease; therefore he should be placed nearest the nurse’s station. Answer B is incorrect because the client with an appendectomy two days ago is more stable. Answer C is incorrect because there is no data to support a need for the client to be placed in the room near the nurse’s station. Answer D is incorrect because the client with a thyroidectomy 24 hours earlier is more stable than the client with emphysema and fever.!
The charge nurse has noticed that there has been an increase in the number of nosocomial infections on the unit. Which action can help to decrease the spread of infection from the nurse to the client?
A. Using a mask while emptying the urinary drainage system
B. Keeping the door closed to each client’s room
C. Asking the client’s family to wear gowns and mask while visiting
D. Washing hands between each client contact
D. Good hand-washing is the best way to prevent the spread of nosocomial infections as well as infections in the home. Answer A is incorrect because there is usually no need to wear a mask when emptying a urinary drainage system. Answer B is incorrect because there is no need to keep the doors closed to all client rooms. Answer C is incorrect because the focus is on preventing transmission of pathogens from the nurse to the client, not on preventing transmission of pathogens from the family to the client.
The nurse is performing a chart review of a client who fell in the bathroom while trying to shower. Which information must be included in the incident report?
A. The cause of the incident
B. The client’s status on admission to the unit
C. The action taken by the nurse as a result of the incident
D. Those family members present at the time of the incident
C. The nurse should include in the incident report the injury to the client and the action taken as a result of the incident. Answer A is incorrect because charting the cause of the incident is speculative on the part of the nurse and can imply liability. Answer B is incorrect because there is no need to chart the client’s status on admission. Answer D is incorrect because there is no need to chart which family members were present at the time of the incident.
Four clients have been assigned to the nurse for a home visit. Which client should the nurse visit first?
A. 65-year-old with diabetes and venous stasis ulcers
B. 10-year-old with spina bifida who performs daily selfcatheterization
C. 75-year-old with a stroke who receives peg tube feedings
D. 35-year-old with systemic lupus who complains of blurred vision and headaches
D. Complaints of headache and blurred vision by the client with SLE can indicate increasing hypertension, which accompanies renal failure, stroke, and myocardial infarction. Answers A, B, and C are incorrect because these clients have more stable conditions; therefore they can be visited later.!
The charge nurse is making assignments for the day. Which client should be cared for by the RN?
A. A client receiving radiation therapy for Graves’ disease
B. A client with cachexia who is receiving total parenteral nutrition
C. A client who is three days post-gastrectomy
D. A client with an above-the-knee amputation
B. TPN is infused via central line; therefore, the client should be cared for by the RN. The RN should assess the client for complications associated with the use of TPN, which include injury during central line placement, sepsis, and metabolic disturbances. Answers A, C, and D are incorrect because the clients can be cared for by the LPN.!
The nursing staff consists of two registered nurses, two licensed vocational nurses, and a certified nursing assistant. The skills of the nursing assistant are best suited to:
A. Feeding a client with Alzheimer’s dementia
B. Bathing a client with a central line
C. Obtaining vital signs on a client with pneumonia
D. Collecting the output from a client with preeclampsia
A. The certified nursing assistant is prepared to provide basic care, such as feeding or bathing, to clients with predictable conditions such as Alzheimer’s dementia. Answer B is incorrect because the nursing assistant will not know what to do if problems are encountered with a central line. Answer C is incorrect because the nurse, not the nursing assistant, is best suited to assess the vital signs of a client with a respiratory infection. Answer D is incorrect because the client with preeclampsia will require hourly output measurements; therefore the output should be measured by the nurse.
A client with a high thoracic spinal cord injury develops an episode of autonomic hyperreflexia. After placing the client in high Fowler’s position, the nurse’s next action should be to:
A. Administer an antihypertensive agent
B. Notify the physician immediately
C. Make sure that the urinary catheter is patent
D. Request medication for pain
C. Common causes of autonomic hyperreflexia in the client with a spinal cord injury are bladder distention and fecal impaction. After placing the client in high Fowler’s position, the nurse should make sure that the urinary catheter is patent. Answer A is incorrect because an antihypertensive is not administered until other measures are taken. Answer B is incorrect because it is not necessary to notify the doctor immediately; autonomic hyperreflexia is a common occurrence in the client with a spinal cord injury. Answer D is incorrect because pain medication is not the treatment for autonomic hyperreflexia.
The nurse is making room assignments for four newly admitted clients. Which client should be placed closest to the nurse’s station?
A. A 47-year-old with an esophageal tamponade
B. A 15-year-old with a fractured tibia and fibula
C. A 70-year-old with diabetes and intermittent leg pain
X. The 70-year-old with diabetes and the 75-year-old with a fractured hip
A. The client with an esophageal tamponade is hemorrhaging from esophageal varices; therefore, the client needs to be near the nurse’s station for frequent assessment. Answers B, C, and D are incorrect because the clients have conditions which are more stable.
While making rounds, the nurse smells smoke coming from a client’s room. On checking the room, the nurse finds a fire in the trash can. The nurse should give priority to:
A. Activating the fire alarms
B. Locating the unit fire extinguisher
C. Moving the client to a safe location
D. Evacuating all the clients to another unit
C. The nurse should give priority to ensuring the safety of the client who is in harm’s way; therefore, the client should be moved to a safe location. Answers A and B are performed after the client is moved; therefore, they are incorrect. Answer D is incorrect because the unit should not be evacuated unless there is a danger to others.
The nurse is caring for a client with tuberculosis. Which of the following is not a part of the client’s care?
A. Keeping the client’s door closed at all times
B. Wearing an N95 mask only when providing direct care
C. Maintaining the client in a room with at least six exchanges of fresh air per hour
D. Providing phototherapy with a source of ultraviolet light
B. The N95 mask should be worn when the nurse is in the room of a client with TB, not just when providing direct care. Answers A, C, and D are incorrect choices because they are a part of the care for the client with tuberculosis.
Which of the following nursing duties is within the scope of practice of the licensed practical nurse?
A. Providing final discharge teaching for a client with a diagnosis of peptic ulcer disease
B. Instructing a newly diagnosed diabetic on how to administer his insulin injections
C. Monitoring the vital signs of a client receiving a blood transfusion
D. Flushing a central line with a heparin solution
C. The LPN can monitor the vital signs of a client receiving a blood transfusion and assess the client for problems related to the transfusion. Answer A is incorrect because the RN, not the LPN, should provide final discharge teaching. The RN provides instruction to the client with a new diagnosis; therefore, Answer B is incorrect. Answer D is incorrect because flushing a central line is not within the scope of practice of the LPN.
The nurse is caring for an infant with suspected Munchausen’s syndrome. While making rounds, the nurse finds the mother putting something in the infant’s bottle. The nurse should:
A. Remove the bottle and report the incident to the charge nurse
B. Ask the mother what she added to the infant’s bottle
C. Check to see whether the infant becomes ill after taking the bottle
D. Request that a dietician visit with the mother
A. Munchausen’s syndrome (abuse by proxy) occurs when illness is caused by the caregiver. Removing the bottle and reporting the incident to the charge nurse can prevent further injury to the infant and provide a means of therapeutic intervention. Answer B is incorrect because of a lack of therapeutic communication between the nurse and mother. Answer C is incorrect because further harm might come to the infant. Answer D is incorrect because the problem is not with the infant’s diet.
The nursing staff of a local clinic is made up of two registered nurses and two licensed practical nurses. Which duty is within the scope of practice of the licensed practical nurse?
A. Administering a monthly infusion of Remicade to a client with rheumatoid arthritis
B. Removing sutures from a client following abdominal surgery
C. Changing a peg tube in a client with a stroke
D. Flushing a Groshong catheter in a client receiving chemotherapy
B. Removing sutures is within the scope of practice of the LPN. Answers A, C, and D are incorrect because they involve skills outside the scope of practice of the LPN.
Four clients have requested medication for pain. Which client should receive pain medication first?
A. A 35-year-old client with fractures of the right femur
B. An 18-year-old client who is one day post appendectomy
C. A 55-year-old client with diverticulitis
D. A 47-year-old client who is one week post myocardial infarction
D. The nurse should give priority to assessing and medicating the client who is one week post-myocardial infarction. Answers A, B, and C are incorrect because the clients’ conditions are more stable; therefore, they can receive medication later.
The nurse on a busy surgical unit has just completed receiving the morning shift report. Which client should the nurse assess first?
A. A post-gastrectomy client with 75 mL bright red nasogastric drainage in the past hour
B. A client receiving total parenteral nutrition following a bowel resection
C. A diabetic client with a morning blood glucose of 210 mg/dL
D. A client with pneumonia receiving intravenous antibiotics
A. The nurse should assess the post-gastrectomy client first because the report of 75 mL bright red bleeding in the past hour indicates excessive bleeding. Answers B, C, and D relate to clients with more stable conditions; therefore, they can be seen after the gastrectomy client.
The nurse is assigning duties for the day’s staff, which consists of RNs, LPNs, and certified nursing assistants. Which facet of care is within the scope of practice of the certified nursing assistant?
A. Performing a sterile dressing change
B. Administering a tube feeding
C. Applying a nitroglycerin patch
D. Cleaning an ocular prosthesis
D. Cleaning an ocular prosthesis can be performed by the certified nursing assistant. Performing sterile dressing changes, administering tube feedings, and applying medicated patches are not within the scope of practice of the certified nursing assistant; therefore answers A, B, and C are incorrect.!
The charge nurse is making room assignments for four newly admitted pediatric clients. Which client should be assigned to the room occupied by a 3-year-old with burns of the hand and arm?
A. A 6-year-old with diabetes
B. A 10-year-old with pneumonia
C. A 2-year-old with facial cellulitis
D. A 4-year-old with gastroenteritis
A. A child with burns should not be placed in the room with any child that poses a risk of infection. The children in Answers B, C, and D all pose a risk of infection; therefore, they are incorrect.
TA client diagnosed with acute mania is admitted to the psychiatric unit for stabilization. Which client is the most suitable roommate for a client with mania?
A. A client with paranoid schizophrenia
B. A client with antisocial personality disorder
C. A client with anorexia nervosa
D. A client with situational depression
D. The most suitable roommate for the client with acute mania is the client with situational depression. Answer A is incorrect because the client with paranoid schizophrenia does not cope well with drastic changes in environment, such as those created by a client with mania. Answer B is incorrect because a client with antisocial personality disorder can manipulate the behavior of the client with mania to disrupt the unit. Answer C is incorrect because a client with anorexia nervosa usually has activity restrictions and the client with acute mania usually incites activity in others.
The nurse is preparing to administer intravenous morphine sulfate to a client recently returned from surgery. Before giving the medication, what is the priority nursing assessment?
A. Checking the client’s respirations
B. Obtaining the client’s temperature
C. Checking the client’s blood pressure
D. Counting the client’s pulse rate
A. Morphine sulfate depresses the respiratory center; therefore, the nurse should check the client’s respirations before administering the medication. Answer B is incorrect because temperature is not affected by the medication. Answers C and D can be lowered by the medication but are not as much concern as the rate of respiration; therefore, they are incorrect.
During her orientation, a graduate nurse is assigned to work with the staff of a large oncology unit. Which client is best assigned to the new graduate?
A. A client receiving chemotherapy via central line for breast cancer
B. A client receiving linear acceleration therapy for lung cancer
C. A client receiving brachytherapy for cervical cancer
D. A client receiving experimental therapy for malignant melanoma
B. The new graduate who is orienting to an oncology unit is best assigned to the client receiving linear acceleration therapy (radiation therapy) for lung cancer. Answers A, C, and D require higher levels of knowledge and skill than those possessed by a new graduate in orientation; therefore, they are incorrect.
The nurse is preparing a care plan for a client with a nutritional deficit. Which plan could be implemented by the nursing assistant?
A. Assess the client’s knowledge of a proper diet
B. Monitor the client’s laboratory values
C. Weight the client daily
D. Administer multivitamins as prescribed
C. It is within the role of the nurse’s assistant to weigh clients. Answers A, B, and D are beyond the scope of practice of a nurse’s assistant, so they are incorrect.!
The charge nurse on the orthopedic unit is giving instructions to a student nurse caring for a client in skeletal traction. Which is most important for the charge nurse to tell the student to report?
A. Complaints of mild pain
B. Small amounts of clear drainage from the pin sites
C. Requests for a position change
D. Looseness of the pins on the traction device
D. A client in skeletal traction with a loose pin is in danger of losing the effect of the pull of the traction, which could produce severe damage, so this is the priority. Answers A and B are both expected in a client with a fracture in skeletal traction, so they are incorrect. In Answer C, the nurse might have to assist the student with positioning the client, but it is not the most important consideration, so it is incorrect.
The nurse is preparing to make rounds after shift report. Which client requires further assessment by the nurse?
A. A 40-year-old 12 hours post-thyroidectomy experiencing numbness in the face
B. A 34-year-old laparoscopic cholecystectomy with a temperature of 99.8° F
C. A 22-year-old being discharged after an appendectomy
D. A 56-year-old diabetic postop colon resection with a blood sugar of 128
A. Complaints of facial numbness in the post-thyroidectomy client suggest hypocalcemia, therefore the client needs further assessment and findings should be reported to the physician. Answers B and D indicate mild abnormalities in temperature and blood sugar, but are not a need for immediate concern, so they are incorrect. Answer C is incorrect because the client is well enough for discharge.
The nurse is giving a report to a senior nursing student. Which would the nurse instruct the student to report on a client diagnosed with hyperthyroidism?
A. Tachycardia
B. Subnormal temperature
C. Frontal headache
D. Insomnia
A. Removing sutures is within the scope of practice of the LPN. Answers A, C, and D are incorrect because they involve skills outside the scope of practice of the LPN.
A client presents to the emergency room complaining of dyspnea, shortness of breath, and a productive cough. The vital signs are temperature 101.4° F, respiratory rate 30, heart rate 108, and BP 124/80. The client is receiving oxygen, with an oxygen saturation rate of 86%. Which of the following physician’s orders should the nurse complete first?
A. Obtain a chest x-ray
B. Administer acetaminophen (Tylenol) X grain
C. Obtain arterial blood gases
D. Administer chlorpheniramine/hydrocodone (Tussionex)
C. The client’s O2 saturation is below normal; therefore, evaluation of the client’s arterial blood is important. Answer A is also important, but not as immediate. Answers B and D are both drugs that might be helpful, but they are not indicated at this time, so they are incorrect.
The nurse is caring for several clients on an orthopedic unit. If the following requests were made simultaneously, which should the nurse do first?
A. A family member calls and requests to speak to the nurse about a patient.
B. A client with a fractured femur complains of pleuritic pain and reports a rash on the chest and under the arms.
C. A client with a fractured leg requests pain medications.
D. A client with a cast reports itching within the cast.
B. The client with pleuritic chest pain and a rash in these areas should be assessed first due to clinical manifestations of an embolus. The situation in Answer A could be done later by the nurse calling the family member back, so it is incorrect. The clients in Answers C and D could have their care delegated to others.
A client with a stroke is receiving heparin intravenously. Which action of the nurse’s assistant would cause a need for the nurse to intervene?
A. Assisting the client with tray setup
B. Writing the client a note to assist with communication
C. Shaving the client with a straight razor
D. Repositioning the client in bed
C. Clients receiving anticoagulants are at risk for bleeding and should be shaved with an electric razor to decrease this risk. Answers A, B, and D are not contraindicated or associated with the use of heparin and a stroke, so they are incorrect.
The nurse is caring for clients on an oncology unit. The supervisor calls to report a need to place two of the patients in the same room. Which of the following patient pairs is best
A. A postoperative laminectomy done to decrease spinal cord compression and a patient with a craniotomy due to lung cancer metastasis.
B. A patient with neutropenia and a patient receiving a blood transfusion
C. A patient with pancreatic cancer and a patient with a white blood cell count of 200
D. A patient on high dose chemotherapy and a patient with prostate cancer who is receiving radiation by external beam.
A. The most suitable roommates would be the two similar clients with palliative treatments. The clients in Answers B and C each involve a risk for infection due to their low WBC counts. Answer D also has some similarities in diagnoses, but do not fit as well as the clients in Answer A.
The nurse is caring for several clients on an orthopedic unit. If the following requests were made simultaneously, which should the nurse do first?
A. Low-sodium diet
B. Identify and continue home medications
C. Limit fluids to 500 mL per shift
D. Administer furosemide (Lasix) IV push.
D. The priority is to remove the excess fluid. Answers A, B, and C are not a priority at this time, so they are incorrect.
The nurse discovers a solution of Heparin IV infusing on a client when D5W is ordered. What is the appropriate initial action?
A. Remove the Heparin and hang D5W
B. Notify the physician about the incident.
C. Inform the charge nurse of the error
D. Complete an occurrence report
A. The initial action by the nurse should be to correct the error, if possible. In this case, the action would be to hang the correct fluid. Answers B, C, and D are all correct interventions but are not the initial action, so they are incorrect.
A client is admitted with severe diarrhea. Which laboratory value is it most important to report to the physician?
A. Hgb 10.8 g/dL
B. WBC count of 12,500/mm
C. BUN 30 mg/dL
D. Potassium 2.0 mEq/L.
D. The normal potassium is 3.5-5.0 mEq/L. Low potassium can be life-threatening and affect every body system, which makes this answer the priority. Answers A and B are near the normal levels, so they are incorrect. Answer C is expected in dehydration and can easily be corrected, so it is incorrect.
A client has just died from terminal pancreatic cancer. Which task is best delegated to the nurse’s assistant?
A. Talking with the family about aftercare
B. Assisting with postmortem care
C. Assessing the chart for funeral arrangements.
D. Calling the doctor about the patient’s death.
B. Assisting with postmortem care is within the role of a nurse’s assistant. Answers A, C, and D are beyond the role of a nurse’s assistant and are best performed by a licensed nurse, so these answers are incorrect.
The charge nurse is assigning staff on an oncology unit. One of the staff is a nurse that was transferred from the psychiatric unit. Which client should the nurse assign to the psychiatric nurse?
A. A client from the intensive care unit who is post-thoracotomy for lung cancer.
B. A client requiring extensive chemotherapy administration on this shift
C. A client who has just been told that her cancer is terminal
D. A client with metastatic colon cancer, returning from a colon resection this shift.
C. The best client choice for a psychiatric nurse is the client that would benefit from therapeutic communication techniques. The clients in Answers A, B, and D require clinical, surgical or specific cancer skills, so they are incorrect.
A client with an abdominal aortic aneurysm complains of sudden lower back pain. What is the nurse’s initial action?
A. Start an IV with an 18-gauge needle
B. Measure the client’s abdominal girth.
C. Assess the peripheral pulses
D. Administer morphine sulfate 6 mg.
B. The nurse should measure the girth to determine whether it has increased. The client might have an expanding or rupturing aneurysm. Answers A and D would need a physician’s order, so they are incorrect. Answer C is not important initially, so it is incorrect.
A nurse’s assessment of a client reveals shortness of breath, anxiety, and asymmetrical chest expansion. After starting the patient on ordered O2 at 3 L/min, what is the nurse’s next action?
A. Assess the chart for pulmonary function test results
B. Place the client in a supine position with his head flat
C. Notify the physician
D. Order a portable chest x-ray
C. The client has symptoms of a pneumothorax and the physician should be notified. Answer A is not appropriate at this time, so it is incorrect. Answer B is incorrect because lowering the head might increase the client’s shortness of breath. Answer D is beyond the scope of the nurse, so it is incorrect.
If the following respiratory clients present in the emergency room at the same time, which client should be seen first?
A. A 2-year-old with cough, congestion, and a temperature of 102° F
B. A 22-year-old with fractured ribs complaining of pain in the chest area.
C. A 60-year-old with dyspnea, distended neck veins, and 2+ pitting edema of lower extremities.
D. A 35-year-old with a sore throat and temperature of 100.5° F
C. The client is exhibiting symptoms of congestive heart failure and is the priority client in this group. The clients in Answers A and D require attention but have no immediate need, so they are incorrect. The client in Answer B exhibits an expected manifestation of rib fractures, so it is an incorrect answer.
The emergency room nurse is assigned to triage four clients. Which client should be seen first?
A. The pregnant client with mild abdominal pain.
B. The client with emphysema with an oxygen saturation level of 83%
C. The client with chronic glomerulonephritis with loss of his AV fistula.
D. The client with diabetes with a blood glucose level of 277 mg/dl.
B. The oxygen saturation is extremely low even for a client with emphysema. Answer A is incorrect because the client’s symptom is mild abdominal pain, which is a vague complaint. Answer C is incorrect because the client with chronic glomerulonephritis with loss of AV fistula does not require immediate attention. Answer D is incorrect because a blood glucose level of 277 mg/dL in the client with diabetes is not life-threatening, although it does require intervention. This client should be seen next.
Which nurse would be best to assign to the client who is 48 hours bone marrow transplant?
A. The RN with 4 years experience in the emergency room setting.
B. The RN with 4 years experience on the geriatric unit
C. The RN with 5 years experience working with clients with AIDS
D. The RN with 10 years experience working in the labor and delivery unit
C. The nurse with five years of experience working with clients with AIDS is most aware of the needs of the immune-suppressed client. The nurses with experience in the other units as noted in A, B, and D are not as well prepared to care for this client, so these answers are incorrect.
The nurse is observing the certified nursing assistant caring for a client who is taking Thorazine (chloropromazine) for psychosis. Which action by the nursing assistant indicates a need for further teaching?
A. The nursing assistant offers the client a magazine to read.
B. The nursing assistant stands on the client’s dominant side during ambulation.
C. The nursing assistant asks the client if he wants to take a walk
D. The nursing assistant allows the client to have hard candy..
A. The client taking Thorazine will probably have blurring of vision, making reading difficult. Answers B, C, and D are appropriate actions by the nursing assistant and do not require further teaching, so they are incorrect.
After taking the morning report, the nurse should visit which client first?
A. The client with pheochromocytoma
B. The client with breast cancer
X. The client with a urinary tract infection
D. The client with myxedema
a. The client with pheochromocytoma (a type of adrenal tumor) will have extremely high blood pressure readings that might result in cardiac and neurological symptoms. The clients in Answers B, C, and D are less acute and can be seen later, so those answers are wrong.
The nurse observes the nursing assistant looking through the belongings of the geriatric client. Which action is most appropriate at this time?
A. Call the social worker so that she can investigate the matter
B. Question the nursing assistant regarding the matter
C. Report the matter to the physician
D. Chart the observation in the client’s medical record.
B. The nurse should first ask the nursing assistant about the incident. The client might have requested that the nursing assistant help her in finding an article. Answers A, C, and D are inappropriate actions at this time, so they are incorrect.
The nurse is preparing to perform a sterile dressing change. He has collected materials needed for the procedure and opened the sterile tray when he is called away to an emergency. Should a second nurse be asked to continue the procedure, she should:
A. Go to the sterile utility room and obtain another tray
B. Continue the procedure utilizing the opened tray.
C. Question the nurse regarding the sterility of the tray
D. Call the physician to discuss the procedure/p>
A. Because the nurse who is performing the procedure is not fully aware of the sterility of the tray, she should obtain a new, unopened tray. Answers B, C, and D are incorrect actions and are therefore incorrect.
The charge nurse is instructing several graduate nurses regarding the need to maintain confidentiality. Which action by the graduate constitutes a breech in client confidentiality?
A. The graduate asks the family member of the client who has had a CVA to sign the permit for surgery.
B. The graduate examines the chart of a relative of her family who is hospitalized for surgery.
C. The graduate talks harshly to the elderly client with dementia..
D. The graduate asks the client’s son if she has a living will.
B. According to the HIPPA law, it is a violation of client confidentiality to examine a chart of a client who is not in the nurse’s immediate care. Answer A is incorrect because it is not unlawful to ask the son to sign the permit when the client is unable to sign for herself. Answers C and D are not a breech in confidentiality, so they are incorrect.
The nurse is preparing to administer four medications to the client with dysphagia following a stroke. Because all of the client’s medications are to be given by mouth, the nurse should administer which medication first?
A. Ketoralac (Toradol)
B. Glypizide (Glucotrol)
C. Doxazosin mesylate (Cardura).
D. Spironalactone (Aldactone).
C. Doxazosin mesylate (Cardura) is an antihypertensive/cardiac medication and should be given first. The nurse should give glypizide second because it is an antidiabetic drug; therefore, answer B is wrong. Spironalactone should be given third because this is a diuretic, so answer D is incorrect. Ketoralac can be given last because it is an NSAID, so answer A is wrong.
The client is scheduled for a positron emission tomography (PETT) scan. Which action indicates the nurse is aware of the needs of the client during the PET scan?
A. The nurse checks the client’s blood glucose level prior to the procedure.
B. The nurse inserts a nasogastric tube for lavage to monitor gastric pH.
C. The nurse tells the client that a catheter will be inserted into his brachial artery
D. The nurse informs the client that he will be asleep during the procedure.
A. A positron emission tomography uses glucose tagged contrast medium. For accuracy of the exam the blood glucose levels must be between 60 and 140 mg/dl. Answers B, C, and D are incorrect statements and are therefore incorrect.
The nurse is caring for a group of clients on a medical surgical unit. Which of the following clients should receive priority status?
A. A client with chronic renal failure whose Hgb is 10.2 g/dL
B. A client with pernicious anemia who is complaining of tingling in the right arm
C. A client with a pleural effusion and an oxygen saturation of 95%
D. A client with hypertension reporting numbness in the right hand.
D. The client with hypertension might be exhibiting stroke symptoms, making this the priority. Answer A is incorrect because a low Hgb level is expected with a client diagnosed with chronic renal failure. Clinical manifestations of pernicious anemia include paresthesia, so Answer B is wrong. Answer C includes a normal oxygen saturation, so this client is low priority, making it incorrect.
The family member of a client with terminal cancer is concerned about providing adequate home care. Which of the following agencies would be the best for the nurse to consider advocating?
A. Hospice home health.
B. Meals on Wheels services.
C. Community action agency
D. Cooperative extension services.
A. The client with terminal cancer, as well as the caregivers, could be benefited by a hospice home health referral, making this the best option. Answers C and D do not offer the correct assistance for this type of client, so they are wrong. Answer B would assist with only one aspect of service, so it is not the best option and is therefore incorrect.
A client is diagnosed with a suspected pulmonary embolus after hip surgery. Which of the following nursing interventions should the nurse complete first?
A. Assess the client’s hip surgical wound
B. Connect ordered oxygen at 2L/min by nasal cannula.
C. Administer daily dose of enoxaparin (Lovenox)
D. Notify the physician of the client’s admission.
B. The oxygen order takes priority in this situation. Answers A, C, and D would all be interventions that are appropriate but are not the priority intervention, so they are incorrect.
The nurse is to obtain surgical consent for a client who is scheduled to be transferred to OR for an appendectomy. The emergency room report indicates meperidine (Demerol) IM and ceftriaxone (Rocephin) IVPB was administered 15 minutes ago. Which action is most appropriate?
A. Get the patient to sign the operative permit
B. Obtain consent signature from the client’s spouse
C. Call surgery and inform the staff to cancel the procedure
D. Waive the signing of the permit because of the emergency
B. The closest adult relative can give consent if the patient is not able to do so. This client is under sedation and unable to give surgical consent; therefore, Answer A is wrong. Answer C is wrong because canceling the procedure is beyond the scope of practice of the registered nurse. There is no information in the stem that justifies an emergency, so Answer D is wrong.
Which of the following occurrences qualify as provider of care outside the scope of practice of the LPN?
A. Performance of tracheostomy care
B. Administering conscious sedation.
C. Monitoring a blood transfusion
D. Inserting a Foley catheter
B. Conscious sedation administration is beyond the scope of the LPN. The answers in A, C, and D are all within the scope of the LPN, so they are incorrect.
A client is in status epilepticus and has the following medications ordered IV. Which does the nurse administer first?
A. Lorazepam (Ativan)
B. Cefazolin (Ancef).
C. Dexamethasone (Decadron).
A. Status epilepticus is a life-threatening condition due to the continual seizures; therefore, stopping the seizure activity is the priority. Ativan is the drug of choice in this situation and is the priority drug to be given. Answers B and C could all be administered after the Ativan, so they are incorrect.
The nurse is approached by a friend in a community setting. The friend asks the nurse about the results of another friend’s x-ray test. Which of the following responses is most appropriate?
A. If you can get me her Social Security number, I will look it up.”
B. “Why don’t you just ask her the result of the test yourself?”
C. “I cannot give out any client information.”
D. “I don’t have that information right now.”
C. Giving out information of this type violates HIPPA and is not allowed, so this is the best response for the nurse to make in this situation. Answer A is inappropriate because of HIPPA, so it is wrong. Answer B is non-therapeutic communication, so it is wrong. Answer D implies that the nurse is not giving the information only because she doesn’t have it at this time, so it is wrong.
Four clients on a busy medical-surgical unit are requesting medication. Which client should receive medication first?
A. A 34-year-old client with a fractured femur who requests pain medication.
B. A 48-year-old client with cirrhosis who requests medication for nausea.
C. A 55-year-old client with peptic ulcer disease who requests an antacid
D. A 36-year-old with ulcerative colitis who requests medication for diarrhea.
B. Complications of cirrhosis include portal hypertension. Increased pressure in portal circulation caused by activities such vomiting, coughing, and straining at stool can result in hemorrhage. Therefore, the client with cirrhosis should receive medication before the client with pain, indigestion, or diarrhea, making Answers A, C, and D incorrect.
Which client should be cared for using airborne transmission-based precautions?
A. A 5-year-old with rubella
B. A 6-month-old with rotovirus.
C. A 2-month-old with pertussis.
D. A 6-year-old with varicella.
D. Airborne precautions are used when caring for the child with varicella. Droplet precautions are used when caring for the child with rubella and the child with pertussis. Contact precautions are used when caring for the child with rotovirus. Therefore Answers A, B, and C are incorrect.
A mass casualty has necessitated the emptying of several hospital beds. Which one of the following clients should be discharged to provide a bed for a trauma victim?
A. A client who is one day postop thyroidectomy.
B. A client who is two days postop gastrectomy
C. A client who is two days postop stapedectomy.
D. A client who is one day postop abdominal cholecystectomy.
C. The client who is two days post stapedectomy can be discharged for follow-up at home. Answers A and B are incorrect because bleeding is a complication associated with both thyroidectomy and gastrectomy. Answer D is incorrect because clients with abdominal cholecystectomy have large abdominal incisions and placement of drains that require nursing assessment and interventions.
The nurse is making assignments for the day. Which client is least appropriate to assign to the novice RN?
A. A client with a newly created arteriovenous fistula who is undergoing dialysis
X. A client with Crohn’s disease who is receiving intravenous immunosuppresives
C. A client with burns who is scheduled for mechanical debridement.
D. A client with an abdominal cholecystectomy with a Jackson Pratt drain
A. The novice RN is least appropriate to assign to the client with a newly created arteriovenous fistula who is undergoing dialysis because the client is less stable than the other clients. Answers B, C, and D are incorrect because the client with Crohn’s disease, the client undergoing mechanical debridement for burns, and the client recovering from an abdominal cholecystectomy have more stable conditions and are more appropriate to assign to the novice RN..
The RN is making assignments for the staff, which contains an LPN. Which duty can be assigned to the LPN?
A. Performing tracheostomy suctioning on a client with a permanent trach
B. Administering total parenteral nutrition to a client with cancer.
C. Obtaining initial vital signs on a client receiving a blood transfusion.
D. Performing discharge teaching for a client with diabetes mellitus.
A. Performing tracheostomy care and suctioning are within the scope of practice of the LPN. Answer B is incorrect because administering TPN is the duty of the RN. Answer C is incorrect because obtaining initial vital signs on the client receiving a blood transfusion is the duty of the RN. Answer D is incorrect because providing discharge teaching is the duty of the RN.
The nursing staff consists of an RN, an LPN, two nursing assistants, and a float RN from the hospital’s psychiatric unit. Which client should be assigned to the float RN?
A. A 25-year-old with traumatic amputation of the right lower leg
B. A 48-year-old with a pulmonary tuberculosis
C. A 56-year-old with cirrhosis and portal hypertension
D. A 72-year-old with end-stage renal disease
A. The skills of the psychiatric nurse are best used for the 25- year-old client with a traumatic amputation of the leg because the client can be expected to have altered body image and depression. Answers B, C, and D are incorrect because these clients are best assigned to the nurse with more extensive experience with medical-surgical nursing
The physician has prescribed an MAO inhibitor for a client with depression. Place an X by each food choice that should be avoided by clients receiving MAO inhibitors:
A. Chocolate pudding
B. Hamburger steak
C. Yogurt
D. Cheddar cheese
E. Banana
F. Grilled tuna
G. Avocados
A, C, D, E, G
The client taking MAO inhibitors should avoid chocolate, yogurt, cheddar cheese, bananas, and avocados because they are sources of tyramine.
Viral hepatitis can be either enteric or parenteral in origin. Place an X beside the parenteral forms of viral hepatitis:
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
F. Hepatitis G
B, C, D, F
Hepatitis B, Hepatitis C, Hepatitis D, and Hepatitis G are parenteral forms of hepatitis. Hepatitis A and Hepatitis E are enteral forms of hepatitis.
Parenteral – through the bloodstream
Enteric – GI tract
The nurse is caring for a client following an abdominal cholecystectomy with insertion of a T-tube. Which aspects of care apply to the client with a T-tube? Check all that apply.
A. Documenting the amount, color, and consistency of the drainag
B. Irrigating the T-tube every four hours
C. Preventing kinking or tangling of the tubing
D. Clamping the tube for 30 minutes every four hours on the second postoperative day
E. Observing for the return of brown-colored stools
F. Maintaining the drainage system below the level of the gallbladder
The nurse is assisting the physician with the removal of a closed chest drainage system. Place an X by the item/items that will not be needed for the procedure:
A. Xylocaine and 5 mL syringe
B. Petroleum gauze
C. Silk or paper tape
D. Suture removal kit
E. Sterile hemostats
F. Sterile 4 x 4 pads
Check all that apply to the skill of traction application:
A. Weights on floor
B. No knots in the cords
C. Sheets off the traction device
D. No frayed cords
E. Weights hanging freely
The nurse is preparing a care plan for a client on the neurological unit with a nursing diagnosis of alteration in cerebral tissue perfusion. Which plans would be beneficial to maintenance or improvement in cerebral tissue perfusion? Check all that apply
A. Elevate the head of the bed 30°
B. Administer mannitol (Osmitrol) as ordered
C. Assist the client to turn, cough, and deep breathe every two hours
D. Monitor neurological status hourly
E. Keep the client’s head turned to the side
A, B, D.
The following should be checked: elevate the head of the bed 30 degrees; administer mannitol (Osmitrol) as ordered; monitor neurological status hourly. Assisting the client to turn, cough, and deep breathe every two hours is incorrect because coughing increases intracranial pressure. The “keep the client’s head turned to the side” action is incorrect because the head should be kept in the neutral position to encourage blood flow from the head and decrease intracranial pressure.
Which of the following foods are allowed on a low-sodium diet? Check all that apply.
A. An orange
B. Broiled chicken
C. Potato chips
D. Yogurt
E. Parmesan cheese
F. Tomato ketchup
G. Canned soup
H. Buttermilk
I. Broccoli
A, B, D, I
The following foods should be checked: an orange, broiled chicken, yogurt, and broccoli. The other foods listed are high in sodium and should be avoided by the client on a low-sodium diet, so they are incorrect.
Place an X by the physiological changes associated with the aging process.
A. Presbyopia
B. Arcus senilis
C. Presbycusis
D. Brudzinski’s sign
E. Sundowning syndrome
F. Aphasia
A, B, C.
The following should have an X: presbyopia, presbycusis, arcus senilis. The other choices are abnormal conditions not associated with the aging process, so they are incorrect.
Place a check by the members of the healthcare team who can be assigned to the care of a client 12 hours following a thyroidectomy
A. Resident physician with 1 year experience
B. Registered nurse with 2 months experience
C. Licensed practical nurse with 1 year experience
D. Nursing assistant with 20 years experience
A, B, C, D.
